93% on room air.\n Plan:\n Continue to monitor respiratory status. d/c to floor.\n"},{"category":"Nursing","chartdate":"2137-12-02 00:00:00.000","description":"Nursing Progress Note","row_id":651552,"text":"Cellulitis\n Assessment:\n neck remains mildly swollen\n afebrile\n Action:\n penrose drains to gravity,\n ampicillin a/o\n normal saline nasal wash\n Response:\n cont to drain serosang from penrose drains\n cellulits improving\n able to raise secretions\n Plan:\n cont ampicllin a/o\n penrose drains to gravity per ENT\n follow low HCT\nborderline per patient (takes procrit and iron at home)\n await wound care recs for abd dressing\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2137-12-04 00:00:00.000\",\n \"description\": \"BY SAME PHYSICIAN\",\n \"row_id\": 1054086,\n \"text\": \", A. ENT CC6A 1:06 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: repeat xray of picc tip since repositioned.\\n Admitting Diagnosis: FACIAL CELLULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old woman with\\n REASON FOR THIS EXAMINATION:\\n repeat xray of picc tip since repositioned.\\n ______________________________________________________________________________\\n PFI REPORT\\n Right PICC tip now in the mid SVC.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2137-12-04 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 1054067,\n \"text\": \" 11:29 AM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: repeat of picc tip. wire pulled out, looking for picc to dro\\n Admitting Diagnosis: FACIAL CELLULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old woman with\\n REASON FOR THIS EXAMINATION:\\n repeat of picc tip. wire pulled out, looking for picc to drop into SVC.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 84-year-old woman with right PICC. Assess PICC placement.\\n\\n COMPARISON: Chest radiographs done approximately 2 hours prior.\\n\\n TECHNIQUE: Portable AP view of the chest.\\n\\n FINDINGS: The right-sided PICC tip now makes a hairpin turn at the upper SVC\\n with the tip doubled back on itself, approximately 4.5 cm from the turn. The\\n remainder of the exam is unchanged.\\n\\n These findings were discussed with , IV nurse, at the time of review on\\n .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2137-12-04 00:00:00.000\",\n \"description\": \"BY SAME PHYSICIAN\",\n \"row_id\": 1054085,\n \"text\": \" 1:06 PM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: repeat xray of picc tip since repositioned.\\n Admitting Diagnosis: FACIAL CELLULITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 84 year old woman with\\n REASON FOR THIS EXAMINATION:\\n repeat xray of picc tip since repositioned.\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKSd WED 8:42 PM\\n Right PICC tip now in the mid SVC.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 84-year-old woman with repositioning of PICC tip.\\n\\n COMPARISON: Multiple chest x-rays, most recently done 2 hours prior.\\n\\n TECHNIQUE: Portable AP view of the chest.\\n\\n FINDINGS: The right PICC tip now appears to be at the mid SVC. The remainder\\n of the exam is unchanged since prior. Findings were discussed with ,\\n IV nurse at the time of review.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2137-11-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 242823,\n \"text\": \"Sinus tachycardia with premature atrial complexes. Normal axis and intervals.\\nSmall Q waves are present in leads II, III and aVF which are probably\\nnon-pathologic. No previous tracing available for comparison.\\n\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2137-12-02 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 651594,\n \"text\": \"SICU\\n HPI:\\n 84 yo F p/w right neck swelling who is s/p submandibular abscess\\n drainage and subsequent teeth extraction\\n Chief complaint:\\n right neck swelling\\n PMHx:\\n CHF, hypothyroidism, Colon Ca, GERD, COPD, PNA, Renal\\n failure, vascular disease, abdominal aortic aneurysm (pt informs\\n that last year it was ~4cm), iron deficiency anemia.\\n Current medications:\\n 24 Hour Events:\\n OR SENT - At 08:15 AM\\n teeth extraction\\n OR RECEIVED - At 09:15 AM\\n INVASIVE VENTILATION - STOP 01:59 PM\\n pt arrived from OR intubated\\n EXTUBATION - At 02:46 PM\\n Post operative day:\\n POD#1 - s/p extrtaction right infected tooth\\n HD #3, POD#2(submandibular abscess)/ POD1 (teeth extract)\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin - 06:14 AM\\n Ampicillin/Sulbactam (Unasyn) - 12:07 AM\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 06:09 PM\\n Heparin Sodium (Prophylaxis) - 10:15 PM\\n Other medications:\\n Flowsheet Data as of 05:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.2\\nC (99\\n T current: 36.6\\nC (97.9\\n HR: 83 (71 - 92) bpm\\n BP: 135/62(80) {85/39(47) - 136/71(80)} mmHg\\n RR: 16 (14 - 26) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 3,181 mL\\n 340 mL\\n PO:\\n 290 mL\\n 240 mL\\n Tube feeding:\\n IV Fluid:\\n 2,641 mL\\n 100 mL\\n Blood products:\\n 250 mL\\n Total out:\\n 1,140 mL\\n 300 mL\\n Urine:\\n 1,095 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,041 mL\\n 40 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 400 (400 - 790) mL\\n PS : 5 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 18\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 11 cmH2O\\n SPO2: 100%\\n ABG: ///25/\\n Ve: 9.7 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 : ), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\\n Labs / Radiology\\n 93 K/uL\\n 6.4 g/dL\\n 90 mg/dL\\n 0.9 mg/dL\\n 25 mEq/L\\n 3.3 mEq/L\\n 13 mg/dL\\n 107 mEq/L\\n 137 mEq/L\\n 20.2 %\\n 7.0 K/uL\\n [image002.jpg]\\n 01:52 AM\\n 03:13 AM\\n 06:17 PM\\n 02:50 AM\\n 04:35 AM\\n 10:16 AM\\n 08:38 PM\\n 01:27 AM\\n WBC\\n 10.6\\n 7.2\\n 5.6\\n 7.9\\n 7.0\\n Hct\\n 22.8\\n 25.0\\n 21.7\\n 21.2\\n 21.2\\n 19.6\\n 20.2\\n Plt\\n 116\\n 118\\n 103\\n 92\\n 93\\n Creatinine\\n 1.0\\n 1.0\\n 1.1\\n 0.9\\n TCO2\\n 25\\n Glucose\\n 150\\n 85\\n 123\\n 90\\n Other labs: PT / PTT / INR:16.7/35.3/1.5, Lactic Acid:1.0 mmol/L,\\n Ca:7.1 mg/dL, Mg:1.7 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n CELLULITIS, .H/O PROBLEM - ENTER DESCRIPTION IN COMMENTS\\n Assessment and Plan: 84 yo F p/w right neck swelling who is s/p\\n submandibular abscess drainage and subsequent teeth extraction\\n Neurologic: fentanyl prn for pain\\n Cardiovascular: will restart home PO lopressor dose\\n Pulmonary: extubated without any difficulties\\n Gastrointestinal / Abdomen: off H2B\\n Nutrition: Regular diet\\n Renal: Foley, Adequate UO, Cr stable\\n Hematology: h/o anemia req transfusions. HCT borderline 20-21.\\n Asymptomatic. No CP/SOB/Abd pain/dizziness; t/c transfuse\\n Endocrine: RISS; d/w pt re synthroid dose\\n Infectious Disease: s/p submandibular abscess drainage and removal\\n ?infected tooth) - on unasyn. f/u Cxs sensitivities\\n Lines / Tubes / Drains: PIV, Foley\\n Wounds: c/d/i\\n Imaging:\\n Fluids: KVO\\n Consults: ENT, P.T., OMFS\\n Billing Diagnosis:\\n ICU Care\\n Nutrition:\\n Comments: regular diet\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer:\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:\\n Total time spent: 32 minutes\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2137-11-30 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 651318,\n \"text\": \"Airway\\n location:\\n Reason:\\n Tube Type\\n ETT:\\n Route: Oral\\n Type: Standard\\n Size: 7mm\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: Diminished\\n Secretions\\n Sputum color / consistency: 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 claim of dyspnea)\\n Invasive ventilation assessment:\\n Trigger work assessment: Triggering synchronously\\n Plan\\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\\n Reason for continuing current ventilatory support: Underlying illness\\n not resolved\\n Respiratory Care Shift Procedures\\n Transports:\\n Destination (R/T)\\n Time\\n Complications\\n Comments\\n CT\\n 1545\\n none\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2137-12-02 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 651670,\n \"text\": \"Neck Abcess\\n Assessment:\\n pt alert and oriented x 3\\n o2 sat 97% room air\\n no sob or resp distress\\n lungs clear\\n rsr\\n afebrile\\n hct 20\\n bp stable\\n tol reg diet\\n one loose bm\\n foley dc\\n skin intact\\n neck dsg with two penrose drains and sutures\\n denies pain\\n Action:\\n one unit prbc\\n oob chair\\n eating\\n swallowing intact\\n neck dsg to be changed by ent this afternoon\\n Response:\\n pt sitting in chair comfortably without complaints\\n pt ambulated well with one assist\\n neck dsg intact\\n blood infusing\\n Plan:\\n transfer to cc6\\n second unit of prbc to be transfused on when pt on floor\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2137-12-02 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 651671,\n \"text\": \"Neck Abcess\\n Assessment:\\n pt alert and oriented x 3\\n o2 sat 97% room air\\n no sob or resp distress\\n lungs clear\\n rsr\\n afebrile\\n hct 20\\n bp stable\\n tol reg diet\\n one loose bm\\n foley dc\\n skin intact\\n neck dsg with two penrose drains and sutures\\n denies pain\\n Action:\\n one unit prbc\\n oob chair\\n eating\\n swallowing intact\\n neck dsg to be changed by ent this afternoon\\n Response:\\n pt sitting in chair comfortably without complaints\\n pt ambulated well with one assist\\n neck dsg intact\\n blood infusing\\n Plan:\\n transfer to cc6\\n second unit of prbc to be transfused on when pt on floor\\n ------ Protected Section ------\\n Demographics\\n Attending MD:\\n A.\\n Admit diagnosis:\\n FACIAL CELLULITIS\\n Code status:\\n Height:\\n Admission weight:\\n 58 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH: COPD, Renal Failure\\n CV-PMH:\\n Additional history: CHF,Colon Ca,GERD,Vascular disease,abdominal aortic\\n aneurysm,iron deficiency anemia.\\n Recent resection for colon CA with subsequent infection that required\\n washout. Recent VAC therapy. Son reports pt. had MRSA in wound.\\n Surgery / Procedure and date: : I & D of neck abscess rt side\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:121\\n D:54\\n Temperature:\\n 97.3\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 21 insp/min\\n Heart Rate:\\n 100 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 40% %\\n 24h total in:\\n 1,583 mL\\n 24h total out:\\n 1,090 mL\\n Pertinent Lab Results:\\n Sodium:\\n 137 mEq/L\\n 01:27 AM\\n Potassium:\\n 3.3 mEq/L\\n 01:27 AM\\n Chloride:\\n 107 mEq/L\\n 01:27 AM\\n CO2:\\n 25 mEq/L\\n 01:27 AM\\n BUN:\\n 13 mg/dL\\n 01:27 AM\\n Creatinine:\\n 0.9 mg/dL\\n 01:27 AM\\n Glucose:\\n 90 mg/dL\\n 01:27 AM\\n Hematocrit:\\n 20.2 %\\n 01:27 AM\\n Finger Stick Glucose:\\n 118\\n 10:00 AM\\n Valuables / Signature\\n Patient valuables: Glasses\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Amount: sent with pt\\n Cards: sent with pt\\n / Credit cards sent home with:\\n Jewelry: one metal ring\\n Transferred from: sicu a\\n Transferred to: cc622\\n Date & time of Transfer: 12:00 AM\\n ------ Protected Section Addendum Entered By: , RN\\n on: 12:37 ------\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2137-12-02 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 651628,\n \"text\": \"SICU\\n HPI:\\n 84 yo F p/w right neck swelling who is s/p submandibular abscess\\n drainage and subsequent teeth extraction\\n Chief complaint:\\n right neck swelling\\n PMHx:\\n CHF, hypothyroidism, Colon Ca, GERD, COPD, PNA, Renal\\n failure, vascular disease, abdominal aortic aneurysm (pt informs\\n that last year it was ~4cm), iron deficiency anemia.\\n Current medications:\\n 24 Hour Events:\\n OR SENT - At 08:15 AM\\n teeth extraction\\n OR RECEIVED - At 09:15 AM\\n INVASIVE VENTILATION - STOP 01:59 PM\\n pt arrived from OR intubated\\n EXTUBATION - At 02:46 PM\\n Post operative day:\\n POD#1 - s/p extrtaction right infected tooth\\n HD #3, POD#2(submandibular abscess)/ POD1 (teeth extract)\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin - 06:14 AM\\n Ampicillin/Sulbactam (Unasyn) - 12:07 AM\\n Infusions:\\n Other ICU medications:\\n Famotidine (Pepcid) - 06:09 PM\\n Heparin Sodium (Prophylaxis) - 10:15 PM\\n Other medications:\\n Flowsheet Data as of 05:47 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 37.2\\nC (99\\n T current: 36.6\\nC (97.9\\n HR: 83 (71 - 92) bpm\\n BP: 135/62(80) {85/39(47) - 136/71(80)} mmHg\\n RR: 16 (14 - 26) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 3,181 mL\\n 340 mL\\n PO:\\n 290 mL\\n 240 mL\\n Tube feeding:\\n IV Fluid:\\n 2,641 mL\\n 100 mL\\n Blood products:\\n 250 mL\\n Total out:\\n 1,140 mL\\n 300 mL\\n Urine:\\n 1,095 mL\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 2,041 mL\\n 40 mL\\n Respiratory support\\n O2 Delivery Device: Nasal cannula\\n Ventilator mode: CPAP/PSV\\n Vt (Set): 500 (500 - 500) mL\\n Vt (Spontaneous): 400 (400 - 790) mL\\n PS : 5 cmH2O\\n RR (Set): 14\\n RR (Spontaneous): 18\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n PIP: 11 cmH2O\\n SPO2: 100%\\n ABG: ///25/\\n Ve: 9.7 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 : ), (Sternum: Stable )\\n Abdominal: Soft, Non-distended, Non-tender\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\\n Labs / Radiology\\n 93 K/uL\\n 6.4 g/dL\\n 90 mg/dL\\n 0.9 mg/dL\\n 25 mEq/L\\n 3.3 mEq/L\\n 13 mg/dL\\n 107 mEq/L\\n 137 mEq/L\\n 20.2 %\\n 7.0 K/uL\\n [image002.jpg]\\n 01:52 AM\\n 03:13 AM\\n 06:17 PM\\n 02:50 AM\\n 04:35 AM\\n 10:16 AM\\n 08:38 PM\\n 01:27 AM\\n WBC\\n 10.6\\n 7.2\\n 5.6\\n 7.9\\n 7.0\\n Hct\\n 22.8\\n 25.0\\n 21.7\\n 21.2\\n 21.2\\n 19.6\\n 20.2\\n Plt\\n 116\\n 118\\n 103\\n 92\\n 93\\n Creatinine\\n 1.0\\n 1.0\\n 1.1\\n 0.9\\n TCO2\\n 25\\n Glucose\\n 150\\n 85\\n 123\\n 90\\n Other labs: PT / PTT / INR:16.7/35.3/1.5, Lactic Acid:1.0 mmol/L,\\n Ca:7.1 mg/dL, Mg:1.7 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n CELLULITIS, .H/O PROBLEM - ENTER DESCRIPTION IN COMMENTS\\n Assessment and Plan: 84 yo F p/w right neck swelling who is s/p\\n submandibular abscess drainage and subsequent teeth extraction\\n Neurologic: fentanyl prn for pain, not using\\n Cardiovascular: will restart home PO lopressor dose\\n Pulmonary: extubated without any difficulties, nasal cannula as needed\\n Gastrointestinal / Abdomen: off H2B\\n Nutrition: Regular diet\\n Renal: Foley, Adequate UO, Cr stable\\n Hematology: h/o anemia req transfusions. HCT borderline 20-21.\\n Asymptomatic. No CP/SOB/Abd pain/dizziness; transfuse one unit prbc\\n Endocrine: RISS; home synthroid dose\\n Infectious Disease: s/p submandibular abscess drainage, unasyn. f/u Cxs\\n sensitivities\\n Lines / Tubes / Drains: PIV, Foley\\n Wounds: wet to dry\\n Imaging: none\\n Fluids: KVO\\n Consults: ENT, P.T., OMFS\\n Billing Diagnosis: Respiratory Insufficiency post-op\\n ICU Care\\n Nutrition:\\n Comments: regular diet\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 01:36 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer:\\n VAP bundle:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition: floor\\n Total time spent: 32 minutes\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2137-12-01 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 651446,\n \"text\": \"SICU\\n HPI:\\n 84 yo F with 1 week of right neck swelling that has spread\\n toward right side of face. She has had right gum tenderness\\n around her right lower tooth (only lower right tooth left), and\\n has long history of odontogenic disease. Her PCP has treated her\\n with oral ciprofloxacin . She went to an OSH ED\\n today where CT with constrast of the neck showed fluid collection\\n in the submandibular space. She was treated with IV unasyn and\\n transferred to . She has trismus, but no respiratory\\n distress or desaturation or stridor. Her floor of mouth is\\n edematous espcially on the right side, but soft. Went for drainage of\\n abscess, left intubated because of concern for postop airway compromise\\n (swelling).\\n Chief complaint:\\n continued pharyngeal swelling\\n PMHx:\\n PMH:CHF, hypothyroidism, Colon Ca, GERD, COPD, PNA, Renal\\n failure, vascular disease, abdominal aortic aneurysm (pt informs\\n that last year it was ~4cm), iron deficiency anemia.\\n Current medications:\\n 1. 2. 20 mEq Potassium Chloride / 1000 mL D5NS 3. Acetaminophen 4.\\n Ampicillin-Sulbactam 5. Calcium Gluconate\\n 6. Famotidine 7. Fentanyl Citrate 8. Heparin 9. Influenza Virus Vaccine\\n 10. Insulin 11. Metoprolol Tartrate\\n 12. Pneumococcal Vac Polyvalent 13. Propofol 14. Sodium Chloride 0.9%\\n Flush\\n 24 Hour Events:\\n FEVER - 103.0\\nF - 12:00 AM\\n : admitted to SICU from OR s/p drainage, left intubated, to OR\\n tomorrow with Dr \\n .\\n Post operative day:\\n POD#0 - s/p extrtaction right infected tooth\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Ampicillin - 06:14 AM\\n Infusions:\\n Propofol - 40 mcg/Kg/min\\n Other ICU medications:\\n Heparin Sodium (Prophylaxis) - 01:00 PM\\n Fentanyl - 05:00 AM\\n Famotidine (Pepcid) - 07:53 AM\\n Other medications:\\n Flowsheet Data as of 10:18 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 39.4\\nC (103\\n T current: 37.1\\nC (98.8\\n HR: 82 (67 - 112) bpm\\n BP: 89/41(52) {87/39(52) - 150/69(88)} mmHg\\n RR: 15 (9 - 19) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 3,133 mL\\n 1,480 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 3,133 mL\\n 1,480 mL\\n Blood products:\\n Total out:\\n 2,125 mL\\n 495 mL\\n Urine:\\n 1,775 mL\\n 450 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 1,008 mL\\n 985 mL\\n Respiratory support\\n O2 Delivery Device: Endotracheal tube\\n Ventilator mode: Standby\\n Vt (Set): 500 (500 - 500) mL\\n RR (Set): 14\\n RR (Spontaneous): 0\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 63\\n PIP: 19 cmH2O\\n Plateau: 14 cmH2O\\n Compliance: 55.6 cmH2O/mL\\n SPO2: 100%\\n ABG: ///23/\\n Ve: 8 L/min\\n Physical Examination\\n General Appearance: No acute distress, Cachectic\\n HEENT: PERRL, EOMI\\n Cardiovascular: (Rhythm: Regular)\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\\n bilateral : )\\n Abdominal: Soft, Non-distended, Non-tender, No(t) Distended\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Skin: (Incision: Clean / Dry / Intact)\\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves\\n all extremities\\n Labs / Radiology\\n 92 K/uL\\n 6.9 g/dL\\n 123 mg/dL\\n 1.1 mg/dL\\n 23 mEq/L\\n 3.5 mEq/L\\n 15 mg/dL\\n 108 mEq/L\\n 138 mEq/L\\n 21.2 %\\n 7.9 K/uL\\n [image002.jpg]\\n 01:52 AM\\n 03:13 AM\\n 06:17 PM\\n 02:50 AM\\n 04:35 AM\\n WBC\\n 10.6\\n 7.2\\n 5.6\\n 7.9\\n Hct\\n 22.8\\n 25.0\\n 21.7\\n 21.2\\n Plt\\n 116\\n 118\\n 103\\n 92\\n Creatinine\\n 1.0\\n 1.0\\n 1.1\\n TCO2\\n 25\\n Glucose\\n 150\\n 85\\n 123\\n Other labs: PT / PTT / INR:15.9/27.1/1.4, Lactic Acid:1.0 mmol/L,\\n Ca:7.6 mg/dL, Mg:1.9 mg/dL, PO4:2.6 mg/dL\\n Assessment and Plan\\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\\n AIRWAY CLEARANCE, COUGH), .H/O PROBLEM - ENTER DESCRIPTION IN\\n COMMENTS\\n Assessment and Plan: 84 yo F with 1 week of right neck swelling that\\n has spread\\n toward right side of face. She has had right gum tenderness\\n around her right lower tooth (only lower right tooth left), and\\n has long history of odontogenic disease. Her PCP has treated her\\n with oral ciprofloxacin . She went to an OSH ED\\n today where CT with constrast of the neck showed fluid collection\\n in the submandibular space. She was treated with IV unasyn and\\n transferred to . She has trismus, but no respiratory\\n distress or desaturation or stridor. Her floor of mouth is\\n edematous espcially on the right side, but soft. Went for drainage of\\n abscess, left intubated because of concern for postop airway compromise\\n (swelling).\\n Neurologic: Neuro checks Q: 4 hr, sedation with propofol, fentanyl prn\\n for pain\\n Cardiovascular: hemodynamically stable, on home lopressor, will give IV\\n until extubated and taking po's. need to clarify dose with family/PCP\\n : (Ventilator mode: CPAP + PS)\\n Gastrointestinal / Abdomen: GI: NPO for now\\n Nutrition: NPO\\n Renal: Foley, Adequate UO, Will use colloid for additional\\n resuscitation.\\n Hematology: Serial Hct, Will continue to follow due to recent hct drop\\n without evidence of hemodilution\\n Endocrine: RISS\\n Infectious Disease: Check cultures\\n Lines / Tubes / Drains: Foley, ETT\\n Wounds: Dry dressings\\n Imaging: CXR today, to assess tracheal deviation or pneumomeds\\n Fluids: D5 1/2 NS\\n Consults: ENT\\n Billing Diagnosis: (Respiratory distress: Failure)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 01:36 AM\\n 20 Gauge - 01:37 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: PPI\\n VAP bundle:\\n Comments:\\n Communication: ICU consent signed Comments:\\n Code status: Full code\\n Disposition: ICU\\n Total time spent: 33 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2137-11-30 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 651187,\n \"text\": \"SICU\\n HPI:\\n 84 yo F with 1 week of right neck swelling that has spread toward right\\n side of face. She has had right gum tenderness around her right lower\\n tooth (only lower right tooth left), and has long history of\\n odontogenic disease. Her PCP has treated her with oral ciprofloxacin\\n . She went to an OSH ED today where CT with constrast of\\n the neck showed fluid collection in the submandibular space. She was\\n treated with IV unasyn and\\n transferred to . She has trismus, but no respiratory distress or\\n desaturation or stridor. Her floor of mouth is\\n edematous espcially on the right side, but soft. Went for drainage of\\n abscess, left intubated because of concern for postop airway compromise\\n (swelling).\\n Chief complaint:\\n submandibular abscess\\n PMHx:\\n CHF, hypothyroidism, Colon Ca, GERD, COPD, PNA, Renal failure, vascular\\n disease, abdominal aortic aneurysm (pt informs that last year it was\\n ~4cm), iron deficiency anemia\\n Current medications:\\n 1. 2. 20 mEq Potassium Chloride / 1000 mL D5NS 3. Ampicillin-Sulbactam\\n 4. Calcium Gluconate 5. Famotidine\\n 6. Fentanyl Citrate 7. Heparin 8. Influenza Virus Vaccine 9. Insulin\\n 10. Metoprolol Tartrate 11. Pneumococcal Vac Polyvalent\\n 12. Propofol 13. Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n INVASIVE VENTILATION - START 01:30 AM\\n pt arrived from OR intubated\\n - admitted to SICU\\n Post operative day:\\n POD #1\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Propofol - 50 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 04:09 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.4\\nC (97.5\\n T current: 36.4\\nC (97.5\\n HR: 92 (92 - 102) bpm\\n BP: 97/54(64) {97/54(64) - 142/82(97)} mmHg\\n RR: 19 (14 - 19) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 702 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 702 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 460 mL\\n Urine:\\n 110 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 242 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): 4\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 63\\n PIP: 21 cmH2O\\n Plateau: 15 cmH2O\\n SPO2: 100%\\n ABG: 7.41/38/488/23/0\\n Ve: 8.7 L/min\\n PaO2 / FiO2: 1,220\\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, open\\n wound in abd, covered in dry gauze\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: Sedated\\n Labs / Radiology\\n 116 K/uL\\n 7.3 g/dL\\n 150 mg/dL\\n 1.0 mg/dL\\n 23 mEq/L\\n 4.3 mEq/L\\n 16 mg/dL\\n 100 mEq/L\\n 131 mEq/L\\n 22.8 %\\n 10.6 K/uL\\n [image002.jpg]\\n 01:52 AM\\n 03:13 AM\\n WBC\\n 10.6\\n Hct\\n 22.8\\n Plt\\n 116\\n Creatinine\\n 1.0\\n TCO2\\n 25\\n Glucose\\n 150\\n Other labs: PT / PTT / INR:16.9/26.5/1.5, Lactic Acid:1.0 mmol/L,\\n Ca:7.7 mg/dL, Mg:1.8 mg/dL, PO4:5.0 mg/dL\\n Assessment and Plan\\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\\n AIRWAY CLEARANCE, COUGH), .H/O PROBLEM - ENTER DESCRIPTION IN\\n COMMENTS\\n Assessment and Plan: 84 yo F with submandibular abscess s/p drainage,\\n left intubated due to concern for airway compromise\\n Neurologic: sedation with propofol, fentanyl prn for pain\\n Cardiovascular: Beta-blocker, hemodynamically stable, on home\\n lopressor, will give IV until extubated and taking po's. need to\\n clarify dose with family/PCP\\n : Extubate today, (Ventilator mode: CPAP + PS),\\n intubated/sedated. wean from vent, extubate when possible.\\n Gastrointestinal / Abdomen: NPO for now; h/o colon CA, has open wound\\n in abd, will watch, cx if issues\\n Nutrition: NPO\\n Renal: Foley, Adequate UO, h/o renal failure, follow creat esp as pt\\n got contrast, currently stable. Na 131, will follow while on IVF\\n (change to D5NS)\\n Hematology: Hct 25.8 at OSH, now 22.8, no indications for transfusion\\n but will f/u Hct, has stable coagulopathy INR 1.5, will follow\\n Endocrine: RISS\\n Infectious Disease: submandibular abscess (likely from infected tooth)\\n - s/p drainage. on unasyn. OMFS consulted, will see pt after extubated,\\n ?take to OR for tooth extraction - want a new head CT\\n Lines / Tubes / Drains: Foley, ETT, PIV\\n Wounds: Dry dressings\\n Imaging: ?CT head soon per OMFS\\n Fluids: D5NS\\n Consults: ENT, OMFS\\n Billing Diagnosis: (Respiratory distress: Failure)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 01:36 AM\\n 20 Gauge - 01:37 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: 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\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2137-11-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651192,\n \"text\": \".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\\n Airway Clearance, Cough)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n .H/O Problem - Description In Comments\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2137-12-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651416,\n \"text\": \".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\\n Airway Clearance, Cough)\\n Assessment:\\n remains intubated for airway protection due to facial swelling.\\n Propofol between 40-60mcg/kg temp spike to 103 now 99, WBC and HCT\\n 21.7\\n Action:\\n propofol titrated to BP and intermittent doses of IV fentanyl given.\\n Tylenol given PR. IVfluids as ordered @80ml/hr\\n Response:\\n sedated on propofol and awake MAE wanting ETT out off propofol.\\n Plan:\\n to OR for teeth extraction , needs consent signed\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2137-12-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651417,\n \"text\": \".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\\n Airway Clearance, Cough)\\n Assessment:\\n remains intubated for airway protection due to facial swelling.\\n Propofol between 40-60mcg/kg temp spike to 103 now 99, WBC 7.9 and HCT\\n 21.7\\n Action:\\n propofol titrated to BP and intermittent doses of IV fentanyl given.\\n Tylenol given PR. IVfluids as ordered @80ml/hr\\n Response:\\n sedated on propofol and awake MAE wanting ETT out off propofol.\\n Plan:\\n to OR for teeth extraction , needs consent signed\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2137-11-30 00:00:00.000\",\n \"description\": \"Intensivist Note\",\n \"row_id\": 651273,\n \"text\": \"SICU\\n HPI:\\n 84 yo F with 1 week of right neck swelling that has spread toward right\\n side of face. She has had right gum tenderness around her right lower\\n tooth (only lower right tooth left), and has long history of\\n odontogenic disease. Her PCP has treated her with oral ciprofloxacin\\n . She went to an OSH ED today where CT with constrast of\\n the neck showed fluid collection in the submandibular space. She was\\n treated with IV unasyn and\\n transferred to . She has trismus, but no respiratory distress or\\n desaturation or stridor. Her floor of mouth is\\n edematous espcially on the right side, but soft. Went for drainage of\\n abscess, left intubated because of concern for postop airway compromise\\n (swelling).\\n Chief complaint:\\n submandibular abscess\\n PMHx:\\n CHF, hypothyroidism, Colon Ca, GERD, COPD, PNA, Renal failure, vascular\\n disease, abdominal aortic aneurysm (pt informs that last year it was\\n ~4cm), iron deficiency anemia\\n Current medications:\\n 1. 2. 20 mEq Potassium Chloride / 1000 mL D5NS 3. Ampicillin-Sulbactam\\n 4. Calcium Gluconate 5. Famotidine\\n 6. Fentanyl Citrate 7. Heparin 8. Influenza Virus Vaccine 9. Insulin\\n 10. Metoprolol Tartrate 11. Pneumococcal Vac Polyvalent\\n 12. Propofol 13. Sodium Chloride 0.9% Flush\\n 24 Hour Events:\\n INVASIVE VENTILATION - START 01:30 AM\\n pt arrived from OR intubated\\n - admitted to SICU\\n Post operative day:\\n POD #1\\n Allergies:\\n No Known Drug Allergies\\n Last dose of Antibiotics:\\n Infusions:\\n Propofol - 50 mcg/Kg/min\\n Other ICU medications:\\n Other medications:\\n Flowsheet Data as of 04:09 AM\\n Vital signs\\n Hemodynamic monitoring\\n Fluid balance\\n 24 hours\\n Since a.m.\\n Tmax: 36.4\\nC (97.5\\n T current: 36.4\\nC (97.5\\n HR: 92 (92 - 102) bpm\\n BP: 97/54(64) {97/54(64) - 142/82(97)} mmHg\\n RR: 19 (14 - 19) insp/min\\n SPO2: 100%\\n Heart rhythm: SR (Sinus Rhythm)\\n Total In:\\n 702 mL\\n PO:\\n Tube feeding:\\n IV Fluid:\\n 702 mL\\n Blood products:\\n Total out:\\n 0 mL\\n 460 mL\\n Urine:\\n 110 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n 242 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): 4\\n PEEP: 5 cmH2O\\n FiO2: 40%\\n RSBI: 63\\n PIP: 21 cmH2O\\n Plateau: 15 cmH2O\\n SPO2: 100%\\n ABG: 7.41/38/488/23/0\\n Ve: 8.7 L/min\\n PaO2 / FiO2: 1,220\\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, open\\n wound in abd, covered in dry gauze\\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\\n Neurologic: Sedated\\n Labs / Radiology\\n 116 K/uL\\n 7.3 g/dL\\n 150 mg/dL\\n 1.0 mg/dL\\n 23 mEq/L\\n 4.3 mEq/L\\n 16 mg/dL\\n 100 mEq/L\\n 131 mEq/L\\n 22.8 %\\n 10.6 K/uL\\n [image002.jpg]\\n 01:52 AM\\n 03:13 AM\\n WBC\\n 10.6\\n Hct\\n 22.8\\n Plt\\n 116\\n Creatinine\\n 1.0\\n TCO2\\n 25\\n Glucose\\n 150\\n Other labs: PT / PTT / INR:16.9/26.5/1.5, Lactic Acid:1.0 mmol/L,\\n Ca:7.7 mg/dL, Mg:1.8 mg/dL, PO4:5.0 mg/dL\\n Assessment and Plan\\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\\n AIRWAY CLEARANCE, COUGH), .H/O PROBLEM - ENTER DESCRIPTION IN\\n COMMENTS\\n Assessment and Plan: 84 yo F with submandibular abscess s/p drainage,\\n left intubated due to concern for airway compromise\\n Neurologic: cont propofol, fentanyl prn for pain. Dilaudid pca if\\n extubation.\\n Cardiovascular: Beta-blocker, hemodynamically stable, on home\\n lopressor, will give IV until extubated and taking po's. need to\\n clarify dose with family/PCP\\n : hold extubation until OMF/ ENT plan. (Ventilator mode: CPAP\\n + PS), intubated/sedated. wean from vent,\\n Gastrointestinal / Abdomen: NPO for now; h/o colon CA, has open wound\\n in abd, will watch, cx if issues\\n Nutrition: place dobhoff.\\n Renal: Foley, Adequate UO, h/o renal failure, follow creat esp as pt\\n got contrast, currently stable. Na 131, will follow while on IVF\\n (change to D5NS)\\n Hematology: Hct 25.8 at OSH, now 22.8, no indications for transfusion\\n but will f/u Hct, has stable coagulopathy INR 1.5, will follow\\n Endocrine: RISS\\n Infectious Disease: submandibular abscess (likely from infected tooth)\\n - s/p drainage. on unasyn. OMFS/ENT surgical plan pending prior to\\n extubation.\\n Lines / Tubes / Drains: Foley, ETT, PIV\\n Wounds: Dry dressings\\n Imaging: ?CT Neck per OMFS\\n Fluids: D5NS\\n Consults: ENT, OMFS\\n Billing Diagnosis: (Respiratory distress: Failure)\\n ICU Care\\n Nutrition:\\n Glycemic Control: Regular insulin sliding scale\\n Lines:\\n 18 Gauge - 01:36 AM\\n 20 Gauge - 01:37 AM\\n Prophylaxis:\\n DVT: Boots, SQ UF Heparin\\n Stress ulcer: H2 blocker\\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\\n Comments:\\n Communication: 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\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2137-11-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651199,\n \"text\": \"84 yo F with 1 week of right neck swelling that has spread toward right\\n side of face. She has had right gum tenderness around her right lower\\n tooth (only lower right tooth left), and has long history of\\n odontogenic disease. Her PCP has treated her with oral ciprofloxacin\\n starting . She went to an OSH ED today where CT with contrast of\\n the neck showed fluid collection in the submandibular space. She was\\n treated with IV unasyn and\\n transferred to . She has trismus, but no respiratory distress or\\n desaturation or stridor. Her floor of mouth is\\n edematous especially on the right side, but soft. Went for drainage of\\n abscess, left intubated because of concern for postop airway compromise\\n (swelling).\\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\\n Airway Clearance, Cough)\\n Assessment:\\n PT came from OR intubated, neck with swelling, tongue and mouth is\\n with swelling\\n Action:\\n Pt on vent AC mode, ABG WNL. Fio2 down to 40% after ABG.\\n Response:\\n LS clear, O2 sat 97-99%\\n Plan:\\n Wean extubate as tolerates\\n .H/O Problem - Description In Comments\\n Assessment:\\n Swelling neck rt side, s/p I & D in the OR.\\n Action:\\n Dressing intact & Dry, 2 pin rose drain per report from the OR\\n Response:\\n intact dressing.\\n Plan:\\n Cont monitoring, dressing change by ENT team.\\n .H/O Problem - Description In Comments\\n Assessment:\\n Open wound on the abd with very foul smelling dressing with greenish\\n drainage ( h/o colon cancer)\\n Action:\\n Dressing changed, wound looks pink, clean and dry\\n Response:\\n wound looks clean.\\n Plan:\\n Dressing , wound care nurse involvement\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2137-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651601,\n \"text\": \"Cellulitis\\n Assessment:\\n neck remains mildly swollen, erythema over left portion of incision\\n afebrile\\n Action:\\n penrose drains to gravity,\\n ampicillin a/o\\n normal saline nasal wash\\n Response:\\n cont to drain serosang from penrose drains\\n cellulits improving\\n able to raise secretions\\n Plan:\\n cont ampicillin a/o\\n penrose drains to gravity per ENT\\n follow low HCT\\nborderline per patient (takes procrit and iron at home)\\n await wound care recs for abd dressing\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2137-11-30 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 651181,\n \"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: OR\\n Reason: Elective\\n Tube Type\\n ETT:\\n Position: 19 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 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 Maintain PEEP at current level and reduce FiO2 as tolerated\\n Reason for continuing current ventilatory support: Sedated / Paralyzed;\\n Comments: Just arrived from OR\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2137-12-01 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 651406,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 2\\n Ideal body weight: 0 None\\n Ideal tidal volume: 0 / 0 / 0 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation:\\n Procedure location:\\n Reason:\\n Tube Type\\n ETT:\\n Position: cm at teeth\\n Route:\\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 / Scant\\n Comments/Plan\\n No changes made overnight, remains intubated and vent supported. Pt to\\n go to OR today, maintain vent support.\\n 06:12\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2137-11-30 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651324,\n \"text\": \"Inability to protect airway\\n Assessment:\\n Pt. is POD 1 s/p maxillofacial abcess I&D. Pt. remains intubated for\\n airway protection per ENT team. Right jaw is firm to hard. Site\\n remains wrapped in DSD with small amts serosang. output via penrose\\n drains. Pt. denies pain via nodding. VSS.\\n Action:\\n Pt. transported to CT this afternoon for maxillofacial CT. Vent weaned\\n to PSV this a.m. Pt. given fentanyl boluses for sedation and propofol\\n gtt titrated to and stable BP. Pt. cont\\ns on unasyn.\\n Response:\\n Airway patent. Cuff leak present. Pt. admitted to breathing\\n uncomfortably on PSV, placed back on CMV by RT. Slight decrease in\\n hardness of right jaw this eve.\\n Plan:\\n OFM specialists to remove abcessed tooth tomorrow. Then plan to\\n extubate.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2137-12-01 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651498,\n \"text\": \".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\\n Airway Clearance, Cough)\\n Assessment:\\n Pt intubated for OR at start of shift. Sent to OR for teeth extraction.\\n , pt stable on CPAP. LSCTA. +cough/gag. Able to lift head/neck\\n off bed. Neck incision site with sutures cdi and 2 patent penrose\\n drains (surrounding skin erythemous). Teeth extraction sites in\\n bilateral lower jaw with sutures cdi.\\n Action:\\n Extubated pt.\\n Response:\\n Pt successfully extubated. LSCTA. O2 sats >93% on room air.\\n Plan:\\n Continue to monitor respiratory status. d/c to floor.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2137-12-02 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 651552,\n \"text\": \"Cellulitis\\n Assessment:\\n neck remains mildly swollen\\n afebrile\\n Action:\\n penrose drains to gravity,\\n ampicillin a/o\\n normal saline nasal wash\\n Response:\\n cont to drain serosang from penrose drains\\n cellulits improving\\n able to raise secretions\\n Plan:\\n cont ampicllin a/o\\n penrose drains to gravity per ENT\\n follow low HCT\\nborderline per patient (takes procrit and iron at home)\\n await wound care recs for abd dressing\\n\"\n }\n]"}}},{"rowIdx":979,"cells":{"subject_id":{"kind":"number","value":2743,"string":"2,743"},"hadm_id":{"kind":"number","value":150517,"string":"150,517"},"target_text":{"kind":"string","value":"1. Hypotension: The patient presented to her primary care physician with hypotension, systolic blood pressure in the 80s in the Emergency Department. Sepsis protocol was initiated due to her blood pressure and her lactic acid. Her hypotension responded nicely to aggressive fluid repletion also to stress dosed steroids and continuation of her DDAVP for diabetes insipidus. By the time she arrived in the Intensive Care Unit her blood pressure was already stable and she was doing much better. This was felt likely to be a combination of prerenal volume depletion perhaps in the setting of urosepsis from her urinary tract infection. The patient was stable after essentially 48 hours to be transferred to the floor at which point her blood pressure was no longer an issue. 2. Urinary tract infection: The patient had a positive urinalysis on admission and was started on Ceftriaxone, Flagyl. Her urine culture grew back a pan sensitive Klebsiella pneumonia urinary tract infection. The patient's Flagyl was discontinued and she was continued on a Ceftriaxone for this urinary tract infection. She completed a seven day course of Ceftriaxone and at the time of discharge was afebrile and had no white blood cell count. 3. Hypernatremia: The patient presented with a sodium of 151. She was likely hypernatremic due to her diabetes insipidus and inability to replete free water on her own due to the vomiting she had been experiencing prior to admission. In the Emergency Department she had also received normal saline, but was of course urinating out dilute free water, thus increasing her sodium. Initial treatment was of her volume with normal saline intravenous fluids. Her hypernatremia was treated with D5, her estimated free water deficit was 3 liters. D5 was then changed over to D5 half normal saline. Her DDAVP was also restarted. With the DDAVP given every day her sodium was as low as 134. In the end the DDAVP was titrated to once per day and she was also continued on her Lasix during this time. The feeling was that with the DDAVP the patient now having access to free water and standing Lasix that she would be able to maintain normal sodium. 4. Renal: The patient presented with an elevated creatinine. This was felt due to dehydration of a prerenal nature. It corrected from a high of 1.6 down to her baseline of 1.1. She also had a metabolic acidosis on admission, which was likely again due to vomiting and maybe wit a little bit of lacticacidosis from decreased perfusion in the setting of her dehydration. This also corrected once she was fluid repleted. 5. Chest pain: The patient did complain of some chest pain on admission, which resolved spontaneously. She had no new electrocardiogram changes and had a PMIBI back in that was unremarkable and showed an EF of 60%. She was continued on her aspirin and enzymes were cycled and she ruled out for an myocardial infarction. Her beta-blocker was restarted as tolerated. 6. Neurosarcoid: The patient was continue stress dosed steroids and at discharge had been tapered down to Prednisone 20 mg per day. 7. Panhypopituitarism: The patient was maintained on her Levothyroxine. 8. Diabetes type 2: The patient's Metformin was held for borderline creatinine and in the context of her acute illness she was maintained on regular insulin sliding scale. 9. Hematology: The patient's hematocrit decreased from admission of 40 to 29 at discharge. Much of this was felt due to fluid repletion though workup of her baseline anemia would be warranted."},"extractive_notes_summ":{"kind":"string","value":"Iv fluid cont at kvo with am na pending.Resp- Lungs clear. EKG FROM EPISODE NOTED ABOVE UNCHANGED WITH TWAVE INVERSIONS. MORE INTERACTIVE THIS MORNING.CARDIAC: ARRIVED TACHY 100'S AND RANGE 99-118 SR/ST WITH NO ECTOPY. The appendix is nondilated nda filled with contrast. ON CEFTRIAXONE FOR UTI.SKIN: SMALL ABRASION TO UPPER BACK.ACCESS: RIJ PRESEP CATH. EKG DONE AND SX'S RESOLVED SPONTANEOUSLY WITHOUT INTERVENTION. Uo minimal 5-10cc q2hrs. Since the previous tracing of sinus tachycardia and further ST-T wave changes are present. The pulmonary vasculature is within normal limits. The rectum is within normal limits. There is interval placement of a right IJ central venous line, with the tip terminating in the right atrium. Contrast reaches the distal colon indicating no evidence of obstruction. DENIES SOB.GI/GU: ABD OBESE, SOFT WITH +BS. Given 40meq kcl iv and 22meq with k-phos. CK WAS FLAT. OCCASIOANL DRY NONPRODUCTIVE COUGH. D/C sepsis protocol. to take po meds without difficulty. + CONTINUES TO BE AN ISSUE 151, STARTED ON D5W @100CC/HR BUT AM NA+ 157. AM FS 258 GIVEN 6UNITS REGULAR.ID: TMAX 98.4 WBC 8.9 NOW 11.6. The cardiomediastinal and hilar contours are stable. An atrophic, postmenopausal uterus and adnexa are unremarkable. BP 126-163/64-82. Sats 99-100% on ra. TOOK MEDS WITHOUT DIFFICULTY. SVO2 CATH IN WITH #'S 66-75. IMPRESSION: No cause for the patient's abdominal pain identified. NO COMPLAINTS OF NAUSEA. HCT STABLE @34.RESP: NO CURRENT ISSUES. CRE IMPROVING NOW 1.1. CT OF THE ABDOMEN WITH CONTRAST: The visualized portions of the lung bases are clear. REASON FOR THIS EXAMINATION: r/o abscess. STARTED ON 12.5MG LOPRESSOR THIS AM. There are several small aortocaval lymph nodes, none of which are pathologic in size. There is no interval change in the position of a left central venous line with the tip in the lower SVC. C/O OF SSCP. NPNNeuro: Pt is alert, talkative, OOB to chair, able to do her ADLs.CV: VSS, conts on lopressor, Mg of 1.6 was replaced with 3 gms.Resp: LS clear, 02 SATs in the high 90s on RAGI: States that she did have abd pain last night but none today. The liver is normal in contour and attenuation with no evidence for hepatic mass or biliary ductal dilitation. LSC ON RA WITH RR 12-21 AND SATS 98-100%. The gallbladder, pancreas, spleen, adrenal glands, and kidneys are normal in appearance. SMICU nsg progress note Pt alert and orientedx3 verbalizing without problem. Left ventricular hypertrophy with ST-T wave changes.Clinical correlation is suggested. There are bilateral low lung volumes. MD CAME TO EXAMINE AND PT. Tall inferior P waves - possible rightatrial abnormality. Evaluate for intrabdominal abscess. Sinus tachycardia. Stating she feels much better. No change. Also noted is a left subclavian central line, with the tip terminating at the junction of the distal SVC and the right atrium. She conts on her IV abx. IMPRESSION: No evidence of heart failure or pneumonia. The lungs are clear and there are no pleural effusions or pneumothoraces. U/O 330-650CC/HR DI. If she does have a BM the team would like it to be sent for cdif.GU: Her u/o decreased to <10cc/hr, she was given her DDAVP this morning, she was started on NS at 125/hr x 1000cc. Taking po's without difficulty.Endocrine- Fs 98-153 on varing doses insulin gtt (see care-vuePlan- Cont to follow lytes. PORTABLE AP CHEST: The study is notable for low lung volumes. Sleeping off and on thoughout night.Cardiac- Bp and hr stable. She was given DDAVP nasaly and her u/o has decresaed significantly through the day and is now 40cc/hr. No contraindications for IV contrast FINAL REPORT INDICATION: A 54-year-old female with sarcoid, fever, and abdominal pain. REFORMATTED IMAGING: Images reformatted in the coronal plane were essential in evaluating the patient's right lower quadrant and large and small bowel and demonstrate no abnormal dilatation or wall thickening. URINE IS CLEAR. IMPRESSION: The distal tip of the right IJ central venous line is in the right atrium and could be pulled back 5 cm for optimal positioning. Baseline artifact. Pt c/o being hungery. There are several subcentimeter low attenuation lesions within the right kidney which are too small to characterize but likely represent simple renal cysts. INITIAL CVP ~9, RECEIVED 500CC FB WITH CVP ^. BLOOD CX'S PENDING. Nonionic contrast was used due to patient renal dysfunction. Na this am at 11 was 148, gluc 521, she was stated on an insulin gtt and it is down to the 200 range.CV: She was hypertensive today to the 170s-180s, it has decreased to the 150s, HR 80s, her lopressor was increased to 25mg . LINE WAS PULLED BACK 5CM BY MD. REASON FOR THIS EXAMINATION: r/o PNA FINAL REPORT INDICATION: Fever. MOVNG ALL EXTREMITIES. LSC PORTACATH.SOCIAL/DISPO: FULL CODE. There is no focal consolidation or pleural effusion. ?transfer to floor in am. Repeat k pending. 11:19 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 100CC NON IONIC CONTRAST; CT RECONSTRUCTION Reason: FEVER,ABDOMEN PAIN,SARCOID.R/O ABSCESS Admitting Diagnosis: ABDOMINAL PAIN;FEVER Field of view: 48 Contrast: VISAPAQUE Amt: 100 MEDICAL CONDITION: 54 year old woman with sarcoid, fever and abd pain. By noon time she was very sommulent though she she could be aroused and was oriented when she could stay awake long enough to answer the questions. Asking freq for water. K back at 2.8."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2128-02-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":814183,"text":" 6:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p RIJ\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with HX OF SARCOIDOSIS with fever.\n\n REASON FOR THIS EXAMINATION:\n s/p RIJ\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sarcoidosis with fever.\n\n CHEST AP PORTABLE: Comparison is made to the prior study obtained two hours\n earlier. There are bilateral low lung volumes. There is interval placement\n of a right IJ central venous line, with the tip terminating in the right\n atrium. There is no evidence of pneumothorax. Also noted is a left\n subclavian central line, with the tip terminating at the junction of the\n distal SVC and the right atrium. There is no focal consolidation or pleural\n effusion.\n\n IMPRESSION: The distal tip of the right IJ central venous line is in the\n right atrium and could be pulled back 5 cm for optimal positioning.\n\n\n"},{"category":"Radiology","chartdate":"2128-02-04 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":814194,"text":" 11:19 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST; CT RECONSTRUCTION\n Reason: FEVER,ABDOMEN PAIN,SARCOID.R/O ABSCESS\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n Field of view: 48 Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with sarcoid, fever and abd pain. Cr. 1.6.\n REASON FOR THIS EXAMINATION:\n r/o abscess.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 54-year-old female with sarcoid, fever, and abdominal pain.\n Evaluate for intrabdominal abscess.\n\n TECHNIQUE: CT imaging of the abdomen and pelvis after the intravenous\n administration of 100 cc of Isopaque. Nonionic contrast was used due to\n patient renal dysfunction.\n\n CT OF THE ABDOMEN WITH CONTRAST: The visualized portions of the lung bases are\n clear. The liver is normal in contour and attenuation with no evidence for\n hepatic mass or biliary ductal dilitation. The gallbladder, pancreas, spleen,\n adrenal glands, and kidneys are normal in appearance. There are several\n subcentimeter low attenuation lesions within the right kidney which are too\n small to characterize but likely represent simple renal cysts. There is no\n evidence of renal mass, stone, or hydronephrosis. There are several small\n aortocaval lymph nodes, none of which are pathologic in size. There is no\n evidence of mesenteric lymphadenopathy. No free fluid or free air is\n identified within the abdomen or pelvis.\n\n CT OF THE PELVIS WITH CONTRAST: The urinary bladder is collapsed with a Foley\n catheter in place. An atrophic, postmenopausal uterus and adnexa are\n unremarkable. The rectum is within normal limits. There is no evidence of\n , thickening, or abdnormal dilitation within large or small\n bowel. Contrast reaches the distal colon indicating no evidence of\n obstruction. The appendix is nondilated nda filled with contrast. There is\n degenerative change within the lumbar spine.\n\n REFORMATTED IMAGING: Images reformatted in the coronal plane were essential in\n evaluating the patient's right lower quadrant and large and small bowel and\n demonstrate no abnormal dilatation or wall thickening.\n\n IMPRESSION: No cause for the patient's abdominal pain identified.\n\n\n"},{"category":"Radiology","chartdate":"2128-02-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":814177,"text":" 4:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with HX OF SARCOIDOSIS with fever.\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever.\n\n COMPARISON: .\n\n PORTABLE AP CHEST: The study is notable for low lung volumes. The\n cardiomediastinal and hilar contours are stable. The lungs are clear and\n there are no pleural effusions or pneumothoraces. There is no evidence of\n mediastinal lymph adenopathy. The pulmonary vasculature is within normal\n limits. There is no interval change in the position of a left central venous\n line with the tip in the lower SVC.\n\n IMPRESSION: No evidence of heart failure or pneumonia. No change.\n\n"},{"category":"ECG","chartdate":"2128-02-04 00:00:00.000","description":"Report","row_id":111988,"text":"Baseline artifact. Sinus tachycardia. Tall inferior P waves - possible right\natrial abnormality. Left ventricular hypertrophy with ST-T wave changes.\nClinical correlation is suggested. Since the previous tracing of \nsinus tachycardia and further ST-T wave changes are present.\n\n"},{"category":"Nursing/other","chartdate":"2128-02-05 00:00:00.000","description":"Report","row_id":1297833,"text":"NPN\n\nNeuro: She was a little difficult to arouse this morning, she was oriented and able to follow commands, asking for food to eat and something to drink. By noon time she was very sommulent though she she could be aroused and was oriented when she could stay awake long enough to answer the questions. She is easier to wake this afternoon but quickly falls back to sleep and states that she is tired. PERL, conts to be oriented. Na this am at 11 was 148, gluc 521, she was stated on an insulin gtt and it is down to the 200 range.\n\nCV: She was hypertensive today to the 170s-180s, it has decreased to the 150s, HR 80s, her lopressor was increased to 25mg . Her CVP is ~ 10.\n\nResp: LS clear, 02 SAT high 90s on RA, her conts SV02 has been 77-84.\n\nGI: Sm amount of stool, she c/o abd pain with palpation but also states that she is hungry; she ate toast and juice for breakfast and then had water.\n\nGU: She was having a brisk diuresis this morning ~ 650cc/hr at a high. She was given DDAVP nasaly and her u/o has decresaed significantly through the day and is now 40cc/hr. She was initially being given D5W at a rate equal to her u/o plus 100cc, this has since been changed to KVO.\n\nEndo: Her BS was 521 at noon, she was started on an insulin gtt, given a 10 unit bolus initially and had a max rate on 9 units/hr - she is presently at 5 units/hr.\n\n\n"},{"category":"Nursing/other","chartdate":"2128-02-06 00:00:00.000","description":"Report","row_id":1297834,"text":"SMICU nsg progress note\n Pt alert and orientedx3 verbalizing without problem. to take po meds without difficulty. Stating she feels much better. Sleeping off and on thoughout night.\nCardiac- Bp and hr stable. Uo minimal 5-10cc q2hrs. K back at 2.8. Given 40meq kcl iv and 22meq with k-phos. Repeat k pending. Iv fluid cont at kvo with am na pending.\nResp- Lungs clear. Sats 99-100% on ra.\n Pt c/o being hungery. Asking freq for water. Taking po's without difficulty.\nEndocrine- Fs 98-153 on varing doses insulin gtt (see care-vue\nPlan- Cont to follow lytes. D/C sepsis protocol. ?transfer to floor in am.\n\n"},{"category":"Nursing/other","chartdate":"2128-02-06 00:00:00.000","description":"Report","row_id":1297835,"text":"NPN\n\nNeuro: Pt is alert, talkative, OOB to chair, able to do her ADLs.\n\nCV: VSS, conts on lopressor, Mg of 1.6 was replaced with 3 gms.\n\nResp: LS clear, 02 SATs in the high 90s on RA\n\nGI: States that she did have abd pain last night but none today. She ate breakfast and lunch; good appitite. If she does have a BM the team would like it to be sent for cdif.\n\nGU: Her u/o decreased to <10cc/hr, she was given her DDAVP this morning, she was started on NS at 125/hr x 1000cc. Her u/o has increased this afternoon to ~ 20-30cc/hr. She has been drinking water in lg quantities today.\n\nEndo: Her insulin gtt was d/ced and she is now on SS insulin, no plans to start her glucophage at present due to her elevated amylase and elevated creat.\n\nID: T 96, her WBC was 20 this morning - this has been atributed to her high does of steroids. She conts on her IV abx.\n"},{"category":"Nursing/other","chartdate":"2128-02-05 00:00:00.000","description":"Report","row_id":1297832,"text":"MICU NPN 7P-7A\nRECEIVED VIA AMBULANCE FROM ED @0130.\n\nNEURO: PATIENT ALERT AND ORIENTED X3. FOLLOWING COMMANDS AND ANSWERING QUESTIONS APPROPIATELY. MOVNG ALL EXTREMITIES. INITIALLY C/O BACK PAIN WHICH SHE STATED WAS FROM PAST SHINGLES EXPOSURE AND NECK PAIN FROM CENTRAL LINE. MD CAME TO EXAMINE AND PT. TEARY AND SLIGHTLY ANXIOUS. C/O OF SSCP. EKG DONE AND SX'S RESOLVED SPONTANEOUSLY WITHOUT INTERVENTION. AFTER INITIAL ASSESSMENT PATIENT SLEEPING SOUNDLY BUT AROUSED EASILY TO VOICE/STIMULI BUT WOULD FALL BACK ASLEEP IN MID SENTENCE. MORE INTERACTIVE THIS MORNING.\n\nCARDIAC: ARRIVED TACHY 100'S AND RANGE 99-118 SR/ST WITH NO ECTOPY. STARTED ON 12.5MG LOPRESSOR THIS AM. BP 126-163/64-82. INITIAL CVP ~9, RECEIVED 500CC FB WITH CVP ^. SVO2 CATH IN WITH #'S 66-75. LINE WAS PULLED BACK 5CM BY MD. + CONTINUES TO BE AN ISSUE 151, STARTED ON D5W @100CC/HR BUT AM NA+ 157. MD AWARE AND WILL INCREASE IVF TO 250CC/HR. CHLORIDE ALSO INCREASING. CK WAS FLAT. EKG FROM EPISODE NOTED ABOVE UNCHANGED WITH TWAVE INVERSIONS. PEDAL PULSES PRESENT. HCT STABLE @34.\n\nRESP: NO CURRENT ISSUES. LSC ON RA WITH RR 12-21 AND SATS 98-100%. OCCASIOANL DRY NONPRODUCTIVE COUGH. DENIES SOB.\n\nGI/GU: ABD OBESE, SOFT WITH +BS. NPO. NO COMPLAINTS OF NAUSEA. TOOK MEDS WITHOUT DIFFICULTY. NO STOOL. U/O 330-650CC/HR DI. CRE IMPROVING NOW 1.1. URINE IS CLEAR. AM FS 258 GIVEN 6UNITS REGULAR.\n\nID: TMAX 98.4 WBC 8.9 NOW 11.6. BLOOD CX'S PENDING. ON CEFTRIAXONE FOR UTI.\n\nSKIN: SMALL ABRASION TO UPPER BACK.\n\nACCESS: RIJ PRESEP CATH. LSC PORTACATH.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-02-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 814183,\n \"text\": \" 6:23 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p RIJ\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old woman with HX OF SARCOIDOSIS with fever.\\n\\n REASON FOR THIS EXAMINATION:\\n s/p RIJ\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Sarcoidosis with fever.\\n\\n CHEST AP PORTABLE: Comparison is made to the prior study obtained two hours\\n earlier. There are bilateral low lung volumes. There is interval placement\\n of a right IJ central venous line, with the tip terminating in the right\\n atrium. There is no evidence of pneumothorax. Also noted is a left\\n subclavian central line, with the tip terminating at the junction of the\\n distal SVC and the right atrium. There is no focal consolidation or pleural\\n effusion.\\n\\n IMPRESSION: The distal tip of the right IJ central venous line is in the\\n right atrium and could be pulled back 5 cm for optimal positioning.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-02-04 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 814194,\n \"text\": \" 11:19 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 100CC NON IONIC CONTRAST; CT RECONSTRUCTION\\n Reason: FEVER,ABDOMEN PAIN,SARCOID.R/O ABSCESS\\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\\n Field of view: 48 Contrast: VISAPAQUE Amt: 100\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old woman with sarcoid, fever and abd pain. Cr. 1.6.\\n REASON FOR THIS EXAMINATION:\\n r/o abscess.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: A 54-year-old female with sarcoid, fever, and abdominal pain.\\n Evaluate for intrabdominal abscess.\\n\\n TECHNIQUE: CT imaging of the abdomen and pelvis after the intravenous\\n administration of 100 cc of Isopaque. Nonionic contrast was used due to\\n patient renal dysfunction.\\n\\n CT OF THE ABDOMEN WITH CONTRAST: The visualized portions of the lung bases are\\n clear. The liver is normal in contour and attenuation with no evidence for\\n hepatic mass or biliary ductal dilitation. The gallbladder, pancreas, spleen,\\n adrenal glands, and kidneys are normal in appearance. There are several\\n subcentimeter low attenuation lesions within the right kidney which are too\\n small to characterize but likely represent simple renal cysts. There is no\\n evidence of renal mass, stone, or hydronephrosis. There are several small\\n aortocaval lymph nodes, none of which are pathologic in size. There is no\\n evidence of mesenteric lymphadenopathy. No free fluid or free air is\\n identified within the abdomen or pelvis.\\n\\n CT OF THE PELVIS WITH CONTRAST: The urinary bladder is collapsed with a Foley\\n catheter in place. An atrophic, postmenopausal uterus and adnexa are\\n unremarkable. The rectum is within normal limits. There is no evidence of\\n , thickening, or abdnormal dilitation within large or small\\n bowel. Contrast reaches the distal colon indicating no evidence of\\n obstruction. The appendix is nondilated nda filled with contrast. There is\\n degenerative change within the lumbar spine.\\n\\n REFORMATTED IMAGING: Images reformatted in the coronal plane were essential in\\n evaluating the patient's right lower quadrant and large and small bowel and\\n demonstrate no abnormal dilatation or wall thickening.\\n\\n IMPRESSION: No cause for the patient's abdominal pain identified.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2128-02-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 814177,\n \"text\": \" 4:34 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o PNA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old woman with HX OF SARCOIDOSIS with fever.\\n REASON FOR THIS EXAMINATION:\\n r/o PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Fever.\\n\\n COMPARISON: .\\n\\n PORTABLE AP CHEST: The study is notable for low lung volumes. The\\n cardiomediastinal and hilar contours are stable. The lungs are clear and\\n there are no pleural effusions or pneumothoraces. There is no evidence of\\n mediastinal lymph adenopathy. The pulmonary vasculature is within normal\\n limits. There is no interval change in the position of a left central venous\\n line with the tip in the lower SVC.\\n\\n IMPRESSION: No evidence of heart failure or pneumonia. No change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2128-02-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 111988,\n \"text\": \"Baseline artifact. Sinus tachycardia. Tall inferior P waves - possible right\\natrial abnormality. Left ventricular hypertrophy with ST-T wave changes.\\nClinical correlation is suggested. Since the previous tracing of \\nsinus tachycardia and further ST-T wave changes are present.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-02-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1297833,\n \"text\": \"NPN\\n\\nNeuro: She was a little difficult to arouse this morning, she was oriented and able to follow commands, asking for food to eat and something to drink. By noon time she was very sommulent though she she could be aroused and was oriented when she could stay awake long enough to answer the questions. She is easier to wake this afternoon but quickly falls back to sleep and states that she is tired. PERL, conts to be oriented. Na this am at 11 was 148, gluc 521, she was stated on an insulin gtt and it is down to the 200 range.\\n\\nCV: She was hypertensive today to the 170s-180s, it has decreased to the 150s, HR 80s, her lopressor was increased to 25mg . Her CVP is ~ 10.\\n\\nResp: LS clear, 02 SAT high 90s on RA, her conts SV02 has been 77-84.\\n\\nGI: Sm amount of stool, she c/o abd pain with palpation but also states that she is hungry; she ate toast and juice for breakfast and then had water.\\n\\nGU: She was having a brisk diuresis this morning ~ 650cc/hr at a high. She was given DDAVP nasaly and her u/o has decresaed significantly through the day and is now 40cc/hr. She was initially being given D5W at a rate equal to her u/o plus 100cc, this has since been changed to KVO.\\n\\nEndo: Her BS was 521 at noon, she was started on an insulin gtt, given a 10 unit bolus initially and had a max rate on 9 units/hr - she is presently at 5 units/hr.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-02-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1297834,\n \"text\": \"SMICU nsg progress note\\n Pt alert and orientedx3 verbalizing without problem. to take po meds without difficulty. Stating she feels much better. Sleeping off and on thoughout night.\\nCardiac- Bp and hr stable. Uo minimal 5-10cc q2hrs. K back at 2.8. Given 40meq kcl iv and 22meq with k-phos. Repeat k pending. Iv fluid cont at kvo with am na pending.\\nResp- Lungs clear. Sats 99-100% on ra.\\n Pt c/o being hungery. Asking freq for water. Taking po's without difficulty.\\nEndocrine- Fs 98-153 on varing doses insulin gtt (see care-vue\\nPlan- Cont to follow lytes. D/C sepsis protocol. ?transfer to floor in am.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-02-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1297835,\n \"text\": \"NPN\\n\\nNeuro: Pt is alert, talkative, OOB to chair, able to do her ADLs.\\n\\nCV: VSS, conts on lopressor, Mg of 1.6 was replaced with 3 gms.\\n\\nResp: LS clear, 02 SATs in the high 90s on RA\\n\\nGI: States that she did have abd pain last night but none today. She ate breakfast and lunch; good appitite. If she does have a BM the team would like it to be sent for cdif.\\n\\nGU: Her u/o decreased to <10cc/hr, she was given her DDAVP this morning, she was started on NS at 125/hr x 1000cc. Her u/o has increased this afternoon to ~ 20-30cc/hr. She has been drinking water in lg quantities today.\\n\\nEndo: Her insulin gtt was d/ced and she is now on SS insulin, no plans to start her glucophage at present due to her elevated amylase and elevated creat.\\n\\nID: T 96, her WBC was 20 this morning - this has been atributed to her high does of steroids. She conts on her IV abx.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2128-02-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1297832,\n \"text\": \"MICU NPN 7P-7A\\nRECEIVED VIA AMBULANCE FROM ED @0130.\\n\\nNEURO: PATIENT ALERT AND ORIENTED X3. FOLLOWING COMMANDS AND ANSWERING QUESTIONS APPROPIATELY. MOVNG ALL EXTREMITIES. INITIALLY C/O BACK PAIN WHICH SHE STATED WAS FROM PAST SHINGLES EXPOSURE AND NECK PAIN FROM CENTRAL LINE. MD CAME TO EXAMINE AND PT. TEARY AND SLIGHTLY ANXIOUS. C/O OF SSCP. EKG DONE AND SX'S RESOLVED SPONTANEOUSLY WITHOUT INTERVENTION. AFTER INITIAL ASSESSMENT PATIENT SLEEPING SOUNDLY BUT AROUSED EASILY TO VOICE/STIMULI BUT WOULD FALL BACK ASLEEP IN MID SENTENCE. MORE INTERACTIVE THIS MORNING.\\n\\nCARDIAC: ARRIVED TACHY 100'S AND RANGE 99-118 SR/ST WITH NO ECTOPY. STARTED ON 12.5MG LOPRESSOR THIS AM. BP 126-163/64-82. INITIAL CVP ~9, RECEIVED 500CC FB WITH CVP ^. SVO2 CATH IN WITH #'S 66-75. LINE WAS PULLED BACK 5CM BY MD. + CONTINUES TO BE AN ISSUE 151, STARTED ON D5W @100CC/HR BUT AM NA+ 157. MD AWARE AND WILL INCREASE IVF TO 250CC/HR. CHLORIDE ALSO INCREASING. CK WAS FLAT. EKG FROM EPISODE NOTED ABOVE UNCHANGED WITH TWAVE INVERSIONS. PEDAL PULSES PRESENT. HCT STABLE @34.\\n\\nRESP: NO CURRENT ISSUES. LSC ON RA WITH RR 12-21 AND SATS 98-100%. OCCASIOANL DRY NONPRODUCTIVE COUGH. DENIES SOB.\\n\\nGI/GU: ABD OBESE, SOFT WITH +BS. NPO. NO COMPLAINTS OF NAUSEA. TOOK MEDS WITHOUT DIFFICULTY. NO STOOL. U/O 330-650CC/HR DI. CRE IMPROVING NOW 1.1. URINE IS CLEAR. AM FS 258 GIVEN 6UNITS REGULAR.\\n\\nID: TMAX 98.4 WBC 8.9 NOW 11.6. BLOOD CX'S PENDING. ON CEFTRIAXONE FOR UTI.\\n\\nSKIN: SMALL ABRASION TO UPPER BACK.\\n\\nACCESS: RIJ PRESEP CATH. LSC PORTACATH.\\n\\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY.\\n\"\n }\n]"}}},{"rowIdx":980,"cells":{"subject_id":{"kind":"number","value":76134,"string":"76,134"},"hadm_id":{"kind":"number","value":199200,"string":"199,200"},"target_text":{"kind":"string","value":"40 year old Caucasian male with a past medical history of morbid obesity, steroid dependent psoriatic arthritis, insulin dependent type II diabetes mellitus, obstructive sleep apnea on CPAP and multiple recent admissions for a left lower extremity wound/cellulitis s/p wound VAC presenting from a rehabilitation facility with episodes of shortness of breath, hypoxemia and palpitations. #HYPOXEMIA: Mr. hospital course was most notable for normal oxygen saturations during the vast majority of his hospitalization. There was significant concern regarding the accuracy of the pulse ox because of the patient's dactylitis, and significant interstitial edema. His intermittent episodes of hypoxemia were initially concerning for expanding or new pulmonary emboli due to their acute onset, association with tachycardia and reports of pre-syncopal symptoms. The patient had also been subtherapeutic on warfarin prior to admission. The pulmonary service was consulted and felt that pulmonary emboli were unlikely the cause of the hypoxemic episodes given their sub-occlusive nature and stable appearance on CT. Flash pulmonary edema was considered because of the patient's report of a 28 lb weight gain prior to admission, association of the episodes with ambulation/tahcycardia and non-specific CT scan findings potentially consistent with edema. The patient was diuresed, with IV and PO furosemide, from an admission weight of 386 lbs to 366 lbs at discharge. Fluids and sodium were restricted. No direct association between diuresis and the episdoes of hypoxemia was noted; however the patient did not experience additional episodes of hypoxemia during the last 12 days of his admission when he was closer to his dry weight. The patient had a poor quality, but nevertheless essentially normal echocardiogram and no definitive evidence of pulmonary edema on any chest imaging. The patient's severe sleep apnea likely contributed to several episodes of hypoxemia. He was placed on CPAP at night with occasional supplemental O2. During the day shift however he was noted to fall asleep occasionally without the CPAP in place."},"extractive_notes_summ":{"kind":"string","value":"Otherwise, withinnormal limits and no longer having frequent ventricular ectopic beats intrigeminy and quadrigeminy compared to previous tracing of .TRACING #1 Sinus rhythm with one ventricular premature beat seen. Sinus rhythm with occasional ventricular premature beats. Sinus rhythm with monomorphic ventricular premature beats. Ventricular premature beats have normal axis andleft bundle-branch block morphology. Indeterminate PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Since the previous tracing ventricularpremature beat is no longer seen. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Tricuspid valve not well visualized. Since the previous tracing of the ventricular premature beats have the same morphology, ventricular prematurebeat couplet is no longer seen. Right ventricular function. Normal biventricular cavity sizes withpreserved global biventricular systolic function.Compared with the prior study (images reviewed) of , the findings aresimilar. Frequent unifocal ventricular premature beats in eithera bigeminal or a trigeminal pattern. Diffuse non-specificST-T wave abnormalities. Compared to the previous tracing frequent ventricularectopy is present. Conducted complexesof borderline low voltage. The mitral valveappears structurally normal with trivial mitral regurgitation. Sinus rhythm and frequent ventricular ectopy. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded.RIGHT VENTRICLE: Normal RV chamber size.AORTA: Normal aortic diameter at the sinus level. Right ventricular chamber size isgrossly normal with good free wall motion (only seen in parasternal long axisorientation). Low precordial lead voltage.Compared to the previous tracing of the rate has slowed. Sinus rhythm. Sinus rhythm. Sinus rhythm with frequent unifocal ventricular ectopy. Compared to theprevious tracing of no change except for the single premature beat.TRACING #1 Otherwise, nodiagnostic interim change. Normal ascending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets (?#). Premature ventricular contractions aremore frequent compared to early tracing of . Sinus tachycardia. Otherwise, no significantchange.TRACING #2 Borderline low voltage. The aortic valve leaflets (?#) appear structurally normal withgood leaflet excursion. Pulmonary embolus.Height: (in) 73Weight (lb): 400BSA (m2): 2.89 m2BP (mm Hg): 126/89HR (bpm): 60Status: InpatientDate/Time: at 10:31Test: TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolicfunction (LVEF>55%). Due to suboptimal technical quality, a focal wall motionabnormality cannot be fully excluded. There is an anterior spacewhich most likely represents a prominent fat pad.IMPRESSION: Suboptimal image quality. Pulmonary hypertension. Compared to tracing #1 nosignificant change except for a faster rate.TRACING #2 The pulmonaryartery systolic pressure could not be determined. Otherwise, normal tracing. Congestive heart failure. Sinus tachycardia with frequent monomorphic ventricular premature beats.Compared to the previous tracing of the rate is increased. PATIENT/TEST INFORMATION:Indication: Left ventricular function. The prior study was also technically suboptimal. Clinical correlation is suggested.TRACING #1 Clinical correlation is suggested.TRACING #2 Otherfindings are similar. Suboptimalimage quality - body habitus.Conclusions:Left ventricular wall thickness, cavity size, and global systolic function arenormal (LVEF>55%). The other findings are similar."},"n_notes":{"kind":"number","value":10,"string":"10"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2204-09-18 00:00:00.000","description":"Report","row_id":70233,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulmonary hypertension. Right ventricular function. Congestive heart failure. Pulmonary embolus.\nHeight: (in) 73\nWeight (lb): 400\nBSA (m2): 2.89 m2\nBP (mm Hg): 126/89\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:31\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\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 - body habitus.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and global systolic function are\nnormal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Right ventricular chamber size is\ngrossly normal with good free wall motion (only seen in parasternal long axis\norientation). The aortic valve leaflets (?#) appear structurally normal with\ngood leaflet excursion. No aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. The pulmonary\nartery systolic pressure could not be determined. There is an anterior space\nwhich most likely represents a prominent fat pad.\n\nIMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with\npreserved global biventricular systolic function.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar. The prior study was also technically suboptimal.\n\n\n"},{"category":"ECG","chartdate":"2204-10-03 00:00:00.000","description":"Report","row_id":156572,"text":"Sinus rhythm and frequent ventricular ectopy. Low precordial lead voltage.\nCompared to the previous tracing of the rate has slowed. Otherwise, no\ndiagnostic interim change.\n\n"},{"category":"ECG","chartdate":"2204-09-28 00:00:00.000","description":"Report","row_id":156573,"text":"Sinus tachycardia with frequent monomorphic ventricular premature beats.\nCompared to the previous tracing of the rate is increased. Other\nfindings are similar.\n\n"},{"category":"ECG","chartdate":"2204-09-22 00:00:00.000","description":"Report","row_id":156574,"text":"Sinus rhythm with frequent unifocal ventricular ectopy. Diffuse non-specific\nST-T wave abnormalities. Compared to the previous tracing frequent ventricular\nectopy is present. The other findings are similar.\n\n"},{"category":"ECG","chartdate":"2204-09-20 00:00:00.000","description":"Report","row_id":156575,"text":"Sinus tachycardia. Otherwise, normal tracing. Compared to tracing #1 no\nsignificant change except for a faster rate.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2204-09-20 00:00:00.000","description":"Report","row_id":156576,"text":"Sinus rhythm with one ventricular premature beat seen. Compared to the\nprevious tracing of no change except for the single premature beat.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2204-09-18 00:00:00.000","description":"Report","row_id":156577,"text":"Sinus rhythm. Borderline low voltage. Since the previous tracing ventricular\npremature beat is no longer seen. Clinical correlation is suggested.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2204-09-17 00:00:00.000","description":"Report","row_id":156578,"text":"Sinus rhythm with monomorphic ventricular premature beats. Conducted complexes\nof borderline low voltage. Ventricular premature beats have normal axis and\nleft bundle-branch block morphology. Since the previous tracing of \nthe ventricular premature beats have the same morphology, ventricular premature\nbeat couplet is no longer seen. Clinical correlation is suggested.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2204-09-17 00:00:00.000","description":"Report","row_id":156579,"text":"Sinus rhythm. Frequent unifocal ventricular premature beats in either\na bigeminal or a trigeminal pattern. Premature ventricular contractions are\nmore frequent compared to early tracing of . Otherwise, no significant\nchange.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2204-09-16 00:00:00.000","description":"Report","row_id":156825,"text":"Sinus rhythm with occasional ventricular premature beats. Otherwise, within\nnormal limits and no longer having frequent ventricular ectopic beats in\ntrigeminy and quadrigeminy compared to previous tracing of .\nTRACING #1\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2204-09-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 70233,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Pulmonary hypertension. Right ventricular function. Congestive heart failure. Pulmonary embolus.\\nHeight: (in) 73\\nWeight (lb): 400\\nBSA (m2): 2.89 m2\\nBP (mm Hg): 126/89\\nHR (bpm): 60\\nStatus: Inpatient\\nDate/Time: at 10:31\\nTest: TTE (Focused views)\\nDoppler: Limited Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nThis study was compared to the prior study of .\\n\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\\nabnormality cannot be fully excluded.\\n\\nRIGHT VENTRICLE: Normal RV chamber size.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\\n\\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\\nsystolic pressure.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\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 - body habitus.\\n\\nConclusions:\\nLeft ventricular wall thickness, cavity size, and global systolic function are\\nnormal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\\nabnormality cannot be fully excluded. Right ventricular chamber size is\\ngrossly normal with good free wall motion (only seen in parasternal long axis\\norientation). The aortic valve leaflets (?#) appear structurally normal with\\ngood leaflet excursion. No aortic regurgitation is seen. The mitral valve\\nappears structurally normal with trivial mitral regurgitation. The pulmonary\\nartery systolic pressure could not be determined. There is an anterior space\\nwhich most likely represents a prominent fat pad.\\n\\nIMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with\\npreserved global biventricular systolic function.\\n\\nCompared with the prior study (images reviewed) of , the findings are\\nsimilar. The prior study was also technically suboptimal.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2204-10-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 156572,\n \"text\": \"Sinus rhythm and frequent ventricular ectopy. Low precordial lead voltage.\\nCompared to the previous tracing of the rate has slowed. Otherwise, no\\ndiagnostic interim change.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2204-09-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 156573,\n \"text\": \"Sinus tachycardia with frequent monomorphic ventricular premature beats.\\nCompared to the previous tracing of the rate is increased. Other\\nfindings are similar.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2204-09-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 156574,\n \"text\": \"Sinus rhythm with frequent unifocal ventricular ectopy. Diffuse non-specific\\nST-T wave abnormalities. Compared to the previous tracing frequent ventricular\\nectopy is present. The other findings are similar.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2204-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 156575,\n \"text\": \"Sinus tachycardia. Otherwise, normal tracing. Compared to tracing #1 no\\nsignificant change except for a faster rate.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2204-09-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 156576,\n \"text\": \"Sinus rhythm with one ventricular premature beat seen. Compared to the\\nprevious tracing of no change except for the single premature beat.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2204-09-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 156577,\n \"text\": \"Sinus rhythm. Borderline low voltage. Since the previous tracing ventricular\\npremature beat is no longer seen. Clinical correlation is suggested.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2204-09-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 156578,\n \"text\": \"Sinus rhythm with monomorphic ventricular premature beats. Conducted complexes\\nof borderline low voltage. Ventricular premature beats have normal axis and\\nleft bundle-branch block morphology. Since the previous tracing of \\nthe ventricular premature beats have the same morphology, ventricular premature\\nbeat couplet is no longer seen. Clinical correlation is suggested.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2204-09-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 156579,\n \"text\": \"Sinus rhythm. Frequent unifocal ventricular premature beats in either\\na bigeminal or a trigeminal pattern. Premature ventricular contractions are\\nmore frequent compared to early tracing of . Otherwise, no significant\\nchange.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2204-09-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 156825,\n \"text\": \"Sinus rhythm with occasional ventricular premature beats. Otherwise, within\\nnormal limits and no longer having frequent ventricular ectopic beats in\\ntrigeminy and quadrigeminy compared to previous tracing of .\\nTRACING #1\\n\\n\"\n }\n]"}}},{"rowIdx":981,"cells":{"subject_id":{"kind":"number","value":81229,"string":"81,229"},"hadm_id":{"kind":"number","value":194995,"string":"194,995"},"target_text":{"kind":"string","value":"62 y/o M with dilated cardiomyopathy admitted for initiation of dofetilide, complicated by torsades, no s/p pacer/ICD placement. . # RHYTHM: He was admitted for inpatient monitoring during the initiation of dofetilide. He was initiated on dofetilide 500mcg Q12hours with EKG 2 hours after each dose, and magnesium oxide 400mg twice daily. Patient had torsades the morning of in the setting of a prolonged QT interval and worsening bradycardia. He was emergently cardioverted, but the rhythm recurred two more times. He was given IV magnesium sulfate, and taken for pacer/ICD placement. The insertion of the pacer was without incident and he was kept overnight in the CCU. No further dofetilide was given and it should simply wash out of his system. He is now paced at 80bpm and had no further arrhythmias on telemetry. Given his history of MRSA and penicillin allergy, he got one day of vancomycin and two days of clindamycin for prophylaxis after pacer placement. He was discharged back on all of his home medications, including warfarin with a goal INR of . . # PUMP: He has a history of dilated cardiomyopathy (EF15%), but appeared euvolemic throughout his stay. He was continued on his home doses of lasix, aldactone, lisinopril. The atenolol was held in the setting of bradycardia, but restarted once he was being paced. Medications on Admission: ALLERGIES: Amiodarone: pulmonary toxicity Sulfa: Rash Tetracycline: Rash PCN: Rash Erythromycin: Rash --------------- --------------- --------------- --------------- Active Medication list as of : Medications - Prescription ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth daily BUPROPION HCL - (Prescribed by Other Provider) - 150 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth daily CAPTOPRIL - (Prescribed by Other Provider) - 12.5 mg Tablet - 1 Tablet(s) by mouth three times a day DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1 Tablet(s) by mouth once a day DOXAZOSIN - (Prescribed by Other Provider) - 1 mg Tablet - Take one Tablet(s) by mouth every day/bedtime FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) - 110 mcg/Actuation Aerosol - 1 puff inhaled twice a day FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1.5 Tablet(s) by mouth twice a day GABAPENTIN [NEURONTIN] - 600 mg Tablet - 2 Tablet(s) by mouth 3 times daily IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol - 1-2 puffs(s) inhaled four times daily as needed for shortness of breath LANSOPRAZOLE [PREVACID SOLUTAB] - 30 mg Tablet,Rapid Dissolve, DR - 1 Tablet(s) by mouth dissolve in mouth 30 min ac LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime daily METOCLOPRAMIDE - (Prescribed by Other Provider) - 5 mg Tablet - tab in am Tablet(s) by mouth 1 day Last dose was prior to dofetilide initation RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth hs SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day SPIRONOLACTONE [ALDACTONE] - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once a day WARFARIN - (Prescribed by Other Provider) - 4 mg Tablet - 1 Tablet(s) by mouth daily dosing is INR dependent/quest in /followed by dr . Also has 1mg, 2mg, 3mg, and 6mg tablets as needed for dose adjustments. Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth prn for headache OXYGEN-AIR DELIVERY SYSTEMS - Device - 2 L/min by nasal cannula nocturnally SENNOSIDES [SENOKOT] - (Prescribed by Other Provider) - 8.6 mg Tablet - 2 Tablet(s) by mouth once a day Discharge Medications: 1. Atenolol 50 mg Tablet : One (1) Tablet PO DAILY (Daily). 2. Bupropion HCl 150 mg Tablet Sustained Release : One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 3. Captopril 12.5 mg Tablet : One (1) Tablet PO TID (3 times a day). 4. Digoxin 125 mcg Tablet : One (1) Tablet PO DAILY (Daily). 5. Doxazosin 1 mg Tablet : One (1) Tablet PO HS (at bedtime). 6. Fluticasone 110 mcg/Actuation Aerosol : One (1) Puff Inhalation (2 times a day). 7. Furosemide 20 mg Tablet : Three (3) Tablet PO BID (2 times a day). 8. Gabapentin 400 mg Capsule : Three (3) Capsule PO TID (3 times a day). 9. Ipratropium Bromide 17 mcg/Actuation Aerosol : Two (2) Puff Inhalation QID PRN () as needed for wheezing/dyspnea. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR : One (1) Tablet,Rapid Dissolve, DR twice a day. 11. Lorazepam 0.5 mg Tablet : One (1) Tablet PO at bedtime. 12. Ranitidine HCl 150 mg Tablet : One (1) Tablet PO HS (at bedtime). 13. Simvastatin 20 mg Tablet : One (1) Tablet PO once a day. 14. Spironolactone 25 mg Tablet : One (1) Tablet PO DAILY (Daily). 15. Warfarin 2 mg Tablet : Two (2) Tablet PO Once Daily at 4 PM. 16. Senna 8.6 mg Tablet : Two (2) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: atrial fibrillation Chronic systolic heart failure torsades de point ventricular fibrillation GERD chronic renal insufficiency depression Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Worked with PT, able to walk stairs without difficulty. Discharge Instructions: You were admitted because we wanted to start you on dofetilide for control of your atrial fibrillation. While you were here, your heart went into a dangerous rhythm, and you had to be shocked and go to the intensive care unit. You had a cardiac defibrillator implantated that also works as a pacemaker, and you are now safe to go home. . No changes were made to your medications. Please take all of your medications as you were prior to admission. . You have heart failure and will accumulate fluid if you are not careful. Please weigh yourself every morning and call your doctor if your weight goes up more than 3 lbs. Please drink less than 1.5 liters of fluid per day. . You have an appointment in the device clinic to make sure your pacemaker is functioning properly. That is Thursday, at 9:30am. . Your most recent INR was 2.7, meaning that you are therapeutic. Please call Dr. office Monday morning at to tell them your INR and ask when it should be tested next. Followup Instructions: Provider: CLINIC Phone: Date/Time: 9:30 Provider: , M.D. Phone: Date/Time: 3:00 Provider: . /DR. Phone: Date/Time: 1:30 Completed by:[**2195-2-22**"},"extractive_notes_summ":{"kind":"string","value":"# GI Medications/GERD/Constipation - continue ranitidine - hold metoclopramide given ? # GI Medications/GERD/Constipation - continue ranitidine - hold metoclopramide given ? # GI Medications/GERD/Constipation - continue ranitidine - hold metoclopramide given ? # Atrial Fibrillation: Continue coumadin. Assessment and Plan 62 y/o M with dilated cardiomyopathy a/w torsades in setting of prolonged QT interval during dofetilide initiation. Assessment and Plan 62 y/o M with dilated cardiomyopathy a/w torsades in setting of prolonged QT interval during dofetilide initiation. ASSESSMENT AND PLAN 62 y/o M with dilated cardiomyopathy a/w torsades in setting of prolonged QT interval during dofetilide initiation. Medications on Transfer (reconciled with home medications and consistent except reglan on hold) -dofetilide -vanco/clinda post procedure . Assessment and Plan ATRIAL FIBRILLATION (AFIB) - will hold on any anti-arrthymics for now. Assessment and Plan ATRIAL FIBRILLATION (AFIB) - will hold on any anti-arrthymics for now. He is now s/p ICD/pacer placement and admitted to CCU for observation- stable hemodynamics, no further VT noted. He is now s/p ICD/pacer placement and admitted to CCU for observation- stable hemodynamics, no further VT noted. He is now s/p ICD/pacer placement and admitted to CCU for observation- stable hemodynamics, no further VT noted. He is now s/p ICD/pacer placement and admitted to CCU for observation- stable hemodynamics, no further VT noted. Held doxazosin dose. Held doxazosin dose. EKG on arrival: HR 80 bpm atrial pacing, inferior q-waves, QTc 469. He is now s/p ICd placement and admitted to CCU for observation- stable hemodynamics, no further VT noted. Chief Complaint: 62 y/o M with dilated cardiomyopathy a/w torsades in setting of prolonged QT interval during dofetilide initiation. Chief Complaint: 62 y/o M with dilated cardiomyopathy a/w torsades in setting of prolonged QT interval during dofetilide initiation. # CORONARIES: - continue statin therapy . Action: Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. Action: Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. Action: Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. -atrial flutter s/p ablation -atrial fibrillation prev controlled on amio (stopped in amio lung toxicity) 3. - device interrogation ok, check CXR (PA/LAT) today. - device interrogation ok, check CXR (PA/LAT) today. # torsades de pointes - prolonged QT in setting of dofetilide initiation. # torsades de pointes - prolonged QT in setting of dofetilide initiation. Vancomycin post procedure xs 1 Followed by clindamycin. Chief Complaint: CHIEF COMPLAINT: Admission for Dofetilide initiation Reason for ICU Admission: Torsades HPI: HISTORY OF PRESENTING ILLNESS: This is a 62 y.o. The second with two electrode enforcements representing the ICD terminates in a position compatible with the apical portion of the right ventricle. Compared to the previous tracing of no diagnosticinterim change.TRACING #1 Compared to the previous tracing of there is nochange.TRACING #1 Compared to tracing #1 no diagnostic interim change.TRACING #2 The patient has recently undergone implantation of a left-sided permanent pacer seen in anterior axillary position. One of these is terminating in a position compatible with the right atrial appendage. Probable inferior myocardial infarction of indeterminate age.ST-T wave changes that are non-specific. FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. Compared to tracing #3 no diagnosticinterim change.TRACING #4 The ICD device is again in place with leads in the region of the right atrial appendage and apex of the right ventricle. Possible old inferior myocardial infarction. Intraventricular conduction delay with left bundle-branchblock pattern and QRS duration of 140 milliseconds. Comparison is made with the next previous available chest examination of . Possible old anterior wallmyocardial infarction. Compared to tracing #1 there is no significant diagnosticchange.TRACING #2 Occasional ventricular prematurebeats. FINDINGS: AP single view of the chest has been obtained with patient sitting upright position. Normal sinus rhythm. Normal sinus rhythm. Normal sinus rhythm. Normal sinus rhythm. Sinus bradycardia with sinus arrhythmia. FINDINGS: In comparison with the earlier study of this date, there is little overall change in the appearance of the ICD implant. P-R interval prolongation. Compared to the previous tracingof multiple described abnormalities persist.TRACING #1 Left axisdeviation. Compared to the previous tracingatrial pacing is new.TRACING #2 Sinus bradycardia. Sinus bradycardia. Likely still a candidate for flecainide. Compared to tracing #2 there is no diagnostic interimchange.TRACING #3 FINDINGS: In comparison with the study of , there is little change. 2:59 PM CHEST (PORTABLE AP) Clip # Reason: r/o pneumothorax Admitting Diagnosis: ATRIAL FIBRILLATION MEDICAL CONDITION: 62 year old man post DDD-ICD implant REASON FOR THIS EXAMINATION: r/o pneumothorax PROVISIONAL FINDINGS IMPRESSION (PFI): SP 4:42 PM PFI: Successful pacer implantation, no pneumothorax. Heart size is unchanged and remains within normal limits. No acute cardiopulmonary disease is identified. , H. 2:59 PM CHEST (PORTABLE AP) Clip # Reason: r/o pneumothorax Admitting Diagnosis: ATRIAL FIBRILLATION MEDICAL CONDITION: 62 year old man post DDD-ICD implant REASON FOR THIS EXAMINATION: r/o pneumothorax PFI REPORT PFI: Successful pacer implantation, no pneumothorax."},"n_notes":{"kind":"number","value":26,"string":"26"},"notes":{"kind":"list like","value":[{"category":"Physician ","chartdate":"2195-02-20 00:00:00.000","description":"Physician Resident Progress Note","row_id":520537,"text":"Chief Complaint: 62 y/o M with dilated cardiomyopathy a/w torsades in\n setting of prolonged QT interval during dofetilide initiation.\n 24 Hour Events:\n s/p pacemaker placement - some soreness around pocket\n Allergies:\n Penicillins\n Unknown; Hives;\n Tetracyclines\n Hives;\n Sulfa (Sulfonamides)\n Hives;\n Erythromycin Base\n Hives;\n Amiodarone\n pulmonary toxic\n Last dose of Antibiotics:\n Vancomycin - 11:57 PM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:27 PM\n Other medications:\n Changes to medical and 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: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 80 (80 - 80) bpm\n BP: 108/65(74) {78/47(54) - 127/71(80)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 96%\n Heart rhythm: A Paced\n Height: 68 Inch\n Total In:\n 940 mL\n PO:\n 740 mL\n TF:\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,400 mL\n 450 mL\n Urine:\n 1,400 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -460 mL\n -450 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 184 K/uL\n 9.9 g/dL\n 90 mg/dL\n 1.3 mg/dL\n 29 mEq/L\n 4.9 mEq/L\n 27 mg/dL\n 99 mEq/L\n 136 mEq/L\n 34.2 %\n 6.0 K/uL\n [image002.jpg]\n 04:59 PM\n 03:45 AM\n WBC\n 6.0\n Hct\n 29.6\n 34.2\n Plt\n 184\n Cr\n 1.3\n Glucose\n 90\n Other labs: PT / PTT / INR:28.0//2.7, Ca++:8.4 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.7 mg/dL\n Imaging: CXR: AP single view of the chest has been obtained with\n patient sitting\n upright position. Comparison is made with the next previous available\n chest\n examination of . The patient has recently undergone\n implantation of a left-sided permanent pacer seen in anterior axillary\n position. The pacer is connected to a dual electrode system. One of\n these is\n terminating in a position compatible with the right atrial appendage.\n The\n second with two electrode enforcements representing the ICD terminates\n in a\n position compatible with the apical portion of the right ventricle.\n Heart\n size is unchanged and remains within normal limits. No pulmonary\n congestion\n is seen and no pneumothorax can be identified.\n Assessment and Plan\n 62 y/o M with dilated cardiomyopathy a/w torsades in setting of\n prolonged QT interval during dofetilide initiation.\n # torsades de pointes - prolonged QT in setting of dofetilide\n initiation. multiple shocks yesterday. s/p pacemaker placement\n - follow up EP recommendations\n - continue beta blocker\n - paced at 80 bpm\n - replete lytes aggressively\n - d/c dofetilide\n - tele monitoring\n - continue digoxin\n - continue warfarin\n # cardiomyopathy: chronic systolic heart failure. EF 15%. Euvolemic. No\n evidence of myocardial stunning after defibrillation.\n - continue lasix\n - continue spironolactone\n - continue lisinopril\n - continue atenolol\n - I/O, weights\n - fluid restrict\n # atrial fibrillation: s/p pacemaker\n - per above\n # Pulmonary Toxicity/Sleep Apnea/Bronchiectasis: No PFT's available.\n - continue home medicaitons and o/n home O2 therapy.\n - stable for now.\n # GI Medications/GERD/Constipation\n - continue ranitidine\n - hold metoclopramide given ? interaction with dofetilide, may\n reinitiate in the future once dofetilide washed out (clarify with EP\n concern with reglan)\n # BPH: Doxazosin qhs\n # Depression: Continue home buproprion\n ICU Care\n Nutrition:\n Comments: heart healthy diet\n Glycemic Control:\n Lines:\n 20 Gauge - 03:09 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"},{"category":"Physician ","chartdate":"2195-02-19 00:00:00.000","description":"Physician Resident Admission Note","row_id":520412,"text":"Chief Complaint: CHIEF COMPLAINT: Admission for Dofetilide initiation\n Reason for ICU Admission: Torsades\n HPI:\n HISTORY OF PRESENTING ILLNESS: This is a 62 y.o. gentleman with\n dilated cardiomyopathy secondary to chemotherapy and radiation therapy\n for Hodgkin's disease 20 years ago. His cardiomyopathy has been\n complicated by atrial flutter and fibrillation, which at one time\n caused significant clinical heart failure. He underwent successful\n atrial flutter ablation in . His atrial fibrillation was\n initially treated with Dofetilide, however after approximately two and\n half years it was no longer effective. He was then switched to\n Amiodarone, however after approximately 2-3 years he developed\n pulmonary toxicity and it was discontinued in the summer of .\n During the fall of he was primarily in NSR. In \n he contracted the HI NI flu, developed PNA, and was also found to have\n MRSA. He was hospitalized for 3 days. At that time he had recurrent\n PAF. He presently reports daily episodes of PAF and was electively\n admitted for initiation of dofetilide therapy.\n .\n Hospital course complicated by progressive prolonged QT interval with\n dofetilide therapy, and bradycardia. On AM prior to admission to CCU,\n patient developed an episode of torsades on telemtry in setting of QT\n of 490-500ms. Was shocked out of the rhythm, but remained\n bradycardic. Attempts to augment his rate with dopamine and later\n isoproterenol were undertaken with limited success. During this time\n patient was given magnesium sulfate 2grams IV, but had three-four\n further episodes of torsades requiring defibrillation. Patient was\n then taken to the EP lab for emergent pacer/ICD implantation.\n .\n Procedure was uncomplicated and AV Pacer/ICD was implanted.\n He is now transfered to the CCU for management with a heart rate of\n 80bpm, until the dofetilide washes out of his system.\n .\n On arrival to the CCU, patient is mentating well. Denies any chest\n pain, shortness of breath or other complaints. Admits to mild nausea\n and light headedness during the episodes. c/o mild shoulder pain\n following implantation of his device. His baseline exercise tolerance\n is about 1 flight of stairs.\n .\n On review of systems, he denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, myalgias, joint pains, cough,\n hemoptysis, black stools or red stools. He denies recent fevers, chills\n or rigors. He denies exertional buttock or calf pain. All of the other\n review of systems were negative.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n .\n On arrival to the CCU, intial VS were: T97, HR 80, BP 112/71, RR 15, o2\n 94%\n Allergies:\n Penicillins\n Unknown; Hives;\n Tetracyclines\n Hives;\n Sulfa (Sulfonamides)\n Hives;\n Erythromycin Base\n Hives;\n Amiodarone\n pulmonary toxic\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 Past Medical History:\n 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, ?Hypertension\n 2. CARDIAC HISTORY:\n -Dilated Cardiomyopathy chemo and xrt 20 years ago (EF\n 10-15%) Was treated with adriamycin.\n -atrial flutter s/p ablation \n -atrial fibrillation prev controlled on amio (stopped in \n amio lung toxicity)\n 3. OTHER PAST MEDICAL HISTORY:\n -Hx of Hodgkin's disease , s/p Chemo and XRT\n -Severe GERD\n -Chronic constipation\n -Chronic lung disease with sleep apnea, emphysema and\n bronchiectasis with a history of severe hemoptysis in ,\n currently off of amiodarone; ? amiodarone induced pulmonary\n toxicity\n -History of diverticulitis x2; the last one was five years ago.\n -CRI\n -Dyslipidemia\n -Depression\n -Obstructive Sleep Apnea - uses nasal CPAP at home\n .\n Outpatient Medications:\n ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth daily\n BUPROPION HCL - (Prescribed by Other Provider) - 150 mg Tablet\n Sustained Release 24 hr - 1 Tablet(s) by mouth daily\n CAPTOPRIL - (Prescribed by Other Provider) - 12.5 mg Tablet - 1\n Tablet(s) by mouth three times a day\n DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1\n Tablet(s) by mouth once a day\n DOXAZOSIN - (Prescribed by Other Provider) - 1 mg Tablet - Take\n one Tablet(s) by mouth every day/bedtime\n FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) - 110\n mcg/Actuation Aerosol - 1 puff inhaled twice a day\n FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1.5\n Tablet(s) by mouth twice a day\n GABAPENTIN [NEURONTIN] - 600 mg Tablet - 2 Tablet(s) by mouth 3\n times daily\n IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol -\n 1-2 puffs(s) inhaled four times daily as needed for shortness of\n breath\n LANSOPRAZOLE [PREVACID SOLUTAB] - 30 mg Tablet,Rapid Dissolve, DR\n - 1 Tablet(s) by mouth dissolve in mouth 30 min ac \n LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1\n Tablet(s) by mouth at bedtime daily\n METOCLOPRAMIDE - (Prescribed by Other Provider) - 5 mg Tablet -\n tab in am Tablet(s) by mouth 1 day Last dose was prior\n to dofetilide initation\n RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth hs\n SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1\n Tablet(s) by mouth once a day\n SPIRONOLACTONE [ALDACTONE] - (Prescribed by Other Provider) - 25\n mg Tablet - 1 Tablet(s) by mouth once a day\n WARFARIN - (Prescribed by Other Provider) - 4 mg Tablet - 1\n Tablet(s) by mouth daily dosing is INR dependent/quest in\n /followed by dr . Also has 1mg, 2mg, 3mg, and\n 6mg tablets as needed for dose adjustments.\n Medications - OTC\n ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet -\n 2 Tablet(s) by mouth prn for headache\n OXYGEN-AIR DELIVERY SYSTEMS - Device - 2 L/min by nasal cannula\n nocturnally\n SENNOSIDES [SENOKOT] - (Prescribed by Other Provider) - 8.6 mg\n Tablet - 2 Tablet(s) by mouth once a day\n .\n Allergies: Penicillins / Tetracyclines / Sulfa (Sulfonamides) /\n Erythromycin Base / Amiodarone\n .\n Medications on Transfer\n (reconciled with home medications and consistent except reglan on hold)\n -dofetilide\n -vanco/clinda post procedure\n .\n Father with CAD age 70's. No other family history of early MI,\n arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise\n non-contributory.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives in with his wife.\n -Tobacco history: > 25 pack year smoking history but quit in\n when diagnosed with Hodgkin's lymphoma\n -ETOH: denies\n -Illicit drugs: denies\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, Weight loss\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\n Respiratory: No(t) Cough, No(t) Dyspnea\n Neurologic: Numbness / tingling\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Flowsheet Data as of 05:26 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 80 (80 - 80) bpm\n BP: 110/66(74) {104/65(73) - 112/71(80)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 96%\n Heart rhythm: A Paced\n Height: 68 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -300 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic), Neck with JVP of 10cm\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished), PT\n pulses present b/l\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n anteriorly), clear posteriorly\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: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: EKG: from this AM sinus rhythm at 60bpm\n LBBB, poor R-wave progression, and q-waves inferiorly.\n EKG on arrival: HR 80 bpm atrial pacing, inferior q-waves, QTc 469.\n Poor R-wave progression,\n .\n TELEMETRY: polymorphic VT by telemetry from .\n .\n 2D-ECHOCARDIOGRAM: \n 1.The left atrium is elongated.\n 2. Left ventricular wall thicknesses are normal. The left ventricular\n cavity size is top normal/borderline dilated. Overall left ventricular\n systolic function is severely depressed, with severe global\n hypokinesis. [ Intrinsoic LV functiom may be depressed given the\n severity of the degree of MR].\n 3. Right ventricular chamber size is normal. The right ventricular\n function appears normal.\n 4.The aortic valve leaflets (3) appear structurally normal with good\n leaflet excursion and no aortic regurgitation.\n 5.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\n regurgitation is seen.\n 6.The estimated pulmonary artery systolic pressure is normal.\n 7.There is a trivial/physiologic pericardial effusion.\n .\n Exercise MIBI: \n IMPRESSION: Fair functional exercise tolerance limited by exertional\n dyspnea. No anginal symptoms with an uninterpretable ECG. Flat blood\n pressure response to exercise. Nuclear report sent separately.\n .\n IMPRESSION: Moderate fixed inferior wall perfusion defect at the level\n of exercise achieved. Global hypokinesis with LVEF of 27%.\n .\n CARDIAC CATH: n/a\n .\n HEMODYNAMICS: n/a\n .\n LABORATORY DATA:\n Magnesium 2.2\n Potassium 4.1\n Dig 1.2\n INR 2.5\n Baseline Cr 1.2, Hct 35\n (see below for full details).\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n .\n ASSESSMENT AND PLAN\n 62 y/o M with dilated cardiomyopathy a/w torsades in setting of\n prolonged QT interval during dofetilide initiation.\n .\n # CORONARIES:\n - continue statin therapy\n .\n # PUMP: EF 15%, euvolemic. No clinical evidence of myocardial\n stunning after defibrillation.\n - Continue lasix, aldactone, lisinopril\n - Beta-blocker okay now that he is paced.\n - Monitor for e/o volume overload\n - daily weight\n - fluid restrict to 1500ml\n .\n # RHYTHM: Torsades in setting of prolonged QT interval.\n - Paced at 80 bpm\n - Maintain Mg > 2.0 and Potassium > 4.5\n - Repeat Mg/K now\n - Monitor on Tele as per ICU protocol.\n - d/c dofetilide\n - continue other home medications.\n - Vanco x1, clindamycin x48 hours given pcn allergy, MRSA\n .\n # Atrial Fibrillation: Continue coumadin.\n - Paced at 80bpm\n .\n # Pulmonary Toxicity/Sleep Apnea/Bronchiectasis: No PFT's available.\n - continue home medicaitons and o/n home O2 therapy.\n - stable for now.\n .\n # GI Medications/GERD/Constipation\n - continue ranitidine\n - hold metoclopramide given ? interaction with dofetilide, may\n reinitiate in the future once dofetilide washed out (clarify with EP\n concern with reglan)\n .\n # BPH: Doxazosin qhs\n .\n # Depression: Continue home buproprion\n .\n FEN: Low Na diet.\n .\n ACCESS: PIV's x2\n .\n PROPHYLAXIS:\n -DVT ppx with coumadin by INR\n -Pain management with oxycodone/tylenol\n -Bowel regimen with senna/bisacodyl - monitor for constipation with\n oxycodone.\n .\n CODE: Full\n .\n COMM: With patient and family\n .\n DISPO: CCU for now, likely c/o in AM.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 03:09 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\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"},{"category":"Nursing","chartdate":"2195-02-19 00:00:00.000","description":"Nursing Progress Note","row_id":520401,"text":"Briefly this is a 62 yo M w/ a PMHx of a dilated cardiomyopathy\n secondary to chemotherapy for Hodgkins lymphoma 20 years ago as well as\n atrial fibrillation who was admitted for initiation of Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated and\n he had torsades. Pt medically treated and sent to EP lab for placement\n of ICD. He is now s/p ICd placement and admitted to CCU for\n observation.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2195-02-20 00:00:00.000","description":"Nursing Transfer Note","row_id":520664,"text":"This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\n chemotherapy for Hodgkin\ns lymphoma 20 years ago as well as atrial\n fibrillation who was admitted to 3 for initiation of\n Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\n EP lab for placement of ICD.\n He is now s/p ICD/pacer placement and admitted to CCU for observation-\n stable hemodynamics, no further VT noted.\n Atrial fibrillation (Afib)\n Assessment:\n Pt hemodynamically stable s/p ICD/pacer placement for toursades.\n Admitted to CCU for further observation overnite.\n Action:\n Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. ICD\n site at left shoulder D/I- no drainage noted. Arm remains immobilized\n in a sling. Dsg d/i\n Response:\n Pt remains A paced, hemodynamics stable. No further tachy or brady\n arrythmias this shift.\n Plan:\n Bedrest x 24 hrs w sling- increase activity once able. Continue to\n monitor for any arrythmias- or hemodynamic issues. Keep pt aware of\n progress, plan of care.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p incision for ICD current w moderate level of pain at site.\n Action:\n Treating pain w repositioning, pain meds. Received oxycontin total 10\n mg this shift\n Response:\n Pt more comfortable w regular dosing of pain med.\n Plan:\n Continue to make pt comfortable as needed- continue close assessment of\n pain level and treat accordingly. Continue to observe incisional site\n for any change/drainage.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n ATRIAL FIBRILLATION\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 84 kg\n Daily weight:\n 84.4 kg\n Allergies/Reactions:\n Penicillins\n Unknown; Hives;\n Tetracyclines\n Hives;\n Sulfa (Sulfonamides)\n Hives;\n Erythromycin Base\n Hives;\n Amiodarone\n pulmonary toxic\n Precautions:\n PMH: COPD\n CV-PMH: Arrhythmias, CHF\n Additional history: h/o cm secondary to Adriamycin for hodgkins\n lymphoma EF 15%\n Depression\n Class III heart failure.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:98\n D:64\n Temperature:\n 97.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n A Paced\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 480 mL\n 24h total out:\n 1,050 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 03:45 AM\n Potassium:\n 4.9 mEq/L\n 03:45 AM\n Chloride:\n 99 mEq/L\n 03:45 AM\n CO2:\n 29 mEq/L\n 03:45 AM\n BUN:\n 27 mg/dL\n 03:45 AM\n Creatinine:\n 1.3 mg/dL\n 03:45 AM\n Glucose:\n 90 mg/dL\n 03:45 AM\n Hematocrit:\n 34.2 %\n 03:45 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: \n Date & time of Transfer: 12:00 AM\n"},{"category":"Physician ","chartdate":"2195-02-19 00:00:00.000","description":"Cardiology Fellow Note/ Addendum","row_id":520389,"text":"TITLE: Cardiology Fellow Note/ Addendum\n Please see residents H and P for full details.\n Briefly this is a 62 yo M w/ a PMHx of a dilated cardiomyopathy\n secondary to chemotherapy for Hodgkins lymphoma 20 years ago as well as\n atrial fibrillation who was admitted for initiation of Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated and\n he had torsades. Pt medically treated and sent to EP lab for placement\n of ICD. He is now s/p ICd placement and admitted to CCU for\n observation.\n Plan:\n -will talk w/ EP regarding treatment of a fib, but will obviously hold\n dofetilide and consider other antiarrhythmic therapy (pt has previously\n failed Amiodarone therapy). Likely still a candidate for flecainide.\n -monitor on tele for residual ventricular tachycardias\n"},{"category":"Nursing","chartdate":"2195-02-20 00:00:00.000","description":"Nursing Progress Note","row_id":520450,"text":"This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\n chemotherapy for Hodgkin\ns lymphoma 20 years ago as well as atrial\n fibrillation who was admitted to 3 for initiation of\n Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\n EP lab for placement of ICD.\n He is now s/p ICd placement and admitted to CCU for observation- stable\n hemodynamics, no further VT noted.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2195-02-20 00:00:00.000","description":"Nursing Progress Note","row_id":520451,"text":"This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\n chemotherapy for Hodgkin\ns lymphoma 20 years ago as well as atrial\n fibrillation who was admitted to 3 for initiation of\n Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\n EP lab for placement of ICD.\n He is now s/p ICD/pacer placement and admitted to CCU for observation-\n stable hemodynamics, no further VT noted.\n Atrial fibrillation (Afib)\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":"Physician ","chartdate":"2195-02-20 00:00:00.000","description":"EP Note","row_id":520658,"text":"History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: Last 24 hours: Yesterday 11am, pt\n developed TdP requiring shock x 4 initiated by VPC after pause and\n brady. ICD placed yesterday and paced at 80bpm, now decreased to\n 75bpm. Defetilide stopped.\n Medications\n Unchanged\n Physical Exam\n BP: 102 / 53 mmHg\n HR: 75 bpm\n Tmax C last 24 hours: 36.6 C\n Tmax F last 24 hours: 97.9 F\n T current C: 36.6 C\n T current F: 97.8 F\n Previous day:\n Intake: 940 mL\n Output: 1,400 mL\n Fluid balance: -460 mL\n Today:\n Output: 750 mL\n Fluid balance: -750 mL\n Cardiovascular: (Auscultation: RRR)\n Respiratory: (Auscultation: CTA anterior)\n Abdomen: (Palpation: soft)\n Neurological: (Orientation: a&o x 3)\n Other: L chest area ICD implant, tender to touch but no evidence of\n hematoma.\n Labs\n 184\n 9.9\n 90\n 1.3\n 29\n 4.9\n 27\n 99\n 136\n 34.2\n 6.0\n [image002.jpg]\n 04:59 PM\n 03:45 AM\n WBC\n 6.0\n Hgb\n 9.9\n Hct (Serum)\n 29.6\n 34.2\n Plt\n 184\n INR\n 2.7\n Na+\n 136\n K + (Serum)\n 4.6\n 4.9\n Cl\n 99\n HCO3\n 29\n BUN\n 27\n Creatinine\n 1.3\n Glucose\n 90\n ABG: / / / 29 / Values as of 03:45 AM\n Tests\n ECG: (Date: ), 8:20am Apace 75, QT 420ms.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB) - will hold on any anti-arrthymics for\n now. just monitor for now and see if increased atrial pacing will\n prevent him from going into afib.\n VT - TdP from dofetilide s/p ICD yesterday Since he is at increased\n risk with DCM and EF 10-15%, the decision was to implant an ICD instead\n of just a ppm. QT shorted with faster HR.\n - device interrogation ok, check CXR (PA/LAT) today.\n - Device clinic visit 9:30am.\n OK to d/c to tele floor for monitoring.\n ------ Protected Section ------\n I interviewed and examined Mr. . I agree with Dr. \ns H+P,\n A+P.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:29 ------\n"},{"category":"Nursing","chartdate":"2195-02-20 00:00:00.000","description":"Nursing Progress Note","row_id":520492,"text":"This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\n chemotherapy for Hodgkin\ns lymphoma 20 years ago as well as atrial\n fibrillation who was admitted to 3 for initiation of\n Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\n EP lab for placement of ICD.\n He is now s/p ICD/pacer placement and admitted to CCU for observation-\n stable hemodynamics, no further VT noted.\n Atrial fibrillation (Afib)\n Assessment:\n Pt hemodynamically stable s/p ICD/pacer placement for toursades.\n Admitted to CCU for further observation overnite.\n Action:\n Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. ICD\n site at left shoulder D/I- no drainage noted. Arm remains immobilized\n in a sling. Given evening dose captopril once SBP>100/ . Held doxazosin\n dose.\n Response:\n Pt remains A paced, hemodynamics stable. No further tachy or brady\n arrythmias this shift.\n Plan:\n Bedrest x 24 hrs w sling- increase activity once able. Continue to\n monitor for any arrythmias- or hemodynamic issues. Keep pt aware of\n progress, plan of care. c/o to 3 once medically appropriate.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p incision for ICD current w moderate level of pain at site.\n Action:\n Treating pain w repositioning, pain meds. Received oxycontin 10 mg, 5\n mg , 5mg this shift, as well as Tylenol 650 mg x 2 doses. Also received\n ativan 0.5 qhs( home dose)\n Response:\n Pt more comfortable w regular dosing of pain med. Slept well w ativan.\n When awakened- or moving, developing moderate pain but diminishing w\n medication\n Plan:\n Continue to make pt comfortable as needed- continue close assessment of\n pain level and treat accordingly. Continue to observe incisional site\n for any change/drainage.\n"},{"category":"Physician ","chartdate":"2195-02-20 00:00:00.000","description":"Physician Resident Progress Note","row_id":520627,"text":"Chief Complaint: 62 y/o M with dilated cardiomyopathy a/w torsades in\n setting of prolonged QT interval during dofetilide initiation.\n 24 Hour Events:\n s/p pacemaker placement - some soreness around pocket\n Allergies:\n Penicillins\n Unknown; Hives;\n Tetracyclines\n Hives;\n Sulfa (Sulfonamides)\n Hives;\n Erythromycin Base\n Hives;\n Amiodarone\n pulmonary toxic\n Last dose of Antibiotics:\n Vancomycin - 11:57 PM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:27 PM\n Other medications:\n Changes to medical and 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: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 80 (80 - 80) bpm\n BP: 108/65(74) {78/47(54) - 127/71(80)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 96%\n Heart rhythm: A Paced\n Height: 68 Inch\n Total In:\n 940 mL\n PO:\n 740 mL\n TF:\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,400 mL\n 450 mL\n Urine:\n 1,400 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -460 mL\n -450 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 184 K/uL\n 9.9 g/dL\n 90 mg/dL\n 1.3 mg/dL\n 29 mEq/L\n 4.9 mEq/L\n 27 mg/dL\n 99 mEq/L\n 136 mEq/L\n 34.2 %\n 6.0 K/uL\n [image002.jpg]\n 04:59 PM\n 03:45 AM\n WBC\n 6.0\n Hct\n 29.6\n 34.2\n Plt\n 184\n Cr\n 1.3\n Glucose\n 90\n Other labs: PT / PTT / INR:28.0//2.7, Ca++:8.4 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.7 mg/dL\n Imaging: CXR: AP single view of the chest has been obtained with\n patient sitting\n upright position. Comparison is made with the next previous available\n chest\n examination of . The patient has recently undergone\n implantation of a left-sided permanent pacer seen in anterior axillary\n position. The pacer is connected to a dual electrode system. One of\n these is\n terminating in a position compatible with the right atrial appendage.\n The\n second with two electrode enforcements representing the ICD terminates\n in a\n position compatible with the apical portion of the right ventricle.\n Heart\n size is unchanged and remains within normal limits. No pulmonary\n congestion\n is seen and no pneumothorax can be identified.\n Assessment and Plan\n 62 y/o M with dilated cardiomyopathy a/w torsades in setting of\n prolonged QT interval during dofetilide initiation.\n # torsades de pointes - prolonged QT in setting of dofetilide\n initiation. multiple shocks yesterday. s/p pacemaker placement\n - follow up EP recommendations\n - continue beta blocker\n - paced at 80 bpm\n - replete lytes aggressively\n - d/c dofetilide\n - tele monitoring\n - continue digoxin\n - continue warfarin\n # cardiomyopathy: chronic systolic heart failure. EF 15%. Euvolemic. No\n evidence of myocardial stunning after defibrillation.\n - continue lasix\n - continue spironolactone\n - continue lisinopril\n - continue atenolol\n - I/O, weights\n - fluid restrict\n # atrial fibrillation: s/p pacemaker\n - per above\n # Pulmonary Toxicity/Sleep Apnea/Bronchiectasis: No PFT's available.\n - continue home medicaitons and o/n home O2 therapy.\n - stable for now.\n # GI Medications/GERD/Constipation\n - continue ranitidine\n - hold metoclopramide given ? interaction with dofetilide, may\n reinitiate in the future once dofetilide washed out (clarify with EP\n concern with reglan)\n # BPH: Doxazosin qhs\n # Depression: Continue home buproprion\n ICU Care\n Nutrition:\n Comments: heart healthy diet\n Glycemic Control:\n Lines:\n 20 Gauge - 03:09 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"},{"category":"Physician ","chartdate":"2195-02-20 00:00:00.000","description":"EP Note","row_id":520601,"text":"History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: Last 24 hours: Yesterday 11am, pt\n developed TdP requiring shock x 4 initiated by VPC after pause and\n brady. ICD placed yesterday and paced at 80bpm, now decreased to\n 75bpm. Defetilide stopped.\n Medications\n Unchanged\n Physical Exam\n BP: 102 / 53 mmHg\n HR: 75 bpm\n Tmax C last 24 hours: 36.6 C\n Tmax F last 24 hours: 97.9 F\n T current C: 36.6 C\n T current F: 97.8 F\n Previous day:\n Intake: 940 mL\n Output: 1,400 mL\n Fluid balance: -460 mL\n Today:\n Output: 750 mL\n Fluid balance: -750 mL\n Cardiovascular: (Auscultation: RRR)\n Respiratory: (Auscultation: CTA anterior)\n Abdomen: (Palpation: soft)\n Neurological: (Orientation: a&o x 3)\n Other: L chest area ICD implant, tender to touch but no evidence of\n hematoma.\n Labs\n 184\n 9.9\n 90\n 1.3\n 29\n 4.9\n 27\n 99\n 136\n 34.2\n 6.0\n [image002.jpg]\n 04:59 PM\n 03:45 AM\n WBC\n 6.0\n Hgb\n 9.9\n Hct (Serum)\n 29.6\n 34.2\n Plt\n 184\n INR\n 2.7\n Na+\n 136\n K + (Serum)\n 4.6\n 4.9\n Cl\n 99\n HCO3\n 29\n BUN\n 27\n Creatinine\n 1.3\n Glucose\n 90\n ABG: / / / 29 / Values as of 03:45 AM\n Tests\n ECG: (Date: ), 8:20am Apace 75, QT 420ms.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB) - will hold on any anti-arrthymics for\n now. just monitor for now and see if increased atrial pacing will\n prevent him from going into afib.\n VT - TdP from dofetilide s/p ICD yesterday Since he is at increased\n risk with DCM and EF 10-15%, the decision was to implant an ICD instead\n of just a ppm. QT shorted with faster HR.\n - device interrogation ok, check CXR (PA/LAT) today.\n - Device clinic visit 9:30am.\n OK to d/c to tele floor for monitoring.\n"},{"category":"Nursing","chartdate":"2195-02-20 00:00:00.000","description":"Nursing Transfer Note","row_id":520573,"text":"This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\n chemotherapy for Hodgkin\ns lymphoma 20 years ago as well as atrial\n fibrillation who was admitted to 3 for initiation of\n Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\n EP lab for placement of ICD.\n He is now s/p ICD/pacer placement and admitted to CCU for observation-\n stable hemodynamics, no further VT noted.\n Atrial fibrillation (Afib)\n Assessment:\n Pt hemodynamically stable s/p ICD/pacer placement for toursades.\n Admitted to CCU for further observation overnite.\n Action:\n Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. ICD\n site at left shoulder D/I- no drainage noted. Arm remains immobilized\n in a sling. Given evening dose captopril once SBP>100/ . Held doxazosin\n dose.\n Response:\n Pt remains A paced, hemodynamics stable. No further tachy or brady\n arrythmias this shift.\n Plan:\n Bedrest x 24 hrs w sling- increase activity once able. Continue to\n monitor for any arrythmias- or hemodynamic issues. Keep pt aware of\n progress, plan of care. c/o to 3 once medically appropriate.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p incision for ICD current w moderate level of pain at site.\n Action:\n Treating pain w repositioning, pain meds. Received oxycontin 10 mg, 5\n mg , 5mg this shift, as well as Tylenol 650 mg x 2 doses. Also received\n ativan 0.5 qhs( home dose)\n Response:\n Pt more comfortable w regular dosing of pain med. Slept well w ativan.\n When awakened- or moving, developing moderate pain but diminishing w\n medication\n Plan:\n Continue to make pt comfortable as needed- continue close assessment of\n pain level and treat accordingly. Continue to observe incisional site\n for any change/drainage.\n"},{"category":"Nursing","chartdate":"2195-02-19 00:00:00.000","description":"Nursing Progress Note","row_id":520432,"text":"Briefly this is a 62 yo M w/ a PMHx of a dilated cardiomyopathy\n secondary to chemotherapy for Hodgkin\ns lymphoma 20 years ago as well\n as atrial fibrillation who was admitted for initiation of Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated and\n he had torsades. Pt medically treated and sent to EP lab for placement\n of ICD. He is now s/p ICd placement and admitted to CCU for\n observation.\n Atrial fibrillation (Afib)\n Assessment:\n Pt received from EP lab s/p placement of ICD/PPM.\n Tele A paced at rate of 80.\n Pacer site is C&D.\n O2 sats 94-96 on room air.\n c/o chest pain at site of pacer.\n Action:\n Dofetilide dc\n To remain on Coumadin.\n Cont to monitor QTC.\n Given Tylenol 650mg po.\n Response:\n Hemodynamically stable A paced.\n Pain improved after Tylenol.\n Plan:\n Check lytes.\n Maintain on bedrest overnite.\n Vancomycin post procedure x\ns 1 Followed by clindamycin.\n"},{"category":"Physician ","chartdate":"2195-02-20 00:00:00.000","description":"Cardiology Fellow Note/ Addendum","row_id":520569,"text":"TITLE: Cardiology Fellow Note/ Addendum\n Please see residents H and P for full details.\n Briefly this is a 62 yo M w/ a PMHx of a dilated cardiomyopathy\n secondary to chemotherapy for Hodgkins lymphoma 20 years ago as well as\n atrial fibrillation who was admitted for initiation of Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated and\n he had torsades. Pt medically treated and sent to EP lab for placement\n of ICD. He is now s/p ICd placement and admitted to CCU for\n observation.\n Plan:\n -will talk w/ EP regarding treatment of a fib, but will obviously hold\n dofetilide and consider other antiarrhythmic therapy (pt has previously\n failed Amiodarone therapy). Likely still a candidate for flecainide.\n -monitor on tele for residual ventricular tachycardias\n ------ Protected Section ------\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n nothing to add\n Physical Examination\n nothing to add\n Medical Decision Making\n nothing to add\n Total time spent on patient care: 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 08:41 ------\n"},{"category":"ECG","chartdate":"2195-02-20 00:00:00.000","description":"Report","row_id":110243,"text":"Atrial paced rhythm. Left bundle-branch block. Compared to the previous tracing\natrial pacing is new.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2195-02-19 00:00:00.000","description":"Report","row_id":110244,"text":"Sinus bradycardia. Left bundle-branch block. Occasional ventricular premature\nbeats. Possible old inferior myocardial infarction. Possible old anterior wall\nmyocardial infarction. Compared to the previous tracing of there is no\nchange.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2195-02-19 00:00:00.000","description":"Report","row_id":110245,"text":"Sinus bradycardia. Compared to tracing #1 there is no significant diagnostic\nchange.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2195-02-18 00:00:00.000","description":"Report","row_id":110246,"text":"Sinus bradycardia with sinus arrhythmia. P-R interval prolongation. Left axis\ndeviation. Probable inferior myocardial infarction of indeterminate age.\nST-T wave changes that are non-specific. Compared to the previous tracing\nof multiple described abnormalities persist.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2195-02-18 00:00:00.000","description":"Report","row_id":110247,"text":"Normal sinus rhythm. Marked leftward axis. Compared to tracing #3 no diagnostic\ninterim change.\nTRACING #4\n\n"},{"category":"ECG","chartdate":"2195-02-17 00:00:00.000","description":"Report","row_id":110248,"text":"Normal sinus rhythm. Compared to tracing #1 no diagnostic interim change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2195-02-18 00:00:00.000","description":"Report","row_id":110295,"text":"Normal sinus rhythm. Compared to tracing #2 there is no diagnostic interim\nchange.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2195-02-17 00:00:00.000","description":"Report","row_id":110296,"text":"Normal sinus rhythm. Intraventricular conduction delay with left bundle-branch\nblock pattern and QRS duration of 140 milliseconds. Leftward axis at\nminus 50 degrees. Compared to the previous tracing of no diagnostic\ninterim change.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2195-02-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1122114,"text":" 7:30 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Please evaluate for changes\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p ICD\n REASON FOR THIS EXAMINATION:\n Please evaluate for changes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ICD.\n\n FINDINGS: In comparison with the study of , there is little change. The\n ICD device is again in place with leads in the region of the right atrial\n appendage and apex of the right ventricle. No evidence of vascular\n congestion, pleural effusion, or acute pneumonia.\n\n\n"},{"category":"Radiology","chartdate":"2195-02-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1122028,"text":" 2:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man post DDD-ICD implant\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 4:42 PM\n PFI: Successful pacer implantation, no pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 62-year-old male patient with ICD implant, evaluate for possible\n pneumothorax.\n\n FINDINGS: AP single view of the chest has been obtained with patient sitting\n upright position. Comparison is made with the next previous available chest\n examination of . The patient has recently undergone\n implantation of a left-sided permanent pacer seen in anterior axillary\n position. The pacer is connected to a dual electrode system. One of these is\n terminating in a position compatible with the right atrial appendage. The\n second with two electrode enforcements representing the ICD terminates in a\n position compatible with the apical portion of the right ventricle. Heart\n size is unchanged and remains within normal limits. No pulmonary congestion\n is seen and no pneumothorax can be identified.\n\n\n"},{"category":"Radiology","chartdate":"2195-02-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1122029,"text":", H. 2:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man post DDD-ICD implant\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n PFI REPORT\n PFI: Successful pacer implantation, no pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2195-02-20 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1122151,"text":" 10:58 AM\n CHEST (PA & LAT) Clip # \n Reason: Leads placement\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man post DDD-ICD implant\n REASON FOR THIS EXAMINATION:\n Leads placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ICD implant.\n\n FINDINGS: In comparison with the earlier study of this date, there is little\n overall change in the appearance of the ICD implant. No acute cardiopulmonary\n disease is identified.\n\n\n"}],"string":"[\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 520537,\n \"text\": \"Chief Complaint: 62 y/o M with dilated cardiomyopathy a/w torsades in\\n setting of prolonged QT interval during dofetilide initiation.\\n 24 Hour Events:\\n s/p pacemaker placement - some soreness around pocket\\n Allergies:\\n Penicillins\\n Unknown; Hives;\\n Tetracyclines\\n Hives;\\n Sulfa (Sulfonamides)\\n Hives;\\n Erythromycin Base\\n Hives;\\n Amiodarone\\n pulmonary toxic\\n Last dose of Antibiotics:\\n Vancomycin - 11:57 PM\\n Infusions:\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 10:27 PM\\n Other medications:\\n Changes to medical and 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: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.8\\n HR: 80 (80 - 80) bpm\\n BP: 108/65(74) {78/47(54) - 127/71(80)} mmHg\\n RR: 16 (13 - 21) insp/min\\n SpO2: 96%\\n Heart rhythm: A Paced\\n Height: 68 Inch\\n Total In:\\n 940 mL\\n PO:\\n 740 mL\\n TF:\\n IVF:\\n 200 mL\\n Blood products:\\n Total out:\\n 1,400 mL\\n 450 mL\\n Urine:\\n 1,400 mL\\n 450 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -460 mL\\n -450 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 96%\\n ABG: ///29/\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Skin: Not assessed\\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\\n assessed, Tone: Not assessed\\n Labs / Radiology\\n 184 K/uL\\n 9.9 g/dL\\n 90 mg/dL\\n 1.3 mg/dL\\n 29 mEq/L\\n 4.9 mEq/L\\n 27 mg/dL\\n 99 mEq/L\\n 136 mEq/L\\n 34.2 %\\n 6.0 K/uL\\n [image002.jpg]\\n 04:59 PM\\n 03:45 AM\\n WBC\\n 6.0\\n Hct\\n 29.6\\n 34.2\\n Plt\\n 184\\n Cr\\n 1.3\\n Glucose\\n 90\\n Other labs: PT / PTT / INR:28.0//2.7, Ca++:8.4 mg/dL, Mg++:2.7 mg/dL,\\n PO4:3.7 mg/dL\\n Imaging: CXR: AP single view of the chest has been obtained with\\n patient sitting\\n upright position. Comparison is made with the next previous available\\n chest\\n examination of . The patient has recently undergone\\n implantation of a left-sided permanent pacer seen in anterior axillary\\n position. The pacer is connected to a dual electrode system. One of\\n these is\\n terminating in a position compatible with the right atrial appendage.\\n The\\n second with two electrode enforcements representing the ICD terminates\\n in a\\n position compatible with the apical portion of the right ventricle.\\n Heart\\n size is unchanged and remains within normal limits. No pulmonary\\n congestion\\n is seen and no pneumothorax can be identified.\\n Assessment and Plan\\n 62 y/o M with dilated cardiomyopathy a/w torsades in setting of\\n prolonged QT interval during dofetilide initiation.\\n # torsades de pointes - prolonged QT in setting of dofetilide\\n initiation. multiple shocks yesterday. s/p pacemaker placement\\n - follow up EP recommendations\\n - continue beta blocker\\n - paced at 80 bpm\\n - replete lytes aggressively\\n - d/c dofetilide\\n - tele monitoring\\n - continue digoxin\\n - continue warfarin\\n # cardiomyopathy: chronic systolic heart failure. EF 15%. Euvolemic. No\\n evidence of myocardial stunning after defibrillation.\\n - continue lasix\\n - continue spironolactone\\n - continue lisinopril\\n - continue atenolol\\n - I/O, weights\\n - fluid restrict\\n # atrial fibrillation: s/p pacemaker\\n - per above\\n # Pulmonary Toxicity/Sleep Apnea/Bronchiectasis: No PFT's available.\\n - continue home medicaitons and o/n home O2 therapy.\\n - stable for now.\\n # GI Medications/GERD/Constipation\\n - continue ranitidine\\n - hold metoclopramide given ? interaction with dofetilide, may\\n reinitiate in the future once dofetilide washed out (clarify with EP\\n concern with reglan)\\n # BPH: Doxazosin qhs\\n # Depression: Continue home buproprion\\n ICU Care\\n Nutrition:\\n Comments: heart healthy diet\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 03:09 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Coumadin)\\n Stress ulcer: H2 blocker\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:Transfer to floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2195-02-19 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 520412,\n \"text\": \"Chief Complaint: CHIEF COMPLAINT: Admission for Dofetilide initiation\\n Reason for ICU Admission: Torsades\\n HPI:\\n HISTORY OF PRESENTING ILLNESS: This is a 62 y.o. gentleman with\\n dilated cardiomyopathy secondary to chemotherapy and radiation therapy\\n for Hodgkin's disease 20 years ago. His cardiomyopathy has been\\n complicated by atrial flutter and fibrillation, which at one time\\n caused significant clinical heart failure. He underwent successful\\n atrial flutter ablation in . His atrial fibrillation was\\n initially treated with Dofetilide, however after approximately two and\\n half years it was no longer effective. He was then switched to\\n Amiodarone, however after approximately 2-3 years he developed\\n pulmonary toxicity and it was discontinued in the summer of .\\n During the fall of he was primarily in NSR. In \\n he contracted the HI NI flu, developed PNA, and was also found to have\\n MRSA. He was hospitalized for 3 days. At that time he had recurrent\\n PAF. He presently reports daily episodes of PAF and was electively\\n admitted for initiation of dofetilide therapy.\\n .\\n Hospital course complicated by progressive prolonged QT interval with\\n dofetilide therapy, and bradycardia. On AM prior to admission to CCU,\\n patient developed an episode of torsades on telemtry in setting of QT\\n of 490-500ms. Was shocked out of the rhythm, but remained\\n bradycardic. Attempts to augment his rate with dopamine and later\\n isoproterenol were undertaken with limited success. During this time\\n patient was given magnesium sulfate 2grams IV, but had three-four\\n further episodes of torsades requiring defibrillation. Patient was\\n then taken to the EP lab for emergent pacer/ICD implantation.\\n .\\n Procedure was uncomplicated and AV Pacer/ICD was implanted.\\n He is now transfered to the CCU for management with a heart rate of\\n 80bpm, until the dofetilide washes out of his system.\\n .\\n On arrival to the CCU, patient is mentating well. Denies any chest\\n pain, shortness of breath or other complaints. Admits to mild nausea\\n and light headedness during the episodes. c/o mild shoulder pain\\n following implantation of his device. His baseline exercise tolerance\\n is about 1 flight of stairs.\\n .\\n On review of systems, he denies any prior history of stroke, TIA, deep\\n venous thrombosis, pulmonary embolism, myalgias, joint pains, cough,\\n hemoptysis, black stools or red stools. He denies recent fevers, chills\\n or rigors. He denies exertional buttock or calf pain. All of the other\\n review of systems were negative.\\n .\\n Cardiac review of systems is notable for absence of chest pain, dyspnea\\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\\n palpitations, syncope or presyncope.\\n .\\n On arrival to the CCU, intial VS were: T97, HR 80, BP 112/71, RR 15, o2\\n 94%\\n Allergies:\\n Penicillins\\n Unknown; Hives;\\n Tetracyclines\\n Hives;\\n Sulfa (Sulfonamides)\\n Hives;\\n Erythromycin Base\\n Hives;\\n Amiodarone\\n pulmonary toxic\\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 Past Medical History:\\n 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, ?Hypertension\\n 2. CARDIAC HISTORY:\\n -Dilated Cardiomyopathy chemo and xrt 20 years ago (EF\\n 10-15%) Was treated with adriamycin.\\n -atrial flutter s/p ablation \\n -atrial fibrillation prev controlled on amio (stopped in \\n amio lung toxicity)\\n 3. OTHER PAST MEDICAL HISTORY:\\n -Hx of Hodgkin's disease , s/p Chemo and XRT\\n -Severe GERD\\n -Chronic constipation\\n -Chronic lung disease with sleep apnea, emphysema and\\n bronchiectasis with a history of severe hemoptysis in ,\\n currently off of amiodarone; ? amiodarone induced pulmonary\\n toxicity\\n -History of diverticulitis x2; the last one was five years ago.\\n -CRI\\n -Dyslipidemia\\n -Depression\\n -Obstructive Sleep Apnea - uses nasal CPAP at home\\n .\\n Outpatient Medications:\\n ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth daily\\n BUPROPION HCL - (Prescribed by Other Provider) - 150 mg Tablet\\n Sustained Release 24 hr - 1 Tablet(s) by mouth daily\\n CAPTOPRIL - (Prescribed by Other Provider) - 12.5 mg Tablet - 1\\n Tablet(s) by mouth three times a day\\n DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1\\n Tablet(s) by mouth once a day\\n DOXAZOSIN - (Prescribed by Other Provider) - 1 mg Tablet - Take\\n one Tablet(s) by mouth every day/bedtime\\n FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) - 110\\n mcg/Actuation Aerosol - 1 puff inhaled twice a day\\n FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1.5\\n Tablet(s) by mouth twice a day\\n GABAPENTIN [NEURONTIN] - 600 mg Tablet - 2 Tablet(s) by mouth 3\\n times daily\\n IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol -\\n 1-2 puffs(s) inhaled four times daily as needed for shortness of\\n breath\\n LANSOPRAZOLE [PREVACID SOLUTAB] - 30 mg Tablet,Rapid Dissolve, DR\\n - 1 Tablet(s) by mouth dissolve in mouth 30 min ac \\n LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1\\n Tablet(s) by mouth at bedtime daily\\n METOCLOPRAMIDE - (Prescribed by Other Provider) - 5 mg Tablet -\\n tab in am Tablet(s) by mouth 1 day Last dose was prior\\n to dofetilide initation\\n RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth hs\\n SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1\\n Tablet(s) by mouth once a day\\n SPIRONOLACTONE [ALDACTONE] - (Prescribed by Other Provider) - 25\\n mg Tablet - 1 Tablet(s) by mouth once a day\\n WARFARIN - (Prescribed by Other Provider) - 4 mg Tablet - 1\\n Tablet(s) by mouth daily dosing is INR dependent/quest in\\n /followed by dr . Also has 1mg, 2mg, 3mg, and\\n 6mg tablets as needed for dose adjustments.\\n Medications - OTC\\n ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet -\\n 2 Tablet(s) by mouth prn for headache\\n OXYGEN-AIR DELIVERY SYSTEMS - Device - 2 L/min by nasal cannula\\n nocturnally\\n SENNOSIDES [SENOKOT] - (Prescribed by Other Provider) - 8.6 mg\\n Tablet - 2 Tablet(s) by mouth once a day\\n .\\n Allergies: Penicillins / Tetracyclines / Sulfa (Sulfonamides) /\\n Erythromycin Base / Amiodarone\\n .\\n Medications on Transfer\\n (reconciled with home medications and consistent except reglan on hold)\\n -dofetilide\\n -vanco/clinda post procedure\\n .\\n Father with CAD age 70's. No other family history of early MI,\\n arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise\\n non-contributory.\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: Lives in with his wife.\\n -Tobacco history: > 25 pack year smoking history but quit in\\n when diagnosed with Hodgkin's lymphoma\\n -ETOH: denies\\n -Illicit drugs: denies\\n Review of systems:\\n Constitutional: No(t) Fatigue, No(t) Fever, Weight loss\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\\n Respiratory: No(t) Cough, No(t) Dyspnea\\n Neurologic: Numbness / tingling\\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\\n No(t) Daytime somnolence\\n Flowsheet Data as of 05:26 PM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since AM\\n Tmax: 36.1\\nC (97\\n Tcurrent: 36.1\\nC (97\\n HR: 80 (80 - 80) bpm\\n BP: 110/66(74) {104/65(73) - 112/71(80)} mmHg\\n RR: 17 (15 - 20) insp/min\\n SpO2: 96%\\n Heart rhythm: A Paced\\n Height: 68 Inch\\n Total In:\\n PO:\\n TF:\\n IVF:\\n Blood products:\\n Total out:\\n 0 mL\\n 300 mL\\n Urine:\\n 300 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 0 mL\\n -300 mL\\n Respiratory\\n O2 Delivery Device: None\\n SpO2: 96%\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, No(t) Overweight\\n / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic), Neck with JVP of 10cm\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished), PT\\n pulses present b/l\\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\\n anteriorly), clear posteriorly\\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: No(t) Muscle wasting\\n Skin: Warm, No(t) Rash: , No(t) Jaundice\\n Neurologic: Attentive, Follows simple commands, Responds to: Not\\n assessed, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\\n Labs / Radiology\\n [image002.jpg]\\n Fluid analysis / Other labs: EKG: from this AM sinus rhythm at 60bpm\\n LBBB, poor R-wave progression, and q-waves inferiorly.\\n EKG on arrival: HR 80 bpm atrial pacing, inferior q-waves, QTc 469.\\n Poor R-wave progression,\\n .\\n TELEMETRY: polymorphic VT by telemetry from .\\n .\\n 2D-ECHOCARDIOGRAM: \\n 1.The left atrium is elongated.\\n 2. Left ventricular wall thicknesses are normal. The left ventricular\\n cavity size is top normal/borderline dilated. Overall left ventricular\\n systolic function is severely depressed, with severe global\\n hypokinesis. [ Intrinsoic LV functiom may be depressed given the\\n severity of the degree of MR].\\n 3. Right ventricular chamber size is normal. The right ventricular\\n function appears normal.\\n 4.The aortic valve leaflets (3) appear structurally normal with good\\n leaflet excursion and no aortic regurgitation.\\n 5.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\\n regurgitation is seen.\\n 6.The estimated pulmonary artery systolic pressure is normal.\\n 7.There is a trivial/physiologic pericardial effusion.\\n .\\n Exercise MIBI: \\n IMPRESSION: Fair functional exercise tolerance limited by exertional\\n dyspnea. No anginal symptoms with an uninterpretable ECG. Flat blood\\n pressure response to exercise. Nuclear report sent separately.\\n .\\n IMPRESSION: Moderate fixed inferior wall perfusion defect at the level\\n of exercise achieved. Global hypokinesis with LVEF of 27%.\\n .\\n CARDIAC CATH: n/a\\n .\\n HEMODYNAMICS: n/a\\n .\\n LABORATORY DATA:\\n Magnesium 2.2\\n Potassium 4.1\\n Dig 1.2\\n INR 2.5\\n Baseline Cr 1.2, Hct 35\\n (see below for full details).\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB)\\n .\\n ASSESSMENT AND PLAN\\n 62 y/o M with dilated cardiomyopathy a/w torsades in setting of\\n prolonged QT interval during dofetilide initiation.\\n .\\n # CORONARIES:\\n - continue statin therapy\\n .\\n # PUMP: EF 15%, euvolemic. No clinical evidence of myocardial\\n stunning after defibrillation.\\n - Continue lasix, aldactone, lisinopril\\n - Beta-blocker okay now that he is paced.\\n - Monitor for e/o volume overload\\n - daily weight\\n - fluid restrict to 1500ml\\n .\\n # RHYTHM: Torsades in setting of prolonged QT interval.\\n - Paced at 80 bpm\\n - Maintain Mg > 2.0 and Potassium > 4.5\\n - Repeat Mg/K now\\n - Monitor on Tele as per ICU protocol.\\n - d/c dofetilide\\n - continue other home medications.\\n - Vanco x1, clindamycin x48 hours given pcn allergy, MRSA\\n .\\n # Atrial Fibrillation: Continue coumadin.\\n - Paced at 80bpm\\n .\\n # Pulmonary Toxicity/Sleep Apnea/Bronchiectasis: No PFT's available.\\n - continue home medicaitons and o/n home O2 therapy.\\n - stable for now.\\n .\\n # GI Medications/GERD/Constipation\\n - continue ranitidine\\n - hold metoclopramide given ? interaction with dofetilide, may\\n reinitiate in the future once dofetilide washed out (clarify with EP\\n concern with reglan)\\n .\\n # BPH: Doxazosin qhs\\n .\\n # Depression: Continue home buproprion\\n .\\n FEN: Low Na diet.\\n .\\n ACCESS: PIV's x2\\n .\\n PROPHYLAXIS:\\n -DVT ppx with coumadin by INR\\n -Pain management with oxycodone/tylenol\\n -Bowel regimen with senna/bisacodyl - monitor for constipation with\\n oxycodone.\\n .\\n CODE: Full\\n .\\n COMM: With patient and family\\n .\\n DISPO: CCU for now, likely c/o in AM.\\n ICU Care\\n Nutrition:\\n Glycemic Control: Blood sugar well controlled\\n Lines:\\n 20 Gauge - 03:09 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Coumadin)\\n Stress ulcer: PPI\\n VAP:\\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\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2195-02-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 520401,\n \"text\": \"Briefly this is a 62 yo M w/ a PMHx of a dilated cardiomyopathy\\n secondary to chemotherapy for Hodgkins lymphoma 20 years ago as well as\\n atrial fibrillation who was admitted for initiation of Dofetilide.\\n While undergoing initiation of Dofetilide therapy his QTc elongated and\\n he had torsades. Pt medically treated and sent to EP lab for placement\\n of ICD. He is now s/p ICd placement and admitted to CCU for\\n observation.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 520664,\n \"text\": \"This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\\n chemotherapy for Hodgkin\\ns lymphoma 20 years ago as well as atrial\\n fibrillation who was admitted to 3 for initiation of\\n Dofetilide.\\n While undergoing initiation of Dofetilide therapy his QTc elongated\\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\\n EP lab for placement of ICD.\\n He is now s/p ICD/pacer placement and admitted to CCU for observation-\\n stable hemodynamics, no further VT noted.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt hemodynamically stable s/p ICD/pacer placement for toursades.\\n Admitted to CCU for further observation overnite.\\n Action:\\n Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. ICD\\n site at left shoulder D/I- no drainage noted. Arm remains immobilized\\n in a sling. Dsg d/i\\n Response:\\n Pt remains A paced, hemodynamics stable. No further tachy or brady\\n arrythmias this shift.\\n Plan:\\n Bedrest x 24 hrs w sling- increase activity once able. Continue to\\n monitor for any arrythmias- or hemodynamic issues. Keep pt aware of\\n progress, plan of care.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt s/p incision for ICD current w moderate level of pain at site.\\n Action:\\n Treating pain w repositioning, pain meds. Received oxycontin total 10\\n mg this shift\\n Response:\\n Pt more comfortable w regular dosing of pain med.\\n Plan:\\n Continue to make pt comfortable as needed- continue close assessment of\\n pain level and treat accordingly. Continue to observe incisional site\\n for any change/drainage.\\n Demographics\\n Attending MD:\\n H.\\n Admit diagnosis:\\n ATRIAL FIBRILLATION\\n Code status:\\n Full code\\n Height:\\n 68 Inch\\n Admission weight:\\n 84 kg\\n Daily weight:\\n 84.4 kg\\n Allergies/Reactions:\\n Penicillins\\n Unknown; Hives;\\n Tetracyclines\\n Hives;\\n Sulfa (Sulfonamides)\\n Hives;\\n Erythromycin Base\\n Hives;\\n Amiodarone\\n pulmonary toxic\\n Precautions:\\n PMH: COPD\\n CV-PMH: Arrhythmias, CHF\\n Additional history: h/o cm secondary to Adriamycin for hodgkins\\n lymphoma EF 15%\\n Depression\\n Class III heart failure.\\n Surgery / Procedure and date:\\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:98\\n D:64\\n Temperature:\\n 97.4\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 16 insp/min\\n Heart Rate:\\n 77 bpm\\n Heart rhythm:\\n A Paced\\n O2 delivery device:\\n None\\n O2 saturation:\\n 97% %\\n O2 flow:\\n FiO2 set:\\n 24h total in:\\n 480 mL\\n 24h total out:\\n 1,050 mL\\n Pertinent Lab Results:\\n Sodium:\\n 136 mEq/L\\n 03:45 AM\\n Potassium:\\n 4.9 mEq/L\\n 03:45 AM\\n Chloride:\\n 99 mEq/L\\n 03:45 AM\\n CO2:\\n 29 mEq/L\\n 03:45 AM\\n BUN:\\n 27 mg/dL\\n 03:45 AM\\n Creatinine:\\n 1.3 mg/dL\\n 03:45 AM\\n Glucose:\\n 90 mg/dL\\n 03:45 AM\\n Hematocrit:\\n 34.2 %\\n 03:45 AM\\n Valuables / Signature\\n Patient valuables:\\n Other valuables:\\n Clothes: Transferred with patient\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with:\\n Jewelry:\\n Transferred from: \\n Transferred to: \\n Date & time of Transfer: 12:00 AM\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2195-02-19 00:00:00.000\",\n \"description\": \"Cardiology Fellow Note/ Addendum\",\n \"row_id\": 520389,\n \"text\": \"TITLE: Cardiology Fellow Note/ Addendum\\n Please see residents H and P for full details.\\n Briefly this is a 62 yo M w/ a PMHx of a dilated cardiomyopathy\\n secondary to chemotherapy for Hodgkins lymphoma 20 years ago as well as\\n atrial fibrillation who was admitted for initiation of Dofetilide.\\n While undergoing initiation of Dofetilide therapy his QTc elongated and\\n he had torsades. Pt medically treated and sent to EP lab for placement\\n of ICD. He is now s/p ICd placement and admitted to CCU for\\n observation.\\n Plan:\\n -will talk w/ EP regarding treatment of a fib, but will obviously hold\\n dofetilide and consider other antiarrhythmic therapy (pt has previously\\n failed Amiodarone therapy). Likely still a candidate for flecainide.\\n -monitor on tele for residual ventricular tachycardias\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 520450,\n \"text\": \"This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\\n chemotherapy for Hodgkin\\ns lymphoma 20 years ago as well as atrial\\n fibrillation who was admitted to 3 for initiation of\\n Dofetilide.\\n While undergoing initiation of Dofetilide therapy his QTc elongated\\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\\n EP lab for placement of ICD.\\n He is now s/p ICd placement and admitted to CCU for observation- stable\\n hemodynamics, no further VT noted.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 520451,\n \"text\": \"This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\\n chemotherapy for Hodgkin\\ns lymphoma 20 years ago as well as atrial\\n fibrillation who was admitted to 3 for initiation of\\n Dofetilide.\\n While undergoing initiation of Dofetilide therapy his QTc elongated\\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\\n EP lab for placement of ICD.\\n He is now s/p ICD/pacer placement and admitted to CCU for observation-\\n stable hemodynamics, no further VT noted.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"EP Note\",\n \"row_id\": 520658,\n \"text\": \"History of Present Illness\\n Date: \\n Subsequent care\\n Events / History of present illness: Last 24 hours: Yesterday 11am, pt\\n developed TdP requiring shock x 4 initiated by VPC after pause and\\n brady. ICD placed yesterday and paced at 80bpm, now decreased to\\n 75bpm. Defetilide stopped.\\n Medications\\n Unchanged\\n Physical Exam\\n BP: 102 / 53 mmHg\\n HR: 75 bpm\\n Tmax C last 24 hours: 36.6 C\\n Tmax F last 24 hours: 97.9 F\\n T current C: 36.6 C\\n T current F: 97.8 F\\n Previous day:\\n Intake: 940 mL\\n Output: 1,400 mL\\n Fluid balance: -460 mL\\n Today:\\n Output: 750 mL\\n Fluid balance: -750 mL\\n Cardiovascular: (Auscultation: RRR)\\n Respiratory: (Auscultation: CTA anterior)\\n Abdomen: (Palpation: soft)\\n Neurological: (Orientation: a&o x 3)\\n Other: L chest area ICD implant, tender to touch but no evidence of\\n hematoma.\\n Labs\\n 184\\n 9.9\\n 90\\n 1.3\\n 29\\n 4.9\\n 27\\n 99\\n 136\\n 34.2\\n 6.0\\n [image002.jpg]\\n 04:59 PM\\n 03:45 AM\\n WBC\\n 6.0\\n Hgb\\n 9.9\\n Hct (Serum)\\n 29.6\\n 34.2\\n Plt\\n 184\\n INR\\n 2.7\\n Na+\\n 136\\n K + (Serum)\\n 4.6\\n 4.9\\n Cl\\n 99\\n HCO3\\n 29\\n BUN\\n 27\\n Creatinine\\n 1.3\\n Glucose\\n 90\\n ABG: / / / 29 / Values as of 03:45 AM\\n Tests\\n ECG: (Date: ), 8:20am Apace 75, QT 420ms.\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB) - will hold on any anti-arrthymics for\\n now. just monitor for now and see if increased atrial pacing will\\n prevent him from going into afib.\\n VT - TdP from dofetilide s/p ICD yesterday Since he is at increased\\n risk with DCM and EF 10-15%, the decision was to implant an ICD instead\\n of just a ppm. QT shorted with faster HR.\\n - device interrogation ok, check CXR (PA/LAT) today.\\n - Device clinic visit 9:30am.\\n OK to d/c to tele floor for monitoring.\\n ------ Protected Section ------\\n I interviewed and examined Mr. . I agree with Dr. \\ns H+P,\\n A+P.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 14:29 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 520492,\n \"text\": \"This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\\n chemotherapy for Hodgkin\\ns lymphoma 20 years ago as well as atrial\\n fibrillation who was admitted to 3 for initiation of\\n Dofetilide.\\n While undergoing initiation of Dofetilide therapy his QTc elongated\\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\\n EP lab for placement of ICD.\\n He is now s/p ICD/pacer placement and admitted to CCU for observation-\\n stable hemodynamics, no further VT noted.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt hemodynamically stable s/p ICD/pacer placement for toursades.\\n Admitted to CCU for further observation overnite.\\n Action:\\n Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. ICD\\n site at left shoulder D/I- no drainage noted. Arm remains immobilized\\n in a sling. Given evening dose captopril once SBP>100/ . Held doxazosin\\n dose.\\n Response:\\n Pt remains A paced, hemodynamics stable. No further tachy or brady\\n arrythmias this shift.\\n Plan:\\n Bedrest x 24 hrs w sling- increase activity once able. Continue to\\n monitor for any arrythmias- or hemodynamic issues. Keep pt aware of\\n progress, plan of care. c/o to 3 once medically appropriate.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt s/p incision for ICD current w moderate level of pain at site.\\n Action:\\n Treating pain w repositioning, pain meds. Received oxycontin 10 mg, 5\\n mg , 5mg this shift, as well as Tylenol 650 mg x 2 doses. Also received\\n ativan 0.5 qhs( home dose)\\n Response:\\n Pt more comfortable w regular dosing of pain med. Slept well w ativan.\\n When awakened- or moving, developing moderate pain but diminishing w\\n medication\\n Plan:\\n Continue to make pt comfortable as needed- continue close assessment of\\n pain level and treat accordingly. Continue to observe incisional site\\n for any change/drainage.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"Physician Resident Progress Note\",\n \"row_id\": 520627,\n \"text\": \"Chief Complaint: 62 y/o M with dilated cardiomyopathy a/w torsades in\\n setting of prolonged QT interval during dofetilide initiation.\\n 24 Hour Events:\\n s/p pacemaker placement - some soreness around pocket\\n Allergies:\\n Penicillins\\n Unknown; Hives;\\n Tetracyclines\\n Hives;\\n Sulfa (Sulfonamides)\\n Hives;\\n Erythromycin Base\\n Hives;\\n Amiodarone\\n pulmonary toxic\\n Last dose of Antibiotics:\\n Vancomycin - 11:57 PM\\n Infusions:\\n Other ICU medications:\\n Ranitidine (Prophylaxis) - 10:27 PM\\n Other medications:\\n Changes to medical and 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: 36.6\\nC (97.9\\n Tcurrent: 36.6\\nC (97.8\\n HR: 80 (80 - 80) bpm\\n BP: 108/65(74) {78/47(54) - 127/71(80)} mmHg\\n RR: 16 (13 - 21) insp/min\\n SpO2: 96%\\n Heart rhythm: A Paced\\n Height: 68 Inch\\n Total In:\\n 940 mL\\n PO:\\n 740 mL\\n TF:\\n IVF:\\n 200 mL\\n Blood products:\\n Total out:\\n 1,400 mL\\n 450 mL\\n Urine:\\n 1,400 mL\\n 450 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n -460 mL\\n -450 mL\\n Respiratory support\\n O2 Delivery Device: None\\n SpO2: 96%\\n ABG: ///29/\\n Physical Examination\\n General Appearance: No acute distress, Thin\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic\\n Cardiovascular: (S1: Normal), (S2: Normal)\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : )\\n Abdominal: Soft, Non-tender, Bowel sounds present\\n Extremities: Right lower extremity edema: Absent, Left lower extremity\\n edema: Absent\\n Skin: Not assessed\\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\\n assessed, Tone: Not assessed\\n Labs / Radiology\\n 184 K/uL\\n 9.9 g/dL\\n 90 mg/dL\\n 1.3 mg/dL\\n 29 mEq/L\\n 4.9 mEq/L\\n 27 mg/dL\\n 99 mEq/L\\n 136 mEq/L\\n 34.2 %\\n 6.0 K/uL\\n [image002.jpg]\\n 04:59 PM\\n 03:45 AM\\n WBC\\n 6.0\\n Hct\\n 29.6\\n 34.2\\n Plt\\n 184\\n Cr\\n 1.3\\n Glucose\\n 90\\n Other labs: PT / PTT / INR:28.0//2.7, Ca++:8.4 mg/dL, Mg++:2.7 mg/dL,\\n PO4:3.7 mg/dL\\n Imaging: CXR: AP single view of the chest has been obtained with\\n patient sitting\\n upright position. Comparison is made with the next previous available\\n chest\\n examination of . The patient has recently undergone\\n implantation of a left-sided permanent pacer seen in anterior axillary\\n position. The pacer is connected to a dual electrode system. One of\\n these is\\n terminating in a position compatible with the right atrial appendage.\\n The\\n second with two electrode enforcements representing the ICD terminates\\n in a\\n position compatible with the apical portion of the right ventricle.\\n Heart\\n size is unchanged and remains within normal limits. No pulmonary\\n congestion\\n is seen and no pneumothorax can be identified.\\n Assessment and Plan\\n 62 y/o M with dilated cardiomyopathy a/w torsades in setting of\\n prolonged QT interval during dofetilide initiation.\\n # torsades de pointes - prolonged QT in setting of dofetilide\\n initiation. multiple shocks yesterday. s/p pacemaker placement\\n - follow up EP recommendations\\n - continue beta blocker\\n - paced at 80 bpm\\n - replete lytes aggressively\\n - d/c dofetilide\\n - tele monitoring\\n - continue digoxin\\n - continue warfarin\\n # cardiomyopathy: chronic systolic heart failure. EF 15%. Euvolemic. No\\n evidence of myocardial stunning after defibrillation.\\n - continue lasix\\n - continue spironolactone\\n - continue lisinopril\\n - continue atenolol\\n - I/O, weights\\n - fluid restrict\\n # atrial fibrillation: s/p pacemaker\\n - per above\\n # Pulmonary Toxicity/Sleep Apnea/Bronchiectasis: No PFT's available.\\n - continue home medicaitons and o/n home O2 therapy.\\n - stable for now.\\n # GI Medications/GERD/Constipation\\n - continue ranitidine\\n - hold metoclopramide given ? interaction with dofetilide, may\\n reinitiate in the future once dofetilide washed out (clarify with EP\\n concern with reglan)\\n # BPH: Doxazosin qhs\\n # Depression: Continue home buproprion\\n ICU Care\\n Nutrition:\\n Comments: heart healthy diet\\n Glycemic Control:\\n Lines:\\n 20 Gauge - 03:09 PM\\n Prophylaxis:\\n DVT: (Systemic anticoagulation: Coumadin)\\n Stress ulcer: H2 blocker\\n VAP:\\n Comments:\\n Communication: Comments:\\n Code status: Full code\\n Disposition:Transfer to floor\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"EP Note\",\n \"row_id\": 520601,\n \"text\": \"History of Present Illness\\n Date: \\n Subsequent care\\n Events / History of present illness: Last 24 hours: Yesterday 11am, pt\\n developed TdP requiring shock x 4 initiated by VPC after pause and\\n brady. ICD placed yesterday and paced at 80bpm, now decreased to\\n 75bpm. Defetilide stopped.\\n Medications\\n Unchanged\\n Physical Exam\\n BP: 102 / 53 mmHg\\n HR: 75 bpm\\n Tmax C last 24 hours: 36.6 C\\n Tmax F last 24 hours: 97.9 F\\n T current C: 36.6 C\\n T current F: 97.8 F\\n Previous day:\\n Intake: 940 mL\\n Output: 1,400 mL\\n Fluid balance: -460 mL\\n Today:\\n Output: 750 mL\\n Fluid balance: -750 mL\\n Cardiovascular: (Auscultation: RRR)\\n Respiratory: (Auscultation: CTA anterior)\\n Abdomen: (Palpation: soft)\\n Neurological: (Orientation: a&o x 3)\\n Other: L chest area ICD implant, tender to touch but no evidence of\\n hematoma.\\n Labs\\n 184\\n 9.9\\n 90\\n 1.3\\n 29\\n 4.9\\n 27\\n 99\\n 136\\n 34.2\\n 6.0\\n [image002.jpg]\\n 04:59 PM\\n 03:45 AM\\n WBC\\n 6.0\\n Hgb\\n 9.9\\n Hct (Serum)\\n 29.6\\n 34.2\\n Plt\\n 184\\n INR\\n 2.7\\n Na+\\n 136\\n K + (Serum)\\n 4.6\\n 4.9\\n Cl\\n 99\\n HCO3\\n 29\\n BUN\\n 27\\n Creatinine\\n 1.3\\n Glucose\\n 90\\n ABG: / / / 29 / Values as of 03:45 AM\\n Tests\\n ECG: (Date: ), 8:20am Apace 75, QT 420ms.\\n Assessment and Plan\\n ATRIAL FIBRILLATION (AFIB) - will hold on any anti-arrthymics for\\n now. just monitor for now and see if increased atrial pacing will\\n prevent him from going into afib.\\n VT - TdP from dofetilide s/p ICD yesterday Since he is at increased\\n risk with DCM and EF 10-15%, the decision was to implant an ICD instead\\n of just a ppm. QT shorted with faster HR.\\n - device interrogation ok, check CXR (PA/LAT) today.\\n - Device clinic visit 9:30am.\\n OK to d/c to tele floor for monitoring.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 520573,\n \"text\": \"This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\\n chemotherapy for Hodgkin\\ns lymphoma 20 years ago as well as atrial\\n fibrillation who was admitted to 3 for initiation of\\n Dofetilide.\\n While undergoing initiation of Dofetilide therapy his QTc elongated\\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\\n EP lab for placement of ICD.\\n He is now s/p ICD/pacer placement and admitted to CCU for observation-\\n stable hemodynamics, no further VT noted.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt hemodynamically stable s/p ICD/pacer placement for toursades.\\n Admitted to CCU for further observation overnite.\\n Action:\\n Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. ICD\\n site at left shoulder D/I- no drainage noted. Arm remains immobilized\\n in a sling. Given evening dose captopril once SBP>100/ . Held doxazosin\\n dose.\\n Response:\\n Pt remains A paced, hemodynamics stable. No further tachy or brady\\n arrythmias this shift.\\n Plan:\\n Bedrest x 24 hrs w sling- increase activity once able. Continue to\\n monitor for any arrythmias- or hemodynamic issues. Keep pt aware of\\n progress, plan of care. c/o to 3 once medically appropriate.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt s/p incision for ICD current w moderate level of pain at site.\\n Action:\\n Treating pain w repositioning, pain meds. Received oxycontin 10 mg, 5\\n mg , 5mg this shift, as well as Tylenol 650 mg x 2 doses. Also received\\n ativan 0.5 qhs( home dose)\\n Response:\\n Pt more comfortable w regular dosing of pain med. Slept well w ativan.\\n When awakened- or moving, developing moderate pain but diminishing w\\n medication\\n Plan:\\n Continue to make pt comfortable as needed- continue close assessment of\\n pain level and treat accordingly. Continue to observe incisional site\\n for any change/drainage.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2195-02-19 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 520432,\n \"text\": \"Briefly this is a 62 yo M w/ a PMHx of a dilated cardiomyopathy\\n secondary to chemotherapy for Hodgkin\\ns lymphoma 20 years ago as well\\n as atrial fibrillation who was admitted for initiation of Dofetilide.\\n While undergoing initiation of Dofetilide therapy his QTc elongated and\\n he had torsades. Pt medically treated and sent to EP lab for placement\\n of ICD. He is now s/p ICd placement and admitted to CCU for\\n observation.\\n Atrial fibrillation (Afib)\\n Assessment:\\n Pt received from EP lab s/p placement of ICD/PPM.\\n Tele A paced at rate of 80.\\n Pacer site is C&D.\\n O2 sats 94-96 on room air.\\n c/o chest pain at site of pacer.\\n Action:\\n Dofetilide dc\\n To remain on Coumadin.\\n Cont to monitor QTC.\\n Given Tylenol 650mg po.\\n Response:\\n Hemodynamically stable A paced.\\n Pain improved after Tylenol.\\n Plan:\\n Check lytes.\\n Maintain on bedrest overnite.\\n Vancomycin post procedure x\\ns 1 Followed by clindamycin.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"Cardiology Fellow Note/ Addendum\",\n \"row_id\": 520569,\n \"text\": \"TITLE: Cardiology Fellow Note/ Addendum\\n Please see residents H and P for full details.\\n Briefly this is a 62 yo M w/ a PMHx of a dilated cardiomyopathy\\n secondary to chemotherapy for Hodgkins lymphoma 20 years ago as well as\\n atrial fibrillation who was admitted for initiation of Dofetilide.\\n While undergoing initiation of Dofetilide therapy his QTc elongated and\\n he had torsades. Pt medically treated and sent to EP lab for placement\\n of ICD. He is now s/p ICd placement and admitted to CCU for\\n observation.\\n Plan:\\n -will talk w/ EP regarding treatment of a fib, but will obviously hold\\n dofetilide and consider other antiarrhythmic therapy (pt has previously\\n failed Amiodarone therapy). Likely still a candidate for flecainide.\\n -monitor on tele for residual ventricular tachycardias\\n ------ Protected Section ------\\n On this day I saw, examined and was physically present with the\\n resident / fellow for the key portions of the services provided. I\\n agree with the above note and plans.\\n I would add the following remarks:\\n History\\n nothing to add\\n Physical Examination\\n nothing to add\\n Medical Decision Making\\n nothing to add\\n Total time spent on patient care: 40 minutes\\n ------ Protected Section Addendum Entered By: , MD\\n on: 08:41 ------\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 110243,\n \"text\": \"Atrial paced rhythm. Left bundle-branch block. Compared to the previous tracing\\natrial pacing is new.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-02-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 110244,\n \"text\": \"Sinus bradycardia. Left bundle-branch block. Occasional ventricular premature\\nbeats. Possible old inferior myocardial infarction. Possible old anterior wall\\nmyocardial infarction. Compared to the previous tracing of there is no\\nchange.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-02-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 110245,\n \"text\": \"Sinus bradycardia. Compared to tracing #1 there is no significant diagnostic\\nchange.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 110246,\n \"text\": \"Sinus bradycardia with sinus arrhythmia. P-R interval prolongation. Left axis\\ndeviation. Probable inferior myocardial infarction of indeterminate age.\\nST-T wave changes that are non-specific. Compared to the previous tracing\\nof multiple described abnormalities persist.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 110247,\n \"text\": \"Normal sinus rhythm. Marked leftward axis. Compared to tracing #3 no diagnostic\\ninterim change.\\nTRACING #4\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 110248,\n \"text\": \"Normal sinus rhythm. Compared to tracing #1 no diagnostic interim change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-02-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 110295,\n \"text\": \"Normal sinus rhythm. Compared to tracing #2 there is no diagnostic interim\\nchange.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2195-02-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 110296,\n \"text\": \"Normal sinus rhythm. Intraventricular conduction delay with left bundle-branch\\nblock pattern and QRS duration of 140 milliseconds. Leftward axis at\\nminus 50 degrees. Compared to the previous tracing of no diagnostic\\ninterim change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1122114,\n \"text\": \" 7:30 AM\\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \\n Reason: Please evaluate for changes\\n Admitting Diagnosis: ATRIAL FIBRILLATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man s/p ICD\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for changes\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: ICD.\\n\\n FINDINGS: In comparison with the study of , there is little change. The\\n ICD device is again in place with leads in the region of the right atrial\\n appendage and apex of the right ventricle. No evidence of vascular\\n congestion, pleural effusion, or acute pneumonia.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-02-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1122028,\n \"text\": \" 2:59 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o pneumothorax\\n Admitting Diagnosis: ATRIAL FIBRILLATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man post DDD-ICD implant\\n REASON FOR THIS EXAMINATION:\\n r/o pneumothorax\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 4:42 PM\\n PFI: Successful pacer implantation, no pneumothorax.\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest AP portable single view.\\n\\n INDICATION: 62-year-old male patient with ICD implant, evaluate for possible\\n pneumothorax.\\n\\n FINDINGS: AP single view of the chest has been obtained with patient sitting\\n upright position. Comparison is made with the next previous available chest\\n examination of . The patient has recently undergone\\n implantation of a left-sided permanent pacer seen in anterior axillary\\n position. The pacer is connected to a dual electrode system. One of these is\\n terminating in a position compatible with the right atrial appendage. The\\n second with two electrode enforcements representing the ICD terminates in a\\n position compatible with the apical portion of the right ventricle. Heart\\n size is unchanged and remains within normal limits. No pulmonary congestion\\n is seen and no pneumothorax can be identified.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-02-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1122029,\n \"text\": \", H. 2:59 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o pneumothorax\\n Admitting Diagnosis: ATRIAL FIBRILLATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man post DDD-ICD implant\\n REASON FOR THIS EXAMINATION:\\n r/o pneumothorax\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Successful pacer implantation, no pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2195-02-20 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1122151,\n \"text\": \" 10:58 AM\\n CHEST (PA & LAT) Clip # \\n Reason: Leads placement\\n Admitting Diagnosis: ATRIAL FIBRILLATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 62 year old man post DDD-ICD implant\\n REASON FOR THIS EXAMINATION:\\n Leads placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: ICD implant.\\n\\n FINDINGS: In comparison with the earlier study of this date, there is little\\n overall change in the appearance of the ICD implant. No acute cardiopulmonary\\n disease is identified.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":982,"cells":{"subject_id":{"kind":"number","value":27894,"string":"27,894"},"hadm_id":{"kind":"number","value":173572,"string":"173,572"},"target_text":{"kind":"string","value":"71M with head and neck cancer, trach/ transferred from an outside hospital with atrial fibrillation with RVR, NSTEMI, acute oliguric renal failure, and acute ischemic hepatitis. . # NSTEMI: Patient has a history of CABG, and had very elevated cardiac enzymes on admission (Trop T 65.48, CKMB 72.1). TTE during this admission shows acute changes, EF from 55-60% on to 25-30%, severely depressed LV systolic function, severe LV global HK in inf, post, lat walls, depressed RV systolic function, 3+MR, 2+TR. EKG shows 2 mm STD V3-V5 which is 0. depression laterally from his old EKGs. CXR shows unchanged pleural effusions and atelectasis. He was maintained on aspirin and metoprolol. He was not started on a statin since he was admitted with acute ischemic hepatitis, and LFTs were still decreasing to normal levels. . # AFIB with rapid ventricular rate: He was in AFIB with rapid ventricular rate, with a pacer for sick sinus/tachy-brady, HR 100-140s, controlled on Metoprolol and Diltiazem. He was not anticoagulated since he has head and neck cancer and had pancytopenia from chemo and radiation. . # Hypoxemic respiratory failure: Likely associated with bilateral pleural effusions, cardiac stunning, and COPD. Patient has a trach and was kept on trach mask for most of the day, with intermittent transition to AC and PS ventilatory support during the night or with decreasing O2 saturation. Patient was diuresed here with lasix gtt, 5-10 mg per hour for pleural effusions, but he was not total body fluid overloaded. Patient has COPD and was placed on albuterol inhalers, spiriva, and advair during admission to be continued. . **As a note, the patient's lasix regimen was added during this admission, and should be titrated up as appropriate to diurese for his bilateral pleural effusions. Currently at the standing dose, he is running even in his fluid goals daily. . # Acute oliguric renal failure: Patient's acute renal failure was prerenal in etiology and associated with a depressed EF and/or post-ischemic ATN, not responsive to fluid boluses. Renal US showed atrophic L kidney unchanged since , no stone, no hydro, no mass. Ulytes consistent with prerenal etiology. Renal failure gradually resolved over admission. . # Acute ischemic hepatitis: Patient had LFTs in the thousands, associated with hepatic congestion from NSTEMI. He showed no signs of cholestasis or obstruction. Tylenol tox screen was negative, hepatitis panel was negative. . # Febrile neutropenia/pancytopenia/L piriform sinus SCC: Patient has head and neck cancer, s/p carboplatin/taxol and XRT, last XRT and chemo . He was neutropenic for only the first day of admission, and was afebrile throughout admission. He is followed as an outpatient by Hem/Onc: , Dr. . He completed a Ceftazidime/Vanco for a 7 day course for neutropenia and coverage in case of pneumonia. He was on neupogen until he was no longer neutropenic. All blood, urine, sputum cultures were negative. His goal Hct was maintained at >28, goal platelets were >30, and these goals were met throughout admission. . # Hypertension: Was unremarkable throughout admission, controlled on Metoprolol and Diltiazem. . # Diabetes mellitus: He was maintained on Lantus 16 qhs and sliding scale."},"extractive_notes_summ":{"kind":"string","value":"TUBE FEEDS OF PROBALANCE FULL STRENGHT WERE PLACED ON HOLD. WHEEZE, WHICH RESOLVED WITH TREATMENTS. HAS BEEN SUCTIONED MODERATE AMT'S OF CLEAR/TAN SECRETIONS. Pt placed back on vent. SINCE THIS PROCEDURE PT. MEDS WERE GIVNE VIA PEG. REMAINS A DNR/DNI.PT. RESP RATE IS CONTROLLED AND PT. Standard position of tracheostomy. Referral sent w/pt. Ascites. FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. Lung sounds shightly ronchorus. resting comfort.GI: seen by tam and J-tube site cleared for discharge. SUITE NOTIFIED AND CT ABD. MDIs given per order. MDIs given per order. MICU 7 RN Note 0700-1300refer to Page 2 referral and discharge plan.Awake alert oriented x2 follows commands MAE random equal strenght. EXCRETING MODERATE TO GROSS AMT'S OF SECRETIONS AROUND THE TRACH ITSELF. resident aware pt recieved Ativan 1mg IV x2 w/calming effect.HR 75-130 Afib recieved diltiezem and Lopressor per routine for controlled afib. HAS NKDA.PT. The pacemaker leads terminates in the right ventricle and right atrium. RECEIVED 60MEQ KCL PO, VIA GTUBE AND 40MEQ KCL IV. Progression of CHF findings. Respiratory Care:Pt recieved on trach mask. Received MDI's as ordered. Needed to be placed back on vent d/t desating to high 80s and tachypnea. 12:54 AM CHEST (PORTABLE AP) Clip # Reason: Eval for infiltrates, effusion interval change. THE VANCO IS ON HOLD VANCO THROUGH 63.2. The pancreas and adrenal glands are within normal limits. NPN PA-7P:NEURO: PT IS A/OX2 OR 3. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. GJ tube tip in jejunal loop. IMPRESSION: No short interval change in CHF/fluid overload. There are bilateral substantial pleural effusions layering in semi-erect position with associated bibasilar atelectasis. Purulent drainage noted, avvelyn applied. HAS BEEN AFBRILE.PT. HAS A BOLVONA TRACH. DSD APPLYED.POC: CONT VENT SUPPORT. REMAINS A DNR/DNI.PT. REMAINS A DNR/DNI.PT. HAS TRACH (BOVONA), PT. REMAINS A DNR/DNI AT THIS TIME. FOLLOWS COMMANDSA AND REMAINS AFEBRILE.PT. HIS RR 15-20.CV: A-FIB W/ PVC NOTED, HR 110-82. Cont PSV. Plan is to wean as tolerates in am. HAS NKDA.PT. HAS NKDA.PT. HR 60-130 Afib occass PVC when HR drifts down AV paced. MDI given as per order. PT HAS SECURE AND INTACT PEG TUBE- DRESSING CHANGED. Peripheral pulses 2+ DP/1+DT. Placed back on trach mask @ ~ 0530. was 138. PLACED BACK ON VENT ON PS SETTINGS. K/MG/PHOS AT . Received MDI's as ordered. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. DUODERM ON COCCYX CHANGED THIS SHIFT.PLAN: CONTINUE TO WEAN VENT AS PT WILL TOLERATE. Resp CarePt remaisn trached with #7.0 h20 cuff. GOOD UA OUT PUT NOTED. TO IR TODAY FOR GJ TUBE. REMAINS ON ROUTINE LASIX DOSING.PT. CONTINUES TO DIURESIS >100CC/HR PT. ABLE TO MAE.RESP: LS MIXED BAG. RIGHT GLUTEAL EXHIBITS AREA AS WELL, WITH ALLELYN DRESSING CHANGED, WHICH REMAINS INTACT AT THIS TIME. Received MDI's, suctioned sm amt thick yellow. 'S REMAIN INTACT, PATENT, AND SECURED, WITH IVF OF N/S AT KVO.PLAN IS FOR POSSIBLE TRANSFER TO REHAB FACILITY. AFEBRILE. DUODERM GEL W/ DSD IS TX ORDER. RESP RATE REMAINS CONTROLLED AND PT. sacral edema.Resp: recieved pt on vent CPAP/PS 10/5 40% #7Bovona trache. TODAY HE WENT TO IR. CONTINUE ESMOLOL GTT FOR RATE CONTROL. Coccyx red allevyn dsg reapplied. EXHIBIT GTUBE, SINGLE LUMEN, WHICH HAS DRESSING INTACT. PRESENTLY PT. TRACH CARE PT TOLERATED WELL.CV: S1 AND S2 AS PER AUSCULTATION. Cont. BLBS course, scutioned for sm-mod amt thick aple yellow secrtions, mdi given per order. Had episode of ^RR, though sats remained good. QUESTION TF. WILL GO TO IR TODAY FOR GJ TUBE. SUCTION MODERATE AMOUNT WHITE SECRETYION.YESTARDAY TOLLEARED TRACH COLLAR FOR 4HR.PT NEEDS IP CONSULT FOR POSSIBLE TRACH CHANGES.CV: AS SAYS ABOVE, START ON DILT GTT.REMAIN OB AFIB NO ECTOPY. Areas with purulent drainage, OTA.ID: Remains neutropenic with last WBC 2.3. recieved lasix Lungs clear raled RLL dim L base. Moderate [2+] tricuspid regurgitation isseen. areas on buttox with breakdown noted. Abd soft + BS GT inplace w/gastric leakage. vanco level sent. CXR showed Rt middle lobe pna. EKG done. vanco level wean vent to trach collor mask as tollerates. L/S coarse T/O, bilateral chest expansion noted. Sxned for sm. W/ OUT RESP DISTRESS NOTED. Cuff remains down w/ improved sats.ID: afebrile t-max 98, WBC 7.5 taken off neutropenic precautions. On neutropenic precautions. NOW ON VANCO AND CEFAZIDIME IV.CV: HE IS R/I FOR A NSETMI. ECG showed ST depressions, Troponin I elevated to 65.48. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. Resp CareFairly quite shift with pt. Abd tender to palpation. Abd tender to palpation. wean on TM for noc as tol. able to oral sxn self. able to oral sxn self. Left ventricularhypertrophy. Pt lab values showed neutropenia and elevated BUN/Cr. HR control, wean vent. gluteal. TF residuals check q4h with 0.0mls returned. ABLE TO MAE.RESP: HE IS TRACHED. HR 130s, and BP 130s/90s. Last BUN/Cr 83/2.7 respectively.ID: Remains on neutropenic precautions with WBC 2.5. LUNG SOUNDS COURS/RONCHI BILAT. PEG tube patent and secure, residuals checked q4h with 0.0ml returned. Last BUN/Cr, 77/2.7 respectively. Seriel CK/troponin trending down although troponin ^ 3.26 (?renal response). antibx for coverage. ECG showed ST depression, and troponin I elevated to 65.48. trached, on vent. Diff. Arrived to MICU trached and PEGed.Nuero: Pt. Diurese to 1L neg. peripheral pulses 3+ DP/2+ DT. areas of breakdown noted on rt. Last LDH 1182, AST 1552, ALT 2522.Skin: Mult. Resp CarePt was sx Q 2-4hrs, alb / atr MDI Q 4 hrs. BUN 77/2.7. , abx cetazipine, Vanco level 53 Vanco d/c.GU/GI: Foley u/o 20-300cc/hr s/p lasix. currently on Diltiazem PO and Metoprolol Po.neuro: A/ox3, comminication wiht mouth words and writting on board. Atrial fibrillation.Weight (lb): 128BP (mm Hg): 146/12HR (bpm): 103Status: InpatientDate/Time: at 15:37Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size."},"n_notes":{"kind":"number","value":45,"string":"45"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2107-10-20 00:00:00.000","description":"CT ABDOMEN W/O CONTRAST","row_id":978233,"text":" 5:12 AM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: please eval for PEG placement.\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n Field of view: 34\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old trached and PEG'd male w/ multiple medical problems including DM,\n COPD, afib, CAD s/p CABG and locally invasive laryngopharyngeal cancer who had\n IR placed GJ tube today, now with extravasation of tube feeds and stool around\n PEG.\n REASON FOR THIS EXAMINATION:\n please eval for PEG placement.\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: 5:32 AM\n 1. GJ tube tip in jejunal loop. No dilated bowel. No free intraperitoneal\n air.\n 2. Large bilateral pleural effusions and associated atelectasis.\n 3. Heavy vascular atherosclerotic calcification. Caliber and contour of\n aorta unchanged from .\n 4. Atrohpic left kidney.\n ______________________________________________________________________________\n FINAL REPORT\n\n\n INDICATION: GJ tube position in patient with leaking around tube during\n feeding\n\n COMPARISONS: Torso CT dated .\n\n TECHNIQUE: MDCT images from the lung bases through the mid iliac level were\n obtained with oral contrast only. Lack of intravenous contrast limits\n evaluation of the solid abdominal viscera. Multiplanar reformations were\n essential to interpretation.\n\n LOWER CHEST: Sternotomy wires are present. Cardiac leads are again\n identified, with scattered CABG clips. There are large, simple bilateral\n pleural effusions with adjacent atelectasis. The left effusion appears\n increased when compared to the previous study.\n\n LIVER: Scattered calcifications are compatible with granuloma. The liver is\n otherwise unremarkable. A large splenic calcification is again noted. The\n pancreas and adrenal glands are within normal limits. The left kidney remains\n shrunken. There is no evidence of hydronephrosis. The gallbladder is\n present.\n\n A gastrojejunostomy tube is in appropriate position, entering through the left\n anterior abdominal wall and coursing through the stomach and duodenum into the\n jejunum in the lower abdomen. The proximal coil of the tube is in the second\n portion of the duodenum. There is no evidence of contrast extravasation.\n There are no abnormal fluid collections at the site of entry. There is trace\n (Over)\n\n 5:12 AM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: please eval for PEG placement.\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n Field of view: 34\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n free fluid in the abdomen. There is a stable abdominal aortic aneurysm\n measuring at least 4 cm in greatest dimension, with extensive atheromatous\n calcification. There are scattered surgical clips in the left periaortic\n region. No pathologically enlarged lymph nodes are identified. There is no\n evidence of bowel dilatation. Diffuse stranding of the subcutaneous tissues\n is compatible with anasarca.\n\n OSSEOUS STRUCTURES: There is a stable sclerotic focus in the left iliac bone.\n Multilevel degenerative changes are present in the lumbar spine.\n\n IMPRESSION:\n 1. Appropriate position of a GJ tube, without evidence of oral contrast\n extravasation or abnormal fluid collection.\n 2. Large bilateral pleural effusions.\n\n\n"},{"category":"Radiology","chartdate":"2107-10-19 00:00:00.000","description":"REPOSITION GASTRIC TUBE INTO DUODENUM","row_id":978077,"text":" 7:27 AM\n PERC G/J TUBE CHECK Clip # \n Reason: Please change G tube (Foley 14 cath currently) to GJ tube\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n Contrast: OPTIRAY Amt: 25CC\n ********************************* CPT Codes ********************************\n * REPOSITION GASTRIC TUBE INTO D CHANGE PERC TUBE OR CATH W/CON *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with NSTEMI, head and neck cancer, drinks PO liquids by mouth,\n does not eat food by mouth\n REASON FOR THIS EXAMINATION:\n Please change G tube (Foley 14 cath currently) to GJ tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR THE EXAM: 71-year-old male with NSTEMI, head and neck cancer\n with G-tube placed.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. . Dr.\n , the attending radiologist, was present and supervising throughout the\n procedure.\n\n FINDINGS AND TECHNIQUE: Following explanation of the potential risks and\n benefits of the procedure, written informed consent was obtained. The patient\n was placed supine on the angiographic table and abdomen was prepped and draped\n in standard sterile fashion. A timeout was performed to confirm patient\n identity and proposed procedure.\n\n Initial fluoroscopic image demonstrated the presence of Foley catheter in the\n abdomen. A small amount of contrast was injected and demonstrated the balloon\n placed inside of the stomach. A 0.035 wire was advanced into the\n stomach trough the Foley catheter. The present Foley catheter was then\n removed over the wire. A 7- French bright tip sheath was advanced over the\n wire with the tip in the stomach. The wire was removed and a 0.035\n straight Glidewire was advanced. A combination of the 0.035 straight\n Glidewire, 0.035 J-guidewire, 4- French 0.035 Cobra catheter, and 5-\n French Kumpe catheter were used to get access to the jejunum. The wire was\n then exchanged for a 0.035 straight Amplatz, that was advanced into the\n jejunum. The catheter was removed. A 14-French peel-away introducer was\n advanced over the wire into the stomach. 14-French gastrojejunostomy\n catheter was advanced through the peel-away over the wire with the tip placed\n in the proximal jejunum. The wire was removed and the pigtail was formed\n within the duodenum. A small amount of contrast was injected through the tube\n and confirmed the position of the tip of the catheter into the jejunum.\n\n The catheter was secured to the skin. The patient tolerated the procedure\n well and there were no immediate complications.\n\n IMPRESSION: Successful insertion of a 14-French G-J tube with tip in\n the jejunum. The tube is ready for use.\n\n\n (Over)\n\n 7:27 AM\n PERC G/J TUBE CHECK Clip # \n Reason: Please change G tube (Foley 14 cath currently) to GJ tube\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n Contrast: OPTIRAY Amt: 25CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"Radiology","chartdate":"2107-10-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":977341,"text":" 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 yo M, h/o of locally invasive laryngopharyngeal CA admitted, trach and PEG\n admitted with hypoxia, MI\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia.\n\n Portable AP chest radiograph compared to .\n\n The tracheostomy tube is in place. The pacemaker leads terminates in the\n right ventricle and right atrium. There is no change in mild cardiomegaly and\n tortuous and calcified aorta.\n\n The bibasilar consolidations and bilateral right more than left pleural\n effusion are essentially unchanged. There is no evidence of congestive heart\n failure.\n\n IMPRESSION: No significant interval change in bibasilar atelectasis and\n pleural effusion. Standard position of tracheostomy.\n\n\n"},{"category":"Radiology","chartdate":"2107-10-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":978048,"text":" 12:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrates, effusion interval change.\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 yo M, h/o of locally invasive laryngopharyngeal CA admitted, trach and PEG\n admitted with hypoxia, MI, now with desatting to 80%.\n REASON FOR THIS EXAMINATION:\n Eval for infiltrates, effusion interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Laryngopharyngeal cancer. MI with SOB.\n\n AP bedside chest. The heart is borderline enlarged with satisfactorily\n positioned dual-chamber bipolar pacing leads and previous CABG. Tracheostomy\n tube. There are bilateral substantial pleural effusions layering in\n semi-erect position with associated bibasilar atelectasis. No demonstrable\n PTX. I cannot exclude consolidations in the obscured bases. Appearances are\n unchanged from exam one day ago and little changed from study .\n\n IMPRESSION: No short interval change in CHF/fluid overload.\n\n\n"},{"category":"Radiology","chartdate":"2107-10-14 00:00:00.000","description":"RENAL U.S.","row_id":977371,"text":" 8:34 AM\n RENAL U.S. Clip # \n Reason: NEW ONSET RENAL FAILURE, S/P CABG R/O OBSTRUCTION\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: New onset renal failure.\n\n Comparison is made to the prior CT of the abdomen and pelvis performed on , .\n\n The right kidney measures 11 cm. No stone, hydronephrosis or mass is noted\n within the right kidney.\n\n The left kidney measures 7.5 cm. No stone, hydronephrosis or mass is noted\n within the left kidney. The bladder was empty and could not be evaluated.\n\n Small amount of free fluid is noted within within the abdomen.\n\n IMPRESSION:\n 1. Atrophic left kidney (seen on prior CT), which is unchanged since \n . No stone, hydronephrosis or mass is noted within the kidneys.\n\n 2. Ascites.\n\n\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2107-10-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":977507,"text":" 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 yo M, h/o of locally invasive laryngopharyngeal CA admitted, trach and PEG\n admitted with hypoxia, MI\n REASON FOR THIS EXAMINATION:\n SOB\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Laryngeal cancer. Hypoxia.\n\n Tracheostomy tube and permanent pacemaker are unchanged in position.\n Cardiomediastinal contours are stable. Perihilar haziness and peripheral\n interstitial opacities are attributed to interstitial pulmonary edema and has\n slightly worsened. Moderate-sized right effusion has slightly increased as\n well as a small left pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2107-10-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":977956,"text":" 12:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change.\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 yo M, h/o of locally invasive laryngopharyngeal CA admitted, trach and PEG\n admitted with hypoxia, MI, please evaluate for interval change.\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: History of locally invasive laryngopharyngeal carcinoma admitted,\n tracheostomy, admitted with hypoxia and MI. Evaluate for interval change.\n\n FINDINGS: AP single view of the chest obtained with patient in semi-upright\n position is analyzed in direct comparison with a similar preceding study dated\n . Tracheostomy, permanent pacer unaltered and stable.\n Previously described diffuse perivascular haze in the pulmonary vasculature\n and bilateral basal densities indicative of pleural effusions have further\n progressed. No new discrete pulmonary parenchymal infiltrates are identified.\n\n IMPRESSION: Stable instrument position. Progression of CHF findings.\n\n\n"},{"category":"Nursing/other","chartdate":"2107-10-21 00:00:00.000","description":"Report","row_id":1626916,"text":"MICU 7 RN Note 0700-1300\n\nrefer to Page 2 referral and discharge plan.\n\nAwake alert oriented x2 follows commands MAE random equal strenght. denies pain. c/o feeling anxious requests to have valium. resident aware pt recieved Ativan 1mg IV x2 w/calming effect.\n\nHR 75-130 Afib recieved diltiezem and Lopressor per routine for controlled afib. Occas episoded AV paced. BP 100-124/50-75 MAPS>60.\n\nRecieved pt on vent CPAP/PS 12/5 40%, #7.0 Bovona Trache. Wean to TM 50% for 2 hrs became tachypneic RR>40 desat 88%, suctioned via ETT for sm amts thick pale yellow. @ 1015 placed on Vent CPAP/PS 15/5 40%. resting comfort.\n\nGI: seen by tam and J-tube site cleared for discharge. leakage slowed down duoderm drsg site. TF probalance adv to 65cc/hr Goal tol well. Abd soft + BS. sm loose Brown stool x1.\n\nGU: Foley u/o 20-80cc/ht recieved Lasix 40mg Via J-tube\n\nderm: Skin impaired Neck wounds radiation burn healling duoderm gel applied gauze drsg. Avellyn drsg .\n\nSocial: DNR/DNI\n Discharged to rehab @ 1300 by ambulance ACLS. Referral sent w/pt.\n\n\n"},{"category":"Nursing/other","chartdate":"2107-10-17 00:00:00.000","description":"Report","row_id":1626897,"text":"Respiratory Care:\nPt remains trached and on vent. Was on PSV most of night, but changed to AC mode for 3 hrs for ^RR. Suctioned mod amt of thick white secretions. Received MDI's as ordered. Morning = 74. Plan to go on trach collar again today.\n"},{"category":"Nursing/other","chartdate":"2107-10-17 00:00:00.000","description":"Report","row_id":1626898,"text":"NPN PA-7P:\n\n\nNEURO: PT IS A/OX2 OR 3. COOP W/CARE. ASKING ABOUT HIS TF. HE IS SWABING HIS BOUTH EVERY 2-3 HOURS. HE IS ABLE TO MOVE ALL EXT.\n\nRESP: TODAY TRACH MASK AT 40%. HE HAS A IN AFFECTIVE COUGH AT TIMES. WHERE HE WILL BRING UP SPUTUM, BUT WILL NOT BE UNABLE TO FORCE THE SPUTUM THROUGHT THE TRACH. HIS TRACH SITE IS A STAGE II. HE HAS DSD OVER THE SITE. AT 1730 HE WENT BACK ON THE VENT RR 38-40, HR 120-125. HIS O2 SAT DROP TO 88-91%. HE WAS PLACED ON CPAP 40%. IMMEDIATELY HIS RR WENT DOWN TO 20-22. LS EXP WHEEZING WHICH RESOLVED W/ HIS INHALERS.\n\nCV:DILT 30MG PP WAS GIVEN ONE HOUR BEFORE THE GTT WAS TURNED OFF. HE WAS GIVEN ONE MORE DOSE OF DILT 30MG AT 1500 2/2 HR UP THE >110. THE DILT WAS CHANGED TO 60MG QID. HE WILL ALSO START LOPRESSOR 12.5MG TONIGHT.\n\nGI/GU: HE IS NPO TODAY. AROUND THE PEG TUBE IS LEAKING THE TF. IP WILL BRONCH HIM TODAY TO LOOK INTO HIS STOMACH TO CHECK THE PLACEMENT OF THE PEG. MEDS WERE GIVNE VIA PEG. LASIX 20MG IV WAS GIVEN. THE GOAL IS 1L NEG. HE HAS PUT OUT 1130 SINCE THE LISIX WAS GIVEN.\n\nI/D: WBC 4.5. THE VANCO IS ON HOLD VANCO THROUGH 63.2. HE WILL CONT ON THE CEFTZ.\n\nPOC: WILL BRONCH HIM TO CHECK PLACEMENT OF PEG TUBE. ATTEMPT TO WEAN HIM FROM THE VENT. GENTLE DIURESIS W/ LASIX. START LOPRESSOR 12.5MG TONIGHT. HE WAS PUT IN FOR A WOUND CONSULT . WILL CONT TO MONITOR.\n"},{"category":"Nursing/other","chartdate":"2107-10-17 00:00:00.000","description":"Report","row_id":1626899,"text":"Respiratory Care:\nPt recieved trached and vented. Pt weaned to trach mask, pt stayed on TM 7hrs, then pt C/O SOB,RR 36-40, SpO2 97-98%, ? anxiety. Pt placed back on vent. Lung sounds coarse.Suctioned for thick yellow secretions. MDIs given per order. Pt to be bronched by IP. Will follow.\n"},{"category":"Nursing/other","chartdate":"2107-10-17 00:00:00.000","description":"Report","row_id":1626900,"text":"NSG PROGRESS ADDENDUM 1830:\n\nTHE PT HAS A BRONCH TO CHECK THE PLACEMENT OF THE TRACH. THE TRACH IS LOCATED AT THE 4TH CARINA. NO CHANGES WERE MADE.\n\nHE IS TO REMAIN NPO OVER NIGHT OR TO CHECK THE PAG.\n"},{"category":"Nursing/other","chartdate":"2107-10-19 00:00:00.000","description":"Report","row_id":1626909,"text":"Respiratory Care:\nPt recieved on trach mask. Needed to be placed back on vent d/t desating to high 80s and tachypnea. Pt currently on PS 15. Lung sounds shightly ronchorus. Suctioned for moderate thick white secretions. MDIs given per order. Pt traveled to and from IR for PEG placement without incident. Will follow.\n"},{"category":"Nursing/other","chartdate":"2107-10-20 00:00:00.000","description":"Report","row_id":1626910,"text":"RESPIRATORY CARE:\n\nPt remained on vent support overnight. Settings PSV 15, CPAP 5. Pt comfortable, NARD. BS's coarse at times, sxing thick white/tan secretions. Administering Albuterol and Atrovent MDI's in line with vent as ordered. See flowsheet for further pt data. Will follow, trache mask trials as tolerated today.\n"},{"category":"Nursing/other","chartdate":"2107-10-20 00:00:00.000","description":"Report","row_id":1626911,"text":"PT. REMAINS A DNR/DNI.\n\nPT. HAS NKDA.\n\nPT. HAS REMAINED A/A/O AND COMMUNICATES BY MOUTHING WORDS AND WRITING ON PAD. PT. FOLLOWS ALL COMMANDS AND HAS DENIED ANY PAIN OR DISCOMFORT DURING THIS SHIFT. PT. HGAS REMAINED AFEBRILE THROUGHOUT THIS SHIFT.\n\nPT. HAS BEEN AFIB IN A CONTROLLED RATE, WITHOUT ECTOPY NOTED. H.R. HAS RANGED 70-103. B/P HAS BEEN STABLE AND WNL'S RANGING 110-130'S/70-80'S. PULSE ARE ALL EASILY PALPABLE WITH NO EDEMA NOTED. PT. K WAS 2.9 AT 2200 AND PT. RECEIVED 60MEQ KCL PO, VIA GTUBE AND 40MEQ KCL IV. AM LABS ARE PENDING. PT. HAS BEEN RECEIVING IV LASIX.\n\nLUNGS ARE COARSE AND RHONCHUS THROUGHOUT. PT. AT TIMES HAS EXHIBITED INSP. WHEEZE, WHICH RESOLVED WITH TREATMENTS. RESP RATE IS CONTROLLED AND PT. REMAINS ON VENT VIA TRACH ON 15/5 THROUGHOUT THIS SHIFT, AND SINCE YESTERDAY AFTERNOON WHEN HE HAD GTUBE PLACEMENT PERFORMED IN I.R. PT. IS FOR POSSIBLE WEAN TO TRACH MASK TODAY. PT. HAS BEEN SUCTIONED MODERATE AMT'S OF CLEAR/TAN SECRETIONS. PT. EXHIBITS STRONG COUGH REFLEX. O2 SATS HAVE REMAINED >96%\n\nPT. HAD GTUBE REPLACED YESTERDAY OVER PRE EXISITNG SITE, WHICH HAD BEEN LEAKING. SINCE THIS PROCEDURE PT. HAS CONTINUES TO DRAIN AT THIS SITE, AND BY 0000 PT. WAS NOTED TO BE DRAINING STOOL LOKE MATERIAL FROM AROUND TUBE INSERTION SITE. TEAM MADE AWARE. PT. DENIED ANY PAIN OR DISCOMFORT, REMAINED AFEBRILE. TUBE FEEDS OF PROBALANCE FULL STRENGHT WERE PLACED ON HOLD. I.R. SUITE NOTIFIED AND CT ABD. TO EVALUATE SITUATION WAS PERFORMED THIS MORNING AT 0530. PT. TOLERATED THIS WELL. BLOOD SUGARS HAVE BEEN MONITORED AND HAVE RANGED 67, 134, 61. PT. TREATED WITHOUT DIFFICULTY, PT. DENIED ANY SYMPTOMS. FOLEY CATHETER REMAINS IN PLACE DRAINING MODERATE AMT'S OF CLEAR YELLOW URINE. PT. IS RECEIVING ROUTINE LASIX IV, AND CONTINUES TO DRAIN >100CC/HR.\n\nSKIN EXHIBITS TO NECK WHICH EXHIBITS ALLELYN DRESSING. TRACJH CARE HAS BEEN PERFORMED SEVERAL TIMES WITH PT. EXCRETING MODERATE TO GROSS AMT'S OF SECRETIONS AROUND THE TRACH ITSELF. PT. ALSO HAS ON RIGHT GLUTEAL. BOTH INTACT, SECURED, AND FUNCTIONING WELL, WITH N/S AT KVO.\n\nPLAN IS TO RE EVALUATE GTUBE AND FOLLOW THROUGH ON POSSIBLE LARGE TUBE PLACEMENT. MONITOR RESP STATUS, AND WEAN WHEN APPROPRIATE.\n"},{"category":"Nursing/other","chartdate":"2107-10-20 00:00:00.000","description":"Report","row_id":1626912,"text":"MICU7 RN Note 0700-1900\n\nEvents: Wean to TM return to PSV, Resumed TF, eval for GT site.\n\nNeuro: awake alert oriented x2, follows commands communicates mouthing word, writing. Pupils 3mm equal react brisk. MAE random equal strength. c/o anxiety @1500 recieved ativan 1mg IV w/ calming effect. S/p care @ 1600 ^ tachypnea/desat ^ anxiety recieved ativan 1mg IVP. Pain Management denies pain @ rest c/o discomfort when providing Neck wound and GT site are.\n\nCV: Recieved Pt rapid Afib HR >125 NPO given Diltiezem 5mg IV HR. HR 60-130 Afib occass PVC when HR drifts down AV paced. recieved Diltiezem 90mg and Lopressor 25mg per parameters. NBP 103-135/55-80 MAPS>60 . IV access 2 NS 10cc/hr. K+ 3.2 repleted KCL40meq/500cc slow infusion K+3.4. Peripheral pulses 2+ DP/1+DT. sacral edema.\n\nResp: recieved pt on vent CPAP/PS 10/5 40% #7Bovona trache. Wean to TM 60% wean to 40% until 1630 return to PSV 12/5. Pt became Increasing ly anxious # 1500 recieved Ativan 1mg w/ sl effect s/p care ^RR>40 ambu and suctioned for sm amt thick yellow recieved Ativan 1mg IVP and returned to PSV. Sats 90-98% TN >350. Lungs coarse DIm L base rales R base. recieved Lasix 20mgI now changed to PO.\n\nGI: abd soft tender GT site Abd CT revealled GT placement ok. GT site leaking sm amt bile. TF restarted @1000. Probalance 25cc/hr adv to goal as tol. Inc loose brown stool x3.\n\nGU: Foley u/o 20-150cc/hr diuresed Lasix 20mg IV.\n\nDerM; Skin impaired Neck/ trach site duoderm gel applied gauze drsg. Coccyx red allevyn dsg reapplied. GT site red bile drangage. duoderm applied for skin protection. Plan to see pt ? need for sutute for closure.\n\nSocial: DNR/DNI, sister called updated on status and plan of care.\n\nPlan: rest on PSV for night.\n consult to evaluate GT wound\n Discharge to rehab \n Refer to page 2 for completion\n\n\n"},{"category":"Nursing/other","chartdate":"2107-10-20 00:00:00.000","description":"Report","row_id":1626913,"text":"Respiratory Care:\nPt off to Trach mask @ 0820 till 1721. O2 sat.any where between 98% and 60%. later in the day his RR slowley increasing to 48. Sx'd given MDI's and returned to PSV 12/5 @ 40%...Given ativan just before going back to vent. Now seems much more comfortable. will follow.\n"},{"category":"Nursing/other","chartdate":"2107-10-21 00:00:00.000","description":"Report","row_id":1626914,"text":"Resp Care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse suct sm th tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required overnoc. Cont PSV.\n"},{"category":"Nursing/other","chartdate":"2107-10-21 00:00:00.000","description":"Report","row_id":1626915,"text":"PT. REMAINS A DNR/DNI.\n\nPT. HAS NKDA.\n\nPT. REMAINS A/A/O AND DENIES ANY PAIN OR DISCOMFORT, DURING THIS SHIFT. PT. FOLLOWS COMMANDSA AND REMAINS AFEBRILE.\n\nPT. REMAINS AFIB IN A CONTROLLED RATE, WITHOUT ECTOPY 80-107. B/P HAS RANGED 115-130/70-90'S. PULSES ARE WEAK, BUT EASILY PALPABLE. NO NOTED EDEMA.\n\nLUNGS ARE COARSE AND DIMINISHED. PT. REMAINS ON VENT AND HAS TOLERATED THIS FINE THROUGHOUT THIS SHIFT. PT. HAS A BOLVONA TRACH. HE HAS BEEN SUCTIONED FOR COPIOUS AMT'S OF CLEAR/TAN SECRETIONS BOTH VIA TRACH AND ORALLY. RESP RATE HAS BEEN WNL'S AND O2 SATS HAVE REMAINED >96%\n\nPT. CONTINUES ON TUBE FEEDS, PRESENTLY AT 45CCHR, WITH GOAL OF 65CC/HR OF PROBALANCE, FULL STRENGTH. ABD. EXHIBIT GTUBE, SINGLE LUMEN, WHICH HAS DRESSING INTACT. INSERTION SITE CONTINUES TO DRAIN SMALL AMT'S OF TUBEFEEDS. NO DARK, FOWL SMELLING DRAINAGE DURING THIS SHIFT. SURGERY CONSULTED AND ASSESSED SITUATION. PLAN TO DISCUSS WHAT TO DO TODAY. BLOOD SUGARS REMAIN WNL'S WITH NO INSULIN COVERAGE GIVEN.\nFOLEY CATHETER INTACT AND DRAINING AMPLE BUT SMALL AMT'S OF CLEAR YELLOW URINE. 60-100CC/HR. PT. REMAINS ON ROUTINE LASIX DOSING.\n\nPT. SKIN EXHIBITS .EXCORIATION TO NECK. ALLELYN DRESSING INTACT AND TRACH CARE PERFORMED. RIGHT GLUTEAL EXHIBITS AREA AS WELL, WITH ALLELYN DRESSING CHANGED, WHICH REMAINS INTACT AT THIS TIME. 'S REMAIN INTACT, PATENT, AND SECURED, WITH IVF OF N/S AT KVO.\n\nPLAN IS FOR POSSIBLE TRANSFER TO REHAB FACILITY. THIS PENDING THE DECISION OF SURGERY ON WHETHER THEY WILL TREAT LEAKAGE AROUND G-TUBE.\n"},{"category":"Nursing/other","chartdate":"2107-10-19 00:00:00.000","description":"Report","row_id":1626906,"text":"PT. REMAINS A DNR/DNI.\n\nPT. HAS NKDA.\n\nPT. REMAINS A/A/O X2, AND BOTH MOUTHS AND WRITES ON PAD TO COMMUNICATE. PT. HAS DENIED ANY PAIN OIR DISCOMFORT THROUGHOUT THIS SHIFT. PT. HAS BEEN AFBRILE.\n\nPT. HAS REMAINED AFIB IN A CONTROLLED RATE WITH NO BURST IF RVR. PT'S MEDS WERE EVAULATED AND CHANGED YESTERDAY WITH DESIRED EFFECTS REACHED. B/P HAS BEEN STABLE RANGING 100-130'S/60-80'S. PULSE ARE EASILY PALPABLE, WITH NO EDEMA NOTED.\n\nPT. HAS TRACH (BOVONA), PT. REMAINED ON TRACH COLLAR FOR >14HRS. PT. DENIED DISTRESS AND DENIED SOB. BUT O2 SATS DROPPED FROM 97% DOWN TO 88% PT. PLACED BACK ON VENT ON PS SETTINGS. PRESENTLY PT. AS OF 0600 IS BACK ON TRACH MASK AT 50% LUNGS HAVE IMPROVED VIA CHEST XRAY IN COMPARSION FROM YESTERDAY MORNING. LUNG FIELDS ARE CLEAR IN RIGHT UPPER AND COARSE IN RIGHT LOWER, DIMINISHED THROUGHOUT LEFT LUNG. RESP RATE REMAINS CONTROLLED AND PT. DENIES AND SOB. PT. HAS BEEN SUCTIONED FOR COPIOUS MAT'S OF THICK CLEAR TO TANNISH SECRETIONS. PT. CONTINUES TO EXHIBIT STRONG COUGH REFLEX.\n\nPT. CONTINUES TO DIURESIS >100CC/HR PT. RECEIVED LASIX 20MG IV LAST EVENING AND AGAIN 20MG THIS AM. PT. HAS FOLEY CATHETER, CLEAR YELLOW URINE NOTED. NO STOOL NOTED THIS SHIFT. PT. HAS PEG TUBE IN PLACE, WHICH CONTINUES TO LEAK. PT. WILL GO TO IR TODAY FOR GJ TUBE. BLOOD SUGARS HAVE BEEN WNL'S WITH NO COVERAGE REQUIRED DURING THIS SHIFT.\n\nSKIN INTEGRITY EXHIBITS TO RIGHT GLUTEAL, AND ABREASION TO NECK WHICH PT. HAS ALLELYN DRESSING IN PLACE. PIV X2 #18 AND #20 BOTH REMAIN INTACT, SECURED, AND PATENT WITH KVO IVF INFUSING.\n\nPLAN IS TO TAKE PT. TO IR TODAY FOR GJ TUBE. CONTINUE TO MONITOR PULMONARY STATUS, AND AID IN PULMONARY TOILETING. PT. REMAINS A DNR/DNI AT THIS TIME.\n"},{"category":"Nursing/other","chartdate":"2107-10-19 00:00:00.000","description":"Report","row_id":1626907,"text":"Resp Care\n\nPt weaning on trach mask until ~ 2400, then accute tachypnea and desaturation which did not rebound to previous level after sxng and bronchodilators by MDI. Pt was then placed o ventialtor on AC mode, then later on PSV. Placed back on trach mask @ ~ 0530. was 138. Pt changed to hi neb due to low saturation on regular neb.\n"},{"category":"Nursing/other","chartdate":"2107-10-19 00:00:00.000","description":"Report","row_id":1626908,"text":"NPN 7A-7P:\n\n\nNEURO: HE IS A/OX2. COOP W/ CARE. HE REQUIST TO HAVE ICE CHIPS AND GREEN SWAB AT THE BED SIDE. BUT I NOTED THE PT DRINKING THE WATER, AND COUGHING. HE FOLLOWS COMMANDS CONSISTENTLY. ABLE TO MAE.\n\nRESP: LS MIXED BAG. RONCHE/INS WHEEZING/POPING/DIMINSHED AT THE BASES. THIS AM HE HAS A LARGE AMOUNTS OF CLEAR SPUTUM. HE HAS A IN AFFECTIVE COUGH. HIS O2 SAT DROP DOWN TO 85% W/ RR 38 ON 30% TRACH MASK. LASIX 20MG IV WAS GIVNE. HE PLACED ON TEH VENT CPAP/PS 15/5. HIS RR 15-20.\n\nCV: A-FIB W/ PVC NOTED, HR 110-82. HE IS ON PO DILT AND LOPRESSOR W/ GOOD EFFECT NOTED.\n\nGI/GU: + BS HE DID HAVE SMALL LIGHT BROWN STOOL TODAY. GOOD UA OUT PUT NOTED. TODAY HE WENT TO IR. NEW J TUBE IN PLACE.\n\nSKIN: HE HAS THREE 0.5X0.5 STAGE II ON HIS COCCYX. DRESSING WAS CHANGED TODAY. HE HAS A XRT BURN ON HIS NECK. DUODERM GEL W/ DSD IS TX ORDER. AROUND THE J TUBE SITE THEIR IS YELLOW DRAINAGE IN LARGE AMOUNTS. DSD APPLYED.\n\nPOC: CONT VENT SUPPORT. ATTEMPT TO WEAN TO TRACH MASK. LASIX NOW . QUESTION TF. VANCO LEVEL W/ LABS IN TEH AM. K/MG/PHOS AT .\n"},{"category":"Nursing/other","chartdate":"2107-10-16 00:00:00.000","description":"Report","row_id":1626895,"text":"Micu nurisng note \n\nCv goal today was to titrate esmolol drip off prior to dc of drip hr 95-105 afib, by 1030 am pt restarted on po metoprolol 75 mg, within 30 min drip dc's hr between 100-130 by 4 pm hr back up to 120's pt given po does of metoprolol hr still 115-120 spoke with resident and ? if we need to increase po does of metoprolol, pt recieved 40 kcl this afternoon. pulses faint but palpable, pt oob to chair x4 hrs tol well.\nResp weaned from ac to pressure support to trach collar ( see care view) today pt on trach collar x4 hr tol well lung sounds now course pt was allows small amount of coffee while sitting in chair but noted the secreations which were white this am now are coffe color even though pt was no coughing while drinking I feel pt still asperates liquids and will now only have swabs for mouth, sats 98% pt suctioned q3 -4 for tan secreations. pt still has large amounts of secreations that come around trach, trach area red and still have wound care consult in for rad burn, area fryable, also trach seems to long and ? pt needs different trach and would recomend ip to look at trach. trach care given and skin covered with barrier cream and dsd\nGi tube feeds on hold area leaking lg amount around tube would like to see peg replaced lg amounts of gastric contents that leak area cleaned with soap and water and barrier cream applied will hold feeds for now\nGU pt given lasix this am u.o 150 hr\nid pt hypothermic this afternoon 95.1 now on warming blanket\nendo bs 166 see \nA/P would keep pt npo, hold feeds and have gi look at peg in am\nwould try trach collar this evening and rest on ps tonight \nwound care consult for neck area and ? ip to look at trach\nwould increase po metoprolol for better rate control\n"},{"category":"Nursing/other","chartdate":"2107-10-17 00:00:00.000","description":"Report","row_id":1626896,"text":"1900-0700 RN NOTES MICU\n\nEVENTS:PT START ON DILTAIZEN GTT FOR HR 120-130,TITRATE TO HR 100,OVERNIGHT HR DOWN TO 90-LOW 100 WITH BP STABLE AT 91-100/50'S, CURRENTLLY DILTAIZEM 7MG/HR. METOPROLO PO HELD MD .\n\nNEURO: PT ALERT/OX3, FOLLOWS COMMANDS, /COOPERATIVE WITH CARE.ABLE TO COMMUNICATE WITH MOUTH WORDS AND WRITTNG ON A BOARD.\n\nRESP: RECIVED ON CPAP/PS 40%/PS 15/PEEP 5, OVERNIGHT BECAME INCREASINGLY TIRED AND C/O TROUBLE TO BREATH, PUT ON AC 405/450/RR14.SAT 99%/LS COARSE CLEAR TO SX. SUCTION MODERATE AMOUNT WHITE SECRETYION.YESTARDAY TOLLEARED TRACH COLLAR FOR 4HR.PT NEEDS IP CONSULT FOR POSSIBLE TRACH CHANGES.\n\nCV: AS SAYS ABOVE, START ON DILT GTT.REMAIN OB AFIB NO ECTOPY. PT WITH , TEE SHOWN ACUTE CHANGES EF DOWN TO 25-30% FROM 55-60%.MORNINF LABS PENDING.\n\nGU/GI: FOLEY DRAINGED YELLOW CLEAR URINE, 30-60CC/HR. PT POS 1300CC FOR 24HR. CONT WITH LEAK ON PEG SITE, TF STOOPED, PT NPO. NEEDS GI CONSULT FOR POSSIBLE PEG CHANGES.\n\nSKIN: OPEN AREA STAGE 2 ON COCCYX, ALLEVYN DSD APLLIED. ALSO RED AREA AROUND NECK. PT NEEDS WOUND CARE CONSULT.\n\nID: AFEBRILE, TMAX 97.8, CONT VANCO/CEFTRAZIDIME,\n\nSOCIAL; DNR/DNI, NO CONTACT FROM FAMILY.\n\nPLAN: CONT MONITORING RESP/CARDIO STATUS\n WEAN DILTIAZEM GTT TO KEEP HR LOW 100'S-90.\n PLEASE SEND VANCO LEVEL AT 7-8AM\n IP, GI WOUND CARE CONSULTES.\n"},{"category":"Nursing/other","chartdate":"2107-10-16 00:00:00.000","description":"Report","row_id":1626892,"text":"NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: ALERT AND ORIENTED X 3- PT ABLE TO COMMUNICATE BY MOUTHING WORDS OR WRITING ON BOARD. PLEASANT. ABLE TO FOLLOW COMMANDS WITHOUT DIFFICULTY. ATTEMPTS TO ASSIST WITH TURNS AND PERSONAL CARE. ENJOYS HIS GINGERALE SWABS. AFEBRILE. PERRLA, 3/BRISK. NO SEIZURE ACTIVITY NOTED.\n\nRR: RECEIVED PT ON CPAP/ HOWEVER, PT BECAME INCREASINGLY TIRED AND TACHYPNIC- FELT LIKE HE WAS \"NOT GETTING ANY AIR\". PT RESTED OVERNIGHT ON AC. HAS DONE VERY WELL. NO FURTHER C/O SOB OR DIFFICULTY BREATHING. BBS= ESSENTIALLY CLEAR TO COARSE THROUGHOUT ALL LUNG FIELDS, NOTED TO BE DIMINISHED TO BASES. BILATERAL CHEST EXPANSION NOTED. SUCTIONING FOR MODERATE AMOUNTS OF YELLOW SPUTUM. PT ABLE TO SELF YANKAUR ORAL SECRETIONS. TRACH CARE PT TOLERATED WELL.\n\nCV: S1 AND S2 AS PER AUSCULTATION. AFIB, HR 80-90'S. RECEIVED PT ON LABETALOL GTT- DC'D AND ESMOLOL GTT INITIATED IN AN ATTEMPT TO PREVENT HYPOTENSION. SBP > OR = TO 90 WITH NO HYPER OR HYPOTENSIVE EPISODES NOTED SINCE STARTING. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PT HAS 2 PIV'S- SECURE AND PATENT. DENIES ANY CHEST PAIN.\n\nGI: ABD IS SOFT, FLAT, NON-DISTENDED. BS X 4 QUADRANTS. PT HAS SECURE AND INTACT PEG TUBE- DRESSING CHANGED. TF AT GOAL- NOTED TO HAVE VERY MINIMAL TO NO GASTRIC RESIDUALS. PT HAD MEDIUM SIZED, BROWN, SOFT STOOL THIS SHIFT. PASSING FLATUS.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nSKIN: FRAGILE SKIN. DUODERM ON COCCYX CHANGED THIS SHIFT.\n\nPLAN: CONTINUE TO WEAN VENT AS PT WILL TOLERATE. CONTINUE ESMOLOL GTT FOR RATE CONTROL. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n\n"},{"category":"Nursing/other","chartdate":"2107-10-16 00:00:00.000","description":"Report","row_id":1626893,"text":"Respiratory Care:\nPt remains trached and on vent. Mode changed to AC to rest overnight, has tolerated well. Received MDI's as ordered. Suctioned lt yellow secretions. Morning = 76. Plan is to wean as tolerates in am.\n"},{"category":"Nursing/other","chartdate":"2107-10-16 00:00:00.000","description":"Report","row_id":1626894,"text":"Resp Care\nPt weaned to psv 5/5 this am then placed on 50% TM for just under 4 hours which he tolerated well satting >95% with rr 20-30. BLBS slightly course, suctioned for sm-mod amt thick white secretions, mdis given per order. Pt placed back on psv at 2pm to allow pt to rest. plan to attempt TM again tomorrow as tolerated.\n"},{"category":"Nursing/other","chartdate":"2107-10-15 00:00:00.000","description":"Report","row_id":1626888,"text":"Nursing Progress Note 1900-0700\n(Continued)\nh care. Purulent drainage noted, avvelyn applied. PEG tube site also with yellow drainage.\n\nEndo: ISS, no coverage this shift, and fixed dose insulin.\n\nPlan: ? consider increasing PO lopressor vs. switching to diltiazem/amiodarone for HR control. Cont. to monitor renal function/ATN. Treat anxiety with lorazepam. CXR showing bilateral effusions. No more fluid boluses. Please see flow sheet as needed for additional information.\n"},{"category":"Nursing/other","chartdate":"2107-10-15 00:00:00.000","description":"Report","row_id":1626889,"text":"Respiratory Care:\nPt remains trached with #7 and on vent. No parameter changes made this shift. Received MDI's, suctioned sm amt thick yellow. Had episode of ^RR, though sats remained good. Morning measured = 168.\n"},{"category":"Nursing/other","chartdate":"2107-10-15 00:00:00.000","description":"Report","row_id":1626890,"text":"Resp Care\nPt remaisn trached with #7.0 h20 cuff. he was weaned to PSV 15/5 this am and has remained there all shift with volumes 375-550 and rr 18-25, pt has short periods of apnea not exceeding 30 seconds. BLBS course, scutioned for sm-mod amt thick aple yellow secrtions, mdi given per order. plan to remains on psv overnight as tolerated and wean ips tomorrow as tolerated.\n"},{"category":"Nursing/other","chartdate":"2107-10-18 00:00:00.000","description":"Report","row_id":1626905,"text":"MICU7 RN Note 0700-1900\n\nEvents: Wean to TM 50%, Episodes Rapid AFib increased Diltiezem, Increased Lopressor.\n\nNeuro: awake alert oriented x2 follows commands Pupils 3mm equal react brisk, MARE random and to command equal strength. Denies pain . c/o feeling anxious recieved Ativan 1mg IV x2 w/calming effect.\n\nCv: HR 85-120 Afib rare PVC, episodes Rapid afib HR>130-150 assymptomatic Diltizem 60mg increased to 90mg TID and Increased Lopressor to 25mg TID. @ 1600 Rapdid Afib HR>150 recieved lopressor 5mg IVP w/HR 90-110. EKG done. recieved Lasix 20mg for u/o trending down. Seriel CK/troponin trending down although troponin ^ 3.26 (?renal response). peripheral pulses 3+ DP/2+ DT. neg edema.\nK+ 3.2 repleted KCL 40meq/500cc\nIV access : 2PIV #18/#20 NS KVO.\n\nresp: Bovona trach recieved pt vent mode CPAP/PSV 15/5 40%. Rr 18-30 TV >350. Sats 92-97%. @ 1000 wean to Trach collar 50% sats mid 90's. suctioned via trach for sm amt thick pale yellow, lg amt secretions drainage around trach stoma. CXR done routine @ 1600 sats low 90's RR 30-40 tachypneic pt denied Difficulty breathing. recieved lasix Lungs clear raled RLL dim L base. trach cuff down strong cough and able to expectorate mod amt thick yellow secretions. Sat ^ mid 90's. Cuff remains down w/ improved sats.\n\nID: afebrile t-max 98, WBC 7.5 taken off neutropenic precautions. , abx cetazipine, Vanco level 53 Vanco d/c.\n\nGU/GI: Foley u/o 20-300cc/hr s/p lasix. Abd soft + BS GT inplace w/gastric leakage. awaiting GJ tube placement in IR . NPO unable to give TF due to Leakage.\n\nDerM; Skin impaired. Radiation burn neck eval by wound care team, Protectent gel appled, frequent trach dsg changes.\n\nSocial: DNR/DNI. Sister called for update.\n\nPlan: IR for Peg revision GJ tube.\n wean on TM for noc as tol.\n Diurese to 1L neg.\n monitor /control Rapid AFib\n"},{"category":"Nursing/other","chartdate":"2107-10-15 00:00:00.000","description":"Report","row_id":1626891,"text":"Micu nursing note \n\nCV pt remains tacky up to the 130's pt given iv metoprolol 5 mg iv x2 durring the day which would drop hr into the 110-120by 530 pm pt started on a labatolol drip at .5 mg/min which is now at .75mg/min BP 89-117/60-70 hr 98-108 afib, pt troponin 3.3 and house staff felt pt still infacting and needed better rate control\nresp pt switch to ps15/5 tv350-500 rr 10-22, lungs clears sats 100% pt sucitoned for thick sticky pale yellow secreation, pt given trach care x2 pt's neck area pink/rad burn area covered with moisture barrier cream and dsd, ( spoke with heme onc floor this was there recomendation) noted chest x ray increasesize of rt effusion\n\nGi pt continues on tube feeds at 65 hr probalance, residuals 10 cc, no stool\nGU pt given lasix 20 mg at 4 pm pt putting out 150 cc hr\nneuro pt awake and alert\nskin consult placed for wound care\nA/P would continue with labatolol for hr control, follow urine output and if pt u/o falls would consider more lasix tonight, pt needs repeat labs tonight.\n\n"},{"category":"Nursing/other","chartdate":"2107-10-18 00:00:00.000","description":"Report","row_id":1626901,"text":"1900-0700 rn notes micu\n\n71 y.omale with h/o of ETOH abuse,Afib, DM, CAD. s/p CABG, s/p trach/peg, head and neck CA undergoing chemo and transfer from OSH with Afib, ,acute renal failure, hypoxia.TEE shown acute changes EF down to 25-30% form 55-60%.in unit was on Osmolol nad diltaizem gtt for rapid Afib. currently on Diltiazem PO and Metoprolol Po.\n\nneuro: A/ox3, comminication wiht mouth words and writting on board. follows commands, and cooperative with care. given trazodone 25mg and Ambien held. pt c/o anxiety with RR up to high 30's, given Ativan 1mg IV with good effect.\n\nresp: on CPAP/PS 15/peep 5,no vent changes made overnight. LS coarse clear to suction for moderate amount white secretion. sat 98-99%.bronch done yesterday for trach placement no changes made.\n\ncv: HR 80-90's, Afib with occass PVC's, once Hr up to 112-115, given additional dose of Diltiazem 30mg PO with good effect.\n\ngi/gu: foley drainged yellow clear urine 20-30cc/hr MD aware, goal nef 1L,pt neg 1l for 24hr. pt NPO for peg revision possible in OR d/t leak. needs ABD CT prior procedure. abd soft, BS +, no BM.\n\naccess: 2piv pattent.\n\nid: affebrile, vanco held d/t level63, needs level in the morning.cont ceftrazidime.\n\nsocail: DNR, no contact from family.\n\nplan: comt monitoring resp/cardio status\n ABD CT and ?or for peg revesion.\n vanco level\n wean vent to trach collor mask as tollerates.\n"},{"category":"Nursing/other","chartdate":"2107-10-18 00:00:00.000","description":"Report","row_id":1626902,"text":"ABD CT canceled, ?OR vs IR. pt had 10 beats of Vtach, bp stable,MD aware. vanco level sent.\n"},{"category":"Nursing/other","chartdate":"2107-10-18 00:00:00.000","description":"Report","row_id":1626903,"text":"Resp Care\n\nPt was sx Q 2-4hrs, alb / atr MDI Q 4 hrs. He has a small tach leak which is positional. Pt is very alert and fairly anxious, he was awake almost all night. this morning was ~ 112. No ABG drawn on this shift. Plan is to continue with current level of support as he seems to need the higher level of PSV.\n\n\u0013\n"},{"category":"Nursing/other","chartdate":"2107-10-18 00:00:00.000","description":"Report","row_id":1626904,"text":"Respiratory Care:\nPt recieved trached and vented. Weaned to trach mask with 50% FiO2. Lung sounds clear with few crackles. Suctioned for moderate thick white secretions. MDIs given per order. Plan is to remain on trach collar if possible over noc. Pt will go for PEG placement tomorrow.Will follow.\n"},{"category":"Nursing/other","chartdate":"2107-10-14 00:00:00.000","description":"Report","row_id":1626883,"text":"Respiratory Care:\n71 Y.O. Male with extensive oncologic HX to neck/throat (arrived with #7 TTS, water filled cuff, trache tube-7cc H20 to seal), here for PNA, and acute neutropenia (on XRT). PMHX: COPD, CAD/CABG. Initiallized on settings per flowsheet. ABG's drawn showing adequate oxygenation with respiratory alkalosis. Awaiting discussion with team regarding possible modality change, or sedation to reduce minute ventilation, also possible increase in FIO2. Pt. awaiting Cardiac Echo today. Will follow.\n"},{"category":"Nursing/other","chartdate":"2107-10-14 00:00:00.000","description":"Report","row_id":1626884,"text":"Nursing Progress Note 1900-0700\nReport received from AM shift. All alarms on monitor and ventilator are functioning properly. Pt's environment secured for safety.\n\nPt is a 71 yo male with a sig. history of afib, PVD, pacemaker, ETOH abuse and 59 pack year smoker, COPD, HTN, DM, CAD s/p CABG, Lt. piriform sinus mass: Squamous cell carcinoma -- radiation treatment, weekly low dose carboplatin/taxol. Pt. was admitted to OSH from rehab on for SOB, chest pain and afib with RVR, O2 dropped to 87%. ECG showed ST depressions, Troponin I elevated to 65.48. CXR revealed cardiomegaly and interstitial pulmonary changes indicative of CHF. Pt. lab values showed neutropenia and elevated BUN/cr. CXR showed Rt middle lobe pna. Arrived to MICU trached and PEGed.\n\nNuero: Pt. alert and oriented when admitted, currently sleeping. Able to mouth words and make needs known. Also able to communicate via pen and paper at bedside. MAE, follows commands consistently. All side rails up for safety.\n\nCV: HR 94-107's afib with rare PVCs noted. BPs 117-139/88-99s, 50mg metoprolol given fore HR control. Feet with mottled looking appearance, but easily palpable pedial pulses and warm to the touch. Denies any chest pain.\n\nRR: Pt. trached, on vent. settings 40%/500/5 PEEP, RR 16. RR 16-24, with sats 97-100%. Sxned for mod. amounts of yellow thick secretions. Pt. able to oral sxn self. Mod. amounts of yellow thick secretions around tracheostomy noted. LS coarse T/O. Bilateral chest expansion noted. Noted teeth missing while performing oral care.\n\nGI/GU: Abd. soft, non-distended. Abd tender to palpation. PEG tube patent and secure, residuals checked q4h with 0.0ml returned. TF started at 25ml/hr, goal rate 65 ml/hr. Pt. received with FIB, draining golden loose stool. Foley catheter is secure and patent draining marginal amounts of clear amber urine. Last BUN/Cr, 77/2.7 respectively. Last LDH 1182, AST 1552, ALT 2522.\n\nSkin: Mult. areas of breakdown noted on rt. gluteal. OTA, pink with no drainage noted. Neck with mult. abrasions and irritation radiation treatment. Areas with purulent drainage, OTA.\n\nID: Remains neutropenic with last WBC 2.3. On neutropenic precautions. Mult. antibx for coverage. Afebrile.\n\nEndo: ISS, and fixed dose insulin for coverage.\n\nPlan: Onc. consult, determine cardiac function; echo tomorrow. HR control, wean vent. as tolerated. Monitor renal function- will administer fluid challenge for decreased UOP.\n\n\n"},{"category":"Nursing/other","chartdate":"2107-10-14 00:00:00.000","description":"Report","row_id":1626885,"text":"Resp Care\nFairly quite shift with pt. Did try CPAP .40 +5 +10PSV and pt tolerated for approx 2 hrs. Pt told RN despite RR of 30-35 that his breathing was fine and then a short time later he stated he was SOB so pt put back on vent with AC as before. Receiving nebs as ordered.\n"},{"category":"Nursing/other","chartdate":"2107-10-14 00:00:00.000","description":"Report","row_id":1626886,"text":"NPN 7P-7A:\n\nTHE PT IS A 71Y/P MALE ADMIT ON W/ DX OF; MI, NEUTROPENIA, SOB. AT THE OSH HIS O2 SAT DROP INTO THE 80'S. HE WAS STARTED CARDIZEM FOR AF AND CHANGED TO LOPRESSOR PO BEFORE TX. . HE HAS A PMH: LEFT PIRIFORM SINUS MASS,TX W/ XRT, TRACH/PEG, DM,HTN,CAD S/P CABGX5, PACER SICK SINUS, AF, COPD,SPONTANEOUS PNEUMOTHORAX S/P CHEST TUBE, COLON CA S/P RESECTION , ESOPHAGEAL STRICTURE, S/P OPEN GASTROSTOMY , S/P TRACH .\nNKDA:\n\nNEURO: HE IS AND MOUTHING WORDS. HE FOLLOWS COMMANDS CONSISTENTLY. ABLE TO MAE.\n\nRESP: HE IS TRACHED. TODAY A ATTEMPT WAS MADE TO CHANGE HIM OVER FROM AC TO CPAP. HE TOLERATED CPAP FOR 15MIN. THAN HE C/O SOB W/ RR UP TO 40'S. BECAME DIAPHERATIC AND FLUSHED. HE WAS CHANGED BACK TO AC NOW HIS RR 20 TO 24 ON 40X450X14 PEEP5. W/ OUT RESP DISTRESS NOTED. LUNG SOUNDS COURS/RONCHI BILAT. SX FOR THICK YELLOW SPUTUM IN MOD AMOUNTS. HE HAS A RIGHT MIDDLE LOBE PNA. NOW ON VANCO AND CEFAZIDIME IV.\n\nCV: HE IS R/I FOR A NSETMI. HIS TROKPI ARE +. HE IS CURRENTLY IN AF W/ HR 98-125. THE LOPRESSOR HAS BEEN INCREASED FORM: LOPRESSOR 50MG TID, TO 75MG TID. WHILE ON CPAP. HIS HR DID INCREASE TO 120-130. A ONE TIME DOSE OF LOPRESSOR 5MG IV WAS GIVEN. HE ALSO DID RECEIVE THE EXTRA 25MG OF LOPRESSOR TO MAKE THE AM DOSE 75MG. DESPITE THE EXTRA LOPRESSOR HIS HR STILL REMAINS FORM 110-125.\n\nGI/GU: HE IS NPO ASPIRATION PRECAUTIONS. HE HAS MISSING THEETH. + BS NO BM. HE HAS A RECTAL BAG IN PLACE. BUN 77/2.7. HE HAS POOR OUT PUT. FLUID CHALLENGE OF 500ML X2 WAS GIVN TODAY. W/ OUT GOOD RESPONSE.\n\nONC: HIS LAST DOSE OF CHEMO WAS ON . HE ALSO HAS A XRT BURN TO THE LEFT SIDE OF HIS NECK. WBC 2.3. HE REMAINS ON NEUTROPENIC PRECAUTIONS.\n\nSKIN: HIS BUTTOCKS HAS MULTIPLE STAGE 2 PINK AREAS. NEW DUODERM WAS APPLYED. HIS PEG TUBE SITE HAS YELLOW DRAINAGE NOTED.\n\nSOCIAL: TODAY HE MADE HIS AND , WHICHE IS HIS BROTHER, AND THE HCP. HE CHANGE THE FULL CODE STATUS TO AND DNR/DNI.\n\nPOC: TO MONITOR CK/TROP, FOR NOW CONT LOPRESSOR. AC OVER NIGHT.\n"},{"category":"Nursing/other","chartdate":"2107-10-15 00:00:00.000","description":"Report","row_id":1626887,"text":"Nursing Progress Note 1900-0700\nReport received from AM shift. All alarms on monitor and ventilator are functioning properly. Pt's environment secured for safety.\n\nCode status changed to DNR/DNI\n\nPt. is a 71yo male with a significant history of afib, PVD, pacemaker, ETOH abuse and 59 pack year smoker, COPD, HTN, DM, CAD s/p CABG, Lt. piriform sinus mass: squamous cell carcinoma-- radiation treatment, and weekly low dose carboplantin/taxol. Pt. was admitted to OSH from rehab on for SOB, c/o chest pain, and afib with RVR, O2 dropped to 87%. ECG showed ST depression, and troponin I elevated to 65.48. CXR showed cardiomegally and intersitial pulmonary changes indicative of CHF. Pt lab values showed neutropenia and elevated BUN/Cr. CXR showed right middle lobe PNA. Arrived to MICU trached and PEGed.\n\nEvents: After completing trach care,repositioning and morning , pt c/o feeling \"tight\" and unable to breath. Sxned for mod amounts of thick yellow secretions. RR up in the 40s. HR 130s, and BP 130s/90s. Neb treatment given by respiratory therapy. Given 5mg lopressor IVP x2, for a total of 10mg. Resulting HR 105-115s, BP 120s/80s. Pt appear anxious and RR remained in the high 40s. Pt did not have any episodes of desaturation with this. Given 1mg lorazepam IVP, with good effect. Dr. aware. CXR showing bitateral effusions (left effusion is new). Question of possible PE- but unable to anticoagulate- will draw ABG this am as well.\n\nNuero: Pt. alert and follows commands consistently. MAE, able to mouth words to make needs known. All side rails up for safety.\n\nCV: HR 105-120s, afib, no ectopy noted. HR increased to 130s periodically T/O the night. Received 5mg lopressor IVP x3, for a total of 15mg IVP given this shift in addition to 75mg PO. ? considering increasing PO dose of lopressor. BP 115-135s/85-85s. Diff. to palpate pedial pulse bilaterally.\n\nResp: Pt trached on vent settings AC 40% 450/14/5 PEEP. RR 18-26, with sats 95-99%. Sxned for sm. - mod. amounts of yellow thick secretions. Pt. able to oral sxn self. Mod. to Copious amounts of thick yellow secretions noted around tracheostomy. L/S coarse T/O, bilateral chest expansion noted. Noted missing mult. teeth while performing oral care.\n\nGI/GU: Abd soft, non-distended. Abd tender to palpation. PEG tube secure and patent. TF at goal rate of 65 ml/hr. TF residuals check q4h with 0.0mls returned. Pt. with FIB, draining golden loose stool. + BS in all 4 quadrants. Foley catheter is secure and patent, draining marginal amounts of clear amber urine. U/O 15-40 ml/hr. Did received 1L fluid bolus low U/O, with no effect. Last BUN/Cr 83/2.7 respectively.\n\nID: Remains on neutropenic precautions with WBC 2.5. Mult. antibiotics for coverage. Afebrile this shift.\n\nSkin: Mult. areas on buttox with breakdown noted. Red, open stage 2 ulcers, new duoderm was applied, D&I. Neck with mult. areas of abrasions and irritation radiation treatment. Performed \n"},{"category":"Echo","chartdate":"2107-10-14 00:00:00.000","description":"Report","row_id":83471,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Atrial fibrillation.\nWeight (lb): 128\nBP (mm Hg): 146/12\nHR (bpm): 103\nStatus: Inpatient\nDate/Time: at 15:37\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Severely depressed\nLVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Dilated RV cavity. RV function\ndepressed.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Focal calcifications in ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Moderate to severe (3+) MR. LV inflow\nuninterpretable due to tachycardia and/or fusion of spectral Doppler E and A\nwaves\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Moderate [2+] TR. Mild PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: 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. Overall left\nventricular systolic function is severely depressed (LVEF= 23-30 %). There is\nglobal hypokinesis with regional variation: the inferior free wall, posterior\nwall, and lateral wall are severely hypokinetic; the rest of the left\nventricle is at least mildly hypokinetic. There is no ventricular septal\ndefect. The right ventricular cavity is dilated. Right ventricular systolic\nfunction appears depressed. The ascending aorta is mildly dilated. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is\nseen. There is mild pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is markedly reduced. The right\nventricle also is now hypocontractile. Mitral and tricuspid regurgitation are\nsignificantly increased.\n\n\n"},{"category":"ECG","chartdate":"2107-10-16 00:00:00.000","description":"Report","row_id":227329,"text":"Atrial fibrillation with rapid ventricular response. Intraventricular\nconduction defect. Diffuse ST-T wave changes may be related to the rate and\nrhythm but cannot rule out myocardial ischemia. Low QRS voltage in the limb\nleads. Compared to tracing of there is no significant diagnostic\nchange.\n\n"},{"category":"ECG","chartdate":"2107-10-14 00:00:00.000","description":"Report","row_id":227558,"text":"Atrial fibrillation with a rapid ventricular response. Left ventricular\nhypertrophy. ST-T wave abnormalities which could be due to left ventricular\nhypertrophy. Compared to the previous tracing of rapid atrial\nfibrillation is new.\n\n"},{"category":"ECG","chartdate":"2107-10-19 00:00:00.000","description":"Report","row_id":227328,"text":"Atrial fibrillation, mean ventricular rate 103. Compared to previous tracing\nof multiple abnormalities as previously noted persist without major\nchange.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-10-20 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/O CONTRAST\",\n \"row_id\": 978233,\n \"text\": \" 5:12 AM\\n CT ABDOMEN W/O CONTRAST Clip # \\n Reason: please eval for PEG placement.\\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\\n Field of view: 34\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old trached and PEG'd male w/ multiple medical problems including DM,\\n COPD, afib, CAD s/p CABG and locally invasive laryngopharyngeal cancer who had\\n IR placed GJ tube today, now with extravasation of tube feeds and stool around\\n PEG.\\n REASON FOR THIS EXAMINATION:\\n please eval for PEG placement.\\n CONTRAINDICATIONS for IV CONTRAST:\\n renal failure\\n ______________________________________________________________________________\\n WET READ: 5:32 AM\\n 1. GJ tube tip in jejunal loop. No dilated bowel. No free intraperitoneal\\n air.\\n 2. Large bilateral pleural effusions and associated atelectasis.\\n 3. Heavy vascular atherosclerotic calcification. Caliber and contour of\\n aorta unchanged from .\\n 4. Atrohpic left kidney.\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n\\n INDICATION: GJ tube position in patient with leaking around tube during\\n feeding\\n\\n COMPARISONS: Torso CT dated .\\n\\n TECHNIQUE: MDCT images from the lung bases through the mid iliac level were\\n obtained with oral contrast only. Lack of intravenous contrast limits\\n evaluation of the solid abdominal viscera. Multiplanar reformations were\\n essential to interpretation.\\n\\n LOWER CHEST: Sternotomy wires are present. Cardiac leads are again\\n identified, with scattered CABG clips. There are large, simple bilateral\\n pleural effusions with adjacent atelectasis. The left effusion appears\\n increased when compared to the previous study.\\n\\n LIVER: Scattered calcifications are compatible with granuloma. The liver is\\n otherwise unremarkable. A large splenic calcification is again noted. The\\n pancreas and adrenal glands are within normal limits. The left kidney remains\\n shrunken. There is no evidence of hydronephrosis. The gallbladder is\\n present.\\n\\n A gastrojejunostomy tube is in appropriate position, entering through the left\\n anterior abdominal wall and coursing through the stomach and duodenum into the\\n jejunum in the lower abdomen. The proximal coil of the tube is in the second\\n portion of the duodenum. There is no evidence of contrast extravasation.\\n There are no abnormal fluid collections at the site of entry. There is trace\\n (Over)\\n\\n 5:12 AM\\n CT ABDOMEN W/O CONTRAST Clip # \\n Reason: please eval for PEG placement.\\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\\n Field of view: 34\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n free fluid in the abdomen. There is a stable abdominal aortic aneurysm\\n measuring at least 4 cm in greatest dimension, with extensive atheromatous\\n calcification. There are scattered surgical clips in the left periaortic\\n region. No pathologically enlarged lymph nodes are identified. There is no\\n evidence of bowel dilatation. Diffuse stranding of the subcutaneous tissues\\n is compatible with anasarca.\\n\\n OSSEOUS STRUCTURES: There is a stable sclerotic focus in the left iliac bone.\\n Multilevel degenerative changes are present in the lumbar spine.\\n\\n IMPRESSION:\\n 1. Appropriate position of a GJ tube, without evidence of oral contrast\\n extravasation or abnormal fluid collection.\\n 2. Large bilateral pleural effusions.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-10-19 00:00:00.000\",\n \"description\": \"REPOSITION GASTRIC TUBE INTO DUODENUM\",\n \"row_id\": 978077,\n \"text\": \" 7:27 AM\\n PERC G/J TUBE CHECK Clip # \\n Reason: Please change G tube (Foley 14 cath currently) to GJ tube\\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\\n Contrast: OPTIRAY Amt: 25CC\\n ********************************* CPT Codes ********************************\\n * REPOSITION GASTRIC TUBE INTO D CHANGE PERC TUBE OR CATH W/CON *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with NSTEMI, head and neck cancer, drinks PO liquids by mouth,\\n does not eat food by mouth\\n REASON FOR THIS EXAMINATION:\\n Please change G tube (Foley 14 cath currently) to GJ tube\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION FOR THE EXAM: 71-year-old male with NSTEMI, head and neck cancer\\n with G-tube placed.\\n\\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. . Dr.\\n , the attending radiologist, was present and supervising throughout the\\n procedure.\\n\\n FINDINGS AND TECHNIQUE: Following explanation of the potential risks and\\n benefits of the procedure, written informed consent was obtained. The patient\\n was placed supine on the angiographic table and abdomen was prepped and draped\\n in standard sterile fashion. A timeout was performed to confirm patient\\n identity and proposed procedure.\\n\\n Initial fluoroscopic image demonstrated the presence of Foley catheter in the\\n abdomen. A small amount of contrast was injected and demonstrated the balloon\\n placed inside of the stomach. A 0.035 wire was advanced into the\\n stomach trough the Foley catheter. The present Foley catheter was then\\n removed over the wire. A 7- French bright tip sheath was advanced over the\\n wire with the tip in the stomach. The wire was removed and a 0.035\\n straight Glidewire was advanced. A combination of the 0.035 straight\\n Glidewire, 0.035 J-guidewire, 4- French 0.035 Cobra catheter, and 5-\\n French Kumpe catheter were used to get access to the jejunum. The wire was\\n then exchanged for a 0.035 straight Amplatz, that was advanced into the\\n jejunum. The catheter was removed. A 14-French peel-away introducer was\\n advanced over the wire into the stomach. 14-French gastrojejunostomy\\n catheter was advanced through the peel-away over the wire with the tip placed\\n in the proximal jejunum. The wire was removed and the pigtail was formed\\n within the duodenum. A small amount of contrast was injected through the tube\\n and confirmed the position of the tip of the catheter into the jejunum.\\n\\n The catheter was secured to the skin. The patient tolerated the procedure\\n well and there were no immediate complications.\\n\\n IMPRESSION: Successful insertion of a 14-French G-J tube with tip in\\n the jejunum. The tube is ready for use.\\n\\n\\n (Over)\\n\\n 7:27 AM\\n PERC G/J TUBE CHECK Clip # \\n Reason: Please change G tube (Foley 14 cath currently) to GJ tube\\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\\n Contrast: OPTIRAY Amt: 25CC\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-10-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 977341,\n \"text\": \" 4:38 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o infiltrate\\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 yo M, h/o of locally invasive laryngopharyngeal CA admitted, trach and PEG\\n admitted with hypoxia, MI\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Hypoxia.\\n\\n Portable AP chest radiograph compared to .\\n\\n The tracheostomy tube is in place. The pacemaker leads terminates in the\\n right ventricle and right atrium. There is no change in mild cardiomegaly and\\n tortuous and calcified aorta.\\n\\n The bibasilar consolidations and bilateral right more than left pleural\\n effusion are essentially unchanged. There is no evidence of congestive heart\\n failure.\\n\\n IMPRESSION: No significant interval change in bibasilar atelectasis and\\n pleural effusion. Standard position of tracheostomy.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-10-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 978048,\n \"text\": \" 12:54 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for infiltrates, effusion interval change.\\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 yo M, h/o of locally invasive laryngopharyngeal CA admitted, trach and PEG\\n admitted with hypoxia, MI, now with desatting to 80%.\\n REASON FOR THIS EXAMINATION:\\n Eval for infiltrates, effusion interval change.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Laryngopharyngeal cancer. MI with SOB.\\n\\n AP bedside chest. The heart is borderline enlarged with satisfactorily\\n positioned dual-chamber bipolar pacing leads and previous CABG. Tracheostomy\\n tube. There are bilateral substantial pleural effusions layering in\\n semi-erect position with associated bibasilar atelectasis. No demonstrable\\n PTX. I cannot exclude consolidations in the obscured bases. Appearances are\\n unchanged from exam one day ago and little changed from study .\\n\\n IMPRESSION: No short interval change in CHF/fluid overload.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-10-14 00:00:00.000\",\n \"description\": \"RENAL U.S.\",\n \"row_id\": 977371,\n \"text\": \" 8:34 AM\\n RENAL U.S. Clip # \\n Reason: NEW ONSET RENAL FAILURE, S/P CABG R/O OBSTRUCTION\\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: New onset renal failure.\\n\\n Comparison is made to the prior CT of the abdomen and pelvis performed on , .\\n\\n The right kidney measures 11 cm. No stone, hydronephrosis or mass is noted\\n within the right kidney.\\n\\n The left kidney measures 7.5 cm. No stone, hydronephrosis or mass is noted\\n within the left kidney. The bladder was empty and could not be evaluated.\\n\\n Small amount of free fluid is noted within within the abdomen.\\n\\n IMPRESSION:\\n 1. Atrophic left kidney (seen on prior CT), which is unchanged since \\n . No stone, hydronephrosis or mass is noted within the kidneys.\\n\\n 2. Ascites.\\n\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-10-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 977507,\n \"text\": \" 4:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: SOB\\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 yo M, h/o of locally invasive laryngopharyngeal CA admitted, trach and PEG\\n admitted with hypoxia, MI\\n REASON FOR THIS EXAMINATION:\\n SOB\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, \\n\\n COMPARISON: .\\n\\n INDICATION: Laryngeal cancer. Hypoxia.\\n\\n Tracheostomy tube and permanent pacemaker are unchanged in position.\\n Cardiomediastinal contours are stable. Perihilar haziness and peripheral\\n interstitial opacities are attributed to interstitial pulmonary edema and has\\n slightly worsened. Moderate-sized right effusion has slightly increased as\\n well as a small left pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2107-10-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 977956,\n \"text\": \" 12:26 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for interval change.\\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 yo M, h/o of locally invasive laryngopharyngeal CA admitted, trach and PEG\\n admitted with hypoxia, MI, please evaluate for interval change.\\n REASON FOR THIS EXAMINATION:\\n please evaluate for interval change.\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest AP portable single view.\\n\\n INDICATION: History of locally invasive laryngopharyngeal carcinoma admitted,\\n tracheostomy, admitted with hypoxia and MI. Evaluate for interval change.\\n\\n FINDINGS: AP single view of the chest obtained with patient in semi-upright\\n position is analyzed in direct comparison with a similar preceding study dated\\n . Tracheostomy, permanent pacer unaltered and stable.\\n Previously described diffuse perivascular haze in the pulmonary vasculature\\n and bilateral basal densities indicative of pleural effusions have further\\n progressed. No new discrete pulmonary parenchymal infiltrates are identified.\\n\\n IMPRESSION: Stable instrument position. Progression of CHF findings.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626916,\n \"text\": \"MICU 7 RN Note 0700-1300\\n\\nrefer to Page 2 referral and discharge plan.\\n\\nAwake alert oriented x2 follows commands MAE random equal strenght. denies pain. c/o feeling anxious requests to have valium. resident aware pt recieved Ativan 1mg IV x2 w/calming effect.\\n\\nHR 75-130 Afib recieved diltiezem and Lopressor per routine for controlled afib. Occas episoded AV paced. BP 100-124/50-75 MAPS>60.\\n\\nRecieved pt on vent CPAP/PS 12/5 40%, #7.0 Bovona Trache. Wean to TM 50% for 2 hrs became tachypneic RR>40 desat 88%, suctioned via ETT for sm amts thick pale yellow. @ 1015 placed on Vent CPAP/PS 15/5 40%. resting comfort.\\n\\nGI: seen by tam and J-tube site cleared for discharge. leakage slowed down duoderm drsg site. TF probalance adv to 65cc/hr Goal tol well. Abd soft + BS. sm loose Brown stool x1.\\n\\nGU: Foley u/o 20-80cc/ht recieved Lasix 40mg Via J-tube\\n\\nderm: Skin impaired Neck wounds radiation burn healling duoderm gel applied gauze drsg. Avellyn drsg .\\n\\nSocial: DNR/DNI\\n Discharged to rehab @ 1300 by ambulance ACLS. Referral sent w/pt.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626897,\n \"text\": \"Respiratory Care:\\nPt remains trached and on vent. Was on PSV most of night, but changed to AC mode for 3 hrs for ^RR. Suctioned mod amt of thick white secretions. Received MDI's as ordered. Morning = 74. Plan to go on trach collar again today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626898,\n \"text\": \"NPN PA-7P:\\n\\n\\nNEURO: PT IS A/OX2 OR 3. COOP W/CARE. ASKING ABOUT HIS TF. HE IS SWABING HIS BOUTH EVERY 2-3 HOURS. HE IS ABLE TO MOVE ALL EXT.\\n\\nRESP: TODAY TRACH MASK AT 40%. HE HAS A IN AFFECTIVE COUGH AT TIMES. WHERE HE WILL BRING UP SPUTUM, BUT WILL NOT BE UNABLE TO FORCE THE SPUTUM THROUGHT THE TRACH. HIS TRACH SITE IS A STAGE II. HE HAS DSD OVER THE SITE. AT 1730 HE WENT BACK ON THE VENT RR 38-40, HR 120-125. HIS O2 SAT DROP TO 88-91%. HE WAS PLACED ON CPAP 40%. IMMEDIATELY HIS RR WENT DOWN TO 20-22. LS EXP WHEEZING WHICH RESOLVED W/ HIS INHALERS.\\n\\nCV:DILT 30MG PP WAS GIVEN ONE HOUR BEFORE THE GTT WAS TURNED OFF. HE WAS GIVEN ONE MORE DOSE OF DILT 30MG AT 1500 2/2 HR UP THE >110. THE DILT WAS CHANGED TO 60MG QID. HE WILL ALSO START LOPRESSOR 12.5MG TONIGHT.\\n\\nGI/GU: HE IS NPO TODAY. AROUND THE PEG TUBE IS LEAKING THE TF. IP WILL BRONCH HIM TODAY TO LOOK INTO HIS STOMACH TO CHECK THE PLACEMENT OF THE PEG. MEDS WERE GIVNE VIA PEG. LASIX 20MG IV WAS GIVEN. THE GOAL IS 1L NEG. HE HAS PUT OUT 1130 SINCE THE LISIX WAS GIVEN.\\n\\nI/D: WBC 4.5. THE VANCO IS ON HOLD VANCO THROUGH 63.2. HE WILL CONT ON THE CEFTZ.\\n\\nPOC: WILL BRONCH HIM TO CHECK PLACEMENT OF PEG TUBE. ATTEMPT TO WEAN HIM FROM THE VENT. GENTLE DIURESIS W/ LASIX. START LOPRESSOR 12.5MG TONIGHT. HE WAS PUT IN FOR A WOUND CONSULT . WILL CONT TO MONITOR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626899,\n \"text\": \"Respiratory Care:\\nPt recieved trached and vented. Pt weaned to trach mask, pt stayed on TM 7hrs, then pt C/O SOB,RR 36-40, SpO2 97-98%, ? anxiety. Pt placed back on vent. Lung sounds coarse.Suctioned for thick yellow secretions. MDIs given per order. Pt to be bronched by IP. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626900,\n \"text\": \"NSG PROGRESS ADDENDUM 1830:\\n\\nTHE PT HAS A BRONCH TO CHECK THE PLACEMENT OF THE TRACH. THE TRACH IS LOCATED AT THE 4TH CARINA. NO CHANGES WERE MADE.\\n\\nHE IS TO REMAIN NPO OVER NIGHT OR TO CHECK THE PAG.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626909,\n \"text\": \"Respiratory Care:\\nPt recieved on trach mask. Needed to be placed back on vent d/t desating to high 80s and tachypnea. Pt currently on PS 15. Lung sounds shightly ronchorus. Suctioned for moderate thick white secretions. MDIs given per order. Pt traveled to and from IR for PEG placement without incident. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626910,\n \"text\": \"RESPIRATORY CARE:\\n\\nPt remained on vent support overnight. Settings PSV 15, CPAP 5. Pt comfortable, NARD. BS's coarse at times, sxing thick white/tan secretions. Administering Albuterol and Atrovent MDI's in line with vent as ordered. See flowsheet for further pt data. Will follow, trache mask trials as tolerated today.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626911,\n \"text\": \"PT. REMAINS A DNR/DNI.\\n\\nPT. HAS NKDA.\\n\\nPT. HAS REMAINED A/A/O AND COMMUNICATES BY MOUTHING WORDS AND WRITING ON PAD. PT. FOLLOWS ALL COMMANDS AND HAS DENIED ANY PAIN OR DISCOMFORT DURING THIS SHIFT. PT. HGAS REMAINED AFEBRILE THROUGHOUT THIS SHIFT.\\n\\nPT. HAS BEEN AFIB IN A CONTROLLED RATE, WITHOUT ECTOPY NOTED. H.R. HAS RANGED 70-103. B/P HAS BEEN STABLE AND WNL'S RANGING 110-130'S/70-80'S. PULSE ARE ALL EASILY PALPABLE WITH NO EDEMA NOTED. PT. K WAS 2.9 AT 2200 AND PT. RECEIVED 60MEQ KCL PO, VIA GTUBE AND 40MEQ KCL IV. AM LABS ARE PENDING. PT. HAS BEEN RECEIVING IV LASIX.\\n\\nLUNGS ARE COARSE AND RHONCHUS THROUGHOUT. PT. AT TIMES HAS EXHIBITED INSP. WHEEZE, WHICH RESOLVED WITH TREATMENTS. RESP RATE IS CONTROLLED AND PT. REMAINS ON VENT VIA TRACH ON 15/5 THROUGHOUT THIS SHIFT, AND SINCE YESTERDAY AFTERNOON WHEN HE HAD GTUBE PLACEMENT PERFORMED IN I.R. PT. IS FOR POSSIBLE WEAN TO TRACH MASK TODAY. PT. HAS BEEN SUCTIONED MODERATE AMT'S OF CLEAR/TAN SECRETIONS. PT. EXHIBITS STRONG COUGH REFLEX. O2 SATS HAVE REMAINED >96%\\n\\nPT. HAD GTUBE REPLACED YESTERDAY OVER PRE EXISITNG SITE, WHICH HAD BEEN LEAKING. SINCE THIS PROCEDURE PT. HAS CONTINUES TO DRAIN AT THIS SITE, AND BY 0000 PT. WAS NOTED TO BE DRAINING STOOL LOKE MATERIAL FROM AROUND TUBE INSERTION SITE. TEAM MADE AWARE. PT. DENIED ANY PAIN OR DISCOMFORT, REMAINED AFEBRILE. TUBE FEEDS OF PROBALANCE FULL STRENGHT WERE PLACED ON HOLD. I.R. SUITE NOTIFIED AND CT ABD. TO EVALUATE SITUATION WAS PERFORMED THIS MORNING AT 0530. PT. TOLERATED THIS WELL. BLOOD SUGARS HAVE BEEN MONITORED AND HAVE RANGED 67, 134, 61. PT. TREATED WITHOUT DIFFICULTY, PT. DENIED ANY SYMPTOMS. FOLEY CATHETER REMAINS IN PLACE DRAINING MODERATE AMT'S OF CLEAR YELLOW URINE. PT. IS RECEIVING ROUTINE LASIX IV, AND CONTINUES TO DRAIN >100CC/HR.\\n\\nSKIN EXHIBITS TO NECK WHICH EXHIBITS ALLELYN DRESSING. TRACJH CARE HAS BEEN PERFORMED SEVERAL TIMES WITH PT. EXCRETING MODERATE TO GROSS AMT'S OF SECRETIONS AROUND THE TRACH ITSELF. PT. ALSO HAS ON RIGHT GLUTEAL. BOTH INTACT, SECURED, AND FUNCTIONING WELL, WITH N/S AT KVO.\\n\\nPLAN IS TO RE EVALUATE GTUBE AND FOLLOW THROUGH ON POSSIBLE LARGE TUBE PLACEMENT. MONITOR RESP STATUS, AND WEAN WHEN APPROPRIATE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626912,\n \"text\": \"MICU7 RN Note 0700-1900\\n\\nEvents: Wean to TM return to PSV, Resumed TF, eval for GT site.\\n\\nNeuro: awake alert oriented x2, follows commands communicates mouthing word, writing. Pupils 3mm equal react brisk. MAE random equal strength. c/o anxiety @1500 recieved ativan 1mg IV w/ calming effect. S/p care @ 1600 ^ tachypnea/desat ^ anxiety recieved ativan 1mg IVP. Pain Management denies pain @ rest c/o discomfort when providing Neck wound and GT site are.\\n\\nCV: Recieved Pt rapid Afib HR >125 NPO given Diltiezem 5mg IV HR. HR 60-130 Afib occass PVC when HR drifts down AV paced. recieved Diltiezem 90mg and Lopressor 25mg per parameters. NBP 103-135/55-80 MAPS>60 . IV access 2 NS 10cc/hr. K+ 3.2 repleted KCL40meq/500cc slow infusion K+3.4. Peripheral pulses 2+ DP/1+DT. sacral edema.\\n\\nResp: recieved pt on vent CPAP/PS 10/5 40% #7Bovona trache. Wean to TM 60% wean to 40% until 1630 return to PSV 12/5. Pt became Increasing ly anxious # 1500 recieved Ativan 1mg w/ sl effect s/p care ^RR>40 ambu and suctioned for sm amt thick yellow recieved Ativan 1mg IVP and returned to PSV. Sats 90-98% TN >350. Lungs coarse DIm L base rales R base. recieved Lasix 20mgI now changed to PO.\\n\\nGI: abd soft tender GT site Abd CT revealled GT placement ok. GT site leaking sm amt bile. TF restarted @1000. Probalance 25cc/hr adv to goal as tol. Inc loose brown stool x3.\\n\\nGU: Foley u/o 20-150cc/hr diuresed Lasix 20mg IV.\\n\\nDerM; Skin impaired Neck/ trach site duoderm gel applied gauze drsg. Coccyx red allevyn dsg reapplied. GT site red bile drangage. duoderm applied for skin protection. Plan to see pt ? need for sutute for closure.\\n\\nSocial: DNR/DNI, sister called updated on status and plan of care.\\n\\nPlan: rest on PSV for night.\\n consult to evaluate GT wound\\n Discharge to rehab \\n Refer to page 2 for completion\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626913,\n \"text\": \"Respiratory Care:\\nPt off to Trach mask @ 0820 till 1721. O2 sat.any where between 98% and 60%. later in the day his RR slowley increasing to 48. Sx'd given MDI's and returned to PSV 12/5 @ 40%...Given ativan just before going back to vent. Now seems much more comfortable. will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626914,\n \"text\": \"Resp Care Note:\\n\\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse suct sm th tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required overnoc. Cont PSV.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626915,\n \"text\": \"PT. REMAINS A DNR/DNI.\\n\\nPT. HAS NKDA.\\n\\nPT. REMAINS A/A/O AND DENIES ANY PAIN OR DISCOMFORT, DURING THIS SHIFT. PT. FOLLOWS COMMANDSA AND REMAINS AFEBRILE.\\n\\nPT. REMAINS AFIB IN A CONTROLLED RATE, WITHOUT ECTOPY 80-107. B/P HAS RANGED 115-130/70-90'S. PULSES ARE WEAK, BUT EASILY PALPABLE. NO NOTED EDEMA.\\n\\nLUNGS ARE COARSE AND DIMINISHED. PT. REMAINS ON VENT AND HAS TOLERATED THIS FINE THROUGHOUT THIS SHIFT. PT. HAS A BOLVONA TRACH. HE HAS BEEN SUCTIONED FOR COPIOUS AMT'S OF CLEAR/TAN SECRETIONS BOTH VIA TRACH AND ORALLY. RESP RATE HAS BEEN WNL'S AND O2 SATS HAVE REMAINED >96%\\n\\nPT. CONTINUES ON TUBE FEEDS, PRESENTLY AT 45CCHR, WITH GOAL OF 65CC/HR OF PROBALANCE, FULL STRENGTH. ABD. EXHIBIT GTUBE, SINGLE LUMEN, WHICH HAS DRESSING INTACT. INSERTION SITE CONTINUES TO DRAIN SMALL AMT'S OF TUBEFEEDS. NO DARK, FOWL SMELLING DRAINAGE DURING THIS SHIFT. SURGERY CONSULTED AND ASSESSED SITUATION. PLAN TO DISCUSS WHAT TO DO TODAY. BLOOD SUGARS REMAIN WNL'S WITH NO INSULIN COVERAGE GIVEN.\\nFOLEY CATHETER INTACT AND DRAINING AMPLE BUT SMALL AMT'S OF CLEAR YELLOW URINE. 60-100CC/HR. PT. REMAINS ON ROUTINE LASIX DOSING.\\n\\nPT. SKIN EXHIBITS .EXCORIATION TO NECK. ALLELYN DRESSING INTACT AND TRACH CARE PERFORMED. RIGHT GLUTEAL EXHIBITS AREA AS WELL, WITH ALLELYN DRESSING CHANGED, WHICH REMAINS INTACT AT THIS TIME. 'S REMAIN INTACT, PATENT, AND SECURED, WITH IVF OF N/S AT KVO.\\n\\nPLAN IS FOR POSSIBLE TRANSFER TO REHAB FACILITY. THIS PENDING THE DECISION OF SURGERY ON WHETHER THEY WILL TREAT LEAKAGE AROUND G-TUBE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626906,\n \"text\": \"PT. REMAINS A DNR/DNI.\\n\\nPT. HAS NKDA.\\n\\nPT. REMAINS A/A/O X2, AND BOTH MOUTHS AND WRITES ON PAD TO COMMUNICATE. PT. HAS DENIED ANY PAIN OIR DISCOMFORT THROUGHOUT THIS SHIFT. PT. HAS BEEN AFBRILE.\\n\\nPT. HAS REMAINED AFIB IN A CONTROLLED RATE WITH NO BURST IF RVR. PT'S MEDS WERE EVAULATED AND CHANGED YESTERDAY WITH DESIRED EFFECTS REACHED. B/P HAS BEEN STABLE RANGING 100-130'S/60-80'S. PULSE ARE EASILY PALPABLE, WITH NO EDEMA NOTED.\\n\\nPT. HAS TRACH (BOVONA), PT. REMAINED ON TRACH COLLAR FOR >14HRS. PT. DENIED DISTRESS AND DENIED SOB. BUT O2 SATS DROPPED FROM 97% DOWN TO 88% PT. PLACED BACK ON VENT ON PS SETTINGS. PRESENTLY PT. AS OF 0600 IS BACK ON TRACH MASK AT 50% LUNGS HAVE IMPROVED VIA CHEST XRAY IN COMPARSION FROM YESTERDAY MORNING. LUNG FIELDS ARE CLEAR IN RIGHT UPPER AND COARSE IN RIGHT LOWER, DIMINISHED THROUGHOUT LEFT LUNG. RESP RATE REMAINS CONTROLLED AND PT. DENIES AND SOB. PT. HAS BEEN SUCTIONED FOR COPIOUS MAT'S OF THICK CLEAR TO TANNISH SECRETIONS. PT. CONTINUES TO EXHIBIT STRONG COUGH REFLEX.\\n\\nPT. CONTINUES TO DIURESIS >100CC/HR PT. RECEIVED LASIX 20MG IV LAST EVENING AND AGAIN 20MG THIS AM. PT. HAS FOLEY CATHETER, CLEAR YELLOW URINE NOTED. NO STOOL NOTED THIS SHIFT. PT. HAS PEG TUBE IN PLACE, WHICH CONTINUES TO LEAK. PT. WILL GO TO IR TODAY FOR GJ TUBE. BLOOD SUGARS HAVE BEEN WNL'S WITH NO COVERAGE REQUIRED DURING THIS SHIFT.\\n\\nSKIN INTEGRITY EXHIBITS TO RIGHT GLUTEAL, AND ABREASION TO NECK WHICH PT. HAS ALLELYN DRESSING IN PLACE. PIV X2 #18 AND #20 BOTH REMAIN INTACT, SECURED, AND PATENT WITH KVO IVF INFUSING.\\n\\nPLAN IS TO TAKE PT. TO IR TODAY FOR GJ TUBE. CONTINUE TO MONITOR PULMONARY STATUS, AND AID IN PULMONARY TOILETING. PT. REMAINS A DNR/DNI AT THIS TIME.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626907,\n \"text\": \"Resp Care\\n\\nPt weaning on trach mask until ~ 2400, then accute tachypnea and desaturation which did not rebound to previous level after sxng and bronchodilators by MDI. Pt was then placed o ventialtor on AC mode, then later on PSV. Placed back on trach mask @ ~ 0530. was 138. Pt changed to hi neb due to low saturation on regular neb.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626908,\n \"text\": \"NPN 7A-7P:\\n\\n\\nNEURO: HE IS A/OX2. COOP W/ CARE. HE REQUIST TO HAVE ICE CHIPS AND GREEN SWAB AT THE BED SIDE. BUT I NOTED THE PT DRINKING THE WATER, AND COUGHING. HE FOLLOWS COMMANDS CONSISTENTLY. ABLE TO MAE.\\n\\nRESP: LS MIXED BAG. RONCHE/INS WHEEZING/POPING/DIMINSHED AT THE BASES. THIS AM HE HAS A LARGE AMOUNTS OF CLEAR SPUTUM. HE HAS A IN AFFECTIVE COUGH. HIS O2 SAT DROP DOWN TO 85% W/ RR 38 ON 30% TRACH MASK. LASIX 20MG IV WAS GIVNE. HE PLACED ON TEH VENT CPAP/PS 15/5. HIS RR 15-20.\\n\\nCV: A-FIB W/ PVC NOTED, HR 110-82. HE IS ON PO DILT AND LOPRESSOR W/ GOOD EFFECT NOTED.\\n\\nGI/GU: + BS HE DID HAVE SMALL LIGHT BROWN STOOL TODAY. GOOD UA OUT PUT NOTED. TODAY HE WENT TO IR. NEW J TUBE IN PLACE.\\n\\nSKIN: HE HAS THREE 0.5X0.5 STAGE II ON HIS COCCYX. DRESSING WAS CHANGED TODAY. HE HAS A XRT BURN ON HIS NECK. DUODERM GEL W/ DSD IS TX ORDER. AROUND THE J TUBE SITE THEIR IS YELLOW DRAINAGE IN LARGE AMOUNTS. DSD APPLYED.\\n\\nPOC: CONT VENT SUPPORT. ATTEMPT TO WEAN TO TRACH MASK. LASIX NOW . QUESTION TF. VANCO LEVEL W/ LABS IN TEH AM. K/MG/PHOS AT .\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626895,\n \"text\": \"Micu nurisng note \\n\\nCv goal today was to titrate esmolol drip off prior to dc of drip hr 95-105 afib, by 1030 am pt restarted on po metoprolol 75 mg, within 30 min drip dc's hr between 100-130 by 4 pm hr back up to 120's pt given po does of metoprolol hr still 115-120 spoke with resident and ? if we need to increase po does of metoprolol, pt recieved 40 kcl this afternoon. pulses faint but palpable, pt oob to chair x4 hrs tol well.\\nResp weaned from ac to pressure support to trach collar ( see care view) today pt on trach collar x4 hr tol well lung sounds now course pt was allows small amount of coffee while sitting in chair but noted the secreations which were white this am now are coffe color even though pt was no coughing while drinking I feel pt still asperates liquids and will now only have swabs for mouth, sats 98% pt suctioned q3 -4 for tan secreations. pt still has large amounts of secreations that come around trach, trach area red and still have wound care consult in for rad burn, area fryable, also trach seems to long and ? pt needs different trach and would recomend ip to look at trach. trach care given and skin covered with barrier cream and dsd\\nGi tube feeds on hold area leaking lg amount around tube would like to see peg replaced lg amounts of gastric contents that leak area cleaned with soap and water and barrier cream applied will hold feeds for now\\nGU pt given lasix this am u.o 150 hr\\nid pt hypothermic this afternoon 95.1 now on warming blanket\\nendo bs 166 see \\nA/P would keep pt npo, hold feeds and have gi look at peg in am\\nwould try trach collar this evening and rest on ps tonight \\nwound care consult for neck area and ? ip to look at trach\\nwould increase po metoprolol for better rate control\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626896,\n \"text\": \"1900-0700 RN NOTES MICU\\n\\nEVENTS:PT START ON DILTAIZEN GTT FOR HR 120-130,TITRATE TO HR 100,OVERNIGHT HR DOWN TO 90-LOW 100 WITH BP STABLE AT 91-100/50'S, CURRENTLLY DILTAIZEM 7MG/HR. METOPROLO PO HELD MD .\\n\\nNEURO: PT ALERT/OX3, FOLLOWS COMMANDS, /COOPERATIVE WITH CARE.ABLE TO COMMUNICATE WITH MOUTH WORDS AND WRITTNG ON A BOARD.\\n\\nRESP: RECIVED ON CPAP/PS 40%/PS 15/PEEP 5, OVERNIGHT BECAME INCREASINGLY TIRED AND C/O TROUBLE TO BREATH, PUT ON AC 405/450/RR14.SAT 99%/LS COARSE CLEAR TO SX. SUCTION MODERATE AMOUNT WHITE SECRETYION.YESTARDAY TOLLEARED TRACH COLLAR FOR 4HR.PT NEEDS IP CONSULT FOR POSSIBLE TRACH CHANGES.\\n\\nCV: AS SAYS ABOVE, START ON DILT GTT.REMAIN OB AFIB NO ECTOPY. PT WITH , TEE SHOWN ACUTE CHANGES EF DOWN TO 25-30% FROM 55-60%.MORNINF LABS PENDING.\\n\\nGU/GI: FOLEY DRAINGED YELLOW CLEAR URINE, 30-60CC/HR. PT POS 1300CC FOR 24HR. CONT WITH LEAK ON PEG SITE, TF STOOPED, PT NPO. NEEDS GI CONSULT FOR POSSIBLE PEG CHANGES.\\n\\nSKIN: OPEN AREA STAGE 2 ON COCCYX, ALLEVYN DSD APLLIED. ALSO RED AREA AROUND NECK. PT NEEDS WOUND CARE CONSULT.\\n\\nID: AFEBRILE, TMAX 97.8, CONT VANCO/CEFTRAZIDIME,\\n\\nSOCIAL; DNR/DNI, NO CONTACT FROM FAMILY.\\n\\nPLAN: CONT MONITORING RESP/CARDIO STATUS\\n WEAN DILTIAZEM GTT TO KEEP HR LOW 100'S-90.\\n PLEASE SEND VANCO LEVEL AT 7-8AM\\n IP, GI WOUND CARE CONSULTES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626892,\n \"text\": \"NURSING PROGRESS NOTE 1900-0700\\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\\n\\nNEURO: ALERT AND ORIENTED X 3- PT ABLE TO COMMUNICATE BY MOUTHING WORDS OR WRITING ON BOARD. PLEASANT. ABLE TO FOLLOW COMMANDS WITHOUT DIFFICULTY. ATTEMPTS TO ASSIST WITH TURNS AND PERSONAL CARE. ENJOYS HIS GINGERALE SWABS. AFEBRILE. PERRLA, 3/BRISK. NO SEIZURE ACTIVITY NOTED.\\n\\nRR: RECEIVED PT ON CPAP/ HOWEVER, PT BECAME INCREASINGLY TIRED AND TACHYPNIC- FELT LIKE HE WAS \\\"NOT GETTING ANY AIR\\\". PT RESTED OVERNIGHT ON AC. HAS DONE VERY WELL. NO FURTHER C/O SOB OR DIFFICULTY BREATHING. BBS= ESSENTIALLY CLEAR TO COARSE THROUGHOUT ALL LUNG FIELDS, NOTED TO BE DIMINISHED TO BASES. BILATERAL CHEST EXPANSION NOTED. SUCTIONING FOR MODERATE AMOUNTS OF YELLOW SPUTUM. PT ABLE TO SELF YANKAUR ORAL SECRETIONS. TRACH CARE PT TOLERATED WELL.\\n\\nCV: S1 AND S2 AS PER AUSCULTATION. AFIB, HR 80-90'S. RECEIVED PT ON LABETALOL GTT- DC'D AND ESMOLOL GTT INITIATED IN AN ATTEMPT TO PREVENT HYPOTENSION. SBP > OR = TO 90 WITH NO HYPER OR HYPOTENSIVE EPISODES NOTED SINCE STARTING. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PT HAS 2 PIV'S- SECURE AND PATENT. DENIES ANY CHEST PAIN.\\n\\nGI: ABD IS SOFT, FLAT, NON-DISTENDED. BS X 4 QUADRANTS. PT HAS SECURE AND INTACT PEG TUBE- DRESSING CHANGED. TF AT GOAL- NOTED TO HAVE VERY MINIMAL TO NO GASTRIC RESIDUALS. PT HAD MEDIUM SIZED, BROWN, SOFT STOOL THIS SHIFT. PASSING FLATUS.\\n\\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\\n\\nSKIN: FRAGILE SKIN. DUODERM ON COCCYX CHANGED THIS SHIFT.\\n\\nPLAN: CONTINUE TO WEAN VENT AS PT WILL TOLERATE. CONTINUE ESMOLOL GTT FOR RATE CONTROL. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626893,\n \"text\": \"Respiratory Care:\\nPt remains trached and on vent. Mode changed to AC to rest overnight, has tolerated well. Received MDI's as ordered. Suctioned lt yellow secretions. Morning = 76. Plan is to wean as tolerates in am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626894,\n \"text\": \"Resp Care\\nPt weaned to psv 5/5 this am then placed on 50% TM for just under 4 hours which he tolerated well satting >95% with rr 20-30. BLBS slightly course, suctioned for sm-mod amt thick white secretions, mdis given per order. Pt placed back on psv at 2pm to allow pt to rest. plan to attempt TM again tomorrow as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626888,\n \"text\": \"Nursing Progress Note 1900-0700\\n(Continued)\\nh care. Purulent drainage noted, avvelyn applied. PEG tube site also with yellow drainage.\\n\\nEndo: ISS, no coverage this shift, and fixed dose insulin.\\n\\nPlan: ? consider increasing PO lopressor vs. switching to diltiazem/amiodarone for HR control. Cont. to monitor renal function/ATN. Treat anxiety with lorazepam. CXR showing bilateral effusions. No more fluid boluses. Please see flow sheet as needed for additional information.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626889,\n \"text\": \"Respiratory Care:\\nPt remains trached with #7 and on vent. No parameter changes made this shift. Received MDI's, suctioned sm amt thick yellow. Had episode of ^RR, though sats remained good. Morning measured = 168.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626890,\n \"text\": \"Resp Care\\nPt remaisn trached with #7.0 h20 cuff. he was weaned to PSV 15/5 this am and has remained there all shift with volumes 375-550 and rr 18-25, pt has short periods of apnea not exceeding 30 seconds. BLBS course, scutioned for sm-mod amt thick aple yellow secrtions, mdi given per order. plan to remains on psv overnight as tolerated and wean ips tomorrow as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626905,\n \"text\": \"MICU7 RN Note 0700-1900\\n\\nEvents: Wean to TM 50%, Episodes Rapid AFib increased Diltiezem, Increased Lopressor.\\n\\nNeuro: awake alert oriented x2 follows commands Pupils 3mm equal react brisk, MARE random and to command equal strength. Denies pain . c/o feeling anxious recieved Ativan 1mg IV x2 w/calming effect.\\n\\nCv: HR 85-120 Afib rare PVC, episodes Rapid afib HR>130-150 assymptomatic Diltizem 60mg increased to 90mg TID and Increased Lopressor to 25mg TID. @ 1600 Rapdid Afib HR>150 recieved lopressor 5mg IVP w/HR 90-110. EKG done. recieved Lasix 20mg for u/o trending down. Seriel CK/troponin trending down although troponin ^ 3.26 (?renal response). peripheral pulses 3+ DP/2+ DT. neg edema.\\nK+ 3.2 repleted KCL 40meq/500cc\\nIV access : 2PIV #18/#20 NS KVO.\\n\\nresp: Bovona trach recieved pt vent mode CPAP/PSV 15/5 40%. Rr 18-30 TV >350. Sats 92-97%. @ 1000 wean to Trach collar 50% sats mid 90's. suctioned via trach for sm amt thick pale yellow, lg amt secretions drainage around trach stoma. CXR done routine @ 1600 sats low 90's RR 30-40 tachypneic pt denied Difficulty breathing. recieved lasix Lungs clear raled RLL dim L base. trach cuff down strong cough and able to expectorate mod amt thick yellow secretions. Sat ^ mid 90's. Cuff remains down w/ improved sats.\\n\\nID: afebrile t-max 98, WBC 7.5 taken off neutropenic precautions. , abx cetazipine, Vanco level 53 Vanco d/c.\\n\\nGU/GI: Foley u/o 20-300cc/hr s/p lasix. Abd soft + BS GT inplace w/gastric leakage. awaiting GJ tube placement in IR . NPO unable to give TF due to Leakage.\\n\\nDerM; Skin impaired. Radiation burn neck eval by wound care team, Protectent gel appled, frequent trach dsg changes.\\n\\nSocial: DNR/DNI. Sister called for update.\\n\\nPlan: IR for Peg revision GJ tube.\\n wean on TM for noc as tol.\\n Diurese to 1L neg.\\n monitor /control Rapid AFib\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626891,\n \"text\": \"Micu nursing note \\n\\nCV pt remains tacky up to the 130's pt given iv metoprolol 5 mg iv x2 durring the day which would drop hr into the 110-120by 530 pm pt started on a labatolol drip at .5 mg/min which is now at .75mg/min BP 89-117/60-70 hr 98-108 afib, pt troponin 3.3 and house staff felt pt still infacting and needed better rate control\\nresp pt switch to ps15/5 tv350-500 rr 10-22, lungs clears sats 100% pt sucitoned for thick sticky pale yellow secreation, pt given trach care x2 pt's neck area pink/rad burn area covered with moisture barrier cream and dsd, ( spoke with heme onc floor this was there recomendation) noted chest x ray increasesize of rt effusion\\n\\nGi pt continues on tube feeds at 65 hr probalance, residuals 10 cc, no stool\\nGU pt given lasix 20 mg at 4 pm pt putting out 150 cc hr\\nneuro pt awake and alert\\nskin consult placed for wound care\\nA/P would continue with labatolol for hr control, follow urine output and if pt u/o falls would consider more lasix tonight, pt needs repeat labs tonight.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626901,\n \"text\": \"1900-0700 rn notes micu\\n\\n71 y.omale with h/o of ETOH abuse,Afib, DM, CAD. s/p CABG, s/p trach/peg, head and neck CA undergoing chemo and transfer from OSH with Afib, ,acute renal failure, hypoxia.TEE shown acute changes EF down to 25-30% form 55-60%.in unit was on Osmolol nad diltaizem gtt for rapid Afib. currently on Diltiazem PO and Metoprolol Po.\\n\\nneuro: A/ox3, comminication wiht mouth words and writting on board. follows commands, and cooperative with care. given trazodone 25mg and Ambien held. pt c/o anxiety with RR up to high 30's, given Ativan 1mg IV with good effect.\\n\\nresp: on CPAP/PS 15/peep 5,no vent changes made overnight. LS coarse clear to suction for moderate amount white secretion. sat 98-99%.bronch done yesterday for trach placement no changes made.\\n\\ncv: HR 80-90's, Afib with occass PVC's, once Hr up to 112-115, given additional dose of Diltiazem 30mg PO with good effect.\\n\\ngi/gu: foley drainged yellow clear urine 20-30cc/hr MD aware, goal nef 1L,pt neg 1l for 24hr. pt NPO for peg revision possible in OR d/t leak. needs ABD CT prior procedure. abd soft, BS +, no BM.\\n\\naccess: 2piv pattent.\\n\\nid: affebrile, vanco held d/t level63, needs level in the morning.cont ceftrazidime.\\n\\nsocail: DNR, no contact from family.\\n\\nplan: comt monitoring resp/cardio status\\n ABD CT and ?or for peg revesion.\\n vanco level\\n wean vent to trach collor mask as tollerates.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626902,\n \"text\": \"ABD CT canceled, ?OR vs IR. pt had 10 beats of Vtach, bp stable,MD aware. vanco level sent.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626903,\n \"text\": \"Resp Care\\n\\nPt was sx Q 2-4hrs, alb / atr MDI Q 4 hrs. He has a small tach leak which is positional. Pt is very alert and fairly anxious, he was awake almost all night. this morning was ~ 112. No ABG drawn on this shift. Plan is to continue with current level of support as he seems to need the higher level of PSV.\\n\\n\\u0013\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626904,\n \"text\": \"Respiratory Care:\\nPt recieved trached and vented. Weaned to trach mask with 50% FiO2. Lung sounds clear with few crackles. Suctioned for moderate thick white secretions. MDIs given per order. Plan is to remain on trach collar if possible over noc. Pt will go for PEG placement tomorrow.Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626883,\n \"text\": \"Respiratory Care:\\n71 Y.O. Male with extensive oncologic HX to neck/throat (arrived with #7 TTS, water filled cuff, trache tube-7cc H20 to seal), here for PNA, and acute neutropenia (on XRT). PMHX: COPD, CAD/CABG. Initiallized on settings per flowsheet. ABG's drawn showing adequate oxygenation with respiratory alkalosis. Awaiting discussion with team regarding possible modality change, or sedation to reduce minute ventilation, also possible increase in FIO2. Pt. awaiting Cardiac Echo today. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626884,\n \"text\": \"Nursing Progress Note 1900-0700\\nReport received from AM shift. All alarms on monitor and ventilator are functioning properly. Pt's environment secured for safety.\\n\\nPt is a 71 yo male with a sig. history of afib, PVD, pacemaker, ETOH abuse and 59 pack year smoker, COPD, HTN, DM, CAD s/p CABG, Lt. piriform sinus mass: Squamous cell carcinoma -- radiation treatment, weekly low dose carboplatin/taxol. Pt. was admitted to OSH from rehab on for SOB, chest pain and afib with RVR, O2 dropped to 87%. ECG showed ST depressions, Troponin I elevated to 65.48. CXR revealed cardiomegaly and interstitial pulmonary changes indicative of CHF. Pt. lab values showed neutropenia and elevated BUN/cr. CXR showed Rt middle lobe pna. Arrived to MICU trached and PEGed.\\n\\nNuero: Pt. alert and oriented when admitted, currently sleeping. Able to mouth words and make needs known. Also able to communicate via pen and paper at bedside. MAE, follows commands consistently. All side rails up for safety.\\n\\nCV: HR 94-107's afib with rare PVCs noted. BPs 117-139/88-99s, 50mg metoprolol given fore HR control. Feet with mottled looking appearance, but easily palpable pedial pulses and warm to the touch. Denies any chest pain.\\n\\nRR: Pt. trached, on vent. settings 40%/500/5 PEEP, RR 16. RR 16-24, with sats 97-100%. Sxned for mod. amounts of yellow thick secretions. Pt. able to oral sxn self. Mod. amounts of yellow thick secretions around tracheostomy noted. LS coarse T/O. Bilateral chest expansion noted. Noted teeth missing while performing oral care.\\n\\nGI/GU: Abd. soft, non-distended. Abd tender to palpation. PEG tube patent and secure, residuals checked q4h with 0.0ml returned. TF started at 25ml/hr, goal rate 65 ml/hr. Pt. received with FIB, draining golden loose stool. Foley catheter is secure and patent draining marginal amounts of clear amber urine. Last BUN/Cr, 77/2.7 respectively. Last LDH 1182, AST 1552, ALT 2522.\\n\\nSkin: Mult. areas of breakdown noted on rt. gluteal. OTA, pink with no drainage noted. Neck with mult. abrasions and irritation radiation treatment. Areas with purulent drainage, OTA.\\n\\nID: Remains neutropenic with last WBC 2.3. On neutropenic precautions. Mult. antibx for coverage. Afebrile.\\n\\nEndo: ISS, and fixed dose insulin for coverage.\\n\\nPlan: Onc. consult, determine cardiac function; echo tomorrow. HR control, wean vent. as tolerated. Monitor renal function- will administer fluid challenge for decreased UOP.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626885,\n \"text\": \"Resp Care\\nFairly quite shift with pt. Did try CPAP .40 +5 +10PSV and pt tolerated for approx 2 hrs. Pt told RN despite RR of 30-35 that his breathing was fine and then a short time later he stated he was SOB so pt put back on vent with AC as before. Receiving nebs as ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626886,\n \"text\": \"NPN 7P-7A:\\n\\nTHE PT IS A 71Y/P MALE ADMIT ON W/ DX OF; MI, NEUTROPENIA, SOB. AT THE OSH HIS O2 SAT DROP INTO THE 80'S. HE WAS STARTED CARDIZEM FOR AF AND CHANGED TO LOPRESSOR PO BEFORE TX. . HE HAS A PMH: LEFT PIRIFORM SINUS MASS,TX W/ XRT, TRACH/PEG, DM,HTN,CAD S/P CABGX5, PACER SICK SINUS, AF, COPD,SPONTANEOUS PNEUMOTHORAX S/P CHEST TUBE, COLON CA S/P RESECTION , ESOPHAGEAL STRICTURE, S/P OPEN GASTROSTOMY , S/P TRACH .\\nNKDA:\\n\\nNEURO: HE IS AND MOUTHING WORDS. HE FOLLOWS COMMANDS CONSISTENTLY. ABLE TO MAE.\\n\\nRESP: HE IS TRACHED. TODAY A ATTEMPT WAS MADE TO CHANGE HIM OVER FROM AC TO CPAP. HE TOLERATED CPAP FOR 15MIN. THAN HE C/O SOB W/ RR UP TO 40'S. BECAME DIAPHERATIC AND FLUSHED. HE WAS CHANGED BACK TO AC NOW HIS RR 20 TO 24 ON 40X450X14 PEEP5. W/ OUT RESP DISTRESS NOTED. LUNG SOUNDS COURS/RONCHI BILAT. SX FOR THICK YELLOW SPUTUM IN MOD AMOUNTS. HE HAS A RIGHT MIDDLE LOBE PNA. NOW ON VANCO AND CEFAZIDIME IV.\\n\\nCV: HE IS R/I FOR A NSETMI. HIS TROKPI ARE +. HE IS CURRENTLY IN AF W/ HR 98-125. THE LOPRESSOR HAS BEEN INCREASED FORM: LOPRESSOR 50MG TID, TO 75MG TID. WHILE ON CPAP. HIS HR DID INCREASE TO 120-130. A ONE TIME DOSE OF LOPRESSOR 5MG IV WAS GIVEN. HE ALSO DID RECEIVE THE EXTRA 25MG OF LOPRESSOR TO MAKE THE AM DOSE 75MG. DESPITE THE EXTRA LOPRESSOR HIS HR STILL REMAINS FORM 110-125.\\n\\nGI/GU: HE IS NPO ASPIRATION PRECAUTIONS. HE HAS MISSING THEETH. + BS NO BM. HE HAS A RECTAL BAG IN PLACE. BUN 77/2.7. HE HAS POOR OUT PUT. FLUID CHALLENGE OF 500ML X2 WAS GIVN TODAY. W/ OUT GOOD RESPONSE.\\n\\nONC: HIS LAST DOSE OF CHEMO WAS ON . HE ALSO HAS A XRT BURN TO THE LEFT SIDE OF HIS NECK. WBC 2.3. HE REMAINS ON NEUTROPENIC PRECAUTIONS.\\n\\nSKIN: HIS BUTTOCKS HAS MULTIPLE STAGE 2 PINK AREAS. NEW DUODERM WAS APPLYED. HIS PEG TUBE SITE HAS YELLOW DRAINAGE NOTED.\\n\\nSOCIAL: TODAY HE MADE HIS AND , WHICHE IS HIS BROTHER, AND THE HCP. HE CHANGE THE FULL CODE STATUS TO AND DNR/DNI.\\n\\nPOC: TO MONITOR CK/TROP, FOR NOW CONT LOPRESSOR. AC OVER NIGHT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2107-10-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1626887,\n \"text\": \"Nursing Progress Note 1900-0700\\nReport received from AM shift. All alarms on monitor and ventilator are functioning properly. Pt's environment secured for safety.\\n\\nCode status changed to DNR/DNI\\n\\nPt. is a 71yo male with a significant history of afib, PVD, pacemaker, ETOH abuse and 59 pack year smoker, COPD, HTN, DM, CAD s/p CABG, Lt. piriform sinus mass: squamous cell carcinoma-- radiation treatment, and weekly low dose carboplantin/taxol. Pt. was admitted to OSH from rehab on for SOB, c/o chest pain, and afib with RVR, O2 dropped to 87%. ECG showed ST depression, and troponin I elevated to 65.48. CXR showed cardiomegally and intersitial pulmonary changes indicative of CHF. Pt lab values showed neutropenia and elevated BUN/Cr. CXR showed right middle lobe PNA. Arrived to MICU trached and PEGed.\\n\\nEvents: After completing trach care,repositioning and morning , pt c/o feeling \\\"tight\\\" and unable to breath. Sxned for mod amounts of thick yellow secretions. RR up in the 40s. HR 130s, and BP 130s/90s. Neb treatment given by respiratory therapy. Given 5mg lopressor IVP x2, for a total of 10mg. Resulting HR 105-115s, BP 120s/80s. Pt appear anxious and RR remained in the high 40s. Pt did not have any episodes of desaturation with this. Given 1mg lorazepam IVP, with good effect. Dr. aware. CXR showing bitateral effusions (left effusion is new). Question of possible PE- but unable to anticoagulate- will draw ABG this am as well.\\n\\nNuero: Pt. alert and follows commands consistently. MAE, able to mouth words to make needs known. All side rails up for safety.\\n\\nCV: HR 105-120s, afib, no ectopy noted. HR increased to 130s periodically T/O the night. Received 5mg lopressor IVP x3, for a total of 15mg IVP given this shift in addition to 75mg PO. ? considering increasing PO dose of lopressor. BP 115-135s/85-85s. Diff. to palpate pedial pulse bilaterally.\\n\\nResp: Pt trached on vent settings AC 40% 450/14/5 PEEP. RR 18-26, with sats 95-99%. Sxned for sm. - mod. amounts of yellow thick secretions. Pt. able to oral sxn self. Mod. to Copious amounts of thick yellow secretions noted around tracheostomy. L/S coarse T/O, bilateral chest expansion noted. Noted missing mult. teeth while performing oral care.\\n\\nGI/GU: Abd soft, non-distended. Abd tender to palpation. PEG tube secure and patent. TF at goal rate of 65 ml/hr. TF residuals check q4h with 0.0mls returned. Pt. with FIB, draining golden loose stool. + BS in all 4 quadrants. Foley catheter is secure and patent, draining marginal amounts of clear amber urine. U/O 15-40 ml/hr. Did received 1L fluid bolus low U/O, with no effect. Last BUN/Cr 83/2.7 respectively.\\n\\nID: Remains on neutropenic precautions with WBC 2.5. Mult. antibiotics for coverage. Afebrile this shift.\\n\\nSkin: Mult. areas on buttox with breakdown noted. Red, open stage 2 ulcers, new duoderm was applied, D&I. Neck with mult. areas of abrasions and irritation radiation treatment. Performed \\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2107-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 83471,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Atrial fibrillation.\\nWeight (lb): 128\\nBP (mm Hg): 146/12\\nHR (bpm): 103\\nStatus: Inpatient\\nDate/Time: at 15:37\\nTest: Portable TTE (Complete)\\nDoppler: Full Doppler and color Doppler\\nContrast: None\\nTechnical Quality: Adequate\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: Normal LA size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\\nseen in the RA and extending into the RV.\\n\\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Severely depressed\\nLVEF. No resting LVOT gradient. No VSD.\\n\\nRIGHT VENTRICLE: Normal RV wall thickness. Dilated RV cavity. RV function\\ndepressed.\\n\\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\\naortic root. Mildly dilated ascending aorta. Focal calcifications in ascending\\naorta.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\\nof papillary muscles. No MS. Moderate to severe (3+) MR. LV inflow\\nuninterpretable due to tachycardia and/or fusion of spectral Doppler E and A\\nwaves\\n\\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\\nvalve supporting structures. No TS. Moderate [2+] TR. Mild PA systolic\\nhypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: 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. Overall left\\nventricular systolic function is severely depressed (LVEF= 23-30 %). There is\\nglobal hypokinesis with regional variation: the inferior free wall, posterior\\nwall, and lateral wall are severely hypokinetic; the rest of the left\\nventricle is at least mildly hypokinetic. There is no ventricular septal\\ndefect. The right ventricular cavity is dilated. Right ventricular systolic\\nfunction appears depressed. The ascending aorta is mildly dilated. The aortic\\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\\nprolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid\\nvalve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is\\nseen. There is mild pulmonary artery systolic hypertension. There is no\\npericardial effusion.\\n\\nCompared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is markedly reduced. The right\\nventricle also is now hypocontractile. Mitral and tricuspid regurgitation are\\nsignificantly increased.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-10-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 227329,\n \"text\": \"Atrial fibrillation with rapid ventricular response. Intraventricular\\nconduction defect. Diffuse ST-T wave changes may be related to the rate and\\nrhythm but cannot rule out myocardial ischemia. Low QRS voltage in the limb\\nleads. Compared to tracing of there is no significant diagnostic\\nchange.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-10-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 227558,\n \"text\": \"Atrial fibrillation with a rapid ventricular response. Left ventricular\\nhypertrophy. ST-T wave abnormalities which could be due to left ventricular\\nhypertrophy. Compared to the previous tracing of rapid atrial\\nfibrillation is new.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2107-10-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 227328,\n \"text\": \"Atrial fibrillation, mean ventricular rate 103. Compared to previous tracing\\nof multiple abnormalities as previously noted persist without major\\nchange.\\n\\n\"\n }\n]"}}},{"rowIdx":983,"cells":{"subject_id":{"kind":"number","value":382,"string":"382"},"hadm_id":{"kind":"number","value":165617,"string":"165,617"},"target_text":{"kind":"string","value":"Cardiac catheterization on showed no MR, LVEF 68%, three vessel disease. On he underwent a CABG x 4, he was transferred to the SICU in critical but stable condition. She awoke neurologically intact and was extubated that same day. She had a brief episode of post op afib which converted with amiodarone. She was transferred to the floor on POD #1. She continued to do well postoperatively. She was seen in consultation by who changed her insulin regimen. She remained in the hospital for further blood sugar management."},"extractive_notes_summ":{"kind":"string","value":"There is a trivial/physiologic pericardial effusion.POST-BYPASS: Pt is in sinus rhythm and on an infusion of phenylephrine1. Focal calcifications in aortic root.Normal ascending aorta diameter. Simple atheroma in aortic arch. Focal calcifications in ascending aorta.Normal aortic arch diameter. Physiologic mitral regurgitation is seen (within normallimits).7. No MS. Physiologic MR (withinnormal limits).TRICUSPID VALVE: Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Significant PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. There are simple atheroma in the aortic arch. Normal descendingaorta diameter. These demonstrate that the previously noted right pleural effusion is at least partially free flowing. Normal regional LV systolic function.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. The lungs are clear except for small left lower retrocardiac atelectasis. Minimal CT serosanguinous drainage. Biventricular systolic function is preserved2. There are simple atheroma inthe descending thoracic aorta.5. IMPRESSION: Stable post-surgery appearance of the chest. Aorta is intact post decannulation3. Regional left ventricular wall motion is normal.3. Cardiac silhouette remains at the upper limits of normal in size. Intra-op TEE for CABGHeight: (in) 62Weight (lb): 135BSA (m2): 1.62 m2Status: InpatientDate/Time: at 08:28Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. Simple atheroma in descending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). IMPRESSION: Opacity projecting over the right lower lung zone, probably discoid atelectasis. The patient has been extubated, mediastinal and lateral chest tubes have been removed and an NG tube has been withdrawn. Cardiomediastinal contours are stable in the postoperative period. Assess pleural effusions. Tylenol and dilaudid with transient relief.Resp: Ls clear in upper lobes to dim at bases. Right ventricular chamber size and free wall motion are normal.4. Sternal dressing with small serosang drainage, occlusive. A left-to-right shunt across the interatrialseptum is seen at rest.2. The right internal jugular line tip is in the lower portion of SVC. The mitral valve leaflets arestructurally normal. There is blunting of both lateral CP angles, with bilateral effusions, small on the left, and moderate on the right. Sternal and mediastinal dressings CDI. The heart size and the mediastinal contours are normal. Nursing Progress NoteNeuro: Intact no defecits, hx of neuropathy.CVS: HR 90's sr, occasional self limited burst of afib to 120's stable pressure, . PA AND LATERAL CHEST: Comparison is made . pac's w few short bursts afib observed,much improved after elyte replacement.extubated to np's w/o incident,instructed in sternal splinting & is. No AR.MITRAL VALVE: Normal mitral valve leaflets. There are two left-sided chest tubes and one mediastinal drain inserted. FINDINGS: PA and lateral chest views were obtained with patient in upright position. Evaluate pleural effusion. On the frontal view only, there is parenchymal opacity overlying the right lower lung zone, probably due to atelectasis. Left ac iv dcd. Left-to-right shunt across the interatrial septum atrest.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). TLC d/c. Minor areas of atelectasis are present in the lung bases adjacent to the effusions but otherwise clear lungs. Small bilateral pleural effusions are present, decreased on the right and minimally increased on the left since the recent chest radiograph. Left ace wrap intact. a line dc'd. Right effusion may be loculated. The patient appears to be in sinus rhythm. The left atrium is normal in size. The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic regurgitation. Bilateral nipple shadows are noted. Aneurysmal interatrialseptum. The patient was under general anesthesia throughout theprocedure. Apatent foramen ovale is present. quiet but tolerating sips clears. PATIENT/TEST INFORMATION:Indication: Left ventricular function. See Conclusions for post-bypassdataConclusions:PRE-BYPASS:1. There is redemonstration of sternal wires and skin staples. A and V wires intact. Comparison is made with the next previous portable chest examination of . palp pedal pulses, skin warm dry pale and intact. TR appears slightly worse and is mild to moderate in severity4. transferred to chair with minimal assist of 2. The heart size is normal. Otherwise, the lungs are clear. CT to wall suction. 2 a and 2 v epicardial wires sense and pace appropriately, per prior shift. Prompt to CDB. Very anxious, calms when conversed with. Neo weaned to off, SBP remains > 100. IMPRESSION: Bilateral pleural effusions, decreased on the right but slightly increased on the left. Portable AP chest radiograph compared to the preoperative film from , . Overall, the volume of fluid is unchanged since study on . NSR with rare PAC's. Very drowsy with dilaudid and reglan. Sinus rhythmSeptal ST-T changes are nonspecificSince previous tracing of , no significant change Neo on then off again. There exist, however, bilateral plate atelectasis on the bases and the lateral pleural sinuses are blunted more marked than was detectable on the previous portable chest examination in supine position. Status post chest tube removal, evaluate for remaining pneumothorax. Sinus rhythmGeneralized low QRS voltagesNonspecific ST-T abnormalities in inferior leadsSince previous tracing of , inferior leads are more marked nausea, received reglan 10mg with relief. Nausea relieved with reglan 5 mg iv x 1. If this is of clinical concern, a right decubitus film could be obtained. Foley cath. The right effusion demonstrates different fluid levels on the frontal view, which could indicate loculation. Comparison is also made with the preoperative chest examination of demonstrating that neither pleural effusions nor the bilateral basal atelectases existed preoperatively. Significant pulmonic regurgitation is seen.8. ppi continues for hx hiatal hernia & gerd.husband in,questions answered. The interatrial septum is aneurysmal. CVP disconnected. Pt up in chair with minimal incisional pain."},"n_notes":{"kind":"number","value":13,"string":"13"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2117-11-30 00:00:00.000","description":"Report","row_id":74729,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Intra-op TEE for CABG\nHeight: (in) 62\nWeight (lb): 135\nBSA (m2): 1.62 m2\nStatus: Inpatient\nDate/Time: at 08:28\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. All four pulmonary veins identified and enter the\nleft atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Aneurysmal interatrial\nseptum. PFO is present. Left-to-right shunt across the interatrial septum at\nrest.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nNormal ascending aorta diameter. Focal calcifications in ascending aorta.\nNormal aortic arch diameter. Simple atheroma in aortic arch. Normal descending\naorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MS. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Significant PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient. See Conclusions for post-bypass\ndata\n\nConclusions:\nPRE-BYPASS:\n1. The left atrium is normal in size. The interatrial septum is aneurysmal. A\npatent foramen ovale is present. A left-to-right shunt across the interatrial\nseptum is seen at rest.\n2. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n3. Right ventricular chamber size and free wall motion are normal.\n4. There are simple atheroma in the aortic arch. There are simple atheroma in\nthe descending thoracic aorta.\n5. The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. 6. The mitral valve leaflets are\nstructurally normal. Physiologic mitral regurgitation is seen (within normal\nlimits).\n7. Significant pulmonic regurgitation is seen.\n8. There is a trivial/physiologic pericardial effusion.\n\nPOST-BYPASS: Pt is in sinus rhythm and on an infusion of phenylephrine\n1. Biventricular systolic function is preserved\n2. Aorta is intact post decannulation\n3. TR appears slightly worse and is mild to moderate in severity\n4. Other findings are unchanged\n\n\n"},{"category":"ECG","chartdate":"2117-11-29 00:00:00.000","description":"Report","row_id":167704,"text":"Sinus rhythm\nSeptal ST-T changes are nonspecific\nSince previous tracing of , no significant change\n\n"},{"category":"ECG","chartdate":"2117-11-30 00:00:00.000","description":"Report","row_id":167705,"text":"Sinus rhythm\nGeneralized low QRS voltages\nNonspecific ST-T abnormalities in inferior leads\nSince previous tracing of , inferior leads are more marked\n\n"},{"category":"Nursing/other","chartdate":"2117-12-01 00:00:00.000","description":"Report","row_id":1265727,"text":"Nursing Progress Note\nNeuro: Intact no defecits, hx of neuropathy.\n\nCVS: HR 90's sr, occasional self limited burst of afib to 120's stable pressure, . Neo weaned to off, SBP remains > 100. Rij multi lumen patent x 3 ports, CVP transduced . 2 a and 2 v epicardial wires sense and pace appropriately, per prior shift. A tested, V not tested due to HR. Sternal dressing with small serosang drainage, occlusive. Left ace wrap intact. palp pedal pulses, skin warm dry pale and intact. Chest tubes with scant serosang drainage.\n\nPain: C/o all over aches and pains, including ahoulders neck and back. Tylenol and dilaudid with transient relief.\n\nResp: Ls clear in upper lobes to dim at bases. Difficulty with cough and deep breathing r/t pain. IS to 500-750. Utilizing pillow. NC o2 at 4 l, mouthbreather but refuses mask or tent.\n\nGI: abd soft non tender, copious belching. Nausea relieved with reglan 5 mg iv x 1. Tolerating po meds and h20.\n\nGU: foley cath draining clear yellow urine > 30 cc hour.\n\nEndo: FS BS following insulin csru gtt scale, off at 0100 for bs 76.\n\nPlan: insulin change to sc and home nph when eating, pain control, pulmonary toileting, increase actiivty as tolerated. Transfer to 2 in am.\n\nSee carevue flowsheet and mars for further details and values.\n\n\n\n\n\n\n"},{"category":"Nursing/other","chartdate":"2117-12-01 00:00:00.000","description":"Report","row_id":1265728,"text":"Nursing Progress Note:\nAssumed care at 1100. Pt up in chair with minimal incisional pain. NSR with rare PAC's. BP 100/40's. TLC d/c. CT to wall suction. Minimal CT serosanguinous drainage. Started pt on nph. Gave 15u nph at noon. Foley cath. Good UO, Clear yellow, urine. Sternal and mediastinal dressings CDI. Pacer off. A and V wires intact. Will transfer to 2 at 1300.\n"},{"category":"Nursing/other","chartdate":"2117-11-30 00:00:00.000","description":"Report","row_id":1265725,"text":"sbp dropping to 80's -90's esp. with movement,coughing with rising hct,low cvp & dark amber urine->add'l volume,increased neo & transient a pacing for bp support.occas. pac's w few short bursts afib observed,much improved after elyte replacement.extubated to np's w/o incident,instructed in sternal splinting & is. able to raise between 500 & 750 cc with coaxing.pain poorly controlled at first,lots morphine given with constant c/o back & shoulder pain when awake & stimulated but otherwise appeared overmedicated & would fall asleep instantly.not an nsaid candidate due to cri-baseline ~ 1.4-1.6. changed to dilaudid with improved relief & alertness. she states she has chronic back pain & usually treats with tylenol,position changes & aleve.tylenol resumed.glucoses in good control on protocol,see flow sheet. abd. quiet but tolerating sips clears. ppi continues for hx hiatal hernia & gerd.husband in,questions answered. encouraged to go home but plans to spend the night in the waiting room. icu visiting guidelines reviewed,will check in in a.m. to arrange visiting time with a.m. r.n.\n"},{"category":"Nursing/other","chartdate":"2117-12-01 00:00:00.000","description":"Report","row_id":1265726,"text":"Nursing Progress Note\namiodarone bolus for more frequents burst of afib. Now 82 sr with very rare pac. Neo on then off again. a line dc'd. CVP disconnected. Left ac iv dcd. OOB to chair. nausea, received reglan 10mg with relief. Very drowsy with dilaudid and reglan. transferred to chair with minimal assist of 2. Very anxious, calms when conversed with. Prompt to CDB. Insulin gtt at 3, continue protocol.\n"},{"category":"Radiology","chartdate":"2117-11-29 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":932737,"text":" 5:33 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: ANGINA;CHEST PAIN\\CATH\n Admitting Diagnosis: ANGINA;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with 3 v CAd, for Cabg.please do after 3 pm today\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old woman with coronary artery disease, pre-operative for\n coronary artery bypass graft surgery.\n\n CHEST, PA AND LATERAL: There are no prior studies available for comparison.\n The heart size is normal. The mediastinal and hilar contours are\n unremarkable. There are no pleural effusions or pneumothorax. On the frontal\n view only, there is parenchymal opacity overlying the right lower lung zone,\n probably due to atelectasis. Otherwise, the lungs are clear. Bilateral\n nipple shadows are noted. The osseous structures are unremarkable.\n\n IMPRESSION: Opacity projecting over the right lower lung zone, probably\n discoid atelectasis.\n\n\n"},{"category":"Radiology","chartdate":"2117-11-30 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":932844,"text":" 11:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusion, pulmonary edema, pneumothorax, tamponade\n Admitting Diagnosis: ANGINA;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n pleural effusion, pulmonary edema, pneumothorax, tamponade\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup after CABG.\n\n Portable AP chest radiograph compared to the preoperative film from , . The ET tube tip is 4.6 cm above the carina. The right internal\n jugular line tip is in the lower portion of SVC. The NG tube tip is within\n the stomach. There are two left-sided chest tubes and one mediastinal drain\n inserted. The heart size and the mediastinal contours are normal. The lungs\n are clear except for small left lower retrocardiac atelectasis. There is no\n sizable pleural effusion. There is no pneumothorax.\n\n IMPRESSION: Stable post-surgery appearance of the chest.\n\n\n"},{"category":"Radiology","chartdate":"2117-12-02 00:00:00.000","description":"CHEST (PA & LAT)","row_id":933199,"text":" 2:26 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pneumothorax s/p chest tube removal\n Admitting Diagnosis: ANGINA;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p cabgx4\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: Status post quadruple bypass surgery. Status post chest tube\n removal, evaluate for remaining pneumothorax.\n\n FINDINGS: PA and lateral chest views were obtained with patient in upright\n position. Comparison is made with the next previous portable chest\n examination of . The patient has been extubated, mediastinal\n and lateral chest tubes have been removed and an NG tube has been withdrawn.\n There is no evidence of pneumothorax. There exist, however, bilateral plate\n atelectasis on the bases and the lateral pleural sinuses are blunted more\n marked than was detectable on the previous portable chest examination in\n supine position. Comparison is also made with the preoperative chest\n examination of demonstrating that neither pleural effusions\n nor the bilateral basal atelectases existed preoperatively. Consequently, it\n is suggested that the patient is followed up with further radiographs to\n document normalization of these changes.\n\n"},{"category":"Radiology","chartdate":"2117-12-04 00:00:00.000","description":"CHEST (LAT DECUB ONLY)","row_id":933531,"text":" 8:25 PM\n CHEST (LAT DECUB ONLY) Clip # \n Reason: evaluate ? loculated effusion noted on CXR please do t\n Admitting Diagnosis: ANGINA;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n evaluate ? loculated effusion noted on CXR please do this evening\n ______________________________________________________________________________\n FINAL REPORT\n CHEST LATERAL DECUB\n\n Two right lateral decubitus views are compared with the previous study done\n . These demonstrate that the previously noted right pleural effusion\n is at least partially free flowing.\n\n\n"},{"category":"Radiology","chartdate":"2117-12-06 00:00:00.000","description":"CHEST (PA & LAT)","row_id":933692,"text":" 10:54 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate effusion specifically right side\n Admitting Diagnosis: ANGINA;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p cabgx4\n\n REASON FOR THIS EXAMINATION:\n evaluate effusion specifically right side\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEWS CHEST X-RAY, \n\n COMPARISON: .\n\n INDICATION: Status post coronary bypass surgery. Evaluate pleural effusion.\n\n Small bilateral pleural effusions are present, decreased on the right and\n minimally increased on the left since the recent chest radiograph. Minor\n areas of atelectasis are present in the lung bases adjacent to the effusions\n but otherwise clear lungs. Cardiomediastinal contours are stable in the\n postoperative period.\n\n IMPRESSION: Bilateral pleural effusions, decreased on the right but slightly\n increased on the left.\n\n\n"},{"category":"Radiology","chartdate":"2117-12-03 00:00:00.000","description":"CHEST (PA & LAT)","row_id":933390,"text":" 7:02 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate plaeural effusions\n Admitting Diagnosis: ANGINA;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p cabgx4\n\n REASON FOR THIS EXAMINATION:\n evaluate plaeural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Recent coronary artery bypass. Assess pleural effusions.\n\n PA AND LATERAL CHEST: Comparison is made . There is\n redemonstration of sternal wires and skin staples. Cardiac silhouette remains\n at the upper limits of normal in size. There is no evidence of worsening\n congestive heart failure. There is blunting of both lateral CP angles, with\n bilateral effusions, small on the left, and moderate on the right. The right\n effusion demonstrates different fluid levels on the frontal view, which could\n indicate loculation. Overall, the volume of fluid is unchanged since study on\n . There is no pneumothorax.\n\n IMPRESSION: No significant change in appearance. Right effusion may be\n loculated. If this is of clinical concern, a right decubitus film could be\n obtained.\n\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2117-11-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 74729,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function. Intra-op TEE for CABG\\nHeight: (in) 62\\nWeight (lb): 135\\nBSA (m2): 1.62 m2\\nStatus: Inpatient\\nDate/Time: at 08:28\\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. All four pulmonary veins identified and enter the\\nleft atrium.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Aneurysmal interatrial\\nseptum. PFO is present. Left-to-right shunt across the interatrial septum at\\nrest.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\\n(LVEF>55%). Normal regional LV systolic function.\\n\\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\\nNormal ascending aorta diameter. Focal calcifications in ascending aorta.\\nNormal aortic arch diameter. Simple atheroma in aortic arch. Normal descending\\naorta diameter. Simple atheroma in descending aorta.\\n\\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Normal mitral valve leaflets. No MS. Physiologic MR (within\\nnormal limits).\\n\\nTRICUSPID VALVE: Physiologic TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Significant PR.\\n\\nPERICARDIUM: Trivial/physiologic pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. No TEE related\\ncomplications. The patient was under general anesthesia throughout the\\nprocedure. The patient appears to be in sinus rhythm. Results were personally\\nreviewed with the MD caring for the patient. See Conclusions for post-bypass\\ndata\\n\\nConclusions:\\nPRE-BYPASS:\\n1. The left atrium is normal in size. The interatrial septum is aneurysmal. A\\npatent foramen ovale is present. A left-to-right shunt across the interatrial\\nseptum is seen at rest.\\n2. Left ventricular wall thickness, cavity size, and systolic function are\\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\\n3. Right ventricular chamber size and free wall motion are normal.\\n4. There are simple atheroma in the aortic arch. There are simple atheroma in\\nthe descending thoracic aorta.\\n5. The aortic valve leaflets (3) appear structurally normal with good leaflet\\nexcursion and no aortic regurgitation. 6. The mitral valve leaflets are\\nstructurally normal. Physiologic mitral regurgitation is seen (within normal\\nlimits).\\n7. Significant pulmonic regurgitation is seen.\\n8. There is a trivial/physiologic pericardial effusion.\\n\\nPOST-BYPASS: Pt is in sinus rhythm and on an infusion of phenylephrine\\n1. Biventricular systolic function is preserved\\n2. Aorta is intact post decannulation\\n3. TR appears slightly worse and is mild to moderate in severity\\n4. Other findings are unchanged\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-11-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 167704,\n \"text\": \"Sinus rhythm\\nSeptal ST-T changes are nonspecific\\nSince previous tracing of , no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-11-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 167705,\n \"text\": \"Sinus rhythm\\nGeneralized low QRS voltages\\nNonspecific ST-T abnormalities in inferior leads\\nSince previous tracing of , inferior leads are more marked\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-12-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1265727,\n \"text\": \"Nursing Progress Note\\nNeuro: Intact no defecits, hx of neuropathy.\\n\\nCVS: HR 90's sr, occasional self limited burst of afib to 120's stable pressure, . Neo weaned to off, SBP remains > 100. Rij multi lumen patent x 3 ports, CVP transduced . 2 a and 2 v epicardial wires sense and pace appropriately, per prior shift. A tested, V not tested due to HR. Sternal dressing with small serosang drainage, occlusive. Left ace wrap intact. palp pedal pulses, skin warm dry pale and intact. Chest tubes with scant serosang drainage.\\n\\nPain: C/o all over aches and pains, including ahoulders neck and back. Tylenol and dilaudid with transient relief.\\n\\nResp: Ls clear in upper lobes to dim at bases. Difficulty with cough and deep breathing r/t pain. IS to 500-750. Utilizing pillow. NC o2 at 4 l, mouthbreather but refuses mask or tent.\\n\\nGI: abd soft non tender, copious belching. Nausea relieved with reglan 5 mg iv x 1. Tolerating po meds and h20.\\n\\nGU: foley cath draining clear yellow urine > 30 cc hour.\\n\\nEndo: FS BS following insulin csru gtt scale, off at 0100 for bs 76.\\n\\nPlan: insulin change to sc and home nph when eating, pain control, pulmonary toileting, increase actiivty as tolerated. Transfer to 2 in am.\\n\\nSee carevue flowsheet and mars for further details and values.\\n\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-12-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1265728,\n \"text\": \"Nursing Progress Note:\\nAssumed care at 1100. Pt up in chair with minimal incisional pain. NSR with rare PAC's. BP 100/40's. TLC d/c. CT to wall suction. Minimal CT serosanguinous drainage. Started pt on nph. Gave 15u nph at noon. Foley cath. Good UO, Clear yellow, urine. Sternal and mediastinal dressings CDI. Pacer off. A and V wires intact. Will transfer to 2 at 1300.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-11-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1265725,\n \"text\": \"sbp dropping to 80's -90's esp. with movement,coughing with rising hct,low cvp & dark amber urine->add'l volume,increased neo & transient a pacing for bp support.occas. pac's w few short bursts afib observed,much improved after elyte replacement.extubated to np's w/o incident,instructed in sternal splinting & is. able to raise between 500 & 750 cc with coaxing.pain poorly controlled at first,lots morphine given with constant c/o back & shoulder pain when awake & stimulated but otherwise appeared overmedicated & would fall asleep instantly.not an nsaid candidate due to cri-baseline ~ 1.4-1.6. changed to dilaudid with improved relief & alertness. she states she has chronic back pain & usually treats with tylenol,position changes & aleve.tylenol resumed.glucoses in good control on protocol,see flow sheet. abd. quiet but tolerating sips clears. ppi continues for hx hiatal hernia & gerd.husband in,questions answered. encouraged to go home but plans to spend the night in the waiting room. icu visiting guidelines reviewed,will check in in a.m. to arrange visiting time with a.m. r.n.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-12-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1265726,\n \"text\": \"Nursing Progress Note\\namiodarone bolus for more frequents burst of afib. Now 82 sr with very rare pac. Neo on then off again. a line dc'd. CVP disconnected. Left ac iv dcd. OOB to chair. nausea, received reglan 10mg with relief. Very drowsy with dilaudid and reglan. transferred to chair with minimal assist of 2. Very anxious, calms when conversed with. Prompt to CDB. Insulin gtt at 3, continue protocol.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-11-29 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 932737,\n \"text\": \" 5:33 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: ANGINA;CHEST PAIN\\\\CATH\\n Admitting Diagnosis: ANGINA;CHEST PAIN\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman with 3 v CAd, for Cabg.please do after 3 pm today\\n REASON FOR THIS EXAMINATION:\\n r/o infiltrate, chf\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56-year-old woman with coronary artery disease, pre-operative for\\n coronary artery bypass graft surgery.\\n\\n CHEST, PA AND LATERAL: There are no prior studies available for comparison.\\n The heart size is normal. The mediastinal and hilar contours are\\n unremarkable. There are no pleural effusions or pneumothorax. On the frontal\\n view only, there is parenchymal opacity overlying the right lower lung zone,\\n probably due to atelectasis. Otherwise, the lungs are clear. Bilateral\\n nipple shadows are noted. The osseous structures are unremarkable.\\n\\n IMPRESSION: Opacity projecting over the right lower lung zone, probably\\n discoid atelectasis.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-11-30 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 932844,\n \"text\": \" 11:56 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pleural effusion, pulmonary edema, pneumothorax, tamponade\\n Admitting Diagnosis: ANGINA;CHEST PAIN\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman s/p CABG\\n REASON FOR THIS EXAMINATION:\\n pleural effusion, pulmonary edema, pneumothorax, tamponade\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup after CABG.\\n\\n Portable AP chest radiograph compared to the preoperative film from , . The ET tube tip is 4.6 cm above the carina. The right internal\\n jugular line tip is in the lower portion of SVC. The NG tube tip is within\\n the stomach. There are two left-sided chest tubes and one mediastinal drain\\n inserted. The heart size and the mediastinal contours are normal. The lungs\\n are clear except for small left lower retrocardiac atelectasis. There is no\\n sizable pleural effusion. There is no pneumothorax.\\n\\n IMPRESSION: Stable post-surgery appearance of the chest.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-12-02 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 933199,\n \"text\": \" 2:26 PM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate for pneumothorax s/p chest tube removal\\n Admitting Diagnosis: ANGINA;CHEST PAIN\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman s/p cabgx4\\n REASON FOR THIS EXAMINATION:\\n evaluate for pneumothorax s/p chest tube removal\\n ______________________________________________________________________________\\n FINAL REPORT\\n TYPE OF EXAMINATION: Chest PA and lateral.\\n\\n INDICATION: Status post quadruple bypass surgery. Status post chest tube\\n removal, evaluate for remaining pneumothorax.\\n\\n FINDINGS: PA and lateral chest views were obtained with patient in upright\\n position. Comparison is made with the next previous portable chest\\n examination of . The patient has been extubated, mediastinal\\n and lateral chest tubes have been removed and an NG tube has been withdrawn.\\n There is no evidence of pneumothorax. There exist, however, bilateral plate\\n atelectasis on the bases and the lateral pleural sinuses are blunted more\\n marked than was detectable on the previous portable chest examination in\\n supine position. Comparison is also made with the preoperative chest\\n examination of demonstrating that neither pleural effusions\\n nor the bilateral basal atelectases existed preoperatively. Consequently, it\\n is suggested that the patient is followed up with further radiographs to\\n document normalization of these changes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-12-04 00:00:00.000\",\n \"description\": \"CHEST (LAT DECUB ONLY)\",\n \"row_id\": 933531,\n \"text\": \" 8:25 PM\\n CHEST (LAT DECUB ONLY) Clip # \\n Reason: evaluate ? loculated effusion noted on CXR please do t\\n Admitting Diagnosis: ANGINA;CHEST PAIN\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman s/p CABG\\n REASON FOR THIS EXAMINATION:\\n evaluate ? loculated effusion noted on CXR please do this evening\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST LATERAL DECUB\\n\\n Two right lateral decubitus views are compared with the previous study done\\n . These demonstrate that the previously noted right pleural effusion\\n is at least partially free flowing.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-12-06 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 933692,\n \"text\": \" 10:54 AM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate effusion specifically right side\\n Admitting Diagnosis: ANGINA;CHEST PAIN\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman s/p cabgx4\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate effusion specifically right side\\n ______________________________________________________________________________\\n FINAL REPORT\\n TWO VIEWS CHEST X-RAY, \\n\\n COMPARISON: .\\n\\n INDICATION: Status post coronary bypass surgery. Evaluate pleural effusion.\\n\\n Small bilateral pleural effusions are present, decreased on the right and\\n minimally increased on the left since the recent chest radiograph. Minor\\n areas of atelectasis are present in the lung bases adjacent to the effusions\\n but otherwise clear lungs. Cardiomediastinal contours are stable in the\\n postoperative period.\\n\\n IMPRESSION: Bilateral pleural effusions, decreased on the right but slightly\\n increased on the left.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-12-03 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 933390,\n \"text\": \" 7:02 PM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate plaeural effusions\\n Admitting Diagnosis: ANGINA;CHEST PAIN\\\\CATH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old woman s/p cabgx4\\n\\n REASON FOR THIS EXAMINATION:\\n evaluate plaeural effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: Recent coronary artery bypass. Assess pleural effusions.\\n\\n PA AND LATERAL CHEST: Comparison is made . There is\\n redemonstration of sternal wires and skin staples. Cardiac silhouette remains\\n at the upper limits of normal in size. There is no evidence of worsening\\n congestive heart failure. There is blunting of both lateral CP angles, with\\n bilateral effusions, small on the left, and moderate on the right. The right\\n effusion demonstrates different fluid levels on the frontal view, which could\\n indicate loculation. Overall, the volume of fluid is unchanged since study on\\n . There is no pneumothorax.\\n\\n IMPRESSION: No significant change in appearance. Right effusion may be\\n loculated. If this is of clinical concern, a right decubitus film could be\\n obtained.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":984,"cells":{"subject_id":{"kind":"number","value":5866,"string":"5,866"},"hadm_id":{"kind":"number","value":122438,"string":"122,438"},"target_text":{"kind":"string","value":"Patient underwent ex lap, LOA, ileostomy and MF takedown on without complications. She had post op hypotension and decreased urine output for which she was given fluid, her epidural was stopped and she was given a PCA, and she was given some pressors (Neo). HCT was stable. Central line was placed on POD1. She was tx from the PACU top the ICU for further observation. Neo was weaned down in ICU, she had fluid resuscitation, and her electorlytes were repleted as needed. She improved, passed flatus and she had her NGT removed and was tx to the floor on POD4. Her diet was advanced on the floor as tolerated - it she had to be slowed down because of nausea, her pain was well controlled, and she ambulated witht the help of PT and nursing staff. On POD7 foley was d/c'd. On POD8 she is in good condition for d/c to rehab."},"extractive_notes_summ":{"kind":"string","value":"PB's and sc heparin for DVT prophylaxis.Resp: LS clear, diminished at bases. Phos to be repleted.Endo: BS 87->89ID; afebrile; no abx coverageSkin: back/buttocks intact; abd incision with dsg intact; sm. Rule out pneumothorax. Dilaudid PCA 0.12mg Q6minutes with good effect.CV: HR 80-90's SR no ectopy noted. 10:05 PM ABDOMEN (SUPINE & ERECT) Clip # Reason: r/o ileus or obstruction. Noted waveform has positional respiratory variation.ENDOCRINE:Has not required coverage per sliding scale.FLUIDS:LR with KCl at 150mls/ hr. NGT to LCWS for scant bilious drainage. A left subclavian catheter terminates in the mid SVC. Rule out CHF. 4:29 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: still requires pressors. Some mild exp wheeze on exertion, resolved when settled. ?diuresis vs. fluid. Mildly tachypneic with anxiety, resps non labored after reassuance and talking down. NBP systolic 110-140's sytolic. These appearances are likely to represent post-operative ileus. To be reduced to 100mls/ hr.GI:Abd obese, bowel sounds present. REASON FOR THIS EXAMINATION: r/o ileus or obstruction. An NGT terminates in the stomach. to assess.CV: HR 70-80'sSR, BP 100-120's/40-50's. OOB as tolerated, PCA for pain ?resume pre op diuretics, cont to monitor and support, follow plan of care. There has been interval decrease in the width of the mediastinum. Benadryl given per order and pt's request. Re-orient prn. The heart size is at the upper limits of normal. 02 via prongs prn. Dr. in to assess pt. There has been interval improvement in the mediastinal contour. PCA off. No antibiotics.RENAL:Diuresed with HCTZ early in shift. Heart size top normal. LSC TLCL wnl. Pt attending to incentive spirometry with encouragement, and pulling 500mls.HEMODYNAMICALLY:SR no ectopy. (Discussed anxiety with pt's attending Dr , no further orders). c/o pain at 1 on scale 0-10, up to with activity. sersang. Primary dressing intact with no further drainage. Abd obease, incision dsg intact, protonix, ngt to LCWS with bilious drainage, npo.Skin/Mobility: Skin grossly intact. The lung volumes are again low. Cardiac silhouette is top normal size. The left subclavian central venous line tip is in the upper superior vena cava. SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: There are low lung volumes. A nasogastric tube tip is not visualized but descends below the diaphragm. Denies difficulty breathing when upright; anxious when HOB lowered for turning. NGT to suction with bilious output. Re-oriented. IMPRESSION: Interval improvement in the mediastinal contour likely related to clearing pulmonary edema. CXR attended. Will cont. IMPRESSION: AP chest compared to chest radiographs since , most recently : Lung volumes have been persistently low. BP stable 120-140 / 50-60s. Globally obese, some dependent edema also. IMPRESSION: AP chest compared to and , most recent prior chest radiographs: Lung volumes are appreciably lower on today's study, which may be due in part to subpulmonic pleural effusions and produces atelectasis at both lung bases. Little if any pleural effusion. Denies n/v. Followup examination at maximum inspiration is recommended for assessment. amt. At 1400 c/o SOB and wheezes treated with albuterol neb X1 with effect, chest x-ray done. Care attended. PCA dilaudid in use, pt using appropriately and it is providing good relief. Nasogastric tube passes to the distal stomach. Persistently low lung volumes. Nursing Progress Note.Please see CareVue for specifics.Pt condition stable overnight.NEURO:Pt sleeping well, wakes easily. 9:03 AM CHEST PORT. T-SICU NPN 1900-0700see carevue for specifics.ROS:Neuro: A+Ox3, MAE's,following commands consistently. Enc. The nasogastric tube tip is not visualized but is below the diaphragm. When asked if she remembered having surgery, pt stated \"I don't want to remember\". There is air distally within nondistended colon. NPO with frequent mouthcare attended by pt.ID:Afebrile. SINGLE PORTABLE AP CHEST RADIOGRAPH: Again seen is the left subclavian central venous catheter with its tip in the mid superior vena cava. There are low lung volumes with atelectatic opacities at the lung bases, more currently at the left base than was present in the prior chest x-ray 24 hours ago. Shortness of breath. IMPRESSION: Improvement in the widening of the mediastinum. pulmonary hygiene. Upper lungs clear. T/SICU RN Progress NoteNeuro: Alert and oriented X3, anxious at times with turning and moving, needs reassurance. CVP 8-12. Evaluate for obstruction. Sleeping well between interventions.RESP:Chest clear, cough minimally productive. please perform UPRIGHT END INSPIRATION CXR to eval lung volumes FINAL REPORT INDICATION: 64-year-old woman status post left subclavian line, hypotensive, follow up. LRw/20meq kcl @150cc/hr, p-boots, SQ heparin.Resp: Lungs clear on 3l n/c, IS encouraged cough/deep breathing. CVP 11-13 with 2 hours 18. Lines and tubes appropriately placed. Urine output remains >80 mls/hr.SKIN:Skin to back and heels intact, no breakdown. Equal hand grasps, pupils 3mm, equal and reactive, following commands. 10:00 AM CHEST PORT. IMPRESSION: Increasing opacity at the left base since . Approx. Pedal pulses palpable. 0530, pt removed BP cuff and o2sat probe, appeared confused; answering most questions \"I don't know\" or \"I don't want to do this\". FINDINGS: There are surgical clips along the left lateral abdomen and mid abdomen. Given 500ccLR bolus X1. No visitors overnight.PLAN:Consider active diuresis, recommencement of home meds.Out of bed to chair.Transfer to floor. Oriented. please perform UPRIGHT END INSPIRA Admitting Diagnosis: ILEOSTOMY CLOSE/SDA MEDICAL CONDITION: 64 year old woman s/p left subclavian central line placement for resucitation after elective ileostomy reversal REASON FOR THIS EXAMINATION: still requires pressors."},"n_notes":{"kind":"number","value":9,"string":"9"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2142-11-09 00:00:00.000","description":"Report","row_id":1339052,"text":"Nursing Progress Note.\nPlease see CareVue for specifics.\n\nPt condition stable overnight.\n\nNEURO:\nPt sleeping well, wakes easily. Oriented. Cooperative. Very anxious, escalates quickly, requiring reassurance, then apologising for snapping at staff. (Discussed anxiety with pt's attending Dr , no further orders). Initially denying she takes anxiolytic at home, then stated she takes benadryl for anxiety. Benadryl given per order and pt's request. She woke x1 occasion requesting more benadryl, for itch and to assist with sleep, but as it was too early for benadryl pt received phenergan with good effect. PCA dilaudid in use, pt using appropriately and it is providing good relief. Assisting staff with repositioning, but reluctant to turn on side despite education regarding importance of doing so. Sleeping well between interventions.\n\nRESP:\nChest clear, cough minimally productive. 02 via prongs prn. Some mild exp wheeze on exertion, resolved when settled. Mildly tachypneic with anxiety, resps non labored after reassuance and talking down. CXR attended. Pt attending to incentive spirometry with encouragement, and pulling 500mls.\n\nHEMODYNAMICALLY:\nSR no ectopy. BP stable 120-140 / 50-60s. Globally obese, some dependent edema also. CVP 11-13 with 2 hours 18. Noted waveform has positional respiratory variation.\n\nENDOCRINE:\nHas not required coverage per sliding scale.\n\nFLUIDS:\nLR with KCl at 150mls/ hr. To be reduced to 100mls/ hr.\n\nGI:\nAbd obese, bowel sounds present. NGT to suction with bilious output. Primary dressing intact with no further drainage. NPO with frequent mouthcare attended by pt.\n\nID:\nAfebrile. No antibiotics.\n\nRENAL:\nDiuresed with HCTZ early in shift. Urine output remains >80 mls/hr.\n\nSKIN:\nSkin to back and heels intact, no breakdown. Care attended. Pt rotated but initially declined to sleep on side despite education. Assisting staff to turn herself over.\n\nSOCIAL:\nDaughter called and spoke to pt. No visitors overnight.\n\nPLAN:\nConsider active diuresis, recommencement of home meds.\nOut of bed to chair.\nTransfer to floor.\n"},{"category":"Nursing/other","chartdate":"2142-11-08 00:00:00.000","description":"Report","row_id":1339050,"text":"T-SICU NPN 1900-0700\nsee carevue for specifics.\nROS:\nNeuro: A+Ox3, MAE's,following commands consistently. c/o pain at 1 on scale 0-10, up to with activity. Approx. 0530, pt removed BP cuff and o2sat probe, appeared confused; answering most questions \"I don't know\" or \"I don't want to do this\". Dr. in to assess pt. PCA off. Equal hand grasps, pupils 3mm, equal and reactive, following commands. Re-oriented. When asked if she remembered having surgery, pt stated \"I don't want to remember\". Will cont. to assess.\nCV: HR 70-80'sSR, BP 100-120's/40-50's. CVP 8-12. Skin warm, dry. Pedal pulses palpable. LSC TLCL wnl. PB's and sc heparin for DVT prophylaxis.\nResp: LS clear, diminished at bases. Denies difficulty breathing when upright; anxious when HOB lowered for turning. RR teens-20's, O2sats 96% on 3lnc.\nGI; abd obese, BS present, no stool/flatus. Denies n/v. NGT to LCWS for scant bilious drainage. Protonix for GI prophylaxis.\nGU: foley patent draining marginal amber urine 10-20cc/hr, 500cc LR bolus x2. Phos to be repleted.\nEndo: BS 87->89\nID; afebrile; no abx coverage\nSkin: back/buttocks intact; abd incision with dsg intact; sm. amt. sersang. drainage, outlined, no adavancement noted.\nPsych/social: pt called and spoke with her daughter via phone upon arrival to ICU; no further contact . pt, information may be shared with her daughter who is her contact person; NO INFORMATION is to be given to daughter per pt's request.\nA: s/p closure of ileostomy, LOA\nmarginal uo; increased confusion this am\nP: Monitor VS, I/O, labs, mental status. Re-orient prn. Enc. pulmonary hygiene. Await further orders from team. ?diuresis vs. fluid. Continue ongoing comfort/support to pt and family.\n"},{"category":"Nursing/other","chartdate":"2142-11-08 00:00:00.000","description":"Report","row_id":1339051,"text":"T/SICU RN Progress Note\nNeuro: Alert and oriented X3, anxious at times with turning and moving, needs reassurance. Dilaudid PCA 0.12mg Q6minutes with good effect.\n\nCV: HR 80-90's SR no ectopy noted. NBP systolic 110-140's sytolic. CVP 4-8 throughout day. LRw/20meq kcl @150cc/hr, p-boots, SQ heparin.\n\nResp: Lungs clear on 3l n/c, IS encouraged cough/deep breathing. Strong congested cough. At 1400 c/o SOB and wheezes treated with albuterol neb X1 with effect, chest x-ray done. RR 12-20 with Sats 97-100%.\n\nGU/GI: Foley with marginal urine output 15-30cc/hr amber urine. Given 500ccLR bolus X1. Abd obease, incision dsg intact, protonix, ngt to LCWS with bilious drainage, npo.\n\nSkin/Mobility: Skin grossly intact. OOB to chair X3 hrs today, with min. assist tolerated well.\n\nSocial: Daughter in to visit, sister called on phone.\n\nPlan: Monitor fluid status, resp status, cont with aggressive pulmonary hygeine. OOB as tolerated, PCA for pain ?resume pre op diuretics, cont to monitor and support, follow plan of care.\n"},{"category":"Radiology","chartdate":"2142-11-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":883258,"text":" 5:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o failure\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p ileostomy reversal\n REASON FOR THIS EXAMINATION:\n r/o failure\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:54 A.M., \n\n HISTORY: Ileostomy reversal. Shortness of breath. Rule out CHF.\n\n IMPRESSION: AP chest compared to chest radiographs since , most\n recently :\n\n Lung volumes have been persistently low. Progressive opacification at the\n left lung base could be pneumonia but is more likely atelectasis, more severe\n than longstanding right lower lobe atelectasis or scarring. Upper lungs\n clear. Heart size top normal. Little if any pleural effusion. No\n pneumothorax. Nasogastric tube passes to the distal stomach.\n\n\n"},{"category":"Radiology","chartdate":"2142-11-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":883212,"text":" 3:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o failure\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p ileostomy reversal with new onset wheezing\n REASON FOR THIS EXAMINATION:\n r/o failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent abdominal surgery with wheezing.\n\n There are low lung volumes with atelectatic opacities at the lung bases, more\n currently at the left base than was present in the prior chest x-ray 24 hours\n ago. An NGT terminates in the stomach. A left subclavian catheter terminates\n in the mid SVC.\n\n IMPRESSION: Increasing opacity at the left base since .\n\n\n"},{"category":"Radiology","chartdate":"2142-11-10 00:00:00.000","description":"ABDOMEN (SUPINE & ERECT)","row_id":883433,"text":" 10:05 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: r/o ileus or obstruction.\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p ileostomy closure, POD 5, now with nausea.\n REASON FOR THIS EXAMINATION:\n r/o ileus or obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL X-RAY (SUPINE AND LEFT LATERAL DECUBITUS)\n\n CLINICAL DETAILS: Day 5 post-ileostomy closure. Evaluate for obstruction.\n\n FINDINGS: There are surgical clips along the left lateral abdomen and mid\n abdomen.\n\n There are a number of mildly dilated loops of small bowel noted in mid abdomen\n which measure up to 4 cm in diameter. No wall thickening. There is air\n distally within nondistended colon. These appearances are likely to represent\n post-operative ileus.\n\n No evidence of free intra-abdominal air on the lateral decubitus film.\n\n\n"},{"category":"Radiology","chartdate":"2142-11-07 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":882997,"text":" 9:03 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check line position and rule out pneumothorax\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p left subclavian central line placement\n REASON FOR THIS EXAMINATION:\n check line position and rule out pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:27 A.M. ON \n\n HISTORY: Left subclavian central venous line placement. Rule out\n pneumothorax.\n\n IMPRESSION: AP chest compared to and , most recent prior\n chest radiographs:\n\n Lung volumes are appreciably lower on today's study, which may be due in part\n to subpulmonic pleural effusions and produces atelectasis at both lung bases.\n It also may account for widening of the mediastinum though alternatively this\n may be due to vascular engorgement, adenopathy, or given the insertion of a\n left-sided central venous line whose tip projects over the SVC, mediastinal\n hematoma. Followup examination at maximum inspiration is recommended for\n assessment.\n\n Cardiac silhouette is top normal size. There is no pneumothorax.\n\n Dr. was paged to discuss these findings.\n\n\n"},{"category":"Radiology","chartdate":"2142-11-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":883065,"text":" 4:29 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: still requires pressors. please perform UPRIGHT END INSPIRA\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p left subclavian central line placement for resucitation\n after elective ileostomy reversal\n REASON FOR THIS EXAMINATION:\n still requires pressors. please perform UPRIGHT END INSPIRATION CXR to eval\n lung volumes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old woman status post left subclavian line, hypotensive,\n follow up.\n\n COMPARISON: Chest x-ray from 10:16 the same day.\n\n SINGLE PORTABLE AP CHEST RADIOGRAPH: Again seen is the left subclavian\n central venous catheter with its tip in the mid superior vena cava. A\n nasogastric tube tip is not visualized but descends below the diaphragm. There\n is no pneumothorax. The lung volumes are again low. There has been interval\n decrease in the width of the mediastinum. There is no evidence of congestive\n heart failure.\n\n IMPRESSION: Interval improvement in the mediastinal contour likely related\n to clearing pulmonary edema. Persistently low lung volumes.\n\n"},{"category":"Radiology","chartdate":"2142-11-07 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":883000,"text":" 10:00 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: repeat CXR after left subclavian central line placement, poo\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p left subclavian central line placement for resucitation\n after elective ileostomy reversal\n REASON FOR THIS EXAMINATION:\n repeat CXR after left subclavian central line placement, poor inspiratory\n effort and distortion of mediastinal anatomy on prior film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old woman status post left subclavian line placement,\n mediastinal contour abnormality seen on prior chest x-ray.\n\n COMPARISON: Chest x-ray from at 9:27 a.m.\n\n SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: There are low lung volumes.\n There has been interval improvement in the mediastinal contour. There is no\n pneumothorax. The left subclavian central venous line tip is in the upper\n superior vena cava. The nasogastric tube tip is not visualized but is below\n the diaphragm. The heart size is at the upper limits of normal.\n\n IMPRESSION: Improvement in the widening of the mediastinum. Lines and tubes\n appropriately placed. No pneumothorax.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2142-11-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1339052,\n \"text\": \"Nursing Progress Note.\\nPlease see CareVue for specifics.\\n\\nPt condition stable overnight.\\n\\nNEURO:\\nPt sleeping well, wakes easily. Oriented. Cooperative. Very anxious, escalates quickly, requiring reassurance, then apologising for snapping at staff. (Discussed anxiety with pt's attending Dr , no further orders). Initially denying she takes anxiolytic at home, then stated she takes benadryl for anxiety. Benadryl given per order and pt's request. She woke x1 occasion requesting more benadryl, for itch and to assist with sleep, but as it was too early for benadryl pt received phenergan with good effect. PCA dilaudid in use, pt using appropriately and it is providing good relief. Assisting staff with repositioning, but reluctant to turn on side despite education regarding importance of doing so. Sleeping well between interventions.\\n\\nRESP:\\nChest clear, cough minimally productive. 02 via prongs prn. Some mild exp wheeze on exertion, resolved when settled. Mildly tachypneic with anxiety, resps non labored after reassuance and talking down. CXR attended. Pt attending to incentive spirometry with encouragement, and pulling 500mls.\\n\\nHEMODYNAMICALLY:\\nSR no ectopy. BP stable 120-140 / 50-60s. Globally obese, some dependent edema also. CVP 11-13 with 2 hours 18. Noted waveform has positional respiratory variation.\\n\\nENDOCRINE:\\nHas not required coverage per sliding scale.\\n\\nFLUIDS:\\nLR with KCl at 150mls/ hr. To be reduced to 100mls/ hr.\\n\\nGI:\\nAbd obese, bowel sounds present. NGT to suction with bilious output. Primary dressing intact with no further drainage. NPO with frequent mouthcare attended by pt.\\n\\nID:\\nAfebrile. No antibiotics.\\n\\nRENAL:\\nDiuresed with HCTZ early in shift. Urine output remains >80 mls/hr.\\n\\nSKIN:\\nSkin to back and heels intact, no breakdown. Care attended. Pt rotated but initially declined to sleep on side despite education. Assisting staff to turn herself over.\\n\\nSOCIAL:\\nDaughter called and spoke to pt. No visitors overnight.\\n\\nPLAN:\\nConsider active diuresis, recommencement of home meds.\\nOut of bed to chair.\\nTransfer to floor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2142-11-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1339050,\n \"text\": \"T-SICU NPN 1900-0700\\nsee carevue for specifics.\\nROS:\\nNeuro: A+Ox3, MAE's,following commands consistently. c/o pain at 1 on scale 0-10, up to with activity. Approx. 0530, pt removed BP cuff and o2sat probe, appeared confused; answering most questions \\\"I don't know\\\" or \\\"I don't want to do this\\\". Dr. in to assess pt. PCA off. Equal hand grasps, pupils 3mm, equal and reactive, following commands. Re-oriented. When asked if she remembered having surgery, pt stated \\\"I don't want to remember\\\". Will cont. to assess.\\nCV: HR 70-80'sSR, BP 100-120's/40-50's. CVP 8-12. Skin warm, dry. Pedal pulses palpable. LSC TLCL wnl. PB's and sc heparin for DVT prophylaxis.\\nResp: LS clear, diminished at bases. Denies difficulty breathing when upright; anxious when HOB lowered for turning. RR teens-20's, O2sats 96% on 3lnc.\\nGI; abd obese, BS present, no stool/flatus. Denies n/v. NGT to LCWS for scant bilious drainage. Protonix for GI prophylaxis.\\nGU: foley patent draining marginal amber urine 10-20cc/hr, 500cc LR bolus x2. Phos to be repleted.\\nEndo: BS 87->89\\nID; afebrile; no abx coverage\\nSkin: back/buttocks intact; abd incision with dsg intact; sm. amt. sersang. drainage, outlined, no adavancement noted.\\nPsych/social: pt called and spoke with her daughter via phone upon arrival to ICU; no further contact . pt, information may be shared with her daughter who is her contact person; NO INFORMATION is to be given to daughter per pt's request.\\nA: s/p closure of ileostomy, LOA\\nmarginal uo; increased confusion this am\\nP: Monitor VS, I/O, labs, mental status. Re-orient prn. Enc. pulmonary hygiene. Await further orders from team. ?diuresis vs. fluid. Continue ongoing comfort/support to pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2142-11-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1339051,\n \"text\": \"T/SICU RN Progress Note\\nNeuro: Alert and oriented X3, anxious at times with turning and moving, needs reassurance. Dilaudid PCA 0.12mg Q6minutes with good effect.\\n\\nCV: HR 80-90's SR no ectopy noted. NBP systolic 110-140's sytolic. CVP 4-8 throughout day. LRw/20meq kcl @150cc/hr, p-boots, SQ heparin.\\n\\nResp: Lungs clear on 3l n/c, IS encouraged cough/deep breathing. Strong congested cough. At 1400 c/o SOB and wheezes treated with albuterol neb X1 with effect, chest x-ray done. RR 12-20 with Sats 97-100%.\\n\\nGU/GI: Foley with marginal urine output 15-30cc/hr amber urine. Given 500ccLR bolus X1. Abd obease, incision dsg intact, protonix, ngt to LCWS with bilious drainage, npo.\\n\\nSkin/Mobility: Skin grossly intact. OOB to chair X3 hrs today, with min. assist tolerated well.\\n\\nSocial: Daughter in to visit, sister called on phone.\\n\\nPlan: Monitor fluid status, resp status, cont with aggressive pulmonary hygeine. OOB as tolerated, PCA for pain ?resume pre op diuretics, cont to monitor and support, follow plan of care.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-11-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 883258,\n \"text\": \" 5:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o failure\\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old woman s/p ileostomy reversal\\n REASON FOR THIS EXAMINATION:\\n r/o failure\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 5:54 A.M., \\n\\n HISTORY: Ileostomy reversal. Shortness of breath. Rule out CHF.\\n\\n IMPRESSION: AP chest compared to chest radiographs since , most\\n recently :\\n\\n Lung volumes have been persistently low. Progressive opacification at the\\n left lung base could be pneumonia but is more likely atelectasis, more severe\\n than longstanding right lower lobe atelectasis or scarring. Upper lungs\\n clear. Heart size top normal. Little if any pleural effusion. No\\n pneumothorax. Nasogastric tube passes to the distal stomach.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-11-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 883212,\n \"text\": \" 3:13 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o failure\\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old woman s/p ileostomy reversal with new onset wheezing\\n REASON FOR THIS EXAMINATION:\\n r/o failure\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Recent abdominal surgery with wheezing.\\n\\n There are low lung volumes with atelectatic opacities at the lung bases, more\\n currently at the left base than was present in the prior chest x-ray 24 hours\\n ago. An NGT terminates in the stomach. A left subclavian catheter terminates\\n in the mid SVC.\\n\\n IMPRESSION: Increasing opacity at the left base since .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-11-10 00:00:00.000\",\n \"description\": \"ABDOMEN (SUPINE & ERECT)\",\n \"row_id\": 883433,\n \"text\": \" 10:05 PM\\n ABDOMEN (SUPINE & ERECT) Clip # \\n Reason: r/o ileus or obstruction.\\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old woman s/p ileostomy closure, POD 5, now with nausea.\\n REASON FOR THIS EXAMINATION:\\n r/o ileus or obstruction.\\n ______________________________________________________________________________\\n FINAL REPORT\\n ABDOMINAL X-RAY (SUPINE AND LEFT LATERAL DECUBITUS)\\n\\n CLINICAL DETAILS: Day 5 post-ileostomy closure. Evaluate for obstruction.\\n\\n FINDINGS: There are surgical clips along the left lateral abdomen and mid\\n abdomen.\\n\\n There are a number of mildly dilated loops of small bowel noted in mid abdomen\\n which measure up to 4 cm in diameter. No wall thickening. There is air\\n distally within nondistended colon. These appearances are likely to represent\\n post-operative ileus.\\n\\n No evidence of free intra-abdominal air on the lateral decubitus film.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-11-07 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 882997,\n \"text\": \" 9:03 AM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: check line position and rule out pneumothorax\\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old woman s/p left subclavian central line placement\\n REASON FOR THIS EXAMINATION:\\n check line position and rule out pneumothorax\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 9:27 A.M. ON \\n\\n HISTORY: Left subclavian central venous line placement. Rule out\\n pneumothorax.\\n\\n IMPRESSION: AP chest compared to and , most recent prior\\n chest radiographs:\\n\\n Lung volumes are appreciably lower on today's study, which may be due in part\\n to subpulmonic pleural effusions and produces atelectasis at both lung bases.\\n It also may account for widening of the mediastinum though alternatively this\\n may be due to vascular engorgement, adenopathy, or given the insertion of a\\n left-sided central venous line whose tip projects over the SVC, mediastinal\\n hematoma. Followup examination at maximum inspiration is recommended for\\n assessment.\\n\\n Cardiac silhouette is top normal size. There is no pneumothorax.\\n\\n Dr. was paged to discuss these findings.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-11-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 883065,\n \"text\": \" 4:29 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: still requires pressors. please perform UPRIGHT END INSPIRA\\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old woman s/p left subclavian central line placement for resucitation\\n after elective ileostomy reversal\\n REASON FOR THIS EXAMINATION:\\n still requires pressors. please perform UPRIGHT END INSPIRATION CXR to eval\\n lung volumes\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 64-year-old woman status post left subclavian line, hypotensive,\\n follow up.\\n\\n COMPARISON: Chest x-ray from 10:16 the same day.\\n\\n SINGLE PORTABLE AP CHEST RADIOGRAPH: Again seen is the left subclavian\\n central venous catheter with its tip in the mid superior vena cava. A\\n nasogastric tube tip is not visualized but descends below the diaphragm. There\\n is no pneumothorax. The lung volumes are again low. There has been interval\\n decrease in the width of the mediastinum. There is no evidence of congestive\\n heart failure.\\n\\n IMPRESSION: Interval improvement in the mediastinal contour likely related\\n to clearing pulmonary edema. Persistently low lung volumes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2142-11-07 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 883000,\n \"text\": \" 10:00 AM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: repeat CXR after left subclavian central line placement, poo\\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 64 year old woman s/p left subclavian central line placement for resucitation\\n after elective ileostomy reversal\\n REASON FOR THIS EXAMINATION:\\n repeat CXR after left subclavian central line placement, poor inspiratory\\n effort and distortion of mediastinal anatomy on prior film\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 64-year-old woman status post left subclavian line placement,\\n mediastinal contour abnormality seen on prior chest x-ray.\\n\\n COMPARISON: Chest x-ray from at 9:27 a.m.\\n\\n SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: There are low lung volumes.\\n There has been interval improvement in the mediastinal contour. There is no\\n pneumothorax. The left subclavian central venous line tip is in the upper\\n superior vena cava. The nasogastric tube tip is not visualized but is below\\n the diaphragm. The heart size is at the upper limits of normal.\\n\\n IMPRESSION: Improvement in the widening of the mediastinum. Lines and tubes\\n appropriately placed. No pneumothorax.\\n\\n\"\n }\n]"}}},{"rowIdx":985,"cells":{"subject_id":{"kind":"number","value":6081,"string":"6,081"},"hadm_id":{"kind":"number","value":179050,"string":"179,050"},"target_text":{"kind":"string","value":"Admitted to hospital, on cardiac surgery service. Heart failure service consulted, recommended diuresis pre-operatively. He was subsequently started on a Lasix drip. Hepatology also consulted, recommending preoperative ultrasound and abdominal CT scan. The RUQ ultrasound showed normal portal venous flow and two small gallbladder polyps. The abdominal scan was essentially unremarkable - there was no focal liver lesions, with only a small amount of perihepatic ascites. He otherwise remained stable on medical therapy and was eventually cleared for surgery. On , Dr. performed four vessel coronary artery bypass grafting utilizing the left internal mammary artery to the diagonal branch of left anterior descending artery, saphenous vein graft to the distal left anterior descending artery, saphenous vein graft to the obtuse marginal branch of the circumflex, saphenous vein graft to the posterior descending coronary artery. Postoperative echo was notable for a LVEF of 20% with no mitral regurgitation or aortic insufficiency. After the operation, he was brought to the CSRU. Within 24 hours, chest tubes were removed and he was extubated. He was slow to wean from inotropic support and initially required AV pacing for junctional rhythm. Beta blockade was initially withheld. The EP service was consulted to evaluate for permanent pacemaker plus/minus AICD(given his severely depressed LV function). He concomitantly experienced aphonia. Bedside swallow examination showed bilateral vocal cord paralysis, diffuse pharyngeal weakness and silent aspiration. He was subsequently made NPO and started on tube feedings. Over several days, his native heart rate improved to the 80's. Epicardial wires were eventually removed without complication. He otherwise remained stable on medical therapy. It was decided that a pacemaker was not indicated at this time but the need for an AICD will need to be assessed three months postoperatively. On postoperative day five, he transferred to the Step Down Unit. He continued to require diuresis and remained stable from a cardiac and liver standpoint. Beta blockade was not resumed. Over several days, he made clinical improvements as he worked daily with physical therapy. At discharge, his oxygen saturations were 99% on room air. His aphonia gradually improved. Repeat bedside swallow examination showed no signs of aspiration with pureed diet. Aspiration was however noted with thin liquids. Videofluroscopic evaluation on confirmed aspiration but functional swallow was achieved with pureed/ground solids and honey thick liquids. Medications were subsequently crushed in puree and repeat videoswallow was recommended in one week to evaluate for diet advancement. By discharge, he was tolerating solids without difficulty. He was eventually cleared for discharge on postoperative day five. He will follow up in , RI on and again in two weeks."},"extractive_notes_summ":{"kind":"string","value":"Tolerated well.Endo: cont on reg ins gtt at 1unit/hr with FS q 2 hrs stable at 100-120.Skin; coccyx reddened, enc to lie on sides.Heme: recieved 1 u prbc today. PT S/P CABG X4-PT WITH LOW EF, CAME OFF PUMP WITH EPI. ASSESSMENT IS AS FOLLOWS:NEURO: REVERSALS GIVEN AND PROP WEANED, PT SLOW TO WAKE. PT INTERMITTENTLY DIAPHORETIC. NGT placed by fluro into jejunum succ right nare. Slept at intervals.CVS; Hemodynamically stable on IV Neo at 0.3mcg/kg/min, attempted wean to 0.2mcg/kg/min with MAP<60. ccu npn 7p-7aS:\"I'm doing ok.\"O: Please see carevue for VS and objective dataCVS: Hemodynamically stable with HR 70-80's NSR, rare PVC noted. NO BS.GU: UOP INITIALLY GOOD NOW TAPERING OFF. scattered rhonchi, improved with TCDB and IS. CO INTIALLY LOW BUT RESPONDED TO IVF NOW CI>3. cont IS, enc cough and DB. Leg inc D&I, approximated. c/o incision discomfort and received percocett with good relief of pain.CV-VSS off pressors x 24hrs SBP 120-140's, HR 72-88 NSR with epicardial A rate decreased to 60. PT WITH RARE MULITFOCAL PVC DESPITE LYTES WNL. Mediast/sternal dressing intact, left leg ace wrap D/I.A: hemodynamically stable s/p cabg, tolerating A pacing with underlying conduction disturbance.P: Cont to monitor rhythm/ a pacing, hemodynamics, wean Neo as tolerated. Lungs clear with diminished bases, occ. PT WITH LG FLUID REQUIREMENT (LR 3.5L AND ALBUMIN X2 WITH LOW RT SIDE FILLING PRESSURES) INCREASE PRESSOR REQUIRMENT. CCU Progress Note:O- see flowsheet for all objective data.resp- In O2 4L via NC- lung sounds coarse & diminished @ the bases- cough weak but con't to expectorate tan colored mucous- resp status much better tonight- RR 22-24- SpO2 94-100%.cv- Tele: SR no ectopy- HR 70-74- no paced beats noted- R radial Aline with ABP 108-120/48-55- MAPs 67-73- sternal incision dry & intact- open to air- mediastinal dsg D&I- L leg incision line with steri strips intact & lower incision with bandaid dsg D&I- no c/o pain tonight- Hct yest 25.4- 1u PRBC's given.neuro- comfortable night- sleeping well- A&O X2- moving all extremities- cooperative- follows command.gi- abd soft (+) bowel sounds- FT removed after CXR read by HO- NPO- ? OOB to commode with assist of RN, MAE, transfers easily with minimal assist.A; Hemodynamically stable POD#5,P: Cont to monitor hemodynamics, rhythm, may remove epicardial wires in am. \"O: Please see carevue for VS and objective data.Neuro: Pt. BP ranges 96-120/50-70 via non-invasive cuff.Resp; Sats 93-99% on 4L n/c. +BS no BM post op.Skin-intact, Sternal incision dressing off open to air, staples intact. SM STAINING ON STERNAL INCISION AND CT SITE.RESP: SLOW TO WEAN VENT. c/o incisional pain but refusing pain medication.CV-VSS gradual wean off Neo by 1430 with SBP 120-130. ARRVIED CSRU ON PROP/NEO/EPI. c/o minimal incisional discomfort, refusing pain medication.CV-VSS SBP 124-145 with HR 78-88 NSR. extubationextubated with rt per . cont plan per pt care rounds. EXTUBATE WHE APPROPRIATE. Right groin CDI, mediast/sternal dsgs spotted drainage, but intact. CCU Nursing Progress NoteS-\"My throat still hurts\"O-Neuro alert and oriented x2-3, quiet with minimal conversation. 2) Multiple lines and tubes removed; trace residual left apical pneumothorax. Bilateral loculated pleural effusions are noted. CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is a moderate loculated pleural effusion in the right hemithorax. Congestive failure and bilateral pleural effusions. There is flattening of the diaphragms, and retrosternal clear space opacity consistent with underlying chronic emphysematous changes. 2) Loculated small right pleural effusion, with small left pleural effusion. 2) Small residual right pleural effusion. There may be a previous inferiorwall myocardial infarction and possibly anteroseptal myocardial infarction.Diffuse ST-T wave abnormalities are noted. Lossof R waves suggests old anterior myocardial infarction. IMPRESSION: 1) Tiny left apical pneumothorax. Probable old inferior wall myocardial infarction. The aorta appears slightly tortuous. InferolateralST-T wave abnormalities suggestive of myocardial ischemia. There is blunting of the right costophrenic angle, consistent with pleural effusion. There is a tiny left apical pneumothorax remaining. IMPRESSION: 1) Slight worsening of pulmonary edema and bilateral pleural effusions. AP SUPINE CHEST: Compared to PA and lateral chest of . There is a compression deformity in the mid-thoracic spine. A small amount of perihepatic ascites is noted. IMPRESSION: Bilateral pleural effusions. There has been near resolution of the moderately sized right pleural effusion with just a small residual effusion remaining. Sternal wire sutures and mediastinal clips are noted. FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. The Dobbhoff tube was not present on the previous preceding examination and now identified to terminate in the lower esophagus, but not reaching the stomach. Small amount of perihepatic ascites. IMPRESSION: Difficulty with oropharyngeal bolus handling, including residue in the valleculae and piriform sinuses. From a recent fluoroscopic examination, the patient is known to have incomplete closure of the vocal cords. There is associated partial compression atelectasis of the left lower lobe and the lingula.the right pleural effusion may be slightly larger at this time. CT OF THE PELVIS WITH IV CONTRAST: Distal ureters and bladder are within normal limits. Multiple left-sided chest tubes and mediastinal tube seen. The endotracheal tube, Swan-Ganz catheter, multiple chest tubes, and NG line have been removed. Assess effusions. Wedge compression deformity in the mid-thoracic spine. There is calcification of the aortic arch. IMPRESSION: 1) Multiple lines and tubes in satisfactory position; no pneumothorax. No definite new consolidation is visualized; however, there is some retrocardiac patchiness, which could be atelectasis or pneumonia. Compared to theprevious tracing of above noted abnormalities persist. 2) Slight interval increase in right-sided pleural effusion. Although he showed adequate elevation of the larynx and palate, there was a lack of epiglottic deflection, and mild to moderate residue in the valleculae, and to a lesser extent, the piriform sinuses. There is flattening of the diaphragms, and increased in the retrosternal clear space, consistent with underlying chronic emphysematous change. 2:42 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # Reason: eval."},"n_notes":{"kind":"number","value":30,"string":"30"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2186-07-18 00:00:00.000","description":"Report","row_id":1342103,"text":"Nursing Note\nCVS: a paced at 88, a wires sense and capture, unable to test V wires, SBP to 70's when not paced. Underlying rythym was sinus to sinus brady with freq PVC'S. Pacing continued for better pressures and wean of vasoactive drugs. Currently off neo, remains on epi at 0.015. Map goal > 60. Received 1 unit PRBC's no S/S of reaction, crit was 25.9 cvp and filling pressures were dipping. (please see carevue flowsheet for specific details and values) Pulses by doppler, feet cooler than hands, + diabetic PVD.\n\nRESP: remains ett and vent due to rising Co2s with weaning, ?due to smoking hx. Plan to wean to at 430 am then extubate if continues alert and participatory in care. Lungs clear to diminished, sxn for copious thick yellow to bloody brown tinge secretions x 1. + strong cough. Chest tube to sxn, no leak, no crepitus.\n\nNEURO: arrouses to voice, focus, follows all commands. Attempting to mouth words over ett. bilateral soft wrist restraints for safety of lines tubes and drains.\n\nGI: continues without BS. OGT in place for meds, draining bright green bilious when not clamped for meds.\n\nGU: UOP adequate, conc amber urine clearing after blood and fluid. Foley patent.\n\nSkin: stage I breakdown of coccyx, red non-blanchable. Dressings CDI.\n\nEndo: insulin drip continues FS 63-109. requiring q 1 hour blood sugars and titration.\n\nIV's: right IJ thermo swan, DSG intact changed last eve. Right groin CDI, mediast/sternal dsgs spotted drainage, but intact. L leg ace wrap intact.\n\nSocial: lives in RI with wife who is staying in family room, she has no ride back to RI right now.\n\nPlan: wean and extubate, increase activity, pressure off coccyx, wean vasoactive drugs. Pain control, pulmo toilet after extubation.\n"},{"category":"Nursing/other","chartdate":"2186-07-18 00:00:00.000","description":"Report","row_id":1342104,"text":"extubation\nextubated with rt per . Face tent 50%, sats 96 rr 28. Able to speak in hoarse voice, deep breathing, coughing. cough pillow provided. Denies SOB or discomfort. Expectorated large amount of loose clear/yellow secretions post extubation.\n"},{"category":"Nursing/other","chartdate":"2186-07-18 00:00:00.000","description":"Report","row_id":1342105,"text":"CV: at 80 with no VEA noted, A wires sense and capture, unable to check either A or V wires as pt IMMEDIATELY drops SBP to 90's and HR to 40's; SBP 110's with MAP >60; Neo gtt cont at 0.5mcg/kg/min; CO >4.9 and CI >2, Swan pulled but cordis kept; Rfem A-line pulled but pt still has RRad A-line; pt currently receiving PCs for HCT 26.1\n\nResp: Cont to sat high 90's-100% on 5L NC since extubation at 0500; LS dim throughout\n\nNeuro: Pt oriented to person and place, unsure of year and month->reorients easily; MAE; PERLA;\n\nGI/GU: Abd soft but absent BS at this time, states feels hungry; adequate clear yellow HUO per foley catheter to gravity\n\nEndo: Pt has IDDM, cont on Ins gtt at 1unit/h with hourly BS running 80's-100's with rare 110's\n\nID: Afebrile, cont ABX\n\nSkin: Coccyx with Stage 1 pressure sore->red but unchanged\n\nPlan: EP for cardiac rhythm, wean neo as tolerated, increase activity as tolerated, transfer to CCU\n"},{"category":"Nursing/other","chartdate":"2186-07-18 00:00:00.000","description":"Report","row_id":1342106,"text":"Addendum: Swan to stay in until PC infused, will attempt additional PIV before transfer\n"},{"category":"Nursing/other","chartdate":"2186-07-20 00:00:00.000","description":"Report","row_id":1342111,"text":"CCU Progress Note:\n\nS- \" I can't cough!\"\n\nO- see flowsheet for all objective data.\n\nresp- Increased RR with congestion noted last evening-SpO2 dropped- encouraged to C&DB however said he couldn't cough- lasix & morphine given- Pt deep suctioned for large amt tan colored mucous- RT called- resp Rx given- IS done- O2 increased to 6L via NC- SpO2 now 95-97%- need much encouragement to C&DB- OOB in chair @ 4am- lung sounds coarse, diminished @ the bases with scattered rhonchi.\n\ncv- Tele: SR- A paced rhythm noted during the night- no ectopy- temp pacer attached to epicardial wires- rate @ 70 Ma 18- chest & L leg dsg D&I- R radial A line with ABP 113-144/51-64 off pressors- MAPs 69-87-\nHct 25.4- K 5- Mg 2.7\n\nneuro- A&O X2- moving all extremities- amb with 2 assist well- cooperative- follows command.\n\ngi- abd soft hypoactive bowel sounds- impaired gag ? if Pt can tolerate PO- no BM.\n\ngu- foley draining amber colored urine in small amts- lasix dose increased to 20mg IV TID- BUN 55 Crea 1.4\n\nA- S/P CABG post-op day 3- hemodynamically stable off pressors but con't to require pacer support.\n\nP- aggressive pulmonary toileting- C&DB with IS Q1 while awake- suction PRN- med for comfort- increase activity- ? swallow study- transfuse today-( Hct low & BUN/Crea climbing)- offer emotional support to Pt & family- keep them updated on plan of care.\n"},{"category":"Nursing/other","chartdate":"2186-07-20 00:00:00.000","description":"Report","row_id":1342112,"text":"CCU Nursing Progress Note\nS-\"I can't speak any louder.\"\nO-Neuro alert and oriented x2-3, cooperative but quiet. Voice is still whisper soft, Speech and Swallow Consult revealed vocal cords not closing completely to protect airway with moderate aspiration via video procedure at bedside. c/o incision discomfort and received percocett with good relief of pain.\nCV-VSS off pressors x 24hrs SBP 120-140's, HR 72-88 NSR with epicardial A rate decreased to 60. No signs of bradycardia or junctional rhythm.\nResp-LS diminished at bases with occ coarse upper airway from secretions. COntinues to cough but voice is wet most of the time.\nO2 sats occ dropping to 88% on 4lNP but after IS/deep breathing exercises O2 sat increase back to 93-96% on 4lnp. IS q1-2hrs but only generating 200-250cc.\nID afebrile\nGU-foley draining 30-40cc/hr fair response to lasix 20mg IVB at 9am.\nGI-Pt had eaten breakfast oatmeal with nectar juice well with minimal coughing. After video study pt made NPO, MD placed feeding tube right nare without difficulty. Awaiting xray for placement confirment. Hypoactive BS no BM.\nSkin-coccyx less reddened, pt trying to change position himself. All surgical dressing intact with ace on left leg.\nActivity-physical therapy into see pt and walked pt in the hallway 100feet and tolerated very well. Sat in chair for 3 hours and did well. No c/o fatigue or SOB.\nSocial-wife with pt all day. Case manager to follow up on pt no insurance issue.\nA/P-s/p CABG post op day#3 with food/fluid aspiration from failure of vocal cord closure.\n*NPO\nFollow up with xray and start tube feeds.\nEncourage pt to get OOB, walk and do ADL's.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2186-07-20 00:00:00.000","description":"Report","row_id":1342113,"text":"NPN \nCV: HR 70-80 NSR, no paced rhythm. A and V epicardial wires still in place, Atrial rate set to 60. Atrial wire tested sensing and capturing appropriately. States incisional pain is less today, , tolerable, stating that he recieve pain pill earlier, did not want medication again yet. Later in eve, sat on side of bed, requested pain med, given 1mg IV Morphine with good effect.\n\nSkin: dressings to chest and leg removed. Chest inc approximated without drainage. left open to air. Old CT sites open, sm amt serosang drainage, covered with DSD. Leg inc D&I, approximated. Ace removed.\n\nResp: LS coarse, congested cough, encouraging pt to cough, deep breath and use IS. Pt using yankar. Sats have remained mid 90's on 4L NC. No episodes desaturation.\n\nGI: NPO, doboff tube not advancing, coiling in esophagus after 2 attempts, team will try again in AM. NPO as pt is high aspiration risk. No stool this eve.\n\nNeuro: A&Ox2, c/o being very fatigued this eve. Sat on side of bed for awhile, but sleeping most of time.\n\nID: afebrile.\n\nSkin: coccyx reddened, not open.\n\nA/P: 3 days post CABG, pt needs feeding tube, npo for swallowing difficulty, mod asp on swallow study. Cont monitor for dysrhythmia's, epicardial wires attached to pacer box. Cont pul toilet, enc increased activity. Support and inform pt/wife.\n\n\n"},{"category":"Nursing/other","chartdate":"2186-07-21 00:00:00.000","description":"Report","row_id":1342114,"text":"CCU Progress Note:\n\nO- see flowsheet for all objective data.\n\nresp- In O2 4L via NC- lung sounds coarse & diminished @ the bases- cough weak but con't to expectorate tan colored mucous- resp status much better tonight- RR 22-24- SpO2 94-100%.\n\ncv- Tele: SR no ectopy- HR 70-74- no paced beats noted- R radial Aline with ABP 108-120/48-55- MAPs 67-73- sternal incision dry & intact- open to air- mediastinal dsg D&I- L leg incision line with steri strips intact & lower incision with bandaid dsg D&I- no c/o pain tonight- Hct yest 25.4- 1u PRBC's given.\n\nneuro- comfortable night- sleeping well- A&O X2- moving all extremities- cooperative- follows command.\n\ngi- abd soft (+) bowel sounds- FT removed after CXR read by HO- NPO- ? reinsert FT in IR today to assure proper placement- No BM this shift.\n\ngu- foley draining yellow colored urine qs- U/O >30cc/hr- (-) 100cc since 12am- (+) 4500cc LOS- BUN & Crea trending up- AM labs pending.\n\nA- S/P CABG day #4- improving resp status tonight- hemodynamically stable off pressors- failed swallow study- NPO ? reinsert FT today.\n\nP- monitor vs, lung sounds, I&O and labs- keep NPO until FT placed- con't aggressive pulmonary toileting- increase activity- offer emotional support to Pt & family- keep them updated on plan of care.\n"},{"category":"Nursing/other","chartdate":"2186-07-17 00:00:00.000","description":"Report","row_id":1342102,"text":"PT S/P CABG X4-PT WITH LOW EF, CAME OFF PUMP WITH EPI. ARRVIED CSRU ON PROP/NEO/EPI. NO UNDERLYING RHYTHM INITIALLY IN OR, ARRIVED AV PACED--PT SB UNDERLYING WHEN ARRIVED. PT WITH LG FLUID REQUIREMENT (LR 3.5L AND ALBUMIN X2 WITH LOW RT SIDE FILLING PRESSURES) INCREASE PRESSOR REQUIRMENT. SLOW TO WAKE. ASSESSMENT IS AS FOLLOWS:\nNEURO: REVERSALS GIVEN AND PROP WEANED, PT SLOW TO WAKE. OPENS EYES AND FOLLOWS COMMANDS BUT FALLS ASLEEP EASILY. PERRLA. NO DEFICITIS NOTED\nCV: PT AT 88---UNDERLYING SB/JUNCTIONAL WITH PAC'S. PT WITH RARE MULITFOCAL PVC DESPITE LYTES WNL. PT WITH ST DEPRESSION ON MONITOR OUT OF OR, AWARE, NO TX ORDERED. BP LABILE, REQUIRING FLUID AND INCREASE PRESSOR REQUIRMENT. CURRENTLY NEO 1.1MCG/ EPI .02MCG. CVP 2-8 PAD 15-20. HCT 28. CO INTIALLY LOW BUT RESPONDED TO IVF NOW CI>3. CT OUPTUT MINIMAL. DOPPLERABLE PEDAL PULSES. PT INTERMITTENTLY DIAPHORETIC. LT FEM DSG SATURATED WITH SANG DRNG IN PM, CHANGED. SM STAINING ON STERNAL INCISION AND CT SITE.\nRESP: SLOW TO WEAN VENT. CHANGED TO CPAP AT 15 PS THIS PM WHEN ATTEMPT WEAN PCO2 IN 50'S, RESTED BACK ON PS 15. NOW ATTEMPTING SLOW WEAN. LUNGS CLEAR. SX FOR SCANT WHITE. OXYGENATION EXCELLENT ON FIO2 40%.\nGI: OGT TO LCWS-> BILIOUS DRNG. , PLACEMENT CONFIRMED BY AUSCULTATION. ABD SOFT. NO BS.\nGU: UOP INITIALLY GOOD NOW TAPERING OFF. TEAM AWARE. FOLEY PATENT.\nENDO: INITIALY BS 50'S, TX 1/4 AMP D50. INSULIN GTT STARTED THIS PM AND TITRATED UP PER PROTOCOL. SEE FLOWSHEET\nSOCIAL: PT WIFE PLEASANT, UPDATED ON CARE. WIFE STAYING IN HOSPITAL OVERNIGHT IN CC6 WAITING AREA\nSKIN: PT COCCYX WITH STAGE 1 PRESSURE AREA OUT OF OR, PINK AND UNBLANCHABLE. PT TURN SIDE TO SIDE. PT C/O PAIN IN AREA.\nPLAN: WEAN VENT. EXTUBATE WHE APPROPRIATE. CONT ASSESS HEMODYANMICS. WEAN PRESSORS AS TOL. CONT ASSESS UNDERLYING RHYTHM. CONT Q1HR BS WHILE ON GTT.\n"},{"category":"Nursing/other","chartdate":"2186-07-18 00:00:00.000","description":"Report","row_id":1342107,"text":"NPN \n61 yr old s/p 4 vessel transferred from CSRU earlier today.\n\nCV: HR 80 a-paced via epicardial wire. Atrial stimulation threshold 6, mA set at 10. Pacing consistantly, underlying rate ~50. BP 100-120/50, Neo decreased to .3mcg/kg/min. Dressing to chest and L leg ace bandage D&I.\n\nPain: incisional pain, level , give 2mg Morphine with good effect, gag still impaired, coughing with sips water, so unable to take po meds. Using cough pillow effectively.\n\nResp: cough productive of thick tan sputum. LS dim with scattered rhonchi. CT pulled earlier today.\n\nID: T 99 cont on, IV vanco for 4 doses.\n\nNeuro: alert, oriented, no voice, feeling weak. Did dangle for ~15min this eve. Tolerated well.\n\nEndo: cont on reg ins gtt at 1unit/hr with FS q 2 hrs stable at 100-120.\n\nSkin; coccyx reddened, enc to lie on sides.\n\nHeme: recieved 1 u prbc today. Order to check labs in AM.\n\nSoc; wife at bedside, has been staying in the hospital.\n\nA/P: s/p CABG, remains on low level of Neo, attempt to wean off, a-paced with intrinsic rate still low. need pacer/ICD, followed by EP. Cont to med for pain prn, increase act, OOB to chair tomorrow. cont IS, enc cough and DB. support pt/wife. cont plan per pt care rounds.\n\n\n"},{"category":"Nursing/other","chartdate":"2186-07-19 00:00:00.000","description":"Report","row_id":1342108,"text":"ccu npn 11p-7a border\nS:\"I'm in Hospital, its .\"\n\nO: Please see carevue for VS and objective data.\n\nNeuro: Pt. A/A/Ox3, pleasant and cooperative, appreciative of care. MAE, PERLA. c/o incisional pain with turning, given 2mg IV Morphine x1 with good effect. Slept at intervals.\n\nCVS; Hemodynamically stable on IV Neo at 0.3mcg/kg/min, attempted wean to 0.2mcg/kg/min with MAP<60. MAP>60 on IV Neo at 0.3. BP ranges via right radial aline. HR 80's 100%, prolonged PR interval 0.28-.30. A/V epicardial wires intact with A wire settings stim. threshold 9, MA 18. /capturing appropriately. Increased and tested previous shift at 2200. MD aware. V wires remain off. No vea noted. Am Hct 27.0 s/p 2 units .\n\nResp; Sats 93-100% on 4L n/c. RR mid to high 20's. Lungs clear with diminished bases, occ. scattered rhonchi, improved with TCDB and IS. Pt. able to raise thick, yellow sputum with yankauer.\n\nGI:GU: Impaired gag, weak cough. No po's given this shift. Abdomen soft with hypoactive bowel sounds. Foley to drainage with clear, amber urine u/o 30-40cc/hour. Total I/O 600cc + at MN.\n\nEndo; Pt. on Regular Insulin drip 1.0-0.5 units/hour. blood sugars 108-89, drip off at 0300 with blood sugars 90's.\n\nID: Tmax 99.9, WBC 12.9, to receive last dose IV Vanco in am.\n\nSkin: Cocccyx remains red without breakdown, turned q2-3 hours, skin care provided. Encouraged Pt. to stay off back. Mediast/sternal dressing intact, left leg ace wrap D/I.\n\nA: hemodynamically stable s/p cabg, tolerating A pacing with underlying conduction disturbance.\n\nP: Cont to monitor rhythm/ a pacing, hemodynamics, wean Neo as tolerated. Pulm. toileting, IS, CPT, TCDB. Follow up with am labs with team. Monitor blood sugars, may switch to SS Regular Insulin. Assess gag, increase diet as tolerated. Activity progression with pain control. Comfort and emotional support to Pt. and family\n"},{"category":"Nursing/other","chartdate":"2186-07-19 00:00:00.000","description":"Report","row_id":1342109,"text":"CCU Nursing Progress Note\nS-\"My throat still hurts\"\nO-Neuro alert and oriented x2-3, quiet with minimal conversation. Voice is hoarse and c/o sore throat. c/o incisional pain but refusing pain medication.\nCV-VSS gradual wean off Neo by 1430 with SBP 120-130. HR 80 A pace 100%. Underlying rhythm is sinus brady with ventricular escape beats with pacer off, SBP drops 80-90. Atrial threshold 9 with output set at 18. EP following pt for pacer or ICD.\nResp-LS diminished bases, O2 4lnp with sats 94-96% RA sat 85%. Freq productive cough moderat amount thick tan sputum, using yankeur sx tip. CPT with fair effect because pt can cough secretions but not expectorate completely.\nID low grade temp received 4th dose vanco today.\nGU-foley draining 30-60cc/hr.\nGI-remains with weak/impaired gag. Unable to take clear liquids +asp/coughing, tolerates soft solid food without coughing. Appetite poor, no BM hypoactive BS x4.\nActivity-Dangle x2, physical therapy saw pt and walked pt to chair with minimal assist. Tolerated chair for 1 hour before getting fatigued.\nSocial-wife with pt all day.\nA/P-Succ CABG post op day #2, with persistant sinus brady/hypotension off pacer.\nContinue to monitor pacing threshold q shift.\nFollow VS off vasopressors.\nCheck gag before food/medications.\nmedicate for pain as needed.\nKeep pt and family aware of POC as discussed in multi disciplanary rounds.\n"},{"category":"Nursing/other","chartdate":"2186-07-19 00:00:00.000","description":"Report","row_id":1342110,"text":" npn\n1500-1900\n\n PA turned pmr down to 70, pt now in sr w/ rate mid 70's. Lasix ^ to 20 mg tid. BS ^ 176 at 1800, covered per riss. Taking soft solids well. Needs encouragement to CDB.\n"},{"category":"Nursing/other","chartdate":"2186-07-21 00:00:00.000","description":"Report","row_id":1342115,"text":"CCU Nursing Progress Note\nS-\"I feel alittle stronger today.\"\nO-Neuro alert and oriented x3, awake most of the day and more interactive. This morning voice was audible but hoarse for 2 words. By afternoon voice was whisper soft again. c/o minimal incisional discomfort, refusing pain medication.\nCV-VSS SBP 124-145 with HR 78-88 NSR. Epicardial a/v wires intact and attached to pacer. Atrial rate at 60 and ventricular pacer off, has not required pacer for 48hrs.\nResp-LS diminished bases, decreased coughing today while being NPO. Sputum is tan/thick, using yankeuer tip. Still requiring O2 3-4l NP with sat dropping to 78-80% on RA. No c/o SOB while walking in hallway.\nID afebrile\nGU-foley removed this morning but DTV 5-7pm.\nGI-Remains NPO d/t failed swallow study . NGT placed by fluro into jejunum succ right nare. Started ProBalance at 20cc/hr at 1730, with GOAL rate at 60cc/hr. +BS no BM post op.\nSkin-intact, Sternal incision dressing off open to air, staples intact. Left leg ace removed and d/c'd.\nActivity-OOB walking in hallway 3 times >yds today with 1 assist. Still using wheelchair to hold on to but endurance has improved.\nPhysical therapy working with pt this evening.\nSocial-wife with pt most of the day, staying with pt in the room.\nCase Manager following d/t no insurance.\nA/P-s/p CABG post op d#4 with failed swallow study now with feeding tube for nutrition.\nContinue to monitor rhythm for bradycardia and pacer use.\nEncourage independance with ADL's.\nCheck TF residuals q4hrs and increase rate 10cc for GOAL rate 60cc/hr by am.\nKeep pt/family aware of POC as discussed in multi disciplanary rounds.\n\n\n"},{"category":"Nursing/other","chartdate":"2186-07-22 00:00:00.000","description":"Report","row_id":1342116,"text":"ccu npn 7p-7a\nS:\"I'm doing ok.\"\nO: Please see carevue for VS and objective data\nCVS: Hemodynamically stable with HR 70-80's NSR, rare PVC noted. Epicardial A/V wires intact, without requiring use. Atrial wire set at rate of 60, with MA 18. Ventricular wire remains off. BP ranges 96-120/50-70 via non-invasive cuff.\nResp; Sats 93-99% on 4L n/c. Lungs clear with diminished bases. Encouraged TCDB. RR 20's. Exporating small amounts of thick, tan sputum.\nGI:GU: Remains NPO after failed swallow studies. TF Probalance started at 20cc/hour, increased q 4hours by 10cc. No residuals with post pyloric tube intact via right nare. In good placement with auscultation. Abdomen soft with bowel sounds, up to commode multiple times for small amount of formed stool. Guaic neg. Voiding qs via urinal/commode, dark, yellow urine. Neg. 730cc at MN, TID IV Lasix dc'd this shift.\nEndo: glucose 141, SS Regular Insulin as ordered\nID: afebrile, see carevue for skin care assessment. Post op sites dry and intact without s/s infection.\nNeuro: Pt. A/A/0x3, pleasant and cooperative. Appreciative of care. Voice remains soft whisper. Wife went home tonight for first time. Called and spoke to RN and Pt. Pt. slept at intervals, given 1mg IV Morphine for sleep/comfort. OOB to commode with assist of RN, MAE, transfers easily with minimal assist.\nA; Hemodynamically stable POD#5,\nP: Cont to monitor hemodynamics, rhythm, may remove epicardial wires in am. Cont to monitor voice, gag. TF with goal rate of 60cc/hour. Assess I/O, U/O. Cont. pulmonary toileting. Activity progression. Comfort and emotional support to Pt. and family\n\n\n"},{"category":"Radiology","chartdate":"2186-07-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":870292,"text":" 2:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p dobhoff placement. Please assess tip location. Include u\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG and ct removal\n\n REASON FOR THIS EXAMINATION:\n s/p dobhoff placement. Please assess tip location. Include upper abdomen.\n ______________________________________________________________________________\n FINAL REPORT\n\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Status post Dobbhoff line placement, status post bypass surgery .\n\n FINDINGS: AP single view of the chest performed on the patient in supine\n position has been directed on lower chest, upper abdominal area purpose to\n identify the recently placed Dobbhoff tube position. Its metallic distal end\n portion is noted to be located in the lower esophagus seen through the\n markedly enlarged heart shadow. Both diaphragms cannot be identified with\n certainty because of pleural densities, but it is most unlikely that the\n Dobbhoff has passed through the hiatal area and certainty is not in a position\n compatible with the fundus of the stomach. Comparison made with a next\n preceding portable chest examination obtained seven hours earlier the same\n date demonstrates grossly unchanged findings with massive bilateral pleural\n densities. The Dobbhoff tube was not present on the previous preceding\n examination and now identified to terminate in the lower esophagus, but not\n reaching the stomach.\n\n\n\n\n"},{"category":"Radiology","chartdate":"2186-07-24 00:00:00.000","description":"VIDEO OROPHARYNGEAL SWALLOW","row_id":870705,"text":" 1:15 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: ASSESS SWALLOW\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man S/P CABG/FAILED SWALLOW\n REASON FOR THIS EXAMINATION:\n ASSESS SWALLOW\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 61-year-old man status post coronary artery bypass surgery with\n swallowing difficulty.\n\n TECHNIQUE: Videotaped oropharyngeal swallowing study under fluoroscopy.\n\n FINDINGS: The study was performed in conjunction with the speech pathologist.\n Several consistencies of barium were orally administered. With nectar, the\n patient exhibited swallowing delay and piecemeal bolus handling, as well as\n some spillover into the piriform sinuses. From a recent fluoroscopic\n examination, the patient is known to have incomplete closure of the vocal\n cords. Although he showed adequate elevation of the larynx and palate, there\n was a lack of epiglottic deflection, and mild to moderate residue in the\n valleculae, and to a lesser extent, the piriform sinuses.\n\n With nectar thickened liquids, both in the upright position and with chin\n tuck, the patient aspirated a small amount of barium and showed no spontaneous\n cough. A cued cough was fairly ineffective. With pureed consistency, he did\n not show aspiration, however.\n\n IMPRESSION: Difficulty with oropharyngeal bolus handling, including residue\n in the valleculae and piriform sinuses. With nectar thickened liquids,\n there was a tendency to aspiration, without adequate cough response.\n\n\n"},{"category":"Radiology","chartdate":"2186-07-23 00:00:00.000","description":"CHEST (PA & LAT)","row_id":870627,"text":" 4:16 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pna\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG and ct removal with prurulent sputum\n\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest tube removal and purulent sputum.\n\n COMPARISON: \n\n Comparison to the film obtained on at 8:10 is necessary since the film\n later that day was obscuring much of the chest.\n\n The right introducer sheath has been removed and there is no PTX. Extensive\n bilateral effusions are seen on the current study. The amount of pleural\n fluid appears to have decreased but may have distributed more dependently.\n Positioning may contribute to this apparent change. No definite new\n consolidation is visualized; however, there is some retrocardiac patchiness,\n which could be atelectasis or pneumonia.\n\n CABG changes are evident and a feeding tube extends below the imaged anatomy\n on the frontal view.\n\n IMPRESSION: Better aerated lung with less pleural fluid as described above.\n No new consolidations. Right introducer sheath removed and no PTX.\n\n\n\n"},{"category":"Radiology","chartdate":"2186-07-21 00:00:00.000","description":"NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)","row_id":870421,"text":" 2:17 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: needs feeding tube, failed bedside attempts\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with aspiration\n REASON FOR THIS EXAMINATION:\n needs feeding tube, failed bedside attempts\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with aspiration. Detailed bedside attempts for\n nasogastric tube placement.\n\n TECHNIQUE/FINDINGS: A weighted - feeding tube was passed\n through the right naris into the esophagus, and into the stomach over a metal\n guidewire. Under fluoroscopic guidance, the tube was then advanced past the\n pylorus, into the duodenum, with the tip terminating at the ligament of\n Treitz. 20 cc of Conray was injected to confirm positioning.\n\n IMPRESSION: Successful placement of post pyloric feeding tube with tip at the\n ligament of Treitz.\n\n\n"},{"category":"Radiology","chartdate":"2186-07-20 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":870315,"text":" 6:14 PM\n PORTABLE ABDOMEN Clip # \n Reason: check feeding tube placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with\n REASON FOR THIS EXAMINATION:\n check feeding tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Feeding tube placement.\n\n COMPARISON: Portable chest of the same date at 14:50 hours.\n\n PORTABLE ABDOMEN: The feeding tube descends into the abdomen, loops\n superiorly into the mid esophagus and then back towards the gastroesophageal\n junction. The tip may reside below the gastroesophageal junction, but this is\n difficult to assess because the hemidiaphragms remain obscured by bilateral\n pleural effusions, left greater than right. The cardiac silhouette is also\n partially obscured. Failure is present. Sternal wire sutures and mediastinal\n clips are noted. Internal jugular line remains in similar position since the\n prior day.\n\n IMPRESSION:\n 1. Feeding tube looped in the stomach and esophagus, as above.\n 2. Congestive failure and bilateral pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2186-07-19 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":870088,"text":" 6:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ptx/effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG and ct removal\n\n REASON FOR THIS EXAMINATION:\n assess ptx/effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old status post CABG , chest tube removal, re-evaluate\n for pneumothoraces or effusions.\n\n AP SEMI-UPRIGHT CHEST: Comparison to the film of the prior day. Right IJ\n catheter unchanged in position. A tiny left aypical pneumothorax is not\n identified on today's study. Persisting bilateral pleural effusions and\n cardiomegaly consistent with congestive heart failure.\n\n IMPRESSION:\n 1) Slight worsening of pulmonary edema and bilateral pleural effusions.\n 2) Tiny left aypical pneumothorax not identified on today's study.\n\n\n"},{"category":"Radiology","chartdate":"2186-07-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":869991,"text":" 11:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG and ct removal\n\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG and chest tube removal.\n\n AP PORTABLE UPRIGHT CHEST: Compared to AP supine chest of the prior day. The\n endotracheal tube, Swan-Ganz catheter, multiple chest tubes, and NG line have\n been removed. The right IJ line remains in place. There is a tiny left\n apical pneumothorax remaining. There has been interval worsening of diffuse\n pulmonary edema with increased bilateral pleural effusions.\n\n IMPRESSION:\n\n 1) Interval development of pulmonary edema with worsening bilateral pleural\n effusions.\n\n 2) Multiple lines and tubes removed; trace residual left apical pneumothorax.\n\n\n"},{"category":"Radiology","chartdate":"2186-07-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":870025,"text":" 3:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG and ct removal\n\n REASON FOR THIS EXAMINATION:\n assess ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old status post CABG with CT removal, assess for\n pneumothorax.\n\n AP UPRIGHT CHEST: Comparison to film of 4 hours prior. Allowing for\n differences in technique, there is no significant change in the tiny left\n apical pneumothorax. There is slight interval increase in right-sided\n effusion. Persisting pulmonary edema. No other interval change.\n\n IMPRESSION:\n 1) Tiny left apical pneumothorax.\n 2) Slight interval increase in right-sided pleural effusion.\n 3) No other significant short interval change.\n\n\n"},{"category":"Radiology","chartdate":"2186-07-20 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":870230,"text":" 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG and ct removal\n\n REASON FOR THIS EXAMINATION:\n assess effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old status post CABG and chest tube removal. Assess\n effusions.\n\n Comparison is made to the prior examination of .\n\n The right IJ line remains in place, unchanged in position. Bilateral loculated\n pleural effusions are noted. The magnitude of the left pleural effusion has\n not changed. There is associated partial compression atelectasis of the left\n lower lobe and the lingula.the right pleural effusion may be slightly larger\n at this time. Associated compression partial atelectasis of the right lower\n lobe and the right middle lobe has worsened since the prior study.\n\n IMPRESSION: Bilateral pleural effusions. The large left pleural effusion has\n not changed since the prior study, but the right loculated pleural effusion\n may have slightly increased since the prior study. No evidence of\n pneumothoraces.\n\n"},{"category":"Radiology","chartdate":"2186-07-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":869895,"text":" 2:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pneumothorax, pleural effusion, pulmonary edema, tamponade\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n Pneumothorax, pleural effusion, pulmonary edema, tamponade\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG.\n\n AP SUPINE CHEST: Compared to PA and lateral chest of . Multiple\n devices overlying the patient obscure sensitivity of the study. Endotracheal\n tube tip 3 cm above the carina. Swan-Ganz catheter with its tip in the distal\n right main pulmonary artery. Multiple left-sided chest tubes and mediastinal\n tube seen. NG line with its tip in the body of the stomach. No pneumothorax\n is identified. There has been near resolution of the moderately sized right\n pleural effusion with just a small residual effusion remaining. The lungs are\n clear. There is no significant volume overload/CHF.\n\n IMPRESSION:\n 1) Multiple lines and tubes in satisfactory position; no pneumothorax.\n 2) Small residual right pleural effusion.\n 3) Cardiomegaly without evidence of significant volume overload/CHF.\n\n\n"},{"category":"Radiology","chartdate":"2186-07-16 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":869755,"text":" 2:42 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: eval. arterial & venous flow of the liver of this preop for\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with HBV, cirrhosis, pre-op CABG\n REASON FOR THIS EXAMINATION:\n eval. arterial & venous flow of the liver of this preop for CABG liver\n cirrhotic.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with hepatitis B and cirrhosis. Preoperative for\n CABG.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is without focal lesions, and\n normal in echotexture and architecture. No intrahepatic biliary ductal\n dilatation is identified. There are a 6 mm polyp in the fundus and a 4 mm\n polyp in the most proximal portion of the gallbladder. No stones are seen.\n Portal venous flow is maintained in the appropriate direction, and no\n intraluminal thrombus is identified. Hepatic venous flow and hepatic arterial\n flow are within normal limits.\n\n IMPRESSION:\n 1) Normal portal venous flow.\n 2) Two small gallbladder polyps.\n\n"},{"category":"Radiology","chartdate":"2186-07-13 00:00:00.000","description":"CHEST (PRE-OP PA & LAT)","row_id":869448,"text":" 8:09 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with severe CAD, cirrhosis, CHF\n REASON FOR THIS EXAMINATION:\n eval pleural effusions/ eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of coronary artery disease, cirrhosis, and CHF. Evaluate\n for pleural effusions or pneumonia. Preoperative evaluation.\n\n COMPARISON: None.\n\n PA AND LATERAL CHEST RADIOGRAPHS: There are increased interstitial markings,\n which may be chronic, though underlying CHF cannot be excluded. There is\n blunting of the right costophrenic angle, consistent with pleural effusion.\n There is cardiomegaly. The mediastinal contours are stable. There is\n calcification of the aortic arch. The aorta appears slightly tortuous. There\n is flattening of the diaphragms, and increased in the retrosternal clear\n space, consistent with underlying chronic emphysematous change. There is a\n compression deformity in the mid-thoracic spine.\n\n IMPRESSION:\n\n 1. There is flattening of the diaphragms, and retrosternal clear space\n opacity consistent with underlying chronic emphysematous changes.\n\n 2. While there are diffusely increased interstitium marking which may be\n chronic, though superimposed mild CHF cannot be excluded.\n\n 3. Cardiomegaly.\n\n 4. Wedge compression deformity in the mid-thoracic spine.\n\n\n"},{"category":"Radiology","chartdate":"2186-07-16 00:00:00.000","description":"CT ABD W&W/O C","row_id":869714,"text":" 9:26 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: triple phase, arterial, venous, solideval. liver & vessels,\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CAD\n REASON FOR THIS EXAMINATION:\n triple phase, arterial, venous, solideval. liver & vessels, pre-op CABG\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with hepatitis, cirrhosis. Preoperative for\n CABG.\n\n TECHNIQUE: After administration of oral contrast, MDCT was used to obtain\n non-IV-contrast images through the liver. Contrast-enhanced images were\n obtained after 35 and 75 second delay. 3-minute delay images were also\n obtained through the abdomen and pelvis.\n\n CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is a moderate loculated\n pleural effusion in the right hemithorax. There is associated compressive\n atelectasis. There is also a small left pleural effusion. Cardiomegaly is\n present, but there is no pericardial effusion.\n\n Although somewhat nodular, the liver is without focal lesions. Portal venous\n flow is patent. The gallbladder is unremarkable. The spleen is borderline\n enlarged. The pancreas, adrenals, kidneys, stomach, and small bowel are\n unremarkable. A small amount of perihepatic ascites is noted. No significant\n lymphadenopathy is identified. There are aortic calcifications, but the aorta\n is not dilated.\n\n CT OF THE PELVIS WITH IV CONTRAST: Distal ureters and bladder are within\n normal limits. Bowel loops are grossly unremarkable. Vasculature is notable\n for extensive calcification. No lymphadenopathy is identified. There is no\n free fluid.\n\n Bone windows are notable for a hemangioma in the left posterior aspect of L3\n vertebral body.\n\n IMPRESSION:\n 1) No focal liver lesion. Small amount of perihepatic ascites.\n 2) Loculated small right pleural effusion, with small left pleural effusion.\n Associated compressive atelectasis.\n 3) Cardiomegaly.\n 4) Vascular calcifications.\n (Over)\n\n 9:26 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: triple phase, arterial, venous, solideval. liver & vessels,\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"},{"category":"ECG","chartdate":"2186-07-17 00:00:00.000","description":"Report","row_id":211666,"text":"Underlying rhythm is sinus rhythm. Occasional atrially paced rhythm. Probable\nleft atrial abnormality. Probable old inferior wall myocardial infarction. Loss\nof R waves suggests old anterior myocardial infarction. Inferolateral\nST-T wave abnormalities suggestive of myocardial ischemia. Compared to the\nprevious tracing of above noted abnormalities persist.\n\n"},{"category":"ECG","chartdate":"2186-07-14 00:00:00.000","description":"Report","row_id":211667,"text":"Sinus rhythm, rate 62. Left axis deviation. There may be a previous inferior\nwall myocardial infarction and possibly anteroseptal myocardial infarction.\nDiffuse ST-T wave abnormalities are noted. No previous tracing available for\ncomparison.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342103,\n \"text\": \"Nursing Note\\nCVS: a paced at 88, a wires sense and capture, unable to test V wires, SBP to 70's when not paced. Underlying rythym was sinus to sinus brady with freq PVC'S. Pacing continued for better pressures and wean of vasoactive drugs. Currently off neo, remains on epi at 0.015. Map goal > 60. Received 1 unit PRBC's no S/S of reaction, crit was 25.9 cvp and filling pressures were dipping. (please see carevue flowsheet for specific details and values) Pulses by doppler, feet cooler than hands, + diabetic PVD.\\n\\nRESP: remains ett and vent due to rising Co2s with weaning, ?due to smoking hx. Plan to wean to at 430 am then extubate if continues alert and participatory in care. Lungs clear to diminished, sxn for copious thick yellow to bloody brown tinge secretions x 1. + strong cough. Chest tube to sxn, no leak, no crepitus.\\n\\nNEURO: arrouses to voice, focus, follows all commands. Attempting to mouth words over ett. bilateral soft wrist restraints for safety of lines tubes and drains.\\n\\nGI: continues without BS. OGT in place for meds, draining bright green bilious when not clamped for meds.\\n\\nGU: UOP adequate, conc amber urine clearing after blood and fluid. Foley patent.\\n\\nSkin: stage I breakdown of coccyx, red non-blanchable. Dressings CDI.\\n\\nEndo: insulin drip continues FS 63-109. requiring q 1 hour blood sugars and titration.\\n\\nIV's: right IJ thermo swan, DSG intact changed last eve. Right groin CDI, mediast/sternal dsgs spotted drainage, but intact. L leg ace wrap intact.\\n\\nSocial: lives in RI with wife who is staying in family room, she has no ride back to RI right now.\\n\\nPlan: wean and extubate, increase activity, pressure off coccyx, wean vasoactive drugs. Pain control, pulmo toilet after extubation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342104,\n \"text\": \"extubation\\nextubated with rt per . Face tent 50%, sats 96 rr 28. Able to speak in hoarse voice, deep breathing, coughing. cough pillow provided. Denies SOB or discomfort. Expectorated large amount of loose clear/yellow secretions post extubation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342105,\n \"text\": \"CV: at 80 with no VEA noted, A wires sense and capture, unable to check either A or V wires as pt IMMEDIATELY drops SBP to 90's and HR to 40's; SBP 110's with MAP >60; Neo gtt cont at 0.5mcg/kg/min; CO >4.9 and CI >2, Swan pulled but cordis kept; Rfem A-line pulled but pt still has RRad A-line; pt currently receiving PCs for HCT 26.1\\n\\nResp: Cont to sat high 90's-100% on 5L NC since extubation at 0500; LS dim throughout\\n\\nNeuro: Pt oriented to person and place, unsure of year and month->reorients easily; MAE; PERLA;\\n\\nGI/GU: Abd soft but absent BS at this time, states feels hungry; adequate clear yellow HUO per foley catheter to gravity\\n\\nEndo: Pt has IDDM, cont on Ins gtt at 1unit/h with hourly BS running 80's-100's with rare 110's\\n\\nID: Afebrile, cont ABX\\n\\nSkin: Coccyx with Stage 1 pressure sore->red but unchanged\\n\\nPlan: EP for cardiac rhythm, wean neo as tolerated, increase activity as tolerated, transfer to CCU\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342106,\n \"text\": \"Addendum: Swan to stay in until PC infused, will attempt additional PIV before transfer\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342111,\n \"text\": \"CCU Progress Note:\\n\\nS- \\\" I can't cough!\\\"\\n\\nO- see flowsheet for all objective data.\\n\\nresp- Increased RR with congestion noted last evening-SpO2 dropped- encouraged to C&DB however said he couldn't cough- lasix & morphine given- Pt deep suctioned for large amt tan colored mucous- RT called- resp Rx given- IS done- O2 increased to 6L via NC- SpO2 now 95-97%- need much encouragement to C&DB- OOB in chair @ 4am- lung sounds coarse, diminished @ the bases with scattered rhonchi.\\n\\ncv- Tele: SR- A paced rhythm noted during the night- no ectopy- temp pacer attached to epicardial wires- rate @ 70 Ma 18- chest & L leg dsg D&I- R radial A line with ABP 113-144/51-64 off pressors- MAPs 69-87-\\nHct 25.4- K 5- Mg 2.7\\n\\nneuro- A&O X2- moving all extremities- amb with 2 assist well- cooperative- follows command.\\n\\ngi- abd soft hypoactive bowel sounds- impaired gag ? if Pt can tolerate PO- no BM.\\n\\ngu- foley draining amber colored urine in small amts- lasix dose increased to 20mg IV TID- BUN 55 Crea 1.4\\n\\nA- S/P CABG post-op day 3- hemodynamically stable off pressors but con't to require pacer support.\\n\\nP- aggressive pulmonary toileting- C&DB with IS Q1 while awake- suction PRN- med for comfort- increase activity- ? swallow study- transfuse today-( Hct low & BUN/Crea climbing)- offer emotional support to Pt & family- keep them updated on plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342112,\n \"text\": \"CCU Nursing Progress Note\\nS-\\\"I can't speak any louder.\\\"\\nO-Neuro alert and oriented x2-3, cooperative but quiet. Voice is still whisper soft, Speech and Swallow Consult revealed vocal cords not closing completely to protect airway with moderate aspiration via video procedure at bedside. c/o incision discomfort and received percocett with good relief of pain.\\nCV-VSS off pressors x 24hrs SBP 120-140's, HR 72-88 NSR with epicardial A rate decreased to 60. No signs of bradycardia or junctional rhythm.\\nResp-LS diminished at bases with occ coarse upper airway from secretions. COntinues to cough but voice is wet most of the time.\\nO2 sats occ dropping to 88% on 4lNP but after IS/deep breathing exercises O2 sat increase back to 93-96% on 4lnp. IS q1-2hrs but only generating 200-250cc.\\nID afebrile\\nGU-foley draining 30-40cc/hr fair response to lasix 20mg IVB at 9am.\\nGI-Pt had eaten breakfast oatmeal with nectar juice well with minimal coughing. After video study pt made NPO, MD placed feeding tube right nare without difficulty. Awaiting xray for placement confirment. Hypoactive BS no BM.\\nSkin-coccyx less reddened, pt trying to change position himself. All surgical dressing intact with ace on left leg.\\nActivity-physical therapy into see pt and walked pt in the hallway 100feet and tolerated very well. Sat in chair for 3 hours and did well. No c/o fatigue or SOB.\\nSocial-wife with pt all day. Case manager to follow up on pt no insurance issue.\\nA/P-s/p CABG post op day#3 with food/fluid aspiration from failure of vocal cord closure.\\n*NPO\\nFollow up with xray and start tube feeds.\\nEncourage pt to get OOB, walk and do ADL's.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342113,\n \"text\": \"NPN \\nCV: HR 70-80 NSR, no paced rhythm. A and V epicardial wires still in place, Atrial rate set to 60. Atrial wire tested sensing and capturing appropriately. States incisional pain is less today, , tolerable, stating that he recieve pain pill earlier, did not want medication again yet. Later in eve, sat on side of bed, requested pain med, given 1mg IV Morphine with good effect.\\n\\nSkin: dressings to chest and leg removed. Chest inc approximated without drainage. left open to air. Old CT sites open, sm amt serosang drainage, covered with DSD. Leg inc D&I, approximated. Ace removed.\\n\\nResp: LS coarse, congested cough, encouraging pt to cough, deep breath and use IS. Pt using yankar. Sats have remained mid 90's on 4L NC. No episodes desaturation.\\n\\nGI: NPO, doboff tube not advancing, coiling in esophagus after 2 attempts, team will try again in AM. NPO as pt is high aspiration risk. No stool this eve.\\n\\nNeuro: A&Ox2, c/o being very fatigued this eve. Sat on side of bed for awhile, but sleeping most of time.\\n\\nID: afebrile.\\n\\nSkin: coccyx reddened, not open.\\n\\nA/P: 3 days post CABG, pt needs feeding tube, npo for swallowing difficulty, mod asp on swallow study. Cont monitor for dysrhythmia's, epicardial wires attached to pacer box. Cont pul toilet, enc increased activity. Support and inform pt/wife.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342114,\n \"text\": \"CCU Progress Note:\\n\\nO- see flowsheet for all objective data.\\n\\nresp- In O2 4L via NC- lung sounds coarse & diminished @ the bases- cough weak but con't to expectorate tan colored mucous- resp status much better tonight- RR 22-24- SpO2 94-100%.\\n\\ncv- Tele: SR no ectopy- HR 70-74- no paced beats noted- R radial Aline with ABP 108-120/48-55- MAPs 67-73- sternal incision dry & intact- open to air- mediastinal dsg D&I- L leg incision line with steri strips intact & lower incision with bandaid dsg D&I- no c/o pain tonight- Hct yest 25.4- 1u PRBC's given.\\n\\nneuro- comfortable night- sleeping well- A&O X2- moving all extremities- cooperative- follows command.\\n\\ngi- abd soft (+) bowel sounds- FT removed after CXR read by HO- NPO- ? reinsert FT in IR today to assure proper placement- No BM this shift.\\n\\ngu- foley draining yellow colored urine qs- U/O >30cc/hr- (-) 100cc since 12am- (+) 4500cc LOS- BUN & Crea trending up- AM labs pending.\\n\\nA- S/P CABG day #4- improving resp status tonight- hemodynamically stable off pressors- failed swallow study- NPO ? reinsert FT today.\\n\\nP- monitor vs, lung sounds, I&O and labs- keep NPO until FT placed- con't aggressive pulmonary toileting- increase activity- offer emotional support to Pt & family- keep them updated on plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342102,\n \"text\": \"PT S/P CABG X4-PT WITH LOW EF, CAME OFF PUMP WITH EPI. ARRVIED CSRU ON PROP/NEO/EPI. NO UNDERLYING RHYTHM INITIALLY IN OR, ARRIVED AV PACED--PT SB UNDERLYING WHEN ARRIVED. PT WITH LG FLUID REQUIREMENT (LR 3.5L AND ALBUMIN X2 WITH LOW RT SIDE FILLING PRESSURES) INCREASE PRESSOR REQUIRMENT. SLOW TO WAKE. ASSESSMENT IS AS FOLLOWS:\\nNEURO: REVERSALS GIVEN AND PROP WEANED, PT SLOW TO WAKE. OPENS EYES AND FOLLOWS COMMANDS BUT FALLS ASLEEP EASILY. PERRLA. NO DEFICITIS NOTED\\nCV: PT AT 88---UNDERLYING SB/JUNCTIONAL WITH PAC'S. PT WITH RARE MULITFOCAL PVC DESPITE LYTES WNL. PT WITH ST DEPRESSION ON MONITOR OUT OF OR, AWARE, NO TX ORDERED. BP LABILE, REQUIRING FLUID AND INCREASE PRESSOR REQUIRMENT. CURRENTLY NEO 1.1MCG/ EPI .02MCG. CVP 2-8 PAD 15-20. HCT 28. CO INTIALLY LOW BUT RESPONDED TO IVF NOW CI>3. CT OUPTUT MINIMAL. DOPPLERABLE PEDAL PULSES. PT INTERMITTENTLY DIAPHORETIC. LT FEM DSG SATURATED WITH SANG DRNG IN PM, CHANGED. SM STAINING ON STERNAL INCISION AND CT SITE.\\nRESP: SLOW TO WEAN VENT. CHANGED TO CPAP AT 15 PS THIS PM WHEN ATTEMPT WEAN PCO2 IN 50'S, RESTED BACK ON PS 15. NOW ATTEMPTING SLOW WEAN. LUNGS CLEAR. SX FOR SCANT WHITE. OXYGENATION EXCELLENT ON FIO2 40%.\\nGI: OGT TO LCWS-> BILIOUS DRNG. , PLACEMENT CONFIRMED BY AUSCULTATION. ABD SOFT. NO BS.\\nGU: UOP INITIALLY GOOD NOW TAPERING OFF. TEAM AWARE. FOLEY PATENT.\\nENDO: INITIALY BS 50'S, TX 1/4 AMP D50. INSULIN GTT STARTED THIS PM AND TITRATED UP PER PROTOCOL. SEE FLOWSHEET\\nSOCIAL: PT WIFE PLEASANT, UPDATED ON CARE. WIFE STAYING IN HOSPITAL OVERNIGHT IN CC6 WAITING AREA\\nSKIN: PT COCCYX WITH STAGE 1 PRESSURE AREA OUT OF OR, PINK AND UNBLANCHABLE. PT TURN SIDE TO SIDE. PT C/O PAIN IN AREA.\\nPLAN: WEAN VENT. EXTUBATE WHE APPROPRIATE. CONT ASSESS HEMODYANMICS. WEAN PRESSORS AS TOL. CONT ASSESS UNDERLYING RHYTHM. CONT Q1HR BS WHILE ON GTT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342107,\n \"text\": \"NPN \\n61 yr old s/p 4 vessel transferred from CSRU earlier today.\\n\\nCV: HR 80 a-paced via epicardial wire. Atrial stimulation threshold 6, mA set at 10. Pacing consistantly, underlying rate ~50. BP 100-120/50, Neo decreased to .3mcg/kg/min. Dressing to chest and L leg ace bandage D&I.\\n\\nPain: incisional pain, level , give 2mg Morphine with good effect, gag still impaired, coughing with sips water, so unable to take po meds. Using cough pillow effectively.\\n\\nResp: cough productive of thick tan sputum. LS dim with scattered rhonchi. CT pulled earlier today.\\n\\nID: T 99 cont on, IV vanco for 4 doses.\\n\\nNeuro: alert, oriented, no voice, feeling weak. Did dangle for ~15min this eve. Tolerated well.\\n\\nEndo: cont on reg ins gtt at 1unit/hr with FS q 2 hrs stable at 100-120.\\n\\nSkin; coccyx reddened, enc to lie on sides.\\n\\nHeme: recieved 1 u prbc today. Order to check labs in AM.\\n\\nSoc; wife at bedside, has been staying in the hospital.\\n\\nA/P: s/p CABG, remains on low level of Neo, attempt to wean off, a-paced with intrinsic rate still low. need pacer/ICD, followed by EP. Cont to med for pain prn, increase act, OOB to chair tomorrow. cont IS, enc cough and DB. support pt/wife. cont plan per pt care rounds.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342108,\n \"text\": \"ccu npn 11p-7a border\\nS:\\\"I'm in Hospital, its .\\\"\\n\\nO: Please see carevue for VS and objective data.\\n\\nNeuro: Pt. A/A/Ox3, pleasant and cooperative, appreciative of care. MAE, PERLA. c/o incisional pain with turning, given 2mg IV Morphine x1 with good effect. Slept at intervals.\\n\\nCVS; Hemodynamically stable on IV Neo at 0.3mcg/kg/min, attempted wean to 0.2mcg/kg/min with MAP<60. MAP>60 on IV Neo at 0.3. BP ranges via right radial aline. HR 80's 100%, prolonged PR interval 0.28-.30. A/V epicardial wires intact with A wire settings stim. threshold 9, MA 18. /capturing appropriately. Increased and tested previous shift at 2200. MD aware. V wires remain off. No vea noted. Am Hct 27.0 s/p 2 units .\\n\\nResp; Sats 93-100% on 4L n/c. RR mid to high 20's. Lungs clear with diminished bases, occ. scattered rhonchi, improved with TCDB and IS. Pt. able to raise thick, yellow sputum with yankauer.\\n\\nGI:GU: Impaired gag, weak cough. No po's given this shift. Abdomen soft with hypoactive bowel sounds. Foley to drainage with clear, amber urine u/o 30-40cc/hour. Total I/O 600cc + at MN.\\n\\nEndo; Pt. on Regular Insulin drip 1.0-0.5 units/hour. blood sugars 108-89, drip off at 0300 with blood sugars 90's.\\n\\nID: Tmax 99.9, WBC 12.9, to receive last dose IV Vanco in am.\\n\\nSkin: Cocccyx remains red without breakdown, turned q2-3 hours, skin care provided. Encouraged Pt. to stay off back. Mediast/sternal dressing intact, left leg ace wrap D/I.\\n\\nA: hemodynamically stable s/p cabg, tolerating A pacing with underlying conduction disturbance.\\n\\nP: Cont to monitor rhythm/ a pacing, hemodynamics, wean Neo as tolerated. Pulm. toileting, IS, CPT, TCDB. Follow up with am labs with team. Monitor blood sugars, may switch to SS Regular Insulin. Assess gag, increase diet as tolerated. Activity progression with pain control. Comfort and emotional support to Pt. and family\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342109,\n \"text\": \"CCU Nursing Progress Note\\nS-\\\"My throat still hurts\\\"\\nO-Neuro alert and oriented x2-3, quiet with minimal conversation. Voice is hoarse and c/o sore throat. c/o incisional pain but refusing pain medication.\\nCV-VSS gradual wean off Neo by 1430 with SBP 120-130. HR 80 A pace 100%. Underlying rhythm is sinus brady with ventricular escape beats with pacer off, SBP drops 80-90. Atrial threshold 9 with output set at 18. EP following pt for pacer or ICD.\\nResp-LS diminished bases, O2 4lnp with sats 94-96% RA sat 85%. Freq productive cough moderat amount thick tan sputum, using yankeur sx tip. CPT with fair effect because pt can cough secretions but not expectorate completely.\\nID low grade temp received 4th dose vanco today.\\nGU-foley draining 30-60cc/hr.\\nGI-remains with weak/impaired gag. Unable to take clear liquids +asp/coughing, tolerates soft solid food without coughing. Appetite poor, no BM hypoactive BS x4.\\nActivity-Dangle x2, physical therapy saw pt and walked pt to chair with minimal assist. Tolerated chair for 1 hour before getting fatigued.\\nSocial-wife with pt all day.\\nA/P-Succ CABG post op day #2, with persistant sinus brady/hypotension off pacer.\\nContinue to monitor pacing threshold q shift.\\nFollow VS off vasopressors.\\nCheck gag before food/medications.\\nmedicate for pain as needed.\\nKeep pt and family aware of POC as discussed in multi disciplanary rounds.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342110,\n \"text\": \" npn\\n1500-1900\\n\\n PA turned pmr down to 70, pt now in sr w/ rate mid 70's. Lasix ^ to 20 mg tid. BS ^ 176 at 1800, covered per riss. Taking soft solids well. Needs encouragement to CDB.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-21 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342115,\n \"text\": \"CCU Nursing Progress Note\\nS-\\\"I feel alittle stronger today.\\\"\\nO-Neuro alert and oriented x3, awake most of the day and more interactive. This morning voice was audible but hoarse for 2 words. By afternoon voice was whisper soft again. c/o minimal incisional discomfort, refusing pain medication.\\nCV-VSS SBP 124-145 with HR 78-88 NSR. Epicardial a/v wires intact and attached to pacer. Atrial rate at 60 and ventricular pacer off, has not required pacer for 48hrs.\\nResp-LS diminished bases, decreased coughing today while being NPO. Sputum is tan/thick, using yankeuer tip. Still requiring O2 3-4l NP with sat dropping to 78-80% on RA. No c/o SOB while walking in hallway.\\nID afebrile\\nGU-foley removed this morning but DTV 5-7pm.\\nGI-Remains NPO d/t failed swallow study . NGT placed by fluro into jejunum succ right nare. Started ProBalance at 20cc/hr at 1730, with GOAL rate at 60cc/hr. +BS no BM post op.\\nSkin-intact, Sternal incision dressing off open to air, staples intact. Left leg ace removed and d/c'd.\\nActivity-OOB walking in hallway 3 times >yds today with 1 assist. Still using wheelchair to hold on to but endurance has improved.\\nPhysical therapy working with pt this evening.\\nSocial-wife with pt most of the day, staying with pt in the room.\\nCase Manager following d/t no insurance.\\nA/P-s/p CABG post op d#4 with failed swallow study now with feeding tube for nutrition.\\nContinue to monitor rhythm for bradycardia and pacer use.\\nEncourage independance with ADL's.\\nCheck TF residuals q4hrs and increase rate 10cc for GOAL rate 60cc/hr by am.\\nKeep pt/family aware of POC as discussed in multi disciplanary rounds.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2186-07-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1342116,\n \"text\": \"ccu npn 7p-7a\\nS:\\\"I'm doing ok.\\\"\\nO: Please see carevue for VS and objective data\\nCVS: Hemodynamically stable with HR 70-80's NSR, rare PVC noted. Epicardial A/V wires intact, without requiring use. Atrial wire set at rate of 60, with MA 18. Ventricular wire remains off. BP ranges 96-120/50-70 via non-invasive cuff.\\nResp; Sats 93-99% on 4L n/c. Lungs clear with diminished bases. Encouraged TCDB. RR 20's. Exporating small amounts of thick, tan sputum.\\nGI:GU: Remains NPO after failed swallow studies. TF Probalance started at 20cc/hour, increased q 4hours by 10cc. No residuals with post pyloric tube intact via right nare. In good placement with auscultation. Abdomen soft with bowel sounds, up to commode multiple times for small amount of formed stool. Guaic neg. Voiding qs via urinal/commode, dark, yellow urine. Neg. 730cc at MN, TID IV Lasix dc'd this shift.\\nEndo: glucose 141, SS Regular Insulin as ordered\\nID: afebrile, see carevue for skin care assessment. Post op sites dry and intact without s/s infection.\\nNeuro: Pt. A/A/0x3, pleasant and cooperative. Appreciative of care. Voice remains soft whisper. Wife went home tonight for first time. Called and spoke to RN and Pt. Pt. slept at intervals, given 1mg IV Morphine for sleep/comfort. OOB to commode with assist of RN, MAE, transfers easily with minimal assist.\\nA; Hemodynamically stable POD#5,\\nP: Cont to monitor hemodynamics, rhythm, may remove epicardial wires in am. Cont to monitor voice, gag. TF with goal rate of 60cc/hour. Assess I/O, U/O. Cont. pulmonary toileting. Activity progression. Comfort and emotional support to Pt. and family\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 870292,\n \"text\": \" 2:56 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p dobhoff placement. Please assess tip location. Include u\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man s/p CABG and ct removal\\n\\n REASON FOR THIS EXAMINATION:\\n s/p dobhoff placement. Please assess tip location. Include upper abdomen.\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n TYPE OF EXAMINATION: Chest AP portable single view.\\n\\n INDICATION: Status post Dobbhoff line placement, status post bypass surgery .\\n\\n FINDINGS: AP single view of the chest performed on the patient in supine\\n position has been directed on lower chest, upper abdominal area purpose to\\n identify the recently placed Dobbhoff tube position. Its metallic distal end\\n portion is noted to be located in the lower esophagus seen through the\\n markedly enlarged heart shadow. Both diaphragms cannot be identified with\\n certainty because of pleural densities, but it is most unlikely that the\\n Dobbhoff has passed through the hiatal area and certainty is not in a position\\n compatible with the fundus of the stomach. Comparison made with a next\\n preceding portable chest examination obtained seven hours earlier the same\\n date demonstrates grossly unchanged findings with massive bilateral pleural\\n densities. The Dobbhoff tube was not present on the previous preceding\\n examination and now identified to terminate in the lower esophagus, but not\\n reaching the stomach.\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-24 00:00:00.000\",\n \"description\": \"VIDEO OROPHARYNGEAL SWALLOW\",\n \"row_id\": 870705,\n \"text\": \" 1:15 PM\\n VIDEO OROPHARYNGEAL SWALLOW Clip # \\n Reason: ASSESS SWALLOW\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man S/P CABG/FAILED SWALLOW\\n REASON FOR THIS EXAMINATION:\\n ASSESS SWALLOW\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: 61-year-old man status post coronary artery bypass surgery with\\n swallowing difficulty.\\n\\n TECHNIQUE: Videotaped oropharyngeal swallowing study under fluoroscopy.\\n\\n FINDINGS: The study was performed in conjunction with the speech pathologist.\\n Several consistencies of barium were orally administered. With nectar, the\\n patient exhibited swallowing delay and piecemeal bolus handling, as well as\\n some spillover into the piriform sinuses. From a recent fluoroscopic\\n examination, the patient is known to have incomplete closure of the vocal\\n cords. Although he showed adequate elevation of the larynx and palate, there\\n was a lack of epiglottic deflection, and mild to moderate residue in the\\n valleculae, and to a lesser extent, the piriform sinuses.\\n\\n With nectar thickened liquids, both in the upright position and with chin\\n tuck, the patient aspirated a small amount of barium and showed no spontaneous\\n cough. A cued cough was fairly ineffective. With pureed consistency, he did\\n not show aspiration, however.\\n\\n IMPRESSION: Difficulty with oropharyngeal bolus handling, including residue\\n in the valleculae and piriform sinuses. With nectar thickened liquids,\\n there was a tendency to aspiration, without adequate cough response.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-23 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 870627,\n \"text\": \" 4:16 PM\\n CHEST (PA & LAT) Clip # \\n Reason: r/o pna\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man s/p CABG and ct removal with prurulent sputum\\n\\n REASON FOR THIS EXAMINATION:\\n r/o pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Chest tube removal and purulent sputum.\\n\\n COMPARISON: \\n\\n Comparison to the film obtained on at 8:10 is necessary since the film\\n later that day was obscuring much of the chest.\\n\\n The right introducer sheath has been removed and there is no PTX. Extensive\\n bilateral effusions are seen on the current study. The amount of pleural\\n fluid appears to have decreased but may have distributed more dependently.\\n Positioning may contribute to this apparent change. No definite new\\n consolidation is visualized; however, there is some retrocardiac patchiness,\\n which could be atelectasis or pneumonia.\\n\\n CABG changes are evident and a feeding tube extends below the imaged anatomy\\n on the frontal view.\\n\\n IMPRESSION: Better aerated lung with less pleural fluid as described above.\\n No new consolidations. Right introducer sheath removed and no PTX.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-21 00:00:00.000\",\n \"description\": \"NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)\",\n \"row_id\": 870421,\n \"text\": \" 2:17 PM\\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \\n Reason: needs feeding tube, failed bedside attempts\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with aspiration\\n REASON FOR THIS EXAMINATION:\\n needs feeding tube, failed bedside attempts\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 61-year-old man with aspiration. Detailed bedside attempts for\\n nasogastric tube placement.\\n\\n TECHNIQUE/FINDINGS: A weighted - feeding tube was passed\\n through the right naris into the esophagus, and into the stomach over a metal\\n guidewire. Under fluoroscopic guidance, the tube was then advanced past the\\n pylorus, into the duodenum, with the tip terminating at the ligament of\\n Treitz. 20 cc of Conray was injected to confirm positioning.\\n\\n IMPRESSION: Successful placement of post pyloric feeding tube with tip at the\\n ligament of Treitz.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-20 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 870315,\n \"text\": \" 6:14 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: check feeding tube placement\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with\\n REASON FOR THIS EXAMINATION:\\n check feeding tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Feeding tube placement.\\n\\n COMPARISON: Portable chest of the same date at 14:50 hours.\\n\\n PORTABLE ABDOMEN: The feeding tube descends into the abdomen, loops\\n superiorly into the mid esophagus and then back towards the gastroesophageal\\n junction. The tip may reside below the gastroesophageal junction, but this is\\n difficult to assess because the hemidiaphragms remain obscured by bilateral\\n pleural effusions, left greater than right. The cardiac silhouette is also\\n partially obscured. Failure is present. Sternal wire sutures and mediastinal\\n clips are noted. Internal jugular line remains in similar position since the\\n prior day.\\n\\n IMPRESSION:\\n 1. Feeding tube looped in the stomach and esophagus, as above.\\n 2. Congestive failure and bilateral pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-19 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 870088,\n \"text\": \" 6:55 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess ptx/effusions\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man s/p CABG and ct removal\\n\\n REASON FOR THIS EXAMINATION:\\n assess ptx/effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 61-year-old status post CABG , chest tube removal, re-evaluate\\n for pneumothoraces or effusions.\\n\\n AP SEMI-UPRIGHT CHEST: Comparison to the film of the prior day. Right IJ\\n catheter unchanged in position. A tiny left aypical pneumothorax is not\\n identified on today's study. Persisting bilateral pleural effusions and\\n cardiomegaly consistent with congestive heart failure.\\n\\n IMPRESSION:\\n 1) Slight worsening of pulmonary edema and bilateral pleural effusions.\\n 2) Tiny left aypical pneumothorax not identified on today's study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 869991,\n \"text\": \" 11:19 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o ptx\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man s/p CABG and ct removal\\n\\n REASON FOR THIS EXAMINATION:\\n r/o ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post CABG and chest tube removal.\\n\\n AP PORTABLE UPRIGHT CHEST: Compared to AP supine chest of the prior day. The\\n endotracheal tube, Swan-Ganz catheter, multiple chest tubes, and NG line have\\n been removed. The right IJ line remains in place. There is a tiny left\\n apical pneumothorax remaining. There has been interval worsening of diffuse\\n pulmonary edema with increased bilateral pleural effusions.\\n\\n IMPRESSION:\\n\\n 1) Interval development of pulmonary edema with worsening bilateral pleural\\n effusions.\\n\\n 2) Multiple lines and tubes removed; trace residual left apical pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 870025,\n \"text\": \" 3:35 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess ptx\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man s/p CABG and ct removal\\n\\n REASON FOR THIS EXAMINATION:\\n assess ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 61-year-old status post CABG with CT removal, assess for\\n pneumothorax.\\n\\n AP UPRIGHT CHEST: Comparison to film of 4 hours prior. Allowing for\\n differences in technique, there is no significant change in the tiny left\\n apical pneumothorax. There is slight interval increase in right-sided\\n effusion. Persisting pulmonary edema. No other interval change.\\n\\n IMPRESSION:\\n 1) Tiny left apical pneumothorax.\\n 2) Slight interval increase in right-sided pleural effusion.\\n 3) No other significant short interval change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-20 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 870230,\n \"text\": \" 8:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess effusions\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man s/p CABG and ct removal\\n\\n REASON FOR THIS EXAMINATION:\\n assess effusions\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 61-year-old status post CABG and chest tube removal. Assess\\n effusions.\\n\\n Comparison is made to the prior examination of .\\n\\n The right IJ line remains in place, unchanged in position. Bilateral loculated\\n pleural effusions are noted. The magnitude of the left pleural effusion has\\n not changed. There is associated partial compression atelectasis of the left\\n lower lobe and the lingula.the right pleural effusion may be slightly larger\\n at this time. Associated compression partial atelectasis of the right lower\\n lobe and the right middle lobe has worsened since the prior study.\\n\\n IMPRESSION: Bilateral pleural effusions. The large left pleural effusion has\\n not changed since the prior study, but the right loculated pleural effusion\\n may have slightly increased since the prior study. No evidence of\\n pneumothoraces.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 869895,\n \"text\": \" 2:46 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Pneumothorax, pleural effusion, pulmonary edema, tamponade\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man s/p CABG\\n REASON FOR THIS EXAMINATION:\\n Pneumothorax, pleural effusion, pulmonary edema, tamponade\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post CABG.\\n\\n AP SUPINE CHEST: Compared to PA and lateral chest of . Multiple\\n devices overlying the patient obscure sensitivity of the study. Endotracheal\\n tube tip 3 cm above the carina. Swan-Ganz catheter with its tip in the distal\\n right main pulmonary artery. Multiple left-sided chest tubes and mediastinal\\n tube seen. NG line with its tip in the body of the stomach. No pneumothorax\\n is identified. There has been near resolution of the moderately sized right\\n pleural effusion with just a small residual effusion remaining. The lungs are\\n clear. There is no significant volume overload/CHF.\\n\\n IMPRESSION:\\n 1) Multiple lines and tubes in satisfactory position; no pneumothorax.\\n 2) Small residual right pleural effusion.\\n 3) Cardiomegaly without evidence of significant volume overload/CHF.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-16 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 869755,\n \"text\": \" 2:42 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \\n Reason: eval. arterial & venous flow of the liver of this preop for\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with HBV, cirrhosis, pre-op CABG\\n REASON FOR THIS EXAMINATION:\\n eval. arterial & venous flow of the liver of this preop for CABG liver\\n cirrhotic.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 61-year-old man with hepatitis B and cirrhosis. Preoperative for\\n CABG.\\n\\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is without focal lesions, and\\n normal in echotexture and architecture. No intrahepatic biliary ductal\\n dilatation is identified. There are a 6 mm polyp in the fundus and a 4 mm\\n polyp in the most proximal portion of the gallbladder. No stones are seen.\\n Portal venous flow is maintained in the appropriate direction, and no\\n intraluminal thrombus is identified. Hepatic venous flow and hepatic arterial\\n flow are within normal limits.\\n\\n IMPRESSION:\\n 1) Normal portal venous flow.\\n 2) Two small gallbladder polyps.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-13 00:00:00.000\",\n \"description\": \"CHEST (PRE-OP PA & LAT)\",\n \"row_id\": 869448,\n \"text\": \" 8:09 PM\\n CHEST (PRE-OP PA & LAT) Clip # \\n Reason: CORONARY ARTERY DISEASE\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with severe CAD, cirrhosis, CHF\\n REASON FOR THIS EXAMINATION:\\n eval pleural effusions/ eval for pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of coronary artery disease, cirrhosis, and CHF. Evaluate\\n for pleural effusions or pneumonia. Preoperative evaluation.\\n\\n COMPARISON: None.\\n\\n PA AND LATERAL CHEST RADIOGRAPHS: There are increased interstitial markings,\\n which may be chronic, though underlying CHF cannot be excluded. There is\\n blunting of the right costophrenic angle, consistent with pleural effusion.\\n There is cardiomegaly. The mediastinal contours are stable. There is\\n calcification of the aortic arch. The aorta appears slightly tortuous. There\\n is flattening of the diaphragms, and increased in the retrosternal clear\\n space, consistent with underlying chronic emphysematous change. There is a\\n compression deformity in the mid-thoracic spine.\\n\\n IMPRESSION:\\n\\n 1. There is flattening of the diaphragms, and retrosternal clear space\\n opacity consistent with underlying chronic emphysematous changes.\\n\\n 2. While there are diffusely increased interstitium marking which may be\\n chronic, though superimposed mild CHF cannot be excluded.\\n\\n 3. Cardiomegaly.\\n\\n 4. Wedge compression deformity in the mid-thoracic spine.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2186-07-16 00:00:00.000\",\n \"description\": \"CT ABD W&W/O C\",\n \"row_id\": 869714,\n \"text\": \" 9:26 AM\\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST\\n Reason: triple phase, arterial, venous, solideval. liver & vessels,\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with CAD\\n REASON FOR THIS EXAMINATION:\\n triple phase, arterial, venous, solideval. liver & vessels, pre-op CABG\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 61-year-old man with hepatitis, cirrhosis. Preoperative for\\n CABG.\\n\\n TECHNIQUE: After administration of oral contrast, MDCT was used to obtain\\n non-IV-contrast images through the liver. Contrast-enhanced images were\\n obtained after 35 and 75 second delay. 3-minute delay images were also\\n obtained through the abdomen and pelvis.\\n\\n CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is a moderate loculated\\n pleural effusion in the right hemithorax. There is associated compressive\\n atelectasis. There is also a small left pleural effusion. Cardiomegaly is\\n present, but there is no pericardial effusion.\\n\\n Although somewhat nodular, the liver is without focal lesions. Portal venous\\n flow is patent. The gallbladder is unremarkable. The spleen is borderline\\n enlarged. The pancreas, adrenals, kidneys, stomach, and small bowel are\\n unremarkable. A small amount of perihepatic ascites is noted. No significant\\n lymphadenopathy is identified. There are aortic calcifications, but the aorta\\n is not dilated.\\n\\n CT OF THE PELVIS WITH IV CONTRAST: Distal ureters and bladder are within\\n normal limits. Bowel loops are grossly unremarkable. Vasculature is notable\\n for extensive calcification. No lymphadenopathy is identified. There is no\\n free fluid.\\n\\n Bone windows are notable for a hemangioma in the left posterior aspect of L3\\n vertebral body.\\n\\n IMPRESSION:\\n 1) No focal liver lesion. Small amount of perihepatic ascites.\\n 2) Loculated small right pleural effusion, with small left pleural effusion.\\n Associated compressive atelectasis.\\n 3) Cardiomegaly.\\n 4) Vascular calcifications.\\n (Over)\\n\\n 9:26 AM\\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST\\n Reason: triple phase, arterial, venous, solideval. liver & vessels,\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\n Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2186-07-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 211666,\n \"text\": \"Underlying rhythm is sinus rhythm. Occasional atrially paced rhythm. Probable\\nleft atrial abnormality. Probable old inferior wall myocardial infarction. Loss\\nof R waves suggests old anterior myocardial infarction. Inferolateral\\nST-T wave abnormalities suggestive of myocardial ischemia. Compared to the\\nprevious tracing of above noted abnormalities persist.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2186-07-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 211667,\n \"text\": \"Sinus rhythm, rate 62. Left axis deviation. There may be a previous inferior\\nwall myocardial infarction and possibly anteroseptal myocardial infarction.\\nDiffuse ST-T wave abnormalities are noted. No previous tracing available for\\ncomparison.\\n\\n\"\n }\n]"}}},{"rowIdx":986,"cells":{"subject_id":{"kind":"number","value":27668,"string":"27,668"},"hadm_id":{"kind":"number","value":169809,"string":"169,809"},"target_text":{"kind":"string","value":"44-year-old male patient with continued paroxysmal episodes of dyspnea associated with symptoms of laryngospasm admitted to the ICU after a witnessed 45 sec episode of resp distress. . #Respiratory distress: intermittent dyspnea over the past several weeks. Likely laryngospasm due to GERD-associated irritation or persistent sinus sx. Much less likely asthmatic sx as a rxn to allergens at home. Infections etiology also possible given sputum production, but pt has been on Levaquin recently, without effect, and hx is not c/w persistent infection to due episodic nature. Ground glass opacities on chest CT and pulmonary nodule RLL. Pt also has persistent allergic rhinitis. Psychogenic paradoxical vocal cord movement is also possible but less likely based on clinical presentation. Sputum gram stain negative, no antibiotics given. Treating GERD as below. Aggressive bronchodilators. Low dose anxiolytics, as anxiety during dyspneic episodes worsens dyspnea. Post nasal drip symptom relief with guaifenesin, cepacol. Needs repeat CT in 3 months to evaluate the pulm nodule. Speech evaluation recommended behavioral modifications to \"break\" attacks, which seem to be working well for patient. . #GERD. scope by ENT showed laryngeal changes associated with GERD. Normal esoph motility study , which is not uncommon with laryngeal-pharyngeal reflux. No aspiration. Currently on PPI and ranitidine qhs. Dietary modifications to reduce GERD symptoms. Outpatient GI f/u as already arranged. . #allergy sx. persistent sinusitis and reactive airway disease ? rxn to environmental allergens, ?rxns to mice and roaches at home? Sx of allergies--persistent PND and phlegm in throat that the patient cannot cough up. RAST neg and IgE levels wnl. Nasal inh steroids and anti-histamines. . #h/o +PPD 20 years ago; patient received BCG as child in Morrocco. Pt was sent for Quanti- Gold assay to determine whether he has latent TB or not--but has never followed up. has a h/o of \"benign mediastinal tumor\" removed and persistent lung nodules, in addition to ground glass opacities in RML and lingula. 3 induced sputums sent, although very low probability of active Tb. PPD positive this admission (22mm induration at 48 hrs); patient to see PCP who can discuss risks and benefits of treating positive PPD with isoniazid. . #FEN: regular diet . # PPX: SC heparin. PPI. . #code: FULL"},"extractive_notes_summ":{"kind":"string","value":"Taking inhalers as ordered.CV: NSR no ectopy noted; BP stable; afebrile. constantly clearing throat.CV: HR 70s-80s NSR with no ectopy, NBP 100s-110s/60s-70s. 7a-3p Nursing Progress Note/review of systems:Neuro: Pt A/O x3; no c/o pain this shift. had enzymes drawn in ED, EKG without changes. All procedures/POC explained to pt prior to initiation with verbalization of understanding.Resp: Pt on RA, sats WNL; lungs clear with nonlabored respirations. Cardiac size is within normal limits. tolerating house diet well, one BM on shift.GU: UO adequate, pt. BP STABLE. NO C/O PAIN.RESP: PT ON ROOM AIR WITH O2 SAT'S IN THE HIGH 90'S. The trachea appears normal in caliber on both the PA and lateral films. WANTS TO BE SURE HE GOES HOME ON THEM.CV: PT IN NSR WITHOUT ECTOPY WITH RATES IN THE 60'S TO 70'S. LUNG SOUNDS CLEAR THROUGHOUT WITH NO C/O LARYNGEAL SPASPMS. Normal sinus rhythm. sbp 89-107/58-76resp: o2 sats 95-98 %.Lungs clear bilateral. On droplet precautions for +PPD/? Chest pain resoved without further episodes.Resp: RR teens, 02 sats high 90s on room air. He MAE, ambulates without difficulty, and c/o pain to his throat. Sinus rhythmSince previous tracing of the same date, no significant change VOIDING GOOD AMT'S OF CLEAR YELLOW URINE.SKIN: INTACT.ACCESS: ONE PIV. Pt instructed on diaphragmatic breathing and pursed lip W good effect increased aeration at bases. RN, pt. He has a hx of GERD for which he takes Prilosec and Ranitidine and is still completing a course of Levaquin for poss. Tracing within normal limits. Voiding in urinal.Skin: Intact.Plan: Pt d/c'd home at 1500-discharge instructions/medications/follow-up appts reviewed with pt prior to discharge; pt verbalized understanding. having h/o previous mantoux positive.Plan:call out to floor when bed available.resp management.emotional support to pt and family. Compared to the previous tracing of low precordialvoltage is present. PT OOB TO COMMODE. has one PIV which is WNL. Lungs are clear all lobes, no stridor noted. R hand PIV d/c'd-site WNL. He did not decrease his sat.Ativan 1 mg iv given to relax him and to aid in sleep.cv: hr 64-79 nsr no ectopy burst to 118 with laryngospasm episode. overnight, treat for anxiety addendum: pt reports benefits of humidified o2. voids.Skin: IntactSocial: No visits today but pt. PT TAKING INHALERS WITHOUT DIFFICULTY AND STATES THAT AFTER USING THEM IT'S THE BEST HE'S EVER FELT. IMPRESSION: Lung fields clear. Technically difficult studySinus rhythmNormal ECGSince previous tracing of the same date, no significant change NURSING PROGRESS NOTE:NEURO: PT ALERT AND ORIENTEDX 3, VERY PLEASANT AND COOPERATIVE. BS clear but shallow. laryngospasm. tolerating liquids.gu: voiding clear yellow urine.neuro: alert and oriented, cooperative. No edema, pulses present bilaterally.GI/GU: Abd soft/+BS; taking po diet, one episode of vomiting this afternoon upon coughing spell/getting up to ambulate. Sinus rhythm. his heart rate decreased to 80's as this Rn entered room.audible upper airway wheezing heard from doorway and ceased as this rn approached pt. In pt. The best exercises with the most noteable improvement were breathing exercises in conjunction with MDI's. Nsg.notes 0700-1900hrsplanned to discharge to home,but vomitted after , decided to call out to the floor when bed available.Neuro:alert and oriented well,pleasant ,calm.denies any pain.saying that having trouble breathing when sleeping on left side.went to outpatient clinic for speech and swallow evaluation.use ice chips or drink water when throat gets more irritated to avid more inflammation.Resp:O2 WEAN OFF TO RA,SATS > 95% LUNGS CLEAR.on respiratory treatments .no episode of laryngeal spasm todayCVS:HR 70-90/min,NSR,no ectopics noted.BP 100-120 SYS.GU/GI:on regular diet,said hungry too much,vomitted after ,but no nausea or vomitting after lunch.no BM tody.voids adequate urine output.IV access:PIV on Rt hand .patent.dressing intact.Integu:skin intact,afebrile,moves on bed self.PPD done on Rt forearm ,to be read on Social:visited by wife and family and updated with MD.calm and co operative.full code. Low precordial lead QRS voltage is non-specific and probably anormal variant. The patient is status post sternotomy. Pt. Pt. Pt. Pt. Pt. ABLE TO GET OOB TO USE COMMODE. He did have one very brief episode of ? No wheezes noted before or after treatment. he states his night was comfortable. PNA. No change from tracingof . feel much better. The right lower lobe nodule seen on the CT has not been demonstrated on the plain film. CHEST: Comparison is made with the prior chest x-ray of . had on episode up on arriving of chest\"pressure\" radiating to throat, EKG done, 1mg IV Morphine and .3mg SL Nitro given. No failure is seen. No episodes of laryngospasm since arriving here. anxious at times treated with ativan iv. he reported that he had fallen asleep and that it awakened him. He was scoped by ENT within last 10 days with normal results. Vital signs all WNL at this time. SEE FLOWSHEET FOR ALL DATA.GI: PT TOLERATED SOME DINNER WITH NO N/V. PT IS FULL CODE. NO CONTACT WITH RN OVERNIGHT. given 2mg IV Ativan for anxiety which made the pt. PPD planted on R forearm and one of 3 AFBs sent.GI: BSX4, pt. the episode ocurred ~2115, his heart rate was upo to 118 st for ~30 seconds. The lung fields are clear. MDI's given with spacer. TB. open face mask .35 % to provide humidity.gi: positive bowel sounds. 8:52 AM CHEST (PA & LAT) Clip # Reason: eval lung fields for interval change MEDICAL CONDITION: 44 yo M w/ repeat laryngospasms and cough REASON FOR THIS EXAMINATION: eval lung fields for interval change FINAL REPORT CLINICAL HISTORY: Recurrent laryngospasm and cough."},"n_notes":{"kind":"number","value":13,"string":"13"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2117-08-29 00:00:00.000","description":"CHEST (PA & LAT)","row_id":970643,"text":" 8:52 AM\n CHEST (PA & LAT) Clip # \n Reason: eval lung fields for interval change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 yo M w/ repeat laryngospasms and cough\n REASON FOR THIS EXAMINATION:\n eval lung fields for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Recurrent laryngospasm and cough.\n\n CHEST:\n\n Comparison is made with the prior chest x-ray of . The patient is\n status post sternotomy. Cardiac size is within normal limits. No failure is\n seen. The lung fields are clear. The costophrenic angles are sharp. The\n trachea appears normal in caliber on both the PA and lateral films. The right\n lower lobe nodule seen on the CT has not been demonstrated on the plain film.\n\n IMPRESSION: Lung fields clear.\n\n\n"},{"category":"Nursing/other","chartdate":"2117-08-30 00:00:00.000","description":"Report","row_id":1624315,"text":"Nsg.notes 0700-1900hrs\n\nplanned to discharge to home,but vomitted after , decided to call out to the floor when bed available.\n\nNeuro:alert and oriented well,pleasant ,calm.denies any pain.saying that having trouble breathing when sleeping on left side.went to outpatient clinic for speech and swallow evaluation.use ice chips or drink water when throat gets more irritated to avid more inflammation.\n\nResp:O2 WEAN OFF TO RA,SATS > 95% LUNGS CLEAR.on respiratory treatments .no episode of laryngeal spasm today\n\nCVS:HR 70-90/min,NSR,no ectopics noted.BP 100-120 SYS.\n\nGU/GI:on regular diet,said hungry too much,vomitted after ,but no nausea or vomitting after lunch.no BM tody.voids adequate urine output.\n\nIV access:PIV on Rt hand .patent.dressing intact.\n\nIntegu:skin intact,afebrile,moves on bed self.PPD done on Rt forearm ,to be read on \n\nSocial:visited by wife and family and updated with MD.calm and co operative.full code. having h/o previous mantoux positive.\n\nPlan:call out to floor when bed available.resp management.emotional support to pt and family.\n"},{"category":"Nursing/other","chartdate":"2117-08-31 00:00:00.000","description":"Report","row_id":1624316,"text":"NURSING PROGRESS NOTE:\nNEURO: PT ALERT AND ORIENTEDX 3, VERY PLEASANT AND COOPERATIVE. ABLE TO GET OOB TO USE COMMODE. NO C/O PAIN.\n\nRESP: PT ON ROOM AIR WITH O2 SAT'S IN THE HIGH 90'S. LUNG SOUNDS CLEAR THROUGHOUT WITH NO C/O LARYNGEAL SPASPMS. NO STRIDOR HEARD. PT TAKING INHALERS WITHOUT DIFFICULTY AND STATES THAT AFTER USING THEM IT'S THE BEST HE'S EVER FELT. WANTS TO BE SURE HE GOES HOME ON THEM.\n\nCV: PT IN NSR WITHOUT ECTOPY WITH RATES IN THE 60'S TO 70'S. BP STABLE. SEE FLOWSHEET FOR ALL DATA.\n\nGI: PT TOLERATED SOME DINNER WITH NO N/V. PT OOB TO COMMODE. VOIDING GOOD AMT'S OF CLEAR YELLOW URINE.\n\nSKIN: INTACT.\n\nACCESS: ONE PIV. WNL.\n\nID: PT HAD PPD PLANTED ON ARM AND IS TO BE READ .\n\nSOCIAL: PT SPEAKS WITH FAMILY ON CELL PHONE. NO CONTACT WITH RN OVERNIGHT. PT IS FULL CODE. PT IS A C/O AND WAITING FOR BED PLACEMENT.\n"},{"category":"Nursing/other","chartdate":"2117-08-31 00:00:00.000","description":"Report","row_id":1624317,"text":"Respiratory therapy\nPt presents in high position on room air sats 96-97%. BS clear but shallow. Pt instructed on diaphragmatic breathing and pursed lip W good effect increased aeration at bases. MDI's given with spacer. No wheezes noted before or after treatment. The best exercises with the most noteable improvement were breathing exercises in conjunction with MDI's. Third AFB to be done later this AM. Plan: continue breathing exercises and follow-up with PFT.\n"},{"category":"Nursing/other","chartdate":"2117-08-31 00:00:00.000","description":"Report","row_id":1624318,"text":"7a-3p Nursing Progress Note/review of systems:\n\nNeuro: Pt A/O x3; no c/o pain this shift. All procedures/POC explained to pt prior to initiation with verbalization of understanding.\nResp: Pt on RA, sats WNL; lungs clear with nonlabored respirations. On droplet precautions for +PPD/? TB. Taking inhalers as ordered.\nCV: NSR no ectopy noted; BP stable; afebrile. No edema, pulses present bilaterally.\nGI/GU: Abd soft/+BS; taking po diet, one episode of vomiting this afternoon upon coughing spell/getting up to ambulate. Voiding in urinal.\nSkin: Intact.\nPlan: Pt d/c'd home at 1500-discharge instructions/medications/follow-up appts reviewed with pt prior to discharge; pt verbalized understanding. R hand PIV d/c'd-site WNL. Pt transported via wheelchair to main entrance with PCT; brother in law with pt.\n"},{"category":"Nursing/other","chartdate":"2117-08-29 00:00:00.000","description":"Report","row_id":1624311,"text":"Nursing Progress Note: 1200-1900\n\nPt. is a 44 yo man who has had 6 visits to the ED in 12 days for c/o dyspnea at times associated with breathing and clearing his throat simultaneously thought to be laryngospasm. He states it often happens upon awakening and after eating. He has same complaint today but also states that he fainted upon standing up from a chair. He was scoped by ENT within last 10 days with normal results. He has a hx of GERD for which he takes Prilosec and Ranitidine and is still completing a course of Levaquin for poss. PNA. In pt. was given 2L fluids for dehydration (poor PO intake and 1 episode of vomiting in last few days). RN, pt. had episode of laryngospasm lasting 45 seconds with audible stridor after coughing. 02 sat monitor fell off during episode so unknown if sats dropped but per nurse pt was diaphoretic, pale, and felt very weak. Decison made to send to MICU for further observation.\n\nReview of systems:\n\nNeuro: Pt. is alert and oriented but upon arrival to MICU was holding his throat and stating he felt so weak that he thought he was to faint. Vital signs all WNL at this time. Pt. given 2mg IV Ativan for anxiety which made the pt. feel much better. He MAE, ambulates without difficulty, and c/o pain to his throat. Pt. constantly clearing throat.\n\nCV: HR 70s-80s NSR with no ectopy, NBP 100s-110s/60s-70s. Pt. has one PIV which is WNL. Pt. had on episode up on arriving of chest\"pressure\" radiating to throat, EKG done, 1mg IV Morphine and .3mg SL Nitro given. Pt. had enzymes drawn in ED, EKG without changes. Chest pain resoved without further episodes.\n\nResp: RR teens, 02 sats high 90s on room air. Lungs are clear all lobes, no stridor noted. No episodes of laryngospasm since arriving here. PPD planted on R forearm and one of 3 AFBs sent.\n\nGI: BSX4, pt. tolerating house diet well, one BM on shift.\n\nGU: UO adequate, pt. voids.\n\nSkin: Intact\n\nSocial: No visits today but pt. in phone contact with wife.\n\nPlan: Observe pt. overnight, treat for anxiety\n\n\n"},{"category":"Nursing/other","chartdate":"2117-08-29 00:00:00.000","description":"Report","row_id":1624312,"text":"Amitted today from ER on TB precaution first sample induced today and sent to lab.\n"},{"category":"Nursing/other","chartdate":"2117-08-30 00:00:00.000","description":"Report","row_id":1624313,"text":"addendum: pt reports benefits of humidified o2. he states his night was comfortable.\n"},{"category":"Nursing/other","chartdate":"2117-08-30 00:00:00.000","description":"Report","row_id":1624314,"text":"pt slept well most of the night. He did have one very brief episode of ? laryngospasm. he reported that he had fallen asleep and that it awakened him. the episode ocurred ~2115, his heart rate was upo to 118 st for ~30 seconds. his heart rate decreased to 80's as this Rn entered room.audible upper airway wheezing heard from doorway and ceased as this rn approached pt. He did not decrease his sat.Ativan 1 mg iv given to relax him and to aid in sleep.\n\ncv: hr 64-79 nsr no ectopy burst to 118 with laryngospasm episode. sbp 89-107/58-76\n\nresp: o2 sats 95-98 %.Lungs clear bilateral. open face mask .35 % to provide humidity.\n\ngi: positive bowel sounds. tolerating liquids.\n\ngu: voiding clear yellow urine.\n\nneuro: alert and oriented, cooperative. anxious at times treated with ativan iv.\n"},{"category":"ECG","chartdate":"2117-08-29 00:00:00.000","description":"Report","row_id":119741,"text":"Sinus rhythm\nSince previous tracing of the same date, no significant change\n\n"},{"category":"ECG","chartdate":"2117-08-29 00:00:00.000","description":"Report","row_id":119742,"text":"Technically difficult study\nSinus rhythm\nNormal ECG\nSince previous tracing of the same date, no significant change\n\n"},{"category":"ECG","chartdate":"2117-08-29 00:00:00.000","description":"Report","row_id":119743,"text":"Normal sinus rhythm. Tracing within normal limits. No change from tracing\nof .\n\n"},{"category":"ECG","chartdate":"2117-08-25 00:00:00.000","description":"Report","row_id":119744,"text":"Sinus rhythm. Low precordial lead QRS voltage is non-specific and probably a\nnormal variant. Compared to the previous tracing of low precordial\nvoltage is present.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2117-08-29 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 970643,\n \"text\": \" 8:52 AM\\n CHEST (PA & LAT) Clip # \\n Reason: eval lung fields for interval change\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 44 yo M w/ repeat laryngospasms and cough\\n REASON FOR THIS EXAMINATION:\\n eval lung fields for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Recurrent laryngospasm and cough.\\n\\n CHEST:\\n\\n Comparison is made with the prior chest x-ray of . The patient is\\n status post sternotomy. Cardiac size is within normal limits. No failure is\\n seen. The lung fields are clear. The costophrenic angles are sharp. The\\n trachea appears normal in caliber on both the PA and lateral films. The right\\n lower lobe nodule seen on the CT has not been demonstrated on the plain film.\\n\\n IMPRESSION: Lung fields clear.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624315,\n \"text\": \"Nsg.notes 0700-1900hrs\\n\\nplanned to discharge to home,but vomitted after , decided to call out to the floor when bed available.\\n\\nNeuro:alert and oriented well,pleasant ,calm.denies any pain.saying that having trouble breathing when sleeping on left side.went to outpatient clinic for speech and swallow evaluation.use ice chips or drink water when throat gets more irritated to avid more inflammation.\\n\\nResp:O2 WEAN OFF TO RA,SATS > 95% LUNGS CLEAR.on respiratory treatments .no episode of laryngeal spasm today\\n\\nCVS:HR 70-90/min,NSR,no ectopics noted.BP 100-120 SYS.\\n\\nGU/GI:on regular diet,said hungry too much,vomitted after ,but no nausea or vomitting after lunch.no BM tody.voids adequate urine output.\\n\\nIV access:PIV on Rt hand .patent.dressing intact.\\n\\nIntegu:skin intact,afebrile,moves on bed self.PPD done on Rt forearm ,to be read on \\n\\nSocial:visited by wife and family and updated with MD.calm and co operative.full code. having h/o previous mantoux positive.\\n\\nPlan:call out to floor when bed available.resp management.emotional support to pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-08-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624316,\n \"text\": \"NURSING PROGRESS NOTE:\\nNEURO: PT ALERT AND ORIENTEDX 3, VERY PLEASANT AND COOPERATIVE. ABLE TO GET OOB TO USE COMMODE. NO C/O PAIN.\\n\\nRESP: PT ON ROOM AIR WITH O2 SAT'S IN THE HIGH 90'S. LUNG SOUNDS CLEAR THROUGHOUT WITH NO C/O LARYNGEAL SPASPMS. NO STRIDOR HEARD. PT TAKING INHALERS WITHOUT DIFFICULTY AND STATES THAT AFTER USING THEM IT'S THE BEST HE'S EVER FELT. WANTS TO BE SURE HE GOES HOME ON THEM.\\n\\nCV: PT IN NSR WITHOUT ECTOPY WITH RATES IN THE 60'S TO 70'S. BP STABLE. SEE FLOWSHEET FOR ALL DATA.\\n\\nGI: PT TOLERATED SOME DINNER WITH NO N/V. PT OOB TO COMMODE. VOIDING GOOD AMT'S OF CLEAR YELLOW URINE.\\n\\nSKIN: INTACT.\\n\\nACCESS: ONE PIV. WNL.\\n\\nID: PT HAD PPD PLANTED ON ARM AND IS TO BE READ .\\n\\nSOCIAL: PT SPEAKS WITH FAMILY ON CELL PHONE. NO CONTACT WITH RN OVERNIGHT. PT IS FULL CODE. PT IS A C/O AND WAITING FOR BED PLACEMENT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-08-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624317,\n \"text\": \"Respiratory therapy\\nPt presents in high position on room air sats 96-97%. BS clear but shallow. Pt instructed on diaphragmatic breathing and pursed lip W good effect increased aeration at bases. MDI's given with spacer. No wheezes noted before or after treatment. The best exercises with the most noteable improvement were breathing exercises in conjunction with MDI's. Third AFB to be done later this AM. Plan: continue breathing exercises and follow-up with PFT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-08-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624318,\n \"text\": \"7a-3p Nursing Progress Note/review of systems:\\n\\nNeuro: Pt A/O x3; no c/o pain this shift. All procedures/POC explained to pt prior to initiation with verbalization of understanding.\\nResp: Pt on RA, sats WNL; lungs clear with nonlabored respirations. On droplet precautions for +PPD/? TB. Taking inhalers as ordered.\\nCV: NSR no ectopy noted; BP stable; afebrile. No edema, pulses present bilaterally.\\nGI/GU: Abd soft/+BS; taking po diet, one episode of vomiting this afternoon upon coughing spell/getting up to ambulate. Voiding in urinal.\\nSkin: Intact.\\nPlan: Pt d/c'd home at 1500-discharge instructions/medications/follow-up appts reviewed with pt prior to discharge; pt verbalized understanding. R hand PIV d/c'd-site WNL. Pt transported via wheelchair to main entrance with PCT; brother in law with pt.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624311,\n \"text\": \"Nursing Progress Note: 1200-1900\\n\\nPt. is a 44 yo man who has had 6 visits to the ED in 12 days for c/o dyspnea at times associated with breathing and clearing his throat simultaneously thought to be laryngospasm. He states it often happens upon awakening and after eating. He has same complaint today but also states that he fainted upon standing up from a chair. He was scoped by ENT within last 10 days with normal results. He has a hx of GERD for which he takes Prilosec and Ranitidine and is still completing a course of Levaquin for poss. PNA. In pt. was given 2L fluids for dehydration (poor PO intake and 1 episode of vomiting in last few days). RN, pt. had episode of laryngospasm lasting 45 seconds with audible stridor after coughing. 02 sat monitor fell off during episode so unknown if sats dropped but per nurse pt was diaphoretic, pale, and felt very weak. Decison made to send to MICU for further observation.\\n\\nReview of systems:\\n\\nNeuro: Pt. is alert and oriented but upon arrival to MICU was holding his throat and stating he felt so weak that he thought he was to faint. Vital signs all WNL at this time. Pt. given 2mg IV Ativan for anxiety which made the pt. feel much better. He MAE, ambulates without difficulty, and c/o pain to his throat. Pt. constantly clearing throat.\\n\\nCV: HR 70s-80s NSR with no ectopy, NBP 100s-110s/60s-70s. Pt. has one PIV which is WNL. Pt. had on episode up on arriving of chest\\\"pressure\\\" radiating to throat, EKG done, 1mg IV Morphine and .3mg SL Nitro given. Pt. had enzymes drawn in ED, EKG without changes. Chest pain resoved without further episodes.\\n\\nResp: RR teens, 02 sats high 90s on room air. Lungs are clear all lobes, no stridor noted. No episodes of laryngospasm since arriving here. PPD planted on R forearm and one of 3 AFBs sent.\\n\\nGI: BSX4, pt. tolerating house diet well, one BM on shift.\\n\\nGU: UO adequate, pt. voids.\\n\\nSkin: Intact\\n\\nSocial: No visits today but pt. in phone contact with wife.\\n\\nPlan: Observe pt. overnight, treat for anxiety\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624312,\n \"text\": \"Amitted today from ER on TB precaution first sample induced today and sent to lab.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624313,\n \"text\": \"addendum: pt reports benefits of humidified o2. he states his night was comfortable.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2117-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1624314,\n \"text\": \"pt slept well most of the night. He did have one very brief episode of ? laryngospasm. he reported that he had fallen asleep and that it awakened him. the episode ocurred ~2115, his heart rate was upo to 118 st for ~30 seconds. his heart rate decreased to 80's as this Rn entered room.audible upper airway wheezing heard from doorway and ceased as this rn approached pt. He did not decrease his sat.Ativan 1 mg iv given to relax him and to aid in sleep.\\n\\ncv: hr 64-79 nsr no ectopy burst to 118 with laryngospasm episode. sbp 89-107/58-76\\n\\nresp: o2 sats 95-98 %.Lungs clear bilateral. open face mask .35 % to provide humidity.\\n\\ngi: positive bowel sounds. tolerating liquids.\\n\\ngu: voiding clear yellow urine.\\n\\nneuro: alert and oriented, cooperative. anxious at times treated with ativan iv.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 119741,\n \"text\": \"Sinus rhythm\\nSince previous tracing of the same date, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 119742,\n \"text\": \"Technically difficult study\\nSinus rhythm\\nNormal ECG\\nSince previous tracing of the same date, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 119743,\n \"text\": \"Normal sinus rhythm. Tracing within normal limits. No change from tracing\\nof .\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2117-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 119744,\n \"text\": \"Sinus rhythm. Low precordial lead QRS voltage is non-specific and probably a\\nnormal variant. Compared to the previous tracing of low precordial\\nvoltage is present.\\n\\n\"\n }\n]"}}},{"rowIdx":987,"cells":{"subject_id":{"kind":"number","value":12821,"string":"12,821"},"hadm_id":{"kind":"number","value":161937,"string":"161,937"},"target_text":{"kind":"string","value":"The patient was treated for septic shock with 15 plus liters of fluid and broad spectrum antibiotics. All external lines and hardware with the exception of the VVI pacer were removed from the patient and the patient was started empirically on Vancomycin, Flagyl, Imipenem and Miconazole powder. She was kept well hydrated with fluids and pressor support as needed. Regarding her cardiac function the CK elevation was in the sating of a high cardiac output due to likely sepsis. Aspirin was continued and the patient was started on a heparin drip and enzymes were cycled. The electrocardiogram with the baseline left bundle branch block and now pacer placement made it difficult to say whether or not the patient was in acute coronary syndrome. The patient was not a good candidate for a cardiac catheterization in the context of sepsis. Echocardiogram revealed that the ejection fraction was 20% with a hypokinetic septum and moderate symmetrical hypertrophy and 3+ mitral regurgitation. The patient had a rhythm of chronic atrial fibrillation with a rate that varied between 60 and 100 beats per minute. Heparin drip was continued for anticoagulation and rate controlling medications were added onto the treatment regimen. Renal, the patient had acute renal failure on admission likely secondary to hypotension and decreased perfusion. The creatinine normalized down to a level of 0.6 on the day of discharge after aggressive hydration and treatment of the underlying causes of heart failure and sepsis. On the first day of admission the pressors that the patient was admitted to on were weaned off, but Dopamine was restarted at a renal dose to improve renal perfusion. The patient became tachycardic to the 130s and therefore the treatment regimen was switched to Levophed. The patient received intravenous fluid boluses for low urine output. Sputum cultures grew 1+ gram negative rods. The patient's ventilator was weaned down to 50% with a PEEP of 8. Tube feeds were started for nutrition and the patient's hematocrit dropped from 31 to 26. A TTE at this time revealed an EF of 20 to 30% with 3+ mitral regurgitation and apical akinesis. The following day diuresis with Lasix and Natrecor were pursued with a goal of removing 2 liters of fluid. Beta blocker was added on and increased with ace inhibitors to reduce SVR. Once the patient was extubated heart rate was aggressively controlled with beta blockers and Digoxin was added. This achieved rate control in the 60s to 80s, but atrial fibrillation persisted. After extubation the patient was cleared for eating by speech and swallow video evaluations and a diet was advanced to thick pureed foods. The patient was weaned off of diuretics as the congestive heart failure and cardiogenic shock resolved and all of her intravenous medications were changed to po. Zoloft was added back to her regimen of medications at this time to treat the depression that she had been managing chronically. Heparin was weaned off as Coumadin was started and the therapeutic INR of greater then 2 was achieved. On the day of discharge the patient's central line was discontinued. The patient was receiving nutrition through thick feedings and her atrial fibrillation, hypertension, hyperlipidemia were controlled on po medications. The patient was evaluated by physical therapy and it was recommended that the patient continue physical therapy, speech therapy and occupational therapy in a skilled nursing facility. The patient's care and needs in a skilled nursing facility were discussed with the family at length and Hungarian interpreters were obtained to clarify all the patient's outpatient needs. At the time of discharge the patient was discharged to an extended care facility. She was instructed to take all of her medications as described most importantly her Metoprolol 50 mg three times a day to control her heart rate and prevent flash pulmonary edema. She was instructed to see her primary care physician within one week and was told to see her heart failure cardiologist Dr. the attending who cared for her in the Critical Care Unit two weeks after discharge. She was instructed to follow a 2 gram sodium diet and to limit herself to 1.5 liters of fluid each day to manage her heart failure. She was also instructed to have daily blood pressure measurements to keep her systolic blood pressure below 140 mmHg and to weigh herself daily. If her weights increase by 2 pounds she was instructed to call her cardiologist or primary care physician to evaluate whether or not her diuresis needs required modification. The patient was discharged in stable condition to a skilled nursing facility."},"extractive_notes_summ":{"kind":"string","value":"Improved CHF with residual small pleural effusions and left basilar atelectasis. Aortic calcifications are once again noted. Aortic calcifications are once again noted. There is diffuse calcification of the aortic arch and descending aorta. Mild cardiomegaly and symmetric perihilar opacities as well as septal lines at the bases are present, slightly improved. A right sided subclavian central venous line terminates in the distal SVC. The right IJ catheter tip remains in the distal SVC. There is reduced laryngeal valve closure. FINDINGS: Endotracheal tube and single-chamber left-sided cardiac pacemaker are again seen. Small bilateral pleural effusions and adjacent atelectasis are unchanged. There are bilateral pleural effusions, R>L, with some fluid tracking into the minor fissure. There is calcification of the aorta. please assess position, effusion, edema. please assess position, effusion, edema. please assess position, effusion, edema. Patient is still in gross pulmonary edema with bilateral pleural effusions. A temporary pacing lead is also present, terminating in the region of the right ventricle. Mildtricuspid [1+] regurgitation is seen. BP TOL DIURESIS WELL. Moderate tosevere (3+) mitral regurgitation is seen. SECONDARY TO WHERE ABG DRAWN IN PATIENTS CHEYNES- CYCLE; PH ^ ? ON IV VANCO, FLAGGYL, & IMIPENUM.ENDO: BS 176->175. INC. STOOL X2 SM.->LG. Atrial fibrillation with a moderate ventricular response. Atrial fibrillation with a moderate ventricular response. There are layering bilateral pleural effusions with perihilar haziness. IMPRESSION: Aspiration with thin barium consistencies. LUNGS RHONCHOROUS IN AM ANTERIORLY BUT BY PM LUNGS MOSTLY CLEAR WITH SOME EXP WHEEZE POST. Right ventricularsystolic function appears depressed.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but notstenotic. please assess position, effusion, edema. ABG 7.44/36/109/25->7.44/36/78/25. SECOND C-DIFF CX SENT. PAD'S, CVP'S AND PCWP SLIGHTLY.RESP: TOL VENT WELL WITH ABG SLIGHTLY ALKALOTIC. Atrial fibrillation with ventricular response and occasional demand ventricularpacingLeft axis deviationPossible Inferior infarct, age indeterminateConsider old anteroseptal myocardial infarctionSince previous tracing, rate is slower Left ventricular function.Height: (in) 57Weight (lb): 139BSA (m2): 1.54 m2BP (mm Hg): 91/38HR (bpm): 78Status: InpatientDate/Time: at 14:46Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. hct 30.4 inr 3.8.coumadin on hold.resp- on 2l sats 94-98. l/s cxs/coarse 1/2 up l>r. Tmax 99.1 core temp.NEURO: lightly sedated on versed and fenanyl q1-2h. INC OF SM LIQ STOOL.GU:U/O BECOMING MORE CONCENTRATED.ENDO:BS ARE MORE STABLE AT THIS TIME.ID:TEMP UP, REPEAT BCSKIN: PT W/ AN EXCORIATED PERIRECTAL AREA. weaned off Levo. nsg referral done, f/u md d/c summary. PT NEG 600 FOR TODAY WITH VIGOROUS DIURESIS AFTER PO LASIX. RECHECK RISBI THIS AM. On Flagyl, Vanco, Imipenem. Abd soft with (+) BSs. CHECK K AND PTT AT . NO BM.ID:TEMP DOWN TO 99.4ENDO:BS W/IN PARAMETERS, NO COV.SKIN:REDDENED, EXCORIATED PERI AREA, APPEARS TO BE IMPROVINGSOC:SPOKE W/ DTR FOR UPDATE ON PHONEA/P:FAILURE TO WEAN, CONTINUE TO DIURESE, RSBI IN AM, ATTEMPT WEANING IN AM. HEPARIN @ 750u/hr.GI/GU: foley patent, good u/o - slightly cloudy. NAIL BEDS PINK, W/ BRISK CAP REFILL.CV:MHR DECREASED TO 80'S A-FIB, OCCASIONAL V-PACED BEATS AT REST.GI:TOL TF. Speech + Swall to re-eval. MAG REPLETED PO AND IV. ccu npnsee transfer note/referrals alsoo- afebrile. NGT in place per CXR. FEBRILE 102 rectal. CXR + EKG done. ALSO ON DIGOXIN. advance ETT per CXR. CCU NSG PROGRESS NOTE 7P-7A/ S/P PULM EDEMA; MRS- INTUBATEDO- SEE FLOWSHEET FOR OBJECTIVE DATA.CV- HR- 68-81 AFIB/ NO VEA. pm abg pnd. pm HCT 26.1 (am 31.4) ?dilutional? Started on Vanco, Imipenem, and Flagyl. admin abx when ordered. IVF boluses of NS started. Lactate 6.8 post NaHCO3 4.8. REMAINS ON CAPTOPRIL 75 TID AND LOPRESSOR 37.5 TID AS WELL AS DIGOXIN 0.125.CO/CI/SVR- 3.6/2.24/1444. CCU progress note 7a-7pEvents: weaned off Levo, fluid boluses of 2L. CXR DONE. epigastric pain gone after am. heparin/coumadin. PAN CXd. k- 4.0. hct 32.resp- as above, on bipap until 11am and back to 6l with sats 94-98, rr down and sob improved. +DIC. ivf d/c'd. Heparin d/c'd. Heparin d/c'd. CCU NSG PROGRESS NOTE 7P-7A/ RESP FX; MRS- INTUBATEDO- SEE FLOWSHEET FOR OBJECTIVE DATA PT OFF PRESSORS BUT WITH MARGINAL BP ONCE SEDATED/ BACK ON A/C MODE VENTILATION. OET pulled back at start of shift, with report of repeat CXR with OET in adequate position. CCU progress note 7a-7pNEURO: sedated on ATIVAN 1mg PO TID + VERSED 1mg/hr gtt. CCU progress note 7a-7pNEURO: lightly sedated on versed gtt @ 1mg/hr and ativan 1mg po TID. Plan to futher diurese this AM. pm ABG pnd. Am captopril dose held. 3+ generalize pitting edema. BS bilat E wheezes w/ rhonchi. pulm toliet. THEY HAVE ADDED NHP + SSI . purposful movements.ID: abx D/C'd. tolerating captopril 75mg tid. CO/CI ON CAPTOPRIL 6.25MG: 3.3/2.05 SVR 1479. IVF D/C'd. THEY HAVE BEEN UPDATE AND SUPPORT GIVENA: CRITICAL/ DIFFICULT WEAN D/T PULM EDEMA.P; CON'T TO DIURESE CHECK WITH HO. NSG NOTECV: REMAINS IN A-FIB. last CO 4.1 CI 2.55 SVR 1015 CVP 10->15. pm dose of lasix held per HO. Resp. Resp. 3+ pitting edema.GI/GU: foley patent. addendumpt. guiac neg. abg 7.47/41/69! ABG within normal limits. freq. +BS. Abd soft with (+) BSs. PT @ 2100 2 U REG/8 U NPH. D/C TO REHAB IN AM. Heparin continues at 800u/hr with AM PTT pending and Natrecor at 0.020mcg/kg/min.RESP: AC/400/10/.50/5 PEEP. 1+ gen edema.ID: afebrile. ABx coverage: Vanco, Flagyl, and Iminpenim. G(+).ID:Tm 100.2 and Tc 99.5. LAST ABG 7.47-74-37. RR 20-30's regular.HCT 31.9 , stable. Ativan dc'd. OGT to right nare changed to OGT oral. HR 70's afib with freq. TF off for extubation. nystatin applied. Increased again to 0.020mcgs/kg/min and awaiting results. ABX CONT. BS WNL. 2+ generalized edema.GI/GU/ENDO: foley patent. appearing comf. Resp. Resp. CPT done w/ turns.GI/GU: foley patent. PA pressures 35-42/17-20, cvp 12-13. HUOs 25-80cc/hr while on Natrecor gtt. LUNGS WITH EXP WHEEZE AND RHONCHI AT TIMES.ID: TMAX 100 CORE, WBC UNCHANGED. afebrile.CARDIAC: AFIB 60-80s. needs promting and enc. Heparin continues at 950u/hr with therepeautic PTTs. MAPs 60s to 70s.PAD 27-38, CVP 14-17, CO/CI/SVR high 3.0s/2.0s/1200-1500. +BS. +BS. Keep heparin gtt 700u/hr, ptt qd and as ordered (goal ptt 60-80). u/o ~30cc/hr. U/O ~30cc/hr. BP contin. on levoquin for UTI. CPT done with turns. Appears comfortable on versed 1mg/hr and ativan 1mg tid. Digoxin 0.25mg po qd.RESP: O2 2L n/c. SBP 100-1teens/60s."},"n_notes":{"kind":"number","value":107,"string":"107"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2152-09-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":797282,"text":" 7:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate PA catheter placement; interval change in ch\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock and volume overload\n REASON FOR THIS EXAMINATION:\n please evaluate PA catheter placement; interval change in chf; ET placement\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: PA CATHETER PLACEMENT.\n\n CHEST, AP PORTABLE: Comparison is made to .\n\n There has been interval pull back of the right IJ PA catheter with the tip\n terminating in the main pulmonary artery. Again noted, is an NG tube, ET\n tube, and pacemaker, unchanged in position. There are bilateral pleural\n effusions and accounting for technical diffuerence there is no significant\n change, Also noted is mild pulmonary edema, unchanged from prior exam.\n\n IMPRESSION: The tip of the right IJ is in right main pulmonary artery in\n satisfactory position. Otherwise, no significant change from prior study.\n\n\n\n"},{"category":"Radiology","chartdate":"2152-09-02 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":797368,"text":" 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated with swan placed, please evaluate in comparison to\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock and volume overload\n\n REASON FOR THIS EXAMINATION:\n Intubated with swan placed, please evaluate in comparison to yesterday\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiac failure.\n\n PORTABLE CHEST: A supine view is compared to . The tip of the ETT is\n relatively low, approximately 1.5 cm above the carina. The nasogastric tube\n courses below the view of the image. The tip of the Swan- Ganz catheter is\n near the origin of the right upper lobe pulmonary artery, simialr to\n yesterday's film. A single electrode pacemaker is unchanged.\n\n The heart size is stable. Pulmonary edema has improved. There are small\n pleural effusions bilaterally. Atelectasis persists in the left lower lobe.\n\n IMPRESSION: 1. ETT tip relatively low, 1.5 cm above carina.\n\n 2. Improved CHF with residual small pleural effusions and left basilar\n atelectasis.\n\n"},{"category":"Radiology","chartdate":"2152-08-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":796772,"text":" 7:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ARDS - compare to prior films\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sepsis,on vent, hypotension,on IVF, pressors\n\n REASON FOR THIS EXAMINATION:\n eval for ARDS - compare to prior films\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79 y/o woman with sepsis on a vent. Hypertensive. ? ARDS.\n\n AP PORTABLE SUPINE CHEST AT 08:00:\n\n There is no change when compared to prior portable chest at 05:44 of the same\n date. Patient is still in gross pulmonary edema with bilateral pleural\n effusions. External support lines are unchanged.\n\n IMPRESSION: No change. Gross pulmonary edema with bilateral pleural\n effusions.\n\n"},{"category":"Radiology","chartdate":"2152-08-26 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":796768,"text":" 5:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for PA catheter placement, ? new pulmonary p\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock on nesiritide with PA catheter;\n sudden increase in pulmonary artery pressure and peak inspiratory pressures,\n otherwise stable vital signs.\n\n REASON FOR THIS EXAMINATION:\n please evaluate for PA catheter placement, ? new pulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79 y/o woman with cardiogenic shock. Sudden increase in pulmonary\n artery pressure and peak inspiratory pressure. Otherwise stable vital signs.\n Please evaluate.\n\n SUPINE PORTABLE CHEST AT 05:44:\n\n Since the prior study dated at 07:30, the right IJ central venous\n catheter has been replaced with a SG catheter, whose tip is in the right\n pulmonary artery. The patient is in gross pulmonary edema with bilateral\n effusions, right greater than left. The rest of the external support tubing\n is unchanged.\n\n IMPRESSION; New right IJ SG catheter with tip in right PA. No evidence of\n pneumothorax. Pulmonary edema with bilateral effusions.\n\n"},{"category":"Radiology","chartdate":"2152-09-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":797576,"text":" 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p extubation for 24 hours, please comment on changes of CH\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker placement\n 3 weeks ago please and repositioning of ETT. please assess position,\n effusion, edema.\n REASON FOR THIS EXAMINATION:\n s/p extubation for 24 hours, please comment on changes of CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of cardiogenic shock and recent extubation.\n\n AP CHEST: In comparison to the prior study of , the NG and ET tubes\n have been removed. The right IJ line is in unchanged position in the distal\n SVC. There is no pneumothorax. Mild cardiomegaly and symmetric perihilar\n opacities as well as septal lines at the bases are present, slightly improved.\n Small bilateral pleural effusions and adjacent atelectasis are unchanged.\n There is diffuse calcification of the aortic arch and descending aorta.\n\n IMPRESSION: Mild left heart failure, slightly improving. Interval removal of\n ET and NG tubes.\n\n"},{"category":"Radiology","chartdate":"2152-08-29 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":796998,"text":" 8:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for changes\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock on nesiritide with PA catheter\n otherwise stable vital signs.\n REASON FOR THIS EXAMINATION:\n Evaluate for changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Pulmonary artery catheter evaluation. Cardiogenic shock.\n\n PORTABLE AP CHEST: A Swan-Ganz catheter remains in place, terminating in the\n region of the interlobar right pulmonary artery. A temporary pacing lead is\n also present, terminating in the region of the right ventricle. Endotracheal\n tube and nasogastric tube are in satisfactory position. Cardiac and\n mediastinal contours are stable. There is vascular engorgement and perihilar\n haziness. A large right pleural effusion is noted as well as a moderate left\n pleural effusion.\n\n IMPRESSION:\n\n 1. Swan-Ganz catheter terminates in interlobar portion of right pulmonary\n artery.\n 2. Large right pleural effusion, and moderate left pleural effusion. Allowing\n for differences in patient positioning between the two studies, they are\n probably not significantly changed.\n 3. Stable CHF pattern.\n\n"},{"category":"Radiology","chartdate":"2152-09-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":797492,"text":" 8:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: REPOSITION ETT CHECKPOSITION\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker placement\n 3 weeks ago please and repositioning of ETT. please assess position,\n effusion, edema.\n REASON FOR THIS EXAMINATION:\n comparison\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ET tube position change.\n\n AP SEMI-UPRIGHT VIEW OF THE CHEST is compared to AP supine view dated .\n\n FINDINGS: The ET tube terminates 2 cm above the carina. The right IJ catheter\n tip remains in the distal SVC. A single pacemaker lead remains at the apex of\n the right ventricle. The NG tube position in the stomach is unchanged. LV\n enlargement and aortic calcifications are again noted. There has been slight\n worsening of the pulmonary edema. The bilateral pleural effusions are\n slightly increased. There is persistent left lower lobe atelectasis, as well\n as minor right lower lobe atelectasis. The visualized osseous structures are\n unchanged.\n\n IMPRESSION:\n\n 1. Satisfactory position of ET tube.\n 2. Slight worsening of CHF.\n\n\n"},{"category":"Radiology","chartdate":"2152-09-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":798051,"text":" 10:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate or evidence of aspiration\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker placement, recent\n extubation after prolonged ICU course. Now with possible aspiration.\n REASON FOR THIS EXAMINATION:\n ?infiltrate or evidence of aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiogenic shock. Possible aspiration.\n\n COMPARISONS: -- 08:00\n\n FINDINGS: Compared to prior the pacemaker wire and right central venous line\n remain unchanged. There is less distention of the pulmonary vasculature and\n some clearing of air space disease with no evidence of new focal\n consolidations. Heart size is stable, bilateral effusions are stable and\n there is no pneumothorax.\n\n IMPRESSION: Persistent but improving CHF. No new consolidations.\n\n"},{"category":"Radiology","chartdate":"2152-09-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":797728,"text":" 4:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: newly placed NG tube, please evaluate whether it is in the s\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker\n placement 3 weeks ago please and repositioning of ETT. please assess\n position, effusion, edema.\n REASON FOR THIS EXAMINATION:\n newly placed NG tube, please evaluate whether it is in the stomach\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post NG tube placement.\n\n FINDINGS: AP supine view is compared to the AP supine view dated .\n The NG tube extends into the body of the stomach, but its tip is not well-\n visualized due to technique. The right IJ catheter and the single pacemaker\n lead remain in unchanged positions. There is persistent cardiomegaly, and the\n interstitial pulmonary edema appears slightly worse. The bilateral effusions\n are also slightly increased. The left lower lobe opacity is unchanged. Aortic\n calcifications are once again noted. The visualized osseous structures are\n unchanged.\n\n IMPRESSION:\n 1) NG tube in satisfactory position.\n 2) Mild worsening of congestive heart failure and bilateral pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2152-08-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":796833,"text":" 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Line placement, eval of CHF\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock on nesiritide with PA catheter;\n sudden increase in pulmonary artery pressure and peak inspiratory pressures,\n otherwise stable vital signs.\n\n REASON FOR THIS EXAMINATION:\n Line placement, eval of CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79 year old woman status post line placement.\n\n AP supine portable chest at 8:15 AM.\n\n Compared to prior study one day earlier, I see no new lines placed. The\n patient is still in gross pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2152-09-08 00:00:00.000","description":"VIDEO OROPHARYNGEAL SWALLOW","row_id":797926,"text":" 2:18 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: please evaluate for swallowing ability\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with swallow evaluation neeeded\n REASON FOR THIS EXAMINATION:\n please evaluate for swallowing ability\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Please evaluate for swallowing ability.\n\n VIDEO OROPHARYNGEAL SWALLOW: Barium of various consistiencies was administered\n to the patient. Aspiration was noted with cup sips of nectar consistiency.\n Laryngeal penetration was seen with thin barium, though no aspiration was\n noted. There is reduced laryngeal valve closure. There is spillover of barium\n into the valleculae. No significant residue is present. Also noted is mild\n delay in initiating the swallow.\n\n IMPRESSION: Aspiration with large cup sips of nectar consistiency, as\n described above.\n\n"},{"category":"Radiology","chartdate":"2152-08-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":796537,"text":" 10:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for Pulmonary Edema\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sepsis, hypotension,on IVF and pressors\n\n REASON FOR THIS EXAMINATION:\n Assess for Pulmonary Edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Follow up CHF.\n\n CHEST, AP PORTABLE: Comparison is made to prior study from 5 hours earlier.\n\n There is interval withdrawal of right subclavian central line. Again noted is\n NG tube, ET tube and pacemaker, all of which remain in satisfactory position.\n The heart is stable in size. There is slight worsening of the prominent\n pulmonary vasculature consistent with bilateral pulmonary edema. There is a\n possible small bilateral pleural effusion.\n\n IMPRESSION: There is slight interval increase of pulmonary edema which could\n be attributed to worsening CHF or fluid overload.\n\n"},{"category":"Radiology","chartdate":"2152-08-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":796574,"text":" 8:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for Pulm edema and/or infiltrates\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sepsis, hypotension,on IVF and pressors\n\n REASON FOR THIS EXAMINATION:\n Eval for Pulm edema and/or infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79 y/o woman with sepsis, hypotension, on IV fluids and Pressors,\n evaluate for pulmonary edema/infiltrate.\n\n PORTABLE AP SUPINE VIEW OF THE CHEST: Comparison . An ETT is\n present in satisfactory position. A single lead pacemaker is unchanged. An NG\n tube is present with its tip in the region of the gastroesophageal junction\n and its side port in the distal esophagus. The heart size is upper limits of\n normal. There are bilateral pleural effusions. Patchy opacities bilaterally\n are slightly improved and consistent with improving failure.\n\n IMPRESSION: 1) NG tube with tip in the distal esophagus. Tube should be\n advanced. 2) Improving failure.\n\n"},{"category":"Radiology","chartdate":"2152-09-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":797873,"text":" 7:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tachypnea, tachycardia, recent extubation\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker\n placement, recent extubation after prolonged ICU course. please eval for pna,\n effusion, ptx.\n REASON FOR THIS EXAMINATION:\n tachypnea, tachycardia, recent extubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress.\n\n FINDINGS: AP upright view is compared to the AP semi-upright view dated .\n The heart remains enlarged. There is bilateral perihilar air space\n consolidation consistent with pulmonary edema, which represents worsening of\n congestive heart failure since the prior study. There are persistent\n bilateral pleural effusions. There is fluid in the minor fissure. Aortic\n calcifications are once again noted. The visualized osseous structures are\n unchanged. The right IJ catheter and the right ventricular pace maker leads\n remain in unchanged positions.\n\n IMPRESSION: Interval worsening of congestive heart failure. Persistent\n bilateral pleural effusions.\n\n"},{"category":"Radiology","chartdate":"2152-08-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":796520,"text":" 4:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o Pneumothorax, edema, pneumonia\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sepsis\n REASON FOR THIS EXAMINATION:\n r/o Pneumothorax, edema, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis.\n\n AP bedside chest film. Endotracheal tube is located just above the carina. An\n NG tube is seen with tip just beneath the GE junction. The proximal port is\n located within the esophagus. A right sided subclavian central venous line\n terminates in the distal SVC. There is a single lead cardiac pacer with tip\n in the expect location of the right ventricular apex. The heart size is\n normal. There are perihilar air space opacities but no effusions or septal\n lines. There is no pneumothorax.\n\n IMPRESSION: Malpositioned ETT and NGT. Central air space opacities suggest of\n fluid overload. The findings were relayed to the responsible medicine house\n officer via telephone on .\n\n\n"},{"category":"Radiology","chartdate":"2152-08-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":796639,"text":" 5:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Placement of central line, pneumothorax? Please also check\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sepsis,on vent, hypotension,on IVF, pressors\n\n REASON FOR THIS EXAMINATION:\n Placement of central line, pneumothorax? Please also check NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis, with central line and NG tube placement.\n\n Single portable AP view of the chest is compared with the prior study from ten\n hours ago.\n\n FINDINGS: Endotracheal tube and single-chamber left-sided cardiac pacemaker\n are again seen. NG tube has been advanced such that the tip now terminates\n within the abdomen with the sideport in the abdomen, as well. Right-sided IJ\n catheter has been placed, with the tip at the SVC/RA junction. There is no\n evidence of pneumothorax. There are bilateral pleural effusions, R>L, with\n some fluid tracking into the minor fissure. It is difficult to assess change\n in pleural effusion given differences in technique. Cardiac silhouette is\n grossly unchanged. There is retrocardiac collapse/consolidation. There is\n calcification of the aorta. Residual barium is present in the colon.\n\n IMPRESSION: Appropriate positioning of NG tube and right-sided IJ catheter;\n no pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2152-08-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":796674,"text":" 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?bilat infiltrates, ?ARDS vs PNA, CHF, line placements\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sepsis,on vent, hypotension,on IVF, pressors\n\n REASON FOR THIS EXAMINATION:\n ?bilat infiltrates, ?ARDS vs PNA, CHF, line placements\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sepsis.\n\n CHEST, AP PORTABLE: Comparison is made to . The lines and tubes remain\n unchanged in position. There is slight interval increase of bilateral pleural\n effusions. Again noted is left lower lobe collapse/consolidation not\n significantly changed from the prior exam. There are bilateral alveolar\n opacities noted consistent with extensive pulmonary edema/ARDS not\n significantly changed from the prior exam.\n\n IMPRESSION: There is slight increase of bilateral pleural effusions.\n Otherwise no significant change in the overall appearance of the extensive\n pulmonary edema/ARDS.\n\n"},{"category":"Radiology","chartdate":"2152-08-25 00:00:00.000","description":"O CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.","row_id":796707,"text":" 12:27 PM\n CHEST FLUORO WITHOUT RADIOLOGIST IN O.R. Clip # \n Reason: SWANN LLINE PLACEMENT;TEMP WIIRE PLACE\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n A chest fluoro was performed without a radiologist present. 3 seconds of\n fluoro time was used. No films submitted.\n\n"},{"category":"Radiology","chartdate":"2152-09-02 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":797395,"text":" 2:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: central line position\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker placement 3\n weeks ago and volume overload s/p resiting central venous access. please\n assess position.\n REASON FOR THIS EXAMINATION:\n central line position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n PORTABLE CHEST: Comparison is made with earlier film from 7:30 am the same\n day. Endotracheal tube tip remains relatively low, approximatedly 1.7 cm\n above the carina. Of note, the nasogastric tube has moved more proximally,\n and has its endhole in the proximal stomach and sidehole in the distal\n esophagus. This can therefore be advanced approximately 7 cm for better\n placement.\n\n Swan-Ganz catheter has been removed and the right IJ central venous catheter\n now terminates in the region of the distal SVC. Midline structures are\n grossly unchanged. There is persistent CHF with a right pleural effusion and\n consolidation/atelectasis in the left retrocardiac area.\n\n IMPRESSION: 1) Endotracheal tube tip remains slightly low.\n 2) Sidehole of the NG tube is now in the distal esophagus.\n 3) Right IJ central venous catheter tip in SVC.\n\n Findings called to the floor.\n\n"},{"category":"Radiology","chartdate":"2152-09-03 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":797433,"text":" 8:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval progression of pulm edema, repositioning of ETT\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker placement 3\n weeks ago please and repositioning of ETT. please assess position, effusion,\n edema.\n REASON FOR THIS EXAMINATION:\n eval progression of pulm edema, repositioning of ETT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ET tube and NG tube repositioning.\n\n PORTABLE CHEST: Comparison is made to film from one day earlier. The ET tube\n has been pulled back and is now in good position, with its tip 3 cm above the\n carina. The nasogastric tube has been advanced and is also in good position,\n with both end and sidehole in stomach. Cardiac and mediastinal contours are\n stable, and there is no change in the appearance of the lungs, with note again\n made of pulmonary edema, right effusion, and left retrocardiac density.\n\n IMPRESSION: 1. The ET tube and nasogastric tube are now in good position.\n 2. No change lungs.\n\n"},{"category":"Radiology","chartdate":"2152-09-11 00:00:00.000","description":"VIDEO OROPHARYNGEAL SWALLOW","row_id":798136,"text":" 9:02 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: swallowing study\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with swallow evaluation neeeded before starting PO intake\n\n REASON FOR THIS EXAMINATION:\n swallowing study\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Evaluate swallow before starting p.o. intake.\n\n VIDEO OROPHARYNGEAK SWALLOW: Barium of varying consistencies was administered\n to the patient. There was delay in the initiation of the oral phase of\n swallowing. There is incomplete closure of the laryngeal valve. No residue\n was noted with any barium consistencies. There was aspiration with swallowing\n thin barium. Overall, there has been improvement from the study done several\n days earlier.\n\n IMPRESSION: Aspiration with thin barium consistencies.\n\n\n\n"},{"category":"Radiology","chartdate":"2152-08-28 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":796875,"text":" 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulm vasc congestion vs infiltrate.\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock on nesiritide with PA catheter;\n sudden increase in pulmonary artery pressure and peak inspiratory pressures,\n otherwise stable vital signs.\n REASON FOR THIS EXAMINATION:\n evaluate for pulm vasc congestion vs infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79 y/o woman with cardiogenic shock. Sudden increase in\n pulmonary pressure and peak inspiratory pressures.\n\n PORTABLE AP VIEW OF THE CHEST: Comparison . SG catheter is present\n with tip in a right interlobar artery. NG tube courses into the stomach, tip\n not visualized. The ET tube is approximately 2.4 cm from the carina (patient\n with neck in flexed position). There are layering bilateral pleural effusions\n with perihilar haziness.\n\n IMPRESSION: Bilateral layering pleural effusions and mild pulmonary edema. ET\n tube is likely in satisfactory position, given the flexed position of the\n neck.\n\n"},{"category":"Echo","chartdate":"2152-08-24 00:00:00.000","description":"Report","row_id":75890,"text":"PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Coronary artery disease. Left ventricular function.\nHeight: (in) 57\nWeight (lb): 139\nBSA (m2): 1.54 m2\nBP (mm Hg): 91/38\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 14:46\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: Overall left ventricular systolic function is severely\ndepressed. There is no resting left ventricular outflow tract obstruction.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. Right ventricular\nsystolic function appears depressed.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. No 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. There is no significant mitral stenosis. Moderate to severe\n(3+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Mild\ntricuspid [1+] regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion. There is an anterior space\nwhich most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. The\nrhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is mildly dilated. Overall left ventricular systolic function\nis severely depressed (ejection fraction 20-30 percent) secondary to severe\nhypokinesis of the anterior septum and anterior free wall, with extensive\napical akinesis. Right ventricular chamber size is normal. Right ventricular\nsystolic function appears depressed. The aortic valve leaflets (3) are mildly\nthickened but not stenotic. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Moderate to\nsevere (3+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. There is moderate pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\n\n"},{"category":"ECG","chartdate":"2152-08-25 00:00:00.000","description":"Report","row_id":178685,"text":"Atrial fibrillation\ndemand ventricular pacing\nMarked left axis deviation\nIntraventricular conduction defect\nInferior infarct - age undetermined\nAnteroseptal infarct - age undetermined\nLateral ST-T changes may be related to electronic pacemaker\nRepolarization changes may be partly due to rhythm\nLow QRS voltages in limb leads\nSince previous tracing of : no significant change\n\n"},{"category":"ECG","chartdate":"2152-08-24 00:00:00.000","description":"Report","row_id":178918,"text":"Tracing taken with a magnet. Atrial fibrillation with a rapid ventricular\nresponse. Intermittent ventricular pacing. Compared to tracing #2 ventricularly\npaced rhythm is more frequent. The intrinsic ventricular response is faster.\nClinical correlation is suggested.\nTRACING #3\n\n"},{"category":"ECG","chartdate":"2152-08-24 00:00:00.000","description":"Report","row_id":178919,"text":"Atrial fibrillation with a moderate ventricular response. There is intermittent\nventricularly paced rhythm. Compared to tracing #1 intermittent ventricular\npacing is new. Clinical correlation is suggested.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2152-08-23 00:00:00.000","description":"Report","row_id":178920,"text":"Atrial fibrillation with a moderate ventricular response. QRS duration is\nslightly greater than 0.12 - most likely left bundle-branch block. Cannot rule\nout old anteroseptal myocardial infarction. No previous tracing available for\ncomparison.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2152-09-04 00:00:00.000","description":"Report","row_id":178680,"text":"Atrial fibrillation with ventricular response and occasional demand ventricular\npacing\nLeft axis deviation\nPossible Inferior infarct, age indeterminate\nConsider old anteroseptal myocardial infarction\nSince previous tracing, rate is slower\n\n"},{"category":"ECG","chartdate":"2152-08-28 00:00:00.000","description":"Report","row_id":178681,"text":"Atrial fibrillation with rapid ventricular response\nDemand ventricular pacing and ineffective stimuli\n*** complex QRS morphology - no further analysis ***\nPossible inferior myocardial infarct\nECG Taken with magnet\nSince previous tracing of : ventricular pacing is seen\n\n"},{"category":"ECG","chartdate":"2152-08-28 00:00:00.000","description":"Report","row_id":178682,"text":"Atrial fibrillation with rapid ventricular response\nLeft axis deviation\nLeft bundle branch block\nPossible inferior infarct - age undetermined\nECG Taken without magnet\nSince previous tracing of : ventricular pacing not present\n\n"},{"category":"ECG","chartdate":"2152-08-27 00:00:00.000","description":"Report","row_id":178683,"text":"Atrial fibrillation\nDemand ventricular pacing\nMarked left axis deviation\nConduction defect of LBBB type\nLow QRS voltages in limb leads\nSince last ECG, no significant change\n\n"},{"category":"ECG","chartdate":"2152-08-25 00:00:00.000","description":"Report","row_id":178684,"text":"Atrial fibrillation with rapid ventricular response\ndemand ventricular pacing\n*** complex QRS morphology - no further analysis ***\nECG Taken with magnet\nSince previous tracing of : no significant change\n\n"},{"category":"Nursing/other","chartdate":"2152-08-26 00:00:00.000","description":"Report","row_id":1430772,"text":"CCU NPN 0700-1900\nS/O:\n\nCV: NATRECOR UNCHANGED. PT LASIX 20 MG IV WITH VIGOROUS DIURESIS. C/O AND C/I ACTUALLY SLIGHTLY LOWER AFTER DIURESIS BECAUSE HCT INC TO 37. BP TOL DIURESIS WELL. PT CONT IN AF, RATE 70'S-130'S WITH OCC PVC'S. K 3.7, REC'D 40 KCL PO X1. HEP AT 7O0U/HR, PTT PND. PAD'S, CVP'S AND PCWP SLIGHTLY.\n\nRESP: TOL VENT WELL WITH ABG SLIGHTLY ALKALOTIC. FI02 INC TO 50% AND PEEP FROM 6 TO 5, ABG PND. SUCTIONED Q2-3H FOR THICK WHITE SPUTUM. LUNGS RHONCHOROUS IN AM ANTERIORLY BUT BY PM LUNGS MOSTLY CLEAR WITH SOME EXP WHEEZE POST. OVERBREATHING VENT 2-3 BREATHS.\n\nID: LOW GRADE CORE TEMP IN 99'S. ABX CONT. PACER SITE D/I WITH NO DRNG.\n\nGI: TF INC TO 45CC/HR, LOW RESIDUALS. PT INC SOFT STOOL FREQ IN SMALL AMOUNTS. SECOND C-DIFF CX SENT. POS BS.\n\nGU: URINE WITH SOME WHITE SEDIMENT. NEG 450CC FOR TODAY. WT DOWN.\n\nMS: OPENING EYES, NODDING YES AND NO TO QUESTIONS FROM FAMILY. REC'D FENT/VERSED Q2-3H BEFORE TURNING. PT C/O BACK PAIN AT ONE POINT, RELIEVED WITH FENT.\n\nSKIN: AREAS WITH YEAST IMPROVING, NO OTHER SKIN BREAKDOWN. PT PLACED ON FIRST STEP MATTRESS AND PNEUMOBOOTS APPLIED.\n\nENDO: BS 190 FOR HIGH, REC'ING SS REG INSULIN PRN.\n\nA/P: IMPROVING HEMODYNAMICS.FOLLOW K LATER TODAY. ? FURTHER DIURESIS TONIGHT. ? START ACE OR BETA BLOCKER TONIGHT. ASSESS TOL TO TF. PLACE RECTAL BAG IF SKIN STARTS TO BREAK DOWN WITH STOOL. ADJUST HEP ACCORDING TO PTT.\n"},{"category":"Nursing/other","chartdate":"2152-08-27 00:00:00.000","description":"Report","row_id":1430773,"text":"NEURO: SEDATED WITH FENTANYL & VERSED PRN. AROUSABLE TO VOICE STIMULA-\n TION. DOES NOT FOLLOW COMMANDS ? D/T LANGUAGE BARRIER. OPENS\n EYES SPONTANEOUSLY. APPEARS TO UNDERSTAND FAMILY MEMBERS THAT\n SPEAK WITH HER. MAE.\nRESP: ON VENT: .50X450 +AC 12 & 5 PEEP. BS CLEAR BUT DIMINISHED AT R.\n BASE. RR . O2 SAT 95-97%. SX FOR SM.-MOD. AMTS THICK\n WHITE-YELLOW SPUTUM. ABG 7.44/36/109/25->7.44/36/78/25. RISB\n 93.5.\nCARDIAC: HR 90-120 AF WITH RARE PVC. BP 101-131/46-66. PAD 28->23, CVP\n 15->12, W 24->21. HEPARIN GTT INFUSING AT 700U/HR. PTT 57.2.\n HEPARIN GTT INCREASED TO 800U/HR PER PROTOCOL. REPEAT PTT\n PENDING. CONT. ON NATRECOR GTT AT .02MCG/KG. MVO2 SAT 60->61.\n CO 3.7/2.3/1254. HCT 34.\nGI: ABD. SOFT. BS+. OGT IN PLACE FOR TF: FS PROMOTE WITH FIBER @ GOAL\n RATE 45CC/HR. RESIDUAL 140CC->TF OFF X 21/2HRS, THEN RESTARTED AT\n 45CC/HR. MINIMAL RESIDUALS. INC. STOOL X2 SM.->LG. AMT. BROWN\n LOOSE STOOL.\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. LASIX 20MG VP X1->\n DIURESED >2L. U/O PRESENTLY 30-80CC/HR.\nID: T(MAX)99.9(TD). CONT. ON IV VANCO, FLAGGYL, & IMIPENUM.\nENDO: BS 176->175. TREATED PER SLIDING SCALE.\nAM LABS PENDING.\n\n"},{"category":"Nursing/other","chartdate":"2152-09-02 00:00:00.000","description":"Report","row_id":1430801,"text":"CCU NURSING NOTE 7A-7P\nS. REMAINS INTUBATED\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nID: TEMP 99.1 PO MAX WBC 9.1 OFF ANTIBX\n\nCV: HR 65-109 AFIB W/VENT PACED BEATS, LOPRESSOR 37.5 ; DIG .25\n BP 100-140'S/40-60 RECEIVING CAPTOPRIL 75 TID, PA LINE D/C'D LAST CO/CI/SVR = 3.8/2.36/1221; TLC PLACED IN RIJ (NEW SITE) CXR CONFIRMED PLACEMENT; LASIX 20 IV X1 W/~1500CC DIURESIS - 800 NEG TODAY LOS 7600+\n\nNEURO: PT VERY AFTER RECEIVING 6AM FENTANYL BOLUS - VERSED GTT D/C'D AT 0730, DID NOT RESTART - PT AWAKE ALT W/PERIODS SLEEP, CALM EXCEPT DURING PERIODS VIGOROUS STIMULATION IE SUX, APPEARS TO UNDERSTAND WHEN FAMILY SPEAKS IN HUNGARIAN\n\nRESP: SIMV + PS CHANGED ~ 1000 TO 15 PS/5 PEEP THEN LATER DECREASED TO 12 PS/5 PEEP - 1600 ABG 7.56/35/132/32/9 REPEAT 7.48/42/79/32/6\nSATS 94-100%, CONTINUES TO HAVE CHEYNES- RESPIRATIONS - LUNGS COARSE AT BASES TO CLEAR, SUX Q1-2 HR FOR THIN, WHITE SECRETIONS\n\nGI: PROMOTE W/FIBER @ 45CC/HR VIS NGT W/MINIMAL RESIDUALS, LARGE LOOSE GOLDEN STOOL X1\n\nENDOCRINE: FS @ 1200 FS 69 - REPEAT 1715 67 AFTR TUBE FEEDS OFF X 2-3 HRS FOR LINE PLACEMENT (RECEIVED 14U NPH USUAL DOSE IN AM)\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE\n\nSOCIAL: SON/DAUGHTER IN TO VISIT THIS EVENING, UPDATED REGARDING CARE\n\nA: VARYING ABG'S - ? SECONDARY TO WHERE ABG DRAWN IN PATIENTS CHEYNES- CYCLE; PH ^ ? SECONDARY CONTRACTION ALKALOSIS\nDIURESING WELL TO LASIX 20 IV\n\nP: MONITOR HR/RHYTHM, BP, CONT DIURESIS QD, PRN; MONITOR ABG'S AND SLOWLY WEAN PRESSURE SUPPORT AS TOLERATED, ? NEED FOR DIAMOX TO RX PH;\n FOLLOW FINGER STICKS, MONITOR PT'S LEVEL OF COMFORT OFF SEDATION; CONTINUE ATIVAN 1MG PO TID AND ADD SEDATION IF NEEDED FOR COMFORT; KEEP FAMILY UPDATED REGARDING PT'S CONDITION AND PLAN OF CARE, CONTINUE SUPPORTIVE CARE.\n"},{"category":"Nursing/other","chartdate":"2152-09-02 00:00:00.000","description":"Report","row_id":1430802,"text":"CCU NURSING ADDENDUM - 1830\nCXR NOTED ETT TO BE ~ 2 CM ABOVE CARINA - TUBED PULLED BACK AND RETAPED FROM 21 AT LIP LINE TO 20CM AT LIP LINE' REPEAT FINGER STICK AT 1815 = 78; WILL CONTINUE TO FOLLOW.\n"},{"category":"Nursing/other","chartdate":"2152-09-02 00:00:00.000","description":"Report","row_id":1430803,"text":"CCU NURSING ADDENDUM 1900\nPRESSURE SUPPORT DECREASED TO 10; TV'S DECREASED TO 150-200, RR 38; HR UP TO 90-110 AFIB, BP 130'S, O2 SATS DECREASED TO 90; PT ALSO WITH INCREASED COUGHING, VERSED RESTARTED AT 1MG IV, RESP PAGED TO CHANGE PT BACK TO PS 12.\n"},{"category":"Nursing/other","chartdate":"2152-09-04 00:00:00.000","description":"Report","row_id":1430811,"text":"CCU progress note 7a-7p\ncorrection!\n\nstated above pre intubation - meant to type pre extubation!!!\n"},{"category":"Nursing/other","chartdate":"2152-09-05 00:00:00.000","description":"Report","row_id":1430812,"text":"CCu Nursing Progress Note\nS:\nO: See for all objective data\nAfebrile\nHR 70's afib with no vea and occasional paced complex. Tolerated lopressor 50mg \nBP 130-150/50-60 Tolerated 75mg po captopril x2 with small drop in bp to 110// Heparin cont 750u/hr with PTT pnd.\nResp coarse bs which clear post cpt and coughing. Producing sputum, but pt swallows. Attempting to use sx catheter. O2 sat 97-100% on 2ln/l and 40%face tent\nu/o 40-60cc/hr is cloudy yellow\nGI - tolerated sips of water with po meds. No gag or difficulty. abd is soft with +bs and no stool this eve.\n4mm-4mm decub noted on coccyx, covered with tegaderm after being washed with soap and water\nTurned and positioned with compresion sleeves on\nA: tolerating po's/sips with meds\nP: Swallow study cx for ? asp difficulties. cont attempt at clear liqs, ?oob today, monitor sugars as pt is not getting tf's.\n\n"},{"category":"Nursing/other","chartdate":"2152-09-10 00:00:00.000","description":"Report","row_id":1430827,"text":"CCU NPN 0700-1900\nS/O:\n\nCV: HR INC TO 90'S UNTIL 50 LOPRESSOR GIVEN AT 1100, HR THEN TO 70'S-80'S AF. BP STABLE. K WNL THIS AM, POOR RESPONSE TO LASIX 40 MG PO BUT PT STILL NEG FOR TODAY. MAG REPLETED PO AND IV. INR 5, WILL GIVE VITAMIN K SC X1.\n\nRESP: O2 WEANED DOWN TO 2LNP WITH SATS IN MID 90'S. LUNGS WITH CRACKLES 1/2 UP. NO SOB, RR COMFORTABLE.\n\nID: AFEB, WBC WNL\n\nGI: LIQUID STOOL THIS AM SO MOM HELD. PT WITH IMPROVED PO INTAKE OF PUREED FOOD. ABLE TO TOL PILLS WELL WHEN CRUSHED IN APPLESAUCE. 1/2 NS INC TO 75CC/HR TO PROVIDE ADEQUATE FLUID. PT STILL C/O OCC BELLY PAIN.\n\nGU: URINE WITH SEDIMENT AND SOME HEMATURIA. U/A, C/S SENT. NO C/O URGENCY\n\nMS: OOB ALL DAY, SPIRITS BETTER WITH FAMILY IN ROOM. PER FAMILY, MS IS CLOSE TO BASELINE WITH SOME INC IN DEPRESSION NOTED.\n\nA/P: QUIET DAY, PLAN IS TO REPEAT SWALLOW TEST TOMORROW AND ASSESS NUTRITION. CONT TO ENCOURAGE OOB AND INC ACTIVITY. ? REHAB EARLY IN WEEK.\n"},{"category":"Nursing/other","chartdate":"2152-09-11 00:00:00.000","description":"Report","row_id":1430828,"text":"CCU NURSING PROGRESS NOTE\nS:PT ANSWERING IN ENGLISH VERY FEW WORDS\nO:PT AWAKE, ALERT FOLLOWED MOST COMMANDS. GRASPS EQUAL. PT DENIES PAIN. RESP:LUNGS W/ CRACKLES UP 1/2 BILAT AND UNCHANGED. O2 SATS REMAIN 96-97%. PT W/ PROD COUGH OF BLOOD TINGED SECRETIONS. SKIN WARM AND DRY. CV:MHR AFIB W/ OCCAS V-PACED BEATS. DP PULSES PALP. VS STABLE. +SYS MUR. GI:ABD SOFT DISTENDED ABLE TO TAKE MED CRUSHED IN CUSTARD. SM STOOL SMEARING. GU:AMBER COLOR URINE, SOME HEMATURIA,SEDIMENT,W/ FOUL ODOR,C+S PENDING.SKIN:PERI AREA AND GROIN SLOWLY IMPROVING W/ MACONAZOLE PWD.\nA/P:SWALLOW MON. PT AND OT FOR RECONDITIONING,MONITOR PT/INR\nPULM TOILETING AS NEEDED HAVE FAMILY TRANSLATE. PROVIDE INFORMATION AND ANSWER QUESTIONS.\n"},{"category":"Nursing/other","chartdate":"2152-09-11 00:00:00.000","description":"Report","row_id":1430829,"text":"ccu npn\nsee transfer note/referrals also\no- afebrile. started on bactrim for uti, then changed to levoquin and re'd 500mg po x1 today, then 250mg po x 4days.\ncv- hr 60-80s af, no vea. bp 120-140s/. k-3.6, re'd 40meq iv x1, to start po tomorrow. mg 1.9, re'd 2amps mgso4 iv x1. hct 30.4 inr 3.8.\ncoumadin on hold.\nresp- on 2l sats 94-98. l/s cxs/coarse 1/2 up l>r. no sob. on ivf 1/2ns at 75cc/hr d/t poor po in. u/o low in am 15-20cc/hr, then diuresed about 500cc over pm after po lasix.\ngi-for repeat swallowing study in early am, transient nausea but no vomiting after study. may have thickened liquids, pureed foods per s+s, asp. precautions. app. poor, needs assist with feeding. enc self feeding. refused most of dinner and refused some food brought in by fx, ?upset stomach. no bm.\nactivity- oob to chair after rested from swallowing study. transferred poorly, requiring max. assist from . oob for 4hrs.\nms- alert, dozed in naps after activity. oriented x1-2, difficult to understand, speech is hoarse and low, and language barrier. cooperative. non verbals appropriate.\nsocial- dtr/husband in , updated on pt status, s+s study and plan for d/c to rehab tomorrow.\nd/c- ?to rehab/ tomorrow, either or . nsg referral done, f/u md d/c summary.\n"},{"category":"Nursing/other","chartdate":"2152-09-11 00:00:00.000","description":"Report","row_id":1430830,"text":"addendum\nsend clot in am for tlc d/c (risk bleeding). may require ffp prior to removal.\n"},{"category":"Nursing/other","chartdate":"2152-09-05 00:00:00.000","description":"Report","row_id":1430813,"text":"CCU progress note 7a-7p\nOOB to chair this afternoon. Speech and Swallow in to see pt earlier this morning, but didn't do well - ?language barrier - gave meds this afternoon w/ no coughing - using thickened liquids - tolerated well. no NGT inserted yet. Speech + Swall to re-eval. Aspiration precautions.\n\nNEURO: moves arms well. talking hungarian - nodding head to questions of 'okay' or 'water'.\n\nRESP: CPT given with turns. to ask family to instruct pt in hungarian to use incentive spirometry. O2 2L n/c w/ sats >97%. expectorating clear thin secretions. pt taught to use yankhaur suctioning.\n\nCARDIAC: AFIB w/ occ paced beats. Lopressor changed to Toprol XL. Tolerating captopril 75mg TID. MAPs >80-100s. ?anxiety factor? L radial aline patent. RIJ TLC patent. HEPARIN @ 750u/hr.\n\nGI/GU: foley patent, good u/o - slightly cloudy. no diuresis today. abd soft +BS no stool today +flatus. taking thickened water for meds without coughing this afternoon - asp prec.\n\nPLAN: pulm toliet. monitor VS. ?antianxiety meds if needed. family to visit this evening.\n"},{"category":"Nursing/other","chartdate":"2152-09-03 00:00:00.000","description":"Report","row_id":1430804,"text":"CCU NURSING PROGRESS NOTE\nS:INTUBATED\nO:PT WITHDRAW, FLAT AFFECT, PT DOES NOT MAKE EYE CONTACT EVEN WHEN NAME CALLED. DISCUSSED PT SYMPTOMS WITH DAUGHTER PER TELEPHONE. DAUGHTER STATED SHE WAS TAKING PAXIL SINCE THE DEATH OF HER SON THREE YEARS AGO. THE ABOVE INFORMATION WAS REPORTED TO DR. . PT DOES NOT FOLLOW COMMANDS. SHE DOES MORE UPPER EXTREMITIES. WITHDRAWS LE TO NOXIOUS STIMULI. PT RESIST ORAL SUCTIONING WITH YANKAUER. STRONG COUGH AND GAG REFLEX. PT ALLOWED TO REST INBETWEEN CARE. REMAINS ON VERSED GTT AT 1MG/HR.\nRESP:VENT WAS ADJUSTED PSV UP TO 15. PT WITH IRREGULAR RESP PATTERN. PAUSES TRIGGERED APNEA ALARM, RT AWARE. NOW PSV BACK DOWN TO 12 WITH TV 330-420, RR 11-26. SATS MAINTAINED 94-97%. LUNGS WITH COARSE BS IN UPPER LUNGFIELDS. BASES DIMINISHED. SKIN PINK, WARM, AND DRY. NAIL BEDS PINK, W/ BRISK CAP REFILL.\nCV:MHR DECREASED TO 80'S A-FIB, OCCASIONAL V-PACED BEATS AT REST.\nGI:TOL TF. INC OF SM LIQ STOOL.\nGU:U/O BECOMING MORE CONCENTRATED.\nENDO:BS ARE MORE STABLE AT THIS TIME.\nID:TEMP UP, REPEAT BC\nSKIN: PT W/ AN EXCORIATED PERIRECTAL AREA. REDDENED PERIRECTAL AREA\nMICONAZOLE APPLIED.\nFAMILY:DAUGHTER UPDATED ON PT STATUS.\nA/P REPEAT BC SENT, TYLENOL GIVEN. CONTINUE TO MONITOR TEMP,CBC, CXR IN AM. RECHECK RISBI THIS AM. ATTEMP WEANING IN AM. SEE FLOW SHEET FOR ADDITIONAL INFORMATION.\n"},{"category":"Nursing/other","chartdate":"2152-09-03 00:00:00.000","description":"Report","row_id":1430805,"text":"Respiratory Care:\n\nPatient remains intubated on Psv. Vent settings Psv 12, Cpap 5, Fio2 40%. RR increasing to low to mid 30's. Psv increased to 15 with good results. RR decreasing to 12-mid teens. Psv later weaned to 12. Spont vols 340-400's. Abg reveal metabolic alkalosis. Sx'd for sm amounts of thick white sputum. RSBI 194. RSBI improved from yesterday. No further changes made. Increased fluid. Slow wean. Continue with Psv as tolerated.\n"},{"category":"Nursing/other","chartdate":"2152-09-03 00:00:00.000","description":"Report","row_id":1430806,"text":"CCU NURSES NOTE\nO:ABG W/ DECREASED PAO2 TO 67 WHILE PT SLEEPING. PT SUCTIONED AND STIMULATED O2 SAT IMPROVED AND PAO2 UP TO 90. U/O ALSO DECREASED WHILE SBP LESS THAN 110. SEE FLOWSHEET FOR MORE INFORMATION. LASIX ORDERED. PERI RECTAL AREA, GROIN,AND LABIA REDDENED AND EXCORIATED, MICONAOLE POWDER APPLIED TO AFFECTED AREA. M-POWDER APPLIED TO REDDENED PEELING SKIN UNDER BOTH AXILLA-REPORTED TO MD.\n"},{"category":"Nursing/other","chartdate":"2152-09-03 00:00:00.000","description":"Report","row_id":1430807,"text":"CCU NURSING 7A-7P\nS. REMAINS INTUBATED\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nNEURO: PT AWAKE ALTERNATING W/PERIODS OF SLEEP, EYES OPENING SPONTANEOUSLY, MOVING UPPER EXTREMITIES PURPOSEFULLY, NODDED HEAD X 1\nTO RN - DIFFICULT TO ASSESS STATUS SECONDARY TO HUNGARIAN SPEAKING BUT APPEARS WITHDRAWN; REMAINS ON VERSED 1MG/HR, ATIVAN 1MG PO TID\n\nID: TEMP MAX 100.8 R - TYLENOL 650 X1, WBC STABLE AT ~9.5, ? VAGINAL YEAST W/SEVERE REDDNESS OF LABIA, GROIN AREA, WHITISH DISCHARGE NOTED, DOSE DIFLUCAN GIVEN\n\nCV: HR 60'S TO 90'S W/BURSTS TO 120 AFIB, NO VEA, LOPRESSOR INCREASED TO 50MG , BP 109-170/40-60'S, CAPTOPRIL 75MG TID - TOLERATED WELL\nLASIX 20MG IV THIS AM W/ONLY 400CC U/O, REMAINED 200CC+ FOR DAY - 1700 RECEIVED LASIX 40MG IV W/EXCELLENT RESPONSE THUS FAR ~ 700CC IN FIRST HOUR; HEPARIN CONTINUES @ 700U/HR W/PTT 76; 4.0 - RECEIVED 40 PO\n\nRESP: VENTED ON PS 12/5 PEEP 40%, ABG @ 1600 AFTER 1 DOSE DIAMOX - 7.49/40/99/31/6 - 1730 PS DOWN TO 10 W/INITIAL TV'S 200-350CC, RR 20-30, RESP PATTERN MORE REGULAR TODAY W/ LESS PERIODS OF CHEYNES-/APNEA NOTED, DAUGHTER STATES SHE IS \"ALMOST POSITIVE SHE HAS SLEEP APNEA AT HOME. SHE SNORES LOUDLY THEN STOPS ALTOGETHER THEN STARTS UP AGAIN\"; LUNGS REMAIN COARSE W/THIN WHITE SECRETIONS FROM ETT\n\nGI: PROMOTE W/FIBER AT 45CC/HR - MINIMAL RESIDUALS GUIAC NEGATIVE, LT BROWN SOFT STOOL X2 - GUIAC NEGATIVE, ABDOMEN SOFT, OBESE, NON-TENDER\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE - UA/C+S SENT\n\nENDOCRINE: FS 120-140, RECEIVED 14 NPH IN AM, NO SS NEEDED\n\nSOCIAL: DAUGHTER , HUSBAND IN TO VISIT, UPDATED REGARDING PT'S CONDITION, PROGRESS MADE\n\nA: HR HIGHER THAN PAST COUPLE DAYS - ? SECONDARY TO LOW GRADE FEVER - NOT COMPLETELY BETA-BLOCKED DESPITE INCREASE IN LOPRESSOR\nRESPONDING VERY WELL TO 40MG IV LASIX, RESP LESS IRREGULAR - ? SEC TO IMPROVED HEART FAILURE\nTOLERATING 10 PS SO FAR - ABG PND\n\nP: FOLLOW RESP RATE/RHYTHM, VITAL SIGNS, ASSESS RESPONSE TO LASIX, REPELTE LYTES AS NEEDED, FOLLOW TEMPS/WBC, TYLENOL, PRN, ASSESS YEAST INFECTION, CONT MICONAZOLE POWDER, CONTINUE TO WEAN VENT AS TOLERATED, CONT DIAMOX AS ORDERED, MONITOR ABG'S, TIDAL VOLUMES; CONTINUE TO KEEP FAMILY INFORMED OF PLAN OF CARE, CONTINUE SUPPORTIVE CARE FOR PATIENT.\n"},{"category":"Nursing/other","chartdate":"2152-09-04 00:00:00.000","description":"Report","row_id":1430808,"text":"CCU NURSING PROGRESS NOTE\nS:VENTED\nO:PT WITH EYES OPEN BUT HAD NO EYE CONTACT WHEN HER NAME IS CALLED. MAE, DOES NOT FOLLOW COMMANDS, LANGUAGE BARRIER. CALM ON VERSED GTT, HAS NOT REQUIRED ANY ADDITIONAL SEDATION.\nRESP:RR UP, TV 200S, PSV INCREASED BACK TO 12 WITH IMPROVEMENT IN RR AND TV. O2 SATS REMAINED >95%. LUNGS W/ COARSE BS AND CRACKLES AT RIGHT BASE. PT SUCTIONED FOR THIN WHITE SECRETIONS. LARGE AMTS OF ORAL SECRETIONS. PT RESISTS MOUTH CARE.\nCV:MHR AFIB W/ OCCASS V-PACED BEATS. DP PALP, SEE FLOW SHEET FOR VS\nGI:TOL TF, MIN RESID, +BS. NO BM.\nID:TEMP DOWN TO 99.4\nENDO:BS W/IN PARAMETERS, NO COV.\nSKIN:REDDENED, EXCORIATED PERI AREA, APPEARS TO BE IMPROVING\nSOC:SPOKE W/ DTR FOR UPDATE ON PHONE\nA/P:FAILURE TO WEAN, CONTINUE TO DIURESE, RSBI IN AM, ATTEMPT WEANING IN AM. EVAL FOR TRACH, OOB TO CHAIR. BC PENDING.\n"},{"category":"Nursing/other","chartdate":"2152-08-25 00:00:00.000","description":"Report","row_id":1430765,"text":"CCU Nursing Progress Note 1900-0700:\nS-Intubated and sedated\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VS\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\n\nO-MS:Arousing to stimuli and voice. Pt appearing more agitated than previous pulling at restraints and found pulling att ETT suction catheter. Recieving Versed and Fentanyl (1mg and 50mcgs times three doses with good effect), resuming 0.5mg and 25mcg dose thereafter Q1-2hr.\nCV:HR 70s to 100s. Afib with intrisic beats and occasional pauses. Periods where pacer not sensing. Attempting to document on EKG, unsuccesful. Dopa shut off for increasing run of RAF/VT. Levo restarted at previous dose and titrated to MAP > 60. CVP transduced and noted to 15-16 overnight. Left groin TLC removed. Site ecchymotic with no hematoma palpated. Pulses palpable distal. K 3.3 this AM with repletion begun.\nRESP: LS course throughout. Vent: AC/450/12/.50/8 PEEP. SpO2 trending down to high 80s. PO2 down to 60s on gas. Inreased Fio2 to 50%. Later found pt to do same thing, noted to have cuff leak. Issues resolving once leak fixed. Suctioning for thick tan secretion in small to moderate amounts. AM RSBI 88.\nGU/GI: HUO trending down post Dopa wean. Given two 500cc fluid boluses with some improvement. At MN 9L(+) and 10L for LOS. Abd soft with (+) BSs. Passing flatus. Passing small amount of brown liqiud stool. G(+). TF advanced to GR at 5AM this morning and thus far tolerating well.\nENDO: FS at MS 149, requiring no coverage and AM FS 190 and treated with sliding scale.\nHCT: Repeat HCT down to 25. Ordered to transfuse 2UPRBCs. 1st unit in and awaiting 2nd unit from BB.\nID: Tm 99.1 Tc 98.1. Continues triple Abx. Cultures still pending. WBC noted to be trending up to 17 from 13 this AM.\nA/P:\nContinue to monitor.\n\n"},{"category":"Nursing/other","chartdate":"2152-08-25 00:00:00.000","description":"Report","row_id":1430766,"text":"RESP CARE\nPT remained intubated and ventilated overnight. Required an inc in fio2 to 50% for a sat of 88. Suctioned for thick tan sput. RSBI done this am=88. Will follow as needed.\n"},{"category":"Nursing/other","chartdate":"2152-08-25 00:00:00.000","description":"Report","row_id":1430767,"text":"Respiratory Care\nPt remains ventilated with small changes made as a result of ABG resluts. Breath sounds dimished throughout. Sx for small amts of light tan secreations. RRT\n"},{"category":"Nursing/other","chartdate":"2152-08-25 00:00:00.000","description":"Report","row_id":1430768,"text":"CCU progress note 7a-7p\nID: initial Cx's show gram neg rods in sputum + yeast in urine. Cdiff cx pnd (need 2 more cultures). BCs pnd. On Flagyl, Vanco, Imipenem. Tmax 99.1 core temp.\n\nNEURO: lightly sedated on versed and fenanyl q1-2h. nods head when awake. husband visiting this evening.\n\nRESP: LS coarse. sx tan to whitish thin secretions. Sats 94-97%. ABG: 77/32/7.45/20/-4 Vented: AC 450x12 50% peep 6. overbreathing vent when awake.\n\nCARDIAC: AFIB 70s-140s (short bursts of RVR w/ lightening of sedation) MAPs 60-70s. weaned off Levo. PA line placed over wire in RIJ. L radial aline patent. goal wedge in the teens.\nPA 57/35 PCWP 31 CVP 21 CO 3.3 CI 2.05 SVR 1455\nHEPARIN started @ 950u/hr - ptt due 2400hrs.\nNATRECOR started @ 0.01mcg/k/min w/ bolus.\n\nGI/GU: foley decreased output - BUN 25 CR 0.9. given 1 fluid bolus 500cc prior to PA line insertion - post insertion noting elvated wedge/cvp - started on natrecor for low bp + high wedge/cvp/pa. stooled in small amts - golden loose stool. NGT - TF promote w/ fibre GR 45cc/hr.\n\nPLAN: cont' natrecor , check PTT @ mn. keep pt sedated for comfort. collect stool for CDIFF.\n"},{"category":"Nursing/other","chartdate":"2152-09-09 00:00:00.000","description":"Report","row_id":1430825,"text":"CCU NPN 0700-1900\nS/O:\n\nCV: VSS, CONT IN AF. HEP D/C'ED THIS AM AFTER INR HIGH BUT THEN RESTARTED WHEN INR TO 4.9 AT 600U/HR. PTT DUE AT . CAPTOPRIL CHANGED TO ZESTRIL 40 MG QD AND LASIX STANDING DOSE OF 40 MG STARTED TODAY. REC'D 20 MEQ KCL IV BECAUSE PT GAGGED AT ONE POINT WHEN TAKING PILLS MIXED IN CUSTARD, TOL PILLS LATER IN THE DAY. PT NEG 600 FOR TODAY WITH VIGOROUS DIURESIS AFTER PO LASIX. EDEMA IMPROVED, ONLY + IN EXTREMETIES.\n\nRESP: WEANED TO 2LNP WITH SATS IN MID 90'S. LUNGS WITH CRACKLES 1/3 UP BILAT, IMPROVED AFTER DIURESIS. NO SOB. OCC PROD COUGH.\n\nID: AFEB, WBC WNL.\n\nGI: SS INSULIN COVERAGE D/C'ED. PT EATING PUREED FOOD ALTHOUGH SHE DOES NOT LIKE THE TASTE. NO BM, POS BS. 1/2 NS STARTED AT 50CC/HR AS PT UNABLE TO SAFELY DRINK LIQUIDS ACCORDING TO LAST SWALLOW STUDY. PLAN IS TO RECHECK SWALLOW STUDY ON MONDAY. NO EVIDENCE OF ASPIRATION DURING MEALS, PT ABLE TO TAKE PILLS WHEN CRUSHED AND MIXED WITH APPLESAUCE.\n\nGU: FOLEY DRAINING CLEAR URINE.\n\nMS: PT ASKING APPROPRIATE QUESTIONS, ABLE TO CONVERSE IN BROKEN ENGLISH. COOPERATIVE ALTHOUGH DID NOT WANT TO GET OOB IN AFTERNOON AND TRIED TO GET BACK IN BED HERSELF AT ONE POINT. PT APPEARS DEPRESSED, C/O BEING \"SO TIRED\" TODAY. ABLE TO TRANSFER TO CHAIR WITH 2 ASSIST AND TAKE FEW STEPS TO PIVOT.FAMILY IN TO VISIT THIS EVENING.\n\nA/P: TOL PUREED FOOD. STABLE ON CURRENT MEDS FOR TODAY. CHECK K AND PTT AT . CONT TO ENCOURAGE REHAB AND INC ACTIVITY. SAFETY PRECAUTIONS AS PT DOES NOT FULLY UNDERSTAND ALL EXPLANATIONS. CONT TO PT.\n"},{"category":"Nursing/other","chartdate":"2152-09-10 00:00:00.000","description":"Report","row_id":1430826,"text":"CCU NURSING PROGRESS NOTE\nS \"HURTS\"\nO:PT COUGHING AND GAGGING AFTER RECIEVING LOPRESSOR XL W/ APPLESAUCE. PT VOMITED SM AMT OF UNDIGESTED GASTRIC CONTENT. SATS DROPPED TO 91% ON 2L. O2 INCREASED TO 4L. SATS UP TO 94% PT'S FACE ALSO TACHYPNEIC AND DYSPNEIC. LUNGS W/ DEPENDANT CRACKLES ON RIGHT 2/3 UP. SITTING UP PT WITH BIB CRACKLES >ON RIGHT. DR. AND DR. IN TO PT. CXR DONE. PT GIVEN LASIX W/ GOOD DIURESIS. RESP STATUS IMPROVED BUT PT HAVE ASPIRATED. PT WAS NOT ABLE SWALLOW LOPRESSOR. MD AWARE. PT REMAINED NPO AND LOW DOSE MAINT. FLUID WICH ARE TO CONTINUE AS PER DR. .\nGI:PT RUBBING LOWER ABD, WHEN ASKED, PT REPEATED HURTS. ABD SOFT AND DISTENDED. +BS, PLACED ON BED PAN BUT W/O BM. LATER PT WAS INC OF A SM FORM BM. MD NOTIFIED OF PT .\nGU:URINE DRK, + HEMATUREA,+SEDIMENT.\nNEURO:PT ALERT EYES ONPEN BUT SPEAKING MOSTLY HUNGARIAN. PT ABLE TO FOLLOW MOST SIMPLE COMANDS GIVENT WITH GESTURES\nID: THE PT AFEBRILE\nSKIN: PERI-AREA REMAINS REDDED SITE CLEANSED. MACONAZOLE APPLI\nA/P CONTINUE TO MONITOR FOR ASPIRATION PERCAUTIONS. SWOLLOW TO BE REPEATED, MONDAYTO CONTINUE. CONTINURE TO MONITOR HEMODYNAMIC STATUS. OOB TO CHAIR TODAY . PT /OT\n"},{"category":"Nursing/other","chartdate":"2152-08-23 00:00:00.000","description":"Report","row_id":1430760,"text":"CCU admit note 1600hrs\nSEE FHP for admit note.\n\nArrived on floor via med flight from . On LEVO titrated up for sBP 80. Aline inserted. CXR + EKG done. PAN CXd. IVF boluses of NS started. FEBRILE 102 rectal. labs drawn.\n\n\nID: TEMP 102 rectal. BC x 3 sets sent - Fungal Cx sent. Nystatin ordered and applied under both breasts, both axilla and to excoriated reddened groins! New Foley cath inserted, scant urine - send u/a + c+s when enough urine accumulated in catheter. To have femoral line inserted tonite - Cx tip when d/c'd. Noted purulent drainage from TLC site. L s/c pacer site dsg was soaked w/ serous/yellowish drainage - dsg removed and site cleansed w/ betadine. site puffy. abx to be ordered. WBC 35.9 (WBC 12 )\n\nNEURO: was paralyzed + sedated for transfer to - woke ~6pm given versed and fentanyl for sedation w/ good effect IVPush. bilat wrist restraints.\n\nCARDIAC: AFIB 70-130s. SBP 80-100s. L radial ALine inserted. to have R s/c line d/c'd tonite and new fem line inserted. LEVO titrated for maps 70s.\n\nRESP: Vented - sx mod amt tan thick bld tinged secretions. 100%. sats 100%. pm abg pnd. LS coarse. CXR showed pneumonia not chf.\n\nGI/GU: new foley inserted - please collect Cx/u/a. abd soft +BS. cleaned up mod amt yellow stool on arrival to CCU. NPO. NGT intact.\n\n\nPLAN: to be collected :urine cx, R s/c TLC tip for cx. admin abx when ordered. con't levo gtt. adjust vent settings per abg results. advance ETT per CXR.\n"},{"category":"Nursing/other","chartdate":"2152-08-24 00:00:00.000","description":"Report","row_id":1430761,"text":"CCU Nursing Progress Note 1900-0700:\nS-Intubated and sedated\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN HEMODYNAMICS\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\n\nO-MS:Arousing to voice, when calling pt's name. Looking around and later closing eyes. Pt \"slavic\" speaking only. Making purposeful movement when hands untied, ie reaching for ETT. Sedated with IVP Versed and Fentanyl, 1mg of Versed and 50mcgs of Fentanyl IVP Q1-2hrs.\nMAEs on bed.\nCV:HR 70s to 100s. AFIB with occasional PVCs. Periods where pacer not sensing. Cards aware. K 5.3 and recently down to 5.1. BPs 70s to 180s. IVF boluses continued, given as much as 3Ls of NS overnight, Levo as high at .4mcgs/kg/min. Pt precipitously dropping BPs once boluses finished infusing. Levo currently at .150mcg/kg/min. Dopa later added for \"renal perfusion,\" with increasing runs. AED placed and continued to monitor. TLL catheter inserted per left femoral sight with difficulty. Site slightly eccyhmotic with no hematoma palpated. Pulses palpable distal. BLEs cool to touch, and slighly mottled.\nRESP: LSs course with some exp wheeze and crackle at bases. ABGs later with metabolic acidosis and later pt hypoxic. Intially increasing rate with no effect. NaHCO3 given with improvement. PEEP and FIO2 increased with effect. Current vent settings: AC/450/16/.60/10 PEEP. Suctioned for thick tan secretion in small amounts. CXR with some worsening failure vs ARDS, (+) b/l infiltrates.\nGU/GI: Intially anuric. Post IVFs and higher BPs, HUOs 80-160cc/hr. Since MN 4.7L(+) and for LOS 5.3Ls(+). Creat slightly down to 1.4(1.5) last night, AM pending. Lactate 6.8 post NaHCO3 4.8. AM pending. Abd soft, non-tender with hypoactive sound. NGT in place per CXR. Aspirating for clear aspirate and heme(+). Nutrition c/s'd for AM, for possible start of TFs today. Tiny smear of stool on pad but not enough to guiac or cx.\nID: Tm 99.0 rectal Tc 98.9 orally. Started on Vanco, Imipenem, and Flagyl. Urine cx and catheter tip cx sent prior. Sputum with prelims of GNR but 25+ PMNs. Blood, urine, and tip pending.\nHEME: HCT on repeat, 32 down from 37. Continue to monitor. DIC work-up (+) in addition to AST and LD elevation. Question hypoperfusion and continue to monitor.\nSOC:Family staying for most of night, two supportive daughters. , youngest daughter is ICU RN at Medical Center in NH. is HCP. is eldest daughter and staying overnight. In all three children. is primary contact. In addition husband in and visiting, slavic speaking only as well, very distraut over wife illness and weeping at bedside. Updated by RN and MDs. Very supportive and kind family.\nA/P: 80 yo female who present to with septic shock with possible sources of sputum, PPM, blood, or urine.\nPlan for possible swan\nAnticipate starting of TFs\nWean pressors as tolerated\nUnlikely to go to cath lab but anticipate\n"},{"category":"Nursing/other","chartdate":"2152-08-24 00:00:00.000","description":"Report","row_id":1430762,"text":"Respiratory Care:\nPt. with marginal oxygenation, requiring increased peep and FIO2>>no RSBI done. ABG's currently showing adequate oxygeantion and a partially compensate metabolic acidosis, with a HCO3 given>>overcompensating for the acidosis, causing a slight alkalosis. ? travel to CT for look at her belly, postponed for now, due to lactate level decreased. OET pulled back at start of shift, with report of repeat CXR with OET in adequate position. Will follow.\n"},{"category":"Nursing/other","chartdate":"2152-08-24 00:00:00.000","description":"Report","row_id":1430763,"text":"RESPIRATORY CARE\nPT REMAINS VENTILATED WITH CORRESPONDING VENT CHANGES TO ABG RESULTS. BREATH SOUNDS DIMINISHED THROUGHOUT. RRT\n"},{"category":"Nursing/other","chartdate":"2152-08-24 00:00:00.000","description":"Report","row_id":1430764,"text":"CCU progress note 7a-7p\nEvents: weaned off Levo, fluid boluses of 2L. Heparin d/c'd. renal dose dopa this afternoon for maps 55 + decreased u/o. New TLC placed in RIJ and L fem TLC to be d/c'd.\n\nNEURO: lightly sedated on boluses of fentanyl and versed. pt opens eyes to stimuli, nodding head appropriately to family - nodded head to \"okay?\". speaks hungarian only - daughters translate if necessary. moves arms when suctioned - soft wrist restraints.\n\nID: Tmax 101 early this morning - tylenol given @ 7am. Temp ranging from 99.6 to 98 this evening. Increased doses of IMIPENUM, FLAGYL + VANCO. Cultures still pnd. WBC 13.5 this afternoon (am 19.6). Culture tip of femoral TLC. nystatin to groins, under breasts and axilla - angry red candidal infection (groins excoriated purple/red).\n\nRESP: LS coarse, sx'd thin tan secretions. multiple vent changes today - current settings: AC 450x12 peep 8 40% ABG: 7.43/36/80/25/0 sats 94-97%. CXR showing improved failure. sputum Cx: gram neg rods.\n\nCARDIAC: AFIB 60s-130s - freq pauses causing paced beats from VVI pacer rate set at 60. short spurts of rapid ventricular response to 100-130s then back to 60-80s. MAPS 50-70s. Dopa initally turned off at 8am. Weaned off LEVO by 1430hrs - total of 2L NS boluses today - on NS @ 100cc/hr. renal dose Dopa restarted @ 3mcg/k/min for low u/o and low maps ~55. Heparin d/c'd. +DIC. INR this afternoon 1.7 (am 2.2). lactic acid 1.9 this afternoon. K + Mg repleated this evening. pm HCT 26.1 (am 31.4) ?dilutional? HO aware. L fem TLC intact, but site comprimised by candidal infection of groins. New site obtained RIJ this evening - CXR pnd.\n\nGI/GU: foley patent, decreased u/o - given fluid boluses earlier now on renal dose dopa. BUN 25 CR 1.1 (am 1.3) abd soft +BS. small amt golden loose stool +flatus. very small trace OB in stool - pt's bottom excoriated + has some hemhrroids bleeding. NGT to be advanced and checked in next CXR this evening post TLC insertion. TF started this afternoon - promote w/ fibre @ 15cc/hr GR 45cc/hr.\n\nENDO: FS QID, started on SSRI.\n\n\nPLAN: titrate pressors to off as tolerated. monitor u/o. con't IVF. con't TF. monitor residuals. FS QID. remove femoral TLC and send tip for culture. save 1 port on TLC for possible TPN. obtain stool cultures if pt stools.\n"},{"category":"Nursing/other","chartdate":"2152-09-08 00:00:00.000","description":"Report","row_id":1430821,"text":"CCU NPN 1900-0700\nO: afeb. HR 70-80's afib with V paced beats. BP stable 120-130's/50's. tolerating 75 captopril in eve. u/o 50-100cc/hr. (-) 1L for and (+) 2L LOS.\n\nLS diminished bases. 2lNC sats 97%. RR 20-30\ntaking meds well with pudding or jello either crushed or whole. appears to be swallowing well with no signs of coughing, difficulty.\n\npt. appearing anxious in eve, moving all around bed, moving legs up in air and wanting to get OOB. given .25 po ativan with very good effect. pt. slept well and is alert this morning, responding to simple commands. unable to determine orientation d/t language barrier.\n\nno stool.\n\nheparin 750u/hr. IVF at 75cc/hr while pt. not taking enough po's.\n\nA: stable night.\nP: contin. with PT/OT> rehab screening. needs additional swallow study with flouro/video ? today.\n\n"},{"category":"Nursing/other","chartdate":"2152-09-08 00:00:00.000","description":"Report","row_id":1430822,"text":"ccu npn\no- afebrile po.\ncv- hr climbing 7:30am and re'd ativan .25mg po for anxiety. however, hr cont to rise to 150-160, bp up to 160/ and became acutely sob/diaphoretic, c/o epigastric pain. re'd total lasix 40mg, lopressor 15mg, iv ntg on to 4.3mic/kg/min and 2mg mso4. ivf d/c'd. 02 increased to 6l n/c plus 100%neb with sats up, but still with high rr and labored breathing. on bipap. hr grad down to 80-100s and bp grad. down. unable to obtain ekg d/t very diaphoretic. cxr done showed increased chf, etc. re'd additional lopressor 5mg iv and then usual po dose. hr high 50s-70s af with occ pacing. bp down to 85-90s and iv ntg grad. weaned off. bp up to 100-120s this pm. cont. on heparin, increased to 800units/hr for ptt 60.4, inr 1.5. check pt/ptt in am. k- 4.0. hct 32.\nresp- as above, on bipap until 11am and back to 6l with sats 94-98, rr down and sob improved. diuresed about 500cc, goal is i+o even today. is neg about 100cc currently. l/s dim, clear upper, cxs on left lower, right lower coarse.\ngi- on thickened liquids/pureed food and tol well. taking meds with thickened water or applesauce (whole), no coughing. down for swallowing study this pm and verbal result per s+s, ?slight aspiration. vomited lge white at end of study while upright. recommended meds with pureed food only. no liquids. reassess monday.\nabd soft with b. sounds. epigastric pain gone after am. no bm.\nms- speaking hungarian, does interact appropriaely nonverbally. ?confused. cooperative.\nskin- intact, nystatin powder to groins, axilla which are pink. repos side to side with skin care q2-3hrs as tolerated. on back, uppright with sob. has 1st step mattress, pneumoboots.\nsocial- fx called, no visitors yet today. dtr updated on am event and pt status.\na- pul edema in am\np- cont. to monitor for high hr, sob. increase lopressor dose this eve. cont. heparin/coumadin. check k if diuresed again this eve. goal i+o even. hold meals and give pureed food with meds only until further notice. ?ngt. ?repeat swallowing study monday. asp. precautions.\n"},{"category":"Nursing/other","chartdate":"2152-09-01 00:00:00.000","description":"Report","row_id":1430794,"text":"CCU NSG PROGRESS NOTE 7P-7A/ S/P PULM EDEMA; MR\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nCV- HR- 68-81 AFIB/ NO VEA. K- 3.8- 40 KCL.\nBP- 108/43-125/53. REMAINS ON CAPTOPRIL 75 TID AND LOPRESSOR 37.5 TID AS WELL AS DIGOXIN 0.125.\nCO/CI/SVR- 3.6/2.24/1444. HEPARIN AT 800U- AM LYTES/CBC/COAG PENDING.\n\n PT REMAINS 50% PS- 15; TV- 420-450 WITH RESP RATE- MID 20'S. PH 7.55- 7.48. OFF LASIX CURRENTLY.\nPO2- 77-88. SX Q 3 HOUR FOR WHITISH THIN SPUTUM.\nCOARSE BREATH SOUNDS BILATERAL.\nPAD- 22-24, CVP- , PCW- 22.\n\nID- AFEBRILE.\n\nGI- TUBE FEEDS 45CC/HOUR- STOOL SOFT FORMED G (-).\n(+) BOWEL SOUNDS. SS/NPH INSULIN COVERAGE\n\nGU- GOOD UO- 40-60CC/HOUR. HELD PM LASIX D/T ALKALOSIS.\nI/O (-) 1 LITER .\n\nMS- VERSED GTT 1 MG.\nSOME BOLUSES WITH AGITATION.\nFAMILY IN TO VISIT.\nDAUGHTER X 2 CALLED, SPOKE AT LENGTH ABOUT PLAN OF CARE\nCURRENT PROGRESS.\n\n\nA/ PT WITH LONG HOSPITAL COURSE WITH MR/LOW EF/PULM EDEMA- CURRENTLY WITH GOOD DIURESIS C/B PERSISTENT ALKALOSIS.\n\nCONTINUE PULM TOILET/WATCH I/O AND PA # AS WELL AS HEMODYNAMICS/CO.\nMAX RPP/CV MEDS.\n?DIAMOX IF PERSISTS WITH ALKALOSIS.\nSEDATION/COMFORT WHILE INVASIVE LINED AND ETT.\nKEEP FAMILY AND PT AWARE OF PLAN OF CARE.\nCONTINUE TO WATCH FOR TEMP/FEVER OFF ANTIBX X 3.\nCULTURE AS NEEDED.\n\n"},{"category":"Nursing/other","chartdate":"2152-09-01 00:00:00.000","description":"Report","row_id":1430795,"text":"Respiratory Care:\n\nPatient remains intubated on Psv. Current settings Psv 15, Cpap 5, Fio2 50%. Spont vols 400's with RR mid teens. Sx'd for moderate amounts of thick white sputum. Bs clear bilaterally. RSBI results 200. PaO2 improving. No further changes made. Continue with Psv as tolerated.\n"},{"category":"Nursing/other","chartdate":"2152-09-01 00:00:00.000","description":"Report","row_id":1430796,"text":"CCU NURSING NOTE 7A-3P\nS. INTUBATED\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nID: TMAX 99.7 CORE, NO ANTIBX, UA/C+S SENT, WBC 11 FROM 9\n\nCV: HR 60-80'S AFIB, DIG GIVEN, LOPRESSOR REMAINS AT 37.5MG\nBP 117-141/50-60'S, CAPTOPRIL AT 75MG TID, PAP'S 36-43/17-22, CVP 10-13, LASIX 20MG IV AT 1030 W/ > 1 LITER DIURESIS, SATS 98/66 W/CO/CI AT 1200 - 4.4/2.73 SVR 1036; HEPARIN DECREASED TO 700U/HR FOR PTT 96\n\nRESP: REMAINS INTUBATED AT 50% 15 PS/5 PEEP - SATS 98-10%, TV 350-550 W/CHEYNES- PATTERN AND FREQUENT PERIODS OF APNEA, LUNGS REMAIN COARSE THROUGHOUT, SUX FOR SM THIN WHITISH SPUTUM Q 2-3HR; LAST ABG 7.45/47/110/34/7\n\nMENTAL STATUS: EASILY ARROUSABLE TO VOICE, DIFFICULT TO ASSESS ORIENTATION SECONDARY TO INTUBATED AND LANGUAGE BARRIER, SLEEPING ON/OFF THROUGHOUT DAY ON VERSED 1MG IV GTT, ATIVAN PO TID CONTINUES FOR PERIODS OF ANXIETY\n\nGI: TOLERATING PROMOTE W/FIBER AT GOAL 45CC/HR, MINIMAL RESIDUALS, ABDOMEN SOFT, DISTENDED, MOD GOLDEN SOFT STOOL X1- LG AMT.\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE W/SEDIMENT NOTED - UA/C+S SENT.600 CC NEGATIVE THUS FAR TODAY\n\nSOCIAL: FAMILY CALLED X2 - WILL BE IN LATER TODAY\n\nSKIN: INTACT EXCEPT FOR RED RASH BILAT AXILLA/UNDER BREASTS/GROIN AREA - CLEANSED THIS AM W/SOAP/H20, MICONAZOLE POWDER APPLIED\n\nA: IMPROVED CARDIAC OUTPUT/INDEX, ABG BETTER W/ONLY MARGINAL ALKALOSIS, TOLERATING CAPTOPRIL/LOPRESSOR W/GOOD BP AND SLOWER HR\nCHEYNES- BREATHING CONTINUES\n\nP: MONITOR HEMODYNAMICS, INCREASE CAPTOPRIL/LOPRESSOR PER TEAM AS TOLERATED; CONTINUE GENTLE DIURESIS AS TOLERATED, DECREASE PRESSURE SUPPORT TO 12 PER TEAM - FOLLOW ABG'S/I+, RECHECK PTT AT 1630,\nEMOTIONAL SUPPORT FOR PT/FAMILY, CONTINUE SUPPORTIVE CARE.\n\n\n"},{"category":"Nursing/other","chartdate":"2152-09-08 00:00:00.000","description":"Report","row_id":1430823,"text":"77 years old female admitted with S.O.B. Patient has PMHX:CAD,multiple cva's,carotid stenosis,anxiety,depressionand insomnia. Went in acute resp distress this am associated with desaturation. Patient placed on non-invasive ventilation for a while now on 5 liter N/C. vent still in room on stand-by.\n"},{"category":"Nursing/other","chartdate":"2152-09-09 00:00:00.000","description":"Report","row_id":1430824,"text":"NSG NOTE\n\nCV: REMAINS IN A-FIB WITH HR 64-74. CON'T ON METROPOLOL XL 100MG/25MG @HS. ALSO ON DIGOXIN. SBP 118-140/38-69 CON'T ON HEPARIN @ 800U/HR AND GETTING COUMADIN 5MG QD.\n\nRESP; O2 SATS ACCEPTABLE 97-99%. HAS RALES 1/2 UP BILAT,BUT APPEARS COMFORTABLE AND RR-20'S. M.D. INTO ASSESS BS IN LIGHT OF RECENT EPISODES OF CHF. NO FURTHER ORDERS GIVEN FOR LASIX.\n\nGI: TOL CUSTARD AND THICK FOODS WITH MEDS ONLY. REMAINS NPO FOR REPEAT SWALLOW STUDY ON MONDAY. ABD SOFT. +BS NONTENDER ABD. NO STOOL THIS SHIFT. M.D. ATTEMPTED NGT PLACMENT,UNSUCCESSFUL.\n\nGU: U/O DOWN TO 10CC-26CC/HR M.D. NOTIFIED. I/O NEG BY 160CC. M.D. WANTS I/O EVEN.\n\nSKIN: PACER SITE UNCHG. BUTTOCKS SL REDDENED BUT INTACT.\n\nNEURO: WILL SMILE ON OCCASSION. FOLLOWS COMMANDS DESPITE LANGUAGE BARRIER. MAE. RESPONDING WELL TOWARDS FAMILY AND INTERACTING WITH THEM.\n\nID: TEMP MAX 96.9\n\nLABS: BS 129 NO SSI REQUIERED.\n\nSOCIAL: FAMILY IN ON EVES.\n\nA: STABLE/DISCHG PLANS IN PROGRESS\n\nP; REPEAT SWALLOW STUDY MONDAY\n ASPIRATION PRECAUTIONS\n PREPARING FOR D/C TO REHAB ONCE SWALLW ISSUES RESOLVED\n\nA: STABLE\n"},{"category":"Nursing/other","chartdate":"2152-08-30 00:00:00.000","description":"Report","row_id":1430788,"text":"CCU progress note 7a-7p\naddendum:\n\nLasix given at 530pm w/ 400cc out in 30min. To be given evening dose of captopril. Cardiac Calcs pending.\n\nBlood Cultures to be drawn later tonite per HO - watching for temp spike - last temp 100.2.\n\nFamily in to visit @ 6pm.\n"},{"category":"Nursing/other","chartdate":"2152-08-29 00:00:00.000","description":"Report","row_id":1430783,"text":"CCU progress note 7a-7p\nNEURO: started on versed gtt for anxiety/sedation - still remains lightly sedated on 2mg/hr - nodding head to questions posed by family - Hungarian speaking only. opens eyes spontaneously, moves arms and legs. to start ativan TID po.\n\nID: tmax 99.5 core. remains on flagyl, vanco, imipenem.\n\nCARDIAC: AFIB 80-140s - VVI pacer set 60 - SBP 120s. PA line RIJ patent. PA 43/26 CVP 16 CO 3.6 CI 2.24 SVR 1222. L radial aline patent. Heparin @ 800u/hr. Natrecor increased to 0.025mcg/k/min. Captopril 37.5mg TID tolerating well ?increase next dose to 50mg. Lopressor 37.5mg tolerating well.\n\nRESP: AC 400x10/50%/5peep - PS wean this evening - alkalotic 7.55ph RR stoking 28-33 to apneic periods <15sec. sats >95%. Sx frothy white this morning, to thick white this afternoon. Diuresed x 2 today. LS coarse, occ exp wheezes. MDI per RT.\n\nGI/GU: foley patent. lasix started 20mg IV BID. good diuresis. goal -1L/24hrs. abd soft +BS. + flatus. stooling small amts loose/soft golden stool. guiac neg. TF goal via OGT - promote w/ fibre @ 45cc/hr. FS QID w/ RISS.\n\nPLAN: cont' to try to adequately relieve pt's anxiety w/ anxiolytics, increase next dose captopril. monitor u/o for goal -1L for today. con't vent wean as tolerated. Cardiac calcs q4h.\n"},{"category":"Nursing/other","chartdate":"2152-08-29 00:00:00.000","description":"Report","row_id":1430784,"text":"addendum\nchanged back to AC - poor cardiac calcs at 6pm. given additional dose of captopril 25mg po at 7pm. Recheck calcs at 8pm.\nAtivan 1mg po given at 6pm - versed gtt off at 7pm until pt is more anxious (maps 58-60).\n"},{"category":"Nursing/other","chartdate":"2152-08-30 00:00:00.000","description":"Report","row_id":1430785,"text":"Respiratory Care\nVent settings unchanged this shift. Attempted RSBI @ 4:30am, no effective spontaneous respiratory efforts noted over 60 second period. Suction several times for small amounts of pale white secreations. RRT\n"},{"category":"Nursing/other","chartdate":"2152-08-30 00:00:00.000","description":"Report","row_id":1430786,"text":"CCU NSG PROGRESS NOTE 7P-7A/ RESP FX; MR\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT OFF PRESSORS BUT WITH MARGINAL BP ONCE SEDATED/ BACK ON A/C MODE VENTILATION. INITIALLY- BP- 130-170/ WITH AGITATION AND SEDATED WITH VERSED 2 MG BOLUSES- RESTARTED GTT 2MG-1.5 MG. BP THROUGHOUT SHIFT RANGED FROM 88/47-114/60 WITH MAPS 55-62. HR 100-110'S AFIB WITH BURSTS UP TO 130'S WITH AGITATION AS WELL. HEPARIN GTT FOR AFIB REMAINS AT 800U/HOUR. CO/CI/SVR THIS SHIFT- 2.9-3/1.8-1.86/1000. NO SIGNIFICANT CHANGES WITH LOWER MAPS ON SEDATION.\nRECEIVED INCREASE CAPTOPRIL DOSE ONCE BP>90/ AND REMAINS ON LOPRESSOR 25 . NO OTHER CHANGE TO MED REGIMEN THIS SHIFT BESIDES INCREASE IN CAPTOPRIL.\n\n PT BACK ON A/C- 50/600/10 - BREATHING OVER VENT RATE- 16-20- SUCTIONED FOR THICK WHITISH SPUTUM Q 2-3 HOURS. COARSE SOUNDS BILATERALLY- PAD- 22-28, CVP 14-17, PCW- 22. GIVEN LASIX LATE AFTERNOON- NO MORE THIS SHIFT= STOPPED NATRECOR D/T MARGINAL BP AT 12 AM. HOLDING FURTHER PUSH FOR DIURETICS D/T RESP ALK AND LOW NORMAL CI WITH DIURESIS 7/29 PER TEAM PLAN.\n\nID- CORE TEMP MAX- 100 REMAINS ON TRIPLE ANTIBX. NO TEMP /FEVER SPIKE THIS SHIFT.\n\nGI- TUBE FEEDS- 45/HOUR PROMOTE WITH FIBER.\n(+) BOWEL SOUNDS. NO STOOL THIS SHIFT.\nSS REG INSULIN- HOLDING D/T BLOOD SUGAR < 160.\n\nGU- FAIR UO WITH MAPS 55-62= MAINTAINING UO 20-50/HOUR VIA FOLEY CATH.\nNO DIURESIS THIS SHIFT- SEE ABOVE.\n\nMS- HUGE AMOUNTS AGITATION/ BRONCHOSPASTIC, COUGHING AND TONGUING ETT WITH ANY SLIGHT STIMULATION; TACHYPNIC, HTN, TACHYCARDIA WITH AGITATION NECESSITATING SEDATION. GIVEN VERSED 2 MG BOLUSES AND RESUMED GTT AT 2 MG, NOW 1.5 MG WITH SLIGHT IMPROVEMENT IN BP/MAP.\nDAUGHTER CALLED 11P TO CHECK ON PROGRESS.\n\n\nA/ PT WITH LONG HOSPITALIZATION /RESP FX REMAINS WITH DIFFICULT TO CONTROL RATE/PRESSURE/PRODUCT- LABILE HEMODYNAMICS/\n\n-CONTINUE TO ATTEMPT TO DECREASE AFTERLOAD WHILE MAINTAINING MAP>60 WITH CURRENT MED REGIMEN.\n-CONSIDER RESTARTING PRESSORS IF UO DROPS OR CREAT THIS AM RISES.\n-CONTINUE TO DISCUSS ? AGGRESSIVE DIURESIS/NOT FOR ELEVATED FILLING PRESSURES/CHF/FX TO WEAN. APPROACH FAMILY WITH CONCEPT OF TRACH IF CONTINUES TO NOT SIGNIFICANTLY IMPROVE FROM RESP STATUS.\n-SEDATION AND COMFORT TO INSURE PT COMFORT/SAFETY AND VENTILATION,\n-ATTEMPT TO WEAN TO MINIMAL AMOUNT NEEDED AS WILL DIRECTLY HELP IMPROVED MAP/BP.\n- KEEP PT AND FAMILY AWARE OF PLAN OF CARE\n-RATE CONTROL WITH LOPRESSOR, AS BP ALLOWS.\n- NUTRITION/BOWEL MEDS/SKIN CARE/ SS REG INSULIN PER PROTOCOL\n- KEEP HEPARIN AT THERAPEUTIC DOSE.\n"},{"category":"Nursing/other","chartdate":"2152-08-30 00:00:00.000","description":"Report","row_id":1430787,"text":"CCU progress note 7a-7p\nNEURO: lightly sedated on versed gtt @ 1mg/hr and ativan 1mg po TID. opens eyes, nods head. hungarian speaking only. family communicates with pt. purposful movements.\n\nID: abx D/C'd. Tmax 99.6. con't to monitor for spike in temp. surveylance blood cultures need to be obtained.\n\nRESP: LS coarse. frothy secretions this morning pre lasix 20mg ivp - then had clear thick secretions during the day. this afternoon ~4pm having white frothy secretions again. pm dose of lasix held per HO. AC most of day, switched to PS 15/5 50% @ 4pm. pm ABG pnd. sats >97%. RR 11-38 - stoking.\n\nCARDIAC: AFIB 90-140s during the day - digoxin load started and now rate AFIB 60-80s this evening. 2nd + 3rd doses of dig IV to be given this evening/nite. PA line RIJ patent. PADs 26-30 CVP 16 PA sats ~ 60% last CO 3.8 CI 2.36 SVR 1200. L radial aline patent. 3+ generalize pitting edema. Remains on Heparin @ 800u/hr. Natrecor remains off. Am captopril dose held. Lopressor 37.5mg . new PIV placed in R hand.\n\nGI/GU: foley patent. fair urine output. lasix 20mg ivp given this morning, pm dose held per HO this evening. u/o >30cc/hr. abd soft, +BS. +BS. +flatus. guiac neg. stooling mod amts loose golden stool.\nENDO: FS QID w/ SSRI and standing dose NPH am/pm.\nNUTRITION: TF promote w/ fibre @ 45cc/hr. minimal residuals. OGT patent.\n\nPLAN: con't to monitor Cardiac Calcs, VS, UO-- complete DIG load. monitor resp status on PS. keep pt comfortable. keep family informed.\n"},{"category":"Nursing/other","chartdate":"2152-08-30 00:00:00.000","description":"Report","row_id":1430789,"text":"Resp. Care Note:\nPt remains intubated and ventilated. Bs coarse throughout. Sx for moderate amounts of white to clear frothy secretions. Pt placed on PSV, tolerating well. ABG within normal limits. Pt has cheynes breathing pattern, Dr . CXR from yesterday showed bilat pleural effusions R>L. Continue on PSV as tolerated, monitor resp. status and vitals.\n"},{"category":"Nursing/other","chartdate":"2152-08-31 00:00:00.000","description":"Report","row_id":1430790,"text":"RESP CARE NOTE\nPT REMAINS INTUBATED, VENTILATION SUPPORTED VIA PB7200 VENT IN CPAP/PS MODE. CHEYNNE- BREATHING PATTERN NOTED W/ SEC APNEIC PERIODS, VT 350-400CC. BS OCCAS SL COARSE, SXN FOR SM-MOD AMTS WHITE FROTHY SEC. AM ABG REFLECTS UNCOMPENSATED METABOLIC ALKALOSIS W/NORMOXIA. RSBI THIS AM 125. SBT NOT INDICATED. PLAN TO CONTINUE CURRENT SUPPORT, WEAN PER TEAM.\n"},{"category":"Nursing/other","chartdate":"2152-08-31 00:00:00.000","description":"Report","row_id":1430791,"text":"CCU NSG PROGRESS NOTE 7P-7A/ RESP FX; MR\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n\n PT REMAINS WITH STABLE HEMODYNAMICS AND BETTER RATE/PRESSURE PRODUCT AS WELL AS CO/CI/SVR ON DIGOXIN/CAPTOPRIL/LOPRESSOR. HR- 60'S AFIB . BP= 130/50- 100/50. RECEIVED LAST OF DIG LOAD AND TO START PO DOSE. REMAINS ON CAPTOPRIL 50, LOPRESSOR 37.5- SEE FLOW FOR CO/CI/SVR VALUES ON CURRENT MED REGIMEN.\nRECEIVED MG 2 AMPS FOR MG- 1.8.\nAM LAB PENDING.\n\n PT DOING WELL ON PRESSURE SUPPORT 15CM/50%. TIDAL VOLUMES 375-450CC WITH RESP RATE LOW TO MID 20'S CHEYNNE STOKE PATTERN\nREMAINS WITH COARSE BREATH SOUNDS, DIM AT BASE WITH SUCTIONING Q 1-3 HOURS THICK WHITISH SPUTUM- LESS THICK THIS AM. MUCH ORAL SECRETIONS.\nROTATED TUBE AND RETAPED.\nPA- 40/22-50/26. CVP- 14-16. PCW- 22.\nNO SIGNIFICANT INCREASE OR DECREASE THIS SHIFT.\n\nID- AFEBRILE- REMAINS OFF ANTIBX THIS SHIFT.\nNO TEMP SPIKE, NO CULTURES OBTAINED.\nWC- 12\n\nGI- TUBE FEEDS 45/HOUR, MINIMAL RESID- SMALL AMOUNTS LIX STOOL- BROWN, G (-).\n\nGU- FAIR TO GOOD UO- DROPPING OFF LATE EVE- REPEAT 20 LASIX WITH GOOD UO- 800CC DIURESIS.\nWITH D/C 1000CC ANTIBX- ABLE TO MAKE I/O (-) FOR 1ST TIME- CURRENTLY (-) 500CC.\nTO REASSESS ? MORE DIURESIS THIS AM.\nDUE FOR DOSE THIS AM\n\n PT AWAKE, FAMILY ALL PRESENT- SPOKE AT LENGTH TO DAUGHTER RE: PLAN OF CARE/NEED FOR DIURESIS PRE-WEANING- LENGTH OF TIME TO TAKE PLACE OVER SEVERAL DAYS, GRADUAL DIURESIS, AND WEAN, ETC.\nAPPEARS TO UNDERSTAND AND TO RELAY PLAN TO NURSE-DAUGHTER .\nCALLED X 1 OVERNITE.\n\nA/ PT WITH EXTENSIVE HOSPITAL COURSE CURRENTLY TOLERATING GRADUAL DIURESIS/PRESSURE SUPPORT WEAN.\nREMAINS IN NEED OF GOOD RPP CONTROL AND VENT SUPPORT AS WELL AS SEDATION FOR VENTILATION.\n\nCONTINUE CV MEDS FOR GOOD DIASTOLIC FILL/RPP.\nCHECK AM LABS- REPLETE AS NEEDED.\nCONTINUE GRADUAL YET AGGRESSIVE AND CONSISTENT DIURESIS -\nPULM TOILET/SEDATION WHILE INTUBATED\nNUTRITION/BS COVERAGE.\nKEEP FAMILY AWARE OF PLAN OF CARE AS WELL AS PT.\n\n"},{"category":"Nursing/other","chartdate":"2152-08-31 00:00:00.000","description":"Report","row_id":1430792,"text":"CCU progress note 7a-7p\nNEURO: sedated on ATIVAN 1mg PO TID + VERSED 1mg/hr gtt. opens eyes spontaneously, doesn't nod head to questions today. family called on phone, husband visiting this evening.\n\nID: Tmax 100 core temp. Surveylance BC x 2 sent. off all ABX. WBC 9\n\nRESP: LS coarse. large amts clear to white sputum. remains on PS - attempted to go to PS 10/5 but PO2 down to 69 w/ decreased TVs sats 89% - increased PS to w/ good TV 300-350s sats 97%. abg 7.48/37/88. This evening pt more tachynpnic w/ TV 250-300 RR 37-44 sats 94%, lg amts clear secretions. abg 7.47/41/69! Increased PS to 15/5. RR decreased to 20-30s - TV increased to >350s. sats ^97%.\n\nCARDIAC: AFIB 60-70s occ paced beats. PAD 21 in am ->25 this evening. last CO 4.1 CI 2.55 SVR 1015 CVP 10->15. HEPARIN @ 800u/hr. Digoxin 0.125mg qd, lopressor 37.5mg + captopril increased to 75mg TID - tolerating well. Aline intact. 3+ pitting edema.\n\nGI/GU: foley patent. diuresed x 1 today Lasix 20mg. abd soft +BS. + flatus. no stool today. TF Promote w/ fibre @ 45cc/hr via OGT. nutrition on consult.\n\n\nPLAN: con't to monitor resp- adjust PS as necessary per ABGs. con't digoxin for rate control. tolerating increased dose of captopril. con't to monitor Cardiac Calcs q4h. keep pt comfortable. keep family notified of pt condition.\n"},{"category":"Nursing/other","chartdate":"2152-08-31 00:00:00.000","description":"Report","row_id":1430793,"text":"Resp. Care Note:\nPt remains intubated and ventilated. Bs coarse throughout. Sx for large amounts of thick clear to white secretions. Attempted to wean PSV throughout day, pt tolerated for short time. Returned to PSV 15/5. Pt continues to have - breathing pattern. Continue to wean as tolerated. See carevue for details.\n"},{"category":"Nursing/other","chartdate":"2152-08-29 00:00:00.000","description":"Report","row_id":1430780,"text":"CCU Nursing Progress Note 1900-0700:\nS-Intubated and sedated\n\nSEE CAREVUE FOR OBJECTIVE DATA AND TRENDS IN VS\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\n\nO-MS:Alert and opening eyes to name. Slavic speaking only. Family at bedside and emotionally supporting and interacting with pt during evening. Appearing comfortable on Versed and Fentanyl push boluses.\nMAEs on bed and making purposeful movements.\nCV: HR 70s to 110s. Afib with rare PVCs. K rechecked and 4.1 on eves. Continues to tolerate Lopressor dose, could withstand increases. ABPs 70s to 120s. VSs hypodynamic with sedation on board and hyperdynamic with suctioning or nursing intervention. PAD 21-27, PCWP 24-27, occasionally unable to wedge swan, CIs > 2.0. Captopril increased in attempt to increased COs. increased and CO/CIs improving slightly. Team wanting to increase but BPs currently unable to withstand. Heparin continues at 800u/hr with AM PTT pending and Natrecor at 0.020mcg/kg/min.\nRESP: AC/400/10/.50/5 PEEP. LS course, occasionally clear in upper fields post suctioning. Suctioning for white thick secretions in small to moderate amounts. Extremely strong gag with suctioning. Tachypenic post with RR mid to high 20s but settling out thereafter.\nGU/GI: Foley draining golden colored urine. HUO 30-70cc/hr. No further diuresis given overnight. At MN (-) 870cc and (+) 9L for LOS. Plan to futher diurese this AM. Abd soft with (+) BSs. Passing golden-brown stool. Loose in appearance. G(-). TF continue at GR, 45cc/hr.\nID: Low grade temps. Continue on ABx.\nENDO: FS at HS 133 and given standing NPH dose. AM FS pending.\nSOC: Family updated by RN and visiting on evenings. Later going home and later updated by RN over phone.\nA/P: CHF and PNA c/b septic and cardiogenic shock\n"},{"category":"Nursing/other","chartdate":"2152-08-29 00:00:00.000","description":"Report","row_id":1430781,"text":"Respiratory Care\nPt remains ventilated with no changes noted. RSBI checked, 125 with irregular spontaneous respiratory pattern. RRT\n"},{"category":"Nursing/other","chartdate":"2152-08-29 00:00:00.000","description":"Report","row_id":1430782,"text":"Resp Care: Pt remains intubated via #7.5 ETT secured 21cm at lip. BS bilat E wheezes w/ rhonchi. Sx'd for mod amt white thick sputum. Pip/Plat 24/21. No vent changes made this shift. Please see carevue for further vent inqueries.\n"},{"category":"Nursing/other","chartdate":"2152-09-07 00:00:00.000","description":"Report","row_id":1430817,"text":"CCU NPN 1900-0700\nO: afeb. HR 70-80's afib. no vEA. occas. Vpaced beats. BP 135-160/40-60. u/o 50cc/hr. IVF D/C'd. (+) 3.3L LOS.\n\nheparin 750u/hr.\n\nTF increased to 20cc/hr. hands restrained. however pt. self d/c'd NGT ~ 0330. not replaced per HO. pt. able to take meds crushed.\n\npt. awake and alert. appearing to doze occas.\ndaughter called during night and stated that pt. was intermittantly confused yesterday req. freq. orientation. unable to determine d/t language barrier but pt. appears to understand simple commands in english.\n\nLS course upper, diminished lower. sats 96-99% on 2-4L NC. RR 20-30. CPT x2. stimulates strong cough, non productive.\n\nmoving all extrem. full lift back to bed in eve.\nTLC Right IJ. foley.\nno stool.\n\nA: pt. pulling out NGT despite hands restrained\nP: swallow study planned for today. OOB. contin. CPT q4-6hours. crush meds.\n"},{"category":"Nursing/other","chartdate":"2152-09-07 00:00:00.000","description":"Report","row_id":1430818,"text":"addendum\npt. becoming more anxious, restless ~ 0600, reaching for siderails and motioning to get out of bed. speaking in hungarian. HR up to 90's - 110 AF. BP stable. HO aware. given .5mg po ativan and lopressor XL early crushed. sats 95-96% on 4lnc.\n"},{"category":"Nursing/other","chartdate":"2152-09-07 00:00:00.000","description":"Report","row_id":1430819,"text":"CCU progress note 7a-7p\nNEURO: sedated this morning from 0.5mg ativan - no further episodes of agitation. MAE. PT/OT on consult. oob to chair - used walker w/ assist of 2 - gen weakness, but did take a few steps. used interpreter for PT excercises and for speech + swallow eval this afternoon. Hungarian speaking - does understand and speak broken english.\n\nID: afebrile. no abx\n\nRESP: LS coarse, occ congested nonproductive cough. O2 2L w/ sats 93-96%. sl SOB on exertion. CPT w/ turns.\n\nCARDIAC: AFIB 120s this morning - now PACED/AFIB 60s-80s. SBP 120s. tolerating captopril 75mg tid. RIJ TLC patent. unable to obtain peripheral access today. HO aware. no aline. veinodynes on.\n\nGI/GU: foley patent, sl mucous noted in urine. good u/o. IVF .45NS 100cc/hr while not taking po well. speech and swallow wants video swallow study tomorrow - but pt may take pureed soft diet as tolerated, aspiration precautions. dentures too loose to wear ?denture paste? no BM today. +BS.\n\nSKIN: groins slightly reddened, nystatin pwd to groins and under breasts and axilla. no further breakdown on buttocks. barrier cream. on 1st step air mattress. OOB to chair.\n\nPLAN: monitor VS -HR/BP. monitor u/o. pulm toliet. emotional support. video swallowing study in am.\n"},{"category":"Nursing/other","chartdate":"2152-09-07 00:00:00.000","description":"Report","row_id":1430820,"text":"addendum:\n\nLasix 20mg IVP given this evening. monitor u/o.\nstarted on coumadin this evening also.\nOnly took a few mouthfuls of pudding this evening - then stated \"enough\".\nHusband and grandson visiting.\nAssisted back to bed by OT w/ walker with assist of 2. Did not weight bear well this time or pivot well.\n"},{"category":"Nursing/other","chartdate":"2152-08-28 00:00:00.000","description":"Report","row_id":1430776,"text":"NSG NOTE\n\nCV: REMAINS IN A-FIB. BETTER RATE CONTROL WITH LOPRESSOR INCREASE TO 25MG . CON'T TO HAVE OCCASSIONAL PVC'S K+ RELATED ,RESOLVING WITH REPLACEMENT KCL. CON'T ON NATRECOR 0.02MCG/KG AND HEPARIN 800U/HR. MAP'S REMAIN > 60. HR 80-102. BECOMES MORE TACHY WITH WAKEFUL PERIODS. CO/CI ON CAPTOPRIL 6.25MG: 3.3/2.05 SVR 1479. THIS AM RECEIVED CAPTOPRIL 12.5MG HEMODYNAMICS CO/CI 3.6/2.24 SVR 1244. NO SIGN CHG IN BP. PT WOULD BENEFIT FROM INCREASE IN LOPRESSOR DOSE AS WELL. PAD 24-29,CVP 16-14,WEDGE 26-23.\n\nGU: RECEIVED LASIX 20MG @ AND AGAIN @ 0330. AGGRESSIVE DIURESIS NOTED. @ MN PT WAS NEG BY 1200CC,HOWEVER OVERALL LOS CON'T TO BE POSITIVE.\n\nRESP: INITIALLY ON CPAP+PS 16 PEEP5. MORE ALKALOTIC ON PS. PT RESTING ON AC OVERNOC. CURRENT SETTINGS AC 50%,VT 400,R-10,PEEP 5. AM ABG'S 7.46,40,81,4,29,97%. PLEASE SEE FLOW SHEET FOR ABG'S AND VENT CHG. SUCTIONED FOR THICK WHITE SECRETIONS. BS CL BILAT RHONCHI AT BASES.\n\nGI: CON'T ON TF @ GOAL RATE OF 45CC VIA OG TUBE. RESIDUALS <10CC. HAD 1 STOOL SOFT/LOOSE GOLDEN WHICH WAS HEME NEG. ON PEPCID 20MG QD. ABD IS SOFT NON TENDER.\n\nSKIN: PACER SITE SS C&D. CON'T TO HAVE YEAST RASH TO GROIN AREAS AND BREAST HOLDS. MYCOSTATIN AS ORDERED APPLIED.\n\nID: LOW GRADE TEMPS NOTED 99.7 WBC DOWN THIS AM TO 14.7 CON'T ON VANCOMYACIN,FLAGYL AND IMINPENIUM. PT HAS IN SPUTUM, + URINE CULTURE/YEAST AND STAPH FROM OLD CVL SITE. PT IS ON DAY 4 OF 7 DAY COURSE.\n\nNEURO: ALERT AT TIMES AND WILL OPEN EYES TO VOICE. RESPONDS BY NODDING AND HAS PURPOSFUL MOVEMENTS. SHE IS STILL NOT FOLLOWING COMMANDS. SHE WILL REACH FOR TUBES AND LINES AND AT TIMES ATTEMPTS TO PULL AT THEM. FENTAYL AND VERSED HAVE BEEN GIVEN WITH ADEQAUTE RESULT.\n\nLABS: CON'T TO HAVE HIGH BS 170-190. SPOKE WITH TEAM LAST EVE. THEY HAVE ADDED NHP + SSI . OVERNOV BS 182,167. PT @ 2100 2 U REG/8 U NPH.\n K+ 3.9 LAST EVE RECEIVED 20 MEQ KCL.\n\nSOCIAL: HUSBAND AND DAUGHTERS IN ON EVES. THEY HAVE BEEN UPDATE AND SUPPORT GIVEN\n\nA: CRITICAL/ DIFFICULT WEAN D/T PULM EDEMA.\n\nP; CON'T TO DIURESE\n CHECK WITH HO. INCREASE LOPRESSOR\n NEEDS ID APPROVAL FOR VANCO(TEAM IS AWARE)\n FAMILY SUPPORT\n PER NSG JUDGEMENT.\n CPAP+PS TRIALS TO CONTINUE TODAY\n\n\n"},{"category":"Nursing/other","chartdate":"2152-08-28 00:00:00.000","description":"Report","row_id":1430777,"text":"pt.changed from psv to ac for the noc to rest. changes made in vt-decreased to 400, bs with rhonchi, sx for white secretions, will probably switch to cpap, failed wean trial this a.m., became agitated, rsbi 225, pt.reamins alkalotic, with metabolic issues.\n"},{"category":"Nursing/other","chartdate":"2152-08-28 00:00:00.000","description":"Report","row_id":1430778,"text":"Resp Care:Received pt on a/c 400,10,.50,peep5.Attempted cpap/psv wean of 16/5 and .50 with pt lasting approx 1 and 1/2 hours. Pt was having frequent periods of apnea so pt was changed back to a/c. Later in the shift pt appeared more alert so cpap/psv wean was attempted again however pt only lasted about 1 hour. At that time pt had an increase in hr 160bpm so pt was returned to a/c. Plan rest pt overnight and attempted wean in am.\n"},{"category":"Nursing/other","chartdate":"2152-08-28 00:00:00.000","description":"Report","row_id":1430779,"text":"NPN 0700-1900;\n\nNEURO; HUNGARIAN SPEAKING LADY INTUBATED AND VENTILATED. SEDATED WITH MIDAZOLAM AND FENTANYL.OPENS EYES SPONTANEOUSLY.MAE SPONTANEOUSLY. FOLLOWS SIMPLE COMMANDS. STUCK TONGUE OUT FOR DAUGHTER.MOVEMENTS ARE VERY PURPOSEFUL WILL ATTEMPT TO PULL OUT TUBES WHEN WRIST RESTRAINTS ARE RELEASED. BECOMES ANXIOUS AT TIMES ESPECIALLY WITH ETT SUCTIONING.\n\nRESP; REMAINED ON AC 50% 400 X10 FOR MOST OF DAY., TOLERATED CPAP WITH 16 PS FOR 2 PERIODS OF 1.30 HOURS PLACED BACK ON VENT FIRST TIME FOR PERIODS OF APNEA AND THE SECOND TIME FOR HR TO 160, AFTER SUCTIONING.LUNG SOUNDS COARSE. SUCTIONED Q1-2 HRS FOR THICK WHITE SECRETIONS,SATS 94-96%.\n\nCVS. TMAX 37.6 CORE, BP 105-134/57. AFIB 94-121 WITH A BURST TI 150-160 TREATED WITHN BOLUS DOSE OF LOPRESSOR 2.5MGDS I,V, WITH GOOD EFFECT.CI DROPPED TO 1.9 WITH THIS EPISODE REPEAT PENDING.PLEASE SEE FLOW SHEETS FOR DETAILS.\n\nGU; GOOD RESPONSE TO LASIX 20 MGS I.V.K 3.5 NEED TO REPLETE.\n\nGI; TOLERATING T/F FS PROMOTE WITH FIBRE AT 45 MLS WITH MIN RESIDUAL. HAD SEVERAL EPISODES OF LARGE AMOUNTS OF THICK SEMI FORMED STOOL RECTAL BAG APPLIED BUT NO FURTHER EPISODES SO FAR.FELT THAT THIS CONTRIBUTED TO EXHAUSTION THIS AM. RECEIVING NPH INSULIN BS 174-134.\n\nID ;CONTINUES ON TRIPLE ANTIBIOTICS.AWAITING RANDOM.LEVEL RESULT.\n\nHEME STABLE HCT 35%\n\nSKIN CONTINUES TO HAVE YEAST IN GROIN. BUT UNDER ARMS AND BREAST SEEMS TO HAVE IMPROVED.\n\nFAMILY INTO VISIT AND UPDATED WITH PT,S CURRENT CONDITION.\n"},{"category":"Nursing/other","chartdate":"2152-09-12 00:00:00.000","description":"Report","row_id":1430833,"text":"CCU NPN 1900-2300\nS/O:\n\nF/E: 20 MG LASIX GIVEN IV X1 WITH 600 CC U/O. LUNGS CONT WITH CRACKLES AT BASES. SATS IN HIGH 90'S ON 2LNP.\n\nGI: INC LARGE AMOUNTS OF STOOL X3, FAILED MUSHROOM CATHETER. FECAL INC BAG ON AND HOLDING. STOOL OB NEG, WITH SOME FORMED STOOL.\n\nA/P: HOLD ALL LAXATIVES, CHECK K WITH AM LABS. D/C TO REHAB IN AM.\n"},{"category":"Nursing/other","chartdate":"2152-09-13 00:00:00.000","description":"Report","row_id":1430834,"text":"CCU progress note 11p-7a\nUneventful nite. slept in naps. VSS. sats 94-97% on 2L n/c. Took hs po med crushed in pudding. aspiration precautions.\n\nNEURO: MAE, gen weakness. speaks/understands small amt broken english - hungarian speaking. Ox2 per family. slight confusion at times. obeys simple commands.\n\nID: on levo for UTI. nystatin to reddened groins. afebrile.\n\nCARDIAC: AFIB 60-80s. Lopressor increased to 75mg TID - tolerating well. Increased dose of Lisinopril to 60mg po qd. coumadin remains on hold d/t still elevated INR. am labs pnd. RIJ TLC patent - pt difficult access (remove line access prior to discarge to rehab facility).\n\nRESP: LS clear, dim/coarse to bases. strong congested occasionally productive cough. O2 2L n/c w/ sats 94-97%. pt took off n/c and on room air w/ sats 88-92% w/ SOB noted. RR 18-32 overnite.\n\nGI/GU/ENDO: FS QID - no sliding scale ordered at present - NPH on hold until pt tolerating diet. ASPIRATION PRECAUTIONS. sit pt bold upright for meals/meds - crush meds in puddings/pureed foods - diet of pureed and nectar thick liquids. Abd soft, distended. +BS. +flatus. stooling overnite large amts of yellow liquid stool. slowing down this morning - failed attempts on rectal tube and fecal incont bags. Foley patent. U/O ~30cc/hr. some sediment/mucous noted in urine. on daily lasix 80mg QD w/ daily KCL supplement.\n\nPT/OT: pt gets OOB to chair - pivots w/ assist of 2 and walker. on air bed. pneumoboots.\n\n\nPLAN: transfer to rehab facility today if INR WNL. monitor VS. keep pt comfortable.\n"},{"category":"Nursing/other","chartdate":"2152-09-01 00:00:00.000","description":"Report","row_id":1430797,"text":"Resp. Care Note\nPt remains intubated and vented on settings as per Resp. flowsheet. PSV level decreased this shift from 15-12-10. Good ABG's on PSV 12, ABG pending on PSV 10. Improved oxygenation. Cont present support, wean vent as tolerated.\n"},{"category":"Nursing/other","chartdate":"2152-09-01 00:00:00.000","description":"Report","row_id":1430798,"text":"D: Please see data, MD notes/orders. Neuro: Pt opens eyes to family, MAE, PERRL. Appears comfortable on versed 1mg/hr and ativan 1mg tid. CV: Afib on monitor, HR 70-90. SBP 100-1teens/60s. PA pressures 35-42/17-20, cvp 12-13. CO/CI 3.7/2.3 with team aware of values.Heparin gtt currently at 700u/hr in theraputic range with last ptt 75. Pulm: Vent changes/settings per care view. Lung sounds coarse, clearing after suction of thin white secretions. Respitory effort unlabored, 02 sat 98%. Latest Abgs per care view.PH 7.5 felt to be due to volume contraction from diuresis after lasix 20mg IVP x 2 today. Pt currently with neg fluid balance 600cc+. GI: Abd soft, bs+, incontinent of med soft brown stool. TF at goal rate, residuals minimal. Skin: surfaces intact, perianal area excoriated. Peripheral pulses palpable. soc: Husband and daughter in this evening. Pts daughter with many questions, Husband speaks minimal english.\n\nP: Titrate versed gtt prn pt comfort. Keep heparin gtt 700u/hr, ptt qd and as ordered (goal ptt 60-80). No further vent changes tonight, prn abg's, notify team of any decline in respitory status. Monitor hourly uo with goal neg fluid bal 1L/24hr per team. Provide meticulous skin care, frequent postion changes, barrier cream/nystatin powder prn. Keep family updated on pt condition and plan of care.\n\nR: As above, Family updated and agreeable to plan of care.\n"},{"category":"Nursing/other","chartdate":"2152-09-02 00:00:00.000","description":"Report","row_id":1430799,"text":"NPN\nCCU\n11 PM - 7 AM\nINTUBATED AND SEDATED\nS/O PLS SEE FLOWSHEET FOR ALL OBJ/NUMERICAL DATA ..\nCV HR 60'S PACED RHYTHM...SBP 120-150'S/40-60'S...TOLERATING TITRATION OF LOP/CAPTOPRIL ...PAD 18-22..CVP 8-10...\nRESP ON 40%..SIMV AND PS ..RATE OF 12 ..INSP TIDAL VOLUMES 250-320...5 PEEP....LUNGS DIMINISHED AT THE BASES ..SUCTIONED FOR SMALL AMOUNTS OF WHITE SXNS ..\nGI ON PROMOTE AT 45 CC/HR VIA OGT..SMALL SOFT STOOL ..OB NEG..MINIMAL RESIDUALS ..\nGU 1500 CC NEG AT MN....\nCOMFORT ..CONTINUES ON VERSED GTT AT 1 MG/HR WITH - 2 MG IVP BOLUS WITH SUCTIONING/BATHING ..TOLERATED WELL...\nTURNED Q3...\nA HEMODYN STABLE\nP FOLLOW HEMODYNAMIC #'S....LABS ..PULM TOILET\n"},{"category":"Nursing/other","chartdate":"2152-09-02 00:00:00.000","description":"Report","row_id":1430800,"text":"Resp. Care Note\nPt remains intubated and vented on settings as per Resp. flowsheet. Pt on SIMV in AM after fentanyl given due to low RR and minute vol. Pt changed back over to CPAP/PSV when more awake. Cont to show alkalosis on ABG's. Plan to cont PSV and wean slowly as tolerated.\n"},{"category":"Nursing/other","chartdate":"2152-09-06 00:00:00.000","description":"Report","row_id":1430814,"text":"CCU NPN 1900-0700\nO: afeb. HR 70's afib with freq. paced beats.\nBP 117-140's/60's. increasing to 160-170's/70's during evening. given captopril 75mg at 2200 crushed with custard. BP contin. to remain high. pt. awake, eyes open, responding to name and simple commands. understands english. ordered for ativan po q8hr for potential benzo . given 1mg at 2300 with good results. pt. falling asleep and BP coming down to goal 120-130's/60. pt. waking again ~ 0500 and BP trending up again to 160/70. HR 70's. pt. appearing comf. with no overt anxiety. due for captopril at 0600.\n\nu/o 40-75cc/hr. (-) 1L for and (+) 3L LOS.\n\ntaking meds crushed with custard. holds in mouth but able to move tongue and swallow with encouragment.\n\nLS course upper airways, somewhat cleared with weak cough. CPT x2. sats 97-98% on 2lnc. trending down in AM to 94%, given CPT and increased to 4lnc-> sats 98% at 0500. RR 20-30's regular.\n\nHCT 31.9 , stable. WBC 8.4.\n\nneuro: as above, pt. awake, moderately alert. responding to name and to simple commands in english. needs promting and enc. to respond to questions. daughter states that pt. understands more english than thought.\n\nheparin 750u/hr via right IJ TLC.\n\nA: stable night , taking po meds. BP stable.\n ativan RTC for possible benzo .\nP: OOB again today. contin. to thicken foods/liquids. crush meds as needed. CPT, wean FIO2. contin. to monitor neuro status.\n"},{"category":"Nursing/other","chartdate":"2152-09-06 00:00:00.000","description":"Report","row_id":1430815,"text":"7a-3p\ncv: hr a-fib with occasional paced bts(66-80), no ectopy, sbp stable(122-162), continues on po digoxin, captopril & lopressor XL\n\nresp: on 4 l np this am, bs+ all lobes & clear, abg sent with good result & o2 decreased to 2 l np, sats 97-99, rr 20-24, coughing productively @ times-sm amts tan sputum\n\ngi: continues on aspiration precautions, thicken liquids/soft solids tol fair, poor po intake, to have feeding tube placed this afternoon, no stool\n\ngu: foley patent, clear yellow urine, uo 30-50 cc/hr\n\nneuro: awake, follows commands, moving all extremities\n\nother: iv fluids started x 1 liter(1/2 ns @ 100cc/hr), L rad a-line dc'd, heparin gtt continues @ 750u/hr, oob to chair with PT @ 1200-tol fair, pt very weak with poor wt. bearing, family called & updated on pt's condition\n\nplan: continue to monitor in icu, start tube feed as ordered once FT placed, ? tx to floor tomorrow\n"},{"category":"Nursing/other","chartdate":"2152-09-06 00:00:00.000","description":"Report","row_id":1430816,"text":"CCU NPN \nGI: NGT placed, placement confirmed by x-ray, started FS Promote with fiber at 10cc/hr at 1800, advance q 4hrs by 10cc to goal 45cc/hr. No residual at onset. NPO until swallow study.\n\nNeuro: alert, confused to time/day per family. Encouraged family to reoriented freq. Pt OOB in chair, has not wanted to return to bed yet. Would lift back, did not bear wt well getting up. Ativan dc'd. Watch for ^HR/BP/agitation, if occurs will need to get order for ativan from team.\n\nA/P: stable, cont to follow resp status, pul toilet, await swallow study, advance TF's as tolerated.\n"},{"category":"Nursing/other","chartdate":"2152-08-27 00:00:00.000","description":"Report","row_id":1430774,"text":"pt.remains on ac ventilation, sx for thick light yellow secretions, rsbi=93.5, no weans scheduled, to unstable at present time, normal abg.\n"},{"category":"Nursing/other","chartdate":"2152-08-27 00:00:00.000","description":"Report","row_id":1430775,"text":"CCU NPN 0700-1900\nS/O:\n\nCV: CAPTOPRIL STARTED AT 1100, C/O DOWN SLIGHTLY X2 AFTER DOSE, AND C/I INC TO 1900. LOPRESSOR INC TO 25 MG TID AND PLAN TO INC TO 50 TOMORROW. HEP AND NATRACOR UNCHANGED. CVP TO 14 AFTER LASIX 20 MG X1 IN AM, UP AGAIN IN AFTERNOON. K 3.9 SO 40 KCL GIVEN X1, MAG 3GM GIVEN X1 FOR MAG 1.6. CONT IN AF WITH RATES TO 80'S-100'S. GOOD DIURESIS AGAIN TO LASIX, NEG ABOUT 500CC FOR NOW. PERIPHERAL EDEMA IMPROVED. PT NEEDS ANOTHER LASIX DOSE TONIGHT.\n\nRESP: ABG ACIDOTIC IN AM AND ALKALOTIC IN PM. VENT WEANED TO 16 PS AND 5 PEEP WITH TV IN LOW 300'S AND RR 12-30, CHEYNES RESP AT TIMES. LAST ABG 7.47-74-37. SUCTIONED Q4-5H FOR THICK WHITE SPUTUM. NO EVIDENCE OF CUFF LEAK. LUNGS WITH EXP WHEEZE AND RHONCHI AT TIMES.\n\nID: TMAX 100 CORE, WBC UNCHANGED. ABX CONT. ALL DRSG AND OF INFECTION.\n\nGI: TOL 45CC/HR OF TF WITH HIGH RESIDUAL AT TIMES BUT NO NEED TO TURN OFF TF. INC SOFT STOOL, TRACE POS. POS BS.\n\nGU: URINE CLEAR.\n\nMS: REC'D LESS FENT/VERSED TODAY, SEEMS TO BE MORE COMFORTABLE ON PS VENT. SITTING UP IN BED AND TURNED FREQ. BOTH DAUGHTERS AND HUSBAND IN TO VISIT.\n\nFAMILY: DAUGHTER WILL RETURN HOME TO WORK TOMORROW, SHE HAS 3 KIDS N VT. STATES FATHER IS CONFUSED AND VERY UPSET ABOUT WIFE.\n\nSKIN: FUNGAL SKIN INFECTION CONT TO IMPROVE, NO OTHER SKIN BREAKDOWN. PNEUMO BOOTS CONT.\n\nA/P: C/O SLIGHTLY AND SVR UP WITH NEW CAPTOPRIL AND INC LOPRESSOR. PT NEEDS MORE LASIX TONIGHT. CONT TO FOLLOW NUMBERS AND ABG. ? REST ON A/C TONIGHT. CONT TO SUPPORT FAMILY.\n\n"},{"category":"Nursing/other","chartdate":"2152-08-26 00:00:00.000","description":"Report","row_id":1430769,"text":"CCU Nursing Progress Note 1900-0700: CV shock\nS-Sedated and intubated\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VS\nSEE ICU UPDATE REPORT FOR OVERNIGHT EVENTS\n\nO-MS:Sedated and intubated overnight on Fent and Versed IVP, requiring Q1-2hrs. Usually requiring 0.5mg of Versed and 25mcgs of Fentanyl. Remaining fairly comfortable with above doses, opening eyes to verbal to name, pt slavic speaking only. Family usually able to engage with pt and pt nodding appropriately. Seeming more \"out of it\" according to family.\nCV: HR 70s to 100s. Afib with occasional PVCs and occasional paced beat. K and Mg in WNLs on eves. SBPs 90s to 110s. MAPs 60s to 70s.\nPAD 27-38, CVP 14-17, CO/CI/SVR high 3.0s/2.0s/1200-1500. Natrecor titrated up to 0.015mcg/kg/min with fair results. PADs down from 38 to 28-30. Increased again to 0.020mcgs/kg/min and awaiting results. Heparin continues at 950u/hr with therepeautic PTTs. Skin warm and dry to touch with palpable pulses distal.\nRESP: LS course, more so on exhalation. VENT: AC/450/12/.50/6 PEEP. Suctioned for thick white secretions in small to moderate amounts. RBSI performed this AM with score of 80, in addition to RR into the 30s and filling pressure elevated as well.\nGU/GI: Foley draining minimal amounts of golden yellow urine. HUOs 25-80cc/hr while on Natrecor gtt. At MN 4L(+) and for LOS 13L(+). BUN/Creat in WNLs AM. Anticipate possible increase this AM.\nAbd soft with (+) BSs. Passing flatus. OGT to right nare changed to OGT oral. Prior to TF at GR of 45cc/hr(Promote w/ fiber). Please confirm placement with CXR prior to use. Passing golden to brown colored loose stools in small to moderate amounts. G(+).\nID:Tm 100.2 and Tc 99.5. Most recent cultures, urine (+) for > 100,000 org, CVL tip cx with staph, sputum with GNR, and blood and stool still pending. ABx coverage: Vanco, Flagyl, and Iminpenim. Yeast not covered as yet, team to discuss on rounds.\nA/P: CV shock c/b by septic shock\nContinue to monitor\n\n\n"},{"category":"Nursing/other","chartdate":"2152-08-26 00:00:00.000","description":"Report","row_id":1430770,"text":"pt.maintained on ac ventilation, unstable cardiac wise, septic, bs with coarse rhonchi bilat, some rales, normal abg, rsbi-80.6, no weans are planned, sx for thin watery clear to white secretions,\n"},{"category":"Nursing/other","chartdate":"2152-08-26 00:00:00.000","description":"Report","row_id":1430771,"text":"Respiratory Care\nPt remains ventilated with no change in settings. Breath sounds equal/few scattered expiratory wheezes. Sx for small amount of light tan secreations. RRT\n"},{"category":"Nursing/other","chartdate":"2152-09-12 00:00:00.000","description":"Report","row_id":1430831,"text":"CCU progress note 7p-7a\nUneventful pm. Family visited late evening. Pt stated to husband \"I feel like I can't swallow\" HO notified. Pt did take crushed medication at midnite in apple sauce - seemed to tolerate well. remains on aspiration precautions and on thickened liquids + pureed foods. transfer to Rehab facility. See Transfer note if transferred to floor.\n\nNEURO: A+Ox3 per family. hungarian speaking - speaks broken english. MAE. gen weakness. 1+ gen edema.\n\nID: afebrile. on levoquin for UTI. no other abx.\n\nCARDIAC: AFIB 70-80s 0cc paced beats. SBP 130-160s. on Lopressor 50mg TID. Daily Lasix 40mg po. Lisinopril 40mg po qd. Digoxin 0.25mg po qd.\n\nRESP: O2 2L n/c. sats 94-97%. sl SOB on exertion. LS clear, coarse/dim bases. weak congested cough. CPT done w/ turns.\n\nGI/GU: foley patent. u/o ~30cc/hr. on daily diuresis w/ daily po KCL. abd soft, distended. +BS. no stool. takes pills crushed in pureed food w/ thickened liquids per swallowing study. ASPIRATION PRECAUTIONS. pt stating she feels like she can't swallow. HO aware.\n\nSKIN: perineum healed well. nystatin applied. on air mattress. turned + repo'd.\n\n\nPLAN: keep pt comfortable. continue pulmonary toliet. con't cardiac meds. aspiration precautions. ?transfer to rehab facility or to floor today?\n"},{"category":"Nursing/other","chartdate":"2152-09-12 00:00:00.000","description":"Report","row_id":1430832,"text":"CCU Nursing Progress Note\nS: That's enough\nO: Pt voicing \"enough\", after few teaspoons of soft solids, yogurt, pudding. Taking very little in po. Pt will assist with encouragement, but minimal po intake today. Able to tolerated smaller pills later in day, otherwise pills were crushed and mixed with nectar consistency water.\n\n 8am meds given crushed in applesauce, then pt vomited. Bp up to 160/ with HR up 140. RR 40 with sat down to 85%. Increased o2 to 100%cool neb with subsequent sat up to 100%. Lopressor 5mg IVP with BP to 130/ and HR to 70-80. Lasix 20IVP with u/o @400cc within 1hr.\n\nAfebrile- cont on Levofloxacin\nHR 80's afib with rare paced. Lopressor increased to 75mg po tid\nBP 130-160/ Increased dose of Lisinopril to 60mg po qd starting , but extra 20mg given at 1800.\nResp - as above, cont with bibase rales despite diuresis and productive cough. Able to wean O2 down to 2ln/p.\nGI - as above for po intake. Passed small amt ob-, soft formed stool\nActivity - OOB to chair with 2 assist. OT to see pt\n\nA: Event of Inc HR and BP responding well to Lopressor IV and Lasix\n\nP: Cont aspiration precautions and encourage po intake\nMonitor need for diuresis this evening. Monitor HR and BP on increased dose of meds. OOB this eve. ? tx to NE \n"},{"category":"Nursing/other","chartdate":"2152-09-04 00:00:00.000","description":"Report","row_id":1430810,"text":"CCU progress note 7a-7p\nEVENTS: EXTUBATED @ 10am - tolerating well!\n\nNEURO: no sedation - versed gtt off since 6am. no ativan given today. mae - very weak. moves feet, moves arms across bed and up to face. nodding head to questions of 'okay?' , mouthing words to family when they visited this afternoon.\n\nID: afebrile. Tmax 98.9po. no abx.\n\nRESP: Extubated at 10am. LS coarse. coughing up some clear thick secretions. O2 3L n/c. cool neb face tent @ 50% for moisture. CPT done with turns. post extubation abg: 7.41/41/114 sats >96%.\n\nCARDIAC: AFIB 70-100s occ paced beats. Lopressor 50mg dose given early pre intubation. Captopril 75mg dose held this afternoon due to NPO status - HO aware - ?may need NGT inserted for meds tonite. Good SBP >130s. L radial aline patent. RIJ TLC patent. HEPARIN gtt increased to 750u/hr per HO tonite. 2+ generalized edema.\n\nGI/GU/ENDO: foley patent. given lasix 20mg IVP x 1 pre intubation w/ good results. abd soft +BS. stooling golden soft stool mod amts q2-3 hrs. TF off for extubation. to attempt sips this evening for meds - otherwise NGT will have to be inserted for meds/feeding. aspiration precautions. BS WNL. no RISS given. on standing dose NPH insulin .\n\nCODE STATUS: FULL CODE. (daughter) {a CCU nurse} is HCP (proxy).\nFAMILY: husband and other daughter () in to visit this afternoon.\n\n\nPLAN: check PM lab results (K,Mg). keep pt comfortable. pulmonary toliet. ?NGT insertion for meds tonite if pt unable to take pills orally due to aspiration concerns. monitor VS.\n"},{"category":"Nursing/other","chartdate":"2152-09-04 00:00:00.000","description":"Report","row_id":1430809,"text":"Respiratory Care:\n\nPatient remains intubated on Psv. Psv increased back to 12cm to rest at noc. RR increasing to 30's. Improved on Psv 12. Current settings Psv 12, Cpap 5, Fio2 40%. RR 13-25 with spont vols 400's. O2 sats 97-100%. Bs clear bilaterally. RSBI 185. RSBI improving over the last 2 days. Still with increased fluid. Plan: Continue with slow Psv wean increasing Psv at noc as needed.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-09-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 797282,\n \"text\": \" 7:57 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate PA catheter placement; interval change in ch\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock and volume overload\\n REASON FOR THIS EXAMINATION:\\n please evaluate PA catheter placement; interval change in chf; ET placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n HISTORY: PA CATHETER PLACEMENT.\\n\\n CHEST, AP PORTABLE: Comparison is made to .\\n\\n There has been interval pull back of the right IJ PA catheter with the tip\\n terminating in the main pulmonary artery. Again noted, is an NG tube, ET\\n tube, and pacemaker, unchanged in position. There are bilateral pleural\\n effusions and accounting for technical diffuerence there is no significant\\n change, Also noted is mild pulmonary edema, unchanged from prior exam.\\n\\n IMPRESSION: The tip of the right IJ is in right main pulmonary artery in\\n satisfactory position. Otherwise, no significant change from prior study.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-09-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 797368,\n \"text\": \" 7:20 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Intubated with swan placed, please evaluate in comparison to\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock and volume overload\\n\\n REASON FOR THIS EXAMINATION:\\n Intubated with swan placed, please evaluate in comparison to yesterday\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Cardiac failure.\\n\\n PORTABLE CHEST: A supine view is compared to . The tip of the ETT is\\n relatively low, approximately 1.5 cm above the carina. The nasogastric tube\\n courses below the view of the image. The tip of the Swan- Ganz catheter is\\n near the origin of the right upper lobe pulmonary artery, simialr to\\n yesterday's film. A single electrode pacemaker is unchanged.\\n\\n The heart size is stable. Pulmonary edema has improved. There are small\\n pleural effusions bilaterally. Atelectasis persists in the left lower lobe.\\n\\n IMPRESSION: 1. ETT tip relatively low, 1.5 cm above carina.\\n\\n 2. Improved CHF with residual small pleural effusions and left basilar\\n atelectasis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-08-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 796772,\n \"text\": \" 7:47 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for ARDS - compare to prior films\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with sepsis,on vent, hypotension,on IVF, pressors\\n\\n REASON FOR THIS EXAMINATION:\\n eval for ARDS - compare to prior films\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 79 y/o woman with sepsis on a vent. Hypertensive. ? ARDS.\\n\\n AP PORTABLE SUPINE CHEST AT 08:00:\\n\\n There is no change when compared to prior portable chest at 05:44 of the same\\n date. Patient is still in gross pulmonary edema with bilateral pleural\\n effusions. External support lines are unchanged.\\n\\n IMPRESSION: No change. Gross pulmonary edema with bilateral pleural\\n effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-08-26 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 796768,\n \"text\": \" 5:28 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please evaluate for PA catheter placement, ? new pulmonary p\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock on nesiritide with PA catheter;\\n sudden increase in pulmonary artery pressure and peak inspiratory pressures,\\n otherwise stable vital signs.\\n\\n REASON FOR THIS EXAMINATION:\\n please evaluate for PA catheter placement, ? new pulmonary process.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 79 y/o woman with cardiogenic shock. Sudden increase in pulmonary\\n artery pressure and peak inspiratory pressure. Otherwise stable vital signs.\\n Please evaluate.\\n\\n SUPINE PORTABLE CHEST AT 05:44:\\n\\n Since the prior study dated at 07:30, the right IJ central venous\\n catheter has been replaced with a SG catheter, whose tip is in the right\\n pulmonary artery. The patient is in gross pulmonary edema with bilateral\\n effusions, right greater than left. The rest of the external support tubing\\n is unchanged.\\n\\n IMPRESSION; New right IJ SG catheter with tip in right PA. No evidence of\\n pneumothorax. Pulmonary edema with bilateral effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-09-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 797576,\n \"text\": \" 7:29 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p extubation for 24 hours, please comment on changes of CH\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock, new pacemaker placement\\n 3 weeks ago please and repositioning of ETT. please assess position,\\n effusion, edema.\\n REASON FOR THIS EXAMINATION:\\n s/p extubation for 24 hours, please comment on changes of CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: History of cardiogenic shock and recent extubation.\\n\\n AP CHEST: In comparison to the prior study of , the NG and ET tubes\\n have been removed. The right IJ line is in unchanged position in the distal\\n SVC. There is no pneumothorax. Mild cardiomegaly and symmetric perihilar\\n opacities as well as septal lines at the bases are present, slightly improved.\\n Small bilateral pleural effusions and adjacent atelectasis are unchanged.\\n There is diffuse calcification of the aortic arch and descending aorta.\\n\\n IMPRESSION: Mild left heart failure, slightly improving. Interval removal of\\n ET and NG tubes.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-08-29 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 796998,\n \"text\": \" 8:15 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Evaluate for changes\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock on nesiritide with PA catheter\\n otherwise stable vital signs.\\n REASON FOR THIS EXAMINATION:\\n Evaluate for changes\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: Pulmonary artery catheter evaluation. Cardiogenic shock.\\n\\n PORTABLE AP CHEST: A Swan-Ganz catheter remains in place, terminating in the\\n region of the interlobar right pulmonary artery. A temporary pacing lead is\\n also present, terminating in the region of the right ventricle. Endotracheal\\n tube and nasogastric tube are in satisfactory position. Cardiac and\\n mediastinal contours are stable. There is vascular engorgement and perihilar\\n haziness. A large right pleural effusion is noted as well as a moderate left\\n pleural effusion.\\n\\n IMPRESSION:\\n\\n 1. Swan-Ganz catheter terminates in interlobar portion of right pulmonary\\n artery.\\n 2. Large right pleural effusion, and moderate left pleural effusion. Allowing\\n for differences in patient positioning between the two studies, they are\\n probably not significantly changed.\\n 3. Stable CHF pattern.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-09-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 797492,\n \"text\": \" 8:42 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: REPOSITION ETT CHECKPOSITION\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock, new pacemaker placement\\n 3 weeks ago please and repositioning of ETT. please assess position,\\n effusion, edema.\\n REASON FOR THIS EXAMINATION:\\n comparison\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: ET tube position change.\\n\\n AP SEMI-UPRIGHT VIEW OF THE CHEST is compared to AP supine view dated .\\n\\n FINDINGS: The ET tube terminates 2 cm above the carina. The right IJ catheter\\n tip remains in the distal SVC. A single pacemaker lead remains at the apex of\\n the right ventricle. The NG tube position in the stomach is unchanged. LV\\n enlargement and aortic calcifications are again noted. There has been slight\\n worsening of the pulmonary edema. The bilateral pleural effusions are\\n slightly increased. There is persistent left lower lobe atelectasis, as well\\n as minor right lower lobe atelectasis. The visualized osseous structures are\\n unchanged.\\n\\n IMPRESSION:\\n\\n 1. Satisfactory position of ET tube.\\n 2. Slight worsening of CHF.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-09-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 798051,\n \"text\": \" 10:33 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?infiltrate or evidence of aspiration\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock, new pacemaker placement, recent\\n extubation after prolonged ICU course. Now with possible aspiration.\\n REASON FOR THIS EXAMINATION:\\n ?infiltrate or evidence of aspiration\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Cardiogenic shock. Possible aspiration.\\n\\n COMPARISONS: -- 08:00\\n\\n FINDINGS: Compared to prior the pacemaker wire and right central venous line\\n remain unchanged. There is less distention of the pulmonary vasculature and\\n some clearing of air space disease with no evidence of new focal\\n consolidations. Heart size is stable, bilateral effusions are stable and\\n there is no pneumothorax.\\n\\n IMPRESSION: Persistent but improving CHF. No new consolidations.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-09-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 797728,\n \"text\": \" 4:32 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: newly placed NG tube, please evaluate whether it is in the s\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock, new pacemaker\\n placement 3 weeks ago please and repositioning of ETT. please assess\\n position, effusion, edema.\\n REASON FOR THIS EXAMINATION:\\n newly placed NG tube, please evaluate whether it is in the stomach\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Status post NG tube placement.\\n\\n FINDINGS: AP supine view is compared to the AP supine view dated .\\n The NG tube extends into the body of the stomach, but its tip is not well-\\n visualized due to technique. The right IJ catheter and the single pacemaker\\n lead remain in unchanged positions. There is persistent cardiomegaly, and the\\n interstitial pulmonary edema appears slightly worse. The bilateral effusions\\n are also slightly increased. The left lower lobe opacity is unchanged. Aortic\\n calcifications are once again noted. The visualized osseous structures are\\n unchanged.\\n\\n IMPRESSION:\\n 1) NG tube in satisfactory position.\\n 2) Mild worsening of congestive heart failure and bilateral pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-08-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 796833,\n \"text\": \" 7:39 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Line placement, eval of CHF\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock on nesiritide with PA catheter;\\n sudden increase in pulmonary artery pressure and peak inspiratory pressures,\\n otherwise stable vital signs.\\n\\n REASON FOR THIS EXAMINATION:\\n Line placement, eval of CHF\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 79 year old woman status post line placement.\\n\\n AP supine portable chest at 8:15 AM.\\n\\n Compared to prior study one day earlier, I see no new lines placed. The\\n patient is still in gross pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-09-08 00:00:00.000\",\n \"description\": \"VIDEO OROPHARYNGEAL SWALLOW\",\n \"row_id\": 797926,\n \"text\": \" 2:18 PM\\n VIDEO OROPHARYNGEAL SWALLOW Clip # \\n Reason: please evaluate for swallowing ability\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with swallow evaluation neeeded\\n REASON FOR THIS EXAMINATION:\\n please evaluate for swallowing ability\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Please evaluate for swallowing ability.\\n\\n VIDEO OROPHARYNGEAL SWALLOW: Barium of various consistiencies was administered\\n to the patient. Aspiration was noted with cup sips of nectar consistiency.\\n Laryngeal penetration was seen with thin barium, though no aspiration was\\n noted. There is reduced laryngeal valve closure. There is spillover of barium\\n into the valleculae. No significant residue is present. Also noted is mild\\n delay in initiating the swallow.\\n\\n IMPRESSION: Aspiration with large cup sips of nectar consistiency, as\\n described above.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-08-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 796537,\n \"text\": \" 10:32 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Assess for Pulmonary Edema\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with sepsis, hypotension,on IVF and pressors\\n\\n REASON FOR THIS EXAMINATION:\\n Assess for Pulmonary Edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Follow up CHF.\\n\\n CHEST, AP PORTABLE: Comparison is made to prior study from 5 hours earlier.\\n\\n There is interval withdrawal of right subclavian central line. Again noted is\\n NG tube, ET tube and pacemaker, all of which remain in satisfactory position.\\n The heart is stable in size. There is slight worsening of the prominent\\n pulmonary vasculature consistent with bilateral pulmonary edema. There is a\\n possible small bilateral pleural effusion.\\n\\n IMPRESSION: There is slight interval increase of pulmonary edema which could\\n be attributed to worsening CHF or fluid overload.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-08-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 796574,\n \"text\": \" 8:47 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Eval for Pulm edema and/or infiltrates\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with sepsis, hypotension,on IVF and pressors\\n\\n REASON FOR THIS EXAMINATION:\\n Eval for Pulm edema and/or infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 79 y/o woman with sepsis, hypotension, on IV fluids and Pressors,\\n evaluate for pulmonary edema/infiltrate.\\n\\n PORTABLE AP SUPINE VIEW OF THE CHEST: Comparison . An ETT is\\n present in satisfactory position. A single lead pacemaker is unchanged. An NG\\n tube is present with its tip in the region of the gastroesophageal junction\\n and its side port in the distal esophagus. The heart size is upper limits of\\n normal. There are bilateral pleural effusions. Patchy opacities bilaterally\\n are slightly improved and consistent with improving failure.\\n\\n IMPRESSION: 1) NG tube with tip in the distal esophagus. Tube should be\\n advanced. 2) Improving failure.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-09-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 797873,\n \"text\": \" 7:54 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: tachypnea, tachycardia, recent extubation\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock, new pacemaker\\n placement, recent extubation after prolonged ICU course. please eval for pna,\\n effusion, ptx.\\n REASON FOR THIS EXAMINATION:\\n tachypnea, tachycardia, recent extubation\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Respiratory distress.\\n\\n FINDINGS: AP upright view is compared to the AP semi-upright view dated .\\n The heart remains enlarged. There is bilateral perihilar air space\\n consolidation consistent with pulmonary edema, which represents worsening of\\n congestive heart failure since the prior study. There are persistent\\n bilateral pleural effusions. There is fluid in the minor fissure. Aortic\\n calcifications are once again noted. The visualized osseous structures are\\n unchanged. The right IJ catheter and the right ventricular pace maker leads\\n remain in unchanged positions.\\n\\n IMPRESSION: Interval worsening of congestive heart failure. Persistent\\n bilateral pleural effusions.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-08-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 796520,\n \"text\": \" 4:55 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o Pneumothorax, edema, pneumonia\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with sepsis\\n REASON FOR THIS EXAMINATION:\\n r/o Pneumothorax, edema, pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Sepsis.\\n\\n AP bedside chest film. Endotracheal tube is located just above the carina. An\\n NG tube is seen with tip just beneath the GE junction. The proximal port is\\n located within the esophagus. A right sided subclavian central venous line\\n terminates in the distal SVC. There is a single lead cardiac pacer with tip\\n in the expect location of the right ventricular apex. The heart size is\\n normal. There are perihilar air space opacities but no effusions or septal\\n lines. There is no pneumothorax.\\n\\n IMPRESSION: Malpositioned ETT and NGT. Central air space opacities suggest of\\n fluid overload. The findings were relayed to the responsible medicine house\\n officer via telephone on .\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-08-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 796639,\n \"text\": \" 5:37 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: Placement of central line, pneumothorax? Please also check\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with sepsis,on vent, hypotension,on IVF, pressors\\n\\n REASON FOR THIS EXAMINATION:\\n Placement of central line, pneumothorax? Please also check NG tube placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Sepsis, with central line and NG tube placement.\\n\\n Single portable AP view of the chest is compared with the prior study from ten\\n hours ago.\\n\\n FINDINGS: Endotracheal tube and single-chamber left-sided cardiac pacemaker\\n are again seen. NG tube has been advanced such that the tip now terminates\\n within the abdomen with the sideport in the abdomen, as well. Right-sided IJ\\n catheter has been placed, with the tip at the SVC/RA junction. There is no\\n evidence of pneumothorax. There are bilateral pleural effusions, R>L, with\\n some fluid tracking into the minor fissure. It is difficult to assess change\\n in pleural effusion given differences in technique. Cardiac silhouette is\\n grossly unchanged. There is retrocardiac collapse/consolidation. There is\\n calcification of the aorta. Residual barium is present in the colon.\\n\\n IMPRESSION: Appropriate positioning of NG tube and right-sided IJ catheter;\\n no pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-08-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 796674,\n \"text\": \" 7:11 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: ?bilat infiltrates, ?ARDS vs PNA, CHF, line placements\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with sepsis,on vent, hypotension,on IVF, pressors\\n\\n REASON FOR THIS EXAMINATION:\\n ?bilat infiltrates, ?ARDS vs PNA, CHF, line placements\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Sepsis.\\n\\n CHEST, AP PORTABLE: Comparison is made to . The lines and tubes remain\\n unchanged in position. There is slight interval increase of bilateral pleural\\n effusions. Again noted is left lower lobe collapse/consolidation not\\n significantly changed from the prior exam. There are bilateral alveolar\\n opacities noted consistent with extensive pulmonary edema/ARDS not\\n significantly changed from the prior exam.\\n\\n IMPRESSION: There is slight increase of bilateral pleural effusions.\\n Otherwise no significant change in the overall appearance of the extensive\\n pulmonary edema/ARDS.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-08-25 00:00:00.000\",\n \"description\": \"O CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.\",\n \"row_id\": 796707,\n \"text\": \" 12:27 PM\\n CHEST FLUORO WITHOUT RADIOLOGIST IN O.R. Clip # \\n Reason: SWANN LLINE PLACEMENT;TEMP WIIRE PLACE\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n FINAL REPORT\\n A chest fluoro was performed without a radiologist present. 3 seconds of\\n fluoro time was used. No films submitted.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-09-02 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 797395,\n \"text\": \" 2:53 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: central line position\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock, new pacemaker placement 3\\n weeks ago and volume overload s/p resiting central venous access. please\\n assess position.\\n REASON FOR THIS EXAMINATION:\\n central line position\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Line placement.\\n\\n PORTABLE CHEST: Comparison is made with earlier film from 7:30 am the same\\n day. Endotracheal tube tip remains relatively low, approximatedly 1.7 cm\\n above the carina. Of note, the nasogastric tube has moved more proximally,\\n and has its endhole in the proximal stomach and sidehole in the distal\\n esophagus. This can therefore be advanced approximately 7 cm for better\\n placement.\\n\\n Swan-Ganz catheter has been removed and the right IJ central venous catheter\\n now terminates in the region of the distal SVC. Midline structures are\\n grossly unchanged. There is persistent CHF with a right pleural effusion and\\n consolidation/atelectasis in the left retrocardiac area.\\n\\n IMPRESSION: 1) Endotracheal tube tip remains slightly low.\\n 2) Sidehole of the NG tube is now in the distal esophagus.\\n 3) Right IJ central venous catheter tip in SVC.\\n\\n Findings called to the floor.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-09-03 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 797433,\n \"text\": \" 8:28 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval progression of pulm edema, repositioning of ETT\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock, new pacemaker placement 3\\n weeks ago please and repositioning of ETT. please assess position, effusion,\\n edema.\\n REASON FOR THIS EXAMINATION:\\n eval progression of pulm edema, repositioning of ETT\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: ET tube and NG tube repositioning.\\n\\n PORTABLE CHEST: Comparison is made to film from one day earlier. The ET tube\\n has been pulled back and is now in good position, with its tip 3 cm above the\\n carina. The nasogastric tube has been advanced and is also in good position,\\n with both end and sidehole in stomach. Cardiac and mediastinal contours are\\n stable, and there is no change in the appearance of the lungs, with note again\\n made of pulmonary edema, right effusion, and left retrocardiac density.\\n\\n IMPRESSION: 1. The ET tube and nasogastric tube are now in good position.\\n 2. No change lungs.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-09-11 00:00:00.000\",\n \"description\": \"VIDEO OROPHARYNGEAL SWALLOW\",\n \"row_id\": 798136,\n \"text\": \" 9:02 AM\\n VIDEO OROPHARYNGEAL SWALLOW Clip # \\n Reason: swallowing study\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with swallow evaluation neeeded before starting PO intake\\n\\n REASON FOR THIS EXAMINATION:\\n swallowing study\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: Evaluate swallow before starting p.o. intake.\\n\\n VIDEO OROPHARYNGEAK SWALLOW: Barium of varying consistencies was administered\\n to the patient. There was delay in the initiation of the oral phase of\\n swallowing. There is incomplete closure of the laryngeal valve. No residue\\n was noted with any barium consistencies. There was aspiration with swallowing\\n thin barium. Overall, there has been improvement from the study done several\\n days earlier.\\n\\n IMPRESSION: Aspiration with thin barium consistencies.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2152-08-28 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 796875,\n \"text\": \" 7:11 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evaluate for pulm vasc congestion vs infiltrate.\\n Admitting Diagnosis: CHF,PNEUMONIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 79 year old woman with cardiogenic shock on nesiritide with PA catheter;\\n sudden increase in pulmonary artery pressure and peak inspiratory pressures,\\n otherwise stable vital signs.\\n REASON FOR THIS EXAMINATION:\\n evaluate for pulm vasc congestion vs infiltrate.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 79 y/o woman with cardiogenic shock. Sudden increase in\\n pulmonary pressure and peak inspiratory pressures.\\n\\n PORTABLE AP VIEW OF THE CHEST: Comparison . SG catheter is present\\n with tip in a right interlobar artery. NG tube courses into the stomach, tip\\n not visualized. The ET tube is approximately 2.4 cm from the carina (patient\\n with neck in flexed position). There are layering bilateral pleural effusions\\n with perihilar haziness.\\n\\n IMPRESSION: Bilateral layering pleural effusions and mild pulmonary edema. ET\\n tube is likely in satisfactory position, given the flexed position of the\\n neck.\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2152-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 75890,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Atrial fibrillation/flutter. Coronary artery disease. Left ventricular function.\\nHeight: (in) 57\\nWeight (lb): 139\\nBSA (m2): 1.54 m2\\nBP (mm Hg): 91/38\\nHR (bpm): 78\\nStatus: Inpatient\\nDate/Time: at 14:46\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is mildly dilated.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. A\\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\\n\\nLEFT VENTRICLE: Overall left ventricular systolic function is severely\\ndepressed. There is no resting left ventricular outflow tract obstruction.\\n\\nRIGHT VENTRICLE: Right ventricular chamber size is normal. Right ventricular\\nsystolic function appears depressed.\\n\\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\\nstenotic. No 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. There is no significant mitral stenosis. Moderate to severe\\n(3+) mitral regurgitation is seen.\\n\\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Mild\\ntricuspid [1+] regurgitation is seen. There is moderate pulmonary artery\\nsystolic hypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\\n\\nPERICARDIUM: There is no pericardial effusion. There is an anterior space\\nwhich most likely represents a fat pad, though a loculated anterior\\npericardial effusion cannot be excluded.\\n\\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. The\\nrhythm appears to be atrial fibrillation.\\n\\nConclusions:\\nThe left atrium is mildly dilated. Overall left ventricular systolic function\\nis severely depressed (ejection fraction 20-30 percent) secondary to severe\\nhypokinesis of the anterior septum and anterior free wall, with extensive\\napical akinesis. Right ventricular chamber size is normal. Right ventricular\\nsystolic function appears depressed. The aortic valve leaflets (3) are mildly\\nthickened but not stenotic. No aortic regurgitation is seen. The mitral valve\\nleaflets are mildly thickened. There is no mitral valve prolapse. Moderate to\\nsevere (3+) mitral regurgitation is seen. The tricuspid valve leaflets are\\nmildly thickened. There is moderate pulmonary artery systolic hypertension.\\nThere is no pericardial effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178685,\n \"text\": \"Atrial fibrillation\\ndemand ventricular pacing\\nMarked left axis deviation\\nIntraventricular conduction defect\\nInferior infarct - age undetermined\\nAnteroseptal infarct - age undetermined\\nLateral ST-T changes may be related to electronic pacemaker\\nRepolarization changes may be partly due to rhythm\\nLow QRS voltages in limb leads\\nSince previous tracing of : no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178918,\n \"text\": \"Tracing taken with a magnet. Atrial fibrillation with a rapid ventricular\\nresponse. Intermittent ventricular pacing. Compared to tracing #2 ventricularly\\npaced rhythm is more frequent. The intrinsic ventricular response is faster.\\nClinical correlation is suggested.\\nTRACING #3\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178919,\n \"text\": \"Atrial fibrillation with a moderate ventricular response. There is intermittent\\nventricularly paced rhythm. Compared to tracing #1 intermittent ventricular\\npacing is new. Clinical correlation is suggested.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178920,\n \"text\": \"Atrial fibrillation with a moderate ventricular response. QRS duration is\\nslightly greater than 0.12 - most likely left bundle-branch block. Cannot rule\\nout old anteroseptal myocardial infarction. No previous tracing available for\\ncomparison.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178680,\n \"text\": \"Atrial fibrillation with ventricular response and occasional demand ventricular\\npacing\\nLeft axis deviation\\nPossible Inferior infarct, age indeterminate\\nConsider old anteroseptal myocardial infarction\\nSince previous tracing, rate is slower\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178681,\n \"text\": \"Atrial fibrillation with rapid ventricular response\\nDemand ventricular pacing and ineffective stimuli\\n*** complex QRS morphology - no further analysis ***\\nPossible inferior myocardial infarct\\nECG Taken with magnet\\nSince previous tracing of : ventricular pacing is seen\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178682,\n \"text\": \"Atrial fibrillation with rapid ventricular response\\nLeft axis deviation\\nLeft bundle branch block\\nPossible inferior infarct - age undetermined\\nECG Taken without magnet\\nSince previous tracing of : ventricular pacing not present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178683,\n \"text\": \"Atrial fibrillation\\nDemand ventricular pacing\\nMarked left axis deviation\\nConduction defect of LBBB type\\nLow QRS voltages in limb leads\\nSince last ECG, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2152-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178684,\n \"text\": \"Atrial fibrillation with rapid ventricular response\\ndemand ventricular pacing\\n*** complex QRS morphology - no further analysis ***\\nECG Taken with magnet\\nSince previous tracing of : no significant change\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430772,\n \"text\": \"CCU NPN 0700-1900\\nS/O:\\n\\nCV: NATRECOR UNCHANGED. PT LASIX 20 MG IV WITH VIGOROUS DIURESIS. C/O AND C/I ACTUALLY SLIGHTLY LOWER AFTER DIURESIS BECAUSE HCT INC TO 37. BP TOL DIURESIS WELL. PT CONT IN AF, RATE 70'S-130'S WITH OCC PVC'S. K 3.7, REC'D 40 KCL PO X1. HEP AT 7O0U/HR, PTT PND. PAD'S, CVP'S AND PCWP SLIGHTLY.\\n\\nRESP: TOL VENT WELL WITH ABG SLIGHTLY ALKALOTIC. FI02 INC TO 50% AND PEEP FROM 6 TO 5, ABG PND. SUCTIONED Q2-3H FOR THICK WHITE SPUTUM. LUNGS RHONCHOROUS IN AM ANTERIORLY BUT BY PM LUNGS MOSTLY CLEAR WITH SOME EXP WHEEZE POST. OVERBREATHING VENT 2-3 BREATHS.\\n\\nID: LOW GRADE CORE TEMP IN 99'S. ABX CONT. PACER SITE D/I WITH NO DRNG.\\n\\nGI: TF INC TO 45CC/HR, LOW RESIDUALS. PT INC SOFT STOOL FREQ IN SMALL AMOUNTS. SECOND C-DIFF CX SENT. POS BS.\\n\\nGU: URINE WITH SOME WHITE SEDIMENT. NEG 450CC FOR TODAY. WT DOWN.\\n\\nMS: OPENING EYES, NODDING YES AND NO TO QUESTIONS FROM FAMILY. REC'D FENT/VERSED Q2-3H BEFORE TURNING. PT C/O BACK PAIN AT ONE POINT, RELIEVED WITH FENT.\\n\\nSKIN: AREAS WITH YEAST IMPROVING, NO OTHER SKIN BREAKDOWN. PT PLACED ON FIRST STEP MATTRESS AND PNEUMOBOOTS APPLIED.\\n\\nENDO: BS 190 FOR HIGH, REC'ING SS REG INSULIN PRN.\\n\\nA/P: IMPROVING HEMODYNAMICS.FOLLOW K LATER TODAY. ? FURTHER DIURESIS TONIGHT. ? START ACE OR BETA BLOCKER TONIGHT. ASSESS TOL TO TF. PLACE RECTAL BAG IF SKIN STARTS TO BREAK DOWN WITH STOOL. ADJUST HEP ACCORDING TO PTT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430773,\n \"text\": \"NEURO: SEDATED WITH FENTANYL & VERSED PRN. AROUSABLE TO VOICE STIMULA-\\n TION. DOES NOT FOLLOW COMMANDS ? D/T LANGUAGE BARRIER. OPENS\\n EYES SPONTANEOUSLY. APPEARS TO UNDERSTAND FAMILY MEMBERS THAT\\n SPEAK WITH HER. MAE.\\nRESP: ON VENT: .50X450 +AC 12 & 5 PEEP. BS CLEAR BUT DIMINISHED AT R.\\n BASE. RR . O2 SAT 95-97%. SX FOR SM.-MOD. AMTS THICK\\n WHITE-YELLOW SPUTUM. ABG 7.44/36/109/25->7.44/36/78/25. RISB\\n 93.5.\\nCARDIAC: HR 90-120 AF WITH RARE PVC. BP 101-131/46-66. PAD 28->23, CVP\\n 15->12, W 24->21. HEPARIN GTT INFUSING AT 700U/HR. PTT 57.2.\\n HEPARIN GTT INCREASED TO 800U/HR PER PROTOCOL. REPEAT PTT\\n PENDING. CONT. ON NATRECOR GTT AT .02MCG/KG. MVO2 SAT 60->61.\\n CO 3.7/2.3/1254. HCT 34.\\nGI: ABD. SOFT. BS+. OGT IN PLACE FOR TF: FS PROMOTE WITH FIBER @ GOAL\\n RATE 45CC/HR. RESIDUAL 140CC->TF OFF X 21/2HRS, THEN RESTARTED AT\\n 45CC/HR. MINIMAL RESIDUALS. INC. STOOL X2 SM.->LG. AMT. BROWN\\n LOOSE STOOL.\\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. LASIX 20MG VP X1->\\n DIURESED >2L. U/O PRESENTLY 30-80CC/HR.\\nID: T(MAX)99.9(TD). CONT. ON IV VANCO, FLAGGYL, & IMIPENUM.\\nENDO: BS 176->175. TREATED PER SLIDING SCALE.\\nAM LABS PENDING.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430801,\n \"text\": \"CCU NURSING NOTE 7A-7P\\nS. REMAINS INTUBATED\\n\\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\\n\\nID: TEMP 99.1 PO MAX WBC 9.1 OFF ANTIBX\\n\\nCV: HR 65-109 AFIB W/VENT PACED BEATS, LOPRESSOR 37.5 ; DIG .25\\n BP 100-140'S/40-60 RECEIVING CAPTOPRIL 75 TID, PA LINE D/C'D LAST CO/CI/SVR = 3.8/2.36/1221; TLC PLACED IN RIJ (NEW SITE) CXR CONFIRMED PLACEMENT; LASIX 20 IV X1 W/~1500CC DIURESIS - 800 NEG TODAY LOS 7600+\\n\\nNEURO: PT VERY AFTER RECEIVING 6AM FENTANYL BOLUS - VERSED GTT D/C'D AT 0730, DID NOT RESTART - PT AWAKE ALT W/PERIODS SLEEP, CALM EXCEPT DURING PERIODS VIGOROUS STIMULATION IE SUX, APPEARS TO UNDERSTAND WHEN FAMILY SPEAKS IN HUNGARIAN\\n\\nRESP: SIMV + PS CHANGED ~ 1000 TO 15 PS/5 PEEP THEN LATER DECREASED TO 12 PS/5 PEEP - 1600 ABG 7.56/35/132/32/9 REPEAT 7.48/42/79/32/6\\nSATS 94-100%, CONTINUES TO HAVE CHEYNES- RESPIRATIONS - LUNGS COARSE AT BASES TO CLEAR, SUX Q1-2 HR FOR THIN, WHITE SECRETIONS\\n\\nGI: PROMOTE W/FIBER @ 45CC/HR VIS NGT W/MINIMAL RESIDUALS, LARGE LOOSE GOLDEN STOOL X1\\n\\nENDOCRINE: FS @ 1200 FS 69 - REPEAT 1715 67 AFTR TUBE FEEDS OFF X 2-3 HRS FOR LINE PLACEMENT (RECEIVED 14U NPH USUAL DOSE IN AM)\\n\\nGU: FOLEY DRAINING CLEAR YELLOW URINE\\n\\nSOCIAL: SON/DAUGHTER IN TO VISIT THIS EVENING, UPDATED REGARDING CARE\\n\\nA: VARYING ABG'S - ? SECONDARY TO WHERE ABG DRAWN IN PATIENTS CHEYNES- CYCLE; PH ^ ? SECONDARY CONTRACTION ALKALOSIS\\nDIURESING WELL TO LASIX 20 IV\\n\\nP: MONITOR HR/RHYTHM, BP, CONT DIURESIS QD, PRN; MONITOR ABG'S AND SLOWLY WEAN PRESSURE SUPPORT AS TOLERATED, ? NEED FOR DIAMOX TO RX PH;\\n FOLLOW FINGER STICKS, MONITOR PT'S LEVEL OF COMFORT OFF SEDATION; CONTINUE ATIVAN 1MG PO TID AND ADD SEDATION IF NEEDED FOR COMFORT; KEEP FAMILY UPDATED REGARDING PT'S CONDITION AND PLAN OF CARE, CONTINUE SUPPORTIVE CARE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430802,\n \"text\": \"CCU NURSING ADDENDUM - 1830\\nCXR NOTED ETT TO BE ~ 2 CM ABOVE CARINA - TUBED PULLED BACK AND RETAPED FROM 21 AT LIP LINE TO 20CM AT LIP LINE' REPEAT FINGER STICK AT 1815 = 78; WILL CONTINUE TO FOLLOW.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430803,\n \"text\": \"CCU NURSING ADDENDUM 1900\\nPRESSURE SUPPORT DECREASED TO 10; TV'S DECREASED TO 150-200, RR 38; HR UP TO 90-110 AFIB, BP 130'S, O2 SATS DECREASED TO 90; PT ALSO WITH INCREASED COUGHING, VERSED RESTARTED AT 1MG IV, RESP PAGED TO CHANGE PT BACK TO PS 12.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430811,\n \"text\": \"CCU progress note 7a-7p\\ncorrection!\\n\\nstated above pre intubation - meant to type pre extubation!!!\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430812,\n \"text\": \"CCu Nursing Progress Note\\nS:\\nO: See for all objective data\\nAfebrile\\nHR 70's afib with no vea and occasional paced complex. Tolerated lopressor 50mg \\nBP 130-150/50-60 Tolerated 75mg po captopril x2 with small drop in bp to 110// Heparin cont 750u/hr with PTT pnd.\\nResp coarse bs which clear post cpt and coughing. Producing sputum, but pt swallows. Attempting to use sx catheter. O2 sat 97-100% on 2ln/l and 40%face tent\\nu/o 40-60cc/hr is cloudy yellow\\nGI - tolerated sips of water with po meds. No gag or difficulty. abd is soft with +bs and no stool this eve.\\n4mm-4mm decub noted on coccyx, covered with tegaderm after being washed with soap and water\\nTurned and positioned with compresion sleeves on\\nA: tolerating po's/sips with meds\\nP: Swallow study cx for ? asp difficulties. cont attempt at clear liqs, ?oob today, monitor sugars as pt is not getting tf's.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430827,\n \"text\": \"CCU NPN 0700-1900\\nS/O:\\n\\nCV: HR INC TO 90'S UNTIL 50 LOPRESSOR GIVEN AT 1100, HR THEN TO 70'S-80'S AF. BP STABLE. K WNL THIS AM, POOR RESPONSE TO LASIX 40 MG PO BUT PT STILL NEG FOR TODAY. MAG REPLETED PO AND IV. INR 5, WILL GIVE VITAMIN K SC X1.\\n\\nRESP: O2 WEANED DOWN TO 2LNP WITH SATS IN MID 90'S. LUNGS WITH CRACKLES 1/2 UP. NO SOB, RR COMFORTABLE.\\n\\nID: AFEB, WBC WNL\\n\\nGI: LIQUID STOOL THIS AM SO MOM HELD. PT WITH IMPROVED PO INTAKE OF PUREED FOOD. ABLE TO TOL PILLS WELL WHEN CRUSHED IN APPLESAUCE. 1/2 NS INC TO 75CC/HR TO PROVIDE ADEQUATE FLUID. PT STILL C/O OCC BELLY PAIN.\\n\\nGU: URINE WITH SEDIMENT AND SOME HEMATURIA. U/A, C/S SENT. NO C/O URGENCY\\n\\nMS: OOB ALL DAY, SPIRITS BETTER WITH FAMILY IN ROOM. PER FAMILY, MS IS CLOSE TO BASELINE WITH SOME INC IN DEPRESSION NOTED.\\n\\nA/P: QUIET DAY, PLAN IS TO REPEAT SWALLOW TEST TOMORROW AND ASSESS NUTRITION. CONT TO ENCOURAGE OOB AND INC ACTIVITY. ? REHAB EARLY IN WEEK.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430828,\n \"text\": \"CCU NURSING PROGRESS NOTE\\nS:PT ANSWERING IN ENGLISH VERY FEW WORDS\\nO:PT AWAKE, ALERT FOLLOWED MOST COMMANDS. GRASPS EQUAL. PT DENIES PAIN. RESP:LUNGS W/ CRACKLES UP 1/2 BILAT AND UNCHANGED. O2 SATS REMAIN 96-97%. PT W/ PROD COUGH OF BLOOD TINGED SECRETIONS. SKIN WARM AND DRY. CV:MHR AFIB W/ OCCAS V-PACED BEATS. DP PULSES PALP. VS STABLE. +SYS MUR. GI:ABD SOFT DISTENDED ABLE TO TAKE MED CRUSHED IN CUSTARD. SM STOOL SMEARING. GU:AMBER COLOR URINE, SOME HEMATURIA,SEDIMENT,W/ FOUL ODOR,C+S PENDING.SKIN:PERI AREA AND GROIN SLOWLY IMPROVING W/ MACONAZOLE PWD.\\nA/P:SWALLOW MON. PT AND OT FOR RECONDITIONING,MONITOR PT/INR\\nPULM TOILETING AS NEEDED HAVE FAMILY TRANSLATE. PROVIDE INFORMATION AND ANSWER QUESTIONS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430829,\n \"text\": \"ccu npn\\nsee transfer note/referrals also\\no- afebrile. started on bactrim for uti, then changed to levoquin and re'd 500mg po x1 today, then 250mg po x 4days.\\ncv- hr 60-80s af, no vea. bp 120-140s/. k-3.6, re'd 40meq iv x1, to start po tomorrow. mg 1.9, re'd 2amps mgso4 iv x1. hct 30.4 inr 3.8.\\ncoumadin on hold.\\nresp- on 2l sats 94-98. l/s cxs/coarse 1/2 up l>r. no sob. on ivf 1/2ns at 75cc/hr d/t poor po in. u/o low in am 15-20cc/hr, then diuresed about 500cc over pm after po lasix.\\ngi-for repeat swallowing study in early am, transient nausea but no vomiting after study. may have thickened liquids, pureed foods per s+s, asp. precautions. app. poor, needs assist with feeding. enc self feeding. refused most of dinner and refused some food brought in by fx, ?upset stomach. no bm.\\nactivity- oob to chair after rested from swallowing study. transferred poorly, requiring max. assist from . oob for 4hrs.\\nms- alert, dozed in naps after activity. oriented x1-2, difficult to understand, speech is hoarse and low, and language barrier. cooperative. non verbals appropriate.\\nsocial- dtr/husband in , updated on pt status, s+s study and plan for d/c to rehab tomorrow.\\nd/c- ?to rehab/ tomorrow, either or . nsg referral done, f/u md d/c summary.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430830,\n \"text\": \"addendum\\nsend clot in am for tlc d/c (risk bleeding). may require ffp prior to removal.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430813,\n \"text\": \"CCU progress note 7a-7p\\nOOB to chair this afternoon. Speech and Swallow in to see pt earlier this morning, but didn't do well - ?language barrier - gave meds this afternoon w/ no coughing - using thickened liquids - tolerated well. no NGT inserted yet. Speech + Swall to re-eval. Aspiration precautions.\\n\\nNEURO: moves arms well. talking hungarian - nodding head to questions of 'okay' or 'water'.\\n\\nRESP: CPT given with turns. to ask family to instruct pt in hungarian to use incentive spirometry. O2 2L n/c w/ sats >97%. expectorating clear thin secretions. pt taught to use yankhaur suctioning.\\n\\nCARDIAC: AFIB w/ occ paced beats. Lopressor changed to Toprol XL. Tolerating captopril 75mg TID. MAPs >80-100s. ?anxiety factor? L radial aline patent. RIJ TLC patent. HEPARIN @ 750u/hr.\\n\\nGI/GU: foley patent, good u/o - slightly cloudy. no diuresis today. abd soft +BS no stool today +flatus. taking thickened water for meds without coughing this afternoon - asp prec.\\n\\nPLAN: pulm toliet. monitor VS. ?antianxiety meds if needed. family to visit this evening.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430804,\n \"text\": \"CCU NURSING PROGRESS NOTE\\nS:INTUBATED\\nO:PT WITHDRAW, FLAT AFFECT, PT DOES NOT MAKE EYE CONTACT EVEN WHEN NAME CALLED. DISCUSSED PT SYMPTOMS WITH DAUGHTER PER TELEPHONE. DAUGHTER STATED SHE WAS TAKING PAXIL SINCE THE DEATH OF HER SON THREE YEARS AGO. THE ABOVE INFORMATION WAS REPORTED TO DR. . PT DOES NOT FOLLOW COMMANDS. SHE DOES MORE UPPER EXTREMITIES. WITHDRAWS LE TO NOXIOUS STIMULI. PT RESIST ORAL SUCTIONING WITH YANKAUER. STRONG COUGH AND GAG REFLEX. PT ALLOWED TO REST INBETWEEN CARE. REMAINS ON VERSED GTT AT 1MG/HR.\\nRESP:VENT WAS ADJUSTED PSV UP TO 15. PT WITH IRREGULAR RESP PATTERN. PAUSES TRIGGERED APNEA ALARM, RT AWARE. NOW PSV BACK DOWN TO 12 WITH TV 330-420, RR 11-26. SATS MAINTAINED 94-97%. LUNGS WITH COARSE BS IN UPPER LUNGFIELDS. BASES DIMINISHED. SKIN PINK, WARM, AND DRY. NAIL BEDS PINK, W/ BRISK CAP REFILL.\\nCV:MHR DECREASED TO 80'S A-FIB, OCCASIONAL V-PACED BEATS AT REST.\\nGI:TOL TF. INC OF SM LIQ STOOL.\\nGU:U/O BECOMING MORE CONCENTRATED.\\nENDO:BS ARE MORE STABLE AT THIS TIME.\\nID:TEMP UP, REPEAT BC\\nSKIN: PT W/ AN EXCORIATED PERIRECTAL AREA. REDDENED PERIRECTAL AREA\\nMICONAZOLE APPLIED.\\nFAMILY:DAUGHTER UPDATED ON PT STATUS.\\nA/P REPEAT BC SENT, TYLENOL GIVEN. CONTINUE TO MONITOR TEMP,CBC, CXR IN AM. RECHECK RISBI THIS AM. ATTEMP WEANING IN AM. SEE FLOW SHEET FOR ADDITIONAL INFORMATION.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430805,\n \"text\": \"Respiratory Care:\\n\\nPatient remains intubated on Psv. Vent settings Psv 12, Cpap 5, Fio2 40%. RR increasing to low to mid 30's. Psv increased to 15 with good results. RR decreasing to 12-mid teens. Psv later weaned to 12. Spont vols 340-400's. Abg reveal metabolic alkalosis. Sx'd for sm amounts of thick white sputum. RSBI 194. RSBI improved from yesterday. No further changes made. Increased fluid. Slow wean. Continue with Psv as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430806,\n \"text\": \"CCU NURSES NOTE\\nO:ABG W/ DECREASED PAO2 TO 67 WHILE PT SLEEPING. PT SUCTIONED AND STIMULATED O2 SAT IMPROVED AND PAO2 UP TO 90. U/O ALSO DECREASED WHILE SBP LESS THAN 110. SEE FLOWSHEET FOR MORE INFORMATION. LASIX ORDERED. PERI RECTAL AREA, GROIN,AND LABIA REDDENED AND EXCORIATED, MICONAOLE POWDER APPLIED TO AFFECTED AREA. M-POWDER APPLIED TO REDDENED PEELING SKIN UNDER BOTH AXILLA-REPORTED TO MD.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430807,\n \"text\": \"CCU NURSING 7A-7P\\nS. REMAINS INTUBATED\\n\\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\\n\\nNEURO: PT AWAKE ALTERNATING W/PERIODS OF SLEEP, EYES OPENING SPONTANEOUSLY, MOVING UPPER EXTREMITIES PURPOSEFULLY, NODDED HEAD X 1\\nTO RN - DIFFICULT TO ASSESS STATUS SECONDARY TO HUNGARIAN SPEAKING BUT APPEARS WITHDRAWN; REMAINS ON VERSED 1MG/HR, ATIVAN 1MG PO TID\\n\\nID: TEMP MAX 100.8 R - TYLENOL 650 X1, WBC STABLE AT ~9.5, ? VAGINAL YEAST W/SEVERE REDDNESS OF LABIA, GROIN AREA, WHITISH DISCHARGE NOTED, DOSE DIFLUCAN GIVEN\\n\\nCV: HR 60'S TO 90'S W/BURSTS TO 120 AFIB, NO VEA, LOPRESSOR INCREASED TO 50MG , BP 109-170/40-60'S, CAPTOPRIL 75MG TID - TOLERATED WELL\\nLASIX 20MG IV THIS AM W/ONLY 400CC U/O, REMAINED 200CC+ FOR DAY - 1700 RECEIVED LASIX 40MG IV W/EXCELLENT RESPONSE THUS FAR ~ 700CC IN FIRST HOUR; HEPARIN CONTINUES @ 700U/HR W/PTT 76; 4.0 - RECEIVED 40 PO\\n\\nRESP: VENTED ON PS 12/5 PEEP 40%, ABG @ 1600 AFTER 1 DOSE DIAMOX - 7.49/40/99/31/6 - 1730 PS DOWN TO 10 W/INITIAL TV'S 200-350CC, RR 20-30, RESP PATTERN MORE REGULAR TODAY W/ LESS PERIODS OF CHEYNES-/APNEA NOTED, DAUGHTER STATES SHE IS \\\"ALMOST POSITIVE SHE HAS SLEEP APNEA AT HOME. SHE SNORES LOUDLY THEN STOPS ALTOGETHER THEN STARTS UP AGAIN\\\"; LUNGS REMAIN COARSE W/THIN WHITE SECRETIONS FROM ETT\\n\\nGI: PROMOTE W/FIBER AT 45CC/HR - MINIMAL RESIDUALS GUIAC NEGATIVE, LT BROWN SOFT STOOL X2 - GUIAC NEGATIVE, ABDOMEN SOFT, OBESE, NON-TENDER\\n\\nGU: FOLEY DRAINING CLEAR YELLOW URINE - UA/C+S SENT\\n\\nENDOCRINE: FS 120-140, RECEIVED 14 NPH IN AM, NO SS NEEDED\\n\\nSOCIAL: DAUGHTER , HUSBAND IN TO VISIT, UPDATED REGARDING PT'S CONDITION, PROGRESS MADE\\n\\nA: HR HIGHER THAN PAST COUPLE DAYS - ? SECONDARY TO LOW GRADE FEVER - NOT COMPLETELY BETA-BLOCKED DESPITE INCREASE IN LOPRESSOR\\nRESPONDING VERY WELL TO 40MG IV LASIX, RESP LESS IRREGULAR - ? SEC TO IMPROVED HEART FAILURE\\nTOLERATING 10 PS SO FAR - ABG PND\\n\\nP: FOLLOW RESP RATE/RHYTHM, VITAL SIGNS, ASSESS RESPONSE TO LASIX, REPELTE LYTES AS NEEDED, FOLLOW TEMPS/WBC, TYLENOL, PRN, ASSESS YEAST INFECTION, CONT MICONAZOLE POWDER, CONTINUE TO WEAN VENT AS TOLERATED, CONT DIAMOX AS ORDERED, MONITOR ABG'S, TIDAL VOLUMES; CONTINUE TO KEEP FAMILY INFORMED OF PLAN OF CARE, CONTINUE SUPPORTIVE CARE FOR PATIENT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430808,\n \"text\": \"CCU NURSING PROGRESS NOTE\\nS:VENTED\\nO:PT WITH EYES OPEN BUT HAD NO EYE CONTACT WHEN HER NAME IS CALLED. MAE, DOES NOT FOLLOW COMMANDS, LANGUAGE BARRIER. CALM ON VERSED GTT, HAS NOT REQUIRED ANY ADDITIONAL SEDATION.\\nRESP:RR UP, TV 200S, PSV INCREASED BACK TO 12 WITH IMPROVEMENT IN RR AND TV. O2 SATS REMAINED >95%. LUNGS W/ COARSE BS AND CRACKLES AT RIGHT BASE. PT SUCTIONED FOR THIN WHITE SECRETIONS. LARGE AMTS OF ORAL SECRETIONS. PT RESISTS MOUTH CARE.\\nCV:MHR AFIB W/ OCCASS V-PACED BEATS. DP PALP, SEE FLOW SHEET FOR VS\\nGI:TOL TF, MIN RESID, +BS. NO BM.\\nID:TEMP DOWN TO 99.4\\nENDO:BS W/IN PARAMETERS, NO COV.\\nSKIN:REDDENED, EXCORIATED PERI AREA, APPEARS TO BE IMPROVING\\nSOC:SPOKE W/ DTR FOR UPDATE ON PHONE\\nA/P:FAILURE TO WEAN, CONTINUE TO DIURESE, RSBI IN AM, ATTEMPT WEANING IN AM. EVAL FOR TRACH, OOB TO CHAIR. BC PENDING.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430765,\n \"text\": \"CCU Nursing Progress Note 1900-0700:\\nS-Intubated and sedated\\n\\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VS\\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\\n\\nO-MS:Arousing to stimuli and voice. Pt appearing more agitated than previous pulling at restraints and found pulling att ETT suction catheter. Recieving Versed and Fentanyl (1mg and 50mcgs times three doses with good effect), resuming 0.5mg and 25mcg dose thereafter Q1-2hr.\\nCV:HR 70s to 100s. Afib with intrisic beats and occasional pauses. Periods where pacer not sensing. Attempting to document on EKG, unsuccesful. Dopa shut off for increasing run of RAF/VT. Levo restarted at previous dose and titrated to MAP > 60. CVP transduced and noted to 15-16 overnight. Left groin TLC removed. Site ecchymotic with no hematoma palpated. Pulses palpable distal. K 3.3 this AM with repletion begun.\\nRESP: LS course throughout. Vent: AC/450/12/.50/8 PEEP. SpO2 trending down to high 80s. PO2 down to 60s on gas. Inreased Fio2 to 50%. Later found pt to do same thing, noted to have cuff leak. Issues resolving once leak fixed. Suctioning for thick tan secretion in small to moderate amounts. AM RSBI 88.\\nGU/GI: HUO trending down post Dopa wean. Given two 500cc fluid boluses with some improvement. At MN 9L(+) and 10L for LOS. Abd soft with (+) BSs. Passing flatus. Passing small amount of brown liqiud stool. G(+). TF advanced to GR at 5AM this morning and thus far tolerating well.\\nENDO: FS at MS 149, requiring no coverage and AM FS 190 and treated with sliding scale.\\nHCT: Repeat HCT down to 25. Ordered to transfuse 2UPRBCs. 1st unit in and awaiting 2nd unit from BB.\\nID: Tm 99.1 Tc 98.1. Continues triple Abx. Cultures still pending. WBC noted to be trending up to 17 from 13 this AM.\\nA/P:\\nContinue to monitor.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430766,\n \"text\": \"RESP CARE\\nPT remained intubated and ventilated overnight. Required an inc in fio2 to 50% for a sat of 88. Suctioned for thick tan sput. RSBI done this am=88. Will follow as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430767,\n \"text\": \"Respiratory Care\\nPt remains ventilated with small changes made as a result of ABG resluts. Breath sounds dimished throughout. Sx for small amts of light tan secreations. RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430768,\n \"text\": \"CCU progress note 7a-7p\\nID: initial Cx's show gram neg rods in sputum + yeast in urine. Cdiff cx pnd (need 2 more cultures). BCs pnd. On Flagyl, Vanco, Imipenem. Tmax 99.1 core temp.\\n\\nNEURO: lightly sedated on versed and fenanyl q1-2h. nods head when awake. husband visiting this evening.\\n\\nRESP: LS coarse. sx tan to whitish thin secretions. Sats 94-97%. ABG: 77/32/7.45/20/-4 Vented: AC 450x12 50% peep 6. overbreathing vent when awake.\\n\\nCARDIAC: AFIB 70s-140s (short bursts of RVR w/ lightening of sedation) MAPs 60-70s. weaned off Levo. PA line placed over wire in RIJ. L radial aline patent. goal wedge in the teens.\\nPA 57/35 PCWP 31 CVP 21 CO 3.3 CI 2.05 SVR 1455\\nHEPARIN started @ 950u/hr - ptt due 2400hrs.\\nNATRECOR started @ 0.01mcg/k/min w/ bolus.\\n\\nGI/GU: foley decreased output - BUN 25 CR 0.9. given 1 fluid bolus 500cc prior to PA line insertion - post insertion noting elvated wedge/cvp - started on natrecor for low bp + high wedge/cvp/pa. stooled in small amts - golden loose stool. NGT - TF promote w/ fibre GR 45cc/hr.\\n\\nPLAN: cont' natrecor , check PTT @ mn. keep pt sedated for comfort. collect stool for CDIFF.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430825,\n \"text\": \"CCU NPN 0700-1900\\nS/O:\\n\\nCV: VSS, CONT IN AF. HEP D/C'ED THIS AM AFTER INR HIGH BUT THEN RESTARTED WHEN INR TO 4.9 AT 600U/HR. PTT DUE AT . CAPTOPRIL CHANGED TO ZESTRIL 40 MG QD AND LASIX STANDING DOSE OF 40 MG STARTED TODAY. REC'D 20 MEQ KCL IV BECAUSE PT GAGGED AT ONE POINT WHEN TAKING PILLS MIXED IN CUSTARD, TOL PILLS LATER IN THE DAY. PT NEG 600 FOR TODAY WITH VIGOROUS DIURESIS AFTER PO LASIX. EDEMA IMPROVED, ONLY + IN EXTREMETIES.\\n\\nRESP: WEANED TO 2LNP WITH SATS IN MID 90'S. LUNGS WITH CRACKLES 1/3 UP BILAT, IMPROVED AFTER DIURESIS. NO SOB. OCC PROD COUGH.\\n\\nID: AFEB, WBC WNL.\\n\\nGI: SS INSULIN COVERAGE D/C'ED. PT EATING PUREED FOOD ALTHOUGH SHE DOES NOT LIKE THE TASTE. NO BM, POS BS. 1/2 NS STARTED AT 50CC/HR AS PT UNABLE TO SAFELY DRINK LIQUIDS ACCORDING TO LAST SWALLOW STUDY. PLAN IS TO RECHECK SWALLOW STUDY ON MONDAY. NO EVIDENCE OF ASPIRATION DURING MEALS, PT ABLE TO TAKE PILLS WHEN CRUSHED AND MIXED WITH APPLESAUCE.\\n\\nGU: FOLEY DRAINING CLEAR URINE.\\n\\nMS: PT ASKING APPROPRIATE QUESTIONS, ABLE TO CONVERSE IN BROKEN ENGLISH. COOPERATIVE ALTHOUGH DID NOT WANT TO GET OOB IN AFTERNOON AND TRIED TO GET BACK IN BED HERSELF AT ONE POINT. PT APPEARS DEPRESSED, C/O BEING \\\"SO TIRED\\\" TODAY. ABLE TO TRANSFER TO CHAIR WITH 2 ASSIST AND TAKE FEW STEPS TO PIVOT.FAMILY IN TO VISIT THIS EVENING.\\n\\nA/P: TOL PUREED FOOD. STABLE ON CURRENT MEDS FOR TODAY. CHECK K AND PTT AT . CONT TO ENCOURAGE REHAB AND INC ACTIVITY. SAFETY PRECAUTIONS AS PT DOES NOT FULLY UNDERSTAND ALL EXPLANATIONS. CONT TO PT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430826,\n \"text\": \"CCU NURSING PROGRESS NOTE\\nS \\\"HURTS\\\"\\nO:PT COUGHING AND GAGGING AFTER RECIEVING LOPRESSOR XL W/ APPLESAUCE. PT VOMITED SM AMT OF UNDIGESTED GASTRIC CONTENT. SATS DROPPED TO 91% ON 2L. O2 INCREASED TO 4L. SATS UP TO 94% PT'S FACE ALSO TACHYPNEIC AND DYSPNEIC. LUNGS W/ DEPENDANT CRACKLES ON RIGHT 2/3 UP. SITTING UP PT WITH BIB CRACKLES >ON RIGHT. DR. AND DR. IN TO PT. CXR DONE. PT GIVEN LASIX W/ GOOD DIURESIS. RESP STATUS IMPROVED BUT PT HAVE ASPIRATED. PT WAS NOT ABLE SWALLOW LOPRESSOR. MD AWARE. PT REMAINED NPO AND LOW DOSE MAINT. FLUID WICH ARE TO CONTINUE AS PER DR. .\\nGI:PT RUBBING LOWER ABD, WHEN ASKED, PT REPEATED HURTS. ABD SOFT AND DISTENDED. +BS, PLACED ON BED PAN BUT W/O BM. LATER PT WAS INC OF A SM FORM BM. MD NOTIFIED OF PT .\\nGU:URINE DRK, + HEMATUREA,+SEDIMENT.\\nNEURO:PT ALERT EYES ONPEN BUT SPEAKING MOSTLY HUNGARIAN. PT ABLE TO FOLLOW MOST SIMPLE COMANDS GIVENT WITH GESTURES\\nID: THE PT AFEBRILE\\nSKIN: PERI-AREA REMAINS REDDED SITE CLEANSED. MACONAZOLE APPLI\\nA/P CONTINUE TO MONITOR FOR ASPIRATION PERCAUTIONS. SWOLLOW TO BE REPEATED, MONDAYTO CONTINUE. CONTINURE TO MONITOR HEMODYNAMIC STATUS. OOB TO CHAIR TODAY . PT /OT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430760,\n \"text\": \"CCU admit note 1600hrs\\nSEE FHP for admit note.\\n\\nArrived on floor via med flight from . On LEVO titrated up for sBP 80. Aline inserted. CXR + EKG done. PAN CXd. IVF boluses of NS started. FEBRILE 102 rectal. labs drawn.\\n\\n\\nID: TEMP 102 rectal. BC x 3 sets sent - Fungal Cx sent. Nystatin ordered and applied under both breasts, both axilla and to excoriated reddened groins! New Foley cath inserted, scant urine - send u/a + c+s when enough urine accumulated in catheter. To have femoral line inserted tonite - Cx tip when d/c'd. Noted purulent drainage from TLC site. L s/c pacer site dsg was soaked w/ serous/yellowish drainage - dsg removed and site cleansed w/ betadine. site puffy. abx to be ordered. WBC 35.9 (WBC 12 )\\n\\nNEURO: was paralyzed + sedated for transfer to - woke ~6pm given versed and fentanyl for sedation w/ good effect IVPush. bilat wrist restraints.\\n\\nCARDIAC: AFIB 70-130s. SBP 80-100s. L radial ALine inserted. to have R s/c line d/c'd tonite and new fem line inserted. LEVO titrated for maps 70s.\\n\\nRESP: Vented - sx mod amt tan thick bld tinged secretions. 100%. sats 100%. pm abg pnd. LS coarse. CXR showed pneumonia not chf.\\n\\nGI/GU: new foley inserted - please collect Cx/u/a. abd soft +BS. cleaned up mod amt yellow stool on arrival to CCU. NPO. NGT intact.\\n\\n\\nPLAN: to be collected :urine cx, R s/c TLC tip for cx. admin abx when ordered. con't levo gtt. adjust vent settings per abg results. advance ETT per CXR.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430761,\n \"text\": \"CCU Nursing Progress Note 1900-0700:\\nS-Intubated and sedated\\n\\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN HEMODYNAMICS\\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\\n\\nO-MS:Arousing to voice, when calling pt's name. Looking around and later closing eyes. Pt \\\"slavic\\\" speaking only. Making purposeful movement when hands untied, ie reaching for ETT. Sedated with IVP Versed and Fentanyl, 1mg of Versed and 50mcgs of Fentanyl IVP Q1-2hrs.\\nMAEs on bed.\\nCV:HR 70s to 100s. AFIB with occasional PVCs. Periods where pacer not sensing. Cards aware. K 5.3 and recently down to 5.1. BPs 70s to 180s. IVF boluses continued, given as much as 3Ls of NS overnight, Levo as high at .4mcgs/kg/min. Pt precipitously dropping BPs once boluses finished infusing. Levo currently at .150mcg/kg/min. Dopa later added for \\\"renal perfusion,\\\" with increasing runs. AED placed and continued to monitor. TLL catheter inserted per left femoral sight with difficulty. Site slightly eccyhmotic with no hematoma palpated. Pulses palpable distal. BLEs cool to touch, and slighly mottled.\\nRESP: LSs course with some exp wheeze and crackle at bases. ABGs later with metabolic acidosis and later pt hypoxic. Intially increasing rate with no effect. NaHCO3 given with improvement. PEEP and FIO2 increased with effect. Current vent settings: AC/450/16/.60/10 PEEP. Suctioned for thick tan secretion in small amounts. CXR with some worsening failure vs ARDS, (+) b/l infiltrates.\\nGU/GI: Intially anuric. Post IVFs and higher BPs, HUOs 80-160cc/hr. Since MN 4.7L(+) and for LOS 5.3Ls(+). Creat slightly down to 1.4(1.5) last night, AM pending. Lactate 6.8 post NaHCO3 4.8. AM pending. Abd soft, non-tender with hypoactive sound. NGT in place per CXR. Aspirating for clear aspirate and heme(+). Nutrition c/s'd for AM, for possible start of TFs today. Tiny smear of stool on pad but not enough to guiac or cx.\\nID: Tm 99.0 rectal Tc 98.9 orally. Started on Vanco, Imipenem, and Flagyl. Urine cx and catheter tip cx sent prior. Sputum with prelims of GNR but 25+ PMNs. Blood, urine, and tip pending.\\nHEME: HCT on repeat, 32 down from 37. Continue to monitor. DIC work-up (+) in addition to AST and LD elevation. Question hypoperfusion and continue to monitor.\\nSOC:Family staying for most of night, two supportive daughters. , youngest daughter is ICU RN at Medical Center in NH. is HCP. is eldest daughter and staying overnight. In all three children. is primary contact. In addition husband in and visiting, slavic speaking only as well, very distraut over wife illness and weeping at bedside. Updated by RN and MDs. Very supportive and kind family.\\nA/P: 80 yo female who present to with septic shock with possible sources of sputum, PPM, blood, or urine.\\nPlan for possible swan\\nAnticipate starting of TFs\\nWean pressors as tolerated\\nUnlikely to go to cath lab but anticipate\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430762,\n \"text\": \"Respiratory Care:\\nPt. with marginal oxygenation, requiring increased peep and FIO2>>no RSBI done. ABG's currently showing adequate oxygeantion and a partially compensate metabolic acidosis, with a HCO3 given>>overcompensating for the acidosis, causing a slight alkalosis. ? travel to CT for look at her belly, postponed for now, due to lactate level decreased. OET pulled back at start of shift, with report of repeat CXR with OET in adequate position. Will follow.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430763,\n \"text\": \"RESPIRATORY CARE\\nPT REMAINS VENTILATED WITH CORRESPONDING VENT CHANGES TO ABG RESULTS. BREATH SOUNDS DIMINISHED THROUGHOUT. RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430764,\n \"text\": \"CCU progress note 7a-7p\\nEvents: weaned off Levo, fluid boluses of 2L. Heparin d/c'd. renal dose dopa this afternoon for maps 55 + decreased u/o. New TLC placed in RIJ and L fem TLC to be d/c'd.\\n\\nNEURO: lightly sedated on boluses of fentanyl and versed. pt opens eyes to stimuli, nodding head appropriately to family - nodded head to \\\"okay?\\\". speaks hungarian only - daughters translate if necessary. moves arms when suctioned - soft wrist restraints.\\n\\nID: Tmax 101 early this morning - tylenol given @ 7am. Temp ranging from 99.6 to 98 this evening. Increased doses of IMIPENUM, FLAGYL + VANCO. Cultures still pnd. WBC 13.5 this afternoon (am 19.6). Culture tip of femoral TLC. nystatin to groins, under breasts and axilla - angry red candidal infection (groins excoriated purple/red).\\n\\nRESP: LS coarse, sx'd thin tan secretions. multiple vent changes today - current settings: AC 450x12 peep 8 40% ABG: 7.43/36/80/25/0 sats 94-97%. CXR showing improved failure. sputum Cx: gram neg rods.\\n\\nCARDIAC: AFIB 60s-130s - freq pauses causing paced beats from VVI pacer rate set at 60. short spurts of rapid ventricular response to 100-130s then back to 60-80s. MAPS 50-70s. Dopa initally turned off at 8am. Weaned off LEVO by 1430hrs - total of 2L NS boluses today - on NS @ 100cc/hr. renal dose Dopa restarted @ 3mcg/k/min for low u/o and low maps ~55. Heparin d/c'd. +DIC. INR this afternoon 1.7 (am 2.2). lactic acid 1.9 this afternoon. K + Mg repleated this evening. pm HCT 26.1 (am 31.4) ?dilutional? HO aware. L fem TLC intact, but site comprimised by candidal infection of groins. New site obtained RIJ this evening - CXR pnd.\\n\\nGI/GU: foley patent, decreased u/o - given fluid boluses earlier now on renal dose dopa. BUN 25 CR 1.1 (am 1.3) abd soft +BS. small amt golden loose stool +flatus. very small trace OB in stool - pt's bottom excoriated + has some hemhrroids bleeding. NGT to be advanced and checked in next CXR this evening post TLC insertion. TF started this afternoon - promote w/ fibre @ 15cc/hr GR 45cc/hr.\\n\\nENDO: FS QID, started on SSRI.\\n\\n\\nPLAN: titrate pressors to off as tolerated. monitor u/o. con't IVF. con't TF. monitor residuals. FS QID. remove femoral TLC and send tip for culture. save 1 port on TLC for possible TPN. obtain stool cultures if pt stools.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430821,\n \"text\": \"CCU NPN 1900-0700\\nO: afeb. HR 70-80's afib with V paced beats. BP stable 120-130's/50's. tolerating 75 captopril in eve. u/o 50-100cc/hr. (-) 1L for and (+) 2L LOS.\\n\\nLS diminished bases. 2lNC sats 97%. RR 20-30\\ntaking meds well with pudding or jello either crushed or whole. appears to be swallowing well with no signs of coughing, difficulty.\\n\\npt. appearing anxious in eve, moving all around bed, moving legs up in air and wanting to get OOB. given .25 po ativan with very good effect. pt. slept well and is alert this morning, responding to simple commands. unable to determine orientation d/t language barrier.\\n\\nno stool.\\n\\nheparin 750u/hr. IVF at 75cc/hr while pt. not taking enough po's.\\n\\nA: stable night.\\nP: contin. with PT/OT> rehab screening. needs additional swallow study with flouro/video ? today.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430822,\n \"text\": \"ccu npn\\no- afebrile po.\\ncv- hr climbing 7:30am and re'd ativan .25mg po for anxiety. however, hr cont to rise to 150-160, bp up to 160/ and became acutely sob/diaphoretic, c/o epigastric pain. re'd total lasix 40mg, lopressor 15mg, iv ntg on to 4.3mic/kg/min and 2mg mso4. ivf d/c'd. 02 increased to 6l n/c plus 100%neb with sats up, but still with high rr and labored breathing. on bipap. hr grad down to 80-100s and bp grad. down. unable to obtain ekg d/t very diaphoretic. cxr done showed increased chf, etc. re'd additional lopressor 5mg iv and then usual po dose. hr high 50s-70s af with occ pacing. bp down to 85-90s and iv ntg grad. weaned off. bp up to 100-120s this pm. cont. on heparin, increased to 800units/hr for ptt 60.4, inr 1.5. check pt/ptt in am. k- 4.0. hct 32.\\nresp- as above, on bipap until 11am and back to 6l with sats 94-98, rr down and sob improved. diuresed about 500cc, goal is i+o even today. is neg about 100cc currently. l/s dim, clear upper, cxs on left lower, right lower coarse.\\ngi- on thickened liquids/pureed food and tol well. taking meds with thickened water or applesauce (whole), no coughing. down for swallowing study this pm and verbal result per s+s, ?slight aspiration. vomited lge white at end of study while upright. recommended meds with pureed food only. no liquids. reassess monday.\\nabd soft with b. sounds. epigastric pain gone after am. no bm.\\nms- speaking hungarian, does interact appropriaely nonverbally. ?confused. cooperative.\\nskin- intact, nystatin powder to groins, axilla which are pink. repos side to side with skin care q2-3hrs as tolerated. on back, uppright with sob. has 1st step mattress, pneumoboots.\\nsocial- fx called, no visitors yet today. dtr updated on am event and pt status.\\na- pul edema in am\\np- cont. to monitor for high hr, sob. increase lopressor dose this eve. cont. heparin/coumadin. check k if diuresed again this eve. goal i+o even. hold meals and give pureed food with meds only until further notice. ?ngt. ?repeat swallowing study monday. asp. precautions.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430794,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ S/P PULM EDEMA; MR\\n\\nS- INTUBATED\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\\n\\nCV- HR- 68-81 AFIB/ NO VEA. K- 3.8- 40 KCL.\\nBP- 108/43-125/53. REMAINS ON CAPTOPRIL 75 TID AND LOPRESSOR 37.5 TID AS WELL AS DIGOXIN 0.125.\\nCO/CI/SVR- 3.6/2.24/1444. HEPARIN AT 800U- AM LYTES/CBC/COAG PENDING.\\n\\n PT REMAINS 50% PS- 15; TV- 420-450 WITH RESP RATE- MID 20'S. PH 7.55- 7.48. OFF LASIX CURRENTLY.\\nPO2- 77-88. SX Q 3 HOUR FOR WHITISH THIN SPUTUM.\\nCOARSE BREATH SOUNDS BILATERAL.\\nPAD- 22-24, CVP- , PCW- 22.\\n\\nID- AFEBRILE.\\n\\nGI- TUBE FEEDS 45CC/HOUR- STOOL SOFT FORMED G (-).\\n(+) BOWEL SOUNDS. SS/NPH INSULIN COVERAGE\\n\\nGU- GOOD UO- 40-60CC/HOUR. HELD PM LASIX D/T ALKALOSIS.\\nI/O (-) 1 LITER .\\n\\nMS- VERSED GTT 1 MG.\\nSOME BOLUSES WITH AGITATION.\\nFAMILY IN TO VISIT.\\nDAUGHTER X 2 CALLED, SPOKE AT LENGTH ABOUT PLAN OF CARE\\nCURRENT PROGRESS.\\n\\n\\nA/ PT WITH LONG HOSPITAL COURSE WITH MR/LOW EF/PULM EDEMA- CURRENTLY WITH GOOD DIURESIS C/B PERSISTENT ALKALOSIS.\\n\\nCONTINUE PULM TOILET/WATCH I/O AND PA # AS WELL AS HEMODYNAMICS/CO.\\nMAX RPP/CV MEDS.\\n?DIAMOX IF PERSISTS WITH ALKALOSIS.\\nSEDATION/COMFORT WHILE INVASIVE LINED AND ETT.\\nKEEP FAMILY AND PT AWARE OF PLAN OF CARE.\\nCONTINUE TO WATCH FOR TEMP/FEVER OFF ANTIBX X 3.\\nCULTURE AS NEEDED.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430795,\n \"text\": \"Respiratory Care:\\n\\nPatient remains intubated on Psv. Current settings Psv 15, Cpap 5, Fio2 50%. Spont vols 400's with RR mid teens. Sx'd for moderate amounts of thick white sputum. Bs clear bilaterally. RSBI results 200. PaO2 improving. No further changes made. Continue with Psv as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430796,\n \"text\": \"CCU NURSING NOTE 7A-3P\\nS. INTUBATED\\n\\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\\n\\nID: TMAX 99.7 CORE, NO ANTIBX, UA/C+S SENT, WBC 11 FROM 9\\n\\nCV: HR 60-80'S AFIB, DIG GIVEN, LOPRESSOR REMAINS AT 37.5MG\\nBP 117-141/50-60'S, CAPTOPRIL AT 75MG TID, PAP'S 36-43/17-22, CVP 10-13, LASIX 20MG IV AT 1030 W/ > 1 LITER DIURESIS, SATS 98/66 W/CO/CI AT 1200 - 4.4/2.73 SVR 1036; HEPARIN DECREASED TO 700U/HR FOR PTT 96\\n\\nRESP: REMAINS INTUBATED AT 50% 15 PS/5 PEEP - SATS 98-10%, TV 350-550 W/CHEYNES- PATTERN AND FREQUENT PERIODS OF APNEA, LUNGS REMAIN COARSE THROUGHOUT, SUX FOR SM THIN WHITISH SPUTUM Q 2-3HR; LAST ABG 7.45/47/110/34/7\\n\\nMENTAL STATUS: EASILY ARROUSABLE TO VOICE, DIFFICULT TO ASSESS ORIENTATION SECONDARY TO INTUBATED AND LANGUAGE BARRIER, SLEEPING ON/OFF THROUGHOUT DAY ON VERSED 1MG IV GTT, ATIVAN PO TID CONTINUES FOR PERIODS OF ANXIETY\\n\\nGI: TOLERATING PROMOTE W/FIBER AT GOAL 45CC/HR, MINIMAL RESIDUALS, ABDOMEN SOFT, DISTENDED, MOD GOLDEN SOFT STOOL X1- LG AMT.\\n\\nGU: FOLEY DRAINING CLEAR YELLOW URINE W/SEDIMENT NOTED - UA/C+S SENT.600 CC NEGATIVE THUS FAR TODAY\\n\\nSOCIAL: FAMILY CALLED X2 - WILL BE IN LATER TODAY\\n\\nSKIN: INTACT EXCEPT FOR RED RASH BILAT AXILLA/UNDER BREASTS/GROIN AREA - CLEANSED THIS AM W/SOAP/H20, MICONAZOLE POWDER APPLIED\\n\\nA: IMPROVED CARDIAC OUTPUT/INDEX, ABG BETTER W/ONLY MARGINAL ALKALOSIS, TOLERATING CAPTOPRIL/LOPRESSOR W/GOOD BP AND SLOWER HR\\nCHEYNES- BREATHING CONTINUES\\n\\nP: MONITOR HEMODYNAMICS, INCREASE CAPTOPRIL/LOPRESSOR PER TEAM AS TOLERATED; CONTINUE GENTLE DIURESIS AS TOLERATED, DECREASE PRESSURE SUPPORT TO 12 PER TEAM - FOLLOW ABG'S/I+, RECHECK PTT AT 1630,\\nEMOTIONAL SUPPORT FOR PT/FAMILY, CONTINUE SUPPORTIVE CARE.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430823,\n \"text\": \"77 years old female admitted with S.O.B. Patient has PMHX:CAD,multiple cva's,carotid stenosis,anxiety,depressionand insomnia. Went in acute resp distress this am associated with desaturation. Patient placed on non-invasive ventilation for a while now on 5 liter N/C. vent still in room on stand-by.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430824,\n \"text\": \"NSG NOTE\\n\\nCV: REMAINS IN A-FIB WITH HR 64-74. CON'T ON METROPOLOL XL 100MG/25MG @HS. ALSO ON DIGOXIN. SBP 118-140/38-69 CON'T ON HEPARIN @ 800U/HR AND GETTING COUMADIN 5MG QD.\\n\\nRESP; O2 SATS ACCEPTABLE 97-99%. HAS RALES 1/2 UP BILAT,BUT APPEARS COMFORTABLE AND RR-20'S. M.D. INTO ASSESS BS IN LIGHT OF RECENT EPISODES OF CHF. NO FURTHER ORDERS GIVEN FOR LASIX.\\n\\nGI: TOL CUSTARD AND THICK FOODS WITH MEDS ONLY. REMAINS NPO FOR REPEAT SWALLOW STUDY ON MONDAY. ABD SOFT. +BS NONTENDER ABD. NO STOOL THIS SHIFT. M.D. ATTEMPTED NGT PLACMENT,UNSUCCESSFUL.\\n\\nGU: U/O DOWN TO 10CC-26CC/HR M.D. NOTIFIED. I/O NEG BY 160CC. M.D. WANTS I/O EVEN.\\n\\nSKIN: PACER SITE UNCHG. BUTTOCKS SL REDDENED BUT INTACT.\\n\\nNEURO: WILL SMILE ON OCCASSION. FOLLOWS COMMANDS DESPITE LANGUAGE BARRIER. MAE. RESPONDING WELL TOWARDS FAMILY AND INTERACTING WITH THEM.\\n\\nID: TEMP MAX 96.9\\n\\nLABS: BS 129 NO SSI REQUIERED.\\n\\nSOCIAL: FAMILY IN ON EVES.\\n\\nA: STABLE/DISCHG PLANS IN PROGRESS\\n\\nP; REPEAT SWALLOW STUDY MONDAY\\n ASPIRATION PRECAUTIONS\\n PREPARING FOR D/C TO REHAB ONCE SWALLW ISSUES RESOLVED\\n\\nA: STABLE\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430788,\n \"text\": \"CCU progress note 7a-7p\\naddendum:\\n\\nLasix given at 530pm w/ 400cc out in 30min. To be given evening dose of captopril. Cardiac Calcs pending.\\n\\nBlood Cultures to be drawn later tonite per HO - watching for temp spike - last temp 100.2.\\n\\nFamily in to visit @ 6pm.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430783,\n \"text\": \"CCU progress note 7a-7p\\nNEURO: started on versed gtt for anxiety/sedation - still remains lightly sedated on 2mg/hr - nodding head to questions posed by family - Hungarian speaking only. opens eyes spontaneously, moves arms and legs. to start ativan TID po.\\n\\nID: tmax 99.5 core. remains on flagyl, vanco, imipenem.\\n\\nCARDIAC: AFIB 80-140s - VVI pacer set 60 - SBP 120s. PA line RIJ patent. PA 43/26 CVP 16 CO 3.6 CI 2.24 SVR 1222. L radial aline patent. Heparin @ 800u/hr. Natrecor increased to 0.025mcg/k/min. Captopril 37.5mg TID tolerating well ?increase next dose to 50mg. Lopressor 37.5mg tolerating well.\\n\\nRESP: AC 400x10/50%/5peep - PS wean this evening - alkalotic 7.55ph RR stoking 28-33 to apneic periods <15sec. sats >95%. Sx frothy white this morning, to thick white this afternoon. Diuresed x 2 today. LS coarse, occ exp wheezes. MDI per RT.\\n\\nGI/GU: foley patent. lasix started 20mg IV BID. good diuresis. goal -1L/24hrs. abd soft +BS. + flatus. stooling small amts loose/soft golden stool. guiac neg. TF goal via OGT - promote w/ fibre @ 45cc/hr. FS QID w/ RISS.\\n\\nPLAN: cont' to try to adequately relieve pt's anxiety w/ anxiolytics, increase next dose captopril. monitor u/o for goal -1L for today. con't vent wean as tolerated. Cardiac calcs q4h.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430784,\n \"text\": \"addendum\\nchanged back to AC - poor cardiac calcs at 6pm. given additional dose of captopril 25mg po at 7pm. Recheck calcs at 8pm.\\nAtivan 1mg po given at 6pm - versed gtt off at 7pm until pt is more anxious (maps 58-60).\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430785,\n \"text\": \"Respiratory Care\\nVent settings unchanged this shift. Attempted RSBI @ 4:30am, no effective spontaneous respiratory efforts noted over 60 second period. Suction several times for small amounts of pale white secreations. RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430786,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ RESP FX; MR\\n\\nS- INTUBATED\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\\n\\n PT OFF PRESSORS BUT WITH MARGINAL BP ONCE SEDATED/ BACK ON A/C MODE VENTILATION. INITIALLY- BP- 130-170/ WITH AGITATION AND SEDATED WITH VERSED 2 MG BOLUSES- RESTARTED GTT 2MG-1.5 MG. BP THROUGHOUT SHIFT RANGED FROM 88/47-114/60 WITH MAPS 55-62. HR 100-110'S AFIB WITH BURSTS UP TO 130'S WITH AGITATION AS WELL. HEPARIN GTT FOR AFIB REMAINS AT 800U/HOUR. CO/CI/SVR THIS SHIFT- 2.9-3/1.8-1.86/1000. NO SIGNIFICANT CHANGES WITH LOWER MAPS ON SEDATION.\\nRECEIVED INCREASE CAPTOPRIL DOSE ONCE BP>90/ AND REMAINS ON LOPRESSOR 25 . NO OTHER CHANGE TO MED REGIMEN THIS SHIFT BESIDES INCREASE IN CAPTOPRIL.\\n\\n PT BACK ON A/C- 50/600/10 - BREATHING OVER VENT RATE- 16-20- SUCTIONED FOR THICK WHITISH SPUTUM Q 2-3 HOURS. COARSE SOUNDS BILATERALLY- PAD- 22-28, CVP 14-17, PCW- 22. GIVEN LASIX LATE AFTERNOON- NO MORE THIS SHIFT= STOPPED NATRECOR D/T MARGINAL BP AT 12 AM. HOLDING FURTHER PUSH FOR DIURETICS D/T RESP ALK AND LOW NORMAL CI WITH DIURESIS 7/29 PER TEAM PLAN.\\n\\nID- CORE TEMP MAX- 100 REMAINS ON TRIPLE ANTIBX. NO TEMP /FEVER SPIKE THIS SHIFT.\\n\\nGI- TUBE FEEDS- 45/HOUR PROMOTE WITH FIBER.\\n(+) BOWEL SOUNDS. NO STOOL THIS SHIFT.\\nSS REG INSULIN- HOLDING D/T BLOOD SUGAR < 160.\\n\\nGU- FAIR UO WITH MAPS 55-62= MAINTAINING UO 20-50/HOUR VIA FOLEY CATH.\\nNO DIURESIS THIS SHIFT- SEE ABOVE.\\n\\nMS- HUGE AMOUNTS AGITATION/ BRONCHOSPASTIC, COUGHING AND TONGUING ETT WITH ANY SLIGHT STIMULATION; TACHYPNIC, HTN, TACHYCARDIA WITH AGITATION NECESSITATING SEDATION. GIVEN VERSED 2 MG BOLUSES AND RESUMED GTT AT 2 MG, NOW 1.5 MG WITH SLIGHT IMPROVEMENT IN BP/MAP.\\nDAUGHTER CALLED 11P TO CHECK ON PROGRESS.\\n\\n\\nA/ PT WITH LONG HOSPITALIZATION /RESP FX REMAINS WITH DIFFICULT TO CONTROL RATE/PRESSURE/PRODUCT- LABILE HEMODYNAMICS/\\n\\n-CONTINUE TO ATTEMPT TO DECREASE AFTERLOAD WHILE MAINTAINING MAP>60 WITH CURRENT MED REGIMEN.\\n-CONSIDER RESTARTING PRESSORS IF UO DROPS OR CREAT THIS AM RISES.\\n-CONTINUE TO DISCUSS ? AGGRESSIVE DIURESIS/NOT FOR ELEVATED FILLING PRESSURES/CHF/FX TO WEAN. APPROACH FAMILY WITH CONCEPT OF TRACH IF CONTINUES TO NOT SIGNIFICANTLY IMPROVE FROM RESP STATUS.\\n-SEDATION AND COMFORT TO INSURE PT COMFORT/SAFETY AND VENTILATION,\\n-ATTEMPT TO WEAN TO MINIMAL AMOUNT NEEDED AS WILL DIRECTLY HELP IMPROVED MAP/BP.\\n- KEEP PT AND FAMILY AWARE OF PLAN OF CARE\\n-RATE CONTROL WITH LOPRESSOR, AS BP ALLOWS.\\n- NUTRITION/BOWEL MEDS/SKIN CARE/ SS REG INSULIN PER PROTOCOL\\n- KEEP HEPARIN AT THERAPEUTIC DOSE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430787,\n \"text\": \"CCU progress note 7a-7p\\nNEURO: lightly sedated on versed gtt @ 1mg/hr and ativan 1mg po TID. opens eyes, nods head. hungarian speaking only. family communicates with pt. purposful movements.\\n\\nID: abx D/C'd. Tmax 99.6. con't to monitor for spike in temp. surveylance blood cultures need to be obtained.\\n\\nRESP: LS coarse. frothy secretions this morning pre lasix 20mg ivp - then had clear thick secretions during the day. this afternoon ~4pm having white frothy secretions again. pm dose of lasix held per HO. AC most of day, switched to PS 15/5 50% @ 4pm. pm ABG pnd. sats >97%. RR 11-38 - stoking.\\n\\nCARDIAC: AFIB 90-140s during the day - digoxin load started and now rate AFIB 60-80s this evening. 2nd + 3rd doses of dig IV to be given this evening/nite. PA line RIJ patent. PADs 26-30 CVP 16 PA sats ~ 60% last CO 3.8 CI 2.36 SVR 1200. L radial aline patent. 3+ generalize pitting edema. Remains on Heparin @ 800u/hr. Natrecor remains off. Am captopril dose held. Lopressor 37.5mg . new PIV placed in R hand.\\n\\nGI/GU: foley patent. fair urine output. lasix 20mg ivp given this morning, pm dose held per HO this evening. u/o >30cc/hr. abd soft, +BS. +BS. +flatus. guiac neg. stooling mod amts loose golden stool.\\nENDO: FS QID w/ SSRI and standing dose NPH am/pm.\\nNUTRITION: TF promote w/ fibre @ 45cc/hr. minimal residuals. OGT patent.\\n\\nPLAN: con't to monitor Cardiac Calcs, VS, UO-- complete DIG load. monitor resp status on PS. keep pt comfortable. keep family informed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430789,\n \"text\": \"Resp. Care Note:\\nPt remains intubated and ventilated. Bs coarse throughout. Sx for moderate amounts of white to clear frothy secretions. Pt placed on PSV, tolerating well. ABG within normal limits. Pt has cheynes breathing pattern, Dr . CXR from yesterday showed bilat pleural effusions R>L. Continue on PSV as tolerated, monitor resp. status and vitals.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430790,\n \"text\": \"RESP CARE NOTE\\nPT REMAINS INTUBATED, VENTILATION SUPPORTED VIA PB7200 VENT IN CPAP/PS MODE. CHEYNNE- BREATHING PATTERN NOTED W/ SEC APNEIC PERIODS, VT 350-400CC. BS OCCAS SL COARSE, SXN FOR SM-MOD AMTS WHITE FROTHY SEC. AM ABG REFLECTS UNCOMPENSATED METABOLIC ALKALOSIS W/NORMOXIA. RSBI THIS AM 125. SBT NOT INDICATED. PLAN TO CONTINUE CURRENT SUPPORT, WEAN PER TEAM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430791,\n \"text\": \"CCU NSG PROGRESS NOTE 7P-7A/ RESP FX; MR\\n\\nS- INTUBATED\\n\\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\\n\\n\\n PT REMAINS WITH STABLE HEMODYNAMICS AND BETTER RATE/PRESSURE PRODUCT AS WELL AS CO/CI/SVR ON DIGOXIN/CAPTOPRIL/LOPRESSOR. HR- 60'S AFIB . BP= 130/50- 100/50. RECEIVED LAST OF DIG LOAD AND TO START PO DOSE. REMAINS ON CAPTOPRIL 50, LOPRESSOR 37.5- SEE FLOW FOR CO/CI/SVR VALUES ON CURRENT MED REGIMEN.\\nRECEIVED MG 2 AMPS FOR MG- 1.8.\\nAM LAB PENDING.\\n\\n PT DOING WELL ON PRESSURE SUPPORT 15CM/50%. TIDAL VOLUMES 375-450CC WITH RESP RATE LOW TO MID 20'S CHEYNNE STOKE PATTERN\\nREMAINS WITH COARSE BREATH SOUNDS, DIM AT BASE WITH SUCTIONING Q 1-3 HOURS THICK WHITISH SPUTUM- LESS THICK THIS AM. MUCH ORAL SECRETIONS.\\nROTATED TUBE AND RETAPED.\\nPA- 40/22-50/26. CVP- 14-16. PCW- 22.\\nNO SIGNIFICANT INCREASE OR DECREASE THIS SHIFT.\\n\\nID- AFEBRILE- REMAINS OFF ANTIBX THIS SHIFT.\\nNO TEMP SPIKE, NO CULTURES OBTAINED.\\nWC- 12\\n\\nGI- TUBE FEEDS 45/HOUR, MINIMAL RESID- SMALL AMOUNTS LIX STOOL- BROWN, G (-).\\n\\nGU- FAIR TO GOOD UO- DROPPING OFF LATE EVE- REPEAT 20 LASIX WITH GOOD UO- 800CC DIURESIS.\\nWITH D/C 1000CC ANTIBX- ABLE TO MAKE I/O (-) FOR 1ST TIME- CURRENTLY (-) 500CC.\\nTO REASSESS ? MORE DIURESIS THIS AM.\\nDUE FOR DOSE THIS AM\\n\\n PT AWAKE, FAMILY ALL PRESENT- SPOKE AT LENGTH TO DAUGHTER RE: PLAN OF CARE/NEED FOR DIURESIS PRE-WEANING- LENGTH OF TIME TO TAKE PLACE OVER SEVERAL DAYS, GRADUAL DIURESIS, AND WEAN, ETC.\\nAPPEARS TO UNDERSTAND AND TO RELAY PLAN TO NURSE-DAUGHTER .\\nCALLED X 1 OVERNITE.\\n\\nA/ PT WITH EXTENSIVE HOSPITAL COURSE CURRENTLY TOLERATING GRADUAL DIURESIS/PRESSURE SUPPORT WEAN.\\nREMAINS IN NEED OF GOOD RPP CONTROL AND VENT SUPPORT AS WELL AS SEDATION FOR VENTILATION.\\n\\nCONTINUE CV MEDS FOR GOOD DIASTOLIC FILL/RPP.\\nCHECK AM LABS- REPLETE AS NEEDED.\\nCONTINUE GRADUAL YET AGGRESSIVE AND CONSISTENT DIURESIS -\\nPULM TOILET/SEDATION WHILE INTUBATED\\nNUTRITION/BS COVERAGE.\\nKEEP FAMILY AWARE OF PLAN OF CARE AS WELL AS PT.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430792,\n \"text\": \"CCU progress note 7a-7p\\nNEURO: sedated on ATIVAN 1mg PO TID + VERSED 1mg/hr gtt. opens eyes spontaneously, doesn't nod head to questions today. family called on phone, husband visiting this evening.\\n\\nID: Tmax 100 core temp. Surveylance BC x 2 sent. off all ABX. WBC 9\\n\\nRESP: LS coarse. large amts clear to white sputum. remains on PS - attempted to go to PS 10/5 but PO2 down to 69 w/ decreased TVs sats 89% - increased PS to w/ good TV 300-350s sats 97%. abg 7.48/37/88. This evening pt more tachynpnic w/ TV 250-300 RR 37-44 sats 94%, lg amts clear secretions. abg 7.47/41/69! Increased PS to 15/5. RR decreased to 20-30s - TV increased to >350s. sats ^97%.\\n\\nCARDIAC: AFIB 60-70s occ paced beats. PAD 21 in am ->25 this evening. last CO 4.1 CI 2.55 SVR 1015 CVP 10->15. HEPARIN @ 800u/hr. Digoxin 0.125mg qd, lopressor 37.5mg + captopril increased to 75mg TID - tolerating well. Aline intact. 3+ pitting edema.\\n\\nGI/GU: foley patent. diuresed x 1 today Lasix 20mg. abd soft +BS. + flatus. no stool today. TF Promote w/ fibre @ 45cc/hr via OGT. nutrition on consult.\\n\\n\\nPLAN: con't to monitor resp- adjust PS as necessary per ABGs. con't digoxin for rate control. tolerating increased dose of captopril. con't to monitor Cardiac Calcs q4h. keep pt comfortable. keep family notified of pt condition.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430793,\n \"text\": \"Resp. Care Note:\\nPt remains intubated and ventilated. Bs coarse throughout. Sx for large amounts of thick clear to white secretions. Attempted to wean PSV throughout day, pt tolerated for short time. Returned to PSV 15/5. Pt continues to have - breathing pattern. Continue to wean as tolerated. See carevue for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430780,\n \"text\": \"CCU Nursing Progress Note 1900-0700:\\nS-Intubated and sedated\\n\\nSEE CAREVUE FOR OBJECTIVE DATA AND TRENDS IN VS\\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\\n\\nO-MS:Alert and opening eyes to name. Slavic speaking only. Family at bedside and emotionally supporting and interacting with pt during evening. Appearing comfortable on Versed and Fentanyl push boluses.\\nMAEs on bed and making purposeful movements.\\nCV: HR 70s to 110s. Afib with rare PVCs. K rechecked and 4.1 on eves. Continues to tolerate Lopressor dose, could withstand increases. ABPs 70s to 120s. VSs hypodynamic with sedation on board and hyperdynamic with suctioning or nursing intervention. PAD 21-27, PCWP 24-27, occasionally unable to wedge swan, CIs > 2.0. Captopril increased in attempt to increased COs. increased and CO/CIs improving slightly. Team wanting to increase but BPs currently unable to withstand. Heparin continues at 800u/hr with AM PTT pending and Natrecor at 0.020mcg/kg/min.\\nRESP: AC/400/10/.50/5 PEEP. LS course, occasionally clear in upper fields post suctioning. Suctioning for white thick secretions in small to moderate amounts. Extremely strong gag with suctioning. Tachypenic post with RR mid to high 20s but settling out thereafter.\\nGU/GI: Foley draining golden colored urine. HUO 30-70cc/hr. No further diuresis given overnight. At MN (-) 870cc and (+) 9L for LOS. Plan to futher diurese this AM. Abd soft with (+) BSs. Passing golden-brown stool. Loose in appearance. G(-). TF continue at GR, 45cc/hr.\\nID: Low grade temps. Continue on ABx.\\nENDO: FS at HS 133 and given standing NPH dose. AM FS pending.\\nSOC: Family updated by RN and visiting on evenings. Later going home and later updated by RN over phone.\\nA/P: CHF and PNA c/b septic and cardiogenic shock\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430781,\n \"text\": \"Respiratory Care\\nPt remains ventilated with no changes noted. RSBI checked, 125 with irregular spontaneous respiratory pattern. RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430782,\n \"text\": \"Resp Care: Pt remains intubated via #7.5 ETT secured 21cm at lip. BS bilat E wheezes w/ rhonchi. Sx'd for mod amt white thick sputum. Pip/Plat 24/21. No vent changes made this shift. Please see carevue for further vent inqueries.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430817,\n \"text\": \"CCU NPN 1900-0700\\nO: afeb. HR 70-80's afib. no vEA. occas. Vpaced beats. BP 135-160/40-60. u/o 50cc/hr. IVF D/C'd. (+) 3.3L LOS.\\n\\nheparin 750u/hr.\\n\\nTF increased to 20cc/hr. hands restrained. however pt. self d/c'd NGT ~ 0330. not replaced per HO. pt. able to take meds crushed.\\n\\npt. awake and alert. appearing to doze occas.\\ndaughter called during night and stated that pt. was intermittantly confused yesterday req. freq. orientation. unable to determine d/t language barrier but pt. appears to understand simple commands in english.\\n\\nLS course upper, diminished lower. sats 96-99% on 2-4L NC. RR 20-30. CPT x2. stimulates strong cough, non productive.\\n\\nmoving all extrem. full lift back to bed in eve.\\nTLC Right IJ. foley.\\nno stool.\\n\\nA: pt. pulling out NGT despite hands restrained\\nP: swallow study planned for today. OOB. contin. CPT q4-6hours. crush meds.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430818,\n \"text\": \"addendum\\npt. becoming more anxious, restless ~ 0600, reaching for siderails and motioning to get out of bed. speaking in hungarian. HR up to 90's - 110 AF. BP stable. HO aware. given .5mg po ativan and lopressor XL early crushed. sats 95-96% on 4lnc.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430819,\n \"text\": \"CCU progress note 7a-7p\\nNEURO: sedated this morning from 0.5mg ativan - no further episodes of agitation. MAE. PT/OT on consult. oob to chair - used walker w/ assist of 2 - gen weakness, but did take a few steps. used interpreter for PT excercises and for speech + swallow eval this afternoon. Hungarian speaking - does understand and speak broken english.\\n\\nID: afebrile. no abx\\n\\nRESP: LS coarse, occ congested nonproductive cough. O2 2L w/ sats 93-96%. sl SOB on exertion. CPT w/ turns.\\n\\nCARDIAC: AFIB 120s this morning - now PACED/AFIB 60s-80s. SBP 120s. tolerating captopril 75mg tid. RIJ TLC patent. unable to obtain peripheral access today. HO aware. no aline. veinodynes on.\\n\\nGI/GU: foley patent, sl mucous noted in urine. good u/o. IVF .45NS 100cc/hr while not taking po well. speech and swallow wants video swallow study tomorrow - but pt may take pureed soft diet as tolerated, aspiration precautions. dentures too loose to wear ?denture paste? no BM today. +BS.\\n\\nSKIN: groins slightly reddened, nystatin pwd to groins and under breasts and axilla. no further breakdown on buttocks. barrier cream. on 1st step air mattress. OOB to chair.\\n\\nPLAN: monitor VS -HR/BP. monitor u/o. pulm toliet. emotional support. video swallowing study in am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430820,\n \"text\": \"addendum:\\n\\nLasix 20mg IVP given this evening. monitor u/o.\\nstarted on coumadin this evening also.\\nOnly took a few mouthfuls of pudding this evening - then stated \\\"enough\\\".\\nHusband and grandson visiting.\\nAssisted back to bed by OT w/ walker with assist of 2. Did not weight bear well this time or pivot well.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430776,\n \"text\": \"NSG NOTE\\n\\nCV: REMAINS IN A-FIB. BETTER RATE CONTROL WITH LOPRESSOR INCREASE TO 25MG . CON'T TO HAVE OCCASSIONAL PVC'S K+ RELATED ,RESOLVING WITH REPLACEMENT KCL. CON'T ON NATRECOR 0.02MCG/KG AND HEPARIN 800U/HR. MAP'S REMAIN > 60. HR 80-102. BECOMES MORE TACHY WITH WAKEFUL PERIODS. CO/CI ON CAPTOPRIL 6.25MG: 3.3/2.05 SVR 1479. THIS AM RECEIVED CAPTOPRIL 12.5MG HEMODYNAMICS CO/CI 3.6/2.24 SVR 1244. NO SIGN CHG IN BP. PT WOULD BENEFIT FROM INCREASE IN LOPRESSOR DOSE AS WELL. PAD 24-29,CVP 16-14,WEDGE 26-23.\\n\\nGU: RECEIVED LASIX 20MG @ AND AGAIN @ 0330. AGGRESSIVE DIURESIS NOTED. @ MN PT WAS NEG BY 1200CC,HOWEVER OVERALL LOS CON'T TO BE POSITIVE.\\n\\nRESP: INITIALLY ON CPAP+PS 16 PEEP5. MORE ALKALOTIC ON PS. PT RESTING ON AC OVERNOC. CURRENT SETTINGS AC 50%,VT 400,R-10,PEEP 5. AM ABG'S 7.46,40,81,4,29,97%. PLEASE SEE FLOW SHEET FOR ABG'S AND VENT CHG. SUCTIONED FOR THICK WHITE SECRETIONS. BS CL BILAT RHONCHI AT BASES.\\n\\nGI: CON'T ON TF @ GOAL RATE OF 45CC VIA OG TUBE. RESIDUALS <10CC. HAD 1 STOOL SOFT/LOOSE GOLDEN WHICH WAS HEME NEG. ON PEPCID 20MG QD. ABD IS SOFT NON TENDER.\\n\\nSKIN: PACER SITE SS C&D. CON'T TO HAVE YEAST RASH TO GROIN AREAS AND BREAST HOLDS. MYCOSTATIN AS ORDERED APPLIED.\\n\\nID: LOW GRADE TEMPS NOTED 99.7 WBC DOWN THIS AM TO 14.7 CON'T ON VANCOMYACIN,FLAGYL AND IMINPENIUM. PT HAS IN SPUTUM, + URINE CULTURE/YEAST AND STAPH FROM OLD CVL SITE. PT IS ON DAY 4 OF 7 DAY COURSE.\\n\\nNEURO: ALERT AT TIMES AND WILL OPEN EYES TO VOICE. RESPONDS BY NODDING AND HAS PURPOSFUL MOVEMENTS. SHE IS STILL NOT FOLLOWING COMMANDS. SHE WILL REACH FOR TUBES AND LINES AND AT TIMES ATTEMPTS TO PULL AT THEM. FENTAYL AND VERSED HAVE BEEN GIVEN WITH ADEQAUTE RESULT.\\n\\nLABS: CON'T TO HAVE HIGH BS 170-190. SPOKE WITH TEAM LAST EVE. THEY HAVE ADDED NHP + SSI . OVERNOV BS 182,167. PT @ 2100 2 U REG/8 U NPH.\\n K+ 3.9 LAST EVE RECEIVED 20 MEQ KCL.\\n\\nSOCIAL: HUSBAND AND DAUGHTERS IN ON EVES. THEY HAVE BEEN UPDATE AND SUPPORT GIVEN\\n\\nA: CRITICAL/ DIFFICULT WEAN D/T PULM EDEMA.\\n\\nP; CON'T TO DIURESE\\n CHECK WITH HO. INCREASE LOPRESSOR\\n NEEDS ID APPROVAL FOR VANCO(TEAM IS AWARE)\\n FAMILY SUPPORT\\n PER NSG JUDGEMENT.\\n CPAP+PS TRIALS TO CONTINUE TODAY\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430777,\n \"text\": \"pt.changed from psv to ac for the noc to rest. changes made in vt-decreased to 400, bs with rhonchi, sx for white secretions, will probably switch to cpap, failed wean trial this a.m., became agitated, rsbi 225, pt.reamins alkalotic, with metabolic issues.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430778,\n \"text\": \"Resp Care:Received pt on a/c 400,10,.50,peep5.Attempted cpap/psv wean of 16/5 and .50 with pt lasting approx 1 and 1/2 hours. Pt was having frequent periods of apnea so pt was changed back to a/c. Later in the shift pt appeared more alert so cpap/psv wean was attempted again however pt only lasted about 1 hour. At that time pt had an increase in hr 160bpm so pt was returned to a/c. Plan rest pt overnight and attempted wean in am.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430779,\n \"text\": \"NPN 0700-1900;\\n\\nNEURO; HUNGARIAN SPEAKING LADY INTUBATED AND VENTILATED. SEDATED WITH MIDAZOLAM AND FENTANYL.OPENS EYES SPONTANEOUSLY.MAE SPONTANEOUSLY. FOLLOWS SIMPLE COMMANDS. STUCK TONGUE OUT FOR DAUGHTER.MOVEMENTS ARE VERY PURPOSEFUL WILL ATTEMPT TO PULL OUT TUBES WHEN WRIST RESTRAINTS ARE RELEASED. BECOMES ANXIOUS AT TIMES ESPECIALLY WITH ETT SUCTIONING.\\n\\nRESP; REMAINED ON AC 50% 400 X10 FOR MOST OF DAY., TOLERATED CPAP WITH 16 PS FOR 2 PERIODS OF 1.30 HOURS PLACED BACK ON VENT FIRST TIME FOR PERIODS OF APNEA AND THE SECOND TIME FOR HR TO 160, AFTER SUCTIONING.LUNG SOUNDS COARSE. SUCTIONED Q1-2 HRS FOR THICK WHITE SECRETIONS,SATS 94-96%.\\n\\nCVS. TMAX 37.6 CORE, BP 105-134/57. AFIB 94-121 WITH A BURST TI 150-160 TREATED WITHN BOLUS DOSE OF LOPRESSOR 2.5MGDS I,V, WITH GOOD EFFECT.CI DROPPED TO 1.9 WITH THIS EPISODE REPEAT PENDING.PLEASE SEE FLOW SHEETS FOR DETAILS.\\n\\nGU; GOOD RESPONSE TO LASIX 20 MGS I.V.K 3.5 NEED TO REPLETE.\\n\\nGI; TOLERATING T/F FS PROMOTE WITH FIBRE AT 45 MLS WITH MIN RESIDUAL. HAD SEVERAL EPISODES OF LARGE AMOUNTS OF THICK SEMI FORMED STOOL RECTAL BAG APPLIED BUT NO FURTHER EPISODES SO FAR.FELT THAT THIS CONTRIBUTED TO EXHAUSTION THIS AM. RECEIVING NPH INSULIN BS 174-134.\\n\\nID ;CONTINUES ON TRIPLE ANTIBIOTICS.AWAITING RANDOM.LEVEL RESULT.\\n\\nHEME STABLE HCT 35%\\n\\nSKIN CONTINUES TO HAVE YEAST IN GROIN. BUT UNDER ARMS AND BREAST SEEMS TO HAVE IMPROVED.\\n\\nFAMILY INTO VISIT AND UPDATED WITH PT,S CURRENT CONDITION.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430833,\n \"text\": \"CCU NPN 1900-2300\\nS/O:\\n\\nF/E: 20 MG LASIX GIVEN IV X1 WITH 600 CC U/O. LUNGS CONT WITH CRACKLES AT BASES. SATS IN HIGH 90'S ON 2LNP.\\n\\nGI: INC LARGE AMOUNTS OF STOOL X3, FAILED MUSHROOM CATHETER. FECAL INC BAG ON AND HOLDING. STOOL OB NEG, WITH SOME FORMED STOOL.\\n\\nA/P: HOLD ALL LAXATIVES, CHECK K WITH AM LABS. D/C TO REHAB IN AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430834,\n \"text\": \"CCU progress note 11p-7a\\nUneventful nite. slept in naps. VSS. sats 94-97% on 2L n/c. Took hs po med crushed in pudding. aspiration precautions.\\n\\nNEURO: MAE, gen weakness. speaks/understands small amt broken english - hungarian speaking. Ox2 per family. slight confusion at times. obeys simple commands.\\n\\nID: on levo for UTI. nystatin to reddened groins. afebrile.\\n\\nCARDIAC: AFIB 60-80s. Lopressor increased to 75mg TID - tolerating well. Increased dose of Lisinopril to 60mg po qd. coumadin remains on hold d/t still elevated INR. am labs pnd. RIJ TLC patent - pt difficult access (remove line access prior to discarge to rehab facility).\\n\\nRESP: LS clear, dim/coarse to bases. strong congested occasionally productive cough. O2 2L n/c w/ sats 94-97%. pt took off n/c and on room air w/ sats 88-92% w/ SOB noted. RR 18-32 overnite.\\n\\nGI/GU/ENDO: FS QID - no sliding scale ordered at present - NPH on hold until pt tolerating diet. ASPIRATION PRECAUTIONS. sit pt bold upright for meals/meds - crush meds in puddings/pureed foods - diet of pureed and nectar thick liquids. Abd soft, distended. +BS. +flatus. stooling overnite large amts of yellow liquid stool. slowing down this morning - failed attempts on rectal tube and fecal incont bags. Foley patent. U/O ~30cc/hr. some sediment/mucous noted in urine. on daily lasix 80mg QD w/ daily KCL supplement.\\n\\nPT/OT: pt gets OOB to chair - pivots w/ assist of 2 and walker. on air bed. pneumoboots.\\n\\n\\nPLAN: transfer to rehab facility today if INR WNL. monitor VS. keep pt comfortable.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430797,\n \"text\": \"Resp. Care Note\\nPt remains intubated and vented on settings as per Resp. flowsheet. PSV level decreased this shift from 15-12-10. Good ABG's on PSV 12, ABG pending on PSV 10. Improved oxygenation. Cont present support, wean vent as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430798,\n \"text\": \"D: Please see data, MD notes/orders. Neuro: Pt opens eyes to family, MAE, PERRL. Appears comfortable on versed 1mg/hr and ativan 1mg tid. CV: Afib on monitor, HR 70-90. SBP 100-1teens/60s. PA pressures 35-42/17-20, cvp 12-13. CO/CI 3.7/2.3 with team aware of values.Heparin gtt currently at 700u/hr in theraputic range with last ptt 75. Pulm: Vent changes/settings per care view. Lung sounds coarse, clearing after suction of thin white secretions. Respitory effort unlabored, 02 sat 98%. Latest Abgs per care view.PH 7.5 felt to be due to volume contraction from diuresis after lasix 20mg IVP x 2 today. Pt currently with neg fluid balance 600cc+. GI: Abd soft, bs+, incontinent of med soft brown stool. TF at goal rate, residuals minimal. Skin: surfaces intact, perianal area excoriated. Peripheral pulses palpable. soc: Husband and daughter in this evening. Pts daughter with many questions, Husband speaks minimal english.\\n\\nP: Titrate versed gtt prn pt comfort. Keep heparin gtt 700u/hr, ptt qd and as ordered (goal ptt 60-80). No further vent changes tonight, prn abg's, notify team of any decline in respitory status. Monitor hourly uo with goal neg fluid bal 1L/24hr per team. Provide meticulous skin care, frequent postion changes, barrier cream/nystatin powder prn. Keep family updated on pt condition and plan of care.\\n\\nR: As above, Family updated and agreeable to plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430799,\n \"text\": \"NPN\\nCCU\\n11 PM - 7 AM\\nINTUBATED AND SEDATED\\nS/O PLS SEE FLOWSHEET FOR ALL OBJ/NUMERICAL DATA ..\\nCV HR 60'S PACED RHYTHM...SBP 120-150'S/40-60'S...TOLERATING TITRATION OF LOP/CAPTOPRIL ...PAD 18-22..CVP 8-10...\\nRESP ON 40%..SIMV AND PS ..RATE OF 12 ..INSP TIDAL VOLUMES 250-320...5 PEEP....LUNGS DIMINISHED AT THE BASES ..SUCTIONED FOR SMALL AMOUNTS OF WHITE SXNS ..\\nGI ON PROMOTE AT 45 CC/HR VIA OGT..SMALL SOFT STOOL ..OB NEG..MINIMAL RESIDUALS ..\\nGU 1500 CC NEG AT MN....\\nCOMFORT ..CONTINUES ON VERSED GTT AT 1 MG/HR WITH - 2 MG IVP BOLUS WITH SUCTIONING/BATHING ..TOLERATED WELL...\\nTURNED Q3...\\nA HEMODYN STABLE\\nP FOLLOW HEMODYNAMIC #'S....LABS ..PULM TOILET\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430800,\n \"text\": \"Resp. Care Note\\nPt remains intubated and vented on settings as per Resp. flowsheet. Pt on SIMV in AM after fentanyl given due to low RR and minute vol. Pt changed back over to CPAP/PSV when more awake. Cont to show alkalosis on ABG's. Plan to cont PSV and wean slowly as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430814,\n \"text\": \"CCU NPN 1900-0700\\nO: afeb. HR 70's afib with freq. paced beats.\\nBP 117-140's/60's. increasing to 160-170's/70's during evening. given captopril 75mg at 2200 crushed with custard. BP contin. to remain high. pt. awake, eyes open, responding to name and simple commands. understands english. ordered for ativan po q8hr for potential benzo . given 1mg at 2300 with good results. pt. falling asleep and BP coming down to goal 120-130's/60. pt. waking again ~ 0500 and BP trending up again to 160/70. HR 70's. pt. appearing comf. with no overt anxiety. due for captopril at 0600.\\n\\nu/o 40-75cc/hr. (-) 1L for and (+) 3L LOS.\\n\\ntaking meds crushed with custard. holds in mouth but able to move tongue and swallow with encouragment.\\n\\nLS course upper airways, somewhat cleared with weak cough. CPT x2. sats 97-98% on 2lnc. trending down in AM to 94%, given CPT and increased to 4lnc-> sats 98% at 0500. RR 20-30's regular.\\n\\nHCT 31.9 , stable. WBC 8.4.\\n\\nneuro: as above, pt. awake, moderately alert. responding to name and to simple commands in english. needs promting and enc. to respond to questions. daughter states that pt. understands more english than thought.\\n\\nheparin 750u/hr via right IJ TLC.\\n\\nA: stable night , taking po meds. BP stable.\\n ativan RTC for possible benzo .\\nP: OOB again today. contin. to thicken foods/liquids. crush meds as needed. CPT, wean FIO2. contin. to monitor neuro status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430815,\n \"text\": \"7a-3p\\ncv: hr a-fib with occasional paced bts(66-80), no ectopy, sbp stable(122-162), continues on po digoxin, captopril & lopressor XL\\n\\nresp: on 4 l np this am, bs+ all lobes & clear, abg sent with good result & o2 decreased to 2 l np, sats 97-99, rr 20-24, coughing productively @ times-sm amts tan sputum\\n\\ngi: continues on aspiration precautions, thicken liquids/soft solids tol fair, poor po intake, to have feeding tube placed this afternoon, no stool\\n\\ngu: foley patent, clear yellow urine, uo 30-50 cc/hr\\n\\nneuro: awake, follows commands, moving all extremities\\n\\nother: iv fluids started x 1 liter(1/2 ns @ 100cc/hr), L rad a-line dc'd, heparin gtt continues @ 750u/hr, oob to chair with PT @ 1200-tol fair, pt very weak with poor wt. bearing, family called & updated on pt's condition\\n\\nplan: continue to monitor in icu, start tube feed as ordered once FT placed, ? tx to floor tomorrow\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430816,\n \"text\": \"CCU NPN \\nGI: NGT placed, placement confirmed by x-ray, started FS Promote with fiber at 10cc/hr at 1800, advance q 4hrs by 10cc to goal 45cc/hr. No residual at onset. NPO until swallow study.\\n\\nNeuro: alert, confused to time/day per family. Encouraged family to reoriented freq. Pt OOB in chair, has not wanted to return to bed yet. Would lift back, did not bear wt well getting up. Ativan dc'd. Watch for ^HR/BP/agitation, if occurs will need to get order for ativan from team.\\n\\nA/P: stable, cont to follow resp status, pul toilet, await swallow study, advance TF's as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430774,\n \"text\": \"pt.remains on ac ventilation, sx for thick light yellow secretions, rsbi=93.5, no weans scheduled, to unstable at present time, normal abg.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430775,\n \"text\": \"CCU NPN 0700-1900\\nS/O:\\n\\nCV: CAPTOPRIL STARTED AT 1100, C/O DOWN SLIGHTLY X2 AFTER DOSE, AND C/I INC TO 1900. LOPRESSOR INC TO 25 MG TID AND PLAN TO INC TO 50 TOMORROW. HEP AND NATRACOR UNCHANGED. CVP TO 14 AFTER LASIX 20 MG X1 IN AM, UP AGAIN IN AFTERNOON. K 3.9 SO 40 KCL GIVEN X1, MAG 3GM GIVEN X1 FOR MAG 1.6. CONT IN AF WITH RATES TO 80'S-100'S. GOOD DIURESIS AGAIN TO LASIX, NEG ABOUT 500CC FOR NOW. PERIPHERAL EDEMA IMPROVED. PT NEEDS ANOTHER LASIX DOSE TONIGHT.\\n\\nRESP: ABG ACIDOTIC IN AM AND ALKALOTIC IN PM. VENT WEANED TO 16 PS AND 5 PEEP WITH TV IN LOW 300'S AND RR 12-30, CHEYNES RESP AT TIMES. LAST ABG 7.47-74-37. SUCTIONED Q4-5H FOR THICK WHITE SPUTUM. NO EVIDENCE OF CUFF LEAK. LUNGS WITH EXP WHEEZE AND RHONCHI AT TIMES.\\n\\nID: TMAX 100 CORE, WBC UNCHANGED. ABX CONT. ALL DRSG AND OF INFECTION.\\n\\nGI: TOL 45CC/HR OF TF WITH HIGH RESIDUAL AT TIMES BUT NO NEED TO TURN OFF TF. INC SOFT STOOL, TRACE POS. POS BS.\\n\\nGU: URINE CLEAR.\\n\\nMS: REC'D LESS FENT/VERSED TODAY, SEEMS TO BE MORE COMFORTABLE ON PS VENT. SITTING UP IN BED AND TURNED FREQ. BOTH DAUGHTERS AND HUSBAND IN TO VISIT.\\n\\nFAMILY: DAUGHTER WILL RETURN HOME TO WORK TOMORROW, SHE HAS 3 KIDS N VT. STATES FATHER IS CONFUSED AND VERY UPSET ABOUT WIFE.\\n\\nSKIN: FUNGAL SKIN INFECTION CONT TO IMPROVE, NO OTHER SKIN BREAKDOWN. PNEUMO BOOTS CONT.\\n\\nA/P: C/O SLIGHTLY AND SVR UP WITH NEW CAPTOPRIL AND INC LOPRESSOR. PT NEEDS MORE LASIX TONIGHT. CONT TO FOLLOW NUMBERS AND ABG. ? REST ON A/C TONIGHT. CONT TO SUPPORT FAMILY.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430769,\n \"text\": \"CCU Nursing Progress Note 1900-0700: CV shock\\nS-Sedated and intubated\\n\\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VS\\nSEE ICU UPDATE REPORT FOR OVERNIGHT EVENTS\\n\\nO-MS:Sedated and intubated overnight on Fent and Versed IVP, requiring Q1-2hrs. Usually requiring 0.5mg of Versed and 25mcgs of Fentanyl. Remaining fairly comfortable with above doses, opening eyes to verbal to name, pt slavic speaking only. Family usually able to engage with pt and pt nodding appropriately. Seeming more \\\"out of it\\\" according to family.\\nCV: HR 70s to 100s. Afib with occasional PVCs and occasional paced beat. K and Mg in WNLs on eves. SBPs 90s to 110s. MAPs 60s to 70s.\\nPAD 27-38, CVP 14-17, CO/CI/SVR high 3.0s/2.0s/1200-1500. Natrecor titrated up to 0.015mcg/kg/min with fair results. PADs down from 38 to 28-30. Increased again to 0.020mcgs/kg/min and awaiting results. Heparin continues at 950u/hr with therepeautic PTTs. Skin warm and dry to touch with palpable pulses distal.\\nRESP: LS course, more so on exhalation. VENT: AC/450/12/.50/6 PEEP. Suctioned for thick white secretions in small to moderate amounts. RBSI performed this AM with score of 80, in addition to RR into the 30s and filling pressure elevated as well.\\nGU/GI: Foley draining minimal amounts of golden yellow urine. HUOs 25-80cc/hr while on Natrecor gtt. At MN 4L(+) and for LOS 13L(+). BUN/Creat in WNLs AM. Anticipate possible increase this AM.\\nAbd soft with (+) BSs. Passing flatus. OGT to right nare changed to OGT oral. Prior to TF at GR of 45cc/hr(Promote w/ fiber). Please confirm placement with CXR prior to use. Passing golden to brown colored loose stools in small to moderate amounts. G(+).\\nID:Tm 100.2 and Tc 99.5. Most recent cultures, urine (+) for > 100,000 org, CVL tip cx with staph, sputum with GNR, and blood and stool still pending. ABx coverage: Vanco, Flagyl, and Iminpenim. Yeast not covered as yet, team to discuss on rounds.\\nA/P: CV shock c/b by septic shock\\nContinue to monitor\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430770,\n \"text\": \"pt.maintained on ac ventilation, unstable cardiac wise, septic, bs with coarse rhonchi bilat, some rales, normal abg, rsbi-80.6, no weans are planned, sx for thin watery clear to white secretions,\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430771,\n \"text\": \"Respiratory Care\\nPt remains ventilated with no change in settings. Breath sounds equal/few scattered expiratory wheezes. Sx for small amount of light tan secreations. RRT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430831,\n \"text\": \"CCU progress note 7p-7a\\nUneventful pm. Family visited late evening. Pt stated to husband \\\"I feel like I can't swallow\\\" HO notified. Pt did take crushed medication at midnite in apple sauce - seemed to tolerate well. remains on aspiration precautions and on thickened liquids + pureed foods. transfer to Rehab facility. See Transfer note if transferred to floor.\\n\\nNEURO: A+Ox3 per family. hungarian speaking - speaks broken english. MAE. gen weakness. 1+ gen edema.\\n\\nID: afebrile. on levoquin for UTI. no other abx.\\n\\nCARDIAC: AFIB 70-80s 0cc paced beats. SBP 130-160s. on Lopressor 50mg TID. Daily Lasix 40mg po. Lisinopril 40mg po qd. Digoxin 0.25mg po qd.\\n\\nRESP: O2 2L n/c. sats 94-97%. sl SOB on exertion. LS clear, coarse/dim bases. weak congested cough. CPT done w/ turns.\\n\\nGI/GU: foley patent. u/o ~30cc/hr. on daily diuresis w/ daily po KCL. abd soft, distended. +BS. no stool. takes pills crushed in pureed food w/ thickened liquids per swallowing study. ASPIRATION PRECAUTIONS. pt stating she feels like she can't swallow. HO aware.\\n\\nSKIN: perineum healed well. nystatin applied. on air mattress. turned + repo'd.\\n\\n\\nPLAN: keep pt comfortable. continue pulmonary toliet. con't cardiac meds. aspiration precautions. ?transfer to rehab facility or to floor today?\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430832,\n \"text\": \"CCU Nursing Progress Note\\nS: That's enough\\nO: Pt voicing \\\"enough\\\", after few teaspoons of soft solids, yogurt, pudding. Taking very little in po. Pt will assist with encouragement, but minimal po intake today. Able to tolerated smaller pills later in day, otherwise pills were crushed and mixed with nectar consistency water.\\n\\n 8am meds given crushed in applesauce, then pt vomited. Bp up to 160/ with HR up 140. RR 40 with sat down to 85%. Increased o2 to 100%cool neb with subsequent sat up to 100%. Lopressor 5mg IVP with BP to 130/ and HR to 70-80. Lasix 20IVP with u/o @400cc within 1hr.\\n\\nAfebrile- cont on Levofloxacin\\nHR 80's afib with rare paced. Lopressor increased to 75mg po tid\\nBP 130-160/ Increased dose of Lisinopril to 60mg po qd starting , but extra 20mg given at 1800.\\nResp - as above, cont with bibase rales despite diuresis and productive cough. Able to wean O2 down to 2ln/p.\\nGI - as above for po intake. Passed small amt ob-, soft formed stool\\nActivity - OOB to chair with 2 assist. OT to see pt\\n\\nA: Event of Inc HR and BP responding well to Lopressor IV and Lasix\\n\\nP: Cont aspiration precautions and encourage po intake\\nMonitor need for diuresis this evening. Monitor HR and BP on increased dose of meds. OOB this eve. ? tx to NE \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430810,\n \"text\": \"CCU progress note 7a-7p\\nEVENTS: EXTUBATED @ 10am - tolerating well!\\n\\nNEURO: no sedation - versed gtt off since 6am. no ativan given today. mae - very weak. moves feet, moves arms across bed and up to face. nodding head to questions of 'okay?' , mouthing words to family when they visited this afternoon.\\n\\nID: afebrile. Tmax 98.9po. no abx.\\n\\nRESP: Extubated at 10am. LS coarse. coughing up some clear thick secretions. O2 3L n/c. cool neb face tent @ 50% for moisture. CPT done with turns. post extubation abg: 7.41/41/114 sats >96%.\\n\\nCARDIAC: AFIB 70-100s occ paced beats. Lopressor 50mg dose given early pre intubation. Captopril 75mg dose held this afternoon due to NPO status - HO aware - ?may need NGT inserted for meds tonite. Good SBP >130s. L radial aline patent. RIJ TLC patent. HEPARIN gtt increased to 750u/hr per HO tonite. 2+ generalized edema.\\n\\nGI/GU/ENDO: foley patent. given lasix 20mg IVP x 1 pre intubation w/ good results. abd soft +BS. stooling golden soft stool mod amts q2-3 hrs. TF off for extubation. to attempt sips this evening for meds - otherwise NGT will have to be inserted for meds/feeding. aspiration precautions. BS WNL. no RISS given. on standing dose NPH insulin .\\n\\nCODE STATUS: FULL CODE. (daughter) {a CCU nurse} is HCP (proxy).\\nFAMILY: husband and other daughter () in to visit this afternoon.\\n\\n\\nPLAN: check PM lab results (K,Mg). keep pt comfortable. pulmonary toliet. ?NGT insertion for meds tonite if pt unable to take pills orally due to aspiration concerns. monitor VS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2152-09-04 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1430809,\n \"text\": \"Respiratory Care:\\n\\nPatient remains intubated on Psv. Psv increased back to 12cm to rest at noc. RR increasing to 30's. Improved on Psv 12. Current settings Psv 12, Cpap 5, Fio2 40%. RR 13-25 with spont vols 400's. O2 sats 97-100%. Bs clear bilaterally. RSBI 185. RSBI improving over the last 2 days. Still with increased fluid. Plan: Continue with slow Psv wean increasing Psv at noc as needed.\\n\"\n }\n]"}}},{"rowIdx":988,"cells":{"subject_id":{"kind":"number","value":11784,"string":"11,784"},"hadm_id":{"kind":"number","value":136351,"string":"136,351"},"target_text":{"kind":"string","value":"On arrival to pt. was evaluated by the emergency department and trauma surgery staff. Pt was imaged and found to have a small splenic laceration and a large perinephric hematoma. Pt was admitted to the trauma SICU for monitoring of vital signs and serial hematocrits. During stay in TSICU, hematocrits dropped to mid 20's, but then stabilized. Pt. was transferred to the floor on bedrest and observed for a number of days. Pt was ready for d/c when had one episode while climbing stairs with PT of transient hypotension, lightheadedness and oxygen desaturation & quickly recovered with addition of 2L o2. Pt. was cleared by PT to return home. Pt was kept for one more night in hospital for observation and was stable. Morning of d/c crit was low but still in stable range, and pt. was offered a blood transfusion for his anemia. Pt refused transfusion and decided that he would return home without it being done. Pt made aware that if there are any concerns or problems including any signs/symptoms of increasing anemia or bleeding, he is to go to the emergency room & to call for the trauma team to adress his concerns. Pt. d/c'd home with PCP follow up within 2 weeks and trauma follow up within 4 weeks."},"extractive_notes_summ":{"kind":"string","value":"Lungs clear with diminished bases L>R.CV- NSR, normotensive. Denies N/V Abd slightly distended. The heart and mediastinum are within normal limits. (Over) 2:54 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: eval splenic lac, perinephric hematoma Admitting Diagnosis: SPLENIC LACERATION Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) Small amount of fluid is identified within the right inguinal ring. In addition, there is a focal cleft within the posterolateral splenic body, which could represent a tiny laceration, however, could represent normal anatomic cleft. Widened mediastinum on flat AP portable CXR. Mild pain to LLQ.GU: Adequate u/o via foley. Nursing Note:REVIEW OF SYSTEMS:CV: Hemodynamic status stable, hr=59-69, sinus bradycardia to nsr, bp=112/53-122/54, ext. There is a trace perihepatic fluid. There are bilateral calcified pleural plaques, compatible with prior asbestos exposure. Small left-sided pleural effusion, and atelectasis within the left lung base. IMPRESSION: Small left pleural effusion and atelectasis in the left lung base. +Bowel sounds. little sore on L side with activity.GI/GU- Abd soft, +BS. widened mediastinum.GI: Abd. There is small left pleural effusion associated with atelectasis in the left lung base. done, reported as unchanged.RESP: Maintained on RA, sat=96=98%, resp. A soft tissue density in the upper Mediastinum. Pt has h/o HTN and takes atenolol QD. Possible tiny splenic laceration, without evidence of active extravasation. Foley patent with adeq UO. Calcified gallstones are identified. The right kidney is grossly normal. Trans to , admit to TSICU for serial hct's.NEURO: Pt is A+Ox3. Lytes WNL.ID: Afebrile.ENDO: Serum gluc WNL.SKIN: Abrasion to left elbow covered with steristrips. There is a large left-sided perinephric hematoma, which measures 10.2 x 6.3 x 8.9 cm. Sinus rhythm. There is minimal amount of low density fluid surrounding the posterolateral aspect of the spleen. The prevertebral soft tissue is unremarkable. The left kidney opacifies well with contrast. There is anterior displacement of the left kidney, however, no active extravasation is identified. If pt hct remain stable, should transfer to floor. There is a small amount of fluid tracking along the left pericolic gutter. Admitted to TSICU for serial hcts and close hemodynamic monitoring. +LOC, and pt hit his head. LS CTA bilat.CV: HR 50s-60s SB/SR no ectopy noted. IVF at 100cc cont. rate=14=17, diminished BS RLL. COMMENTS: PA and lateral radiographs of the chest are reviewed. There is question of pleural plaques in the lateral portion of the right lung as well as right hemidiaphragm. PA and lateral chest radiograph is recommended for further evaluation. Repeat CXR for ? CERVICAL SPINE, MULTIPLE VIEWS: The vertebral body heights are preserved. There is a Foley catheter within a decompressed urinary bladder. Vertebral body height is preserved throughout. The renal vein is patent, and the collecting system is intact. warm, + dp bil. CHEST AP: There is widening of the mediastinum. The pulmonary vasculature is normal. The pancreas and adrenal glands are normal. He sustained a left elbow abrasion. VS/labs stable at this time.PLAN: Cont to monitor vs, serial hcts, monitor abd and report increases in pain, f/u with team re: ?trans to floor if hct's stable today. The surrounding soft tissue and osseous structures are unremarkable. BG <100. Afebrile. IMPRESSION: 1. No free intraperitoneal gas. NPN 1900-0700 Pt intact.Resp- On RA, adeq sats >96% when awake, drifts to 93% when sound asleep. Pt c/o headache and recievd tylenol, otherwise no pain at rest. There is some disc space narrowing at the C5-C6 level with anterior and posterior osteophytosis, consistent with degenerative changes. Gallstones. 650mg tylenol PO x 1 for headache with effect. Evaluation of osseous structures reveals degenerative change amongst both hip joints, right side greater than left. Contrast is visualized in the urinary bladder from a previous examination. The lungs are clear otherwise. BP currently 120s/50s.HEME: Hct in 30s. Back/buttocks grossly intact.SOCIAL: Wife and son at bedside and supportive.ASMT: Pt s/p fall, left perinephric hematoma, splenic lac. At OSH pt had GCS 16, he was dx'd with a splenic lac and left perinephric hematoma. 9:58 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: TRAUMA FINAL REPORT INDICATION: Trauma. Probable asbestos related pleural disease. States mild discomfort to left flank which is tolerable. distended, soft, hypoactive BS, denies nausea, notes left flank tenderness to touch and with re-positioning.GU: Foley to gravity, u/o=60-100cc/hrSKIN: Steri-strips to left elbow, full ROM, mild edemaMENTATION: Alert and oriented x3, follows commands, sleeping in napsENDO: No insulin requirementID: AfebrileSOCIAL: Wife and children in to visit, members updated by Dr. PLAN: Continue to follow serial hct, plan for transfer in am if hct/hemodynamic status stable. The patient is status post prostatectomy and nodal dissection, with numerous clips within the pelvis. No active extravasation identified. No BM. 2:54 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: eval splenic lac, perinephric hematoma Admitting Diagnosis: SPLENIC LACERATION Contrast: OPTIRAY Amt: 150 MEDICAL CONDITION: 74 year old man s/p fall REASON FOR THIS EXAMINATION: eval splenic lac, perinephric hematoma No contraindications for IV contrast FINAL REPORT CT OF THE ABDOMEN AND PELVIS WITH THE ADMINISTRATION OF INTRAVENOUS CONTRAST INDICATION: 74-year-old male status post fall with splenic laceration and perinephric hematoma."},"n_notes":{"kind":"number","value":8,"string":"8"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2140-10-28 00:00:00.000","description":"TRAUMA #2 (AP CXR & PELVIS PORT)","row_id":884144,"text":" 9:58 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Trauma.\n\n CHEST AP: There is widening of the mediastinum. Although this could be\n projectional, a mediastinal injury cannot be excluded. The lungs are clear.\n There are no pleural effusions. The pulmonary vasculature is normal. The\n surrounding soft tissue and osseous structures are unremarkable.\n\n PELVIS AP: There are no fractures, dislocations or focal bony lesions.\n Contrast is visualized in the urinary bladder from a previous examination.\n Multiple surgical clips are present in the pelvis.\n\n"},{"category":"Radiology","chartdate":"2140-10-28 00:00:00.000","description":"C-SPINE, TRAUMA","row_id":884145,"text":" 10:30 PM\n C-SPINE, TRAUMA Clip # \n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man status post fall.\n\n CERVICAL SPINE, MULTIPLE VIEWS: The vertebral body heights are preserved.\n There is some disc space narrowing at the C5-C6 level with anterior and\n posterior osteophytosis, consistent with degenerative changes. There are no\n fractures or dislocations visualized. The prevertebral soft tissue is\n unremarkable. A soft tissue density in the upper Mediastinum. PA and lateral\n chest radiograph is recommended for further evaluation.\n\n"},{"category":"Radiology","chartdate":"2140-10-29 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":884219,"text":" 2:54 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval splenic lac, perinephric hematoma\n Admitting Diagnosis: SPLENIC LACERATION\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n eval splenic lac, perinephric hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS WITH THE ADMINISTRATION OF INTRAVENOUS CONTRAST\n\n INDICATION: 74-year-old male status post fall with splenic laceration and\n perinephric hematoma.\n\n TECHNIQUE: Contiguous 5 mm axial images were obtained from the lung bases to\n the pubic symphysis with the administration of intravenous contrast. Images\n were reformatted in the sagittal and coronal planes.\n\n FINDINGS: No prior examination for comparison. There are bilateral\n calcified pleural plaques, compatible with prior asbestos exposure. Small\n left-sided pleural effusion, and atelectasis within the left lung base. No\n consolidation or pulmonary mass in the visualized lung fields.\n\n Evaluation of the liver demonstrates numerous hypodense lesions, the largest\n measuring 1.5 cm within the liver dome, with central density measurements of-5\n Hounsfield units. Findings most compatible with simple cysts, however, some\n of the smaller lesions are too small to characterize. There is no\n intrahepatic biliary ductal dilatation. There is a trace perihepatic fluid.\n Calcified gallstones are identified.\n\n There is minimal amount of low density fluid surrounding the posterolateral\n aspect of the spleen. In addition, there is a focal cleft within the\n posterolateral splenic body, which could represent a tiny laceration, however,\n could represent normal anatomic cleft. No active extravasation is seen.\n\n There is a large left-sided perinephric hematoma, which measures 10.2 x 6.3 x\n 8.9 cm. There is anterior displacement of the left kidney, however, no active\n extravasation is identified. The left kidney opacifies well with contrast.\n The renal vein is patent, and the collecting system is intact. The right\n kidney is grossly normal. The pancreas and adrenal glands are normal.\n\n There are no dilated loops of large or small bowel. No free intraperitoneal\n gas. There is a small amount of fluid tracking along the left pericolic\n gutter.\n\n The patient is status post prostatectomy and nodal dissection, with numerous\n clips within the pelvis. There is a Foley catheter within a decompressed\n urinary bladder.\n (Over)\n\n 2:54 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval splenic lac, perinephric hematoma\n Admitting Diagnosis: SPLENIC LACERATION\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Small amount of fluid is identified within the right inguinal ring.\n\n Evaluation of osseous structures reveals degenerative change amongst both hip\n joints, right side greater than left. There is also degenerative change and\n osteophyte formation within the thoracic and upper lumbar spine. No displaced\n rib fractures are identified. Vertebral body height is preserved throughout.\n\n IMPRESSION:\n 1. Large left perinephric hematoma with associated mass effect on the left\n kidney. No active extravasation identified.\n\n 2. Possible tiny splenic laceration, without evidence of active\n extravasation.\n\n 3. Gallstones.\n\n\n\n\n\n"},{"category":"ECG","chartdate":"2140-10-28 00:00:00.000","description":"Report","row_id":213036,"text":"Sinus rhythm. No previous tracing available for comparison.\n\n"},{"category":"Radiology","chartdate":"2140-10-29 00:00:00.000","description":"CHEST (PA & LAT)","row_id":884187,"text":" 9:44 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate mediastinum with PA/lat CXR\n Admitting Diagnosis: SPLENIC LACERATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with L perinehpric hematoma & splenic lac s/p fall. Widened\n mediastinum on flat AP portable CXR.\n REASON FOR THIS EXAMINATION:\n evaluate mediastinum with PA/lat CXR\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS.\n\n INDICATION: 74-year-old man with left perinephric hematoma.\n\n COMMENTS: PA and lateral radiographs of the chest are reviewed. No previous\n study is available for comparison.\n\n There is small left pleural effusion associated with atelectasis in the left\n lung base. The lungs are clear otherwise. The heart and mediastinum are\n within normal limits.\n\n There is question of pleural plaques in the lateral portion of the right lung\n as well as right hemidiaphragm.\n\n IMPRESSION: Small left pleural effusion and atelectasis in the left lung\n base. Probable asbestos related pleural disease.\n\n\n"},{"category":"Nursing/other","chartdate":"2140-10-29 00:00:00.000","description":"Report","row_id":1416273,"text":"TSICU ADMIT NOTE\nPt is 74 yo male who works in a warehouse. At approx 1230 on he fell from a standing position onto left side with left arm pinned under torso. No LOC. He sustained a left elbow abrasion. Pt cont to work through the day and proceeded home. At approx 1600, pt was talking to wife and turned pale, fainted and fell from standing position. +LOC, and pt hit his head. Wife helped pt off of the floor and later took pt to the ER. (Pt decided to shower before going to ER so was admitted some time after 1700). At OSH pt had GCS 16, he was dx'd with a splenic lac and left perinephric hematoma. Trans to , admit to TSICU for serial hct's.\n\nNEURO: Pt is A+Ox3. MAE, follows commands. States mild discomfort to left flank which is tolerable. 650mg tylenol PO x 1 for headache with effect. C-spine cleared at 0400.\n\nRESP: Sats 95% on RA. LS CTA bilat.\n\nCV: HR 50s-60s SB/SR no ectopy noted. Pt has h/o HTN and takes atenolol QD. BP currently 120s/50s.\n\nHEME: Hct in 30s. Serial hcts ordered q4.\n\nGI: NPO. Denies N/V Abd slightly distended. +Bowel sounds. Mild pain to LLQ.\n\nGU: Adequate u/o via foley. Lytes WNL.\n\nID: Afebrile.\n\nENDO: Serum gluc WNL.\n\nSKIN: Abrasion to left elbow covered with steristrips. Back/buttocks grossly intact.\n\nSOCIAL: Wife and son at bedside and supportive.\n\nASMT: Pt s/p fall, left perinephric hematoma, splenic lac. Admitted to TSICU for serial hcts and close hemodynamic monitoring. VS/labs stable at this time.\n\nPLAN: Cont to monitor vs, serial hcts, monitor abd and report increases in pain, f/u with team re: ?trans to floor if hct's stable today.\n\n\n"},{"category":"Nursing/other","chartdate":"2140-10-29 00:00:00.000","description":"Report","row_id":1416274,"text":"Nursing Note:\nREVIEW OF SYSTEMS:\n\nCV: Hemodynamic status stable, hr=59-69, sinus bradycardia to nsr, bp=112/53-122/54, ext. warm, + dp bil. Serial hct, hct=25.3, cat scan abd. done, reported as unchanged.\n\nRESP: Maintained on RA, sat=96=98%, resp. rate=14=17, diminished BS RLL. Repeat CXR for ? widened mediastinum.\n\nGI: Abd. distended, soft, hypoactive BS, denies nausea, notes left flank tenderness to touch and with re-positioning.\n\nGU: Foley to gravity, u/o=60-100cc/hr\n\nSKIN: Steri-strips to left elbow, full ROM, mild edema\n\nMENTATION: Alert and oriented x3, follows commands, sleeping in naps\n\nENDO: No insulin requirement\n\nID: Afebrile\n\nSOCIAL: Wife and children in to visit, members updated by Dr. \n\nPLAN: Continue to follow serial hct, plan for transfer in am if hct/hemodynamic status stable.\n"},{"category":"Nursing/other","chartdate":"2140-10-30 00:00:00.000","description":"Report","row_id":1416275,"text":"NPN 1900-0700\n Pt intact.\n\nResp- On RA, adeq sats >96% when awake, drifts to 93% when sound asleep. Lungs clear with diminished bases L>R.\n\nCV- NSR, normotensive. Afebrile. Serial HCTs stable, 6am pending. BG <100. IVF at 100cc cont. Pt c/o headache and recievd tylenol, otherwise no pain at rest. little sore on L side with activity.\n\nGI/GU- Abd soft, +BS. No BM. Foley patent with adeq UO.\n\n If pt hct remain stable, should transfer to floor.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-10-28 00:00:00.000\",\n \"description\": \"TRAUMA #2 (AP CXR & PELVIS PORT)\",\n \"row_id\": 884144,\n \"text\": \" 9:58 PM\\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \\n Reason: TRAUMA\\n ______________________________________________________________________________\\n FINAL REPORT\\n\\n INDICATION: Trauma.\\n\\n CHEST AP: There is widening of the mediastinum. Although this could be\\n projectional, a mediastinal injury cannot be excluded. The lungs are clear.\\n There are no pleural effusions. The pulmonary vasculature is normal. The\\n surrounding soft tissue and osseous structures are unremarkable.\\n\\n PELVIS AP: There are no fractures, dislocations or focal bony lesions.\\n Contrast is visualized in the urinary bladder from a previous examination.\\n Multiple surgical clips are present in the pelvis.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-10-28 00:00:00.000\",\n \"description\": \"C-SPINE, TRAUMA\",\n \"row_id\": 884145,\n \"text\": \" 10:30 PM\\n C-SPINE, TRAUMA Clip # \\n Reason: fx\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man s/p fall\\n REASON FOR THIS EXAMINATION:\\n fx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 74-year-old man status post fall.\\n\\n CERVICAL SPINE, MULTIPLE VIEWS: The vertebral body heights are preserved.\\n There is some disc space narrowing at the C5-C6 level with anterior and\\n posterior osteophytosis, consistent with degenerative changes. There are no\\n fractures or dislocations visualized. The prevertebral soft tissue is\\n unremarkable. A soft tissue density in the upper Mediastinum. PA and lateral\\n chest radiograph is recommended for further evaluation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-10-29 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 884219,\n \"text\": \" 2:54 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST\\n Reason: eval splenic lac, perinephric hematoma\\n Admitting Diagnosis: SPLENIC LACERATION\\n Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man s/p fall\\n REASON FOR THIS EXAMINATION:\\n eval splenic lac, perinephric hematoma\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n CT OF THE ABDOMEN AND PELVIS WITH THE ADMINISTRATION OF INTRAVENOUS CONTRAST\\n\\n INDICATION: 74-year-old male status post fall with splenic laceration and\\n perinephric hematoma.\\n\\n TECHNIQUE: Contiguous 5 mm axial images were obtained from the lung bases to\\n the pubic symphysis with the administration of intravenous contrast. Images\\n were reformatted in the sagittal and coronal planes.\\n\\n FINDINGS: No prior examination for comparison. There are bilateral\\n calcified pleural plaques, compatible with prior asbestos exposure. Small\\n left-sided pleural effusion, and atelectasis within the left lung base. No\\n consolidation or pulmonary mass in the visualized lung fields.\\n\\n Evaluation of the liver demonstrates numerous hypodense lesions, the largest\\n measuring 1.5 cm within the liver dome, with central density measurements of-5\\n Hounsfield units. Findings most compatible with simple cysts, however, some\\n of the smaller lesions are too small to characterize. There is no\\n intrahepatic biliary ductal dilatation. There is a trace perihepatic fluid.\\n Calcified gallstones are identified.\\n\\n There is minimal amount of low density fluid surrounding the posterolateral\\n aspect of the spleen. In addition, there is a focal cleft within the\\n posterolateral splenic body, which could represent a tiny laceration, however,\\n could represent normal anatomic cleft. No active extravasation is seen.\\n\\n There is a large left-sided perinephric hematoma, which measures 10.2 x 6.3 x\\n 8.9 cm. There is anterior displacement of the left kidney, however, no active\\n extravasation is identified. The left kidney opacifies well with contrast.\\n The renal vein is patent, and the collecting system is intact. The right\\n kidney is grossly normal. The pancreas and adrenal glands are normal.\\n\\n There are no dilated loops of large or small bowel. No free intraperitoneal\\n gas. There is a small amount of fluid tracking along the left pericolic\\n gutter.\\n\\n The patient is status post prostatectomy and nodal dissection, with numerous\\n clips within the pelvis. There is a Foley catheter within a decompressed\\n urinary bladder.\\n (Over)\\n\\n 2:54 PM\\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \\n CT 150CC NONIONIC CONTRAST\\n Reason: eval splenic lac, perinephric hematoma\\n Admitting Diagnosis: SPLENIC LACERATION\\n Contrast: OPTIRAY Amt: 150\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n\\n Small amount of fluid is identified within the right inguinal ring.\\n\\n Evaluation of osseous structures reveals degenerative change amongst both hip\\n joints, right side greater than left. There is also degenerative change and\\n osteophyte formation within the thoracic and upper lumbar spine. No displaced\\n rib fractures are identified. Vertebral body height is preserved throughout.\\n\\n IMPRESSION:\\n 1. Large left perinephric hematoma with associated mass effect on the left\\n kidney. No active extravasation identified.\\n\\n 2. Possible tiny splenic laceration, without evidence of active\\n extravasation.\\n\\n 3. Gallstones.\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-10-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 213036,\n \"text\": \"Sinus rhythm. No previous tracing available for comparison.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-10-29 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 884187,\n \"text\": \" 9:44 AM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate mediastinum with PA/lat CXR\\n Admitting Diagnosis: SPLENIC LACERATION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 74 year old man with L perinehpric hematoma & splenic lac s/p fall. Widened\\n mediastinum on flat AP portable CXR.\\n REASON FOR THIS EXAMINATION:\\n evaluate mediastinum with PA/lat CXR\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST TWO VIEWS.\\n\\n INDICATION: 74-year-old man with left perinephric hematoma.\\n\\n COMMENTS: PA and lateral radiographs of the chest are reviewed. No previous\\n study is available for comparison.\\n\\n There is small left pleural effusion associated with atelectasis in the left\\n lung base. The lungs are clear otherwise. The heart and mediastinum are\\n within normal limits.\\n\\n There is question of pleural plaques in the lateral portion of the right lung\\n as well as right hemidiaphragm.\\n\\n IMPRESSION: Small left pleural effusion and atelectasis in the left lung\\n base. Probable asbestos related pleural disease.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-10-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1416273,\n \"text\": \"TSICU ADMIT NOTE\\nPt is 74 yo male who works in a warehouse. At approx 1230 on he fell from a standing position onto left side with left arm pinned under torso. No LOC. He sustained a left elbow abrasion. Pt cont to work through the day and proceeded home. At approx 1600, pt was talking to wife and turned pale, fainted and fell from standing position. +LOC, and pt hit his head. Wife helped pt off of the floor and later took pt to the ER. (Pt decided to shower before going to ER so was admitted some time after 1700). At OSH pt had GCS 16, he was dx'd with a splenic lac and left perinephric hematoma. Trans to , admit to TSICU for serial hct's.\\n\\nNEURO: Pt is A+Ox3. MAE, follows commands. States mild discomfort to left flank which is tolerable. 650mg tylenol PO x 1 for headache with effect. C-spine cleared at 0400.\\n\\nRESP: Sats 95% on RA. LS CTA bilat.\\n\\nCV: HR 50s-60s SB/SR no ectopy noted. Pt has h/o HTN and takes atenolol QD. BP currently 120s/50s.\\n\\nHEME: Hct in 30s. Serial hcts ordered q4.\\n\\nGI: NPO. Denies N/V Abd slightly distended. +Bowel sounds. Mild pain to LLQ.\\n\\nGU: Adequate u/o via foley. Lytes WNL.\\n\\nID: Afebrile.\\n\\nENDO: Serum gluc WNL.\\n\\nSKIN: Abrasion to left elbow covered with steristrips. Back/buttocks grossly intact.\\n\\nSOCIAL: Wife and son at bedside and supportive.\\n\\nASMT: Pt s/p fall, left perinephric hematoma, splenic lac. Admitted to TSICU for serial hcts and close hemodynamic monitoring. VS/labs stable at this time.\\n\\nPLAN: Cont to monitor vs, serial hcts, monitor abd and report increases in pain, f/u with team re: ?trans to floor if hct's stable today.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-10-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1416274,\n \"text\": \"Nursing Note:\\nREVIEW OF SYSTEMS:\\n\\nCV: Hemodynamic status stable, hr=59-69, sinus bradycardia to nsr, bp=112/53-122/54, ext. warm, + dp bil. Serial hct, hct=25.3, cat scan abd. done, reported as unchanged.\\n\\nRESP: Maintained on RA, sat=96=98%, resp. rate=14=17, diminished BS RLL. Repeat CXR for ? widened mediastinum.\\n\\nGI: Abd. distended, soft, hypoactive BS, denies nausea, notes left flank tenderness to touch and with re-positioning.\\n\\nGU: Foley to gravity, u/o=60-100cc/hr\\n\\nSKIN: Steri-strips to left elbow, full ROM, mild edema\\n\\nMENTATION: Alert and oriented x3, follows commands, sleeping in naps\\n\\nENDO: No insulin requirement\\n\\nID: Afebrile\\n\\nSOCIAL: Wife and children in to visit, members updated by Dr. \\n\\nPLAN: Continue to follow serial hct, plan for transfer in am if hct/hemodynamic status stable.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2140-10-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1416275,\n \"text\": \"NPN 1900-0700\\n Pt intact.\\n\\nResp- On RA, adeq sats >96% when awake, drifts to 93% when sound asleep. Lungs clear with diminished bases L>R.\\n\\nCV- NSR, normotensive. Afebrile. Serial HCTs stable, 6am pending. BG <100. IVF at 100cc cont. Pt c/o headache and recievd tylenol, otherwise no pain at rest. little sore on L side with activity.\\n\\nGI/GU- Abd soft, +BS. No BM. Foley patent with adeq UO.\\n\\n If pt hct remain stable, should transfer to floor.\\n\"\n }\n]"}}},{"rowIdx":989,"cells":{"subject_id":{"kind":"number","value":14060,"string":"14,060"},"hadm_id":{"kind":"number","value":171645,"string":"171,645"},"target_text":{"kind":"string","value":"The patient was admitted to the East surgical service from the emergencydepartment. An NG tube was placed, started on IVF, kept NPO and IV pain medicine given as needed."},"extractive_notes_summ":{"kind":"string","value":"There is a small amount of mesenteric free air (2:48) anteriorly adjacent to an open anterior abdominal wall defect with overlying packing material. Moderate PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: Small pericardial effusion. Mildly dilated rightventricle with preserved systolic function. TECHNIQUE: MDCT acquired images were obtained through the chest, abdomen and pelvis after the uneventful administration of 130 cc IV Optiray contrast. Small amount of free fluid in the midline which cannot be further characterized with ultrasound. Pulmonary embolus.Height: (in) 68Weight (lb): 204BSA (m2): 2.06 m2BP (mm Hg): 83/58HR (bpm): 126Status: InpatientDate/Time: at 15:28Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Mildly dilated RV cavity. Right IJ catheter terminates in the superior vena cava in appropriate position. A new small left pleural effusion is noted on today's examination. IMPRESSION: Appearances consistent with small-bowel obstruction either recent or incomplete. FINDINGS: Patient is status thoracic fixation. Persistent right hilar and infrahilar well-defined opacity likely atelectasis versus aspiration. BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler son of the right and left common femoral, superficial femoral, deep femoral, and popliteal veins were obtained demonstrating appropriate flow, compressibility, augmentation, and waveforms. FINDINGS: Again identified are the diffuse multifocal alveolar opacities that have remained stable in the right lung while they have started to decrease in the left lung. There is atelectasis versus consolidation at the left lung base with a small left pleural effusion. Again noted is patchy opacification of the right lung and left lung with small left pleural effusion and atelectasis at the left lung base. As outpatient he is on Atenolol, Aldactone, Norvasc. As outpatient he is on Atenolol, Aldactone, Norvasc. As outpatient he is on Atenolol, Aldactone, Norvasc. Now oliguric, hypotensive, requiring max vent support. Received prn dose of zofran. Received prn dose of zofran. Received prn dose of zofran. pt was febrile to 101.6, tachycardic to and tachypneac. pt was febrile to 101.6, tachycardic to and tachypneac. pt was febrile to 101.6, tachycardic to and tachypneac. pt was febrile to 101.6, tachycardic to and tachypneac. 7.39/34/65 on NRB, lactate 3.0. Resp distress with tachypnea, 7.39/35/81 on NRB. #FEN - Hypokalemia: Arrived to with K replacement hanging. #FEN - Hypokalemia: Arrived to with K replacement hanging. #FEN - Hypokalemia: Arrived to with K replacement hanging. Now oliguric, hypotensive, requiring max vent support. Now oliguric, hypotensive, requiring max vent support. 7.39/34/65 on NRB, lactate 3.0. 7.39/34/65 on NRB, lactate 3.0. Resp distress with tachypnea, 7.39/35/81 on NRB. Resp distress with tachypnea, 7.39/35/81 on NRB. Lactate 3.0 Upon arrival here pt. # Abdominal source sepsis. C/o pain despite dilaudid PCA. # Prophylaxis: Pneumoboots, PPI. BS clear apeces, descending to bases audible crackles to diminished. # Hypertension. - Back to OR for re-exploration and abdominal decompression. Lung exam with dffuse crackles. Lung exam with dffuse crackles. Response: Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L. Response: Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L. Response: Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L. LGE AMT HUO/ADEQUATE DIURESIS LASIX DRIP. CONT ++GEN/SCROTAL EDEMA, PALP PP. A-LINE DAMPENED AT TIMES R/T LOCATION/PT . ABD DSD C/D/I, LLQ POUCH/DRAIN W/SM AMT SEROUS DRNG. PEEP and PSV weaned. RESP SUPPORT, WEAN AS TOL. +generalized edema. GEN EDEMA. LYTES REPLETED PRN. CONT TF VIA NGT, MIN RESIDUALS. K+ 3.1 repleted with 60meq IV. Abg shows compensated metabolic alkolosis. WEAN VENT AS TOL. SUCTIONED FOR MOD-LGE AMTS THICK, TAN SECRETIONS, CPT DONE AS TOL. K/CALCIUM REPLETED AS NEEDED DIURESIS. Midline abd incision with some purlulent drainage noted, primary team aware. ABD INC W/COPIOUS AMTS SEROUS DRNG, STAPLES REMOVED THIS AM BY DR. . CONT LASIX DRIP FOR DIURESIS/NEG FLUID BAL GOALS. Generalized edema. BS essentially clear w diminished bases. SICU NN: SEE CAREVUE FOR SPECIFICS. on AC as noted in Carevue. Albuterol given at appropriate times. Continue to replace cc:cc of OG output. PROTONIX CHANGED TO FAMOTADINE.GU--LASIX ONCE, CURRENTLY ON LASIX GTT WITH GOAL 1-1.5 LITERS NEGATAIVE.CV--STABLE OFF PRESSORS. Prn Nebs are ordered yet not indicated at this time; bs = cta with good aeration. Palpable peripheral pulses.RESP-Pt remains intubated, ventilated on settings: AC mode-45%fio2,450 X 26, 16 PEEP. EKG/CKW/TROPONIN DONE AFTER? AFEBRILE.ENDO--BLOOD SUGARS CONTROLLED WITH SLIDING SCALE.PLAN: CONTINUE WITH SLOW WEAN ON FENT/ATIVAN (APPROX. TOLERATING CPAP + PRESSURE SUPPORT . Pt continues to have generalized edema present. focus update noteD: ARDS resolved with active vent wean, diuresis with lasix gtt goal 1-2 liters negative-, pt length of stay is 16L positive, hemodynamically stable off pressors and moniotoring device discontinued.T max 98 50s- 70 NSR, no ectopy, sbp 106-120 /50-60, with aggitation repositioning and suctioning pt hypertensive SBP 160-170. ativan gtt discontinued pt may have PRN ativan for aggitation. Respiratory carePt remains intubated recieved on a/c weaned to cpap/psv. Line placement trial.Palpable pulses,Plasma lyte at 150ml/hr, cvp 14-21cm,afebrile.HCT 30's and wbc 23, plt 44, primary team aware.K and calcium replaced.Resp: Remains on vent, vent changes with ABG's, pls see resp notes and flow sheet for changes. CXR done, results pending.GI-OG with no output, now pt with increased output via ileostomy. Nsg.progress notes:See flow sheet for specific:Neuro: Pt is alert and oriented x , confused inbetween,but easily reoriented back, c/o pain, dilaudid prn with good effcet, ativan 1mg as pt c/o insomnia with fair effect, pleasant and co op with care.CV: NSR, HR in 60's, SBP 140-170, on po lopressor,ivf kvo only, afebrile, ++PP, + edema scrotum & penis, still on aldactone.CVP 2-4cm.denies Cp or discomfort.Resp: Remains on RA, ls clear, ++cough, pt is able to suction it from mouth, using IS appropriately, encouraged deep breath and cough.O2 sat 96-99%.GI: Abd softly distneded, Hypoactive BS, Tf at goal."},"n_notes":{"kind":"number","value":123,"string":"123"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2178-06-16 00:00:00.000","description":"CT ABDOMEN W/CONTRAST","row_id":1020280,"text":" 1:15 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: evaluate for fever source including fluid collection\n Admitting Diagnosis: OBSTRUCTION\n Field of view: 44\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man w/ respiratory failure s/p aspiration and s/p parastomal hernia\n repair. PO and IV contrast\n REASON FOR THIS EXAMINATION:\n evaluate for fever source including fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56 year old man with repiratory failure and history of aspiration\n post parastomal hernia repair.\n\n COMPARISON: Multiple prior chest radiographs and CT abdomen/pelvis performed\n .\n\n TECHNIQUE: MDCT acquired images were obtained through the chest, abdomen and\n pelvis after the uneventful administration of 130 cc IV Optiray contrast. Oral\n contrast was also administered. Multiplanar reformats were reviewed.\n\n CT CHEST: The lungs demonstrate diffuse bilateral tree-in- opacities\n involving the right middle lobe and both lower lobes. There is dense\n consolidation in the lower lobe with left lower lobe cavitating lesion\n measuring approximately 6.3 x 5.5 cm. There may be a low density fluid\n component which may be pleural.\n\n CT ABDOMEN: The liver, spleen, adrenals, pancreas and kidneys are grossly\n unremarkable. There is a small amount of mesenteric free air (2:48)\n anteriorly adjacent to an open anterior abdominal wall defect with overlying\n packing material. The bowel id exposed to air, and the intraperitoneal air\n is likley related to the abdominal wall defect - rather than an\n intraabdominal process. (This was discussed with the ICU resident)..\n\n CT PELVIS: The rectum, sigmoid, Foley and bladder are unremarkable. There is\n no pelvic free fluid or free air.\n\n Bone windows demonstrate no suspicious lytic or blastic lesions with marked\n degenerative . A right iliac bone harvesting site is again noted.\n\n Spinal fusion hardware in the thoracic spine is unchanged. An endotracheal\n tube terminates in the mid trachea. A nasogastric tube terminates in the mid\n stomach. A left internal jugular catheter terminates at the superior\n cavoatrial junction.\n\n IMPRESSION:\n 1. Extensive bilateral bronchopneumonia with left lower lobe cavitating\n lesion which could represent necrotizing pneumonia (possibly aspergillosis).\n\n (Over)\n\n 1:15 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: evaluate for fever source including fluid collection\n Admitting Diagnosis: OBSTRUCTION\n Field of view: 44\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Small amount free air in adjacent to the anterior bowel loops is likley\n relsated to open peritoneum.\n\n Findings were discussed with Dr. at 4 PM on and the SICU\n resident at 5:15 PM, who confirmed that the peritoneum was open.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-10 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1019308,"text":" 2:49 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval OGT placement prior to starting tube feeds\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p parastomal hernia repair and ex lap\n REASON FOR THIS EXAMINATION:\n eval OGT placement prior to starting tube feeds\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man status post hernia repair. Here to evaluate for\n OGT placement prior to initiating tube feeds.\n\n COMPARISON: Abdominal radiograph from .\n\n FINDINGS: Portable supine image is provided showing a paucity of bowel gas\n with no tube detected within the abdomen. Note is made of thoracic spine\n hardware and clips to the right of the midline, and a stent overlying the\n lower thoracic vertebra.\n\n IMPRESSION: Paucity of bowel gas with no tube detected within the abdomen.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-25 00:00:00.000","description":"O CHEST (SINGLE VIEW) IN O.R.","row_id":1021853,"text":" 8:47 PM\n CHEST (SINGLE VIEW) IN O.R.; CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: IVC FILTER PLACEMENT\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n AP SPOT FILM, P.M., \n\n A single frontal fluoroscopic spot film centered on the upper abdomen in the\n midline shows inferior vena caval umbrella filters and the lower end of spinal\n stabilization hardware, is submitted for documentation of a procedure\n performed under fluoroscopic guidance without a radiologist in attendance.\n\n"},{"category":"Radiology","chartdate":"2178-06-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1019743,"text":" 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Question pneumonia, ARDS.\n\n COMPARISON STUDY: .\n\n Patient is status post posterior fixation of the thoracic spine.\n\n There is an increased patchy density in the right mid to lower lung zone which\n could represent pneumonia. There is also increased opacification of the mid\n and left lower lung zones which could also represent pneumonia, or aspiration.\n There is a small left lower lobe effusion.\n\n Right IJ catheter terminates in the cavoatrial junction. ET tube terminates\n at the thoracic junction. Nasogastric tube courses towards the stomach but\n the tip is not seen.\n\n IMPRESSION:\n 1. Increased density of right mid to lower lung zone opacity, concerning for\n pneumonia.\n 2. Increased density of left lung opacities also concerning for pneumonia.\n Small left pleural effusion.\n\n"},{"category":"Radiology","chartdate":"2178-06-23 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":1021504,"text":", A. 12R 6:10 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: R/O LOWER EXTREMITY DVT/PT HAS PULMONARY EMBOLI ? SOURCE\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with PE's\n REASON FOR THIS EXAMINATION:\n r/o lower extremity dvt\n ______________________________________________________________________________\n PFI REPORT\n No evidence of lower extremity DVT.\n\n"},{"category":"Radiology","chartdate":"2178-06-11 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1019574,"text":" 10:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ARDS, for NG placement.\n\n FINDINGS: In comparison with the study of , the nasogastric tube extends\n to the distal stomach. Patchy areas of increased opacification are seen at\n both bases. Although these could represent atelectasis, the possibility of\n superimposed pneumonia can certainly not be excluded. Probable small\n bilateral pleural effusions.\n\n The metallic devices and monitoring leads remain in place.\n\n\n"},{"category":"Radiology","chartdate":"2178-05-27 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1017145,"text":" 5:38 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with n/v\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with nausea and vomiting, evaluate for pneumonia.\n\n COMPARISON: .\n\n PA AND LATERAL VIEWS, CHEST: Limited radiograph due to underpenetration and\n soft tissue scatter. The lung volumes are low. Otherwise, the lungs are\n clear without focal consolidations. There is no pleural effusion or\n pneumothorax. The heart size is normal. Pulmonary vasculature is\n unremarkable without evidence of pulmonary edema. Posterior thoracic fusion\n hardware is noted.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-06 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1018683,"text":" 9:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with sepsis, ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Sepsis and ARDS.\n\n Indwelling devices are unchanged in position. Widespread heterogeneous\n alveolar opacities demonstrate mixed changes, with improvement in left upper\n lobe, worsening in left lower lobe, and overall slight progression within the\n right lung. Small left pleural effusion is unchanged.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-05 00:00:00.000","description":"P BILAT LOWER EXT VEINS PORT","row_id":1018543,"text":" 3:13 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: Please eval for DVT\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ? PE\n REASON FOR THIS EXAMINATION:\n Please eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY ULTRASOUND WITH DOPPLER STUDIES.\n\n HISTORY: Shortness of breath. Question pulmonary embolism. Also evaluate\n for DVT.\n\n FINDINGS: No prior scans available for comparison.\n\n The common femoral, superficial femoral and the popliteal veins show normal\n appearance, compressibility and Doppler flow bilaterally.\n\n CONCLUSION: No ultrasound evidence of DVT in either lower leg.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1018222,"text":" 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, pulm edema\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with UC s/p colectomy now presents with SBO s/p LOA, parastomal\n hernia repair.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, pulm edema\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:21 AM\n Increase in right-sided opacity.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n As compared to the previous radiograph from , there is unchanged\n visualization of thoracic fusion hardware. The lung volumes are slightly\n lower than on the previous examination, the cardiac silhouette is slightly\n larger. Probably due to positioning effect, the transparency of the right\n hemithorax has decreased, however, some small amount of right-sided pleural\n effusion cannot be excluded. There are no signs suggestive of overhydration.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-04 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1018223,"text":", M. MED 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, pulm edema\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with UC s/p colectomy now presents with SBO s/p LOA, parastomal\n hernia repair.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, pulm edema\n ______________________________________________________________________________\n PFI REPORT\n Increase in right-sided opacity.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-07 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1018717,"text":" 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with sepsis, ards\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Sepsis and ARDS.\n\n New 6 mm diameter radiopaque density is identified to the left of the trachea,\n and appears separate from the expected esophageal lumen based upon the\n rightward location of nasogastric tube at this level. This structure could\n potentially be external to the patient, but repeat radiograph following\n removal of external structures may be helpful to exclude a foreign body. With\n the exception of this finding, the remainder of the examination is unchanged.\n\n\n"},{"category":"Echo","chartdate":"2178-06-05 00:00:00.000","description":"Report","row_id":79059,"text":"PATIENT/TEST INFORMATION:\nIndication: ? Pulmonary embolus.\nHeight: (in) 68\nWeight (lb): 204\nBSA (m2): 2.06 m2\nBP (mm Hg): 83/58\nHR (bpm): 126\nStatus: Inpatient\nDate/Time: at 15:28\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 size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: ?# aortic valve leaflets. No AR.\n\nMITRAL VALVE: Trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Moderate PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\nEchocardiographic results were reviewed by telephone with the MD caring for\nthe patient.\n\nConclusions:\nViews were limited. The left atrium is normal in size. Left ventricular wall\nthickness, cavity size and regional/global systolic function are normal (LVEF\n>55%) The right ventricular cavity is mildly dilated with normal free wall\ncontractility. The number of aortic valve leaflets cannot be determined. No\naortic regurgitation is seen. Trivial mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is a small pericardial\neffusion. There are no echocardiographic signs of tamponade. Dr. was\nnotified by telephone on at 3:50 pm\n\nCompared with the prior study (images reviewed) of ,pulmonary\npressures are higher, right ventricle appears bigger.\n\nIMPRESSION: Preserved left ventricular systolic function. Mildly dilated right\nventricle with preserved systolic function. Moderate pulmonary hypertension.\nNo obvious valvular abnormalities but views were limited.\n\n\n"},{"category":"Radiology","chartdate":"2178-05-27 00:00:00.000","description":"ABDOMEN (SUPINE & ERECT)","row_id":1017146,"text":" 5:39 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ? SBO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with n/v\n REASON FOR THIS EXAMINATION:\n ? SBO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with nausea and vomiting. Rule out small bowel\n obstruction.\n\n COMPARISON: .\n\n ABDOMEN, SUPINE AND ERECT VIEWS: Mildly distended small bowel loops measuring\n up to 4.3 cm are noted. The bowel gas pattern is otherwise nonspecific. There\n are also scattered air-fluid levels predominantly noted in the right upper\n quadrant. There is no evidence of pneumoperitoneum. Lower thoracic fusion\n hardware is in unchanged location.\n\n IMPRESSION: Mildly distended small bowel loops and scattered air-fluid\n levels, may indicate partial obstruction. CT may be obtained for further\n evaluation.\n\n"},{"category":"Radiology","chartdate":"2178-06-01 00:00:00.000","description":"SMALL BOWEL ONLY (BARIUM)","row_id":1017809,"text":" 1:02 PM\n SMALL BOWEL ONLY (BARIUM) Clip # \n Reason: Rule out obstruction, massess, fistulae, abscess\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56M w/ colitis s/p lap total abd colectomy, end ileostomy presented\n with abd pain, no output, bilious emesis on , n/w excessive ostomy output\n with intermittent s/s of PSBO.\n REASON FOR THIS EXAMINATION:\n Rule out obstruction, massess, fistulae, abscess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old male with colitis, status post total abdominal\n colectomy and end ileostomy from . Here with abdominal pain.\n\n COMPARISON: CT of the abdomen and pelvis from , MR\n enterography from .\n\n FINDINGS: Thin barium was orally ingested for this small bowel follow-through\n study. Overhead radiographs and fluoroscopic images show filling of the bowel\n loops after about approximately three hours. There is likely fluid in the\n bowel loops as the contrast appears markedly diluted. The small bowel is\n dilated in some regions measuring up to 5.7 cm. There is no transition point\n identified, no obvious fistula formation with no apparent leak or area of\n stricture as barium visibly made it to the patient's ostomy bag.\n\n IMPRESSION: Ingested oral contrast found in the ostomy bag after slight\n motility delay with dilated small bowel loops with no obvious fistula\n formation or obstruction.\n\n"},{"category":"Radiology","chartdate":"2178-05-27 00:00:00.000","description":"T-SPINE","row_id":1017107,"text":" 1:44 PM\n T-SPINE Clip # \n Reason: S/p Thoracie Fusion, T6-T12 Assess fpr healing\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Ostomyelitis, Kyphosis\n REASON FOR THIS EXAMINATION:\n S/p Thoracie Fusion, T6-T12 Assess fpr healing\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Thoracic fusion, to assess for healing.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Again the patient is status post placement of cage prosthesis across\n the wedged T10 vertebral body with lateral fusion from T9-T11. Anterior\n interbody fusion device is seen at T11-12, unchanged in position. Posterior\n fusion hardware extends from T6-7 through T12 level, with paired pedicle\n screws at T11 and T12. No evidence of hardware-related complication.\n\n IMPRESSION: Little change.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-08 00:00:00.000","description":"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT","row_id":1018928,"text":" 12:48 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: assess obstruction vs. infection\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS, now with rising wbc, elevated tbili\n REASON FOR THIS EXAMINATION:\n assess obstruction vs. infection\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JBK MON 8:37 PM\n No biliary dilatation and no findings to suggest infection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with rising white blood count and elevated T-\n bili.\n\n COMPARISON: Abdomen CT, .\n\n FINDINGS: The liver shows no focal or textural abnormality. There is no\n biliary dilatation and the common duct measures 0.3 cm. The portal vein is\n patent with hepatopetal flow. The gallbladder is normal without evidence of\n stones, and there are no signs of cholecystitis. A small right pleural\n effusion is seen. A small amount of free fluid is identified adjacent to the\n midline surgical incision. The spleen is somewhat enlarged measuring 13.7 cm.\n\n IMPRESSION:\n 1. No gallstones, no signs of cholecystitis, and no biliary dilatation.\n 2. Small amount of free fluid in the midline which cannot be further\n characterized with ultrasound. If concern for infection persists, an\n abdominal CT is recommended.\n 3. Small right pleural effusion.\n 4. Splenomegaly.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-08 00:00:00.000","description":"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT","row_id":1018929,"text":", J. SICU-B 12:48 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: assess obstruction vs. infection\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS, now with rising wbc, elevated tbili\n REASON FOR THIS EXAMINATION:\n assess obstruction vs. infection\n ______________________________________________________________________________\n PFI REPORT\n No biliary dilatation and no findings to suggest infection.\n\n"},{"category":"Radiology","chartdate":"2178-06-05 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1018449,"text":" 9:40 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess for infiltrate and new line position\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with resp failure\n REASON FOR THIS EXAMINATION:\n please assess for infiltrate and new line position\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable for line placement on .\n\n COMPARISON: at 03:31.\n\n HISTORY: 50-year-old man with respiratory failure, evaluate for infiltrate\n and new line position.\n\n FINDINGS:\n\n Over a period of only 6 hours, there is diffuse airspace disease occupying\n almost all of the left lung and a major portion of the right lung. The\n infiltrate and/or atelectasis seen in the right hilar area has also worsened.\n A new small left pleural effusion is noted on today's examination. There is\n no right pleural effusion. The heart size is normal. Multiple fixation\n vertebral body plates and screws in intervertebral body are again noted\n unchanged. A new endotracheal tube has been placed with tip approximately 4.5\n cm from the carina. A right internal jugular line has also been introduced\n recently with a tip in the upper one-third of the SVC.\n\n IMPRESSION:\n 1. New diffuse airspace disease in both lungs, left more than right. This\n can represent a non-cardiogenic pulmonary edema, ARDS, diffuse alveolar\n damage, or even alveolar hemorrhage.\n 2. Newly placed endotracheal tube, right internal jugular line, and feeding\n tube, all in satisfactory location.\n 3. New small left pleural effusion.\n\n\n Case discusses with Dr \n\n"},{"category":"Radiology","chartdate":"2178-06-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1019057,"text":", J. SICU-B 4:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Patient with ARDS, evaluate for change.\n\n Stable diffuse air space disease in the right lung while the air space disease\n in the left lung has slightly started to decrease.\n\n"},{"category":"Radiology","chartdate":"2178-06-10 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1019206,"text":" 5:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ARDS, to evaluate for change.\n\n FINDINGS: In comparison with the study of , there is progression of the\n multifocal alveolar opacifications, especially involving the right mid and\n lower lung zones. Some prominence of interstitial markings suggests\n superimposed elevated pulmonary venous pressure. Probable bilateral pleural\n effusions. The monitoring devices remain in place.\n\n IMPRESSION: Worsening appearance primarily involving the right mid and lower\n lung zones.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1020049,"text":" 11:08 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: congfirm NGT placement\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ards\n REASON FOR THIS EXAMINATION:\n congfirm NGT placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB MON 11:58 AM\n Nasogastric tube terminates in the stomach.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Nasogastric tube placement.\n\n Nasogastric tube terminates in the stomach. Approximately 8 mm diameter\n radiodense foreign body is demonstrated in the left upper quadrant of the\n abdomen. It is not seen on older radiographs but is identifiable since more\n recent studies dating to . This could potentially be an\n aspirated piece of dental hardware if the patient had a traumatic intubation\n during the hospital course. Appearance of the lungs and pleura are unchanged\n since the recent radiograph of approximately two hours earlier.\n\n"},{"category":"Radiology","chartdate":"2178-06-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1020050,"text":", A. SICU-B 11:08 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: congfirm NGT placement\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ards\n REASON FOR THIS EXAMINATION:\n congfirm NGT placement\n ______________________________________________________________________________\n PFI REPORT\n Nasogastric tube terminates in the stomach.\n\n"},{"category":"Radiology","chartdate":"2178-06-08 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1018811,"text":" 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change, worsening hypoxia\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with sepsis, ards\n REASON FOR THIS EXAMINATION:\n eval for interval change, worsening hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis and ARDS.\n\n COMPARISON: , and .\n\n SEMI UPRIGHT CHEST RADIOGRAPH: A nasogastric tube, endotracheal tube,\n and right- sided internal jugular central venous line are appropriately\n positioned. The cardiomediastinal silhouette is unchanged. Again identified\n are diffuse multifocal alveolar opacities. There has been a mixed response\n with increased aeration in the left upper lung zone and increased opacity\n within the right lower lung zones. There is evidence of prior thoracic\n vertebral body fusion.\n\n IMPRESSION: Mixed response of multifocal alveolar opacities improved in the\n left upper lung zone and worsened within the right lower lung zone.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1019860,"text":" 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 05:32.\n\n COMPARISON STUDY: .\n\n CLINICAL INFORMATION: ARDS.\n\n FINDINGS:\n\n Patient is status thoracic fixation. There is essentially no change in the\n appearance of the chest since the prior study with the exception of removal of\n a right IJ catheter. The patient is intubated, and the ET tube terminates\n somewhat high just above the thoracic inlet. Nasogastric tube courses towards\n the stomach but the tip is not seen. Left subclavian catheter terminates at\n the superior vena cava.\n\n There is patchy opacification of the right lung base, unchanged, consistent\n with pneumonia. There is atelectasis versus consolidation at the left lung\n base with a small left pleural effusion. There is mild cardiomegaly and\n probable superimposed mild congestive failure.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1018408,"text":" 3:15 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate for infiltrate or volume overload. Recent CX\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with recent abdominal surgery transferred to the ICU with\n tachypnea and hypoxia.\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrate or volume overload. Recent CXR with very poor\n inspiratory effort limits interpretation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recent abdominal surgery with hypoxia.\n\n FINDINGS: In comparison with earlier study of this date, the patient has\n taken a slightly better inspiration. Extensive opacification persists in the\n right mid and lower lung zones medially. This is consistent with atelectasis\n or possible supervening pneumonia. There may also be some increased\n opacification in the retrocardiac region that would be better evaluated by\n lateral view if this were clinically possible.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-09 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1019056,"text":" 4:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MEz TUE 12:42 PM\n PFI: Patient with ARDS, evaluate for change.\n\n Stable diffuse air space disease in the right lung while the air space disease\n in the left lung has slightly started to decrease.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 56-year-old man with ARDS, evaluate for interval change.\n\n FINDINGS: Again identified are the diffuse multifocal alveolar opacities that\n have remained stable in the right lung while they have started to decrease in\n the left lung. The cardiomediastinal silhouette is stable. The nasogastric\n tube, endotracheal tube, and right-sided internal jugular central venous line\n are appropriately positioned. There is no pleural effusion. The patient is\n status post thoracic vertebral body fusion.\n\n IMPRESSION: Stable mixed response of multifocal alveolar opacities,pneumonia\n in the right lung and edema in the left lung.\n\n"},{"category":"Radiology","chartdate":"2178-06-13 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":1019766,"text":" 8:05 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: assess position of new left subclavian line\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDs, new left subclavian line placement\n REASON FOR THIS EXAMINATION:\n assess position of new left subclavian line\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 08:23\n\n COMPARISON STUDY: at 04:29\n\n CLINICAL INFORMATION: ARDS, new subclavian line placement.\n\n FINDINGS:\n\n Patient is status post fusion of the thoracic spine. Right IJ catheter\n terminates in the superior vena cava in appropriate position. Nasogastric\n tube terminates in the stomach. Again noted is patchy opacification of the\n right lung and left lung with small left pleural effusion and atelectasis at\n the left lung base. There is no appreciable change since the prior study.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-22 00:00:00.000","description":"CT CHEST W/CONTRAST","row_id":1021285,"text":" 6:39 PM\n CT CHEST W/CONTRAST Clip # \n Reason: please assess for interval change in abscess.\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with known lung abscess\n REASON FOR THIS EXAMINATION:\n please assess for interval change in abscess.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc MON 10:57 PM\n Unchanged B lower lobe consolidations, L > R; left demonstrates low density\n component. Precarinal lymph node enlargement. -\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with known lung abscess. Assess for interval\n change.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images through the chest were obtained following the\n administration of intravenous contrast and displayed at 5- and 1.25-mm\n collimation. A series of sagittal and coronal images were reformatted for\n review.\n\n CT CHEST WITH IV CONTRAST: The lung abscess in the left lower lobe measures\n 62 x 42 mm (previously 63 x 55 mm). The amount of fluid within the collection\n has mildly decreased and has been replaced by air/gas. The abscess\n demonstrates connection with the subsegmental left lower lobe bronchi and\n likely has two loculated components medially. The remaining diffuse\n parenchymal abnormalities continue improve. Dense consolidation within the\n right lower lobe has decreased with some residual consolidation demonstrating\n central lucency without frank cavitation. Parenchymal consolidation within the\n right upper lobe as well as diffuse centrilobular nodules and tree-in-\n opacities have also mildly decreased.\n\n Filling defects in the right and left lower lobe segmental and subsegmental\n pulmonary arteries are consistent with acute pulmonary emboli. There are no\n enlarged central lymph nodes. The airways are patent to the subsegmental\n level bilaterally. There are calcifications of the coronary arteries.\n\n While not tailored to infradiaphragmatic evaluation, the patient is status\n post parastomal hernia repair and an open anterior abdominal wall defect with\n overlying packing material again identified.\n\n Patient has undergone prior T6 through T12 fusion as well as prior left\n thoracotomy.\n\n IMPRESSION:\n\n 1. Bilateral lower lobe segmental and subsegmental pulmonary emboli.\n\n (Over)\n\n 6:39 PM\n CT CHEST W/CONTRAST Clip # \n Reason: please assess for interval change in abscess.\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Minimal interval decrease in the size of the left lower lobe lung abscess.\n\n 3. Mild improvement in right upper and lower lobe consolidations, as well as\n diffuse tree-in- opacities.\n\n The above findings were discussed with Dr. on .\n\n\n\n"},{"category":"Radiology","chartdate":"2178-05-31 00:00:00.000","description":"ABDOMEN (SUPINE & ERECT)","row_id":1017658,"text":" 10:05 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ?obstruction\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with abd pain, distention\n REASON FOR THIS EXAMINATION:\n ?obstruction\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Abdominal pain and distention, evaluate for obstruction.\n\n Spinal hardware is again seen.\n\n Distended loops of small bowel are present with multiple air-fluid levels on\n the upright film indicating likely small-bowel obstruction. Some air is seen\n within non dilated loops which indicates either the obstruction is recent or\n is incomplete.\n\n IMPRESSION: Appearances consistent with small-bowel obstruction either recent\n or incomplete. Dr. informed.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-05 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1018402,"text":" 12:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for effusion\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man POD 1 s/p parastomal hernia repair now in respiratory distress,\n crackles on physical exam\n REASON FOR THIS EXAMINATION:\n please assess for effusion\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 56-year-old man with POD status post stomal hernia repair, no\n respiratory distress. Crackles on physical examination.\n\n FINDINGS: A persistent perihilar opacity with well-defined margin inferiorly\n is stable on today's examination. The left lung is clear. There is no\n evidence of pleural effusion at the bases. The heart size is normal.\n\n IMPRESSION:\n 1. Persistent right hilar and infrahilar well-defined opacity likely\n atelectasis versus aspiration. Pneumonia in the proper clinical setting\n cannot be completely excluded.\n 2. No pleural effusion is seen.\n\n The case was discussed with Dr. .\n\n"},{"category":"Radiology","chartdate":"2178-06-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1020016,"text":" 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB MON 10:49 AM\n Coiling of nasogastric tube in cervical region. Slight improved aeration at\n the lung bases.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n \t\n COMPARISON: .\n\n INDICATION: ARDS.\n\n Lines and tubes remain in standard position except for a nasogastric tube.\n Although the tip terminates in the stomach, there is apparent coiling of the\n tube in the cervical region, as communicated by phone to Dr. . The exam is\n mostly without change since the recent study, except for slight improved\n aeration at the lung bases.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1020017,"text":", A. SICU-B 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n PFI REPORT\n Coiling of nasogastric tube in cervical region. Slight improved aeration at\n the lung bases.\n\n\n"},{"category":"Radiology","chartdate":"2178-06-23 00:00:00.000","description":"BILAT LOWER EXT VEINS","row_id":1021503,"text":" 6:10 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: R/O LOWER EXTREMITY DVT/PT HAS PULMONARY EMBOLI ? SOURCE\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with PE's\n REASON FOR THIS EXAMINATION:\n r/o lower extremity dvt\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe TUE 7:57 PM\n No evidence of lower extremity DVT.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old man with newly diagnosed bilateral pulmonary emboli.\n Evaluate for DVT.\n\n Comparison is made to ultrasound.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND:\n\n Grayscale and Doppler son of the right and left common femoral,\n superficial femoral, deep femoral, and popliteal veins were obtained\n demonstrating appropriate flow, compressibility, augmentation, and waveforms.\n Appropriate compression was noted within the tibial veins bilaterally.\n Appropriate color flow was noted within the peroneal veins bilaterally.\n\n IMPRESSION:\n\n No evidence of bilateral lower extremity DVT.\n\n"},{"category":"ECG","chartdate":"2178-06-17 00:00:00.000","description":"Report","row_id":192611,"text":"Sinus rhythm. T wave inversion in leads V1-V2 with ST segment depression\nin these leads. Biphasic T waves in lead V3. These findings are new as\ncompared with tracing . The rate has slowed. The ST-T wave changes\nraise the question of anterior ischemia. Followup and clinical correlation are\nsuggested.\n\n"},{"category":"ECG","chartdate":"2178-06-05 00:00:00.000","description":"Report","row_id":192612,"text":"Sinus tachycardia. The P-R interval is short without evidence of\npre-excitation. Non-specific ST-T wave changes. Compared to the previous\ntracing there is no significant change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2178-06-05 00:00:00.000","description":"Report","row_id":192613,"text":"Sinus tachycardia. The P-R interval is 110 milliseconds which is short but\nwithout evidence of pre-excitation. Non-specific ST-T wave changes. Compared\nto the previous tracing the rate is faster and the P-R interval is shorter.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2178-06-03 00:00:00.000","description":"Report","row_id":192614,"text":"Sinus bradycardia\nModest nonspecific precordial/anterior T wave changes\nSince previous tracing of , sinus bradycardia and modest T wave changes\nnow present\n\n"},{"category":"ECG","chartdate":"2178-06-02 00:00:00.000","description":"Report","row_id":192615,"text":"Sinus rhythm\nBorderline prolonged/upper limits of normal Q-Tc interval - is nonspecific -\nwithin normal limits\nBaseline artifact in lead V4 -V6 makes assessment difficult\nClinical correlation is suggested\nSince previous tracing of , sinus bradycardia absent\n\n"},{"category":"Nursing","chartdate":"2178-06-04 00:00:00.000","description":"Nursing Progress Note","row_id":328765,"text":"56yo man with PMH of ulcerative colitis s/p total colectomy w/\n illeostomy in . Admitted to on w/ abd pain and\n increased ostomy output. Pain remained persistant during admission and\n pt underwent exploratory laprascopy w/ hernia repair and lysis of\n adhesions on . pt was febrile to 101.6, tachycardic to\n and tachypneac. Pt received total of 5 liters IVF in OR/PACU.\n Pt was transferred to M/SICU for further mgt of tachycardia/tachypnea.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n HR 110-125 ST, no ectopy.\n SBP 95-110\n UO 15-30cc/hr, dark amber. Cr 1.2 in PACU.\n JP drain and ostomy w/ minimal output.\n Pt states he has\ndry mouth and is thirsty\n, NPO at present.\n Action:\n Received 2 L IVF bolus overnight.\n Receiving D5NS 150cc/hr.\n Received 650mg Tylenol overnight.-\n Response:\n Minimal increase in urine output following IVF bolus.\n HR remains 115-125 ST.\n 6.5 L positive LOS at present.\n House staff and surgery aware.\n Plan:\n Cont to monitor vitals, intake/output, labs.\n Cont IV fluid replacement as ordered.\n ? advance PO intake today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain in abdominal incision and foley cath on dilaudid PCA.\n c/o nausea, no vomiting.\n Action:\n PCA dose increased overnight.\n Lidocaine urojet applied to foley cath.\n Received prn dose of zofran.\n Response:\n Pain improved to following increase in PCA and urojet.\n Nausea improved w/ zofran.\n Plan:\n Cont to monitor pain level, effectiveness of PCA.\n Cont to encourage deep breathing/IS as tolerated.\n"},{"category":"Nursing","chartdate":"2178-06-05 00:00:00.000","description":"Nursing Progress Note","row_id":328838,"text":"Mr. is a 56 year old male with history of ulcerative colitis (pt\n of Dr. failed medical management, s/p colectomy with ileostomy\n and preservation of rectum 12/. Post operative course was\n complicated by ileus. He had been doing well post operatively until\n when he presented to the ED with abdominal pain at the site of the\n stoma and increased ostomy output. He was admitted to the surgical\n service and treated conservatively with IVF, NG tube, and NPO. Serial\n abdominal films showed air fluid levels in the small bowel. Small\n bowel follow through showed no fistula formation or obstructive point\n but patient continued to have episodic cramping pain. Due to\n persistent pain, the patient was consented and taken to the OR for\n exploratory laparoscopy. He was found to have parastomal hernia and\n adhesive disease, hernia repair and lysis of adhesions was performed.\n He was transferred from the PACU here to ICU for monitoring due to\n tachypnea, tachycardia. He was transferred to 12R as he was\n stable.\n .\n Early this am pt. became tachypneic, tachycardic up to 140\ns and\n oliguric. Placed on 100% NRB with good effect. CXR wnl, EKG wnl,\n Crackles bilat. Given 80mg of lasix and transferred here to ICU for\n further management.\n"},{"category":"Nursing","chartdate":"2178-06-04 00:00:00.000","description":"Nursing Progress Note","row_id":328759,"text":"56yo man with PMH of ulcerative colitis s/p total colectomy w/\n illeostomy in . Admitted to on w/ abd pain and\n increased ostomy output. Pain remained persistant during admission and\n pt underwent exploratory laprascopy w/ hernia repair and lysis of\n adhesions on . pt was febrile to 101.6, tachycardic to\n and tachypneac. Pt received total of 5 liters IVF in OR/PACU.\n Pt was transferred to M/SICU for further mgt of tachycardia/tachypnea.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n HR 110-125 ST, no ectopy.\n SBP 95-110\n UO 15-30cc/hr, dark amber. Cr 1.2 in PACU.\n JP drain and ostomy w/ minimal output.\n Pt states he has\ndry mouth and is thirsty\n, NPO at present.\n Action:\n Received 1.5 L IVF bolus overnight.\n Receiving D5NS 150cc/hr.\n Received 650mg Tylenol overnight.-\n Response:\n Minimal increase in urine output following IVF bolus.\n HR remains 115-125 ST.\n 6.5 L positive LOS at present.\n House staff and surgery aware.\n Plan:\n Cont to monitor vitals, intake/output, labs.\n Cont IV fluid replacement as ordered.\n ? advance PO intake today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain in abdominal incision and foley cath on dilaudid PCA.\n c/o nausea, no vomiting.\n Action:\n PCA dose increased overnight.\n Lidocaine urojet applied to foley cath.\n Received prn dose of zofran.\n Response:\n Pain improved to following increase in PCA and urojet.\n Nausea improved w/ zofran.\n Plan:\n Cont to monitor pain level, effectiveness of PCA.\n Cont to encourage deep breathing/IS as tolerated.\n"},{"category":"Nursing","chartdate":"2178-06-04 00:00:00.000","description":"Nursing Progress Note","row_id":328757,"text":"56yo man with PMH of ulcerative colitis s/p total colectomy w/\n illeostomy in . Admitted to on w/ abd pain and\n increased ostomy output. Pain remained persistant during admission and\n pt underwent exploratory laprascopy w/ hernia repair and lysis of\n adhesions on . pt was febrile to 101.6, tachycardic to\n and tachypneac. Pt received total of 5 liters IVF in OR/PACU.\n Pt was transferred to M/SICU for further mgt.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n HR 110-125 ST, no ectopy.\n SBP 95-110\n UO 15-30cc/hr, dark amber. Cr 1.2 in PACU.\n JP drain and ostomy w/ minimal output.\n Pt states he has\ndry mouth and is thirsty\n Action:\n Received 1.5 L IVF bolus overnight.\n Receiving D5NS 150cc/hr.\n Response:\n Minimal increase in urine output following IVF bolus.\n HR remains 115-125 ST.\n House staff and surgery aware.\n Plan:\n Cont to monitor vitals, intake/output, labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain in abdominal incision and foley cath on dilaudid PCA.\n c/o nausea, no vomiting.\n Action:\n PCA dose increased overnight.\n Lidocaine urojet applied to foley cath.\n Received prn dose of zofran.\n Response:\n Pain improved to following increase in PCA and urojet.\n Nausea improved w/ zofran.\n Plan:\n Cont to monitor pain level, effectiveness of PCA.\n Cont to encourage deep breathing/IS as tolerated.\n"},{"category":"Physician ","chartdate":"2178-06-04 00:00:00.000","description":"Physician Resident Admission Note","row_id":328752,"text":"Chief Complaint: Xfer from surgery for tachypnea, tachycardia\n HPI:\n Mr. is a 56 year old male with history of ulcerative colitis (pt\n of Dr. failed medical management, s/p colectomy with ileostomy\n and preservation of rectum 12/. Post operative course was\n complicated by ileus. He had been doing well post operatively until\n when he presented to the ED with abdominal pain at the site of the\n stoma and increased ostomy output. He was admitted to the surgical\n service and treated conservatively with IVF, NG tube, and NPO. Serial\n abdominal films showed air fluid levels in the small bowel. Small\n bowel follow through showed no fistula formation or obstructive point\n but patient continued to have episodic cramping pain. Due to\n persistent pain, the patient was consented and taken to the OR today\n for exploratory laparoscopy. He was found to have parastomal hernia\n and adhesive disease, hernia repair and lysis of adhesions was\n performed. Estimated blood loss was minimal. He was given 2700 IVF\n however had 55cc urine output. He is being transferred from the PACU\n for monitoring due to tachypnea, tachycardia.\n .\n On arrival to the the patient is somnolent but arousable. He has\n dilaudid PCA within reach. He denies pain at rest but has pain\n with any movement. He denies fevers, chills, shortness of breath,\n nausea, chest pain or palpitations. He states that he is thirsty.\n Patient admitted from: OR / PACU\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 Celexa 10mg daily\n Aciphex 20mg daily\n Atenolol 25mg daily\n Aldactone 25mg daily\n Norvasc 2.5mg daily\n Past medical history:\n Family history:\n Social History:\n (taken from surgical admission note)\n Hypertension\n Depression\n Ulcerative colitis as above, history of chronic steroid use\n GERD\n MSSA bacteremia\n T10 diskitis\n Multiple spine surgeries: Fusion T6-T12\n Multiple thoracic laminetomies\n Partial vertebrectomy of T10-T11\n Hyperlipidemia\n History of PE\n C diff\n Hemochromatosis\n s/p arthroscopic knee surgery\n Non-contributory\n Occupation: Does not work\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Married with two children\n Review of systems:\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: Foley\n Psychiatric / Sleep: No(t) Agitated\n Pain: No pain / appears comfortable\n Pain location: Pain with movement\n Flowsheet Data as of 12:33 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: 38\nC (100.4\n HR: 125 (125 - 125) bpm\n BP: 102/66(74) {96/66(74) - 102/66(74)} mmHg\n RR: 34 (29 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n 6,218 mL\n 4 mL\n PO:\n TF:\n IVF:\n 6,218 mL\n 4 mL\n Blood products:\n Total out:\n 875 mL\n 32 mL\n Urine:\n 120 mL\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,343 mL\n -29 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, very dry mm, JVP flat\n Cardiovascular: (S1: Normal, Absent), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Tender: to palpation diffusely,\n Obese, Soft, ND, tender to palpation diffusely across abdomen,\n ileostomy intact with no drainage, hypoactive BS. JP drain in place\n with minimal output. Dressing c/d/i.\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 226\n 125\n 1.2\n 24\n 22\n 102\n 3.1\n 137\n 39.1\n 6.4\n [image002.jpg]\n Other labs: PT / PTT / INR:14/23/1.2, Ca++:9.0, Mg++:2.4, PO4:3.1\n Imaging: SB follow through: FINDINGS: Thin barium was orally\n ingested for this small bowel follow-through\n study. Overhead radiographs and fluoroscopic images show filling of the\n bowel loops after about approximately three hours. There is likely\n fluid in the\n bowel loops as the contrast appears markedly diluted. The small bowel\n is\n dilated in some regions measuring up to 5.7 cm. There is no transition\n point\n identified, no obvious fistula formation with no apparent leak or area\n of\n stricture as barium visibly made it to the patient's ostomy bag.\n IMPRESSION: Ingested oral contrast found in the ostomy bag after slight\n motility delay with dilated small bowel loops with no obvious fistula\n formation or obstruction.\n KUB: Distended loops of small bowel are present with multiple\n air-fluid levels on the upright film indicating likely small-bowel\n obstruction. Some air is seen within non dilated loops which indicates\n either the obstruction is recent or is incomplete.\n IMPRESSION: Appearances consistent with small-bowel obstruction either\n recent or incomplete. Dr. informed.\n Microbiology: Urine culture: Negative\n Assessment and Plan\n Mr. is a 56 year old male with history of UC s/p colectomy and\n ileostomy () who presented on with SBO and parastomal\n hernia now s/p LOA and parastomal hernia repair transferred to for\n tachypnea.\n .\n # Tachypnea: Upon arrival to patient RR 29-30. He is somnolent\n but arousable with shallow breaths, likely has atelectasis.\n - Continue supplemental O2.\n - Would like to try incentive spirometry however patient limited due to\n pain.\n - Treat pain with dilaudid PCA\n - Consider CXR in the AM\n .\n # Tachycardia: Likely multifactorial due to pain, fever, dehydration as\n well as withdrawal from daily atenolol. Patient stated that he is\n thirsty and has very dry MM. Had poor UOP during case which picked up\n after 3L IVF.\n - Continue with IVF to catch up and then continue with maintenance\n fluids. Normal EF on echocardiogram in 04/.\n - Tylenol for fever\n - Dilaudid PCA to treat pain\n - Continue with IV metoprolol per surgery\n .\n # s/p laparoscopy, parastomal hernia repair: POD1. Site appears clean,\n dry, intact. Tender at surgical site. JP drain in place.\n - NPO, IVF bolus plus maintenance. Has low grade fever post op.\n - Continue PCA\n - No antibiotics per surgery\n - Anticoagulation with heparin subq\n - Surgery recs in the AM.\n - Monitor JP drain output.\n - Continue PPI, ondansetron\n - Will continue to monitor fever curve. be related to\n atelectasis. Will hold on abx for now per surgical team.\n .\n # Acute renal failure: Presented with acute renal failure which was\n attributed to ileostomy losses, now resolved with fluids. Urine lytes\n on appear prerenal.\n - Continue to monitor and give IVF as above. Follow urine output\n overnight.\n .\n # Hypertension: Not active issue.\n - Plan to start PO meds once patient's diet is advanced. As outpatient\n he is on Atenolol, Aldactone, Norvasc.\n .\n # Depression:\n - Continue celexa once able to tolerate PO\n .\n #FEN\n - Hypokalemia: Arrived to with K replacement hanging. Will\n recheck in the AM and replete lytes PRN\n .\n #ACCESS: PIV\n .\n #PPx\n - Heparin sub-q for DVT prophylaxis\n - replete lytes PRN\n - PPI IV convert to PO once able.\n - bowel meds\n .\n #CODE: FULL\n .\n #COMMUNICATION: patient, medical records\n .\n #DISPO: ICU, likely call out to the floor in the AM.\n ICU Care\n Nutrition:\n Comments: NPO as diet overnight\n Glycemic Control:\n Lines:\n 22 Gauge - 11:00 PM\n Prophylaxis:\n DVT: Boots, 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":"2178-06-04 00:00:00.000","description":"Physician Resident Admission Note","row_id":328755,"text":"Chief Complaint: Xfer from surgery for tachypnea, tachycardia\n HPI:\n Mr. is a 56 year old male with history of ulcerative colitis (pt\n of Dr. failed medical management, s/p colectomy with ileostomy\n and preservation of rectum 12/. Post operative course was\n complicated by ileus. He had been doing well post operatively until\n when he presented to the ED with abdominal pain at the site of the\n stoma and increased ostomy output. He was admitted to the surgical\n service and treated conservatively with IVF, NG tube, and NPO. Serial\n abdominal films showed air fluid levels in the small bowel. Small\n bowel follow through showed no fistula formation or obstructive point\n but patient continued to have episodic cramping pain. Due to\n persistent pain, the patient was consented and taken to the OR today\n for exploratory laparoscopy. He was found to have parastomal hernia\n and adhesive disease, hernia repair and lysis of adhesions was\n performed. Estimated blood loss was minimal. He was given 2700 IVF\n however had 55cc urine output. He is being transferred from the PACU\n for monitoring due to tachypnea, tachycardia.\n .\n On arrival to the the patient is somnolent but arousable. He has\n dilaudid PCA within reach. He denies pain at rest but has pain\n with any movement. He denies fevers, chills, shortness of breath,\n nausea, chest pain or palpitations. He states that he is thirsty.\n Patient admitted from: OR / PACU\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 Celexa 10mg daily\n Aciphex 20mg daily\n Atenolol 25mg daily\n Aldactone 25mg daily\n Norvasc 2.5mg daily\n Past medical history:\n Family history:\n Social History:\n (taken from surgical admission note)\n Hypertension\n Depression\n Ulcerative colitis as above, history of chronic steroid use\n GERD\n MSSA bacteremia\n T10 diskitis\n Multiple spine surgeries: Fusion T6-T12\n Multiple thoracic laminetomies\n Partial vertebrectomy of T10-T11\n Hyperlipidemia\n History of PE\n C diff\n Hemochromatosis\n s/p arthroscopic knee surgery\n Non-contributory\n Occupation: Does not work\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Married with two children\n Review of systems:\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: Foley\n Psychiatric / Sleep: No(t) Agitated\n Pain: No pain / appears comfortable\n Pain location: Pain with movement\n Flowsheet Data as of 12:33 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: 38\nC (100.4\n HR: 125 (125 - 125) bpm\n BP: 102/66(74) {96/66(74) - 102/66(74)} mmHg\n RR: 34 (29 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n 6,218 mL\n 4 mL\n PO:\n TF:\n IVF:\n 6,218 mL\n 4 mL\n Blood products:\n Total out:\n 875 mL\n 32 mL\n Urine:\n 120 mL\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,343 mL\n -29 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, very dry mm, JVP flat\n Cardiovascular: (S1: Normal, Absent), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Tender: to palpation diffusely,\n Obese, Soft, ND, tender to palpation diffusely across abdomen,\n ileostomy intact with no drainage, hypoactive BS. JP drain in place\n with minimal output. Dressing c/d/i.\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 226\n 125\n 1.2\n 24\n 22\n 102\n 3.1\n 137\n 39.1\n 6.4\n [image002.jpg]\n Other labs: PT / PTT / INR:14/23/1.2, Ca++:9.0, Mg++:2.4, PO4:3.1\n Imaging: SB follow through: FINDINGS: Thin barium was orally\n ingested for this small bowel follow-through\n study. Overhead radiographs and fluoroscopic images show filling of the\n bowel loops after about approximately three hours. There is likely\n fluid in the\n bowel loops as the contrast appears markedly diluted. The small bowel\n is\n dilated in some regions measuring up to 5.7 cm. There is no transition\n point\n identified, no obvious fistula formation with no apparent leak or area\n of\n stricture as barium visibly made it to the patient's ostomy bag.\n IMPRESSION: Ingested oral contrast found in the ostomy bag after slight\n motility delay with dilated small bowel loops with no obvious fistula\n formation or obstruction.\n KUB: Distended loops of small bowel are present with multiple\n air-fluid levels on the upright film indicating likely small-bowel\n obstruction. Some air is seen within non dilated loops which indicates\n either the obstruction is recent or is incomplete.\n IMPRESSION: Appearances consistent with small-bowel obstruction either\n recent or incomplete. Dr. informed.\n Microbiology: Urine culture: Negative\n Assessment and Plan\n Mr. is a 56 year old male with history of UC s/p colectomy and\n ileostomy () who presented on with SBO and parastomal\n hernia now s/p LOA and parastomal hernia repair transferred to for\n tachypnea.\n .\n # Tachycardia: Likely multifactorial due to pain, fever, dehydration as\n well as withdrawal from daily atenolol. Patient stated that he is\n thirsty and has very dry MM. Had poor UOP during case which picked up\n slightly after 3L IVF.\n - Continue with maintenance IVF per surgery. They would like no\n additional fluids\n only maintenance. Concern because patient got so\n much fluid in OR as well as in PACU.\n - Tylenol for fever\n - Dilaudid PCA to treat pain\n - Continue with IV metoprolol per surgery\n - Monitor on telemetry. Per surgery ok for HR 110-120s.\n .\n # Tachypnea: Upon arrival to patient RR 29-30. He is somnolent\n but arousable with shallow breathing. No evidence of respiratory\n distress.\n - Continue supplemental O2.\n - Would like to try incentive spirometry however patient limited due to\n pain.\n - Treat pain with dilaudid PCA\n - Consider CXR in the AM as patient has received multiple liters of IVF\n over the day.\n .\n # s/p laparoscopy, parastomal hernia repair: POD1. Site appears clean,\n dry, intact. Tender at surgical site. JP drain in place.\n - NPO, IVF maintenance only as above. Has low grade fever post op.\n - Continue PCA\n - No antibiotics per surgery\n - Anticoagulation with heparin subq\n - Surgery recs in the AM.\n - Monitor JP drain output, ostomy output. Match output from ostomy 1cc\n to 1cc with NS.\n - Continue PPI, ondansetron\n - Will continue to monitor fever curve, WBC count. be related to\n atelectasis. Will hold on abx for now per surgical team.\n .\n # Acute renal failure: Presented with acute renal failure which was\n attributed to ileostomy losses, now resolved with fluids. Urine lytes\n on appear prerenal.\n - Continue to monitor and give IVF as above. Follow urine output\n overnight.\n .\n # Hypertension: Not active issue.\n - Plan to start PO meds once patient's diet is advanced. As outpatient\n he is on Atenolol, Aldactone, Norvasc.\n .\n # Depression:\n - Continue celexa once able to tolerate PO\n .\n #FEN\n - Hypokalemia: Arrived to with K replacement hanging. Will\n recheck in the AM and replete lytes PRN\n .\n #ACCESS: PIV\n .\n #PPx\n - Heparin sub-q for DVT prophylaxis\n - replete lytes PRN\n - PPI IV convert to PO once able.\n - bowel meds\n .\n #CODE: FULL\n .\n #COMMUNICATION: patient, medical records\n .\n #DISPO: ICU, likely call out to the floor in the AM.\n ICU Care\n Nutrition:\n Comments: NPO as diet overnight\n Glycemic Control:\n Lines:\n 22 Gauge - 11:00 PM\n Prophylaxis:\n DVT: Boots, 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":"Nursing","chartdate":"2178-06-04 00:00:00.000","description":"Nursing Progress Note","row_id":328756,"text":"56yo man with PMH of ulcerative colitis s/p total colectomy w/\n illeostomy in . Admitted to on w/ abd pain and\n increased ostomy output. Pain remained persistant during admission and\n pt underwent exploratory laprascopy w/ hernia repair and lysis of\n adhesions on . pt was febrile to 101.6, tachycardic to\n and tachypneac. Pt received total of 5 liters IVF in OR/PACU.\n Pt was transferred to M/SICU for further mgt.\n"},{"category":"Physician ","chartdate":"2178-06-04 00:00:00.000","description":"Physician Resident Admission Note","row_id":328813,"text":"Chief Complaint: Xfer from surgery for tachypnea, tachycardia\n HPI:\n Mr. is a 56 year old male with history of ulcerative colitis (pt\n of Dr. failed medical management, s/p colectomy with ileostomy\n and preservation of rectum 12/. Post operative course was\n complicated by ileus. He had been doing well post operatively until\n when he presented to the ED with abdominal pain at the site of the\n stoma and increased ostomy output. He was admitted to the surgical\n service and treated conservatively with IVF, NG tube, and NPO. Serial\n abdominal films showed air fluid levels in the small bowel. Small\n bowel follow through showed no fistula formation or obstructive point\n but patient continued to have episodic cramping pain. Due to\n persistent pain, the patient was consented and taken to the OR today\n for exploratory laparoscopy. He was found to have parastomal hernia\n and adhesive disease, hernia repair and lysis of adhesions was\n performed. Estimated blood loss was minimal. He was given 2700 IVF\n however had 55cc urine output. He is being transferred from the PACU\n for monitoring due to tachypnea, tachycardia.\n .\n On arrival to the the patient is somnolent but arousable. He has\n dilaudid PCA within reach. He denies pain at rest but has pain\n with any movement. He denies fevers, chills, shortness of breath,\n nausea, chest pain or palpitations. He states that he is thirsty.\n Patient admitted from: OR / PACU\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 Celexa 10mg daily\n Aciphex 20mg daily\n Atenolol 25mg daily\n Aldactone 25mg daily\n Norvasc 2.5mg daily\n Past medical history:\n Family history:\n Social History:\n (taken from surgical admission note)\n Hypertension\n Depression\n Ulcerative colitis as above, history of chronic steroid use\n GERD\n MSSA bacteremia\n T10 diskitis\n Multiple spine surgeries: Fusion T6-T12\n Multiple thoracic laminetomies\n Partial vertebrectomy of T10-T11\n Hyperlipidemia\n History of PE\n C diff\n Hemochromatosis\n s/p arthroscopic knee surgery\n Non-contributory\n Occupation: Does not work\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Married with two children\n Review of systems:\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: Foley\n Psychiatric / Sleep: No(t) Agitated\n Pain: No pain / appears comfortable\n Pain location: Pain with movement\n Flowsheet Data as of 12:33 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: 38\nC (100.4\n HR: 125 (125 - 125) bpm\n BP: 102/66(74) {96/66(74) - 102/66(74)} mmHg\n RR: 34 (29 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n 6,218 mL\n 4 mL\n PO:\n TF:\n IVF:\n 6,218 mL\n 4 mL\n Blood products:\n Total out:\n 875 mL\n 32 mL\n Urine:\n 120 mL\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,343 mL\n -29 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, very dry mm, JVP flat\n Cardiovascular: (S1: Normal, Absent), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Tender: to palpation diffusely,\n Obese, Soft, ND, tender to palpation diffusely across abdomen,\n ileostomy intact with no drainage, hypoactive BS. JP drain in place\n with minimal output. Dressing c/d/i.\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 226\n 125\n 1.2\n 24\n 22\n 102\n 3.1\n 137\n 39.1\n 6.4\n [image002.jpg]\n Other labs: PT / PTT / INR:14/23/1.2, Ca++:9.0, Mg++:2.4, PO4:3.1\n Imaging: SB follow through: FINDINGS: Thin barium was orally\n ingested for this small bowel follow-through\n study. Overhead radiographs and fluoroscopic images show filling of the\n bowel loops after about approximately three hours. There is likely\n fluid in the\n bowel loops as the contrast appears markedly diluted. The small bowel\n is\n dilated in some regions measuring up to 5.7 cm. There is no transition\n point\n identified, no obvious fistula formation with no apparent leak or area\n of\n stricture as barium visibly made it to the patient's ostomy bag.\n IMPRESSION: Ingested oral contrast found in the ostomy bag after slight\n motility delay with dilated small bowel loops with no obvious fistula\n formation or obstruction.\n KUB: Distended loops of small bowel are present with multiple\n air-fluid levels on the upright film indicating likely small-bowel\n obstruction. Some air is seen within non dilated loops which indicates\n either the obstruction is recent or is incomplete.\n IMPRESSION: Appearances consistent with small-bowel obstruction either\n recent or incomplete. Dr. informed.\n Microbiology: Urine culture: Negative\n Assessment and Plan\n Mr. is a 56 year old male with history of UC s/p colectomy and\n ileostomy () who presented on with SBO and parastomal\n hernia now s/p LOA and parastomal hernia repair transferred to for\n tachypnea.\n .\n # Tachycardia: Likely multifactorial due to pain, fever, dehydration as\n well as withdrawal from daily atenolol. Patient stated that he is\n thirsty and has very dry MM. Had poor UOP during case which picked up\n slightly after 3L IVF.\n - Continue with maintenance IVF per surgery. They would like no\n additional fluids\n only maintenance. Concern because patient got so\n much fluid in OR as well as in PACU.\n - Tylenol for fever\n - Dilaudid PCA to treat pain\n - Continue with IV metoprolol per surgery\n - Monitor on telemetry. Per surgery ok for HR 110-120s.\n .\n # Tachypnea: Upon arrival to patient RR 29-30. He is somnolent\n but arousable with shallow breathing. No evidence of respiratory\n distress.\n - Continue supplemental O2.\n - Would like to try incentive spirometry however patient limited due to\n pain.\n - Treat pain with dilaudid PCA\n - Consider CXR in the AM as patient has received multiple liters of IVF\n over the day.\n .\n # s/p laparoscopy, parastomal hernia repair: POD1. Site appears clean,\n dry, intact. Tender at surgical site. JP drain in place.\n - NPO, IVF maintenance only as above. Has low grade fever post op.\n - Continue PCA\n - No antibiotics per surgery\n - Anticoagulation with heparin subq\n - Surgery recs in the AM.\n - Monitor JP drain output, ostomy output. Match output from ostomy 1cc\n to 1cc with NS.\n - Continue PPI, ondansetron\n - Will continue to monitor fever curve, WBC count. be related to\n atelectasis. Will hold on abx for now per surgical team.\n .\n # Acute renal failure: Presented with acute renal failure which was\n attributed to ileostomy losses, now resolved with fluids. Urine lytes\n on appear prerenal.\n - Continue to monitor and give IVF as above. Follow urine output\n overnight.\n .\n # Hypertension: Not active issue.\n - Plan to start PO meds once patient's diet is advanced. As outpatient\n he is on Atenolol, Aldactone, Norvasc.\n .\n # Depression:\n - Continue celexa once able to tolerate PO\n .\n #FEN\n - Hypokalemia: Arrived to with K replacement hanging. Will\n recheck in the AM and replete lytes PRN\n .\n #ACCESS: PIV\n .\n #PPx\n - Heparin sub-q for DVT prophylaxis\n - replete lytes PRN\n - PPI IV convert to PO once able.\n - bowel meds\n .\n #CODE: FULL\n .\n #COMMUNICATION: patient, medical records\n .\n #DISPO: ICU, likely call out to the floor in the AM.\n ICU Care\n Nutrition:\n Comments: NPO as diet overnight\n Glycemic Control:\n Lines:\n 22 Gauge - 11:00 PM\n Prophylaxis:\n DVT: Boots, 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 ------ 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.\n Very well appearing on my exam this morning. Sleepy but easily\n arousable. Comfortable on pain regimen. Lungs CTA. No further need for\n ICU level care.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:10 ------\n"},{"category":"Respiratory ","chartdate":"2178-06-05 00:00:00.000","description":"Respiratory Care Shift Note","row_id":328903,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: 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: Nasal flaring, Accessory muscle\n use, Tachypneic (RR> 35 b/min), Gasping efforts, Intercostal\n retractions, Active exhalations\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\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 Recruitment Maneuvers Done\n CPAP pressure used: 35 cm H2O\n Duration: 30 sec\n Times per shift: 2\n Comments: poorly tolerated decreased bp.\n Multiple vent changes through out shift , please see metavision.\n"},{"category":"General","chartdate":"2178-06-05 00:00:00.000","description":"ICU Event Note","row_id":328905,"text":"Clinician: Attending\n Spoke with Dr who requests that all management issues for Mr\n are handled only by the surgical service. MICU residents will be\n available for emergency backup, but will not be called for management\n issues and pt will not be rounded on by MICU team or seen by MICU\n attending. Pt will transfer to SICU as soon as it is safe for .\n"},{"category":"Nursing","chartdate":"2178-06-05 00:00:00.000","description":"Nursing Progress Note","row_id":328906,"text":"56yo male POD #2 for exploratory lap w/ hernia repair, back to OR for\n ?acute abdomen, bladder pressure of 40. No apparent intra peritoneal\n process , tube placed, had edematous bowel and 3L fluid in\n abdomen removed. ? aspiration -> bronched -> no significant\n secretions, BAL sent. Abdomen decompressed, bladder pressures 23-25.\n Acidosis, Metabolic\n Assessment:\n Pt returned from OR at ~ 0900, intubated with poor ABG\ns despite fiO2\n of 100%. Lactate 4.2\n Action:\n Multiple changes made to vent throughout the day with plan to follow\n ARDS protocol. Presently is on AC 550X32X100%X15 with ABG\n 7.30/45/71/-3. Given bicarb gtt 150meq/1000 D5W at 150/hr and total of\n 5L LR.\n Response:\n ABG\ns as above.\n Plan:\n Monitor ABG\ns frequently and adjust vent accordingly following ARDS\n guidelines.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Persistent hypoxemia and hypercapnia despite high fiO2 and peeps. CXR\n -> bilat patchy infiltrates esp L upper lobe; TTE showed pulm embolism\n unlikely but has some pulmonary hypertension, LENI\ns also negative.\n Lung sounds are clear throughout, diminished LLL. No secretions noted.\n Action:\n Vent settings adjusted as above with satisfactory ABG\ns, given total of\n 5L of IVF today for hypotension and low urine output. Triadyne bed\n ordered for proning but so far not needed. Sedation changed from\n propofol to fent/versed 50/2 but resp pattern is shallow, labored and\n disynchronous so fent increased to 75mcg.\n Response:\n Resp status unstable.\n Plan:\n Prone pt if does not improve, titrate sedation to keep respirations\n unlabored without dropping BP,\n Sepsis without organ dysfunction\n Assessment:\n No infectious source identified so far. Tmax 99.7, lactate 4.2\n Action:\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\n flagyl/levo/vanc.\n Response:\n Pending.\n Plan:\n Monitor temp, wbc\ns, lactate. Follow cultures, continue abx until\n sensitivities available.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP\ns 70\ns-130/ 50-70\ns, HR 118-128 ST no ectopy, CVP 10-16\n Action:\n Phenylephrine gtt titrated throughout the day, was maxed for a short\n time but presently is at .9mcg/kg/min. Received total 5L LR, 25gm\n albumin, 1L D5W w/ 150meq bicarb.\n Response:\n Presently ABP\ns are 100\ns/ 60\ns, fluid status is +4L, urine output is\n 40-200cc/hr.\n Plan:\n Titrate neo to map >60, wean if possible, monitor fluid status, give 1L\n LR boluses for low urine output and hypotension.\n"},{"category":"Nursing","chartdate":"2178-06-05 00:00:00.000","description":"Nursing Progress Note","row_id":328907,"text":"56yo male POD #2 for exploratory lap w/ hernia repair, back to OR for\n ?acute abdomen, bladder pressure of 40. No apparent intra peritoneal\n process , tube placed, had edematous bowel and 3L fluid in\n abdomen removed. ? aspiration -> bronched -> no significant\n secretions, BAL sent. Abdomen decompressed, bladder pressures 23-25.\n Acidosis, Metabolic\n Assessment:\n Pt returned from OR at ~ 0900, intubated with poor ABG\ns despite fiO2\n of 100%. Lactate 4.2\n Action:\n Multiple changes made to vent throughout the day with plan to follow\n ARDS protocol. Presently is on AC 550X32X100%X15 with ABG\n 7.30/45/71/-3. Given bicarb gtt 150meq/1000 D5W at 150/hr and total of\n 5L LR.\n Response:\n ABG\ns as above.\n Plan:\n Monitor ABG\ns frequently and adjust vent accordingly following ARDS\n guidelines.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Persistent hypoxemia and hypercapnia despite high fiO2 and peeps. CXR\n -> bilat patchy infiltrates esp L upper lobe; TTE showed pulm embolism\n unlikely but has some pulmonary hypertension, LENI\ns also negative.\n Lung sounds are clear throughout, diminished LLL. No secretions noted.\n Action:\n Vent settings adjusted as above with satisfactory ABG\ns, given total of\n 5L of IVF today for hypotension and low urine output. Triadyne bed\n ordered for proning but so far not needed. Sedation changed from\n propofol to fent/versed 50/2 but resp pattern is shallow, labored and\n disynchronous so fent increased to 75mcg.\n Response:\n Resp status unstable.\n Plan:\n Prone pt if does not improve, titrate sedation to keep respirations\n unlabored without dropping BP,\n Sepsis without organ dysfunction\n Assessment:\n No infectious source identified so far. Tmax 99.7, lactate 4.2\n Action:\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\n flagyl/levo/vanc.\n Response:\n Pending.\n Plan:\n Monitor temp, wbc\ns, lactate. Follow cultures, continue abx until\n sensitivities available.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP\ns 70\ns-130/ 50-70\ns, HR 118-128 ST no ectopy, CVP 10-16\n Action:\n Phenylephrine gtt titrated throughout the day, was maxed for a short\n time but presently is at .9mcg/kg/min. Received total 5L LR, 25gm\n albumin, 1L D5W w/ 150meq bicarb.\n Response:\n Presently ABP\ns are 100\ns/ 60\ns, fluid status is +4L, urine output is\n 40-200cc/hr.\n Plan:\n Titrate neo to map >60, wean if possible, monitor fluid status, give 1L\n LR boluses for low urine output and hypotension.\n"},{"category":"Physician ","chartdate":"2178-06-05 00:00:00.000","description":"ICU Attending Note","row_id":328885,"text":"Clinician: Attending\n 56 yo man with colitis, presumed UC, colectomy , adm with\n high ostomy output and abd pain. Ostomy output attributed to bowel wall\n edema and poor absorption. In MICU with transient tachypnea and\n tachycardia but not hypoxemia following hernia repair and ex-lap. Was\n persistantly tachycardic, likely dehydrated. Tachypnea resolved\n overnight, transferred back to surgical floor yesterday morning. Total\n 6L net + over 24 h, with decreasing urine output finally to < 10cc/h.\n WBC rose 6--> 26--> 38K with 20% bandemia. Resp distress with\n tachypnea, 7.39/35/81 on NRB. Tranferred to MICU. Initial mental status\n normal, becamse confused within hours. Increasing oxygen requirement.\n 7.39/34/65 on NRB, lactate 3.0. Lung exam with dffuse crackles.\n Oliguric with no response to lasix. Concern for abd distension, bladder\n pressure was 40 mm Hg. Initial CXR showed low lung volumes but no sig\n parenchymal process, right mid lung zone atelectasis. Went to OR got\n right IJ, art line, found to have edematous bowel, stomach had 3L\n fluid. Bowel decompressed. Bronch with no sig secretions, BAL done.\n Since surgery hypoxia progressed. Severe metabolic acidosis. CXR with\n bilateral patchy infiltrates esp left upper lung field. Sedated on\n propofol. Hypotensive with 87/64, MAP 71. SpO2 88% on FiO2 1.0, PEEP 15\n TV 450 RR 35 PIP 35 Plateau 26 Compliance 45. Abdomen distension much\n improved.\n 7.13/63/70 on rate 26.\n HCo3 22, gap 15. BUN/Cr 39/2.5 (inc from 1.4 yest). WBC 25K. Hct 42%.\n LFTs wnl. INR 1.6. Lactate rose to 4.5.\n Severely critically ill with ARDS, septic shock, unclear if he had\n aspiration event or secondary to sepsis, abd surgery. Now oliguric,\n hypotensive, requiring max vent support. Bladder pressure decreased\n from 40 to 25 after decompression. Broad abx, no cx data yet.\n flagyl/levo/vanc to cover bowel and lung sources. ARDSnet but pushing\n PEEP for continued hypoxia. Permissive hypercapnia, and RR raised for\n acidemia, but will give bicarb if repeat ABG shows no correction of pH.\n Trying right side down to try to improve V/Q mismatch. Will likely\n switch to PCV to improve oxygenation if ineffective.\n Patient is critically ill.\n ------ Protected Section ------\n Spoke with Dr , who told me there is no contraindication\n to proning, if that becomes necessary.\n Bicarb infusion.\n Phenylephrine now at 2.5mcg/kg/min.\n Placing esophageal balloon, as abd pressure suggested he will need much\n higher PEEP.\n Time spent 80 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:29 ------\n Remains critically ill with ARDS, septic shock. pH improved now at 7.30\n on PRVC vent, PEEP 15, Vt at 4.5cc/kg. Received 5L crystalloid, with\n good urine output and CVP 15 (though high PEEP). Remains on\n phenylephrine, but down to 0.9. Highly doubt PE given that we have a\n good reason for hypoxic resp failure given cxr and ARDS physiology, I\n suspect aspiration event. I feel risk of empiric heparin outweighs\n theoretical benefit, despite h/o PE 1 year ago. Repeat coags pending.\n Echo result pending but on my review RV appeared to contract well and\n have reasonably normal chamber size.\n Time: additional 60 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:30 ------\n"},{"category":"Nursing","chartdate":"2178-06-04 00:00:00.000","description":"Nursing Transfer Note","row_id":328782,"text":"Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hernia, other\n Assessment:\n Action:\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2178-06-05 00:00:00.000","description":"Nursing Progress Note","row_id":328898,"text":"56yo male POD #2 for exploratory lap w/ hernia repair, back to OR for\n ?acute abdomen, bladder pressure of 40. No intra peritoneal process ,\n tube placed, had edematous bowel and 3L fluid in abdomen. ?\n aspiration -> bronched -> no significant secretions, BAL sent. Abdomen\n decompressed, bladder pressures 23-25.\n Acidosis, Metabolic\n Assessment:\n Pt returned from OR at ~ 0900, intubated with poor ABG\ns despite fiO2\n of 100%. Lactate 4.2\n Action:\n Multiple changes made to vent throughout the day with plan to follow\n ARDS protocol. Presently is on AC 550X32X100%X15 with ABG\n 7.30/45/71/-3. Given bicarb gtt 150meq/1000 D5W at 150/hr and total of\n 5L LR.\n Response:\n ABG\ns as above.\n Plan:\n Monitor ABG\ns frequently and adjust vent accordingly following ARDS\n guidelines.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Persistent hypoxemia and hypercapnia despite high fiO2 and peeps. CXR\n -> bilat patchy infiltrates esp L upper lobe; TTE showed pulm embolism\n unlikely but has some pulmonary hypertension, LENI\ns also negative.\n Lung sounds are clear throughout, diminished LLL. No secretions noted.\n Action:\n Vent settings adjusted as above with satisfactory ABG\ns, given total of\n 5L of IVF today for hypotension and low urine output. Triadyne bed\n ordered for proning but so far not needed. Sedation changed from\n propofol to fent/versed 50/2 but resp pattern is shallow, labored and\n disynchronous so fent increased to 75mcg.\n Response:\n Resp status unstable.\n Plan:\n Prone pt if does not improve, titrate sedation to keep respirations\n unlabored without dropping BP,\n Sepsis without organ dysfunction\n Assessment:\n No infectious source identified so far. Tmax 99.7, lactate 4.2\n Action:\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\n flagyl/levo/vanc.\n Response:\n Pending.\n Plan:\n Monitor temp, wbc\ns, lactate. Follow cultures, continue abx until\n sensitivities available.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP\ns 70\ns-130/ 50-70\ns, HR 118-128 ST no ectopy, CVP 10-16\n Action:\n Phenylephrine gtt titrated throughout the day, was maxed for a short\n time but presently is at .9mcg/kg/min. Received total 5L LR, 25gm\n albumin, 1L D5W w/ 150meq bicarb.\n Response:\n Presently ABP\ns are 100\ns/ 60\ns, fluid status is +4L, urine output is\n 40-200cc/hr.\n Plan:\n Titrate neo to map >60, wean if possible, monitor fluid status, give 1L\n LR boluses for low urine output and hypotension.\n"},{"category":"Nursing","chartdate":"2178-06-04 00:00:00.000","description":"Nursing Transfer Note","row_id":328784,"text":"Mr. is a 56 year old male with history of ulcerative colitis (pt\n of Dr. failed medical management, s/p colectomy with ileostomy\n and preservation of rectum 12/. Post operative course was\n complicated by ileus. He had been doing well post operatively until\n when he presented to the ED with abdominal pain at the site of the\n stoma and increased ostomy output. He was admitted to the surgical\n service and treated conservatively with IVF, NG tube, and NPO. Serial\n abdominal films showed air fluid levels in the small bowel. Small\n bowel follow through showed no fistula formation or obstructive point\n but patient continued to have episodic cramping pain. Due to\n persistent pain, the patient was consented and taken to the OR today\n for exploratory laparoscopy. He was found to have parastomal hernia\n and adhesive disease, hernia repair and lysis of adhesions was\n performed. Estimated blood loss was minimal. He was given 2700 IVF\n however had 55cc urine output. He is being transferred from the PACU\n for monitoring due to tachypnea, tachycardia.\n .\n On arrival to the the patient is somnolent but arousable. He has\n dilaudid PCA within reach. PCA dose increased overnight. He reports\n pain at 3/10, reports that it is now much better controlled. Pain with\n any movement. He denies fevers, chills, shortness of breath, nausea,\n chest pain or palpitations. He states that he is thirsty.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Pt received 3 fluid boluses overnight for total of 2 L, was started\n on maintenance fluid at 150cc/hr, HR: 102-125, trending down,\n BP:94-109/65-87, trending up, u/o~20-30 cc/hr, cr this am 1.4\n Action:\n No further fluid boluses given this shift per surgery, pt reporting\n that he is thirsty, following hemodynamics, pt receiving metoprolol as\n ordered\n Response:\n Ongoing\n Plan:\n Encourage Po intact when ordered, pt currently NPO, continue maintance\n fluids, montitor I/O, ? recs, continue cardiac meds per wants\n pt beta blocked on atenolol at home\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt on dilaudid PCA as noted above, 0.37 mg increased overnight with\n good effect, 6min lock out, no basal rate, 1 hour max 3.7mg, pt\n reporting pain at 3/10 at rest, increased pain with activity, pt\n describes pain as sharp and radiating, sleeping at times arouses with\n pain but controlled with PCA dosing\n Action:\n Encouraging pt to use PCA, PCA teaching, continuing to provide current\n dosing as ordered\n Response:\n Pt with good pain control, pain reported at 3/10 while at rest\n Plan:\n Transition to po pain meds as tolerated when pt started on Pos,\n continue PCA for now, continue to monitor pain control\n Hernia, other\n Assessment:\n Pt with hernia repair , by this am to view incision, two mid\n line incisions noted, dressing dry and intact, serous drainage\n noted on upper dsg, JP drain on lower, draining serous fluid, iliostomy\n with minimal out put draining serous fluid as well, bowel sounds\n present\n Action:\n Monitoring\n Response:\n Ongoing\n Plan:\n Continue to monitor abd for increased tenderness, redness and pain,\n monitor JP drainage for change in color or odor, f/ recs for dsg\n changes\n Demographics\n Attending MD:\n \n Admit diagnosis:\n OBSTRUCTION\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 95.3 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: ulcerative colitis s/p total colectomy in .\n Depression, GERD.Thoracic back pain. multiple spinal surgeries,\n arthroscopic knee surgery.\n Surgery / Procedure and date: Exploratory Lap w/ Hernia Repair \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:87\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 108 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 2,607 mL\n 24h total out:\n 219 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 04:05 AM\n Potassium:\n 4.1 mEq/L\n 04:05 AM\n Chloride:\n 109 mEq/L\n 04:05 AM\n CO2:\n 19 mEq/L\n 04:05 AM\n BUN:\n 24 mg/dL\n 04:05 AM\n Creatinine:\n 1.4 mg/dL\n 04:05 AM\n Glucose:\n 144 mg/dL\n 04:05 AM\n Hematocrit:\n 35.7 %\n 04:05 AM\n Additional pertinent labs:\n BUN 24 CR 1.4\n Lines / Tubes / Drains:\n JP drain, 2 PIV\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/\n Transferred to: 12R\n Date & time of Transfer: 1100\n"},{"category":"Nursing","chartdate":"2178-06-05 00:00:00.000","description":"Nursing Progress Note","row_id":328843,"text":"Mr. is a 56 year old male with history of ulcerative colitis (pt\n of Dr. failed medical management, s/p colectomy with ileostomy\n and preservation of rectum 12/. Post operative course was\n complicated by ileus. He had been doing well post operatively until\n when he presented to the ED with abdominal pain at the site of the\n stoma and increased ostomy output. He was admitted to the surgical\n service and treated conservatively with IVF, NG tube, and NPO. Serial\n abdominal films showed air fluid levels in the small bowel. Small\n bowel follow through showed no fistula formation or obstructive point\n but patient continued to have episodic cramping pain. Due to\n persistent pain, the patient was consented and taken to the OR for\n exploratory laparoscopy. He was found to have parastomal hernia and\n adhesive disease, hernia repair and lysis of adhesions was performed.\n He was transferred from the PACU here to ICU for monitoring due to\n tachypnea, tachycardia. He was transferred to 12R as he was\n stable.\n .\n Early this am pt. became tachypneic, tachycardic up to 140\ns and\n oliguric. Placed on 100% NRB with good effect. CXR wnl, EKG wnl,\n Crackles bilat. Given 80mg of lasix and transferred here to ICU for\n further management. Labs drawn on floor. White count rising. Lactate\n 3.0\n Upon arrival here pt. found to have HR up to 150\ns. BP WNL. Tachypneic\n and very confused. Notably cold/clammy. Unable to draw labs. Abdomen\n Firm. Bowel sounds absent. C/o pain despite dilaudid PCA. Bladder\n pressure checked and was 40. Surgeon called immediately. Pt. refusing\n central line and a line. Plan is to go to OR. ? Compartment syndrome\n vs. intra-abdominal process.\n"},{"category":"Physician ","chartdate":"2178-06-05 00:00:00.000","description":"Physician Resident Admission Note","row_id":328844,"text":"Chief Complaint: Transfer from surgery for tachypnea, shortness of\n breath.\n HPI:\n 56 yo M with a history of UC s/p colectomy with ileostomy in \n admitted on with abdominal pain and increased ostomy output\n now POD #2 from ex lap with parastomal hernia repair and lysis of\n adhesions who represents to the ICU with acute onset tachypnea and\n shortness of breath and oliguric renal failure.\n .\n The patient was originally admitted on . He had been doing well\n since his surgery in until he developed abdominal pain at the\n site of the stoma and increased ostomy output. He was admitted to the\n surgical service and treated conservatively with IVF, NG tube, and\n NPO. Serial abdominal films showed air fluid levels in the small\n bowel. Small bowel follow through showed no fistula formation or\n obstructive point but patient continued to have episodic cramping\n pain. Due to persistent pain, the patient was consented and taken to\n the OR on for exploratory laparoscopy. He was found to have\n parastomal hernia and adhesive disease, hernia repair and lysis of\n adhesions was performed. The patient was in the ICU overnight the\n evening after surgery for tachypnea, tachycardia and relative hypoxia.\n At that time he was felt likely to be hypovolemic possibly with a\n component of beta-blocker withdrawal. With minimal intervention\n overnight, the patient's symptoms improved and he was called back out\n to the surgical floor.\n .\n Since that time, the patient has received an estimated 6L of fluid\n rescucitation per the report of the surgery team and recent \n records. He had poor urine output of approximately 500cc. He had rising\n WBC, Hct and platelets.\n .\n The surgical resident was called to evaluate the patient where he was\n found to be tachycardic, tachypneic and hypoxic requiring a\n non-rebreather. He was noted to be oliguric with declining urine output\n to approximately 10cc/hr. ABG at that time revealed 7.39/35/81 on a\n NRB. He was transferred to the ICU where repeat ABG revealed 7.39/34/65\n on a NRB with lactate 3.0. He received 50mg IV lasix on the floor and\n an additional 80mg IV lasix in the ICU without significant urine\n output.\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 Furosemide (Lasix) - 02:15 AM\n Other medications:\n Meds on admission:\n Celexa 10mg daily\n Aciphex 20mg daily\n Atenolol 25mg daily\n Aldactone 25mg daily\n Norvasc 2.5mg daily\n .\n Meds on transfer:\n Hyoscyamine 0.125 mg SL QID\n Ipratropium Bromide Neb 1 NEB IH Q6H\n Acetaminophen 325-650 mg PO Q6H:PRN\n Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN\n Metoprolol Tartrate 5 mg IV Q6H\n DiphenhydrAMINE 25 mg PO HS:PRN\n Ondansetron 4 mg IV Q8H:PRN\n Pantoprazole 40 mg IV Q24H\n HYDROmorphone (Dilaudid) 0.37 mg IVPCA\n Heparin 5000 UNIT SC TID\n Past medical history:\n Family history:\n Social History:\n Hypertension\n Depression\n Ulcerative colitis as above, history of chronic steroid use\n GERD\n MSSA bacteremia\n T10 diskitis\n Multiple spine surgeries: Fusion T6-T12\n Multiple thoracic laminetomies\n Partial vertebrectomy of T10-T11\n Hyperlipidemia\n History of PE\n C diff\n Hemochromatosis\n s/p arthroscopic knee surgery\n See recent admit note\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: See recent admit note\n Review of systems: Notes abdominal pain and shortness of breath,\n otherwise negative in detail.\n Flowsheet Data as of 04:54 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: 35.7\nC (96.3\n HR: 143 (102 - 147) bpm\n BP: 125/108(112) {100/68(75) - 133/108(112)} mmHg\n RR: 28 (20 - 35) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Bladder pressure: 40 (40 - 40) mmHg\n Total In:\n 2,853 mL\n 23 mL\n PO:\n TF:\n IVF:\n 2,853 mL\n 23 mL\n Blood products:\n Total out:\n 249 mL\n 337 mL\n Urine:\n 229 mL\n 67 mL\n NG:\n Stool:\n Drains:\n 20 mL\n 70 mL\n Balance:\n 2,604 mL\n -314 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n Physical Examination\n Gen: Somewhat uncomfortable gentleman with NRB on. Intermittent\n complaints of abdominal pain.\n HEENT: JVP difficult to assess.\n CV: RRR. Normal S1 and S2. No M/R/G.\n Pulm: Diffuse crackles R>L.\n Abd: Mildly distended. Hypoactive bowel sounds. Diffuse tenderness.\n Ext: No edema.\n Bladder pressure: 40\n Labs / Radiology\n 245 K/uL\n 11.4 g/dL\n 144 mg/dL\n 1.4 mg/dL\n 24 mg/dL\n 19 mEq/L\n 109 mEq/L\n 4.1 mEq/L\n 140 mEq/L\n 35.7 %\n 26.9 K/uL\n [image002.jpg]\n \n 2:33 A6/19/ 04:05 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 26.9\n Hct\n 35.7\n Plt\n 245\n Cr\n 1.4\n Glucose\n 144\n Other labs: Lactic Acid:3.0, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Fluid analysis / Other labs: ABG: 7.39/35/81 -> 7.39/34/65\n Imaging: CXR (): As compared to the previous radiograph from\n , there is unchanged visualization of thoracic fusion\n hardware. The lung volumes are slightly lower than on the previous\n examination, the cardiac silhouette is slightly larger. Probably due to\n positioning effect, the transparency of the right hemithorax has\n decreased, however, some small amount of right-sided pleural effusion\n cannot be excluded. There are no signs suggestive of overhydration.\n .\n CXR (): Small lung volumes. No infiltrates. No obvious signs of\n volume overload.\n Microbiology: Urine culture (): <10,000 organisms/ml\n ECG: Sinus tachycardia at 147. Normal axis and intervals. Downgoing t's\n in V1 as seen previously. Morphologic change across the precordium with\n very poor R wave progression and predominantly negative QRS complex in\n V2-4 more pronounced than prior and near isoelectric V5-6 new from\n prior. No signs of right heart strain.\n Assessment and Plan\n A/P: 56 yo M with a history of UC s/p colectomy with ileostomy in\n admitted on with abdominal pain and increased ostomy\n output now POD #2 from ex lap with parastomal hernia repair and lysis\n of adhesions who represents to the ICU with sepsis physiology, acute\n onset tachypnea and shortness of breath and oliguric renal failure\n concerning for abdominal compartment syndrome.\n .\n # Abdominal source sepsis. Tachycardia, tachypnea, leukocytosis and\n lacate elevation suggestive of sepsis physiology. Likely source is\n recent abdominal surgery with enterotomy.\n - Broad spectrum antibiotics with vanc, levo, flagyl.\n - Blood and urine cultures.\n - Back to OR per surgery.\n .\n # Tachypnea, shortness of breath. Most likely secondary to pulmonary\n edema due to 3rd spacing of fluid in the lungs with diffuse crackles on\n exam and large A-a gradient. This is likely in part due to sepsis\n physiology (leukocytosis and lactate elevation) with capillary leak\n Cannot exclude PE though less likely given exam and clinical\n appearance. Flash edema from hypertension or MI cannot be excluded\n though also less likely. Hypoventilation due to pain and abdominal\n compartment syndrome with elevated bladder pressure is possible though\n this does not explain the large A-a gradient well. These seems unlikely\n to represent a pulmonary source of infection.\n - Continue oxygen supplementation support. Positive pressure and\n mechanical ventilation as necessary for respiratory decline.\n - Difficult volume status, intravascularly deplete, 3rd space volume\n overloaded in lungs and abdomen. Unresponsive to lasix likely secondary\n to abdominal compartment syndrome. Maintain I/O status even as\n possible.\n - Requires decompression of likely abdominal compartment syndrome to\n allow for improved perfusion of kidneys and diuresis.\n - Rule out MI.\n - Likely TTE post-operatively.\n .\n # Tachycardia. Likely sepsis physiology. Cannot exclude a component of\n pain or secondary to respiratory distress.\n - Broad spectrum antibiotics.\n - Maintain I/O even as possible.\n .\n # Oliguric renal failure. Likely secondary to abdominal compartment\n syndrome. Bladder pressure 40.\n - To OR for decompression of abdominal compartment syndrome.\n .\n # UC s/p ostomy with recent abdominal surgery for paraostomy hernia\n repair and lysis of adhesions. Complications as above of likely\n abdominal source sepsis +/- abdominal compartment syndrome.\n - Back to OR for re-exploration and abdominal decompression.\n .\n # Hypertension. Hold beta-blocker in the setting of likely hypotension.\n .\n # FEN: NPO.\n .\n # Access: Peripheral IV. Refusing central line.\n .\n # Prophylaxis: Pneumoboots, PPI.\n .\n # Code: Full\n .\n # Dispo: ICU.\n .\n ICU Care\n Nutrition:\n 22 Gauge - 02:20 AM\n Prophylaxis:\n DVT: Boots\n Code status: Full code\n"},{"category":"Physician ","chartdate":"2178-06-05 00:00:00.000","description":"Physician Attending Admission Note","row_id":328839,"text":"Chief Complaint: Increasing dyspnea, s/p abdom surgery today with\n lysis of adhesions and one incidence of inadvertent enterotomy. Since\n surgery, increasing WBC, abdominal distention, worsening hypoxemia with\n rising lactate.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n As Above\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 Furosemide (Lasix) - 02:15 AM\n Other medications:\n Metoprolol, Albuterol Nebs, Ipratropium, Dilaudid PCA\n Past medical history:\n Family history:\n Social History:\n Ulcerative Colitis\n PE\n C Difficile\n Non contrib\n Occupation: Disability\n Drugs: None\n Tobacco: Quit \n Alcohol: None\n Other:\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Nutritional Support: NPO\n Respiratory: Tachypnea\n Gastrointestinal: Diarrhea, Watery output from enterostomy\n Genitourinary: Foley\n Flowsheet Data as of 04:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.7\nC (96.3\n HR: 143 (102 - 147) bpm\n BP: 125/108(112) {100/68(75) - 133/108(112)} mmHg\n RR: 28 (20 - 35) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n 2,853 mL\n 16 mL\n PO:\n TF:\n IVF:\n 2,853 mL\n 16 mL\n Blood products:\n Total out:\n 249 mL\n 337 mL\n Urine:\n 229 mL\n 67 mL\n NG:\n Stool:\n Drains:\n 20 mL\n 70 mL\n Balance:\n 2,604 mL\n -321 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: 7.39/34/65\n Physical Examination\n General Appearance: 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: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Crackles : )\n Abdominal: Distended, Tender: Rebound present\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: 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 245 K/uL\n 35.7 %\n 11.4 g/dL\n 144 mg/dL\n 1.4 mg/dL\n 24 mg/dL\n 19 mEq/L\n 109 mEq/L\n 4.1 mEq/L\n 140 mEq/L\n 26.9 K/uL\n [image002.jpg]\n 04:05 AM\n WBC\n 26.9\n Hct\n 35.7\n Plt\n 245\n Cr\n 1.4\n Glucose\n 144\n Other labs: Lactic Acid:3.0, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n Acute Abdomen with Compartment Syndrome - Bladder Pressure 40\n Needs re-explore for possible enterostomy leak, ? abdominal sepsis\n Doubt PE - hold heparin\n Will cover with broad spectrum antibiotics\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 22 Gauge - 02:20 AM\n Comments:\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: 75 minutes\n Patient is critically ill\n"},{"category":"Nursing","chartdate":"2178-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":328916,"text":"56yo male POD #2 for exploratory lap w/ hernia repair, back to OR\n yesterday for ?acute abdomen, bladder pressure of 40. No apparent\n intra peritoneal process , tube placed, had edematous bowel and\n 3L fluid in abdomen removed. ? aspiration, apparently vomited during\n procedure -> bronched in MICU -> no significant secretions, BAL sent.\n Abdomen decompressed, bladder pressures 23-25.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n CXR -> bilat patchy infiltrates, opacities esp. in left lobe; Echo\n done, showed PE unlikely. Lung sounds are slightly coarse upper with\n significantly diminished lower lobes. ABG at 1900 7.33/46/93/25 on\n 100%FiO2/15 PEEP. Fent at 75mcg/hr/Versed at 2 mg/hr.\n Action:\n Surgery in to see patient overnight, dropped Fi02 to 60%, PEEP 13.\n Corresponding ABG 7.38/45/65/28. Surgery fine with PaO2 > 60 on 60%.\n Response:\n Pt. overbreathing vent by 2-5 bpm, appearing uncomfortable and awake.\n Increased Fent to 100mcg/hr and Versed to 3mg/hr with improvement in RR\n and comfort. BP remained stable after increase in sedation.\n Plan:\n Prone pt if does not improve, titrate sedation to keep respirations\n unlabored without dropping BP,\n Sepsis without organ dysfunction\n Assessment:\n No infectious source identified so far. Tmax 100.7, lactate 4.3, skin\n much more warm to touch.\n Action:\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\n flagyl/levo/vanc.\n Response:\n Pending.\n Plan:\n Monitor temp, wbc\ns, lactate. Follow cultures, continue abx until\n sensitivities available.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP\ns 70\ns-110/ 50-70\ns, HR 118-128 ST no ectopy, CVP 10-16. Neo turned\n off at . Yesterday received total 5L LR, 25gm albumin, 1L D5W w/\n 150meq bicarb. UO 70-300cc/hr.\n Action:\n Overnight, surgery ordered 2 L LR, 5% Albumin. SBP remained stable in\n high 90\ns-low 100\ns. At 0300 was slightly tachy into 130\ns, SBP\n dropping into 80\ns, T 100.7, UO around 70cc/hr. Bolused another liter\n of LR.\n Response:\n Plan:\n"},{"category":"Nursing","chartdate":"2178-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":328922,"text":"56yo male POD #2 for exploratory lap w/ hernia repair, back to OR\n yesterday for ?acute abdomen, bladder pressure of 40. No apparent\n intra peritoneal process , tube placed, had edematous bowel and\n 3L fluid in abdomen removed. ? aspiration, apparently vomited during\n procedure -> bronched in MICU -> no significant secretions, BAL sent.\n Abdomen decompressed, bladder pressures 23-25.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n CXR -> bilat patchy infiltrates, opacities esp. in left lobe; Echo\n done, showed PE unlikely. Lung sounds are slightly coarse upper with\n significantly diminished lower lobes. ABG at 1900 7.33/46/93/25 on\n 100%FiO2/15 PEEP. Fent at 75mcg/hr/Versed at 2 mg/hr.\n Action:\n Surgery in to see patient overnight, dropped Fi02 to 60%. Corresponding\n ABG 7.38/45/65/28.\n Response:\n Pt. overbreathing vent by 2-5 bpm, appearing uncomfortable and awake.\n Increased Fent to 100mcg/hr and Versed to 3mg/hr with improvement in RR\n and comfort. BP remained stable after increase in sedation. PEEP to 13.\n ABG at 0430 7.46/41/97/30. PEEP decreased to 10. ABG:\n Plan:\n Prone pt if does not improve, titrate sedation to keep respirations\n unlabored without dropping BP,\n Sepsis without organ dysfunction\n Assessment:\n No infectious source identified so far. Tmax 100.8, lactate 3.1, skin\n much more warm to touch.\n Action:\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\n flagyl/levo/vanc.\n Response:\n Pending.\n Plan:\n Monitor temp, wbc\ns, lactate. Follow cultures, continue abx until\n sensitivities available.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP\ns 70\ns-110/ 50-70\ns, HR 118-128 ST no ectopy, CVP 8-12. Neo turned\n off at . Yesterday received total 5L LR, 25gm albumin, 1L D5W w/\n 150meq bicarb. UO 70-300cc/hr.\n Action:\n Overnight, surgery ordered 2 L LR, 5% Albumin. SBP remained stable in\n high 90\ns-low 100\ns. At 0300 was slightly tachy into 130\ns, SBP\n dropping into 80\ns, T 100.7, UO around 70cc/hr. Bolused another liter\n of LR. Pt. put out 500cc via oral gastric tube over 8 hrs. Cannister\n changed and immediately put out another 450cc of bilious fluid.\n Response:\n ABPs 90-110/55-70. MAP >60. UO >50cc/hr.\n Plan:\n Continue boluses for hypotension and decreased urine output.\n Dr. has expressed she would like patient to go west if stable\n enough for transport today.\n"},{"category":"Respiratory ","chartdate":"2178-06-06 00:00:00.000","description":"Respiratory Care Shift Note","row_id":328923,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\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: 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: Clear / 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: Gasping efforts, High flow\n 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 Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\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: Pt remains on vent. Weaning as tolerated per team. Abgs\n improving. Plan to transfer to . Will continue to monitor.\n"},{"category":"Nursing","chartdate":"2178-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":328976,"text":"56 yo M with history of UC s/p colectomy with ileostomy in \n admitted on with abdominal pain and increased ostomy output now\n POD #3 from ex lap with parastomal hernia repair and lysis of\n adhesions. Transferred to ICU from floor 2 days post op with acute\n onset tachypnea, SOB, and oliguric renal failure. In ICU he was on\n 100% NRB with good sats, CXR wnl, EKG wnl, crackles bilateral lung\n bases -> given lasix, labs showed rising wbc\ns and lactate. Also found\n to have bladder pressure of 40 so taken back to OR for ? abdominal\n compartment syndrome. No apparent intra-peritoneal process, tube\n placed, had edematous bowel and 3L fluid in abdomen removed. Had\n vomiting with ?aspiration during induction -> bronched, no significant\n secretions, BAL sent. To ICU intubated with O2 sats in high 80\ns, low\n 90\ns despite 100% fiO2. On phenylephrine at .9mcg for hypotension.\n Throughout the next 24hrs pt was given a total of 9-10L of LR for low\n urine output, hypotension, and tachycardia. Vent settings were adjusted\n per ARDS protocol and antibiotics levo/flagyl/vanc started. Also had\n echo to r/o PE since too unstable for CT and LENI\ns done. Both were\n negative.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vented on PRVC mode with settings 450X32X60%X10 and ABG\ns early this am\n 7.47/37/109/3/28. Lung sounds are clear, diminished in bases. Suctioned\n for small amts thick tan secretions or no secretions at all.\n Action:\n Sedated on fentanyl/versed 75/2 but requiring boluses of 25-30mcg for\n RR in the 40\ns and agitation. No vent changes made today.\n Response:\n Respiratory status stable.\n Plan:\n Transfer to SICU. Wean vent as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n Tmax 101.2, last BC done on is pending. Also pending are urine,\n BAL, and abdominal fluid cultures. Abdomen is softly distended, bowel\n sounds are absent although there is some greenish liquid output in\n ileostomy and j-tube drain. OGT to low suction drained ~700cc\n bilious liquid. Abdominal dressings are D&I, small amt of old SS drnge\n on L quad dressing. Hemodynamic status is much improved, no IVF\n boluses or pressors required.\n Action:\n Antibiotics changed from levo/flagyl/vanc to zosyn/vanc. Vanc trough\n this am 6.3\n Response:\n Sepsis improving.\n Plan:\n Follow fever curve, wbc\ns, cultures, sensitivities, continue abx.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP 95-131/52-71; HR 115-123, ST no ectopy, CVP 10-12. Urine output\n 50-120cc/hr\n Action:\n 1unit PRBC\ns given for volume. Crit this am 27.7; receiving maintenance\n IVF LR at 125/hr, no fluid boluses or pressors required.\n Response:\n Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L.\n Plan:\n Continue to monitor ABP, CVP, UO, HR.\n"},{"category":"Nursing","chartdate":"2178-06-06 00:00:00.000","description":"Nursing Transfer Note","row_id":328977,"text":"56 yo M with history of UC s/p colectomy with ileostomy in \n admitted on with abdominal pain and increased ostomy output now\n POD #3 from ex lap with parastomal hernia repair and lysis of\n adhesions. Transferred to ICU from floor 2 days post op with acute\n onset tachypnea, SOB, and oliguric renal failure. In ICU he was on\n 100% NRB with good sats, CXR wnl, EKG wnl, crackles bilateral lung\n bases -> given lasix, labs showed rising wbc\ns and lactate. Also found\n to have bladder pressure of 40 so taken back to OR for ? abdominal\n compartment syndrome. No apparent intra-peritoneal process, tube\n placed, had edematous bowel and 3L fluid in abdomen removed. Had\n vomiting with ?aspiration during induction -> bronched, no significant\n secretions, BAL sent. To ICU intubated with O2 sats in high 80\ns, low\n 90\ns despite 100% fiO2. On phenylephrine at .9mcg for hypotension.\n Throughout the next 24hrs pt was given a total of 9-10L of LR for low\n urine output, hypotension, and tachycardia. Vent settings were adjusted\n per ARDS protocol and antibiotics levo/flagyl/vanc started. Also had\n echo to r/o PE since too unstable for CT and LENI\ns done. Both were\n negative.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vented on PRVC mode with settings 450X32X60%X10 and ABG\ns early this am\n 7.47/37/109/3/28. Lung sounds are clear, diminished in bases. Suctioned\n for small amts thick tan secretions or no secretions at all.\n Action:\n Sedated on fentanyl/versed 75/2 but requiring boluses of 25-30mcg for\n RR in the 40\ns and agitation. No vent changes made today.\n Response:\n Respiratory status stable.\n Plan:\n Transfer to SICU. Wean vent as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n Tmax 101.2, last BC done on is pending. Also pending are urine,\n BAL, and abdominal fluid cultures. Abdomen is softly distended, bowel\n sounds are absent although there is some greenish liquid output in\n ileostomy and j-tube drain. OGT to low suction drained ~700cc\n bilious liquid. Abdominal dressings are D&I, small amt of old SS drnge\n on L quad dressing. Hemodynamic status is much improved, no IVF\n boluses or pressors required.\n Action:\n Antibiotics changed from levo/flagyl/vanc to zosyn/vanc. Vanc trough\n this am 6.3\n Response:\n Sepsis improving.\n Plan:\n Follow fever curve, wbc\ns, cultures, sensitivities, continue abx.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP 95-131/52-71; HR 115-123, ST no ectopy, CVP 10-12. Urine output\n 50-120cc/hr\n Action:\n 1unit PRBC\ns given for volume. Crit this am 27.7; receiving maintenance\n IVF LR at 125/hr, no fluid boluses or pressors required.\n Response:\n Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L.\n Plan:\n Continue to monitor ABP, CVP, UO, HR.\n"},{"category":"Nursing","chartdate":"2178-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":328978,"text":"56 yo M with history of UC s/p colectomy with ileostomy in \n admitted on with abdominal pain and increased ostomy output now\n POD #3 from ex lap with parastomal hernia repair and lysis of\n adhesions. Transferred to ICU from floor 2 days post op with acute\n onset tachypnea, SOB, and oliguric renal failure. In ICU he was on\n 100% NRB with good sats, CXR wnl, EKG wnl, crackles bilateral lung\n bases -> given lasix, labs showed rising wbc\ns and lactate. Also found\n to have bladder pressure of 40 so taken back to OR for ? abdominal\n compartment syndrome. No apparent intra-peritoneal process, tube\n placed, had edematous bowel and 3L fluid in abdomen removed. Had\n vomiting with ?aspiration during induction -> bronched, no significant\n secretions, BAL sent. To ICU intubated with O2 sats in high 80\ns, low\n 90\ns despite 100% fiO2. On phenylephrine at .9mcg for hypotension.\n Throughout the next 24hrs pt was given a total of 9-10L of LR for low\n urine output, hypotension, and tachycardia. Vent settings were adjusted\n per ARDS protocol and antibiotics levo/flagyl/vanc started. Also had\n echo to r/o PE since too unstable for CT and LENI\ns done. Both were\n negative.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vented on PRVC mode with settings 450X32X60%X10 and ABG\ns early this am\n 7.47/37/109/3/28. Lung sounds are clear, diminished in bases. Suctioned\n for small amts thick tan secretions or no secretions at all.\n Action:\n Sedated on fentanyl/versed 75/2 but requiring boluses of 25-30mcg for\n RR in the 40\ns and agitation. No vent changes made today.\n Response:\n Respiratory status stable.\n Plan:\n Transfer to SICU. Wean vent as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n Tmax 101.2, last BC done on is pending. Also pending are urine,\n BAL, and abdominal fluid cultures. Abdomen is softly distended, bowel\n sounds are absent although there is some greenish liquid output in\n ileostomy and j-tube drain. OGT to low suction drained ~700cc\n bilious liquid. Abdominal dressings are D&I, small amt of old SS drnge\n on L quad dressing. Hemodynamic status is much improved, no IVF\n boluses or pressors required.\n Action:\n Antibiotics changed from levo/flagyl/vanc to zosyn/vanc. Vanc trough\n this am 6.3\n Response:\n Sepsis improving.\n Plan:\n Follow fever curve, wbc\ns, cultures, sensitivities, continue abx.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP 95-131/52-71; HR 115-123, ST no ectopy, CVP 10-12. Urine output\n 50-120cc/hr\n Action:\n 1unit PRBC\ns given for volume. Crit this am 27.7; receiving maintenance\n IVF LR at 125/hr, no fluid boluses or pressors required.\n Response:\n Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L.\n Plan:\n Continue to monitor ABP, CVP, UO, HR.\n"},{"category":"Nursing","chartdate":"2178-06-06 00:00:00.000","description":"Nursing Transfer Note","row_id":328979,"text":"56 yo M with history of UC s/p colectomy with ileostomy in \n admitted on with abdominal pain and increased ostomy output now\n POD #3 from ex lap with parastomal hernia repair and lysis of\n adhesions. Transferred to ICU from floor 2 days post op with acute\n onset tachypnea, SOB, and oliguric renal failure. In ICU he was on\n 100% NRB with good sats, CXR wnl, EKG wnl, crackles bilateral lung\n bases -> given lasix, labs showed rising wbc\ns and lactate. Also found\n to have bladder pressure of 40 so taken back to OR for ? abdominal\n compartment syndrome. No apparent intra-peritoneal process, tube\n placed, had edematous bowel and 3L fluid in abdomen removed. Had\n vomiting with ?aspiration during induction -> bronched, no significant\n secretions, BAL sent. To ICU intubated with O2 sats in high 80\ns, low\n 90\ns despite 100% fiO2. On phenylephrine at .9mcg for hypotension.\n Throughout the next 24hrs pt was given a total of 9-10L of LR for low\n urine output, hypotension, and tachycardia. Vent settings were adjusted\n per ARDS protocol and antibiotics levo/flagyl/vanc started. Also had\n echo to r/o PE since too unstable for CT and LENI\ns done. Both were\n negative.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vented on PRVC mode with settings 450X32X60%X10 and ABG\ns early this am\n 7.47/37/109/3/28. Lung sounds are clear, diminished in bases. Suctioned\n for small amts thick tan secretions or no secretions at all.\n Action:\n Sedated on fentanyl/versed 75/2 but requiring boluses of 25-30mcg for\n RR in the 40\ns and agitation. No vent changes made today.\n Response:\n Respiratory status stable.\n Plan:\n Transfer to SICU. Wean vent as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n Tmax 101.2, last BC done on is pending. Also pending are urine,\n BAL, and abdominal fluid cultures. Abdomen is softly distended, bowel\n sounds are absent although there is some greenish liquid output in\n ileostomy and j-tube drain. OGT to low suction drained ~700cc\n bilious liquid. Abdominal dressings are D&I, small amt of old SS drnge\n on L quad dressing. Hemodynamic status is much improved, no IVF\n boluses or pressors required.\n Action:\n Antibiotics changed from levo/flagyl/vanc to zosyn/vanc. Vanc trough\n this am 6.3\n Response:\n Sepsis improving.\n Plan:\n Follow fever curve, wbc\ns, cultures, sensitivities, continue abx.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP 95-131/52-71; HR 115-123, ST no ectopy, CVP 10-12. Urine output\n 50-120cc/hr\n Action:\n 1unit PRBC\ns given for volume. Crit this am 27.7; receiving maintenance\n IVF LR at 125/hr, no fluid boluses or pressors required.\n Response:\n Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L.\n Plan:\n Continue to monitor ABP, CVP, UO, HR.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n OBSTRUCTION\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 95.3 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: ulcerative colitis s/p total colectomy in .\n Depression, GERD.Thoracic back pain. multiple spinal surgeries,\n arthroscopic knee surgery.\n Surgery / Procedure and date: Exploratory Lap w/ Hernia Repair \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:103\n D:60\n Temperature:\n 100.4\n Arterial BP:\n S:95\n D:59\n Respiratory rate:\n 36 insp/min\n Heart Rate:\n 121 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Non-rebreather\n O2 saturation:\n 98% %\n O2 flow:\n 6 L/min\n FiO2 set:\n 60% %\n 24h total in:\n 6,578 mL\n 24h total out:\n 3,740 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:05 PM\n Potassium:\n 3.4 mEq/L\n 02:05 PM\n Chloride:\n 102 mEq/L\n 02:05 PM\n CO2:\n 27 mEq/L\n 02:05 PM\n BUN:\n 31 mg/dL\n 02:05 PM\n Creatinine:\n 1.7 mg/dL\n 02:05 PM\n Glucose:\n 98 mg/dL\n 02:05 PM\n Hematocrit:\n 29.2 %\n 02:05 PM\n Finger Stick Glucose:\n 114\n 10:18 PM\n Valuables / Signature\n Patient valuables: with pt.\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: none\n Jewelry:\n Transferred from: \n Transferred to: SICU B\n Date & time of Transfer: 1800\n"},{"category":"Respiratory ","chartdate":"2178-06-06 00:00:00.000","description":"Respiratory Care Shift Note","row_id":328983,"text":"Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\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: 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: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions,\n Accessory muscle use, Prolonged exhalation, Tachypneic (RR> 35 b/min),\n Gasping efforts, Intercostal retractions, Active exhalations, High flow\n 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, Abnormal trigger\n efforts (efforts during inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts, Possible air\n trapping, Erratic exhaled Tidal Volumes, Frequent alarms (High rate)\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\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 Pt to transfer to .\n"},{"category":"Nursing","chartdate":"2178-06-06 00:00:00.000","description":"Nursing Progress Note","row_id":328931,"text":"56yo male POD #2 for exploratory lap w/ hernia repair, back to OR\n yesterday for ?acute abdomen, bladder pressure of 40. No apparent\n intra peritoneal process , tube placed, had edematous bowel and\n 3L fluid in abdomen removed. ? aspiration, apparently vomited during\n procedure -> bronched in MICU -> no significant secretions, BAL sent.\n Abdomen decompressed, bladder pressures 23-25.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n CXR -> bilat patchy infiltrates, opacities esp. in left lobe; Echo\n done, showed PE unlikely. Lung sounds are slightly coarse upper with\n significantly diminished lower lobes. ABG at 1900 7.33/46/93/25 on\n 100%FiO2/15 PEEP. Fent at 75mcg/hr/Versed at 2 mg/hr.\n Action:\n Surgery in to see patient overnight, dropped Fi02 to 60%. Corresponding\n ABG 7.38/45/65/28.\n Response:\n Pt. overbreathing vent by 2-5 bpm, appearing uncomfortable and awake.\n Increased Fent to 100mcg/hr and Versed to 3mg/hr with improvement in RR\n and comfort. BP remained stable after increase in sedation. PEEP to 13.\n ABG at 0430 7.46/41/97/30. PEEP decreased to 10. ABG: 7.47/37/109/28\n Plan:\n Prone pt if does not improve, titrate sedation to keep respirations\n unlabored without dropping BP,\n Sepsis without organ dysfunction\n Assessment:\n No infectious source identified so far. Tmax 100.8, lactate 3.1, skin\n much more warm to touch.\n Action:\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\n flagyl/levo/vanc.\n Response:\n Pending.\n Plan:\n Monitor temp, wbc\ns, lactate. Follow cultures, continue abx until\n sensitivities available.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP\ns 70\ns-110/ 50-70\ns, HR 118-128 ST no ectopy, CVP 8-12. Neo turned\n off at . Yesterday received total 5L LR, 25gm albumin, 1L D5W w/\n 150meq bicarb. UO 70-300cc/hr.\n Action:\n Overnight, surgery ordered 2 L LR, 5% Albumin. SBP remained stable in\n high 90\ns-low 100\ns. At 0300 was slightly tachy into 130\ns, SBP\n dropping into 80\ns, T 100.7, UO around 70cc/hr. Bolused another liter\n of LR. Pt. put out 500cc via oral gastric tube over 8 hrs. Cannister\n changed and immediately put out another 450cc of bilious fluid. Pt.\n remained hypotensive with SBP in 80\ns, MAPs 50-55. Bolused 1L LR x2, 5%\n Albumin hung to gravity.\n Response:\n ABP remains 80\ns-90\ns with MAPs around 55.\n Plan:\n Continue boluses for hypotension and decreased urine output. Albumin\n for intravascular volume, consider PRBC.\n Dr. has expressed she would like patient to go west if stable\n enough for transport today.\n"},{"category":"Nutrition","chartdate":"2178-06-05 00:00:00.000","description":"Clinical Nutrition Note","row_id":328861,"text":"Subjective\n Nausea, has been thirsty\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 95.3 kg\n 31.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 70 kg\n 136%\n 76\n Diagnosis: Obstruction\n PMH : UC s/p colectomy/ileostomy (), hypertension, depression,\n GERD, hyperlipidemia, PE, c.diff\n Food allergies and intolerances: None needed\n Pertinent medications: flagyl, pantoprazole\n Labs:\n Value\n Date\n Glucose\n 146 mg/dL\n 08:01 AM\n BUN\n 24 mg/dL\n 04:05 AM\n Creatinine\n 1.4 mg/dL\n 04:05 AM\n Sodium\n 140 mEq/L\n 08:01 AM\n Potassium\n 3.4 mEq/L\n 08:01 AM\n Chloride\n 104 mEq/L\n 08:01 AM\n TCO2\n 19 mEq/L\n 04:05 AM\n Albumin\n 3.4 g/dL\n 06:45 PM\n Calcium non-ionized\n 7.9 mg/dL\n 04:05 AM\n Phosphorus\n 2.9 mg/dL\n 04:05 AM\n Ionized Calcium\n 1.11 mmol/L\n 08:01 AM\n Magnesium\n 1.6 mg/dL\n 04:05 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen firm/distended with absent BS, ostomy - 200ml, JP - 100ml\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: 1900-2300 (BEE x or / 25-30 cal/kg)\n Protein: 90-110 (1.2-1.5 g/kg)\n Fluid: per team\n Specifics:\n 56 year old male with history of UC s/p colectomy, ileostomy with\n preservation of rectum in doing well post-op until presenting\n with abdominal pain, increased ostomy output now s/p ex-lap, hernia\n repair on transferred to ICU with tachycardia, tachypnea, sepsis\n with concern for acute abdomen. Noted per chart, patient refused\n central line. If unable to advance diet and patient continues to refuse\n central line, could use PPN temporarily (goal if TF<400 is 2L standard\n PPN with 250ml lipids to provide 1140kcal and 70g protein. PPN not able\n to meet patient\ns needs. If Patient agrees to central line, can do TPN\n with goal of 1.9L (320gdex/100gAA/40g lipids) to provide 1888kcal and\n 100g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue parenteral nutiriton if continues to be unable to\n take PO intake.\n 2. Monitor/replete lytes\n 3. Check TG if PPN or TPN to start\n 09:46\n"},{"category":"Physician ","chartdate":"2178-06-05 00:00:00.000","description":"ICU Attending Note","row_id":328862,"text":"Clinician: Attending\n 56 yo man with colitis, presumed UC, colectomy , adm with\n high ostomy output and abd pain. Ostomy output attributed to bowel wall\n edema and poor absorption. In MICU with transient tachypnea and\n tachycardia but not hypoxemia following hernia repair and ex-lap. Was\n persistantly tachycardic, likely dehydrated. Tachypnea resolved\n overnight, transferred back to surgical floor yesterday morning. Total\n 6L net + over 24 h, with decreasing urine output finally to < 10cc/h.\n WBC rose 6--> 26--> 38K with 20% bandemia. Resp distress with\n tachypnea, 7.39/35/81 on NRB. Tranferred to MICU. Initial mental status\n normal, becamse confused within hours. Increasing oxygen requirement.\n 7.39/34/65 on NRB, lactate 3.0. Lung exam with dffuse crackles.\n Oliguric with no response to lasix. Concern for abd distension, bladder\n pressure was 40 mm Hg. Initial CXR showed low lung volumes but no sig\n parenchymal process, right mid lung zone atelectasis. Went to OR got\n right IJ, art line, found to have edematous bowel, stomach had 3L\n fluid. Bowel decompressed. Bronch with no sig secretions, BAL done.\n Since surgery hypoxia progressed. Severe metabolic acidosis. CXR with\n bilateral patchy infiltrates esp left upper lung field. Sedated on\n propofol. Hypotensive with 87/64, MAP 71. SpO2 88% on FiO2 1.0, PEEP 15\n TV 450 RR 35 PIP 35 Plateau 26 Compliance 45. Abdomen distension much\n improved.\n 7.13/63/70 on rate 26.\n HCo3 22, gap 15. BUN/Cr 39/2.5 (inc from 1.4 yest). WBC 25K. Hct 42%.\n LFTs wnl. INR 1.6. Lactate rose to 4.5.\n Severely critically ill with ARDS, septic shock, unclear if he had\n aspiration event or secondary to sepsis, abd surgery. Now oliguric,\n hypotensive, requiring max vent support. Bladder pressure decreased\n from 40 to 25 after decompression. Broad abx, no cx data yet.\n flagyl/levo/vanc to cover bowel and lung sources. ARDSnet but pushing\n PEEP for continued hypoxia. Permissive hypercapnia, and RR raised for\n acidemia, but will give bicarb if repeat ABG shows no correction of pH.\n Trying right side down to try to improve V/Q mismatch. Will likely\n switch to PCV to improve oxygenation if ineffective.\n Patient is critically ill.\n"},{"category":"Physician ","chartdate":"2178-06-05 00:00:00.000","description":"ICU Attending Note","row_id":328869,"text":"Clinician: Attending\n 56 yo man with colitis, presumed UC, colectomy , adm with\n high ostomy output and abd pain. Ostomy output attributed to bowel wall\n edema and poor absorption. In MICU with transient tachypnea and\n tachycardia but not hypoxemia following hernia repair and ex-lap. Was\n persistantly tachycardic, likely dehydrated. Tachypnea resolved\n overnight, transferred back to surgical floor yesterday morning. Total\n 6L net + over 24 h, with decreasing urine output finally to < 10cc/h.\n WBC rose 6--> 26--> 38K with 20% bandemia. Resp distress with\n tachypnea, 7.39/35/81 on NRB. Tranferred to MICU. Initial mental status\n normal, becamse confused within hours. Increasing oxygen requirement.\n 7.39/34/65 on NRB, lactate 3.0. Lung exam with dffuse crackles.\n Oliguric with no response to lasix. Concern for abd distension, bladder\n pressure was 40 mm Hg. Initial CXR showed low lung volumes but no sig\n parenchymal process, right mid lung zone atelectasis. Went to OR got\n right IJ, art line, found to have edematous bowel, stomach had 3L\n fluid. Bowel decompressed. Bronch with no sig secretions, BAL done.\n Since surgery hypoxia progressed. Severe metabolic acidosis. CXR with\n bilateral patchy infiltrates esp left upper lung field. Sedated on\n propofol. Hypotensive with 87/64, MAP 71. SpO2 88% on FiO2 1.0, PEEP 15\n TV 450 RR 35 PIP 35 Plateau 26 Compliance 45. Abdomen distension much\n improved.\n 7.13/63/70 on rate 26.\n HCo3 22, gap 15. BUN/Cr 39/2.5 (inc from 1.4 yest). WBC 25K. Hct 42%.\n LFTs wnl. INR 1.6. Lactate rose to 4.5.\n Severely critically ill with ARDS, septic shock, unclear if he had\n aspiration event or secondary to sepsis, abd surgery. Now oliguric,\n hypotensive, requiring max vent support. Bladder pressure decreased\n from 40 to 25 after decompression. Broad abx, no cx data yet.\n flagyl/levo/vanc to cover bowel and lung sources. ARDSnet but pushing\n PEEP for continued hypoxia. Permissive hypercapnia, and RR raised for\n acidemia, but will give bicarb if repeat ABG shows no correction of pH.\n Trying right side down to try to improve V/Q mismatch. Will likely\n switch to PCV to improve oxygenation if ineffective.\n Patient is critically ill.\n ------ Protected Section ------\n Spoke with Dr , who told me there is no contraindication\n to proning, if that becomes necessary.\n Bicarb infusion.\n Phenylephrine now at 2.5mcg/kg/min.\n Placing esophageal balloon, as abd pressure suggested he will need much\n higher PEEP.\n Time spent 80 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:29 ------\n"},{"category":"Nursing/other","chartdate":"2178-06-14 00:00:00.000","description":"Report","row_id":1445651,"text":"Respiratory Therapy\nPt remains orally intubated on PSV, appears comfortable. Vt 400-600. BS clear apeces, descending to bases audible crackles to diminished. Sx for moderate amounts thick tenacious dark tan secretions. ABG this AM: 7.42/49/130/33. RSBI held due to Peep requirement.\n"},{"category":"Nursing/other","chartdate":"2178-06-14 00:00:00.000","description":"Report","row_id":1445652,"text":"SICU NN: SEE CAREVUE FOR SPECIFICS. PATIENT SEDATED ON FENTANYL DRIP AND PRN ATIVAN. ET TO VENT, NO CHANGES OVERNIGHT. RSR. BP WNL. AFEBRILE. ANASARCA. TUBE FEEDS AT GOAL VIA NGT. ILEOSTOMY, RED STOMA, PUTTING OUT LIQUID BROWN STOOL AND FLATUS. ABDOMINAL INCISION WITH STAPLES AND PARTIALLY OPENED AND PACKED, DRAINING MODERATE TO LARGE AMTS OF SEROSANG. FOLEY, LASIX DRIP, TITRATING FOR GOAL 3L NEG. SACCRUM INTACT. LEFT SC CVL. LEFT AXILLARY ALINE. NO PHONE CALLS NO VISITORS. REPLETING LYTES PRN. PLAN: CONTINUE DIURESIS, DIAMOX AS ORDERED, VENT WEAN AS TOL, MONITOR HEMODYNAMICS, PULM TOLIET, SEDATION/PAIN CONTROL, ANTIBIOTICS AS ORDERED, BLOOD GLUCOSE CONTROL, EMOTIONAL SUPPORT.\n"},{"category":"Nursing/other","chartdate":"2178-06-14 00:00:00.000","description":"Report","row_id":1445653,"text":"BS coarse crackles; no change with MDI's. Suctioned for moderate amount thick tan secretions, less than yesterday. CXR ? slight improvement. Diuresis with Diamox proceeds but still 7 liters positive. Will not wean vent until fluid balance improved more.\n"},{"category":"Nursing/other","chartdate":"2178-06-14 00:00:00.000","description":"Report","row_id":1445654,"text":"focus update note\nT-98.6, 60-80s NSR, no ectopy, sbp 100-150/60-80\n\nlasix gtt at 2-4 mg /hr goal diuresis 3 liters negative by 12 midnight, pt given 2 doses of diamox and ordered for one more dose tonight. potassium level 3 despite 80 meq kcl given po x 2 and 100 meq kcl given 1v, icu resident aware.\n\nresp: no vent changes today as pt is still 6.5 liters positive for his length of stay and will not bee extubated in the next 24 hours, abgs improved 7.44/40/172/28/3/98, lung sounds clear to coarse, pt suctioned for moderate amount brown thick secretions from ETT, pt continues on zosyn and cipro.\n\ngu/gi: tube feeding at goal, bowel sounds positive, 350 cc brown liquid stool from ileostomy- pink stoma, clear light yellow urine from foley cath.\n\nabd: vac dressing to be placed over open abd incision on Tuesday, copious amounts of serous fluid from abd wound,surgical team assessed abd wound this am and packing was changed by team at 0830, pink wound base, pt nodding head yes to pain intermittently throughout day, fentanyl gtt provides good reilf of pain as well as repositioning.\n\nskin: generalized edema, left groin drainage from old puncture site has resolved, waffle boots on\n\nneuro: ativan discontinued today, pt not aggitated today, pt easily redirected when talked to, following commands consistently, mae+, nodding head inconsistently to questions, pupils perla- 3mm brisk reaction, opens eyes to voice or spontaneously, spontaneous movement purposful\n\nsocial: wife into visit with 2 other family members, wife updated at pt bedside by nursing, pt likes to watch golf/cooking channel on TV.\n\nplan: continue with aggressive diuresis and repleation of electrolytes, consider extubation when pt fluid body status at admission weight, monitor resp status, continue with antibiotic therapy, vac dressing planned for tuesday to open abd wound, limit sedation, provide supportive care to pt and family\n\n\n"},{"category":"Nursing/other","chartdate":"2178-06-15 00:00:00.000","description":"Report","row_id":1445655,"text":"SICU NN: SEE CAREVUE FOR SPECIFICS. PATIENT SEDATED ON FENTANYL DRIP. INCONSISTENTLY FOLLOWING COMMANDS. MOVING ALL EXTREMITIES SPONTANEOUSLY. PERRL. ET TO VENT, NO CHANGES OVERNIGHT. FREQUENT SUCTIONING REQUIRED FOR THICK BROWN SECRETIONS, PLUGGY AT TIMES. RSR. BP WNL. AFEBRILE. CVL AND ALINE INTACT. PALP PEDALS. GEN EDEMA. TUBE FEEDS AT GOAL. ILEOSTOMY WITH LOOSE BROWN STOOL AND FLATUS. STOMA PINK AND MOIST. APPLIANCE INTACT. MIDLINE ABD INCISION WITH STAPLES AND TWO LARGE OPEN AREAS. PACKING IN PLACE, DRESSING REINFORCED. HEAVY TO COPIOUS SEROUS/SEROSANG DRAINAGE, FOUL SMELLING AT TIMES, TEAM AWARE. FOLEY, LASIX DRIP GOAL 3 LITERS NEGATIVE. SACCRUM INTACT. FENTANYL DRIP FOR PAIN. LYTES REPLETED PRN. NPH AND SSI FOR GLUCOSE CONTROL. FAMILY VISITED LAST PM. PLAN: AGGRESSIVE DIURESIS, VAC ABD WOUND TUES, OSTOMY CARE, SKIN CARE, PAIN CONTROL, VENT WEAN AS TOL, PULM TOLIET, FOLLOW CULTURES, ANTIBIOTICS AS ORDERED, EMOTIONAL SUPPORT.\n"},{"category":"Nursing/other","chartdate":"2178-06-15 00:00:00.000","description":"Report","row_id":1445656,"text":"Respiratory Therapy\nPt remains orally intubated on PSV. No changes overnight. BS essentially clear w diminished bases. Sx for moderate amounts thick dark tan secretions SPC. RSBI 31 This AM . Plan continue ventilatory support.\n"},{"category":"Nursing/other","chartdate":"2178-06-15 00:00:00.000","description":"Report","row_id":1445657,"text":"nursing progress note\nSee carevue for specifics.\nT-max 101.5 md aware. Pan cx sent. Tylenol elixer given. Abd incision open, packed with dsd. Changed frequently due to large amt of serosang foul smelling secretion. SICU team aware of odor. No order to culture wound at this time. Remains lightly sedated on 200mcg's of fent. Inconsistantly follows commands. Clonidine 0.2mg po given for aggitation with no real changes observed in behavior. LS clear with dim bases. Suctioned for moderate amt of thick brown/secretions.Small Vent changes made per ABG's, see resp note for specifics.\nHr NSR no ectopy noted.\nLasix Gtt @ 2mg/hr diuresing ~200ml/hr. Goal is to pull off 2L qday. Currently -2500 since MN. Md aware. K+ 3.1 repleted with 60meq IV. In addition to 80meq Q6hr po dose.\nCxr this am showed ngt coiled in the cervical area. Pulled back ~2cm per SICU team. Repeat cxr shows ngt in good position, viewed by , MD. @ goal of 65ml/hr, residuals 0-10ml's.\nPOC\nkeep lightly sedated for possible extubation in am.\nmonitor temp\ncontinue to monitor electrolytes, replete as needed.\nchange dsg's TID and prn packing with dsd.\n\n\n"},{"category":"Nursing/other","chartdate":"2178-06-15 00:00:00.000","description":"Report","row_id":1445658,"text":"BS CTAB; no change with MDI's. Suctioned for moderate amount thick tan secretions. Tmax 101.5. PEEP and PSV weaned. Could extubate put team wants to draw of L of fluid today and extubate in AM.\n"},{"category":"Nursing/other","chartdate":"2178-06-16 00:00:00.000","description":"Report","row_id":1445659,"text":"Respiratory Care\nPt remains on ventilator, with pressure support settings being adequate for pt's spontanous respiratory drive. Pt was suctioned by both RT and RN for copious amounts of brown/yellow/thick sputum. Pt becomes agitated after suctioning procedures. Albuterol given at appropriate times. Pt performed strong RSBI, and responds to questions. Pt to be considered for extubation by MD team, continuing current support.\n"},{"category":"Nursing/other","chartdate":"2178-06-13 00:00:00.000","description":"Report","row_id":1445646,"text":"Respiratory Therapy\nPt remains orally intubated on PSV. BS clear bilaterally Sx moderate amounts thick dark tan secretions. MDI's as ordered. ABG on .4, 7.44/50/102/35 no RSBI due to peep requirement. CXR done awaiting official read. Plan: wean as tol\n"},{"category":"Nursing/other","chartdate":"2178-06-13 00:00:00.000","description":"Report","row_id":1445647,"text":"Condition update\nSee careview for details:\n\nRemains sedated on fentanyl gtt and prn ativan for sedation with good effect. Appears comfortable when sedated. Afebrile. WBC 16.7 this am (up from 13). Dr (sicu) aware. SR HR 60-70 no ectopy. BP stable, becomes hypertensive with aggitation but returns to baseline when sedated. Generalized edema. Lungs coarse but clears with suction. Diminished at bases. Suction for large amt thick tan secreations with some plugs, Dr aware. Remains on CPAP, fio2 weaned to 40% and PEEP down to 5 from 8 briefly, although cont to have adequate oxygenation increased d/t worsening chest xray. Remains on 10 pressure support. Abg shows compensated metabolic alkolosis. Abd soft, ostomy putting out stool, tolerating tube feeds. RISS, requiring mod amt coverage. Midline abd incision with some purlulent drainage noted, primary team aware. Cont on lasix gtt for goal 2-3 liters negative, 2.9 neg at midnight. Plan to cont to diureses, ?start diamox for increasing metabolic alkososis, start long acting insulin, wean vent as tolerated, maitain comfort.\n"},{"category":"Nursing/other","chartdate":"2178-06-13 00:00:00.000","description":"Report","row_id":1445648,"text":"NURSING NOTE\nAddendum: Son in to visit this evening\n"},{"category":"Nursing/other","chartdate":"2178-06-13 00:00:00.000","description":"Report","row_id":1445649,"text":"NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n PT REMAINS LIGHTLY SEDATED ON FENTANYL FOR COMFORT, EASILY . ATIVAN FOR INTERMITTENT AGITATION/RESTLESSNESS W/EFFECT. INCONSISTENTLY FOLLOWS COMMANDS, MAES, NOT TRACKING. AFEBRILE, HR 70S-90S, NSR, SBP 100S-150S, UP TO 180S W/AGITATION. A-LINE DAMPENED AT TIMES R/T LOCATION/PT . CVL RE-SITED, OLD CVL TIP SENT FOR CX. CVP 6-9, CONT ++GEN/SCROTAL EDEMA, PALP PP. LASIX DRIP CONT FOR AGGRESSIVE DIURESIS AS BP TOL PER DR.. GOAL FLUID BAL 2-3L NEG, REMAINS >10L UP FOR LOS. K/CALCIUM REPLETED AS NEEDED DIURESIS. NO VENT CHANGES MADE, MINI BAL SENT. LUNGS COARSE, VERY DIMINISHED AT BASES. SUCTIONED FOR MOD-LGE AMTS THICK, TAN SECRETIONS, CPT DONE AS TOL. ABD INC W/COPIOUS AMTS SEROUS DRNG, STAPLES REMOVED THIS AM BY DR. . WND PACKED W/DRY DSGS, CONT DRAINING COPIOUS SEROUS FLUID, DR. AWARE. CONT TF VIA NGT, MIN RESIDUALS. NPH ADDED TO INSULIN REGIMEN. NO FAMILY CONTACT.\n\n PLAN: CONT AGGRESSIVE DIURESIS AS HEMODYNAMICS ALLOW. FENTANYL DRIP FOR COMFORT, ATIVAN FOR INT AGITATION. WEAN VENT AS TOL. MONITOR FOR ALKALOSIS DIURESIS, LYTE REPLETION AS NEEDED. WND/SKIN CARE.\n"},{"category":"Nursing/other","chartdate":"2178-06-13 00:00:00.000","description":"Report","row_id":1445650,"text":"BS coarse crackles, occasional rhonchi; no change with MDI's. Suctioned for large amount thick, tan-yellow secretions with plugs. Mini-BAL sent. Metabolic alkalosis persists; ? 0800 ABG. PEEP still at 8cm due to possibility of increased atelectasis though CXR more consistent with increased bilateral LL densities. Plan is to continue with aggressive diuresis.\n"},{"category":"Nursing/other","chartdate":"2178-06-12 00:00:00.000","description":"Report","row_id":1445641,"text":"Condition update\nSee careview for objective data/trends:\n\nEpisodes tachypnia and tachycardia with stimulation this evening, prn ativan increased and given with good effect. Fentanyl gtt continues for sedation, decreased this am as pt appears comfortable. More alert this am, opening eyes spontanously and moving all ext spontanously. Not following any commands. Afebrile. SB-SR HR 50-80's no ectopy. BP stable 110-140's when well sedated. +generalized edema. CVP 9-12. Lungs coarse throughout, diminished at bases. CPAP +PS, pt very tachypnic this evening, Dr aware and increased support from 8 peep 10 ps to 10 peep and 12 ps. Peep decreased back to 8 this morning. Abd softly distended, no bowel sounds noted, Dr aware. Tubefeeds at goal and residuals 10-50cc. Ileostomy with sm amt stool ouptut. Stoma pink. 1.7L neg at MN. BUN/Creat remain slightly elevated but stable. Requiring frequent potassium repleation. Attempted to repleate with po slidding scale but unable to maintain adequate k levels. Plan to cont to monitor neuro status, wean sedation as tolerated monitor hemodyanmics, maintain comfort.\n"},{"category":"Nursing/other","chartdate":"2178-06-12 00:00:00.000","description":"Report","row_id":1445642,"text":"Respiratory Care:\n\nPt remain orally intubated on spontaneous ventilation. Yesterday eve we increased PEEP & IPS for increased WOB & tachypnea, we increased sedation also. We attempting to wean it again this morning. RSBI done ~138. Bs are dim & coarse bil. W are sxtn for small amt of thick brownish secretions from ETT. Plan: wean as tol & monitor VS. See Careview for more details.\n"},{"category":"Nursing/other","chartdate":"2178-06-12 00:00:00.000","description":"Report","row_id":1445643,"text":"NURSING NOTE\nAddendum: Pt w/copious amts serous drng originating from ABD dsg this eve. ABD inc w/staples DSD changed.\n"},{"category":"Nursing/other","chartdate":"2178-06-12 00:00:00.000","description":"Report","row_id":1445644,"text":"NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n PT EASILY ON FENTANYL FOR LIGHT SEDATION. INCONSISTENTLY FOLLOWS COMMANDS, MAES. HR 60S-70S, NSR, NO ECTOPY. SBP 110S-130S, UP TO 170'S W/STIMULATION OR AGITATION. CVP 6-11, LASIX DRIP UP TO 5MG/HR FOR GOAL NEG FLUID BAL 2-2.5L, CURRENTLY ~1.5L NEG. CONT ++GEN/SCROTAL EDEMA, PALP PP. PO/IV K REPLETED FOR PERSISTENT HYPOKALEMIA DOWN TO 3, CA REPLETED. CONT ON PSV-50%/8/PS DOWN TO 10, RR 17-20S, BECOMES TACHYPNEIC TO 30S W/STIM. LUNGS COARSE, DIMINISHED AT BASES, SUCTIONED FOR SM-MOD AMTS THICK, TAN SECRETIONS. ABD SOFT, +BS ILEOSTOMY PATENT W/MOD AMT LOOSE, BROWN STOOL-APPLIANCE CHANGED BY OSTOMY RN. LGE AMT HUO/ADEQUATE DIURESIS LASIX DRIP. ABD DSD C/D/I, LLQ POUCH/DRAIN W/SM AMT SEROUS DRNG. SON IN TO VISIT BRIEFLY, NO OTHER FMAILY CONTACT.\n\n PLAN: CONT HEMODYNAMIC MONITORING, FENTANYL DRIP FOR COMFORT. CONT LASIX DRIP FOR DIURESIS/NEG FLUID BAL GOALS. RESP SUPPORT, WEAN AS TOL. REPLETE LYTES FREQUENTLY.\n"},{"category":"Nursing/other","chartdate":"2178-06-12 00:00:00.000","description":"Report","row_id":1445645,"text":"Respiratory\nPt. weaned from 12 to 10 of PS as noted in Carevue. Pt. on AC as noted in Carevue. Diminished breath sounds bilaterally in the bases more pronounced on RLL. After MDI's and Sx'ing, greater aeration was heard throughout but still decreased in bases. Pt. producing moderate amount of thick brown blood tinged secretions. Plan: wean vent. settings slowly as tolerated.\n"},{"category":"Nursing/other","chartdate":"2178-06-07 00:00:00.000","description":"Report","row_id":1445622,"text":"Nursing Note\nPt transferred from () at 1800 to SICU for monitoring and management. Pt s/p exploratory lap with parastomal hernia repair and LOA on . Pt had post-op complications of severe tachypnea/tachycardia, fevers with elevating WBC, oliguria and bladder pressure of 40 and subsequently had to return to the OR . Pt had 3 liters fluid removed from abdomen and had tube placed in abdomen and pt transferred to SICU.\nUpon arrival to SICU, pt sedated as he had required versed/fentanyl boluses during tranfer from east to west campuses. Pt's Fentanyl drips and versed drips on hold initially as pt sedated and SBP low. Pt intubated and ventilated on CMV settings-Multiple setting changed overnoc (see carevue) Having difficult time ventilating patient. Pt RR ranging from 30-40s and ABGs showing a respiratory alkalosis. Pox maintaining at 96-100%, LS diminished and pt being suctioned for moderate amounts of thick, tanish/ colored sputum. Pt abdomen is large, soft. Absent BS. Dressing and tube intact to abdomnen, ostomy also present with pink, moist stoma. Pt putting out large amounts of bilious fliud via OG tube and now being replaced cc:cc of NS.\nPt's HR 100-120s, BP elevates to 180s when turning/repositioning/suctioning and gets very restless requiring increasing amounts of sedation however pt's BP drops after pt settles down and sedation is subsequently put on hold. Pt BP dropping into 70s and requiring multiple fluid boluses to maintain BP. Pt also given one unit PRBC . Follow Q 6 hour HCTS\nPt has been febrile with Tmax 101.9. Dr. aware. Pt pan cultured prior to transfer from , results pending.\nPLAN-sedate patient in ordert o ventilate andf manage BP. Administer fluids/colloids as needed. Continue to replace cc:cc of OG output. Follow ABGs.\n"},{"category":"Nursing/other","chartdate":"2178-06-07 00:00:00.000","description":"Report","row_id":1445623,"text":"RESP CARE NOTE\n56 YO S/P COLOSTOMY CONTINUES ON A/C 32/450/50%/+10. LAS TABG 7.56/29/108/5/98. PT CONTINUES IN ARDS. DIFFICULTY CORRECTING RESPIRATORY ALKALOSIS SINCE PT IS OVERBREATHING VENT. DIFFICULTY MAINTAINING BP WAS LIMITING SEDATION. SX VERY THICK BROWN\n"},{"category":"Nursing/other","chartdate":"2178-06-07 00:00:00.000","description":"Report","row_id":1445624,"text":"RESPIRATORY CARE: PT REMAINS INTUBATED W/ A 7.5 ORAL ETT IN PLACE AND CHANGED TO PS 22/8 .50 AS PER CV DUE TO PERSISTENT AGGITATION AND VENTILATOR DYSYNCHRONY. ABG C/W A COMBINED METABOLIC AND RESPIRATORY ALKALOSIS AND MARGINAL OXYGENATION. WILL TOLERATE PO2 55 OR GREATER PER DR AT LEAST FOR TODAY. WILL INCREASE TO .60 IF NECESSARY. SEDATION REGIMEN ADJUSTED BY SICU TEAM. SX FOR TAN SPUTUM. WILL C/W PS 22 AS TOLERATED.\n"},{"category":"Nursing/other","chartdate":"2178-06-18 00:00:00.000","description":"Report","row_id":1445667,"text":"NURSING NOTE\nASSESSMENT:\n PATIENT ABLE TO OBEY COMMANDS & MOVE ALL EXTREMITIES. COMMUNICATING BY MOUTHING WORDS AND NODDING. PATIENT OCCASIONALLY GETTING ANXIOUS & STATING HE WANTS ET TUBE OUT, GIVEN ATIVAN AS NEEDED WITH GOOD EFFECT. FENTANYL GTT CONTINUES WITH ADEQUATE PAIN CONTROL.\n AFEBRILE. HEART RATE RANGING 60-70'S NORMAL SINUS. BRADYCARDIC AFTER LOPRESSOR WITH HR 40'S-50'S. SBP REMAINS 110-160'S. PATIENT MAKING ADEQUATE HOURLY URINE, WEIGHT CONTINUES TO DECREASE.\n TOLERATING CPAP + PRESSURE SUPPORT . LUNG SOUNDS OCCASIONALLY COARSE AND SUCTIONED FREQUENTLY FOR THICK RUST/BROWN SECRETIONS. PATIENT HAS STRONG COUGH & ABLE TO RAISE SECRETIONS IN ET TUBE.\n ABDOMEN SOFT, NONDISTENDED. ABDOMINAL WOUND VAC INTACT, DRAINING MODERATE AMOUNTS SEROSANG DRAINAGE. STOPPED @ 12AM AND IV FLUIDS STARTED. ILEOSTOMY CONTINUES TO PUT OUT LOOSE BROWN STOOL. 10 UNITS NPH GIVEN LAST NIGHT (1/2 DOSE) PER DR. DUE TO NPO STATUS.\nPLAN:\n IR TODAY FOR ? DRAINAGE FLUID COLLECTION. ? EXTUBATE AFTER IR. CONTINUE TO PROVIDE SUPPORT. ? PHYSICAL THERAPY CONSULT.\n"},{"category":"Nursing/other","chartdate":"2178-06-18 00:00:00.000","description":"Report","row_id":1445668,"text":"Resp Care\nPt maintained intubated and on mech ventilation PCV. tol well AM RSBI 28. Bilat breath sounds course rhonchi with some inspiratory wheezes, suctioned for moderate to large thick tan secretions. plan to further wean and possible extubation. no vent settings changed during the shift see flowsheet.\n"},{"category":"Nursing/other","chartdate":"2178-06-18 00:00:00.000","description":"Report","row_id":1445669,"text":"focus update note\nafebrile, 40-80 heart rate no ectopy, sbp 120-170/50-60.\n\nresp: electively extubated, pt now on 2 liters o2 via nasal cannula, o2 sat 100%, lung sounds clear, pt coughing and raising secretions, LLL abcess to be treated conservatively with current regime of antibiotics verses ct guided drainage per pulmonology and infectious disease.\n\nneuro: pt confused, alert x , follows commands consistently, opens eyes spontaneously, mae+, no ativan given today.\n\npain: fentanyl gtt discontinued, new pt order for PRN diludid, pt has had no complaints of abdominal pain.\n\nskin: ostomy appliance changed today, stoma red, brown liquid stool large amount, + bowel sounds no breakdown on back, vac dressing to open abd wound. per icu team black foam covers white foam.\n\nmobility: pt worked with PT/OT today OOB to chair\n\nsocial : wife called and sons called, nurse updated wife regarding pt upodate over the telephone\n\ngu/gi: foley catheter draining > 50 cc urine q 1 hr, pt continues on aldactone po, fluid volume status now negative for length of stay, tube feedings restarted at goal rate, no residual. NPH held this am as pt was NPO icu team aware\n\nplan: continue to monitor resp status, fluid volume status, consider hydrocort taper, consider discontinuing aldactone, encourage coughing and deep breathing and incentive spirometry, ? speech and swallow consult tomorrow\n"},{"category":"Nursing/other","chartdate":"2178-06-18 00:00:00.000","description":"Report","row_id":1445670,"text":"Resp Care:\n\nPt extubated this a.m. & placed on cool mist at 40% FiO2. Tol prcedure well & able to give strong cough & vocalize well. FiO2 titrated to n/c. Prn Nebs are ordered yet not indicated at this time; bs = cta with good aeration. Plan to continue to monitor patient & encourage DB & C.\n"},{"category":"Nursing/other","chartdate":"2178-06-06 00:00:00.000","description":"Report","row_id":1445621,"text":"RESPIRATORY CARE: PT TRANSFERRED FROM 4 TO SICU B AT 1830 TODAY. PT W/ A 7.5 ORAL ETT AT 21 LIP AND ON THE AC MODE AS\nPER CV. WILL ADJUST SETTINGS AS PER ABG'S POST TRANSFER.\n"},{"category":"Nursing/other","chartdate":"2178-06-11 00:00:00.000","description":"Report","row_id":1445637,"text":"7pm-7am Nursing Note\nSee CareVue for objective data and trends:\nNEURO-Pt sedated on fentanyl/ativan drips. Pt with facial grimacing during turing/painful stimuli. Withdraws upper extremities to nail bed pressure. Facial grimace with BLE nailbed pressure and some minimal spontaneous movement noted to feet. Pupils at 2mm and reactive to light.\nCV-ABP ranging 100s-120s/60s-70s. CVP 10-14,C.O ranging . SVV although pt remains on lasix drip to goal of liters negative per day. Pt continues to have generalized edema present. Palpable peripheral pulses.\nRESP-Pt remains intubated, ventilated on settings: AC mode-45%fio2,450 X 26, 16 PEEP. LS clear, occasionally coarse prior to suctioning, diminished in bilateral lower bases with right worse than left. Suctioning pt for thick, blood tinged sputum.\nGI-Pt continues TF via OG. No residuals. Abdomen is large, soft with hypoiactive bowel sounds. Minimal output via ostomy-started on reglan Q 6 hours. Surgical insicion with staples, dressing changed X 1.\nGU-pt on lasix drip, urine clear yellow.\nID-Pt afebrile. WBC trending down. Continue Zosyn.\nPLAN-wean vent slowly, pulmonary toilet. Follow abdominal exams, labs. Continue IV antibiotics.\n"},{"category":"Nursing/other","chartdate":"2178-06-11 00:00:00.000","description":"Report","row_id":1445638,"text":"RESP CARE: Pt remains orally intubated/on vent on settings per carevue. Off paralytic.No changes in settings overnoc. Overbreathing vent 1-2bpm. Esophageal balloon remains in place. ABGs acceptable. Lungs dim bibasilar R>L,rhonchi. Sxd thick bld tinged yellow sputum. Difficulty passing sx catheter at times, pt biting ETT. No RSBI due to PEEP level.\n"},{"category":"Nursing/other","chartdate":"2178-06-11 00:00:00.000","description":"Report","row_id":1445639,"text":"focus update note\nD: ARDS resolved with active vent wean, diuresis with lasix gtt goal 1-2 liters negative-, pt length of stay is 16L positive, hemodynamically stable off pressors and moniotoring device discontinued.\n\nT max 98 50s- 70 NSR, no ectopy, sbp 106-120 /50-60, with aggitation repositioning and suctioning pt hypertensive SBP 160-170. ativan gtt discontinued pt may have PRN ativan for aggitation. fentanyl gtt continues at 150 mcq/hr\n\nresp: vent wean to cpap with pressure support peep 8 pressure support at 10 40% fio2- RR 20s, Vt 500, lung sounds clear to coarse with diminished bases.\n\nneuro: pt opening eyes spontaneously at times, mae+, intermittently following commands, will grasp with hands to command. pupils 2mm with brisk reaction\n\ngu/gi: nutrition consult- probalance with goal rate 65cchr, low residuals 10-20cc q 4 hours, no bowel sounds heard icu team aware, small amount brown liuid from ileostomy, midline incision well approximated and scant serous drainage. lasix gtt at 8 mg hr to max 10 mg hr- to achieve goal 2 liters negative by 12 nidnight.\n\nskin: ETT not rotated mouth sore in right corner, skin on back intact- pt transferred back to atmos icu bed, pt continues to have generalized edema.\n\nplan; continue with aggressive diuresis with lasix gtt, continue with vent wean as tolerated by pt, monitor residuals with tube feedings, provide supportoive care to pt and family\n"},{"category":"Nursing/other","chartdate":"2178-06-11 00:00:00.000","description":"Report","row_id":1445640,"text":"Respiratory care\nPt remains intubated recieved on a/c weaned to cpap/psv. recieved on peep of 16 wened to 8cm , abg on psv of 12cm 746/39/98/29/3 weaned to 10cm. Fio2 weaned to 40%. Plan to continue to wean support as tolerated.\n"},{"category":"Nursing/other","chartdate":"2178-06-17 00:00:00.000","description":"Report","row_id":1445663,"text":"NPN (NOC):\n\nRESP: PT REMAINS INTUBATED. CURRENT VENT SETTINGS: PS 8 X 5 PEEP X40%. RR TEENS TO 20'S, VT'S 700'S, LATEST ABG: 163/35/7.40/23. BS'S FAIRLY CLEAR. SX'D X 2 FOR MOD AMTS OF THICK BROWN SECRETIONS. RSBI = 40.\n\nNEURO: PT HAD BECOME INCREASINGLY MORE RESTLESS, TACHYPNEIC AND HYPERTENSIVE ON FENTYNL 200 MCG'S. ATIVAN 1 MG IV GIVEN AT MN AND PT IMMEDIATELY FELL ASLEEP AND BP AND RR CAME DOWN. IS BECOMING MORE AWAKE AND INTERMITTANTLY RESTLESS NOW (6 AM ). ? EXTUBATE TODAY.\n\nGI: TOL TF WELL. OSTOMY WAS PUTTING OUT ALOT OF WATERY STOOL BUT HAS SLOWED DOWN CONSIDERABLE SINCE MN. ABD REMAINS OPEN. DSG CHANGED AT 4AM. SURGICAL TEAM IS CONSIDERING A VAC DSG TODAY.\n\nF/E: I&O - 6 LITERS AT MN AND WT IS DOWN 8 KG'S. HIS UO HAS ALSO SLOWED CONSIDERABLY SINCE MN. 100 MEQ'S OF KCL AND 2 AMPS CALCIUM GIVEN OVERNOC. NA IS NORMALIZING ON D5W DRIP. FSBS' CONTROLLED W/ SSI.\n"},{"category":"Nursing/other","chartdate":"2178-06-17 00:00:00.000","description":"Report","row_id":1445664,"text":"Resp Care\npt maintained on mech vetilation PSV, tol well AM RSBI 40.6. Bilat breath sounds course rhonchi, suctioned moderate thick yellow. no vent settings changed seeflow sheet.\n"},{"category":"Nursing/other","chartdate":"2178-06-17 00:00:00.000","description":"Report","row_id":1445665,"text":"Resp Care:\n\nPt remains intubated & ventilated. PSV decreased this a.m. to with good results; pt remains on 40% FiO2. Suctioned for mod amts of rust colored secs throughout shift; with BS = crse t/o. MDI's given as ordered. Plan to continue ventilating pt through noc with IR procedure planned for tomorrow. Please see flowsheet for details.\n"},{"category":"Nursing/other","chartdate":"2178-06-17 00:00:00.000","description":"Report","row_id":1445666,"text":"FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\nNEURO--VERY AWAKE , ALERT AND COOPERATIVE. FENT @200 MCG. ATIVAN ORDERED FOR PRN DUE TO ONE MORE DAY OF INTUBATION.\nRESP--WEANED TO CPAP 5/5. READY TO EXTUBATE TODAY, DECISION MADE NOT TO AS PATIENT WILL TO TO IR TOMORROW FOR FLURO GUIDED DRAINAGE OF LUNG MASS/ABCESS. SUCTIONED FOR MOD-LARGE AMOUNTS OF THICK RUST SPUTUM.\nGU--ADEQUATE URINE, MUCH LESS THAN YESTERDAY.\nGI--THICK LOOSE BROWN STOOL FROM ILEOSTOMY. ABD. WOUND VAC'ED BY PRIMARY TEAM W/ WHITE THEN BLACK SPONGE W/GOOD SUCTION. BELLY SOFT.\nENDO-- NPH AND SLIDING SCALE CONTROLLING BLOOD SUGARS.\nID--AFBERILE TODAY. FLAGYL ADDED TO ZOSYN AND CIPRO. WBC DOWN.\nCV--STABLE. EKG/CKW/TROPONIN DONE AFTER? 5BEAT VTACH/ARTIFACT. (MOST LIKELY ARTIFACT). DENYS AND CPAIN, NO FURTHER EPISODES, LOTS OF ARTIFACT WHEN PATIENT MOVING.\nSOCIAL--WIFE/SON . UPDATE GIVEN.\nPLAN: NPH THIS PM, NPO AFTER MIDNIGHT FOR PROCEDURE\n PRN ATIVAN @ HS.\n CPT /PULMONARY TOILET FOR THICK SECRETIONS.\n TEAM AWARE OF ABOVE. CALL HO WITH ANY CHANGES.\n"},{"category":"Nursing/other","chartdate":"2178-06-10 00:00:00.000","description":"Report","row_id":1445633,"text":"Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: PT is still on fentanyl, ativan and cisatracurium gtt,with Lt ulnar TOF monitor with twitches, nimbex ^ 0.08mg as pt overbreahing vent.other than that fully relaxed and sedated.\n\nCV: NST- SB, HR 56-60/min, no ectopy noted, SBP 110-120, levo off sine yesterday.Afebrile, + PP, ++generalized edema.IVF KVO only, Plt still low 56 today with am lab, WBC trending down and 16.5 this am, hct:27.8.cont with PCCO monitoring.\n\nResp; Remains on vent FIo2 down to 45% , Good ABG's.LS coarse and dinished at bases, O 2sat 96-100%, Minimal secretion only.\n\nGI: Abd distended, very hypoactive BS, ileostomy with minimal greenish out put more thick today. tube kept clamped per primary team since day time.OGT to LCWS with bilious out put.\n\nGU: Foley cath patent with amber clear urine adq amt.\n\nEndo; Bld sug q6h, on ssri, treated per SS.\n\nID: Afebrile,cont with anbx.\n\nAct: Pt is on kinair bed, turned q2h, stable during turning and positioning.\n\nSocial: Visited by wife and her sister during early shift, updated with POC.\n\nPlan: Cont monitoring,cont pulm toilet, frequent positioning, skin care,pain mngt, ? DC paraletic today, ? start nutrition OGT or TPN.support to pt and family.abg's.\n"},{"category":"Nursing/other","chartdate":"2178-06-10 00:00:00.000","description":"Report","row_id":1445634,"text":"RESP CARE: Pt remaisn orally intubated with 7.5ETT/21 lip. On AC 450/26/.45/18 PEEP. 02 Sat dropped to 89% at start of shift following turn to R. FI02 increased to .50 at that time. No drops in sats overnight/ABGs WNL. Esophageal balloon remains in place. No measurements overnight.Lungs coarse rhonchi bilat. Sxd thick bld tinged tan sputum. No RSBI due to pEEP level. Continue to wean FI02/vent as tol\n"},{"category":"Nursing/other","chartdate":"2178-06-10 00:00:00.000","description":"Report","row_id":1445635,"text":"FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\nNEURO--PARALYTIC OFF THIS AM. RESPONDING TO PAIN WITH SOME SPONTANEOUS MOVEMENT OF LOWER ARMS. WINCES TO STERNAL RUB. TOLERATING VENTILATOR WELL AT THIS POINT ON FENT/ATIVAN. SLOWLY WEANING THESE DOWN AS WELL.\nPUPILS 2=REACTIVE.\n\nRESP--PEEP TO 16, TOLERATED WELL. ONE PERIOD OF DESATURATION DUE TO LARGE AMOUNT OF THICK, RUSTY SECRETIONS. SUCTIONED AND LARVAGED FOR LARGE AMOUNT WITH IMPROVING SATS AND IMPRVOING GASES. LUNGS CLEAR AND DIMINISHED.\n\nGI---BELLY DISTENDED, SOFT., NICE PINK STOMA, MINIMAL STOOL. REPLETE W/FIBER STARTED AT 10CC HR AFTER PLACEMENT OF NGT CONFIRMED BY CXRAY. PROTONIX CHANGED TO FAMOTADINE.\n\nGU--LASIX ONCE, CURRENTLY ON LASIX GTT WITH GOAL 1-1.5 LITERS NEGATAIVE.\n\nCV--STABLE OFF PRESSORS. CARDIAC NUMBERS PER FLOW SHEET. AFEBRILE.\n\nENDO--BLOOD SUGARS CONTROLLED WITH SLIDING SCALE.\n\nPLAN: CONTINUE WITH SLOW WEAN ON FENT/ATIVAN (APPROX. 20% Q 12 HRS)\nCONTINUE PEEP WEAN AS DIRECTED BY HO AND GASES.\nCONTINUE DIURESIS AS LONG AS TOLERATES, WILL CHECK LATATE AND BLOOD PRESSURE PARAMETERS.\nREPLACE LYTES AS NEEDED.\nCALL HO WITH ANY CHANGES.\nVANCO DOSED ACCORDING TO LEVEL.\n"},{"category":"Nursing/other","chartdate":"2178-06-10 00:00:00.000","description":"Report","row_id":1445636,"text":"Respiratory care\nPt remains on a/c vent with peep decreased to 16cm, ttp -5.5. Abgs wnl on 40%. Plan to wean paralytic and continue to wean support as tolerated.\n"},{"category":"Nursing/other","chartdate":"2178-06-16 00:00:00.000","description":"Report","row_id":1445660,"text":"pt febrile 102-101 wbc^up 14k. tylenol 650mg x2 given\nhtn sb/p 180-160 most of night agitation. lopressor 25mg via ngt\nw/ min effect.\nrr-35 w/ stimulation(turning/bathing/suctioning) but settles down w/ rr24-28. suction frequently q2hrs for mod amt thick brown sputum.\no2sats 99-97% on cpap 5/8ips/40%.\npt slightly sedated on fentanyl 200mcg/hr. pt nodding to ?'s. restless\n@ times. mae in bed.\nlasix gtt was stopped last evening @ 1800 pt autodiuresising large amt of urine 500-230cc/hr. wt down 5kgs from previous day. k+ low repleted\nw/ 80meq down ngt and 40meq iv.\nabd. soft-ileostomy stoma pink-large amt watery brown stool and air.\nabd. dsg changed x1 for mod. serous drge\n"},{"category":"Nursing/other","chartdate":"2178-06-16 00:00:00.000","description":"Report","row_id":1445661,"text":"Resp Care\nPt remains intaubted on PSV 8/5 with vts 500-600 rr 20-30. BLBS course and diminished suctioned for very thick tan/brown secretions, mdis given. PLan to continue on current settings overnight as tolerated.\n"},{"category":"Nursing/other","chartdate":"2178-06-08 00:00:00.000","description":"Report","row_id":1445627,"text":"resp care\npt continues on psv. more frank blood sx from ett. o2 slowwean presently 70%. plan to bronch today\n"},{"category":"Nursing/other","chartdate":"2178-06-08 00:00:00.000","description":"Report","row_id":1445628,"text":"resp care - Pt remains intubated, paralyzed and on full vent support. A copious amount of bloody secretions were suctioned when pt was turned early in shift. Pt was additionally suctioned for blood-tinged secretions during bronch. Sample was sent to lab. PEEP was raised, balloon measurement indicating that transpulmonary pressure was +1. Plan is to wean as tolerated.\n"},{"category":"Nursing/other","chartdate":"2178-06-08 00:00:00.000","description":"Report","row_id":1445629,"text":"SICU Nursing Note: See flowsheet for details\nEvents: Patient bronched - went into SVT 190s-200s, converted while 150 mg bolus of amiodarone infusing; PCCO monitor applied to watch C.O./CI; septic looking picture with increasingly worse CXR/ARDS picture; multiple vent setting changes, paralyzed with nimbex.\n\nRespiratory: Increased sedation levels this morning, changing over to ativan gtt from versed and increasing fentanyl gtt then pt placed on controlled settings. Currently able to wean Fi02 to 60 and slightly decreased PEEP. Pt bronched for thick bloody secretions - LS coarse but slightly less diminished in bases than this morning. Turning patient on his sides, keeping him off back to maximize use of lung space.\n\nHemodynamics: Remains on low dose levo; T max 102.1, currently afebrile; SR/ST 80s-120s. After bronch, patient went into an SVT 190s-200s - converted back to sinus tach in 100s-110s during 150 mg amiodarone bolus. PCCO monitor applied, Aline placed on L axilla for use of PCCO. Pt's C.O./C.I. showing low normal numbers, decreased SVR. 2 500 cc boluses of LR administered; currently remains on plasmalyte at 150/hour. CVP 16-24; generalized anasarca; peripheral pulses easily palpable. Ca repleted multiple times. Hydrocort. started because patient didn't respond normally to stem test administered this morning.\n\nNeuro: PERRL; sedated on fentanyl/ativan gtts and paralyzed with nimbex; TOF applied to L ulnar, currently getting thumb twitches. Earlier pre-paralytic, pt. withdrawing to pain in all 4 extremities and spontaneously moving limbs to stimulation but not following commands, grimacing to pain.\n\nGI: Remains NPO; no output via OGT which is on CLWS; ostomy put out guiac - liquid green stool, mainly water; tube in place putting out same liquid green substance as his ostomy; abd soft distended with very hypo bowel sounds. Glucose WNL, no insulin required this shift.\n\nSkin: Intact, very edematous, generalized edema; buttocks slightly red but intact; barrier creme applied to scrotum.\n\nFamily: Son into visit, spoke to ; wife phoned. Family needs support as they continue to understand patient's condition and relative gravity.\n\nPLAN: Keep low dose levo for squeeze (per ); ARDS protocol; monitor culture results/cont ABX; monitor PCCO, bolus fluid as needed; monitor train of fours while paralyzed; pain and sedation management for comfort.\n"},{"category":"Nursing/other","chartdate":"2178-06-16 00:00:00.000","description":"Report","row_id":1445662,"text":"FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\nNEURO--SEDATED ON FENTANYL 175 MCG. ALERT TO NAME AND WILL FOLLOW COMMANDS. PURPOSEFUL MOVEMENT OF UPPER EXTREMITIES, MOVES ALL EXTREMITIES. SLOWLY WEANING FENTANYL.ATIVAN DC/D YESTERDAY, DID WELL OFF IT TODAY.\nRESP--NO VENT CHANGES TODAY, TOLERATING CPAP WELL. CAN DECREASE PRESSURE SUPPORT TO 5 TOMORROW. LUNGS CLEAR TO COARSE DEPENDING UPON WHEN SUCTIONED LAST. SUCTIONED FOR THICK BROWN SPTUTUM.\nGI--NOT TOLERATING TUBE FEEDS WELL AS HAS A LARGE IEOSTOMY OUTPUT, AND DOES NOT ABSORB ANY PO K. BELLY SOFT, INCISION ESSENTIALLY OPENED EXCEPT FOR A FEW STAPLES AROUND BELLY BUTTON. SMALL BOWEL VISIBLE IN LOWER ASPECT OF WOUND. CHANGED MULTIPLE TIMES TODAY WITH DSD KERLIX. MOD AMOUNT OF SEROUS DRAINAGE. WOUND LOOKS PINK IN LOWERS ASPECT, LESS PINK IN UPPER ASPECT. CT OF CHEST/ABD W/CONTRAST DONE--?RESULTS.\nGU--AUTO DIURESING LARGE AMOUNTS OF URINE. CONTINUOUS K REPLACEMENT. D5W@80 STARTED FOR FLUID BALANCE MANAGEMENT. WEIGHT CONTINUES TO GO DOWN.\nID--LESS FEBRILE TODAY. CHANGED TO MOTRIN FROM TYLENOL FOR FEVER MANAGEMENT. STOOL SENT FOR CDIF. OTHER ANTIBIOTICS UNCHANGED.\nCV--STABLE. LOPRESSOR INCREASED WITH BETTER BLOOD PRESSURE CONTROL\nPLAN: CONTINUE TO MONITOR WOUND, CHANGE PRN\n FREQUENT LYTE CHECKS, NEEDS K QUITE FREQUENTLY\n SUCTION WHEN NEEDED, ?DECREASE PRESSURE SUPPORT IN AM\n NUTRITION CONSULT FOR IMPORVED ABSORPTION OF FEEDS.\nFAMILY IN, UPDATE GIVEN. APPROPRIATELY SUPPORTIVE. ALL TEAMS AWARE OF ABOVE. WILL CALL HO WITH ANY CHANGES.\n"},{"category":"Nursing/other","chartdate":"2178-06-07 00:00:00.000","description":"Report","row_id":1445625,"text":"Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Pt is on fentanyl and versed gtt, opens eyes to call, not following any commands, agitated when low sedation,so prn dilaudid for pain started with good effect, PERL.moving all extrimities to pain and spontaneously.\n\nCV: ST-NSR, HR 106-83, no ectopy noted, SBP was in 80's early shift, fluid bolus x2 with immediate effect and drops down once fluid is off, Neo started at 2mcg/kg/min and tapered to 0.5mcg now, 25% alb 50ml & 2 units PRBC given. ++PP, ++edema.IVF LR at 200ml/hr, lytes replaced per sliding scale.\n\nResp: Remains on vent, pls see flow sheet and resp notes for changes, LS coarse - clear and diminished at bases, sxn thick bld tinged secretion, ABG's still reps alkalosis, O2 sat 90-94% can tolerate sats 90-92 today per Dr..\n\nGI: Abd softly distended, hypoactive BS, No BM. OGT with bilious drain replaicng cc:cc with NS. tube with clear drain, and ileostomy with light greenish thin out put.abd . staples intact and dry, DSD removed by primary team today.\n\nGU: Foley cath patent with yellow clear urine adq amt.\n\nEndo: Bld sug q6h, WNL.\n\nAct: Turned from side to side,skin intact.\n\nSocial: Visited by wife , updated by Dr. and RN.\n\nID: T max 102.3, pan cx, on anbx.\n\nPlan: Cont monitoring, pulm hygiene, abg's,pain mngt, wean Neo as tolerates.support to pt and family, check lytes and replace per sliding scale. change position q2h and skin care.\n"},{"category":"Nursing/other","chartdate":"2178-06-09 00:00:00.000","description":"Report","row_id":1445630,"text":"Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Patient is on fentanyl, ativan and cisatracurium gtt, lt ulnar TOF monitor with twitches, Pupils 1-2mm sluggishly reactive.cont same amt of cisatracurium per Dr..\n\nCV: NSR, HR in 70's,no ectopy noted, SBP 100-110 w/ map of 80-90 levophed wean down to 0.03 per Dr..PCCO monitor with better numbers now, calibrated q8h, CO 5-6.7L,++ generalized edema, weeping from rt. groin ? Line placement trial.Palpable pulses,Plasma lyte at 150ml/hr, cvp 14-21cm,afebrile.HCT 30's and wbc 23, plt 44, primary team aware.K and calcium replaced.\n\nResp: Remains on vent, vent changes with ABG's, pls see resp notes and flow sheet for changes. Ls coarse - clear and diminished at bases, O2 sat 94 -97%, sxn bld tinged secretions.ABG acceptable.\n\nGI: Abd distended, very hypoactive BS, NO BM today, OGT w/very minimal drain , primary team informed, ileostomy with small amt greenish liq drain, tube with minimal out put also, all drains greenish.abd post op wound +oozing, dressing changed.\n\nGU: Foley cath patent with amber clear urine adq amt.\n\nEndo: Bld sug q6h, on SSRI.\n\nID: Afebrile, on anbx, ciprofloxacin started last night.\n\nAct: Turned q2h, skin intact.\n\nSocial; Visted by pt's wife early shift, updated by RN and SICU MD.\n\nPlan: Cont monitoring, pulm hygiene, regular positioning,skin care cont tof monitoring, wean off levophed as tolerates, support to pt and family.\n\n\n"},{"category":"Nursing/other","chartdate":"2178-06-09 00:00:00.000","description":"Report","row_id":1445631,"text":"Resp Care\nPt remains on vent. Sucitoned for mod amt of thick blood-tinged secreitons. Weaning based on abgs, Improving. Mdis given as ordered. Will continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2178-06-09 00:00:00.000","description":"Report","row_id":1445632,"text":"SICU Nursing Note: See flowsheet for details\nResp: Continues on CMV; no sputum via ETT; LS coarse/rhonchorous; de-recruited after a re-position with desats to 86% - ambu bagged and placed on 100-% Fi02 then PEEP increased to 18 after esoph. balloon revealed a PEEP of 14 too low at this time. After moving into Kinair bed, placed patient in modified swimmer's position and he didn't tolerate it despite re-recruitment, sats remained at 87-88% so he was placed on his side instead.\n\nHemodynamics: Afebrile; sinus brady/normal sinus in 50s-70s with no ectopy noted; SBP 80s-120s with MAPs above 65. Low dose levo off since mid-afternoon after patient was hypertensive in 140s and heart rate dipped to 49-50, currently remains off but should be titrated back on if MAP <65. Still w/ generalized 3+ edema; UO 30-60 an hour via foley. Lytes repleted PRN; showing low normal CO, SVV within normal limits, water volume in lungs slightly less than yesterday but still higher than PICCOs normal range; CVP 14-20. PLT increased to 59 from 44, no s/s bleeding/hematoma noted.\n\nGI: Remains NPO; off nutrition for 10 days; insulin per sliding scale, scale tightened for better controls; abd soft distended with hypo BS; ostomy put out scant amounts of slightly formed green stool. tube capped per Dr. - before being capped, no output from it\n\nNeuro: Paralyzed; PERRL; train of fours eliciting 2,3, or 4 twitches; titrating nimbex today based on patient at one point moving mouth and bucking vent slightly; able to titrate back down.\n\nSkin: Intact; scrotum still extremely edematous but intact; turn and reposition frequently.\n\nSocial: Son into visit and called on behalf of patient's wife.\n\nPLAN: Titrate MAP >65; plan to stop paralysis tomorrow; continue sedation; No PEEP decreases without knowledge and assent; if tighter insulin scale fails to control glucose, should start insulin gtt; encourage teams to make nutrition plan for patient either enteral or TPN; continue to titrate sedation to ensure patient's comfort; continue SICU plan of care.\n"},{"category":"Nursing/other","chartdate":"2178-06-08 00:00:00.000","description":"Report","row_id":1445626,"text":"7pm-7am Nursing Note\nSee CareVue for objective data and trends:\nNEURO-Pt sedated on versed and fentanyl drips, also receiving intermittent dosing of IV dilaudid for further pain management. Pt will grimace face but not open eyes. Pt's pupils at 2mm bilaterally and reactive to light. Pt withdraws extremities to nail bed pressure.\nCV-Pt HR 90s-110s, SR. SBP maintaining 90s-100. Continue phenylephrine drip to maintain MAP >60. Pt with generalized edema present.\nRESP-LS clear to coarse and very diminished at bases. Pt's sputum now more bloody and remains thick. Dr. aware. Pt continues to be ventilated and initially on CPAP settings, ABG improved however pt requiring 100% fio2 and has been unable to wean fio2 down as pt's sats decrease into the high 80s. Pt changed over to AC mode at 0500 - will monitor ABG but repiratory rate elevated into 40s. CXR done, results pending.\nGI-OG with no output, now pt with increased output via ileostomy. Abdomen is softly distended with faint, hpoactive bowel sounds present. Midline surgical incision with staples and small amounts of serosanquinous drainaige-DSD applied. drain remains intact with minimal output.\nGU-foley intact and putting out adequate amounts of urine.\nLABS-Pt's platelets continue to drop, INR elevated. HIT panel pending. WBC elevated as well- Tmax 102.1, SICU team aware, Pan cultured yesterday. Continues Vancomycin and zosyn.\nPLAN-Monitor respiratory status, pulmonary toilet. ?bronchoscopy today secondary to thick, bloody secretions. Follow temps, continue antibiotics. Follow GI status/exams. Monitor labs.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2178-06-19 00:00:00.000","description":"Report","row_id":1445671,"text":"Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Pt is alert and oriented x , confused inbetween,but easily reoriented back, c/o pain, dilaudid prn with good effcet, ativan 1mg as pt c/o insomnia with fair effect, pleasant and co op with care.\n\nCV: NSR, HR in 60's, SBP 140-170, on po lopressor,ivf kvo only, afebrile, ++PP, + edema scrotum & penis, still on aldactone.CVP 2-4cm.denies Cp or discomfort.\n\nResp: Remains on RA, ls clear, ++cough, pt is able to suction it from mouth, using IS appropriately, encouraged deep breath and cough.O2 sat 96-99%.\n\nGI: Abd softly distneded, Hypoactive BS, Tf at goal. tolerated well, ileostomy with brown loose stool, banana flakes TID. tube clamped.\n\nGU: Foley cath patent with yellow clear urine adq amt.\n\nEndo; Bld sug q6h, on SSRI and NPH .\n\nID: Afebrile, on anbx.\n\nSocial: Visited by wife early shift, aware of \n\nAct: turned in bed, skin intact.\n\nPlan: Cont monitoring, pulm hygiene, encourage deep breath cough & IS, ? ^ lopressor for SBP 170's, taper hydrocortisone, ambulate as tolerates , support to pt and family.\n"},{"category":"Nursing/other","chartdate":"2178-06-19 00:00:00.000","description":"Report","row_id":1445672,"text":"SICU Nursing Note: See flowsheet for details\nPt remains on RA, coughing scant secretions, using IS, pivoted with 2 assist to chair, needed heavy 3-assist to return to chair however; motivated to get physical therapy for his sons' weddings upcoming. Added norvasc to his BP regime for better BP control; taking clear liquids without problem, appetite fair. VAC dressing to abd incision changed by surgery, ileostomy appliances changed at same time. Remains slightly confused by pleasant, oriented, cooperative with care. Wife phoned today for update.\n\nPLAN: VAC and ileo appliances due to be changed on Sunday (VAC changed by east surgery team only); advance diet as tol; PT/OT; pain management; continue to encourage IS, cough/deep breathe, continue ICU plan of care.\n"},{"category":"Nursing/other","chartdate":"2178-06-20 00:00:00.000","description":"Report","row_id":1445673,"text":"Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro:Alert and orinented x3, MAE, c/o abd pain dilaudid x1 and ativan 1mg per pt's request and slightly confused towards late night,\" No body told me it is time to go for the wedding\"reoriented back,appropriate with answers,aware of palce, time and self.trying to get OOB at times, bed alarm on.\n\nCV: HR 60-70, no ectopy noted, SBP 140-170, ++PP,less edema good diuresis with aldectone, K and calcium replaced.\n\nResp : On RA O 2sat 99-100%, LS clear, good cough w/ minimal secretion,Deep breath and cough and IS encouraged.\n\nGI: Abd soft,Hypoactive BS, Ileostomy w/ more thick stool with gas. can't drain to the bag, banana flakes held last night, vac dressing intact with SS drain.TF at goal, tolerated clears too.\n\nGU: Foley cath patent with yellow clear uirne adq amt.\n\nEndo; bld sug q6h, on SSRI & NPH.\n\nAct: Turned in bed, skin intact.\n\nSocial; Called by pt's son last night, updated with him.\n\nPlan: Cont monitoring, pulm hygiene, ambulate, ? Advance diet, change pain meds to po., support to pt nad family.\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-16 00:00:00.000\",\n \"description\": \"CT ABDOMEN W/CONTRAST\",\n \"row_id\": 1020280,\n \"text\": \" 1:15 PM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: evaluate for fever source including fluid collection\\n Admitting Diagnosis: OBSTRUCTION\\n Field of view: 44\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man w/ respiratory failure s/p aspiration and s/p parastomal hernia\\n repair. PO and IV contrast\\n REASON FOR THIS EXAMINATION:\\n evaluate for fever source including fluid collection\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56 year old man with repiratory failure and history of aspiration\\n post parastomal hernia repair.\\n\\n COMPARISON: Multiple prior chest radiographs and CT abdomen/pelvis performed\\n .\\n\\n TECHNIQUE: MDCT acquired images were obtained through the chest, abdomen and\\n pelvis after the uneventful administration of 130 cc IV Optiray contrast. Oral\\n contrast was also administered. Multiplanar reformats were reviewed.\\n\\n CT CHEST: The lungs demonstrate diffuse bilateral tree-in- opacities\\n involving the right middle lobe and both lower lobes. There is dense\\n consolidation in the lower lobe with left lower lobe cavitating lesion\\n measuring approximately 6.3 x 5.5 cm. There may be a low density fluid\\n component which may be pleural.\\n\\n CT ABDOMEN: The liver, spleen, adrenals, pancreas and kidneys are grossly\\n unremarkable. There is a small amount of mesenteric free air (2:48)\\n anteriorly adjacent to an open anterior abdominal wall defect with overlying\\n packing material. The bowel id exposed to air, and the intraperitoneal air\\n is likley related to the abdominal wall defect - rather than an\\n intraabdominal process. (This was discussed with the ICU resident)..\\n\\n CT PELVIS: The rectum, sigmoid, Foley and bladder are unremarkable. There is\\n no pelvic free fluid or free air.\\n\\n Bone windows demonstrate no suspicious lytic or blastic lesions with marked\\n degenerative . A right iliac bone harvesting site is again noted.\\n\\n Spinal fusion hardware in the thoracic spine is unchanged. An endotracheal\\n tube terminates in the mid trachea. A nasogastric tube terminates in the mid\\n stomach. A left internal jugular catheter terminates at the superior\\n cavoatrial junction.\\n\\n IMPRESSION:\\n 1. Extensive bilateral bronchopneumonia with left lower lobe cavitating\\n lesion which could represent necrotizing pneumonia (possibly aspergillosis).\\n\\n (Over)\\n\\n 1:15 PM\\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \\n CT PELVIS W/CONTRAST\\n Reason: evaluate for fever source including fluid collection\\n Admitting Diagnosis: OBSTRUCTION\\n Field of view: 44\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 2. Small amount free air in adjacent to the anterior bowel loops is likley\\n relsated to open peritoneum.\\n\\n Findings were discussed with Dr. at 4 PM on and the SICU\\n resident at 5:15 PM, who confirmed that the peritoneum was open.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-10 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1019308,\n \"text\": \" 2:49 PM\\n PORTABLE ABDOMEN Clip # \\n Reason: eval OGT placement prior to starting tube feeds\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man s/p parastomal hernia repair and ex lap\\n REASON FOR THIS EXAMINATION:\\n eval OGT placement prior to starting tube feeds\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56-year-old man status post hernia repair. Here to evaluate for\\n OGT placement prior to initiating tube feeds.\\n\\n COMPARISON: Abdominal radiograph from .\\n\\n FINDINGS: Portable supine image is provided showing a paucity of bowel gas\\n with no tube detected within the abdomen. Note is made of thoracic spine\\n hardware and clips to the right of the midline, and a stent overlying the\\n lower thoracic vertebra.\\n\\n IMPRESSION: Paucity of bowel gas with no tube detected within the abdomen.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-25 00:00:00.000\",\n \"description\": \"O CHEST (SINGLE VIEW) IN O.R.\",\n \"row_id\": 1021853,\n \"text\": \" 8:47 PM\\n CHEST (SINGLE VIEW) IN O.R.; CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \\n Reason: IVC FILTER PLACEMENT\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP SPOT FILM, P.M., \\n\\n A single frontal fluoroscopic spot film centered on the upper abdomen in the\\n midline shows inferior vena caval umbrella filters and the lower end of spinal\\n stabilization hardware, is submitted for documentation of a procedure\\n performed under fluoroscopic guidance without a radiologist in attendance.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1019743,\n \"text\": \" 4:25 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o PNA\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ARDS\\n REASON FOR THIS EXAMINATION:\\n r/o PNA\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST \\n\\n CLINICAL INFORMATION: Question pneumonia, ARDS.\\n\\n COMPARISON STUDY: .\\n\\n Patient is status post posterior fixation of the thoracic spine.\\n\\n There is an increased patchy density in the right mid to lower lung zone which\\n could represent pneumonia. There is also increased opacification of the mid\\n and left lower lung zones which could also represent pneumonia, or aspiration.\\n There is a small left lower lobe effusion.\\n\\n Right IJ catheter terminates in the cavoatrial junction. ET tube terminates\\n at the thoracic junction. Nasogastric tube courses towards the stomach but\\n the tip is not seen.\\n\\n IMPRESSION:\\n 1. Increased density of right mid to lower lung zone opacity, concerning for\\n pneumonia.\\n 2. Increased density of left lung opacities also concerning for pneumonia.\\n Small left pleural effusion.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-23 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 1021504,\n \"text\": \", A. 12R 6:10 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: R/O LOWER EXTREMITY DVT/PT HAS PULMONARY EMBOLI ? SOURCE\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with PE's\\n REASON FOR THIS EXAMINATION:\\n r/o lower extremity dvt\\n ______________________________________________________________________________\\n PFI REPORT\\n No evidence of lower extremity DVT.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-11 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1019574,\n \"text\": \" 10:10 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: NGT placement\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ARDS\\n REASON FOR THIS EXAMINATION:\\n NGT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: ARDS, for NG placement.\\n\\n FINDINGS: In comparison with the study of , the nasogastric tube extends\\n to the distal stomach. Patchy areas of increased opacification are seen at\\n both bases. Although these could represent atelectasis, the possibility of\\n superimposed pneumonia can certainly not be excluded. Probable small\\n bilateral pleural effusions.\\n\\n The metallic devices and monitoring leads remain in place.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1017145,\n \"text\": \" 5:38 PM\\n CHEST (PA & LAT) Clip # \\n Reason: ? pna\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with n/v\\n REASON FOR THIS EXAMINATION:\\n ? pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56-year-old man with nausea and vomiting, evaluate for pneumonia.\\n\\n COMPARISON: .\\n\\n PA AND LATERAL VIEWS, CHEST: Limited radiograph due to underpenetration and\\n soft tissue scatter. The lung volumes are low. Otherwise, the lungs are\\n clear without focal consolidations. There is no pleural effusion or\\n pneumothorax. The heart size is normal. Pulmonary vasculature is\\n unremarkable without evidence of pulmonary edema. Posterior thoracic fusion\\n hardware is noted.\\n\\n IMPRESSION: No acute cardiopulmonary process.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-06 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1018683,\n \"text\": \" 9:20 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess interval change\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with sepsis, ARDS\\n REASON FOR THIS EXAMINATION:\\n assess interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, \\n\\n COMPARISON: .\\n\\n INDICATION: Sepsis and ARDS.\\n\\n Indwelling devices are unchanged in position. Widespread heterogeneous\\n alveolar opacities demonstrate mixed changes, with improvement in left upper\\n lobe, worsening in left lower lobe, and overall slight progression within the\\n right lung. Small left pleural effusion is unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"P BILAT LOWER EXT VEINS PORT\",\n \"row_id\": 1018543,\n \"text\": \" 3:13 PM\\n BILAT LOWER EXT VEINS PORT Clip # \\n Reason: Please eval for DVT\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ? PE\\n REASON FOR THIS EXAMINATION:\\n Please eval for DVT\\n ______________________________________________________________________________\\n FINAL REPORT\\n BILATERAL LOWER EXTREMITY ULTRASOUND WITH DOPPLER STUDIES.\\n\\n HISTORY: Shortness of breath. Question pulmonary embolism. Also evaluate\\n for DVT.\\n\\n FINDINGS: No prior scans available for comparison.\\n\\n The common femoral, superficial femoral and the popliteal veins show normal\\n appearance, compressibility and Doppler flow bilaterally.\\n\\n CONCLUSION: No ultrasound evidence of DVT in either lower leg.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1018222,\n \"text\": \" 6:06 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate, pulm edema\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with UC s/p colectomy now presents with SBO s/p LOA, parastomal\\n hernia repair.\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate, pulm edema\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:21 AM\\n Increase in right-sided opacity.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n As compared to the previous radiograph from , there is unchanged\\n visualization of thoracic fusion hardware. The lung volumes are slightly\\n lower than on the previous examination, the cardiac silhouette is slightly\\n larger. Probably due to positioning effect, the transparency of the right\\n hemithorax has decreased, however, some small amount of right-sided pleural\\n effusion cannot be excluded. There are no signs suggestive of overhydration.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-04 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1018223,\n \"text\": \", M. MED 6:06 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for infiltrate, pulm edema\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with UC s/p colectomy now presents with SBO s/p LOA, parastomal\\n hernia repair.\\n REASON FOR THIS EXAMINATION:\\n eval for infiltrate, pulm edema\\n ______________________________________________________________________________\\n PFI REPORT\\n Increase in right-sided opacity.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-07 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1018717,\n \"text\": \" 4:46 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess interval change\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with sepsis, ards\\n REASON FOR THIS EXAMINATION:\\n assess interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, \\n\\n COMPARISON: .\\n\\n INDICATION: Sepsis and ARDS.\\n\\n New 6 mm diameter radiopaque density is identified to the left of the trachea,\\n and appears separate from the expected esophageal lumen based upon the\\n rightward location of nasogastric tube at this level. This structure could\\n potentially be external to the patient, but repeat radiograph following\\n removal of external structures may be helpful to exclude a foreign body. With\\n the exception of this finding, the remainder of the examination is unchanged.\\n\\n\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 79059,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: ? Pulmonary embolus.\\nHeight: (in) 68\\nWeight (lb): 204\\nBSA (m2): 2.06 m2\\nBP (mm Hg): 83/58\\nHR (bpm): 126\\nStatus: Inpatient\\nDate/Time: at 15:28\\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 size.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\\nsystolic function (LVEF >55%).\\n\\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\\n\\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\\ndiameter.\\n\\nAORTIC VALVE: ?# aortic valve leaflets. No AR.\\n\\nMITRAL VALVE: Trivial MR.\\n\\nTRICUSPID VALVE: Tricuspid valve not well visualized. Moderate PA systolic\\nhypertension.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\\n\\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\\ntamponade.\\n\\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\\nEchocardiographic results were reviewed by telephone with the MD caring for\\nthe patient.\\n\\nConclusions:\\nViews were limited. The left atrium is normal in size. Left ventricular wall\\nthickness, cavity size and regional/global systolic function are normal (LVEF\\n>55%) The right ventricular cavity is mildly dilated with normal free wall\\ncontractility. The number of aortic valve leaflets cannot be determined. No\\naortic regurgitation is seen. Trivial mitral regurgitation is seen. There is\\nmoderate pulmonary artery systolic hypertension. There is a small pericardial\\neffusion. There are no echocardiographic signs of tamponade. Dr. was\\nnotified by telephone on at 3:50 pm\\n\\nCompared with the prior study (images reviewed) of ,pulmonary\\npressures are higher, right ventricle appears bigger.\\n\\nIMPRESSION: Preserved left ventricular systolic function. Mildly dilated right\\nventricle with preserved systolic function. Moderate pulmonary hypertension.\\nNo obvious valvular abnormalities but views were limited.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"ABDOMEN (SUPINE & ERECT)\",\n \"row_id\": 1017146,\n \"text\": \" 5:39 PM\\n ABDOMEN (SUPINE & ERECT) Clip # \\n Reason: ? SBO\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with n/v\\n REASON FOR THIS EXAMINATION:\\n ? SBO\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56-year-old man with nausea and vomiting. Rule out small bowel\\n obstruction.\\n\\n COMPARISON: .\\n\\n ABDOMEN, SUPINE AND ERECT VIEWS: Mildly distended small bowel loops measuring\\n up to 4.3 cm are noted. The bowel gas pattern is otherwise nonspecific. There\\n are also scattered air-fluid levels predominantly noted in the right upper\\n quadrant. There is no evidence of pneumoperitoneum. Lower thoracic fusion\\n hardware is in unchanged location.\\n\\n IMPRESSION: Mildly distended small bowel loops and scattered air-fluid\\n levels, may indicate partial obstruction. CT may be obtained for further\\n evaluation.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-01 00:00:00.000\",\n \"description\": \"SMALL BOWEL ONLY (BARIUM)\",\n \"row_id\": 1017809,\n \"text\": \" 1:02 PM\\n SMALL BOWEL ONLY (BARIUM) Clip # \\n Reason: Rule out obstruction, massess, fistulae, abscess\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56M w/ colitis s/p lap total abd colectomy, end ileostomy presented\\n with abd pain, no output, bilious emesis on , n/w excessive ostomy output\\n with intermittent s/s of PSBO.\\n REASON FOR THIS EXAMINATION:\\n Rule out obstruction, massess, fistulae, abscess\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56-year-old male with colitis, status post total abdominal\\n colectomy and end ileostomy from . Here with abdominal pain.\\n\\n COMPARISON: CT of the abdomen and pelvis from , MR\\n enterography from .\\n\\n FINDINGS: Thin barium was orally ingested for this small bowel follow-through\\n study. Overhead radiographs and fluoroscopic images show filling of the bowel\\n loops after about approximately three hours. There is likely fluid in the\\n bowel loops as the contrast appears markedly diluted. The small bowel is\\n dilated in some regions measuring up to 5.7 cm. There is no transition point\\n identified, no obvious fistula formation with no apparent leak or area of\\n stricture as barium visibly made it to the patient's ostomy bag.\\n\\n IMPRESSION: Ingested oral contrast found in the ostomy bag after slight\\n motility delay with dilated small bowel loops with no obvious fistula\\n formation or obstruction.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-05-27 00:00:00.000\",\n \"description\": \"T-SPINE\",\n \"row_id\": 1017107,\n \"text\": \" 1:44 PM\\n T-SPINE Clip # \\n Reason: S/p Thoracie Fusion, T6-T12 Assess fpr healing\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n Ostomyelitis, Kyphosis\\n REASON FOR THIS EXAMINATION:\\n S/p Thoracie Fusion, T6-T12 Assess fpr healing\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Thoracic fusion, to assess for healing.\\n\\n FINDINGS: In comparison with the study of , there is little overall\\n change. Again the patient is status post placement of cage prosthesis across\\n the wedged T10 vertebral body with lateral fusion from T9-T11. Anterior\\n interbody fusion device is seen at T11-12, unchanged in position. Posterior\\n fusion hardware extends from T6-7 through T12 level, with paired pedicle\\n screws at T11 and T12. No evidence of hardware-related complication.\\n\\n IMPRESSION: Little change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-08 00:00:00.000\",\n \"description\": \"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT\",\n \"row_id\": 1018928,\n \"text\": \" 12:48 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \\n Reason: assess obstruction vs. infection\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ARDS, now with rising wbc, elevated tbili\\n REASON FOR THIS EXAMINATION:\\n assess obstruction vs. infection\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JBK MON 8:37 PM\\n No biliary dilatation and no findings to suggest infection.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56-year-old man with rising white blood count and elevated T-\\n bili.\\n\\n COMPARISON: Abdomen CT, .\\n\\n FINDINGS: The liver shows no focal or textural abnormality. There is no\\n biliary dilatation and the common duct measures 0.3 cm. The portal vein is\\n patent with hepatopetal flow. The gallbladder is normal without evidence of\\n stones, and there are no signs of cholecystitis. A small right pleural\\n effusion is seen. A small amount of free fluid is identified adjacent to the\\n midline surgical incision. The spleen is somewhat enlarged measuring 13.7 cm.\\n\\n IMPRESSION:\\n 1. No gallstones, no signs of cholecystitis, and no biliary dilatation.\\n 2. Small amount of free fluid in the midline which cannot be further\\n characterized with ultrasound. If concern for infection persists, an\\n abdominal CT is recommended.\\n 3. Small right pleural effusion.\\n 4. Splenomegaly.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-08 00:00:00.000\",\n \"description\": \"P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT\",\n \"row_id\": 1018929,\n \"text\": \", J. SICU-B 12:48 PM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \\n Reason: assess obstruction vs. infection\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ARDS, now with rising wbc, elevated tbili\\n REASON FOR THIS EXAMINATION:\\n assess obstruction vs. infection\\n ______________________________________________________________________________\\n PFI REPORT\\n No biliary dilatation and no findings to suggest infection.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1018449,\n \"text\": \" 9:40 AM\\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \\n Reason: please assess for infiltrate and new line position\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with resp failure\\n REASON FOR THIS EXAMINATION:\\n please assess for infiltrate and new line position\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: Chest portable for line placement on .\\n\\n COMPARISON: at 03:31.\\n\\n HISTORY: 50-year-old man with respiratory failure, evaluate for infiltrate\\n and new line position.\\n\\n FINDINGS:\\n\\n Over a period of only 6 hours, there is diffuse airspace disease occupying\\n almost all of the left lung and a major portion of the right lung. The\\n infiltrate and/or atelectasis seen in the right hilar area has also worsened.\\n A new small left pleural effusion is noted on today's examination. There is\\n no right pleural effusion. The heart size is normal. Multiple fixation\\n vertebral body plates and screws in intervertebral body are again noted\\n unchanged. A new endotracheal tube has been placed with tip approximately 4.5\\n cm from the carina. A right internal jugular line has also been introduced\\n recently with a tip in the upper one-third of the SVC.\\n\\n IMPRESSION:\\n 1. New diffuse airspace disease in both lungs, left more than right. This\\n can represent a non-cardiogenic pulmonary edema, ARDS, diffuse alveolar\\n damage, or even alveolar hemorrhage.\\n 2. Newly placed endotracheal tube, right internal jugular line, and feeding\\n tube, all in satisfactory location.\\n 3. New small left pleural effusion.\\n\\n\\n Case discusses with Dr \\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1019057,\n \"text\": \", J. SICU-B 4:45 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess interval change\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ARDS\\n REASON FOR THIS EXAMINATION:\\n assess interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n PFI: Patient with ARDS, evaluate for change.\\n\\n Stable diffuse air space disease in the right lung while the air space disease\\n in the left lung has slightly started to decrease.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-10 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1019206,\n \"text\": \" 5:16 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ARDS\\n REASON FOR THIS EXAMINATION:\\n eval for interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: ARDS, to evaluate for change.\\n\\n FINDINGS: In comparison with the study of , there is progression of the\\n multifocal alveolar opacifications, especially involving the right mid and\\n lower lung zones. Some prominence of interstitial markings suggests\\n superimposed elevated pulmonary venous pressure. Probable bilateral pleural\\n effusions. The monitoring devices remain in place.\\n\\n IMPRESSION: Worsening appearance primarily involving the right mid and lower\\n lung zones.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1020049,\n \"text\": \" 11:08 AM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: congfirm NGT placement\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ards\\n REASON FOR THIS EXAMINATION:\\n congfirm NGT placement\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB MON 11:58 AM\\n Nasogastric tube terminates in the stomach.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Nasogastric tube placement.\\n\\n Nasogastric tube terminates in the stomach. Approximately 8 mm diameter\\n radiodense foreign body is demonstrated in the left upper quadrant of the\\n abdomen. It is not seen on older radiographs but is identifiable since more\\n recent studies dating to . This could potentially be an\\n aspirated piece of dental hardware if the patient had a traumatic intubation\\n during the hospital course. Appearance of the lungs and pleura are unchanged\\n since the recent radiograph of approximately two hours earlier.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1020050,\n \"text\": \", A. SICU-B 11:08 AM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: congfirm NGT placement\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ards\\n REASON FOR THIS EXAMINATION:\\n congfirm NGT placement\\n ______________________________________________________________________________\\n PFI REPORT\\n Nasogastric tube terminates in the stomach.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-08 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1018811,\n \"text\": \" 4:25 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for interval change, worsening hypoxia\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with sepsis, ards\\n REASON FOR THIS EXAMINATION:\\n eval for interval change, worsening hypoxia\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Sepsis and ARDS.\\n\\n COMPARISON: , and .\\n\\n SEMI UPRIGHT CHEST RADIOGRAPH: A nasogastric tube, endotracheal tube,\\n and right- sided internal jugular central venous line are appropriately\\n positioned. The cardiomediastinal silhouette is unchanged. Again identified\\n are diffuse multifocal alveolar opacities. There has been a mixed response\\n with increased aeration in the left upper lung zone and increased opacity\\n within the right lower lung zones. There is evidence of prior thoracic\\n vertebral body fusion.\\n\\n IMPRESSION: Mixed response of multifocal alveolar opacities improved in the\\n left upper lung zone and worsened within the right lower lung zone.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1019860,\n \"text\": \" 4:43 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess interval change\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ARDS\\n REASON FOR THIS EXAMINATION:\\n assess interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST AT 05:32.\\n\\n COMPARISON STUDY: .\\n\\n CLINICAL INFORMATION: ARDS.\\n\\n FINDINGS:\\n\\n Patient is status thoracic fixation. There is essentially no change in the\\n appearance of the chest since the prior study with the exception of removal of\\n a right IJ catheter. The patient is intubated, and the ET tube terminates\\n somewhat high just above the thoracic inlet. Nasogastric tube courses towards\\n the stomach but the tip is not seen. Left subclavian catheter terminates at\\n the superior vena cava.\\n\\n There is patchy opacification of the right lung base, unchanged, consistent\\n with pneumonia. There is atelectasis versus consolidation at the left lung\\n base with a small left pleural effusion. There is mild cardiomegaly and\\n probable superimposed mild congestive failure.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1018408,\n \"text\": \" 3:15 AM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: Please evaluate for infiltrate or volume overload. Recent CX\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with recent abdominal surgery transferred to the ICU with\\n tachypnea and hypoxia.\\n REASON FOR THIS EXAMINATION:\\n Please evaluate for infiltrate or volume overload. Recent CXR with very poor\\n inspiratory effort limits interpretation.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Recent abdominal surgery with hypoxia.\\n\\n FINDINGS: In comparison with earlier study of this date, the patient has\\n taken a slightly better inspiration. Extensive opacification persists in the\\n right mid and lower lung zones medially. This is consistent with atelectasis\\n or possible supervening pneumonia. There may also be some increased\\n opacification in the retrocardiac region that would be better evaluated by\\n lateral view if this were clinically possible.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-09 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1019056,\n \"text\": \" 4:45 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess interval change\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ARDS\\n REASON FOR THIS EXAMINATION:\\n assess interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): MEz TUE 12:42 PM\\n PFI: Patient with ARDS, evaluate for change.\\n\\n Stable diffuse air space disease in the right lung while the air space disease\\n in the left lung has slightly started to decrease.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: Chest portable AP on .\\n\\n COMPARISON: .\\n\\n HISTORY: 56-year-old man with ARDS, evaluate for interval change.\\n\\n FINDINGS: Again identified are the diffuse multifocal alveolar opacities that\\n have remained stable in the right lung while they have started to decrease in\\n the left lung. The cardiomediastinal silhouette is stable. The nasogastric\\n tube, endotracheal tube, and right-sided internal jugular central venous line\\n are appropriately positioned. There is no pleural effusion. The patient is\\n status post thoracic vertebral body fusion.\\n\\n IMPRESSION: Stable mixed response of multifocal alveolar opacities,pneumonia\\n in the right lung and edema in the left lung.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-13 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 1019766,\n \"text\": \" 8:05 AM\\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \\n Reason: assess position of new left subclavian line\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ARDs, new left subclavian line placement\\n REASON FOR THIS EXAMINATION:\\n assess position of new left subclavian line\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST AT 08:23\\n\\n COMPARISON STUDY: at 04:29\\n\\n CLINICAL INFORMATION: ARDS, new subclavian line placement.\\n\\n FINDINGS:\\n\\n Patient is status post fusion of the thoracic spine. Right IJ catheter\\n terminates in the superior vena cava in appropriate position. Nasogastric\\n tube terminates in the stomach. Again noted is patchy opacification of the\\n right lung and left lung with small left pleural effusion and atelectasis at\\n the left lung base. There is no appreciable change since the prior study.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-22 00:00:00.000\",\n \"description\": \"CT CHEST W/CONTRAST\",\n \"row_id\": 1021285,\n \"text\": \" 6:39 PM\\n CT CHEST W/CONTRAST Clip # \\n Reason: please assess for interval change in abscess.\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with known lung abscess\\n REASON FOR THIS EXAMINATION:\\n please assess for interval change in abscess.\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: RSRc MON 10:57 PM\\n Unchanged B lower lobe consolidations, L > R; left demonstrates low density\\n component. Precarinal lymph node enlargement. -\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 56-year-old man with known lung abscess. Assess for interval\\n change.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: MDCT axial images through the chest were obtained following the\\n administration of intravenous contrast and displayed at 5- and 1.25-mm\\n collimation. A series of sagittal and coronal images were reformatted for\\n review.\\n\\n CT CHEST WITH IV CONTRAST: The lung abscess in the left lower lobe measures\\n 62 x 42 mm (previously 63 x 55 mm). The amount of fluid within the collection\\n has mildly decreased and has been replaced by air/gas. The abscess\\n demonstrates connection with the subsegmental left lower lobe bronchi and\\n likely has two loculated components medially. The remaining diffuse\\n parenchymal abnormalities continue improve. Dense consolidation within the\\n right lower lobe has decreased with some residual consolidation demonstrating\\n central lucency without frank cavitation. Parenchymal consolidation within the\\n right upper lobe as well as diffuse centrilobular nodules and tree-in-\\n opacities have also mildly decreased.\\n\\n Filling defects in the right and left lower lobe segmental and subsegmental\\n pulmonary arteries are consistent with acute pulmonary emboli. There are no\\n enlarged central lymph nodes. The airways are patent to the subsegmental\\n level bilaterally. There are calcifications of the coronary arteries.\\n\\n While not tailored to infradiaphragmatic evaluation, the patient is status\\n post parastomal hernia repair and an open anterior abdominal wall defect with\\n overlying packing material again identified.\\n\\n Patient has undergone prior T6 through T12 fusion as well as prior left\\n thoracotomy.\\n\\n IMPRESSION:\\n\\n 1. Bilateral lower lobe segmental and subsegmental pulmonary emboli.\\n\\n (Over)\\n\\n 6:39 PM\\n CT CHEST W/CONTRAST Clip # \\n Reason: please assess for interval change in abscess.\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n 2. Minimal interval decrease in the size of the left lower lobe lung abscess.\\n\\n 3. Mild improvement in right upper and lower lobe consolidations, as well as\\n diffuse tree-in- opacities.\\n\\n The above findings were discussed with Dr. on .\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-05-31 00:00:00.000\",\n \"description\": \"ABDOMEN (SUPINE & ERECT)\",\n \"row_id\": 1017658,\n \"text\": \" 10:05 AM\\n ABDOMEN (SUPINE & ERECT) Clip # \\n Reason: ?obstruction\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with abd pain, distention\\n REASON FOR THIS EXAMINATION:\\n ?obstruction\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Abdominal pain and distention, evaluate for obstruction.\\n\\n Spinal hardware is again seen.\\n\\n Distended loops of small bowel are present with multiple air-fluid levels on\\n the upright film indicating likely small-bowel obstruction. Some air is seen\\n within non dilated loops which indicates either the obstruction is recent or\\n is incomplete.\\n\\n IMPRESSION: Appearances consistent with small-bowel obstruction either recent\\n or incomplete. Dr. informed.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1018402,\n \"text\": \" 12:51 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please assess for effusion\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man POD 1 s/p parastomal hernia repair now in respiratory distress,\\n crackles on physical exam\\n REASON FOR THIS EXAMINATION:\\n please assess for effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n PROCEDURE: Chest portable AP on .\\n\\n COMPARISON: .\\n\\n HISTORY: 56-year-old man with POD status post stomal hernia repair, no\\n respiratory distress. Crackles on physical examination.\\n\\n FINDINGS: A persistent perihilar opacity with well-defined margin inferiorly\\n is stable on today's examination. The left lung is clear. There is no\\n evidence of pleural effusion at the bases. The heart size is normal.\\n\\n IMPRESSION:\\n 1. Persistent right hilar and infrahilar well-defined opacity likely\\n atelectasis versus aspiration. Pneumonia in the proper clinical setting\\n cannot be completely excluded.\\n 2. No pleural effusion is seen.\\n\\n The case was discussed with Dr. .\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1020016,\n \"text\": \" 9:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess interval change\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ARDS\\n REASON FOR THIS EXAMINATION:\\n assess interval change\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB MON 10:49 AM\\n Coiling of nasogastric tube in cervical region. Slight improved aeration at\\n the lung bases.\\n ______________________________________________________________________________\\n FINAL REPORT\\n PORTABLE CHEST, .\\n \\t\\n COMPARISON: .\\n\\n INDICATION: ARDS.\\n\\n Lines and tubes remain in standard position except for a nasogastric tube.\\n Although the tip terminates in the stomach, there is apparent coiling of the\\n tube in the cervical region, as communicated by phone to Dr. . The exam is\\n mostly without change since the recent study, except for slight improved\\n aeration at the lung bases.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1020017,\n \"text\": \", A. SICU-B 9:10 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess interval change\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with ARDS\\n REASON FOR THIS EXAMINATION:\\n assess interval change\\n ______________________________________________________________________________\\n PFI REPORT\\n Coiling of nasogastric tube in cervical region. Slight improved aeration at\\n the lung bases.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2178-06-23 00:00:00.000\",\n \"description\": \"BILAT LOWER EXT VEINS\",\n \"row_id\": 1021503,\n \"text\": \" 6:10 PM\\n BILAT LOWER EXT VEINS Clip # \\n Reason: R/O LOWER EXTREMITY DVT/PT HAS PULMONARY EMBOLI ? SOURCE\\n Admitting Diagnosis: OBSTRUCTION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 56 year old man with PE's\\n REASON FOR THIS EXAMINATION:\\n r/o lower extremity dvt\\n ______________________________________________________________________________\\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe TUE 7:57 PM\\n No evidence of lower extremity DVT.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 56-year-old man with newly diagnosed bilateral pulmonary emboli.\\n Evaluate for DVT.\\n\\n Comparison is made to ultrasound.\\n\\n BILATERAL LOWER EXTREMITY ULTRASOUND:\\n\\n Grayscale and Doppler son of the right and left common femoral,\\n superficial femoral, deep femoral, and popliteal veins were obtained\\n demonstrating appropriate flow, compressibility, augmentation, and waveforms.\\n Appropriate compression was noted within the tibial veins bilaterally.\\n Appropriate color flow was noted within the peroneal veins bilaterally.\\n\\n IMPRESSION:\\n\\n No evidence of bilateral lower extremity DVT.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2178-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192611,\n \"text\": \"Sinus rhythm. T wave inversion in leads V1-V2 with ST segment depression\\nin these leads. Biphasic T waves in lead V3. These findings are new as\\ncompared with tracing . The rate has slowed. The ST-T wave changes\\nraise the question of anterior ischemia. Followup and clinical correlation are\\nsuggested.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192612,\n \"text\": \"Sinus tachycardia. The P-R interval is short without evidence of\\npre-excitation. Non-specific ST-T wave changes. Compared to the previous\\ntracing there is no significant change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192613,\n \"text\": \"Sinus tachycardia. The P-R interval is 110 milliseconds which is short but\\nwithout evidence of pre-excitation. Non-specific ST-T wave changes. Compared\\nto the previous tracing the rate is faster and the P-R interval is shorter.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2178-06-03 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192614,\n \"text\": \"Sinus bradycardia\\nModest nonspecific precordial/anterior T wave changes\\nSince previous tracing of , sinus bradycardia and modest T wave changes\\nnow present\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2178-06-02 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 192615,\n \"text\": \"Sinus rhythm\\nBorderline prolonged/upper limits of normal Q-Tc interval - is nonspecific -\\nwithin normal limits\\nBaseline artifact in lead V4 -V6 makes assessment difficult\\nClinical correlation is suggested\\nSince previous tracing of , sinus bradycardia absent\\n\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328765,\n \"text\": \"56yo man with PMH of ulcerative colitis s/p total colectomy w/\\n illeostomy in . Admitted to on w/ abd pain and\\n increased ostomy output. Pain remained persistant during admission and\\n pt underwent exploratory laprascopy w/ hernia repair and lysis of\\n adhesions on . pt was febrile to 101.6, tachycardic to\\n and tachypneac. Pt received total of 5 liters IVF in OR/PACU.\\n Pt was transferred to M/SICU for further mgt of tachycardia/tachypnea.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n HR 110-125 ST, no ectopy.\\n SBP 95-110\\n UO 15-30cc/hr, dark amber. Cr 1.2 in PACU.\\n JP drain and ostomy w/ minimal output.\\n Pt states he has\\ndry mouth and is thirsty\\n, NPO at present.\\n Action:\\n Received 2 L IVF bolus overnight.\\n Receiving D5NS 150cc/hr.\\n Received 650mg Tylenol overnight.-\\n Response:\\n Minimal increase in urine output following IVF bolus.\\n HR remains 115-125 ST.\\n 6.5 L positive LOS at present.\\n House staff and surgery aware.\\n Plan:\\n Cont to monitor vitals, intake/output, labs.\\n Cont IV fluid replacement as ordered.\\n ? advance PO intake today.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt c/o pain in abdominal incision and foley cath on dilaudid PCA.\\n c/o nausea, no vomiting.\\n Action:\\n PCA dose increased overnight.\\n Lidocaine urojet applied to foley cath.\\n Received prn dose of zofran.\\n Response:\\n Pain improved to following increase in PCA and urojet.\\n Nausea improved w/ zofran.\\n Plan:\\n Cont to monitor pain level, effectiveness of PCA.\\n Cont to encourage deep breathing/IS as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328838,\n \"text\": \"Mr. is a 56 year old male with history of ulcerative colitis (pt\\n of Dr. failed medical management, s/p colectomy with ileostomy\\n and preservation of rectum 12/. Post operative course was\\n complicated by ileus. He had been doing well post operatively until\\n when he presented to the ED with abdominal pain at the site of the\\n stoma and increased ostomy output. He was admitted to the surgical\\n service and treated conservatively with IVF, NG tube, and NPO. Serial\\n abdominal films showed air fluid levels in the small bowel. Small\\n bowel follow through showed no fistula formation or obstructive point\\n but patient continued to have episodic cramping pain. Due to\\n persistent pain, the patient was consented and taken to the OR for\\n exploratory laparoscopy. He was found to have parastomal hernia and\\n adhesive disease, hernia repair and lysis of adhesions was performed.\\n He was transferred from the PACU here to ICU for monitoring due to\\n tachypnea, tachycardia. He was transferred to 12R as he was\\n stable.\\n .\\n Early this am pt. became tachypneic, tachycardic up to 140\\ns and\\n oliguric. Placed on 100% NRB with good effect. CXR wnl, EKG wnl,\\n Crackles bilat. Given 80mg of lasix and transferred here to ICU for\\n further management.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328759,\n \"text\": \"56yo man with PMH of ulcerative colitis s/p total colectomy w/\\n illeostomy in . Admitted to on w/ abd pain and\\n increased ostomy output. Pain remained persistant during admission and\\n pt underwent exploratory laprascopy w/ hernia repair and lysis of\\n adhesions on . pt was febrile to 101.6, tachycardic to\\n and tachypneac. Pt received total of 5 liters IVF in OR/PACU.\\n Pt was transferred to M/SICU for further mgt of tachycardia/tachypnea.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n HR 110-125 ST, no ectopy.\\n SBP 95-110\\n UO 15-30cc/hr, dark amber. Cr 1.2 in PACU.\\n JP drain and ostomy w/ minimal output.\\n Pt states he has\\ndry mouth and is thirsty\\n, NPO at present.\\n Action:\\n Received 1.5 L IVF bolus overnight.\\n Receiving D5NS 150cc/hr.\\n Received 650mg Tylenol overnight.-\\n Response:\\n Minimal increase in urine output following IVF bolus.\\n HR remains 115-125 ST.\\n 6.5 L positive LOS at present.\\n House staff and surgery aware.\\n Plan:\\n Cont to monitor vitals, intake/output, labs.\\n Cont IV fluid replacement as ordered.\\n ? advance PO intake today.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt c/o pain in abdominal incision and foley cath on dilaudid PCA.\\n c/o nausea, no vomiting.\\n Action:\\n PCA dose increased overnight.\\n Lidocaine urojet applied to foley cath.\\n Received prn dose of zofran.\\n Response:\\n Pain improved to following increase in PCA and urojet.\\n Nausea improved w/ zofran.\\n Plan:\\n Cont to monitor pain level, effectiveness of PCA.\\n Cont to encourage deep breathing/IS as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328757,\n \"text\": \"56yo man with PMH of ulcerative colitis s/p total colectomy w/\\n illeostomy in . Admitted to on w/ abd pain and\\n increased ostomy output. Pain remained persistant during admission and\\n pt underwent exploratory laprascopy w/ hernia repair and lysis of\\n adhesions on . pt was febrile to 101.6, tachycardic to\\n and tachypneac. Pt received total of 5 liters IVF in OR/PACU.\\n Pt was transferred to M/SICU for further mgt.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n HR 110-125 ST, no ectopy.\\n SBP 95-110\\n UO 15-30cc/hr, dark amber. Cr 1.2 in PACU.\\n JP drain and ostomy w/ minimal output.\\n Pt states he has\\ndry mouth and is thirsty\\n Action:\\n Received 1.5 L IVF bolus overnight.\\n Receiving D5NS 150cc/hr.\\n Response:\\n Minimal increase in urine output following IVF bolus.\\n HR remains 115-125 ST.\\n House staff and surgery aware.\\n Plan:\\n Cont to monitor vitals, intake/output, labs.\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt c/o pain in abdominal incision and foley cath on dilaudid PCA.\\n c/o nausea, no vomiting.\\n Action:\\n PCA dose increased overnight.\\n Lidocaine urojet applied to foley cath.\\n Received prn dose of zofran.\\n Response:\\n Pain improved to following increase in PCA and urojet.\\n Nausea improved w/ zofran.\\n Plan:\\n Cont to monitor pain level, effectiveness of PCA.\\n Cont to encourage deep breathing/IS as tolerated.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-06-04 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 328752,\n \"text\": \"Chief Complaint: Xfer from surgery for tachypnea, tachycardia\\n HPI:\\n Mr. is a 56 year old male with history of ulcerative colitis (pt\\n of Dr. failed medical management, s/p colectomy with ileostomy\\n and preservation of rectum 12/. Post operative course was\\n complicated by ileus. He had been doing well post operatively until\\n when he presented to the ED with abdominal pain at the site of the\\n stoma and increased ostomy output. He was admitted to the surgical\\n service and treated conservatively with IVF, NG tube, and NPO. Serial\\n abdominal films showed air fluid levels in the small bowel. Small\\n bowel follow through showed no fistula formation or obstructive point\\n but patient continued to have episodic cramping pain. Due to\\n persistent pain, the patient was consented and taken to the OR today\\n for exploratory laparoscopy. He was found to have parastomal hernia\\n and adhesive disease, hernia repair and lysis of adhesions was\\n performed. Estimated blood loss was minimal. He was given 2700 IVF\\n however had 55cc urine output. He is being transferred from the PACU\\n for monitoring due to tachypnea, tachycardia.\\n .\\n On arrival to the the patient is somnolent but arousable. He has\\n dilaudid PCA within reach. He denies pain at rest but has pain\\n with any movement. He denies fevers, chills, shortness of breath,\\n nausea, chest pain or palpitations. He states that he is thirsty.\\n Patient admitted from: OR / PACU\\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 Celexa 10mg daily\\n Aciphex 20mg daily\\n Atenolol 25mg daily\\n Aldactone 25mg daily\\n Norvasc 2.5mg daily\\n Past medical history:\\n Family history:\\n Social History:\\n (taken from surgical admission note)\\n Hypertension\\n Depression\\n Ulcerative colitis as above, history of chronic steroid use\\n GERD\\n MSSA bacteremia\\n T10 diskitis\\n Multiple spine surgeries: Fusion T6-T12\\n Multiple thoracic laminetomies\\n Partial vertebrectomy of T10-T11\\n Hyperlipidemia\\n History of PE\\n C diff\\n Hemochromatosis\\n s/p arthroscopic knee surgery\\n Non-contributory\\n Occupation: Does not work\\n Drugs: None\\n Tobacco: None\\n Alcohol: None\\n Other: Married with two children\\n Review of systems:\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\\n Respiratory: No(t) Dyspnea, No(t) Wheeze\\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis\\n Genitourinary: Foley\\n Psychiatric / Sleep: No(t) Agitated\\n Pain: No pain / appears comfortable\\n Pain location: Pain with movement\\n Flowsheet Data as of 12:33 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: 38\\nC (100.4\\n HR: 125 (125 - 125) bpm\\n BP: 102/66(74) {96/66(74) - 102/66(74)} mmHg\\n RR: 34 (29 - 34) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 68 Inch\\n Total In:\\n 6,218 mL\\n 4 mL\\n PO:\\n TF:\\n IVF:\\n 6,218 mL\\n 4 mL\\n Blood products:\\n Total out:\\n 875 mL\\n 32 mL\\n Urine:\\n 120 mL\\n 32 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 5,343 mL\\n -29 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, No(t) Overweight\\n / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, very dry mm, JVP flat\\n Cardiovascular: (S1: Normal, Absent), tachycardic\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : )\\n Abdominal: Soft, No(t) Non-tender, Tender: to palpation diffusely,\\n Obese, Soft, ND, tender to palpation diffusely across abdomen,\\n ileostomy intact with no drainage, hypoactive BS. JP drain in place\\n with minimal output. Dressing c/d/i.\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\\n Clubbing\\n Skin: Warm\\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\\n Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 226\\n 125\\n 1.2\\n 24\\n 22\\n 102\\n 3.1\\n 137\\n 39.1\\n 6.4\\n [image002.jpg]\\n Other labs: PT / PTT / INR:14/23/1.2, Ca++:9.0, Mg++:2.4, PO4:3.1\\n Imaging: SB follow through: FINDINGS: Thin barium was orally\\n ingested for this small bowel follow-through\\n study. Overhead radiographs and fluoroscopic images show filling of the\\n bowel loops after about approximately three hours. There is likely\\n fluid in the\\n bowel loops as the contrast appears markedly diluted. The small bowel\\n is\\n dilated in some regions measuring up to 5.7 cm. There is no transition\\n point\\n identified, no obvious fistula formation with no apparent leak or area\\n of\\n stricture as barium visibly made it to the patient's ostomy bag.\\n IMPRESSION: Ingested oral contrast found in the ostomy bag after slight\\n motility delay with dilated small bowel loops with no obvious fistula\\n formation or obstruction.\\n KUB: Distended loops of small bowel are present with multiple\\n air-fluid levels on the upright film indicating likely small-bowel\\n obstruction. Some air is seen within non dilated loops which indicates\\n either the obstruction is recent or is incomplete.\\n IMPRESSION: Appearances consistent with small-bowel obstruction either\\n recent or incomplete. Dr. informed.\\n Microbiology: Urine culture: Negative\\n Assessment and Plan\\n Mr. is a 56 year old male with history of UC s/p colectomy and\\n ileostomy () who presented on with SBO and parastomal\\n hernia now s/p LOA and parastomal hernia repair transferred to for\\n tachypnea.\\n .\\n # Tachypnea: Upon arrival to patient RR 29-30. He is somnolent\\n but arousable with shallow breaths, likely has atelectasis.\\n - Continue supplemental O2.\\n - Would like to try incentive spirometry however patient limited due to\\n pain.\\n - Treat pain with dilaudid PCA\\n - Consider CXR in the AM\\n .\\n # Tachycardia: Likely multifactorial due to pain, fever, dehydration as\\n well as withdrawal from daily atenolol. Patient stated that he is\\n thirsty and has very dry MM. Had poor UOP during case which picked up\\n after 3L IVF.\\n - Continue with IVF to catch up and then continue with maintenance\\n fluids. Normal EF on echocardiogram in 04/.\\n - Tylenol for fever\\n - Dilaudid PCA to treat pain\\n - Continue with IV metoprolol per surgery\\n .\\n # s/p laparoscopy, parastomal hernia repair: POD1. Site appears clean,\\n dry, intact. Tender at surgical site. JP drain in place.\\n - NPO, IVF bolus plus maintenance. Has low grade fever post op.\\n - Continue PCA\\n - No antibiotics per surgery\\n - Anticoagulation with heparin subq\\n - Surgery recs in the AM.\\n - Monitor JP drain output.\\n - Continue PPI, ondansetron\\n - Will continue to monitor fever curve. be related to\\n atelectasis. Will hold on abx for now per surgical team.\\n .\\n # Acute renal failure: Presented with acute renal failure which was\\n attributed to ileostomy losses, now resolved with fluids. Urine lytes\\n on appear prerenal.\\n - Continue to monitor and give IVF as above. Follow urine output\\n overnight.\\n .\\n # Hypertension: Not active issue.\\n - Plan to start PO meds once patient's diet is advanced. As outpatient\\n he is on Atenolol, Aldactone, Norvasc.\\n .\\n # Depression:\\n - Continue celexa once able to tolerate PO\\n .\\n #FEN\\n - Hypokalemia: Arrived to with K replacement hanging. Will\\n recheck in the AM and replete lytes PRN\\n .\\n #ACCESS: PIV\\n .\\n #PPx\\n - Heparin sub-q for DVT prophylaxis\\n - replete lytes PRN\\n - PPI IV convert to PO once able.\\n - bowel meds\\n .\\n #CODE: FULL\\n .\\n #COMMUNICATION: patient, medical records\\n .\\n #DISPO: ICU, likely call out to the floor in the AM.\\n ICU Care\\n Nutrition:\\n Comments: NPO as diet overnight\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 11:00 PM\\n Prophylaxis:\\n DVT: Boots, 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\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-06-04 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 328755,\n \"text\": \"Chief Complaint: Xfer from surgery for tachypnea, tachycardia\\n HPI:\\n Mr. is a 56 year old male with history of ulcerative colitis (pt\\n of Dr. failed medical management, s/p colectomy with ileostomy\\n and preservation of rectum 12/. Post operative course was\\n complicated by ileus. He had been doing well post operatively until\\n when he presented to the ED with abdominal pain at the site of the\\n stoma and increased ostomy output. He was admitted to the surgical\\n service and treated conservatively with IVF, NG tube, and NPO. Serial\\n abdominal films showed air fluid levels in the small bowel. Small\\n bowel follow through showed no fistula formation or obstructive point\\n but patient continued to have episodic cramping pain. Due to\\n persistent pain, the patient was consented and taken to the OR today\\n for exploratory laparoscopy. He was found to have parastomal hernia\\n and adhesive disease, hernia repair and lysis of adhesions was\\n performed. Estimated blood loss was minimal. He was given 2700 IVF\\n however had 55cc urine output. He is being transferred from the PACU\\n for monitoring due to tachypnea, tachycardia.\\n .\\n On arrival to the the patient is somnolent but arousable. He has\\n dilaudid PCA within reach. He denies pain at rest but has pain\\n with any movement. He denies fevers, chills, shortness of breath,\\n nausea, chest pain or palpitations. He states that he is thirsty.\\n Patient admitted from: OR / PACU\\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 Celexa 10mg daily\\n Aciphex 20mg daily\\n Atenolol 25mg daily\\n Aldactone 25mg daily\\n Norvasc 2.5mg daily\\n Past medical history:\\n Family history:\\n Social History:\\n (taken from surgical admission note)\\n Hypertension\\n Depression\\n Ulcerative colitis as above, history of chronic steroid use\\n GERD\\n MSSA bacteremia\\n T10 diskitis\\n Multiple spine surgeries: Fusion T6-T12\\n Multiple thoracic laminetomies\\n Partial vertebrectomy of T10-T11\\n Hyperlipidemia\\n History of PE\\n C diff\\n Hemochromatosis\\n s/p arthroscopic knee surgery\\n Non-contributory\\n Occupation: Does not work\\n Drugs: None\\n Tobacco: None\\n Alcohol: None\\n Other: Married with two children\\n Review of systems:\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\\n Respiratory: No(t) Dyspnea, No(t) Wheeze\\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis\\n Genitourinary: Foley\\n Psychiatric / Sleep: No(t) Agitated\\n Pain: No pain / appears comfortable\\n Pain location: Pain with movement\\n Flowsheet Data as of 12:33 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: 38\\nC (100.4\\n HR: 125 (125 - 125) bpm\\n BP: 102/66(74) {96/66(74) - 102/66(74)} mmHg\\n RR: 34 (29 - 34) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 68 Inch\\n Total In:\\n 6,218 mL\\n 4 mL\\n PO:\\n TF:\\n IVF:\\n 6,218 mL\\n 4 mL\\n Blood products:\\n Total out:\\n 875 mL\\n 32 mL\\n Urine:\\n 120 mL\\n 32 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 5,343 mL\\n -29 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, No(t) Overweight\\n / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, very dry mm, JVP flat\\n Cardiovascular: (S1: Normal, Absent), tachycardic\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : )\\n Abdominal: Soft, No(t) Non-tender, Tender: to palpation diffusely,\\n Obese, Soft, ND, tender to palpation diffusely across abdomen,\\n ileostomy intact with no drainage, hypoactive BS. JP drain in place\\n with minimal output. Dressing c/d/i.\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\\n Clubbing\\n Skin: Warm\\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\\n Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 226\\n 125\\n 1.2\\n 24\\n 22\\n 102\\n 3.1\\n 137\\n 39.1\\n 6.4\\n [image002.jpg]\\n Other labs: PT / PTT / INR:14/23/1.2, Ca++:9.0, Mg++:2.4, PO4:3.1\\n Imaging: SB follow through: FINDINGS: Thin barium was orally\\n ingested for this small bowel follow-through\\n study. Overhead radiographs and fluoroscopic images show filling of the\\n bowel loops after about approximately three hours. There is likely\\n fluid in the\\n bowel loops as the contrast appears markedly diluted. The small bowel\\n is\\n dilated in some regions measuring up to 5.7 cm. There is no transition\\n point\\n identified, no obvious fistula formation with no apparent leak or area\\n of\\n stricture as barium visibly made it to the patient's ostomy bag.\\n IMPRESSION: Ingested oral contrast found in the ostomy bag after slight\\n motility delay with dilated small bowel loops with no obvious fistula\\n formation or obstruction.\\n KUB: Distended loops of small bowel are present with multiple\\n air-fluid levels on the upright film indicating likely small-bowel\\n obstruction. Some air is seen within non dilated loops which indicates\\n either the obstruction is recent or is incomplete.\\n IMPRESSION: Appearances consistent with small-bowel obstruction either\\n recent or incomplete. Dr. informed.\\n Microbiology: Urine culture: Negative\\n Assessment and Plan\\n Mr. is a 56 year old male with history of UC s/p colectomy and\\n ileostomy () who presented on with SBO and parastomal\\n hernia now s/p LOA and parastomal hernia repair transferred to for\\n tachypnea.\\n .\\n # Tachycardia: Likely multifactorial due to pain, fever, dehydration as\\n well as withdrawal from daily atenolol. Patient stated that he is\\n thirsty and has very dry MM. Had poor UOP during case which picked up\\n slightly after 3L IVF.\\n - Continue with maintenance IVF per surgery. They would like no\\n additional fluids\\n only maintenance. Concern because patient got so\\n much fluid in OR as well as in PACU.\\n - Tylenol for fever\\n - Dilaudid PCA to treat pain\\n - Continue with IV metoprolol per surgery\\n - Monitor on telemetry. Per surgery ok for HR 110-120s.\\n .\\n # Tachypnea: Upon arrival to patient RR 29-30. He is somnolent\\n but arousable with shallow breathing. No evidence of respiratory\\n distress.\\n - Continue supplemental O2.\\n - Would like to try incentive spirometry however patient limited due to\\n pain.\\n - Treat pain with dilaudid PCA\\n - Consider CXR in the AM as patient has received multiple liters of IVF\\n over the day.\\n .\\n # s/p laparoscopy, parastomal hernia repair: POD1. Site appears clean,\\n dry, intact. Tender at surgical site. JP drain in place.\\n - NPO, IVF maintenance only as above. Has low grade fever post op.\\n - Continue PCA\\n - No antibiotics per surgery\\n - Anticoagulation with heparin subq\\n - Surgery recs in the AM.\\n - Monitor JP drain output, ostomy output. Match output from ostomy 1cc\\n to 1cc with NS.\\n - Continue PPI, ondansetron\\n - Will continue to monitor fever curve, WBC count. be related to\\n atelectasis. Will hold on abx for now per surgical team.\\n .\\n # Acute renal failure: Presented with acute renal failure which was\\n attributed to ileostomy losses, now resolved with fluids. Urine lytes\\n on appear prerenal.\\n - Continue to monitor and give IVF as above. Follow urine output\\n overnight.\\n .\\n # Hypertension: Not active issue.\\n - Plan to start PO meds once patient's diet is advanced. As outpatient\\n he is on Atenolol, Aldactone, Norvasc.\\n .\\n # Depression:\\n - Continue celexa once able to tolerate PO\\n .\\n #FEN\\n - Hypokalemia: Arrived to with K replacement hanging. Will\\n recheck in the AM and replete lytes PRN\\n .\\n #ACCESS: PIV\\n .\\n #PPx\\n - Heparin sub-q for DVT prophylaxis\\n - replete lytes PRN\\n - PPI IV convert to PO once able.\\n - bowel meds\\n .\\n #CODE: FULL\\n .\\n #COMMUNICATION: patient, medical records\\n .\\n #DISPO: ICU, likely call out to the floor in the AM.\\n ICU Care\\n Nutrition:\\n Comments: NPO as diet overnight\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 11:00 PM\\n Prophylaxis:\\n DVT: Boots, 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\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-04 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328756,\n \"text\": \"56yo man with PMH of ulcerative colitis s/p total colectomy w/\\n illeostomy in . Admitted to on w/ abd pain and\\n increased ostomy output. Pain remained persistant during admission and\\n pt underwent exploratory laprascopy w/ hernia repair and lysis of\\n adhesions on . pt was febrile to 101.6, tachycardic to\\n and tachypneac. Pt received total of 5 liters IVF in OR/PACU.\\n Pt was transferred to M/SICU for further mgt.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-06-04 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 328813,\n \"text\": \"Chief Complaint: Xfer from surgery for tachypnea, tachycardia\\n HPI:\\n Mr. is a 56 year old male with history of ulcerative colitis (pt\\n of Dr. failed medical management, s/p colectomy with ileostomy\\n and preservation of rectum 12/. Post operative course was\\n complicated by ileus. He had been doing well post operatively until\\n when he presented to the ED with abdominal pain at the site of the\\n stoma and increased ostomy output. He was admitted to the surgical\\n service and treated conservatively with IVF, NG tube, and NPO. Serial\\n abdominal films showed air fluid levels in the small bowel. Small\\n bowel follow through showed no fistula formation or obstructive point\\n but patient continued to have episodic cramping pain. Due to\\n persistent pain, the patient was consented and taken to the OR today\\n for exploratory laparoscopy. He was found to have parastomal hernia\\n and adhesive disease, hernia repair and lysis of adhesions was\\n performed. Estimated blood loss was minimal. He was given 2700 IVF\\n however had 55cc urine output. He is being transferred from the PACU\\n for monitoring due to tachypnea, tachycardia.\\n .\\n On arrival to the the patient is somnolent but arousable. He has\\n dilaudid PCA within reach. He denies pain at rest but has pain\\n with any movement. He denies fevers, chills, shortness of breath,\\n nausea, chest pain or palpitations. He states that he is thirsty.\\n Patient admitted from: OR / PACU\\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 Celexa 10mg daily\\n Aciphex 20mg daily\\n Atenolol 25mg daily\\n Aldactone 25mg daily\\n Norvasc 2.5mg daily\\n Past medical history:\\n Family history:\\n Social History:\\n (taken from surgical admission note)\\n Hypertension\\n Depression\\n Ulcerative colitis as above, history of chronic steroid use\\n GERD\\n MSSA bacteremia\\n T10 diskitis\\n Multiple spine surgeries: Fusion T6-T12\\n Multiple thoracic laminetomies\\n Partial vertebrectomy of T10-T11\\n Hyperlipidemia\\n History of PE\\n C diff\\n Hemochromatosis\\n s/p arthroscopic knee surgery\\n Non-contributory\\n Occupation: Does not work\\n Drugs: None\\n Tobacco: None\\n Alcohol: None\\n Other: Married with two children\\n Review of systems:\\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\\n Respiratory: No(t) Dyspnea, No(t) Wheeze\\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis\\n Genitourinary: Foley\\n Psychiatric / Sleep: No(t) Agitated\\n Pain: No pain / appears comfortable\\n Pain location: Pain with movement\\n Flowsheet Data as of 12:33 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: 38\\nC (100.4\\n HR: 125 (125 - 125) bpm\\n BP: 102/66(74) {96/66(74) - 102/66(74)} mmHg\\n RR: 34 (29 - 34) insp/min\\n SpO2: 95%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 68 Inch\\n Total In:\\n 6,218 mL\\n 4 mL\\n PO:\\n TF:\\n IVF:\\n 6,218 mL\\n 4 mL\\n Blood products:\\n Total out:\\n 875 mL\\n 32 mL\\n Urine:\\n 120 mL\\n 32 mL\\n NG:\\n Stool:\\n Drains:\\n Balance:\\n 5,343 mL\\n -29 mL\\n Respiratory\\n O2 Delivery Device: Nasal cannula\\n SpO2: 95%\\n Physical Examination\\n General Appearance: Well nourished, No acute distress, No(t) Overweight\\n / Obese\\n Eyes / Conjunctiva: PERRL\\n Head, Ears, Nose, Throat: Normocephalic, very dry mm, JVP flat\\n Cardiovascular: (S1: Normal, Absent), tachycardic\\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\\n (Breath Sounds: Clear : )\\n Abdominal: Soft, No(t) Non-tender, Tender: to palpation diffusely,\\n Obese, Soft, ND, tender to palpation diffusely across abdomen,\\n ileostomy intact with no drainage, hypoactive BS. JP drain in place\\n with minimal output. Dressing c/d/i.\\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\\n Clubbing\\n Skin: Warm\\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\\n Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\\n Labs / Radiology\\n 226\\n 125\\n 1.2\\n 24\\n 22\\n 102\\n 3.1\\n 137\\n 39.1\\n 6.4\\n [image002.jpg]\\n Other labs: PT / PTT / INR:14/23/1.2, Ca++:9.0, Mg++:2.4, PO4:3.1\\n Imaging: SB follow through: FINDINGS: Thin barium was orally\\n ingested for this small bowel follow-through\\n study. Overhead radiographs and fluoroscopic images show filling of the\\n bowel loops after about approximately three hours. There is likely\\n fluid in the\\n bowel loops as the contrast appears markedly diluted. The small bowel\\n is\\n dilated in some regions measuring up to 5.7 cm. There is no transition\\n point\\n identified, no obvious fistula formation with no apparent leak or area\\n of\\n stricture as barium visibly made it to the patient's ostomy bag.\\n IMPRESSION: Ingested oral contrast found in the ostomy bag after slight\\n motility delay with dilated small bowel loops with no obvious fistula\\n formation or obstruction.\\n KUB: Distended loops of small bowel are present with multiple\\n air-fluid levels on the upright film indicating likely small-bowel\\n obstruction. Some air is seen within non dilated loops which indicates\\n either the obstruction is recent or is incomplete.\\n IMPRESSION: Appearances consistent with small-bowel obstruction either\\n recent or incomplete. Dr. informed.\\n Microbiology: Urine culture: Negative\\n Assessment and Plan\\n Mr. is a 56 year old male with history of UC s/p colectomy and\\n ileostomy () who presented on with SBO and parastomal\\n hernia now s/p LOA and parastomal hernia repair transferred to for\\n tachypnea.\\n .\\n # Tachycardia: Likely multifactorial due to pain, fever, dehydration as\\n well as withdrawal from daily atenolol. Patient stated that he is\\n thirsty and has very dry MM. Had poor UOP during case which picked up\\n slightly after 3L IVF.\\n - Continue with maintenance IVF per surgery. They would like no\\n additional fluids\\n only maintenance. Concern because patient got so\\n much fluid in OR as well as in PACU.\\n - Tylenol for fever\\n - Dilaudid PCA to treat pain\\n - Continue with IV metoprolol per surgery\\n - Monitor on telemetry. Per surgery ok for HR 110-120s.\\n .\\n # Tachypnea: Upon arrival to patient RR 29-30. He is somnolent\\n but arousable with shallow breathing. No evidence of respiratory\\n distress.\\n - Continue supplemental O2.\\n - Would like to try incentive spirometry however patient limited due to\\n pain.\\n - Treat pain with dilaudid PCA\\n - Consider CXR in the AM as patient has received multiple liters of IVF\\n over the day.\\n .\\n # s/p laparoscopy, parastomal hernia repair: POD1. Site appears clean,\\n dry, intact. Tender at surgical site. JP drain in place.\\n - NPO, IVF maintenance only as above. Has low grade fever post op.\\n - Continue PCA\\n - No antibiotics per surgery\\n - Anticoagulation with heparin subq\\n - Surgery recs in the AM.\\n - Monitor JP drain output, ostomy output. Match output from ostomy 1cc\\n to 1cc with NS.\\n - Continue PPI, ondansetron\\n - Will continue to monitor fever curve, WBC count. be related to\\n atelectasis. Will hold on abx for now per surgical team.\\n .\\n # Acute renal failure: Presented with acute renal failure which was\\n attributed to ileostomy losses, now resolved with fluids. Urine lytes\\n on appear prerenal.\\n - Continue to monitor and give IVF as above. Follow urine output\\n overnight.\\n .\\n # Hypertension: Not active issue.\\n - Plan to start PO meds once patient's diet is advanced. As outpatient\\n he is on Atenolol, Aldactone, Norvasc.\\n .\\n # Depression:\\n - Continue celexa once able to tolerate PO\\n .\\n #FEN\\n - Hypokalemia: Arrived to with K replacement hanging. Will\\n recheck in the AM and replete lytes PRN\\n .\\n #ACCESS: PIV\\n .\\n #PPx\\n - Heparin sub-q for DVT prophylaxis\\n - replete lytes PRN\\n - PPI IV convert to PO once able.\\n - bowel meds\\n .\\n #CODE: FULL\\n .\\n #COMMUNICATION: patient, medical records\\n .\\n #DISPO: ICU, likely call out to the floor in the AM.\\n ICU Care\\n Nutrition:\\n Comments: NPO as diet overnight\\n Glycemic Control:\\n Lines:\\n 22 Gauge - 11:00 PM\\n Prophylaxis:\\n DVT: Boots, 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 ------ 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.\\n Very well appearing on my exam this morning. Sleepy but easily\\n arousable. Comfortable on pain regimen. Lungs CTA. No further need for\\n ICU level care.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 17:10 ------\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 328903,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 1\\n Ideal body weight: 69.9 None\\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\\n Airway\\n Airway Placement Data\\n Known difficult intubation: No\\n Procedure location: OR\\n Reason:\\n Tube Type\\n ETT:\\n Position: 23 cm at teeth\\n Route:\\n Type: Standard\\n Size: 7.5mm\\n Tracheostomy tube:\\n Type:\\n Manufacturer:\\n Size:\\n PMV:\\n Cuff Management:\\n Vol/Press:\\n Cuff pressure: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Clear\\n RUL Lung Sounds: Clear\\n LUL Lung Sounds: Clear\\n LLL Lung Sounds: 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: Nasal flaring, Accessory muscle\\n use, Tachypneic (RR> 35 b/min), Gasping efforts, Intercostal\\n retractions, Active exhalations\\n Assessment of breathing comfort: No response (sleeping / sedated)\\n Non-invasive ventilation assessment:\\n Invasive ventilation assessment:\\n Trigger work assessment:\\n Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Utilize ARDSnet protocol\\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 Recruitment Maneuvers Done\\n CPAP pressure used: 35 cm H2O\\n Duration: 30 sec\\n Times per shift: 2\\n Comments: poorly tolerated decreased bp.\\n Multiple vent changes through out shift , please see metavision.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 328905,\n \"text\": \"Clinician: Attending\\n Spoke with Dr who requests that all management issues for Mr\\n are handled only by the surgical service. MICU residents will be\\n available for emergency backup, but will not be called for management\\n issues and pt will not be rounded on by MICU team or seen by MICU\\n attending. Pt will transfer to SICU as soon as it is safe for .\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328906,\n \"text\": \"56yo male POD #2 for exploratory lap w/ hernia repair, back to OR for\\n ?acute abdomen, bladder pressure of 40. No apparent intra peritoneal\\n process , tube placed, had edematous bowel and 3L fluid in\\n abdomen removed. ? aspiration -> bronched -> no significant\\n secretions, BAL sent. Abdomen decompressed, bladder pressures 23-25.\\n Acidosis, Metabolic\\n Assessment:\\n Pt returned from OR at ~ 0900, intubated with poor ABG\\ns despite fiO2\\n of 100%. Lactate 4.2\\n Action:\\n Multiple changes made to vent throughout the day with plan to follow\\n ARDS protocol. Presently is on AC 550X32X100%X15 with ABG\\n 7.30/45/71/-3. Given bicarb gtt 150meq/1000 D5W at 150/hr and total of\\n 5L LR.\\n Response:\\n ABG\\ns as above.\\n Plan:\\n Monitor ABG\\ns frequently and adjust vent accordingly following ARDS\\n guidelines.\\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\\n Assessment:\\n Persistent hypoxemia and hypercapnia despite high fiO2 and peeps. CXR\\n -> bilat patchy infiltrates esp L upper lobe; TTE showed pulm embolism\\n unlikely but has some pulmonary hypertension, LENI\\ns also negative.\\n Lung sounds are clear throughout, diminished LLL. No secretions noted.\\n Action:\\n Vent settings adjusted as above with satisfactory ABG\\ns, given total of\\n 5L of IVF today for hypotension and low urine output. Triadyne bed\\n ordered for proning but so far not needed. Sedation changed from\\n propofol to fent/versed 50/2 but resp pattern is shallow, labored and\\n disynchronous so fent increased to 75mcg.\\n Response:\\n Resp status unstable.\\n Plan:\\n Prone pt if does not improve, titrate sedation to keep respirations\\n unlabored without dropping BP,\\n Sepsis without organ dysfunction\\n Assessment:\\n No infectious source identified so far. Tmax 99.7, lactate 4.2\\n Action:\\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\\n flagyl/levo/vanc.\\n Response:\\n Pending.\\n Plan:\\n Monitor temp, wbc\\ns, lactate. Follow cultures, continue abx until\\n sensitivities available.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n ABP\\ns 70\\ns-130/ 50-70\\ns, HR 118-128 ST no ectopy, CVP 10-16\\n Action:\\n Phenylephrine gtt titrated throughout the day, was maxed for a short\\n time but presently is at .9mcg/kg/min. Received total 5L LR, 25gm\\n albumin, 1L D5W w/ 150meq bicarb.\\n Response:\\n Presently ABP\\ns are 100\\ns/ 60\\ns, fluid status is +4L, urine output is\\n 40-200cc/hr.\\n Plan:\\n Titrate neo to map >60, wean if possible, monitor fluid status, give 1L\\n LR boluses for low urine output and hypotension.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328907,\n \"text\": \"56yo male POD #2 for exploratory lap w/ hernia repair, back to OR for\\n ?acute abdomen, bladder pressure of 40. No apparent intra peritoneal\\n process , tube placed, had edematous bowel and 3L fluid in\\n abdomen removed. ? aspiration -> bronched -> no significant\\n secretions, BAL sent. Abdomen decompressed, bladder pressures 23-25.\\n Acidosis, Metabolic\\n Assessment:\\n Pt returned from OR at ~ 0900, intubated with poor ABG\\ns despite fiO2\\n of 100%. Lactate 4.2\\n Action:\\n Multiple changes made to vent throughout the day with plan to follow\\n ARDS protocol. Presently is on AC 550X32X100%X15 with ABG\\n 7.30/45/71/-3. Given bicarb gtt 150meq/1000 D5W at 150/hr and total of\\n 5L LR.\\n Response:\\n ABG\\ns as above.\\n Plan:\\n Monitor ABG\\ns frequently and adjust vent accordingly following ARDS\\n guidelines.\\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\\n Assessment:\\n Persistent hypoxemia and hypercapnia despite high fiO2 and peeps. CXR\\n -> bilat patchy infiltrates esp L upper lobe; TTE showed pulm embolism\\n unlikely but has some pulmonary hypertension, LENI\\ns also negative.\\n Lung sounds are clear throughout, diminished LLL. No secretions noted.\\n Action:\\n Vent settings adjusted as above with satisfactory ABG\\ns, given total of\\n 5L of IVF today for hypotension and low urine output. Triadyne bed\\n ordered for proning but so far not needed. Sedation changed from\\n propofol to fent/versed 50/2 but resp pattern is shallow, labored and\\n disynchronous so fent increased to 75mcg.\\n Response:\\n Resp status unstable.\\n Plan:\\n Prone pt if does not improve, titrate sedation to keep respirations\\n unlabored without dropping BP,\\n Sepsis without organ dysfunction\\n Assessment:\\n No infectious source identified so far. Tmax 99.7, lactate 4.2\\n Action:\\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\\n flagyl/levo/vanc.\\n Response:\\n Pending.\\n Plan:\\n Monitor temp, wbc\\ns, lactate. Follow cultures, continue abx until\\n sensitivities available.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n ABP\\ns 70\\ns-130/ 50-70\\ns, HR 118-128 ST no ectopy, CVP 10-16\\n Action:\\n Phenylephrine gtt titrated throughout the day, was maxed for a short\\n time but presently is at .9mcg/kg/min. Received total 5L LR, 25gm\\n albumin, 1L D5W w/ 150meq bicarb.\\n Response:\\n Presently ABP\\ns are 100\\ns/ 60\\ns, fluid status is +4L, urine output is\\n 40-200cc/hr.\\n Plan:\\n Titrate neo to map >60, wean if possible, monitor fluid status, give 1L\\n LR boluses for low urine output and hypotension.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"ICU Attending Note\",\n \"row_id\": 328885,\n \"text\": \"Clinician: Attending\\n 56 yo man with colitis, presumed UC, colectomy , adm with\\n high ostomy output and abd pain. Ostomy output attributed to bowel wall\\n edema and poor absorption. In MICU with transient tachypnea and\\n tachycardia but not hypoxemia following hernia repair and ex-lap. Was\\n persistantly tachycardic, likely dehydrated. Tachypnea resolved\\n overnight, transferred back to surgical floor yesterday morning. Total\\n 6L net + over 24 h, with decreasing urine output finally to < 10cc/h.\\n WBC rose 6--> 26--> 38K with 20% bandemia. Resp distress with\\n tachypnea, 7.39/35/81 on NRB. Tranferred to MICU. Initial mental status\\n normal, becamse confused within hours. Increasing oxygen requirement.\\n 7.39/34/65 on NRB, lactate 3.0. Lung exam with dffuse crackles.\\n Oliguric with no response to lasix. Concern for abd distension, bladder\\n pressure was 40 mm Hg. Initial CXR showed low lung volumes but no sig\\n parenchymal process, right mid lung zone atelectasis. Went to OR got\\n right IJ, art line, found to have edematous bowel, stomach had 3L\\n fluid. Bowel decompressed. Bronch with no sig secretions, BAL done.\\n Since surgery hypoxia progressed. Severe metabolic acidosis. CXR with\\n bilateral patchy infiltrates esp left upper lung field. Sedated on\\n propofol. Hypotensive with 87/64, MAP 71. SpO2 88% on FiO2 1.0, PEEP 15\\n TV 450 RR 35 PIP 35 Plateau 26 Compliance 45. Abdomen distension much\\n improved.\\n 7.13/63/70 on rate 26.\\n HCo3 22, gap 15. BUN/Cr 39/2.5 (inc from 1.4 yest). WBC 25K. Hct 42%.\\n LFTs wnl. INR 1.6. Lactate rose to 4.5.\\n Severely critically ill with ARDS, septic shock, unclear if he had\\n aspiration event or secondary to sepsis, abd surgery. Now oliguric,\\n hypotensive, requiring max vent support. Bladder pressure decreased\\n from 40 to 25 after decompression. Broad abx, no cx data yet.\\n flagyl/levo/vanc to cover bowel and lung sources. ARDSnet but pushing\\n PEEP for continued hypoxia. Permissive hypercapnia, and RR raised for\\n acidemia, but will give bicarb if repeat ABG shows no correction of pH.\\n Trying right side down to try to improve V/Q mismatch. Will likely\\n switch to PCV to improve oxygenation if ineffective.\\n Patient is critically ill.\\n ------ Protected Section ------\\n Spoke with Dr , who told me there is no contraindication\\n to proning, if that becomes necessary.\\n Bicarb infusion.\\n Phenylephrine now at 2.5mcg/kg/min.\\n Placing esophageal balloon, as abd pressure suggested he will need much\\n higher PEEP.\\n Time spent 80 minutes.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 11:29 ------\\n Remains critically ill with ARDS, septic shock. pH improved now at 7.30\\n on PRVC vent, PEEP 15, Vt at 4.5cc/kg. Received 5L crystalloid, with\\n good urine output and CVP 15 (though high PEEP). Remains on\\n phenylephrine, but down to 0.9. Highly doubt PE given that we have a\\n good reason for hypoxic resp failure given cxr and ARDS physiology, I\\n suspect aspiration event. I feel risk of empiric heparin outweighs\\n theoretical benefit, despite h/o PE 1 year ago. Repeat coags pending.\\n Echo result pending but on my review RV appeared to contract well and\\n have reasonably normal chamber size.\\n Time: additional 60 minutes.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 16:30 ------\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-04 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 328782,\n \"text\": \"Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n Hernia, other\\n Assessment:\\n Action:\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328898,\n \"text\": \"56yo male POD #2 for exploratory lap w/ hernia repair, back to OR for\\n ?acute abdomen, bladder pressure of 40. No intra peritoneal process ,\\n tube placed, had edematous bowel and 3L fluid in abdomen. ?\\n aspiration -> bronched -> no significant secretions, BAL sent. Abdomen\\n decompressed, bladder pressures 23-25.\\n Acidosis, Metabolic\\n Assessment:\\n Pt returned from OR at ~ 0900, intubated with poor ABG\\ns despite fiO2\\n of 100%. Lactate 4.2\\n Action:\\n Multiple changes made to vent throughout the day with plan to follow\\n ARDS protocol. Presently is on AC 550X32X100%X15 with ABG\\n 7.30/45/71/-3. Given bicarb gtt 150meq/1000 D5W at 150/hr and total of\\n 5L LR.\\n Response:\\n ABG\\ns as above.\\n Plan:\\n Monitor ABG\\ns frequently and adjust vent accordingly following ARDS\\n guidelines.\\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\\n Assessment:\\n Persistent hypoxemia and hypercapnia despite high fiO2 and peeps. CXR\\n -> bilat patchy infiltrates esp L upper lobe; TTE showed pulm embolism\\n unlikely but has some pulmonary hypertension, LENI\\ns also negative.\\n Lung sounds are clear throughout, diminished LLL. No secretions noted.\\n Action:\\n Vent settings adjusted as above with satisfactory ABG\\ns, given total of\\n 5L of IVF today for hypotension and low urine output. Triadyne bed\\n ordered for proning but so far not needed. Sedation changed from\\n propofol to fent/versed 50/2 but resp pattern is shallow, labored and\\n disynchronous so fent increased to 75mcg.\\n Response:\\n Resp status unstable.\\n Plan:\\n Prone pt if does not improve, titrate sedation to keep respirations\\n unlabored without dropping BP,\\n Sepsis without organ dysfunction\\n Assessment:\\n No infectious source identified so far. Tmax 99.7, lactate 4.2\\n Action:\\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\\n flagyl/levo/vanc.\\n Response:\\n Pending.\\n Plan:\\n Monitor temp, wbc\\ns, lactate. Follow cultures, continue abx until\\n sensitivities available.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n ABP\\ns 70\\ns-130/ 50-70\\ns, HR 118-128 ST no ectopy, CVP 10-16\\n Action:\\n Phenylephrine gtt titrated throughout the day, was maxed for a short\\n time but presently is at .9mcg/kg/min. Received total 5L LR, 25gm\\n albumin, 1L D5W w/ 150meq bicarb.\\n Response:\\n Presently ABP\\ns are 100\\ns/ 60\\ns, fluid status is +4L, urine output is\\n 40-200cc/hr.\\n Plan:\\n Titrate neo to map >60, wean if possible, monitor fluid status, give 1L\\n LR boluses for low urine output and hypotension.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-04 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 328784,\n \"text\": \"Mr. is a 56 year old male with history of ulcerative colitis (pt\\n of Dr. failed medical management, s/p colectomy with ileostomy\\n and preservation of rectum 12/. Post operative course was\\n complicated by ileus. He had been doing well post operatively until\\n when he presented to the ED with abdominal pain at the site of the\\n stoma and increased ostomy output. He was admitted to the surgical\\n service and treated conservatively with IVF, NG tube, and NPO. Serial\\n abdominal films showed air fluid levels in the small bowel. Small\\n bowel follow through showed no fistula formation or obstructive point\\n but patient continued to have episodic cramping pain. Due to\\n persistent pain, the patient was consented and taken to the OR today\\n for exploratory laparoscopy. He was found to have parastomal hernia\\n and adhesive disease, hernia repair and lysis of adhesions was\\n performed. Estimated blood loss was minimal. He was given 2700 IVF\\n however had 55cc urine output. He is being transferred from the PACU\\n for monitoring due to tachypnea, tachycardia.\\n .\\n On arrival to the the patient is somnolent but arousable. He has\\n dilaudid PCA within reach. PCA dose increased overnight. He reports\\n pain at 3/10, reports that it is now much better controlled. Pain with\\n any movement. He denies fevers, chills, shortness of breath, nausea,\\n chest pain or palpitations. He states that he is thirsty.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n Pt received 3 fluid boluses overnight for total of 2 L, was started\\n on maintenance fluid at 150cc/hr, HR: 102-125, trending down,\\n BP:94-109/65-87, trending up, u/o~20-30 cc/hr, cr this am 1.4\\n Action:\\n No further fluid boluses given this shift per surgery, pt reporting\\n that he is thirsty, following hemodynamics, pt receiving metoprolol as\\n ordered\\n Response:\\n Ongoing\\n Plan:\\n Encourage Po intact when ordered, pt currently NPO, continue maintance\\n fluids, montitor I/O, ? recs, continue cardiac meds per wants\\n pt beta blocked on atenolol at home\\n Pain control (acute pain, chronic pain)\\n Assessment:\\n Pt on dilaudid PCA as noted above, 0.37 mg increased overnight with\\n good effect, 6min lock out, no basal rate, 1 hour max 3.7mg, pt\\n reporting pain at 3/10 at rest, increased pain with activity, pt\\n describes pain as sharp and radiating, sleeping at times arouses with\\n pain but controlled with PCA dosing\\n Action:\\n Encouraging pt to use PCA, PCA teaching, continuing to provide current\\n dosing as ordered\\n Response:\\n Pt with good pain control, pain reported at 3/10 while at rest\\n Plan:\\n Transition to po pain meds as tolerated when pt started on Pos,\\n continue PCA for now, continue to monitor pain control\\n Hernia, other\\n Assessment:\\n Pt with hernia repair , by this am to view incision, two mid\\n line incisions noted, dressing dry and intact, serous drainage\\n noted on upper dsg, JP drain on lower, draining serous fluid, iliostomy\\n with minimal out put draining serous fluid as well, bowel sounds\\n present\\n Action:\\n Monitoring\\n Response:\\n Ongoing\\n Plan:\\n Continue to monitor abd for increased tenderness, redness and pain,\\n monitor JP drainage for change in color or odor, f/ recs for dsg\\n changes\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n OBSTRUCTION\\n Code status:\\n Full code\\n Height:\\n 68 Inch\\n Admission weight:\\n 95.3 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: ulcerative colitis s/p total colectomy in .\\n Depression, GERD.Thoracic back pain. multiple spinal surgeries,\\n arthroscopic knee surgery.\\n Surgery / Procedure and date: Exploratory Lap w/ Hernia Repair \\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:107\\n D:87\\n Temperature:\\n 97.5\\n Arterial BP:\\n S:\\n D:\\n Respiratory rate:\\n 21 insp/min\\n Heart Rate:\\n 108 bpm\\n Heart rhythm:\\n ST (Sinus Tachycardia)\\n O2 delivery device:\\n Nasal cannula\\n O2 saturation:\\n 97% %\\n O2 flow:\\n 3 L/min\\n FiO2 set:\\n 24h total in:\\n 2,607 mL\\n 24h total out:\\n 219 mL\\n Pertinent Lab Results:\\n Sodium:\\n 140 mEq/L\\n 04:05 AM\\n Potassium:\\n 4.1 mEq/L\\n 04:05 AM\\n Chloride:\\n 109 mEq/L\\n 04:05 AM\\n CO2:\\n 19 mEq/L\\n 04:05 AM\\n BUN:\\n 24 mg/dL\\n 04:05 AM\\n Creatinine:\\n 1.4 mg/dL\\n 04:05 AM\\n Glucose:\\n 144 mg/dL\\n 04:05 AM\\n Hematocrit:\\n 35.7 %\\n 04:05 AM\\n Additional pertinent labs:\\n BUN 24 CR 1.4\\n Lines / Tubes / Drains:\\n JP drain, 2 PIV\\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/\\n Transferred to: 12R\\n Date & time of Transfer: 1100\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328843,\n \"text\": \"Mr. is a 56 year old male with history of ulcerative colitis (pt\\n of Dr. failed medical management, s/p colectomy with ileostomy\\n and preservation of rectum 12/. Post operative course was\\n complicated by ileus. He had been doing well post operatively until\\n when he presented to the ED with abdominal pain at the site of the\\n stoma and increased ostomy output. He was admitted to the surgical\\n service and treated conservatively with IVF, NG tube, and NPO. Serial\\n abdominal films showed air fluid levels in the small bowel. Small\\n bowel follow through showed no fistula formation or obstructive point\\n but patient continued to have episodic cramping pain. Due to\\n persistent pain, the patient was consented and taken to the OR for\\n exploratory laparoscopy. He was found to have parastomal hernia and\\n adhesive disease, hernia repair and lysis of adhesions was performed.\\n He was transferred from the PACU here to ICU for monitoring due to\\n tachypnea, tachycardia. He was transferred to 12R as he was\\n stable.\\n .\\n Early this am pt. became tachypneic, tachycardic up to 140\\ns and\\n oliguric. Placed on 100% NRB with good effect. CXR wnl, EKG wnl,\\n Crackles bilat. Given 80mg of lasix and transferred here to ICU for\\n further management. Labs drawn on floor. White count rising. Lactate\\n 3.0\\n Upon arrival here pt. found to have HR up to 150\\ns. BP WNL. Tachypneic\\n and very confused. Notably cold/clammy. Unable to draw labs. Abdomen\\n Firm. Bowel sounds absent. C/o pain despite dilaudid PCA. Bladder\\n pressure checked and was 40. Surgeon called immediately. Pt. refusing\\n central line and a line. Plan is to go to OR. ? Compartment syndrome\\n vs. intra-abdominal process.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"Physician Resident Admission Note\",\n \"row_id\": 328844,\n \"text\": \"Chief Complaint: Transfer from surgery for tachypnea, shortness of\\n breath.\\n HPI:\\n 56 yo M with a history of UC s/p colectomy with ileostomy in \\n admitted on with abdominal pain and increased ostomy output\\n now POD #2 from ex lap with parastomal hernia repair and lysis of\\n adhesions who represents to the ICU with acute onset tachypnea and\\n shortness of breath and oliguric renal failure.\\n .\\n The patient was originally admitted on . He had been doing well\\n since his surgery in until he developed abdominal pain at the\\n site of the stoma and increased ostomy output. He was admitted to the\\n surgical service and treated conservatively with IVF, NG tube, and\\n NPO. Serial abdominal films showed air fluid levels in the small\\n bowel. Small bowel follow through showed no fistula formation or\\n obstructive point but patient continued to have episodic cramping\\n pain. Due to persistent pain, the patient was consented and taken to\\n the OR on for exploratory laparoscopy. He was found to have\\n parastomal hernia and adhesive disease, hernia repair and lysis of\\n adhesions was performed. The patient was in the ICU overnight the\\n evening after surgery for tachypnea, tachycardia and relative hypoxia.\\n At that time he was felt likely to be hypovolemic possibly with a\\n component of beta-blocker withdrawal. With minimal intervention\\n overnight, the patient's symptoms improved and he was called back out\\n to the surgical floor.\\n .\\n Since that time, the patient has received an estimated 6L of fluid\\n rescucitation per the report of the surgery team and recent \\n records. He had poor urine output of approximately 500cc. He had rising\\n WBC, Hct and platelets.\\n .\\n The surgical resident was called to evaluate the patient where he was\\n found to be tachycardic, tachypneic and hypoxic requiring a\\n non-rebreather. He was noted to be oliguric with declining urine output\\n to approximately 10cc/hr. ABG at that time revealed 7.39/35/81 on a\\n NRB. He was transferred to the ICU where repeat ABG revealed 7.39/34/65\\n on a NRB with lactate 3.0. He received 50mg IV lasix on the floor and\\n an additional 80mg IV lasix in the ICU without significant urine\\n output.\\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 Furosemide (Lasix) - 02:15 AM\\n Other medications:\\n Meds on admission:\\n Celexa 10mg daily\\n Aciphex 20mg daily\\n Atenolol 25mg daily\\n Aldactone 25mg daily\\n Norvasc 2.5mg daily\\n .\\n Meds on transfer:\\n Hyoscyamine 0.125 mg SL QID\\n Ipratropium Bromide Neb 1 NEB IH Q6H\\n Acetaminophen 325-650 mg PO Q6H:PRN\\n Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN\\n Metoprolol Tartrate 5 mg IV Q6H\\n DiphenhydrAMINE 25 mg PO HS:PRN\\n Ondansetron 4 mg IV Q8H:PRN\\n Pantoprazole 40 mg IV Q24H\\n HYDROmorphone (Dilaudid) 0.37 mg IVPCA\\n Heparin 5000 UNIT SC TID\\n Past medical history:\\n Family history:\\n Social History:\\n Hypertension\\n Depression\\n Ulcerative colitis as above, history of chronic steroid use\\n GERD\\n MSSA bacteremia\\n T10 diskitis\\n Multiple spine surgeries: Fusion T6-T12\\n Multiple thoracic laminetomies\\n Partial vertebrectomy of T10-T11\\n Hyperlipidemia\\n History of PE\\n C diff\\n Hemochromatosis\\n s/p arthroscopic knee surgery\\n See recent admit note\\n Occupation:\\n Drugs:\\n Tobacco:\\n Alcohol:\\n Other: See recent admit note\\n Review of systems: Notes abdominal pain and shortness of breath,\\n otherwise negative in detail.\\n Flowsheet Data as of 04:54 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: 35.7\\nC (96.3\\n HR: 143 (102 - 147) bpm\\n BP: 125/108(112) {100/68(75) - 133/108(112)} mmHg\\n RR: 28 (20 - 35) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 68 Inch\\n Bladder pressure: 40 (40 - 40) mmHg\\n Total In:\\n 2,853 mL\\n 23 mL\\n PO:\\n TF:\\n IVF:\\n 2,853 mL\\n 23 mL\\n Blood products:\\n Total out:\\n 249 mL\\n 337 mL\\n Urine:\\n 229 mL\\n 67 mL\\n NG:\\n Stool:\\n Drains:\\n 20 mL\\n 70 mL\\n Balance:\\n 2,604 mL\\n -314 mL\\n Respiratory\\n O2 Delivery Device: Non-rebreather\\n SpO2: 100%\\n Physical Examination\\n Gen: Somewhat uncomfortable gentleman with NRB on. Intermittent\\n complaints of abdominal pain.\\n HEENT: JVP difficult to assess.\\n CV: RRR. Normal S1 and S2. No M/R/G.\\n Pulm: Diffuse crackles R>L.\\n Abd: Mildly distended. Hypoactive bowel sounds. Diffuse tenderness.\\n Ext: No edema.\\n Bladder pressure: 40\\n Labs / Radiology\\n 245 K/uL\\n 11.4 g/dL\\n 144 mg/dL\\n 1.4 mg/dL\\n 24 mg/dL\\n 19 mEq/L\\n 109 mEq/L\\n 4.1 mEq/L\\n 140 mEq/L\\n 35.7 %\\n 26.9 K/uL\\n [image002.jpg]\\n \\n 2:33 A6/19/ 04:05 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 26.9\\n Hct\\n 35.7\\n Plt\\n 245\\n Cr\\n 1.4\\n Glucose\\n 144\\n Other labs: Lactic Acid:3.0, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\\n mg/dL\\n Fluid analysis / Other labs: ABG: 7.39/35/81 -> 7.39/34/65\\n Imaging: CXR (): As compared to the previous radiograph from\\n , there is unchanged visualization of thoracic fusion\\n hardware. The lung volumes are slightly lower than on the previous\\n examination, the cardiac silhouette is slightly larger. Probably due to\\n positioning effect, the transparency of the right hemithorax has\\n decreased, however, some small amount of right-sided pleural effusion\\n cannot be excluded. There are no signs suggestive of overhydration.\\n .\\n CXR (): Small lung volumes. No infiltrates. No obvious signs of\\n volume overload.\\n Microbiology: Urine culture (): <10,000 organisms/ml\\n ECG: Sinus tachycardia at 147. Normal axis and intervals. Downgoing t's\\n in V1 as seen previously. Morphologic change across the precordium with\\n very poor R wave progression and predominantly negative QRS complex in\\n V2-4 more pronounced than prior and near isoelectric V5-6 new from\\n prior. No signs of right heart strain.\\n Assessment and Plan\\n A/P: 56 yo M with a history of UC s/p colectomy with ileostomy in\\n admitted on with abdominal pain and increased ostomy\\n output now POD #2 from ex lap with parastomal hernia repair and lysis\\n of adhesions who represents to the ICU with sepsis physiology, acute\\n onset tachypnea and shortness of breath and oliguric renal failure\\n concerning for abdominal compartment syndrome.\\n .\\n # Abdominal source sepsis. Tachycardia, tachypnea, leukocytosis and\\n lacate elevation suggestive of sepsis physiology. Likely source is\\n recent abdominal surgery with enterotomy.\\n - Broad spectrum antibiotics with vanc, levo, flagyl.\\n - Blood and urine cultures.\\n - Back to OR per surgery.\\n .\\n # Tachypnea, shortness of breath. Most likely secondary to pulmonary\\n edema due to 3rd spacing of fluid in the lungs with diffuse crackles on\\n exam and large A-a gradient. This is likely in part due to sepsis\\n physiology (leukocytosis and lactate elevation) with capillary leak\\n Cannot exclude PE though less likely given exam and clinical\\n appearance. Flash edema from hypertension or MI cannot be excluded\\n though also less likely. Hypoventilation due to pain and abdominal\\n compartment syndrome with elevated bladder pressure is possible though\\n this does not explain the large A-a gradient well. These seems unlikely\\n to represent a pulmonary source of infection.\\n - Continue oxygen supplementation support. Positive pressure and\\n mechanical ventilation as necessary for respiratory decline.\\n - Difficult volume status, intravascularly deplete, 3rd space volume\\n overloaded in lungs and abdomen. Unresponsive to lasix likely secondary\\n to abdominal compartment syndrome. Maintain I/O status even as\\n possible.\\n - Requires decompression of likely abdominal compartment syndrome to\\n allow for improved perfusion of kidneys and diuresis.\\n - Rule out MI.\\n - Likely TTE post-operatively.\\n .\\n # Tachycardia. Likely sepsis physiology. Cannot exclude a component of\\n pain or secondary to respiratory distress.\\n - Broad spectrum antibiotics.\\n - Maintain I/O even as possible.\\n .\\n # Oliguric renal failure. Likely secondary to abdominal compartment\\n syndrome. Bladder pressure 40.\\n - To OR for decompression of abdominal compartment syndrome.\\n .\\n # UC s/p ostomy with recent abdominal surgery for paraostomy hernia\\n repair and lysis of adhesions. Complications as above of likely\\n abdominal source sepsis +/- abdominal compartment syndrome.\\n - Back to OR for re-exploration and abdominal decompression.\\n .\\n # Hypertension. Hold beta-blocker in the setting of likely hypotension.\\n .\\n # FEN: NPO.\\n .\\n # Access: Peripheral IV. Refusing central line.\\n .\\n # Prophylaxis: Pneumoboots, PPI.\\n .\\n # Code: Full\\n .\\n # Dispo: ICU.\\n .\\n ICU Care\\n Nutrition:\\n 22 Gauge - 02:20 AM\\n Prophylaxis:\\n DVT: Boots\\n Code status: Full code\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"Physician Attending Admission Note\",\n \"row_id\": 328839,\n \"text\": \"Chief Complaint: Increasing dyspnea, s/p abdom surgery today with\\n lysis of adhesions and one incidence of inadvertent enterotomy. Since\\n surgery, increasing WBC, abdominal distention, worsening hypoxemia with\\n rising lactate.\\n I saw and examined the patient, and was physically present with the ICU\\n Resident for key portions of the services provided. I agree with his /\\n her note above, including assessment and plan.\\n HPI:\\n As Above\\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 Furosemide (Lasix) - 02:15 AM\\n Other medications:\\n Metoprolol, Albuterol Nebs, Ipratropium, Dilaudid PCA\\n Past medical history:\\n Family history:\\n Social History:\\n Ulcerative Colitis\\n PE\\n C Difficile\\n Non contrib\\n Occupation: Disability\\n Drugs: None\\n Tobacco: Quit \\n Alcohol: None\\n Other:\\n Review of systems:\\n Constitutional: Fatigue\\n Cardiovascular: Tachycardia\\n Nutritional Support: NPO\\n Respiratory: Tachypnea\\n Gastrointestinal: Diarrhea, Watery output from enterostomy\\n Genitourinary: Foley\\n Flowsheet Data as of 04:20 AM\\n Vital Signs\\n Hemodynamic monitoring\\n Fluid Balance\\n 24 hours\\n Since 12 AM\\n Tmax: 36.4\\nC (97.5\\n Tcurrent: 35.7\\nC (96.3\\n HR: 143 (102 - 147) bpm\\n BP: 125/108(112) {100/68(75) - 133/108(112)} mmHg\\n RR: 28 (20 - 35) insp/min\\n SpO2: 100%\\n Heart rhythm: ST (Sinus Tachycardia)\\n Height: 68 Inch\\n Total In:\\n 2,853 mL\\n 16 mL\\n PO:\\n TF:\\n IVF:\\n 2,853 mL\\n 16 mL\\n Blood products:\\n Total out:\\n 249 mL\\n 337 mL\\n Urine:\\n 229 mL\\n 67 mL\\n NG:\\n Stool:\\n Drains:\\n 20 mL\\n 70 mL\\n Balance:\\n 2,604 mL\\n -321 mL\\n Respiratory\\n O2 Delivery Device: Non-rebreather\\n SpO2: 100%\\n ABG: 7.39/34/65\\n Physical Examination\\n General Appearance: 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: Not assessed), (Left DP pulse: Not assessed)\\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\\n Resonant : ), (Breath Sounds: Crackles : )\\n Abdominal: Distended, Tender: Rebound present\\n Extremities: Right: 1+, Left: 1+\\n Musculoskeletal: 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 245 K/uL\\n 35.7 %\\n 11.4 g/dL\\n 144 mg/dL\\n 1.4 mg/dL\\n 24 mg/dL\\n 19 mEq/L\\n 109 mEq/L\\n 4.1 mEq/L\\n 140 mEq/L\\n 26.9 K/uL\\n [image002.jpg]\\n 04:05 AM\\n WBC\\n 26.9\\n Hct\\n 35.7\\n Plt\\n 245\\n Cr\\n 1.4\\n Glucose\\n 144\\n Other labs: Lactic Acid:3.0, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\\n mg/dL\\n Assessment and Plan\\n Acute Abdomen with Compartment Syndrome - Bladder Pressure 40\\n Needs re-explore for possible enterostomy leak, ? abdominal sepsis\\n Doubt PE - hold heparin\\n Will cover with broad spectrum antibiotics\\n ICU Care\\n Nutrition:\\n Glycemic Control: Blood sugar well controlled\\n Lines / Intubation:\\n 22 Gauge - 02:20 AM\\n Comments:\\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: 75 minutes\\n Patient is critically ill\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328916,\n \"text\": \"56yo male POD #2 for exploratory lap w/ hernia repair, back to OR\\n yesterday for ?acute abdomen, bladder pressure of 40. No apparent\\n intra peritoneal process , tube placed, had edematous bowel and\\n 3L fluid in abdomen removed. ? aspiration, apparently vomited during\\n procedure -> bronched in MICU -> no significant secretions, BAL sent.\\n Abdomen decompressed, bladder pressures 23-25.\\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\\n Assessment:\\n CXR -> bilat patchy infiltrates, opacities esp. in left lobe; Echo\\n done, showed PE unlikely. Lung sounds are slightly coarse upper with\\n significantly diminished lower lobes. ABG at 1900 7.33/46/93/25 on\\n 100%FiO2/15 PEEP. Fent at 75mcg/hr/Versed at 2 mg/hr.\\n Action:\\n Surgery in to see patient overnight, dropped Fi02 to 60%, PEEP 13.\\n Corresponding ABG 7.38/45/65/28. Surgery fine with PaO2 > 60 on 60%.\\n Response:\\n Pt. overbreathing vent by 2-5 bpm, appearing uncomfortable and awake.\\n Increased Fent to 100mcg/hr and Versed to 3mg/hr with improvement in RR\\n and comfort. BP remained stable after increase in sedation.\\n Plan:\\n Prone pt if does not improve, titrate sedation to keep respirations\\n unlabored without dropping BP,\\n Sepsis without organ dysfunction\\n Assessment:\\n No infectious source identified so far. Tmax 100.7, lactate 4.3, skin\\n much more warm to touch.\\n Action:\\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\\n flagyl/levo/vanc.\\n Response:\\n Pending.\\n Plan:\\n Monitor temp, wbc\\ns, lactate. Follow cultures, continue abx until\\n sensitivities available.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n ABP\\ns 70\\ns-110/ 50-70\\ns, HR 118-128 ST no ectopy, CVP 10-16. Neo turned\\n off at . Yesterday received total 5L LR, 25gm albumin, 1L D5W w/\\n 150meq bicarb. UO 70-300cc/hr.\\n Action:\\n Overnight, surgery ordered 2 L LR, 5% Albumin. SBP remained stable in\\n high 90\\ns-low 100\\ns. At 0300 was slightly tachy into 130\\ns, SBP\\n dropping into 80\\ns, T 100.7, UO around 70cc/hr. Bolused another liter\\n of LR.\\n Response:\\n Plan:\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328922,\n \"text\": \"56yo male POD #2 for exploratory lap w/ hernia repair, back to OR\\n yesterday for ?acute abdomen, bladder pressure of 40. No apparent\\n intra peritoneal process , tube placed, had edematous bowel and\\n 3L fluid in abdomen removed. ? aspiration, apparently vomited during\\n procedure -> bronched in MICU -> no significant secretions, BAL sent.\\n Abdomen decompressed, bladder pressures 23-25.\\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\\n Assessment:\\n CXR -> bilat patchy infiltrates, opacities esp. in left lobe; Echo\\n done, showed PE unlikely. Lung sounds are slightly coarse upper with\\n significantly diminished lower lobes. ABG at 1900 7.33/46/93/25 on\\n 100%FiO2/15 PEEP. Fent at 75mcg/hr/Versed at 2 mg/hr.\\n Action:\\n Surgery in to see patient overnight, dropped Fi02 to 60%. Corresponding\\n ABG 7.38/45/65/28.\\n Response:\\n Pt. overbreathing vent by 2-5 bpm, appearing uncomfortable and awake.\\n Increased Fent to 100mcg/hr and Versed to 3mg/hr with improvement in RR\\n and comfort. BP remained stable after increase in sedation. PEEP to 13.\\n ABG at 0430 7.46/41/97/30. PEEP decreased to 10. ABG:\\n Plan:\\n Prone pt if does not improve, titrate sedation to keep respirations\\n unlabored without dropping BP,\\n Sepsis without organ dysfunction\\n Assessment:\\n No infectious source identified so far. Tmax 100.8, lactate 3.1, skin\\n much more warm to touch.\\n Action:\\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\\n flagyl/levo/vanc.\\n Response:\\n Pending.\\n Plan:\\n Monitor temp, wbc\\ns, lactate. Follow cultures, continue abx until\\n sensitivities available.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n ABP\\ns 70\\ns-110/ 50-70\\ns, HR 118-128 ST no ectopy, CVP 8-12. Neo turned\\n off at . Yesterday received total 5L LR, 25gm albumin, 1L D5W w/\\n 150meq bicarb. UO 70-300cc/hr.\\n Action:\\n Overnight, surgery ordered 2 L LR, 5% Albumin. SBP remained stable in\\n high 90\\ns-low 100\\ns. At 0300 was slightly tachy into 130\\ns, SBP\\n dropping into 80\\ns, T 100.7, UO around 70cc/hr. Bolused another liter\\n of LR. Pt. put out 500cc via oral gastric tube over 8 hrs. Cannister\\n changed and immediately put out another 450cc of bilious fluid.\\n Response:\\n ABPs 90-110/55-70. MAP >60. UO >50cc/hr.\\n Plan:\\n Continue boluses for hypotension and decreased urine output.\\n Dr. has expressed she would like patient to go west if stable\\n enough for transport today.\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2178-06-06 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 328923,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 2\\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: 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: Clear / 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: Gasping efforts, High flow\\n 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 Dysynchrony assessment:\\n Comments:\\n Plan\\n Next 24-48 hours: Utilize ARDSnet protocol\\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: Pt remains on vent. Weaning as tolerated per team. Abgs\\n improving. Plan to transfer to . Will continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328976,\n \"text\": \"56 yo M with history of UC s/p colectomy with ileostomy in \\n admitted on with abdominal pain and increased ostomy output now\\n POD #3 from ex lap with parastomal hernia repair and lysis of\\n adhesions. Transferred to ICU from floor 2 days post op with acute\\n onset tachypnea, SOB, and oliguric renal failure. In ICU he was on\\n 100% NRB with good sats, CXR wnl, EKG wnl, crackles bilateral lung\\n bases -> given lasix, labs showed rising wbc\\ns and lactate. Also found\\n to have bladder pressure of 40 so taken back to OR for ? abdominal\\n compartment syndrome. No apparent intra-peritoneal process, tube\\n placed, had edematous bowel and 3L fluid in abdomen removed. Had\\n vomiting with ?aspiration during induction -> bronched, no significant\\n secretions, BAL sent. To ICU intubated with O2 sats in high 80\\ns, low\\n 90\\ns despite 100% fiO2. On phenylephrine at .9mcg for hypotension.\\n Throughout the next 24hrs pt was given a total of 9-10L of LR for low\\n urine output, hypotension, and tachycardia. Vent settings were adjusted\\n per ARDS protocol and antibiotics levo/flagyl/vanc started. Also had\\n echo to r/o PE since too unstable for CT and LENI\\ns done. Both were\\n negative.\\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\\n Assessment:\\n Vented on PRVC mode with settings 450X32X60%X10 and ABG\\ns early this am\\n 7.47/37/109/3/28. Lung sounds are clear, diminished in bases. Suctioned\\n for small amts thick tan secretions or no secretions at all.\\n Action:\\n Sedated on fentanyl/versed 75/2 but requiring boluses of 25-30mcg for\\n RR in the 40\\ns and agitation. No vent changes made today.\\n Response:\\n Respiratory status stable.\\n Plan:\\n Transfer to SICU. Wean vent as tolerated.\\n Sepsis without organ dysfunction\\n Assessment:\\n Tmax 101.2, last BC done on is pending. Also pending are urine,\\n BAL, and abdominal fluid cultures. Abdomen is softly distended, bowel\\n sounds are absent although there is some greenish liquid output in\\n ileostomy and j-tube drain. OGT to low suction drained ~700cc\\n bilious liquid. Abdominal dressings are D&I, small amt of old SS drnge\\n on L quad dressing. Hemodynamic status is much improved, no IVF\\n boluses or pressors required.\\n Action:\\n Antibiotics changed from levo/flagyl/vanc to zosyn/vanc. Vanc trough\\n this am 6.3\\n Response:\\n Sepsis improving.\\n Plan:\\n Follow fever curve, wbc\\ns, cultures, sensitivities, continue abx.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n ABP 95-131/52-71; HR 115-123, ST no ectopy, CVP 10-12. Urine output\\n 50-120cc/hr\\n Action:\\n 1unit PRBC\\ns given for volume. Crit this am 27.7; receiving maintenance\\n IVF LR at 125/hr, no fluid boluses or pressors required.\\n Response:\\n Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L.\\n Plan:\\n Continue to monitor ABP, CVP, UO, HR.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-06 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 328977,\n \"text\": \"56 yo M with history of UC s/p colectomy with ileostomy in \\n admitted on with abdominal pain and increased ostomy output now\\n POD #3 from ex lap with parastomal hernia repair and lysis of\\n adhesions. Transferred to ICU from floor 2 days post op with acute\\n onset tachypnea, SOB, and oliguric renal failure. In ICU he was on\\n 100% NRB with good sats, CXR wnl, EKG wnl, crackles bilateral lung\\n bases -> given lasix, labs showed rising wbc\\ns and lactate. Also found\\n to have bladder pressure of 40 so taken back to OR for ? abdominal\\n compartment syndrome. No apparent intra-peritoneal process, tube\\n placed, had edematous bowel and 3L fluid in abdomen removed. Had\\n vomiting with ?aspiration during induction -> bronched, no significant\\n secretions, BAL sent. To ICU intubated with O2 sats in high 80\\ns, low\\n 90\\ns despite 100% fiO2. On phenylephrine at .9mcg for hypotension.\\n Throughout the next 24hrs pt was given a total of 9-10L of LR for low\\n urine output, hypotension, and tachycardia. Vent settings were adjusted\\n per ARDS protocol and antibiotics levo/flagyl/vanc started. Also had\\n echo to r/o PE since too unstable for CT and LENI\\ns done. Both were\\n negative.\\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\\n Assessment:\\n Vented on PRVC mode with settings 450X32X60%X10 and ABG\\ns early this am\\n 7.47/37/109/3/28. Lung sounds are clear, diminished in bases. Suctioned\\n for small amts thick tan secretions or no secretions at all.\\n Action:\\n Sedated on fentanyl/versed 75/2 but requiring boluses of 25-30mcg for\\n RR in the 40\\ns and agitation. No vent changes made today.\\n Response:\\n Respiratory status stable.\\n Plan:\\n Transfer to SICU. Wean vent as tolerated.\\n Sepsis without organ dysfunction\\n Assessment:\\n Tmax 101.2, last BC done on is pending. Also pending are urine,\\n BAL, and abdominal fluid cultures. Abdomen is softly distended, bowel\\n sounds are absent although there is some greenish liquid output in\\n ileostomy and j-tube drain. OGT to low suction drained ~700cc\\n bilious liquid. Abdominal dressings are D&I, small amt of old SS drnge\\n on L quad dressing. Hemodynamic status is much improved, no IVF\\n boluses or pressors required.\\n Action:\\n Antibiotics changed from levo/flagyl/vanc to zosyn/vanc. Vanc trough\\n this am 6.3\\n Response:\\n Sepsis improving.\\n Plan:\\n Follow fever curve, wbc\\ns, cultures, sensitivities, continue abx.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n ABP 95-131/52-71; HR 115-123, ST no ectopy, CVP 10-12. Urine output\\n 50-120cc/hr\\n Action:\\n 1unit PRBC\\ns given for volume. Crit this am 27.7; receiving maintenance\\n IVF LR at 125/hr, no fluid boluses or pressors required.\\n Response:\\n Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L.\\n Plan:\\n Continue to monitor ABP, CVP, UO, HR.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328978,\n \"text\": \"56 yo M with history of UC s/p colectomy with ileostomy in \\n admitted on with abdominal pain and increased ostomy output now\\n POD #3 from ex lap with parastomal hernia repair and lysis of\\n adhesions. Transferred to ICU from floor 2 days post op with acute\\n onset tachypnea, SOB, and oliguric renal failure. In ICU he was on\\n 100% NRB with good sats, CXR wnl, EKG wnl, crackles bilateral lung\\n bases -> given lasix, labs showed rising wbc\\ns and lactate. Also found\\n to have bladder pressure of 40 so taken back to OR for ? abdominal\\n compartment syndrome. No apparent intra-peritoneal process, tube\\n placed, had edematous bowel and 3L fluid in abdomen removed. Had\\n vomiting with ?aspiration during induction -> bronched, no significant\\n secretions, BAL sent. To ICU intubated with O2 sats in high 80\\ns, low\\n 90\\ns despite 100% fiO2. On phenylephrine at .9mcg for hypotension.\\n Throughout the next 24hrs pt was given a total of 9-10L of LR for low\\n urine output, hypotension, and tachycardia. Vent settings were adjusted\\n per ARDS protocol and antibiotics levo/flagyl/vanc started. Also had\\n echo to r/o PE since too unstable for CT and LENI\\ns done. Both were\\n negative.\\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\\n Assessment:\\n Vented on PRVC mode with settings 450X32X60%X10 and ABG\\ns early this am\\n 7.47/37/109/3/28. Lung sounds are clear, diminished in bases. Suctioned\\n for small amts thick tan secretions or no secretions at all.\\n Action:\\n Sedated on fentanyl/versed 75/2 but requiring boluses of 25-30mcg for\\n RR in the 40\\ns and agitation. No vent changes made today.\\n Response:\\n Respiratory status stable.\\n Plan:\\n Transfer to SICU. Wean vent as tolerated.\\n Sepsis without organ dysfunction\\n Assessment:\\n Tmax 101.2, last BC done on is pending. Also pending are urine,\\n BAL, and abdominal fluid cultures. Abdomen is softly distended, bowel\\n sounds are absent although there is some greenish liquid output in\\n ileostomy and j-tube drain. OGT to low suction drained ~700cc\\n bilious liquid. Abdominal dressings are D&I, small amt of old SS drnge\\n on L quad dressing. Hemodynamic status is much improved, no IVF\\n boluses or pressors required.\\n Action:\\n Antibiotics changed from levo/flagyl/vanc to zosyn/vanc. Vanc trough\\n this am 6.3\\n Response:\\n Sepsis improving.\\n Plan:\\n Follow fever curve, wbc\\ns, cultures, sensitivities, continue abx.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n ABP 95-131/52-71; HR 115-123, ST no ectopy, CVP 10-12. Urine output\\n 50-120cc/hr\\n Action:\\n 1unit PRBC\\ns given for volume. Crit this am 27.7; receiving maintenance\\n IVF LR at 125/hr, no fluid boluses or pressors required.\\n Response:\\n Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L.\\n Plan:\\n Continue to monitor ABP, CVP, UO, HR.\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-06 00:00:00.000\",\n \"description\": \"Nursing Transfer Note\",\n \"row_id\": 328979,\n \"text\": \"56 yo M with history of UC s/p colectomy with ileostomy in \\n admitted on with abdominal pain and increased ostomy output now\\n POD #3 from ex lap with parastomal hernia repair and lysis of\\n adhesions. Transferred to ICU from floor 2 days post op with acute\\n onset tachypnea, SOB, and oliguric renal failure. In ICU he was on\\n 100% NRB with good sats, CXR wnl, EKG wnl, crackles bilateral lung\\n bases -> given lasix, labs showed rising wbc\\ns and lactate. Also found\\n to have bladder pressure of 40 so taken back to OR for ? abdominal\\n compartment syndrome. No apparent intra-peritoneal process, tube\\n placed, had edematous bowel and 3L fluid in abdomen removed. Had\\n vomiting with ?aspiration during induction -> bronched, no significant\\n secretions, BAL sent. To ICU intubated with O2 sats in high 80\\ns, low\\n 90\\ns despite 100% fiO2. On phenylephrine at .9mcg for hypotension.\\n Throughout the next 24hrs pt was given a total of 9-10L of LR for low\\n urine output, hypotension, and tachycardia. Vent settings were adjusted\\n per ARDS protocol and antibiotics levo/flagyl/vanc started. Also had\\n echo to r/o PE since too unstable for CT and LENI\\ns done. Both were\\n negative.\\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\\n Assessment:\\n Vented on PRVC mode with settings 450X32X60%X10 and ABG\\ns early this am\\n 7.47/37/109/3/28. Lung sounds are clear, diminished in bases. Suctioned\\n for small amts thick tan secretions or no secretions at all.\\n Action:\\n Sedated on fentanyl/versed 75/2 but requiring boluses of 25-30mcg for\\n RR in the 40\\ns and agitation. No vent changes made today.\\n Response:\\n Respiratory status stable.\\n Plan:\\n Transfer to SICU. Wean vent as tolerated.\\n Sepsis without organ dysfunction\\n Assessment:\\n Tmax 101.2, last BC done on is pending. Also pending are urine,\\n BAL, and abdominal fluid cultures. Abdomen is softly distended, bowel\\n sounds are absent although there is some greenish liquid output in\\n ileostomy and j-tube drain. OGT to low suction drained ~700cc\\n bilious liquid. Abdominal dressings are D&I, small amt of old SS drnge\\n on L quad dressing. Hemodynamic status is much improved, no IVF\\n boluses or pressors required.\\n Action:\\n Antibiotics changed from levo/flagyl/vanc to zosyn/vanc. Vanc trough\\n this am 6.3\\n Response:\\n Sepsis improving.\\n Plan:\\n Follow fever curve, wbc\\ns, cultures, sensitivities, continue abx.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n ABP 95-131/52-71; HR 115-123, ST no ectopy, CVP 10-12. Urine output\\n 50-120cc/hr\\n Action:\\n 1unit PRBC\\ns given for volume. Crit this am 27.7; receiving maintenance\\n IVF LR at 125/hr, no fluid boluses or pressors required.\\n Response:\\n Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L.\\n Plan:\\n Continue to monitor ABP, CVP, UO, HR.\\n Demographics\\n Attending MD:\\n \\n Admit diagnosis:\\n OBSTRUCTION\\n Code status:\\n Full code\\n Height:\\n 68 Inch\\n Admission weight:\\n 95.3 kg\\n Daily weight:\\n Allergies/Reactions:\\n No Known Drug Allergies\\n Precautions:\\n PMH:\\n CV-PMH: Hypertension\\n Additional history: ulcerative colitis s/p total colectomy in .\\n Depression, GERD.Thoracic back pain. multiple spinal surgeries,\\n arthroscopic knee surgery.\\n Surgery / Procedure and date: Exploratory Lap w/ Hernia Repair \\n Latest Vital Signs and I/O\\n Non-invasive BP:\\n S:103\\n D:60\\n Temperature:\\n 100.4\\n Arterial BP:\\n S:95\\n D:59\\n Respiratory rate:\\n 36 insp/min\\n Heart Rate:\\n 121 bpm\\n Heart rhythm:\\n ST (Sinus Tachycardia)\\n O2 delivery device:\\n Non-rebreather\\n O2 saturation:\\n 98% %\\n O2 flow:\\n 6 L/min\\n FiO2 set:\\n 60% %\\n 24h total in:\\n 6,578 mL\\n 24h total out:\\n 3,740 mL\\n Pertinent Lab Results:\\n Sodium:\\n 140 mEq/L\\n 02:05 PM\\n Potassium:\\n 3.4 mEq/L\\n 02:05 PM\\n Chloride:\\n 102 mEq/L\\n 02:05 PM\\n CO2:\\n 27 mEq/L\\n 02:05 PM\\n BUN:\\n 31 mg/dL\\n 02:05 PM\\n Creatinine:\\n 1.7 mg/dL\\n 02:05 PM\\n Glucose:\\n 98 mg/dL\\n 02:05 PM\\n Hematocrit:\\n 29.2 %\\n 02:05 PM\\n Finger Stick Glucose:\\n 114\\n 10:18 PM\\n Valuables / Signature\\n Patient valuables: with pt.\\n Other valuables:\\n Clothes: Sent home with:\\n Wallet / Money:\\n No money / wallet\\n Cash / Credit cards sent home with: none\\n Jewelry:\\n Transferred from: \\n Transferred to: SICU B\\n Date & time of Transfer: 1800\\n\"\n },\n {\n \"category\": \"Respiratory \",\n \"chartdate\": \"2178-06-06 00:00:00.000\",\n \"description\": \"Respiratory Care Shift Note\",\n \"row_id\": 328983,\n \"text\": \"Demographics\\n Day of intubation:\\n Day of mechanical ventilation: 2\\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: 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: cmH2O\\n Cuff volume: mL /\\n Airway problems:\\n Comments:\\n Lung sounds\\n RLL Lung Sounds: Diminished\\n RUL Lung Sounds: Rhonchi\\n LUL Lung Sounds: Rhonchi\\n LLL Lung Sounds: Diminished\\n Comments:\\n Secretions\\n Sputum color / consistency: Tan / Thick\\n Sputum source/amount: Suctioned / Scant\\n Comments:\\n Ventilation Assessment\\n Level of breathing assistance: Continuous invasive ventilation\\n Visual assessment of breathing pattern: Supra-sternal retractions,\\n Accessory muscle use, Prolonged exhalation, Tachypneic (RR> 35 b/min),\\n Gasping efforts, Intercostal retractions, Active exhalations, High flow\\n 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, Abnormal trigger\\n efforts (efforts during inspiratory)\\n Dysynchrony assessment: Vigorous inspiratory efforts, Possible air\\n trapping, Erratic exhaled Tidal Volumes, Frequent alarms (High rate)\\n Comments:\\n Plan\\n Next 24-48 hours: Utilize ARDSnet protocol\\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 Pt to transfer to .\\n\"\n },\n {\n \"category\": \"Nursing\",\n \"chartdate\": \"2178-06-06 00:00:00.000\",\n \"description\": \"Nursing Progress Note\",\n \"row_id\": 328931,\n \"text\": \"56yo male POD #2 for exploratory lap w/ hernia repair, back to OR\\n yesterday for ?acute abdomen, bladder pressure of 40. No apparent\\n intra peritoneal process , tube placed, had edematous bowel and\\n 3L fluid in abdomen removed. ? aspiration, apparently vomited during\\n procedure -> bronched in MICU -> no significant secretions, BAL sent.\\n Abdomen decompressed, bladder pressures 23-25.\\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\\n Assessment:\\n CXR -> bilat patchy infiltrates, opacities esp. in left lobe; Echo\\n done, showed PE unlikely. Lung sounds are slightly coarse upper with\\n significantly diminished lower lobes. ABG at 1900 7.33/46/93/25 on\\n 100%FiO2/15 PEEP. Fent at 75mcg/hr/Versed at 2 mg/hr.\\n Action:\\n Surgery in to see patient overnight, dropped Fi02 to 60%. Corresponding\\n ABG 7.38/45/65/28.\\n Response:\\n Pt. overbreathing vent by 2-5 bpm, appearing uncomfortable and awake.\\n Increased Fent to 100mcg/hr and Versed to 3mg/hr with improvement in RR\\n and comfort. BP remained stable after increase in sedation. PEEP to 13.\\n ABG at 0430 7.46/41/97/30. PEEP decreased to 10. ABG: 7.47/37/109/28\\n Plan:\\n Prone pt if does not improve, titrate sedation to keep respirations\\n unlabored without dropping BP,\\n Sepsis without organ dysfunction\\n Assessment:\\n No infectious source identified so far. Tmax 100.8, lactate 3.1, skin\\n much more warm to touch.\\n Action:\\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\\n flagyl/levo/vanc.\\n Response:\\n Pending.\\n Plan:\\n Monitor temp, wbc\\ns, lactate. Follow cultures, continue abx until\\n sensitivities available.\\n Hypovolemia (Volume Depletion - without shock)\\n Assessment:\\n ABP\\ns 70\\ns-110/ 50-70\\ns, HR 118-128 ST no ectopy, CVP 8-12. Neo turned\\n off at . Yesterday received total 5L LR, 25gm albumin, 1L D5W w/\\n 150meq bicarb. UO 70-300cc/hr.\\n Action:\\n Overnight, surgery ordered 2 L LR, 5% Albumin. SBP remained stable in\\n high 90\\ns-low 100\\ns. At 0300 was slightly tachy into 130\\ns, SBP\\n dropping into 80\\ns, T 100.7, UO around 70cc/hr. Bolused another liter\\n of LR. Pt. put out 500cc via oral gastric tube over 8 hrs. Cannister\\n changed and immediately put out another 450cc of bilious fluid. Pt.\\n remained hypotensive with SBP in 80\\ns, MAPs 50-55. Bolused 1L LR x2, 5%\\n Albumin hung to gravity.\\n Response:\\n ABP remains 80\\ns-90\\ns with MAPs around 55.\\n Plan:\\n Continue boluses for hypotension and decreased urine output. Albumin\\n for intravascular volume, consider PRBC.\\n Dr. has expressed she would like patient to go west if stable\\n enough for transport today.\\n\"\n },\n {\n \"category\": \"Nutrition\",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"Clinical Nutrition Note\",\n \"row_id\": 328861,\n \"text\": \"Subjective\\n Nausea, has been thirsty\\n Objective\\n Height\\n Admit weight\\n Daily weight\\n Weight change\\n BMI\\n 173 cm\\n 95.3 kg\\n 31.9\\n Ideal body weight\\n % Ideal body weight\\n Adjusted weight\\n Usual body weight\\n % Usual body weight\\n 70 kg\\n 136%\\n 76\\n Diagnosis: Obstruction\\n PMH : UC s/p colectomy/ileostomy (), hypertension, depression,\\n GERD, hyperlipidemia, PE, c.diff\\n Food allergies and intolerances: None needed\\n Pertinent medications: flagyl, pantoprazole\\n Labs:\\n Value\\n Date\\n Glucose\\n 146 mg/dL\\n 08:01 AM\\n BUN\\n 24 mg/dL\\n 04:05 AM\\n Creatinine\\n 1.4 mg/dL\\n 04:05 AM\\n Sodium\\n 140 mEq/L\\n 08:01 AM\\n Potassium\\n 3.4 mEq/L\\n 08:01 AM\\n Chloride\\n 104 mEq/L\\n 08:01 AM\\n TCO2\\n 19 mEq/L\\n 04:05 AM\\n Albumin\\n 3.4 g/dL\\n 06:45 PM\\n Calcium non-ionized\\n 7.9 mg/dL\\n 04:05 AM\\n Phosphorus\\n 2.9 mg/dL\\n 04:05 AM\\n Ionized Calcium\\n 1.11 mmol/L\\n 08:01 AM\\n Magnesium\\n 1.6 mg/dL\\n 04:05 AM\\n Current diet order / nutrition support: NPO\\n GI: Abdomen firm/distended with absent BS, ostomy - 200ml, JP - 100ml\\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: 1900-2300 (BEE x or / 25-30 cal/kg)\\n Protein: 90-110 (1.2-1.5 g/kg)\\n Fluid: per team\\n Specifics:\\n 56 year old male with history of UC s/p colectomy, ileostomy with\\n preservation of rectum in doing well post-op until presenting\\n with abdominal pain, increased ostomy output now s/p ex-lap, hernia\\n repair on transferred to ICU with tachycardia, tachypnea, sepsis\\n with concern for acute abdomen. Noted per chart, patient refused\\n central line. If unable to advance diet and patient continues to refuse\\n central line, could use PPN temporarily (goal if TF<400 is 2L standard\\n PPN with 250ml lipids to provide 1140kcal and 70g protein. PPN not able\\n to meet patient\\ns needs. If Patient agrees to central line, can do TPN\\n with goal of 1.9L (320gdex/100gAA/40g lipids) to provide 1888kcal and\\n 100g protein.\\n Medical Nutrition Therapy Plan - Recommend the Following\\n 1. Continue parenteral nutiriton if continues to be unable to\\n take PO intake.\\n 2. Monitor/replete lytes\\n 3. Check TG if PPN or TPN to start\\n 09:46\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"ICU Attending Note\",\n \"row_id\": 328862,\n \"text\": \"Clinician: Attending\\n 56 yo man with colitis, presumed UC, colectomy , adm with\\n high ostomy output and abd pain. Ostomy output attributed to bowel wall\\n edema and poor absorption. In MICU with transient tachypnea and\\n tachycardia but not hypoxemia following hernia repair and ex-lap. Was\\n persistantly tachycardic, likely dehydrated. Tachypnea resolved\\n overnight, transferred back to surgical floor yesterday morning. Total\\n 6L net + over 24 h, with decreasing urine output finally to < 10cc/h.\\n WBC rose 6--> 26--> 38K with 20% bandemia. Resp distress with\\n tachypnea, 7.39/35/81 on NRB. Tranferred to MICU. Initial mental status\\n normal, becamse confused within hours. Increasing oxygen requirement.\\n 7.39/34/65 on NRB, lactate 3.0. Lung exam with dffuse crackles.\\n Oliguric with no response to lasix. Concern for abd distension, bladder\\n pressure was 40 mm Hg. Initial CXR showed low lung volumes but no sig\\n parenchymal process, right mid lung zone atelectasis. Went to OR got\\n right IJ, art line, found to have edematous bowel, stomach had 3L\\n fluid. Bowel decompressed. Bronch with no sig secretions, BAL done.\\n Since surgery hypoxia progressed. Severe metabolic acidosis. CXR with\\n bilateral patchy infiltrates esp left upper lung field. Sedated on\\n propofol. Hypotensive with 87/64, MAP 71. SpO2 88% on FiO2 1.0, PEEP 15\\n TV 450 RR 35 PIP 35 Plateau 26 Compliance 45. Abdomen distension much\\n improved.\\n 7.13/63/70 on rate 26.\\n HCo3 22, gap 15. BUN/Cr 39/2.5 (inc from 1.4 yest). WBC 25K. Hct 42%.\\n LFTs wnl. INR 1.6. Lactate rose to 4.5.\\n Severely critically ill with ARDS, septic shock, unclear if he had\\n aspiration event or secondary to sepsis, abd surgery. Now oliguric,\\n hypotensive, requiring max vent support. Bladder pressure decreased\\n from 40 to 25 after decompression. Broad abx, no cx data yet.\\n flagyl/levo/vanc to cover bowel and lung sources. ARDSnet but pushing\\n PEEP for continued hypoxia. Permissive hypercapnia, and RR raised for\\n acidemia, but will give bicarb if repeat ABG shows no correction of pH.\\n Trying right side down to try to improve V/Q mismatch. Will likely\\n switch to PCV to improve oxygenation if ineffective.\\n Patient is critically ill.\\n\"\n },\n {\n \"category\": \"Physician \",\n \"chartdate\": \"2178-06-05 00:00:00.000\",\n \"description\": \"ICU Attending Note\",\n \"row_id\": 328869,\n \"text\": \"Clinician: Attending\\n 56 yo man with colitis, presumed UC, colectomy , adm with\\n high ostomy output and abd pain. Ostomy output attributed to bowel wall\\n edema and poor absorption. In MICU with transient tachypnea and\\n tachycardia but not hypoxemia following hernia repair and ex-lap. Was\\n persistantly tachycardic, likely dehydrated. Tachypnea resolved\\n overnight, transferred back to surgical floor yesterday morning. Total\\n 6L net + over 24 h, with decreasing urine output finally to < 10cc/h.\\n WBC rose 6--> 26--> 38K with 20% bandemia. Resp distress with\\n tachypnea, 7.39/35/81 on NRB. Tranferred to MICU. Initial mental status\\n normal, becamse confused within hours. Increasing oxygen requirement.\\n 7.39/34/65 on NRB, lactate 3.0. Lung exam with dffuse crackles.\\n Oliguric with no response to lasix. Concern for abd distension, bladder\\n pressure was 40 mm Hg. Initial CXR showed low lung volumes but no sig\\n parenchymal process, right mid lung zone atelectasis. Went to OR got\\n right IJ, art line, found to have edematous bowel, stomach had 3L\\n fluid. Bowel decompressed. Bronch with no sig secretions, BAL done.\\n Since surgery hypoxia progressed. Severe metabolic acidosis. CXR with\\n bilateral patchy infiltrates esp left upper lung field. Sedated on\\n propofol. Hypotensive with 87/64, MAP 71. SpO2 88% on FiO2 1.0, PEEP 15\\n TV 450 RR 35 PIP 35 Plateau 26 Compliance 45. Abdomen distension much\\n improved.\\n 7.13/63/70 on rate 26.\\n HCo3 22, gap 15. BUN/Cr 39/2.5 (inc from 1.4 yest). WBC 25K. Hct 42%.\\n LFTs wnl. INR 1.6. Lactate rose to 4.5.\\n Severely critically ill with ARDS, septic shock, unclear if he had\\n aspiration event or secondary to sepsis, abd surgery. Now oliguric,\\n hypotensive, requiring max vent support. Bladder pressure decreased\\n from 40 to 25 after decompression. Broad abx, no cx data yet.\\n flagyl/levo/vanc to cover bowel and lung sources. ARDSnet but pushing\\n PEEP for continued hypoxia. Permissive hypercapnia, and RR raised for\\n acidemia, but will give bicarb if repeat ABG shows no correction of pH.\\n Trying right side down to try to improve V/Q mismatch. Will likely\\n switch to PCV to improve oxygenation if ineffective.\\n Patient is critically ill.\\n ------ Protected Section ------\\n Spoke with Dr , who told me there is no contraindication\\n to proning, if that becomes necessary.\\n Bicarb infusion.\\n Phenylephrine now at 2.5mcg/kg/min.\\n Placing esophageal balloon, as abd pressure suggested he will need much\\n higher PEEP.\\n Time spent 80 minutes.\\n ------ Protected Section Addendum Entered By: , MD\\n on: 11:29 ------\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445651,\n \"text\": \"Respiratory Therapy\\nPt remains orally intubated on PSV, appears comfortable. Vt 400-600. BS clear apeces, descending to bases audible crackles to diminished. Sx for moderate amounts thick tenacious dark tan secretions. ABG this AM: 7.42/49/130/33. RSBI held due to Peep requirement.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445652,\n \"text\": \"SICU NN: SEE CAREVUE FOR SPECIFICS. PATIENT SEDATED ON FENTANYL DRIP AND PRN ATIVAN. ET TO VENT, NO CHANGES OVERNIGHT. RSR. BP WNL. AFEBRILE. ANASARCA. TUBE FEEDS AT GOAL VIA NGT. ILEOSTOMY, RED STOMA, PUTTING OUT LIQUID BROWN STOOL AND FLATUS. ABDOMINAL INCISION WITH STAPLES AND PARTIALLY OPENED AND PACKED, DRAINING MODERATE TO LARGE AMTS OF SEROSANG. FOLEY, LASIX DRIP, TITRATING FOR GOAL 3L NEG. SACCRUM INTACT. LEFT SC CVL. LEFT AXILLARY ALINE. NO PHONE CALLS NO VISITORS. REPLETING LYTES PRN. PLAN: CONTINUE DIURESIS, DIAMOX AS ORDERED, VENT WEAN AS TOL, MONITOR HEMODYNAMICS, PULM TOLIET, SEDATION/PAIN CONTROL, ANTIBIOTICS AS ORDERED, BLOOD GLUCOSE CONTROL, EMOTIONAL SUPPORT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445653,\n \"text\": \"BS coarse crackles; no change with MDI's. Suctioned for moderate amount thick tan secretions, less than yesterday. CXR ? slight improvement. Diuresis with Diamox proceeds but still 7 liters positive. Will not wean vent until fluid balance improved more.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445654,\n \"text\": \"focus update note\\nT-98.6, 60-80s NSR, no ectopy, sbp 100-150/60-80\\n\\nlasix gtt at 2-4 mg /hr goal diuresis 3 liters negative by 12 midnight, pt given 2 doses of diamox and ordered for one more dose tonight. potassium level 3 despite 80 meq kcl given po x 2 and 100 meq kcl given 1v, icu resident aware.\\n\\nresp: no vent changes today as pt is still 6.5 liters positive for his length of stay and will not bee extubated in the next 24 hours, abgs improved 7.44/40/172/28/3/98, lung sounds clear to coarse, pt suctioned for moderate amount brown thick secretions from ETT, pt continues on zosyn and cipro.\\n\\ngu/gi: tube feeding at goal, bowel sounds positive, 350 cc brown liquid stool from ileostomy- pink stoma, clear light yellow urine from foley cath.\\n\\nabd: vac dressing to be placed over open abd incision on Tuesday, copious amounts of serous fluid from abd wound,surgical team assessed abd wound this am and packing was changed by team at 0830, pink wound base, pt nodding head yes to pain intermittently throughout day, fentanyl gtt provides good reilf of pain as well as repositioning.\\n\\nskin: generalized edema, left groin drainage from old puncture site has resolved, waffle boots on\\n\\nneuro: ativan discontinued today, pt not aggitated today, pt easily redirected when talked to, following commands consistently, mae+, nodding head inconsistently to questions, pupils perla- 3mm brisk reaction, opens eyes to voice or spontaneously, spontaneous movement purposful\\n\\nsocial: wife into visit with 2 other family members, wife updated at pt bedside by nursing, pt likes to watch golf/cooking channel on TV.\\n\\nplan: continue with aggressive diuresis and repleation of electrolytes, consider extubation when pt fluid body status at admission weight, monitor resp status, continue with antibiotic therapy, vac dressing planned for tuesday to open abd wound, limit sedation, provide supportive care to pt and family\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445655,\n \"text\": \"SICU NN: SEE CAREVUE FOR SPECIFICS. PATIENT SEDATED ON FENTANYL DRIP. INCONSISTENTLY FOLLOWING COMMANDS. MOVING ALL EXTREMITIES SPONTANEOUSLY. PERRL. ET TO VENT, NO CHANGES OVERNIGHT. FREQUENT SUCTIONING REQUIRED FOR THICK BROWN SECRETIONS, PLUGGY AT TIMES. RSR. BP WNL. AFEBRILE. CVL AND ALINE INTACT. PALP PEDALS. GEN EDEMA. TUBE FEEDS AT GOAL. ILEOSTOMY WITH LOOSE BROWN STOOL AND FLATUS. STOMA PINK AND MOIST. APPLIANCE INTACT. MIDLINE ABD INCISION WITH STAPLES AND TWO LARGE OPEN AREAS. PACKING IN PLACE, DRESSING REINFORCED. HEAVY TO COPIOUS SEROUS/SEROSANG DRAINAGE, FOUL SMELLING AT TIMES, TEAM AWARE. FOLEY, LASIX DRIP GOAL 3 LITERS NEGATIVE. SACCRUM INTACT. FENTANYL DRIP FOR PAIN. LYTES REPLETED PRN. NPH AND SSI FOR GLUCOSE CONTROL. FAMILY VISITED LAST PM. PLAN: AGGRESSIVE DIURESIS, VAC ABD WOUND TUES, OSTOMY CARE, SKIN CARE, PAIN CONTROL, VENT WEAN AS TOL, PULM TOLIET, FOLLOW CULTURES, ANTIBIOTICS AS ORDERED, EMOTIONAL SUPPORT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445656,\n \"text\": \"Respiratory Therapy\\nPt remains orally intubated on PSV. No changes overnight. BS essentially clear w diminished bases. Sx for moderate amounts thick dark tan secretions SPC. RSBI 31 This AM . Plan continue ventilatory support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445657,\n \"text\": \"nursing progress note\\nSee carevue for specifics.\\nT-max 101.5 md aware. Pan cx sent. Tylenol elixer given. Abd incision open, packed with dsd. Changed frequently due to large amt of serosang foul smelling secretion. SICU team aware of odor. No order to culture wound at this time. Remains lightly sedated on 200mcg's of fent. Inconsistantly follows commands. Clonidine 0.2mg po given for aggitation with no real changes observed in behavior. LS clear with dim bases. Suctioned for moderate amt of thick brown/secretions.Small Vent changes made per ABG's, see resp note for specifics.\\nHr NSR no ectopy noted.\\nLasix Gtt @ 2mg/hr diuresing ~200ml/hr. Goal is to pull off 2L qday. Currently -2500 since MN. Md aware. K+ 3.1 repleted with 60meq IV. In addition to 80meq Q6hr po dose.\\nCxr this am showed ngt coiled in the cervical area. Pulled back ~2cm per SICU team. Repeat cxr shows ngt in good position, viewed by , MD. @ goal of 65ml/hr, residuals 0-10ml's.\\nPOC\\nkeep lightly sedated for possible extubation in am.\\nmonitor temp\\ncontinue to monitor electrolytes, replete as needed.\\nchange dsg's TID and prn packing with dsd.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445658,\n \"text\": \"BS CTAB; no change with MDI's. Suctioned for moderate amount thick tan secretions. Tmax 101.5. PEEP and PSV weaned. Could extubate put team wants to draw of L of fluid today and extubate in AM.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445659,\n \"text\": \"Respiratory Care\\nPt remains on ventilator, with pressure support settings being adequate for pt's spontanous respiratory drive. Pt was suctioned by both RT and RN for copious amounts of brown/yellow/thick sputum. Pt becomes agitated after suctioning procedures. Albuterol given at appropriate times. Pt performed strong RSBI, and responds to questions. Pt to be considered for extubation by MD team, continuing current support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445646,\n \"text\": \"Respiratory Therapy\\nPt remains orally intubated on PSV. BS clear bilaterally Sx moderate amounts thick dark tan secretions. MDI's as ordered. ABG on .4, 7.44/50/102/35 no RSBI due to peep requirement. CXR done awaiting official read. Plan: wean as tol\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445647,\n \"text\": \"Condition update\\nSee careview for details:\\n\\nRemains sedated on fentanyl gtt and prn ativan for sedation with good effect. Appears comfortable when sedated. Afebrile. WBC 16.7 this am (up from 13). Dr (sicu) aware. SR HR 60-70 no ectopy. BP stable, becomes hypertensive with aggitation but returns to baseline when sedated. Generalized edema. Lungs coarse but clears with suction. Diminished at bases. Suction for large amt thick tan secreations with some plugs, Dr aware. Remains on CPAP, fio2 weaned to 40% and PEEP down to 5 from 8 briefly, although cont to have adequate oxygenation increased d/t worsening chest xray. Remains on 10 pressure support. Abg shows compensated metabolic alkolosis. Abd soft, ostomy putting out stool, tolerating tube feeds. RISS, requiring mod amt coverage. Midline abd incision with some purlulent drainage noted, primary team aware. Cont on lasix gtt for goal 2-3 liters negative, 2.9 neg at midnight. Plan to cont to diureses, ?start diamox for increasing metabolic alkososis, start long acting insulin, wean vent as tolerated, maitain comfort.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445648,\n \"text\": \"NURSING NOTE\\nAddendum: Son in to visit this evening\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445649,\n \"text\": \"NURSING NOTE\\nPLEASE SEE CAREVUE FOR DETAILS\\n PT REMAINS LIGHTLY SEDATED ON FENTANYL FOR COMFORT, EASILY . ATIVAN FOR INTERMITTENT AGITATION/RESTLESSNESS W/EFFECT. INCONSISTENTLY FOLLOWS COMMANDS, MAES, NOT TRACKING. AFEBRILE, HR 70S-90S, NSR, SBP 100S-150S, UP TO 180S W/AGITATION. A-LINE DAMPENED AT TIMES R/T LOCATION/PT . CVL RE-SITED, OLD CVL TIP SENT FOR CX. CVP 6-9, CONT ++GEN/SCROTAL EDEMA, PALP PP. LASIX DRIP CONT FOR AGGRESSIVE DIURESIS AS BP TOL PER DR.. GOAL FLUID BAL 2-3L NEG, REMAINS >10L UP FOR LOS. K/CALCIUM REPLETED AS NEEDED DIURESIS. NO VENT CHANGES MADE, MINI BAL SENT. LUNGS COARSE, VERY DIMINISHED AT BASES. SUCTIONED FOR MOD-LGE AMTS THICK, TAN SECRETIONS, CPT DONE AS TOL. ABD INC W/COPIOUS AMTS SEROUS DRNG, STAPLES REMOVED THIS AM BY DR. . WND PACKED W/DRY DSGS, CONT DRAINING COPIOUS SEROUS FLUID, DR. AWARE. CONT TF VIA NGT, MIN RESIDUALS. NPH ADDED TO INSULIN REGIMEN. NO FAMILY CONTACT.\\n\\n PLAN: CONT AGGRESSIVE DIURESIS AS HEMODYNAMICS ALLOW. FENTANYL DRIP FOR COMFORT, ATIVAN FOR INT AGITATION. WEAN VENT AS TOL. MONITOR FOR ALKALOSIS DIURESIS, LYTE REPLETION AS NEEDED. WND/SKIN CARE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445650,\n \"text\": \"BS coarse crackles, occasional rhonchi; no change with MDI's. Suctioned for large amount thick, tan-yellow secretions with plugs. Mini-BAL sent. Metabolic alkalosis persists; ? 0800 ABG. PEEP still at 8cm due to possibility of increased atelectasis though CXR more consistent with increased bilateral LL densities. Plan is to continue with aggressive diuresis.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445641,\n \"text\": \"Condition update\\nSee careview for objective data/trends:\\n\\nEpisodes tachypnia and tachycardia with stimulation this evening, prn ativan increased and given with good effect. Fentanyl gtt continues for sedation, decreased this am as pt appears comfortable. More alert this am, opening eyes spontanously and moving all ext spontanously. Not following any commands. Afebrile. SB-SR HR 50-80's no ectopy. BP stable 110-140's when well sedated. +generalized edema. CVP 9-12. Lungs coarse throughout, diminished at bases. CPAP +PS, pt very tachypnic this evening, Dr aware and increased support from 8 peep 10 ps to 10 peep and 12 ps. Peep decreased back to 8 this morning. Abd softly distended, no bowel sounds noted, Dr aware. Tubefeeds at goal and residuals 10-50cc. Ileostomy with sm amt stool ouptut. Stoma pink. 1.7L neg at MN. BUN/Creat remain slightly elevated but stable. Requiring frequent potassium repleation. Attempted to repleate with po slidding scale but unable to maintain adequate k levels. Plan to cont to monitor neuro status, wean sedation as tolerated monitor hemodyanmics, maintain comfort.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445642,\n \"text\": \"Respiratory Care:\\n\\nPt remain orally intubated on spontaneous ventilation. Yesterday eve we increased PEEP & IPS for increased WOB & tachypnea, we increased sedation also. We attempting to wean it again this morning. RSBI done ~138. Bs are dim & coarse bil. W are sxtn for small amt of thick brownish secretions from ETT. Plan: wean as tol & monitor VS. See Careview for more details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445643,\n \"text\": \"NURSING NOTE\\nAddendum: Pt w/copious amts serous drng originating from ABD dsg this eve. ABD inc w/staples DSD changed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445644,\n \"text\": \"NURSING NOTE\\nPLEASE SEE CAREVUE FOR DETAILS\\n PT EASILY ON FENTANYL FOR LIGHT SEDATION. INCONSISTENTLY FOLLOWS COMMANDS, MAES. HR 60S-70S, NSR, NO ECTOPY. SBP 110S-130S, UP TO 170'S W/STIMULATION OR AGITATION. CVP 6-11, LASIX DRIP UP TO 5MG/HR FOR GOAL NEG FLUID BAL 2-2.5L, CURRENTLY ~1.5L NEG. CONT ++GEN/SCROTAL EDEMA, PALP PP. PO/IV K REPLETED FOR PERSISTENT HYPOKALEMIA DOWN TO 3, CA REPLETED. CONT ON PSV-50%/8/PS DOWN TO 10, RR 17-20S, BECOMES TACHYPNEIC TO 30S W/STIM. LUNGS COARSE, DIMINISHED AT BASES, SUCTIONED FOR SM-MOD AMTS THICK, TAN SECRETIONS. ABD SOFT, +BS ILEOSTOMY PATENT W/MOD AMT LOOSE, BROWN STOOL-APPLIANCE CHANGED BY OSTOMY RN. LGE AMT HUO/ADEQUATE DIURESIS LASIX DRIP. ABD DSD C/D/I, LLQ POUCH/DRAIN W/SM AMT SEROUS DRNG. SON IN TO VISIT BRIEFLY, NO OTHER FMAILY CONTACT.\\n\\n PLAN: CONT HEMODYNAMIC MONITORING, FENTANYL DRIP FOR COMFORT. CONT LASIX DRIP FOR DIURESIS/NEG FLUID BAL GOALS. RESP SUPPORT, WEAN AS TOL. REPLETE LYTES FREQUENTLY.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445645,\n \"text\": \"Respiratory\\nPt. weaned from 12 to 10 of PS as noted in Carevue. Pt. on AC as noted in Carevue. Diminished breath sounds bilaterally in the bases more pronounced on RLL. After MDI's and Sx'ing, greater aeration was heard throughout but still decreased in bases. Pt. producing moderate amount of thick brown blood tinged secretions. Plan: wean vent. settings slowly as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445622,\n \"text\": \"Nursing Note\\nPt transferred from () at 1800 to SICU for monitoring and management. Pt s/p exploratory lap with parastomal hernia repair and LOA on . Pt had post-op complications of severe tachypnea/tachycardia, fevers with elevating WBC, oliguria and bladder pressure of 40 and subsequently had to return to the OR . Pt had 3 liters fluid removed from abdomen and had tube placed in abdomen and pt transferred to SICU.\\nUpon arrival to SICU, pt sedated as he had required versed/fentanyl boluses during tranfer from east to west campuses. Pt's Fentanyl drips and versed drips on hold initially as pt sedated and SBP low. Pt intubated and ventilated on CMV settings-Multiple setting changed overnoc (see carevue) Having difficult time ventilating patient. Pt RR ranging from 30-40s and ABGs showing a respiratory alkalosis. Pox maintaining at 96-100%, LS diminished and pt being suctioned for moderate amounts of thick, tanish/ colored sputum. Pt abdomen is large, soft. Absent BS. Dressing and tube intact to abdomnen, ostomy also present with pink, moist stoma. Pt putting out large amounts of bilious fliud via OG tube and now being replaced cc:cc of NS.\\nPt's HR 100-120s, BP elevates to 180s when turning/repositioning/suctioning and gets very restless requiring increasing amounts of sedation however pt's BP drops after pt settles down and sedation is subsequently put on hold. Pt BP dropping into 70s and requiring multiple fluid boluses to maintain BP. Pt also given one unit PRBC . Follow Q 6 hour HCTS\\nPt has been febrile with Tmax 101.9. Dr. aware. Pt pan cultured prior to transfer from , results pending.\\nPLAN-sedate patient in ordert o ventilate andf manage BP. Administer fluids/colloids as needed. Continue to replace cc:cc of OG output. Follow ABGs.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445623,\n \"text\": \"RESP CARE NOTE\\n56 YO S/P COLOSTOMY CONTINUES ON A/C 32/450/50%/+10. LAS TABG 7.56/29/108/5/98. PT CONTINUES IN ARDS. DIFFICULTY CORRECTING RESPIRATORY ALKALOSIS SINCE PT IS OVERBREATHING VENT. DIFFICULTY MAINTAINING BP WAS LIMITING SEDATION. SX VERY THICK BROWN\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445624,\n \"text\": \"RESPIRATORY CARE: PT REMAINS INTUBATED W/ A 7.5 ORAL ETT IN PLACE AND CHANGED TO PS 22/8 .50 AS PER CV DUE TO PERSISTENT AGGITATION AND VENTILATOR DYSYNCHRONY. ABG C/W A COMBINED METABOLIC AND RESPIRATORY ALKALOSIS AND MARGINAL OXYGENATION. WILL TOLERATE PO2 55 OR GREATER PER DR AT LEAST FOR TODAY. WILL INCREASE TO .60 IF NECESSARY. SEDATION REGIMEN ADJUSTED BY SICU TEAM. SX FOR TAN SPUTUM. WILL C/W PS 22 AS TOLERATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445667,\n \"text\": \"NURSING NOTE\\nASSESSMENT:\\n PATIENT ABLE TO OBEY COMMANDS & MOVE ALL EXTREMITIES. COMMUNICATING BY MOUTHING WORDS AND NODDING. PATIENT OCCASIONALLY GETTING ANXIOUS & STATING HE WANTS ET TUBE OUT, GIVEN ATIVAN AS NEEDED WITH GOOD EFFECT. FENTANYL GTT CONTINUES WITH ADEQUATE PAIN CONTROL.\\n AFEBRILE. HEART RATE RANGING 60-70'S NORMAL SINUS. BRADYCARDIC AFTER LOPRESSOR WITH HR 40'S-50'S. SBP REMAINS 110-160'S. PATIENT MAKING ADEQUATE HOURLY URINE, WEIGHT CONTINUES TO DECREASE.\\n TOLERATING CPAP + PRESSURE SUPPORT . LUNG SOUNDS OCCASIONALLY COARSE AND SUCTIONED FREQUENTLY FOR THICK RUST/BROWN SECRETIONS. PATIENT HAS STRONG COUGH & ABLE TO RAISE SECRETIONS IN ET TUBE.\\n ABDOMEN SOFT, NONDISTENDED. ABDOMINAL WOUND VAC INTACT, DRAINING MODERATE AMOUNTS SEROSANG DRAINAGE. STOPPED @ 12AM AND IV FLUIDS STARTED. ILEOSTOMY CONTINUES TO PUT OUT LOOSE BROWN STOOL. 10 UNITS NPH GIVEN LAST NIGHT (1/2 DOSE) PER DR. DUE TO NPO STATUS.\\nPLAN:\\n IR TODAY FOR ? DRAINAGE FLUID COLLECTION. ? EXTUBATE AFTER IR. CONTINUE TO PROVIDE SUPPORT. ? PHYSICAL THERAPY CONSULT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445668,\n \"text\": \"Resp Care\\nPt maintained intubated and on mech ventilation PCV. tol well AM RSBI 28. Bilat breath sounds course rhonchi with some inspiratory wheezes, suctioned for moderate to large thick tan secretions. plan to further wean and possible extubation. no vent settings changed during the shift see flowsheet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445669,\n \"text\": \"focus update note\\nafebrile, 40-80 heart rate no ectopy, sbp 120-170/50-60.\\n\\nresp: electively extubated, pt now on 2 liters o2 via nasal cannula, o2 sat 100%, lung sounds clear, pt coughing and raising secretions, LLL abcess to be treated conservatively with current regime of antibiotics verses ct guided drainage per pulmonology and infectious disease.\\n\\nneuro: pt confused, alert x , follows commands consistently, opens eyes spontaneously, mae+, no ativan given today.\\n\\npain: fentanyl gtt discontinued, new pt order for PRN diludid, pt has had no complaints of abdominal pain.\\n\\nskin: ostomy appliance changed today, stoma red, brown liquid stool large amount, + bowel sounds no breakdown on back, vac dressing to open abd wound. per icu team black foam covers white foam.\\n\\nmobility: pt worked with PT/OT today OOB to chair\\n\\nsocial : wife called and sons called, nurse updated wife regarding pt upodate over the telephone\\n\\ngu/gi: foley catheter draining > 50 cc urine q 1 hr, pt continues on aldactone po, fluid volume status now negative for length of stay, tube feedings restarted at goal rate, no residual. NPH held this am as pt was NPO icu team aware\\n\\nplan: continue to monitor resp status, fluid volume status, consider hydrocort taper, consider discontinuing aldactone, encourage coughing and deep breathing and incentive spirometry, ? speech and swallow consult tomorrow\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445670,\n \"text\": \"Resp Care:\\n\\nPt extubated this a.m. & placed on cool mist at 40% FiO2. Tol prcedure well & able to give strong cough & vocalize well. FiO2 titrated to n/c. Prn Nebs are ordered yet not indicated at this time; bs = cta with good aeration. Plan to continue to monitor patient & encourage DB & C.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-06 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445621,\n \"text\": \"RESPIRATORY CARE: PT TRANSFERRED FROM 4 TO SICU B AT 1830 TODAY. PT W/ A 7.5 ORAL ETT AT 21 LIP AND ON THE AC MODE AS\\nPER CV. WILL ADJUST SETTINGS AS PER ABG'S POST TRANSFER.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445637,\n \"text\": \"7pm-7am Nursing Note\\nSee CareVue for objective data and trends:\\nNEURO-Pt sedated on fentanyl/ativan drips. Pt with facial grimacing during turing/painful stimuli. Withdraws upper extremities to nail bed pressure. Facial grimace with BLE nailbed pressure and some minimal spontaneous movement noted to feet. Pupils at 2mm and reactive to light.\\nCV-ABP ranging 100s-120s/60s-70s. CVP 10-14,C.O ranging . SVV although pt remains on lasix drip to goal of liters negative per day. Pt continues to have generalized edema present. Palpable peripheral pulses.\\nRESP-Pt remains intubated, ventilated on settings: AC mode-45%fio2,450 X 26, 16 PEEP. LS clear, occasionally coarse prior to suctioning, diminished in bilateral lower bases with right worse than left. Suctioning pt for thick, blood tinged sputum.\\nGI-Pt continues TF via OG. No residuals. Abdomen is large, soft with hypoiactive bowel sounds. Minimal output via ostomy-started on reglan Q 6 hours. Surgical insicion with staples, dressing changed X 1.\\nGU-pt on lasix drip, urine clear yellow.\\nID-Pt afebrile. WBC trending down. Continue Zosyn.\\nPLAN-wean vent slowly, pulmonary toilet. Follow abdominal exams, labs. Continue IV antibiotics.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445638,\n \"text\": \"RESP CARE: Pt remains orally intubated/on vent on settings per carevue. Off paralytic.No changes in settings overnoc. Overbreathing vent 1-2bpm. Esophageal balloon remains in place. ABGs acceptable. Lungs dim bibasilar R>L,rhonchi. Sxd thick bld tinged yellow sputum. Difficulty passing sx catheter at times, pt biting ETT. No RSBI due to PEEP level.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445639,\n \"text\": \"focus update note\\nD: ARDS resolved with active vent wean, diuresis with lasix gtt goal 1-2 liters negative-, pt length of stay is 16L positive, hemodynamically stable off pressors and moniotoring device discontinued.\\n\\nT max 98 50s- 70 NSR, no ectopy, sbp 106-120 /50-60, with aggitation repositioning and suctioning pt hypertensive SBP 160-170. ativan gtt discontinued pt may have PRN ativan for aggitation. fentanyl gtt continues at 150 mcq/hr\\n\\nresp: vent wean to cpap with pressure support peep 8 pressure support at 10 40% fio2- RR 20s, Vt 500, lung sounds clear to coarse with diminished bases.\\n\\nneuro: pt opening eyes spontaneously at times, mae+, intermittently following commands, will grasp with hands to command. pupils 2mm with brisk reaction\\n\\ngu/gi: nutrition consult- probalance with goal rate 65cchr, low residuals 10-20cc q 4 hours, no bowel sounds heard icu team aware, small amount brown liuid from ileostomy, midline incision well approximated and scant serous drainage. lasix gtt at 8 mg hr to max 10 mg hr- to achieve goal 2 liters negative by 12 nidnight.\\n\\nskin: ETT not rotated mouth sore in right corner, skin on back intact- pt transferred back to atmos icu bed, pt continues to have generalized edema.\\n\\nplan; continue with aggressive diuresis with lasix gtt, continue with vent wean as tolerated by pt, monitor residuals with tube feedings, provide supportoive care to pt and family\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445640,\n \"text\": \"Respiratory care\\nPt remains intubated recieved on a/c weaned to cpap/psv. recieved on peep of 16 wened to 8cm , abg on psv of 12cm 746/39/98/29/3 weaned to 10cm. Fio2 weaned to 40%. Plan to continue to wean support as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445663,\n \"text\": \"NPN (NOC):\\n\\nRESP: PT REMAINS INTUBATED. CURRENT VENT SETTINGS: PS 8 X 5 PEEP X40%. RR TEENS TO 20'S, VT'S 700'S, LATEST ABG: 163/35/7.40/23. BS'S FAIRLY CLEAR. SX'D X 2 FOR MOD AMTS OF THICK BROWN SECRETIONS. RSBI = 40.\\n\\nNEURO: PT HAD BECOME INCREASINGLY MORE RESTLESS, TACHYPNEIC AND HYPERTENSIVE ON FENTYNL 200 MCG'S. ATIVAN 1 MG IV GIVEN AT MN AND PT IMMEDIATELY FELL ASLEEP AND BP AND RR CAME DOWN. IS BECOMING MORE AWAKE AND INTERMITTANTLY RESTLESS NOW (6 AM ). ? EXTUBATE TODAY.\\n\\nGI: TOL TF WELL. OSTOMY WAS PUTTING OUT ALOT OF WATERY STOOL BUT HAS SLOWED DOWN CONSIDERABLE SINCE MN. ABD REMAINS OPEN. DSG CHANGED AT 4AM. SURGICAL TEAM IS CONSIDERING A VAC DSG TODAY.\\n\\nF/E: I&O - 6 LITERS AT MN AND WT IS DOWN 8 KG'S. HIS UO HAS ALSO SLOWED CONSIDERABLY SINCE MN. 100 MEQ'S OF KCL AND 2 AMPS CALCIUM GIVEN OVERNOC. NA IS NORMALIZING ON D5W DRIP. FSBS' CONTROLLED W/ SSI.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445664,\n \"text\": \"Resp Care\\npt maintained on mech vetilation PSV, tol well AM RSBI 40.6. Bilat breath sounds course rhonchi, suctioned moderate thick yellow. no vent settings changed seeflow sheet.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445665,\n \"text\": \"Resp Care:\\n\\nPt remains intubated & ventilated. PSV decreased this a.m. to with good results; pt remains on 40% FiO2. Suctioned for mod amts of rust colored secs throughout shift; with BS = crse t/o. MDI's given as ordered. Plan to continue ventilating pt through noc with IR procedure planned for tomorrow. Please see flowsheet for details.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445666,\n \"text\": \"FOCUS: CONDITION UPDATE\\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\\nNEURO--VERY AWAKE , ALERT AND COOPERATIVE. FENT @200 MCG. ATIVAN ORDERED FOR PRN DUE TO ONE MORE DAY OF INTUBATION.\\nRESP--WEANED TO CPAP 5/5. READY TO EXTUBATE TODAY, DECISION MADE NOT TO AS PATIENT WILL TO TO IR TOMORROW FOR FLURO GUIDED DRAINAGE OF LUNG MASS/ABCESS. SUCTIONED FOR MOD-LARGE AMOUNTS OF THICK RUST SPUTUM.\\nGU--ADEQUATE URINE, MUCH LESS THAN YESTERDAY.\\nGI--THICK LOOSE BROWN STOOL FROM ILEOSTOMY. ABD. WOUND VAC'ED BY PRIMARY TEAM W/ WHITE THEN BLACK SPONGE W/GOOD SUCTION. BELLY SOFT.\\nENDO-- NPH AND SLIDING SCALE CONTROLLING BLOOD SUGARS.\\nID--AFBERILE TODAY. FLAGYL ADDED TO ZOSYN AND CIPRO. WBC DOWN.\\nCV--STABLE. EKG/CKW/TROPONIN DONE AFTER? 5BEAT VTACH/ARTIFACT. (MOST LIKELY ARTIFACT). DENYS AND CPAIN, NO FURTHER EPISODES, LOTS OF ARTIFACT WHEN PATIENT MOVING.\\nSOCIAL--WIFE/SON . UPDATE GIVEN.\\nPLAN: NPH THIS PM, NPO AFTER MIDNIGHT FOR PROCEDURE\\n PRN ATIVAN @ HS.\\n CPT /PULMONARY TOILET FOR THICK SECRETIONS.\\n TEAM AWARE OF ABOVE. CALL HO WITH ANY CHANGES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445633,\n \"text\": \"Nsg.progress notes:\\nSee flow sheet for specific:\\n\\nNeuro: PT is still on fentanyl, ativan and cisatracurium gtt,with Lt ulnar TOF monitor with twitches, nimbex ^ 0.08mg as pt overbreahing vent.other than that fully relaxed and sedated.\\n\\nCV: NST- SB, HR 56-60/min, no ectopy noted, SBP 110-120, levo off sine yesterday.Afebrile, + PP, ++generalized edema.IVF KVO only, Plt still low 56 today with am lab, WBC trending down and 16.5 this am, hct:27.8.cont with PCCO monitoring.\\n\\nResp; Remains on vent FIo2 down to 45% , Good ABG's.LS coarse and dinished at bases, O 2sat 96-100%, Minimal secretion only.\\n\\nGI: Abd distended, very hypoactive BS, ileostomy with minimal greenish out put more thick today. tube kept clamped per primary team since day time.OGT to LCWS with bilious out put.\\n\\nGU: Foley cath patent with amber clear urine adq amt.\\n\\nEndo; Bld sug q6h, on ssri, treated per SS.\\n\\nID: Afebrile,cont with anbx.\\n\\nAct: Pt is on kinair bed, turned q2h, stable during turning and positioning.\\n\\nSocial: Visited by wife and her sister during early shift, updated with POC.\\n\\nPlan: Cont monitoring,cont pulm toilet, frequent positioning, skin care,pain mngt, ? DC paraletic today, ? start nutrition OGT or TPN.support to pt and family.abg's.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445634,\n \"text\": \"RESP CARE: Pt remaisn orally intubated with 7.5ETT/21 lip. On AC 450/26/.45/18 PEEP. 02 Sat dropped to 89% at start of shift following turn to R. FI02 increased to .50 at that time. No drops in sats overnight/ABGs WNL. Esophageal balloon remains in place. No measurements overnight.Lungs coarse rhonchi bilat. Sxd thick bld tinged tan sputum. No RSBI due to pEEP level. Continue to wean FI02/vent as tol\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445635,\n \"text\": \"FOCUS: CONDITION UPDATE\\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\\nNEURO--PARALYTIC OFF THIS AM. RESPONDING TO PAIN WITH SOME SPONTANEOUS MOVEMENT OF LOWER ARMS. WINCES TO STERNAL RUB. TOLERATING VENTILATOR WELL AT THIS POINT ON FENT/ATIVAN. SLOWLY WEANING THESE DOWN AS WELL.\\nPUPILS 2=REACTIVE.\\n\\nRESP--PEEP TO 16, TOLERATED WELL. ONE PERIOD OF DESATURATION DUE TO LARGE AMOUNT OF THICK, RUSTY SECRETIONS. SUCTIONED AND LARVAGED FOR LARGE AMOUNT WITH IMPROVING SATS AND IMPRVOING GASES. LUNGS CLEAR AND DIMINISHED.\\n\\nGI---BELLY DISTENDED, SOFT., NICE PINK STOMA, MINIMAL STOOL. REPLETE W/FIBER STARTED AT 10CC HR AFTER PLACEMENT OF NGT CONFIRMED BY CXRAY. PROTONIX CHANGED TO FAMOTADINE.\\n\\nGU--LASIX ONCE, CURRENTLY ON LASIX GTT WITH GOAL 1-1.5 LITERS NEGATAIVE.\\n\\nCV--STABLE OFF PRESSORS. CARDIAC NUMBERS PER FLOW SHEET. AFEBRILE.\\n\\nENDO--BLOOD SUGARS CONTROLLED WITH SLIDING SCALE.\\n\\nPLAN: CONTINUE WITH SLOW WEAN ON FENT/ATIVAN (APPROX. 20% Q 12 HRS)\\nCONTINUE PEEP WEAN AS DIRECTED BY HO AND GASES.\\nCONTINUE DIURESIS AS LONG AS TOLERATES, WILL CHECK LATATE AND BLOOD PRESSURE PARAMETERS.\\nREPLACE LYTES AS NEEDED.\\nCALL HO WITH ANY CHANGES.\\nVANCO DOSED ACCORDING TO LEVEL.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-10 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445636,\n \"text\": \"Respiratory care\\nPt remains on a/c vent with peep decreased to 16cm, ttp -5.5. Abgs wnl on 40%. Plan to wean paralytic and continue to wean support as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445660,\n \"text\": \"pt febrile 102-101 wbc^up 14k. tylenol 650mg x2 given\\nhtn sb/p 180-160 most of night agitation. lopressor 25mg via ngt\\nw/ min effect.\\nrr-35 w/ stimulation(turning/bathing/suctioning) but settles down w/ rr24-28. suction frequently q2hrs for mod amt thick brown sputum.\\no2sats 99-97% on cpap 5/8ips/40%.\\npt slightly sedated on fentanyl 200mcg/hr. pt nodding to ?'s. restless\\n@ times. mae in bed.\\nlasix gtt was stopped last evening @ 1800 pt autodiuresising large amt of urine 500-230cc/hr. wt down 5kgs from previous day. k+ low repleted\\nw/ 80meq down ngt and 40meq iv.\\nabd. soft-ileostomy stoma pink-large amt watery brown stool and air.\\nabd. dsg changed x1 for mod. serous drge\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445661,\n \"text\": \"Resp Care\\nPt remains intaubted on PSV 8/5 with vts 500-600 rr 20-30. BLBS course and diminished suctioned for very thick tan/brown secretions, mdis given. PLan to continue on current settings overnight as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445627,\n \"text\": \"resp care\\npt continues on psv. more frank blood sx from ett. o2 slowwean presently 70%. plan to bronch today\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445628,\n \"text\": \"resp care - Pt remains intubated, paralyzed and on full vent support. A copious amount of bloody secretions were suctioned when pt was turned early in shift. Pt was additionally suctioned for blood-tinged secretions during bronch. Sample was sent to lab. PEEP was raised, balloon measurement indicating that transpulmonary pressure was +1. Plan is to wean as tolerated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445629,\n \"text\": \"SICU Nursing Note: See flowsheet for details\\nEvents: Patient bronched - went into SVT 190s-200s, converted while 150 mg bolus of amiodarone infusing; PCCO monitor applied to watch C.O./CI; septic looking picture with increasingly worse CXR/ARDS picture; multiple vent setting changes, paralyzed with nimbex.\\n\\nRespiratory: Increased sedation levels this morning, changing over to ativan gtt from versed and increasing fentanyl gtt then pt placed on controlled settings. Currently able to wean Fi02 to 60 and slightly decreased PEEP. Pt bronched for thick bloody secretions - LS coarse but slightly less diminished in bases than this morning. Turning patient on his sides, keeping him off back to maximize use of lung space.\\n\\nHemodynamics: Remains on low dose levo; T max 102.1, currently afebrile; SR/ST 80s-120s. After bronch, patient went into an SVT 190s-200s - converted back to sinus tach in 100s-110s during 150 mg amiodarone bolus. PCCO monitor applied, Aline placed on L axilla for use of PCCO. Pt's C.O./C.I. showing low normal numbers, decreased SVR. 2 500 cc boluses of LR administered; currently remains on plasmalyte at 150/hour. CVP 16-24; generalized anasarca; peripheral pulses easily palpable. Ca repleted multiple times. Hydrocort. started because patient didn't respond normally to stem test administered this morning.\\n\\nNeuro: PERRL; sedated on fentanyl/ativan gtts and paralyzed with nimbex; TOF applied to L ulnar, currently getting thumb twitches. Earlier pre-paralytic, pt. withdrawing to pain in all 4 extremities and spontaneously moving limbs to stimulation but not following commands, grimacing to pain.\\n\\nGI: Remains NPO; no output via OGT which is on CLWS; ostomy put out guiac - liquid green stool, mainly water; tube in place putting out same liquid green substance as his ostomy; abd soft distended with very hypo bowel sounds. Glucose WNL, no insulin required this shift.\\n\\nSkin: Intact, very edematous, generalized edema; buttocks slightly red but intact; barrier creme applied to scrotum.\\n\\nFamily: Son into visit, spoke to ; wife phoned. Family needs support as they continue to understand patient's condition and relative gravity.\\n\\nPLAN: Keep low dose levo for squeeze (per ); ARDS protocol; monitor culture results/cont ABX; monitor PCCO, bolus fluid as needed; monitor train of fours while paralyzed; pain and sedation management for comfort.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445662,\n \"text\": \"FOCUS: CONDITION UPDATE\\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\\nNEURO--SEDATED ON FENTANYL 175 MCG. ALERT TO NAME AND WILL FOLLOW COMMANDS. PURPOSEFUL MOVEMENT OF UPPER EXTREMITIES, MOVES ALL EXTREMITIES. SLOWLY WEANING FENTANYL.ATIVAN DC/D YESTERDAY, DID WELL OFF IT TODAY.\\nRESP--NO VENT CHANGES TODAY, TOLERATING CPAP WELL. CAN DECREASE PRESSURE SUPPORT TO 5 TOMORROW. LUNGS CLEAR TO COARSE DEPENDING UPON WHEN SUCTIONED LAST. SUCTIONED FOR THICK BROWN SPTUTUM.\\nGI--NOT TOLERATING TUBE FEEDS WELL AS HAS A LARGE IEOSTOMY OUTPUT, AND DOES NOT ABSORB ANY PO K. BELLY SOFT, INCISION ESSENTIALLY OPENED EXCEPT FOR A FEW STAPLES AROUND BELLY BUTTON. SMALL BOWEL VISIBLE IN LOWER ASPECT OF WOUND. CHANGED MULTIPLE TIMES TODAY WITH DSD KERLIX. MOD AMOUNT OF SEROUS DRAINAGE. WOUND LOOKS PINK IN LOWERS ASPECT, LESS PINK IN UPPER ASPECT. CT OF CHEST/ABD W/CONTRAST DONE--?RESULTS.\\nGU--AUTO DIURESING LARGE AMOUNTS OF URINE. CONTINUOUS K REPLACEMENT. D5W@80 STARTED FOR FLUID BALANCE MANAGEMENT. WEIGHT CONTINUES TO GO DOWN.\\nID--LESS FEBRILE TODAY. CHANGED TO MOTRIN FROM TYLENOL FOR FEVER MANAGEMENT. STOOL SENT FOR CDIF. OTHER ANTIBIOTICS UNCHANGED.\\nCV--STABLE. LOPRESSOR INCREASED WITH BETTER BLOOD PRESSURE CONTROL\\nPLAN: CONTINUE TO MONITOR WOUND, CHANGE PRN\\n FREQUENT LYTE CHECKS, NEEDS K QUITE FREQUENTLY\\n SUCTION WHEN NEEDED, ?DECREASE PRESSURE SUPPORT IN AM\\n NUTRITION CONSULT FOR IMPORVED ABSORPTION OF FEEDS.\\nFAMILY IN, UPDATE GIVEN. APPROPRIATELY SUPPORTIVE. ALL TEAMS AWARE OF ABOVE. WILL CALL HO WITH ANY CHANGES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-07 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445625,\n \"text\": \"Nsg.progress notes:\\nSee flow sheet for specific:\\n\\nNeuro: Pt is on fentanyl and versed gtt, opens eyes to call, not following any commands, agitated when low sedation,so prn dilaudid for pain started with good effect, PERL.moving all extrimities to pain and spontaneously.\\n\\nCV: ST-NSR, HR 106-83, no ectopy noted, SBP was in 80's early shift, fluid bolus x2 with immediate effect and drops down once fluid is off, Neo started at 2mcg/kg/min and tapered to 0.5mcg now, 25% alb 50ml & 2 units PRBC given. ++PP, ++edema.IVF LR at 200ml/hr, lytes replaced per sliding scale.\\n\\nResp: Remains on vent, pls see flow sheet and resp notes for changes, LS coarse - clear and diminished at bases, sxn thick bld tinged secretion, ABG's still reps alkalosis, O2 sat 90-94% can tolerate sats 90-92 today per Dr..\\n\\nGI: Abd softly distended, hypoactive BS, No BM. OGT with bilious drain replaicng cc:cc with NS. tube with clear drain, and ileostomy with light greenish thin out put.abd . staples intact and dry, DSD removed by primary team today.\\n\\nGU: Foley cath patent with yellow clear urine adq amt.\\n\\nEndo: Bld sug q6h, WNL.\\n\\nAct: Turned from side to side,skin intact.\\n\\nSocial: Visited by wife , updated by Dr. and RN.\\n\\nID: T max 102.3, pan cx, on anbx.\\n\\nPlan: Cont monitoring, pulm hygiene, abg's,pain mngt, wean Neo as tolerates.support to pt and family, check lytes and replace per sliding scale. change position q2h and skin care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445630,\n \"text\": \"Nsg.progress notes:\\nSee flow sheet for specific:\\n\\nNeuro: Patient is on fentanyl, ativan and cisatracurium gtt, lt ulnar TOF monitor with twitches, Pupils 1-2mm sluggishly reactive.cont same amt of cisatracurium per Dr..\\n\\nCV: NSR, HR in 70's,no ectopy noted, SBP 100-110 w/ map of 80-90 levophed wean down to 0.03 per Dr..PCCO monitor with better numbers now, calibrated q8h, CO 5-6.7L,++ generalized edema, weeping from rt. groin ? Line placement trial.Palpable pulses,Plasma lyte at 150ml/hr, cvp 14-21cm,afebrile.HCT 30's and wbc 23, plt 44, primary team aware.K and calcium replaced.\\n\\nResp: Remains on vent, vent changes with ABG's, pls see resp notes and flow sheet for changes. Ls coarse - clear and diminished at bases, O2 sat 94 -97%, sxn bld tinged secretions.ABG acceptable.\\n\\nGI: Abd distended, very hypoactive BS, NO BM today, OGT w/very minimal drain , primary team informed, ileostomy with small amt greenish liq drain, tube with minimal out put also, all drains greenish.abd post op wound +oozing, dressing changed.\\n\\nGU: Foley cath patent with amber clear urine adq amt.\\n\\nEndo: Bld sug q6h, on SSRI.\\n\\nID: Afebrile, on anbx, ciprofloxacin started last night.\\n\\nAct: Turned q2h, skin intact.\\n\\nSocial; Visted by pt's wife early shift, updated by RN and SICU MD.\\n\\nPlan: Cont monitoring, pulm hygiene, regular positioning,skin care cont tof monitoring, wean off levophed as tolerates, support to pt and family.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445631,\n \"text\": \"Resp Care\\nPt remains on vent. Sucitoned for mod amt of thick blood-tinged secreitons. Weaning based on abgs, Improving. Mdis given as ordered. Will continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-09 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445632,\n \"text\": \"SICU Nursing Note: See flowsheet for details\\nResp: Continues on CMV; no sputum via ETT; LS coarse/rhonchorous; de-recruited after a re-position with desats to 86% - ambu bagged and placed on 100-% Fi02 then PEEP increased to 18 after esoph. balloon revealed a PEEP of 14 too low at this time. After moving into Kinair bed, placed patient in modified swimmer's position and he didn't tolerate it despite re-recruitment, sats remained at 87-88% so he was placed on his side instead.\\n\\nHemodynamics: Afebrile; sinus brady/normal sinus in 50s-70s with no ectopy noted; SBP 80s-120s with MAPs above 65. Low dose levo off since mid-afternoon after patient was hypertensive in 140s and heart rate dipped to 49-50, currently remains off but should be titrated back on if MAP <65. Still w/ generalized 3+ edema; UO 30-60 an hour via foley. Lytes repleted PRN; showing low normal CO, SVV within normal limits, water volume in lungs slightly less than yesterday but still higher than PICCOs normal range; CVP 14-20. PLT increased to 59 from 44, no s/s bleeding/hematoma noted.\\n\\nGI: Remains NPO; off nutrition for 10 days; insulin per sliding scale, scale tightened for better controls; abd soft distended with hypo BS; ostomy put out scant amounts of slightly formed green stool. tube capped per Dr. - before being capped, no output from it\\n\\nNeuro: Paralyzed; PERRL; train of fours eliciting 2,3, or 4 twitches; titrating nimbex today based on patient at one point moving mouth and bucking vent slightly; able to titrate back down.\\n\\nSkin: Intact; scrotum still extremely edematous but intact; turn and reposition frequently.\\n\\nSocial: Son into visit and called on behalf of patient's wife.\\n\\nPLAN: Titrate MAP >65; plan to stop paralysis tomorrow; continue sedation; No PEEP decreases without knowledge and assent; if tighter insulin scale fails to control glucose, should start insulin gtt; encourage teams to make nutrition plan for patient either enteral or TPN; continue to titrate sedation to ensure patient's comfort; continue SICU plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-08 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445626,\n \"text\": \"7pm-7am Nursing Note\\nSee CareVue for objective data and trends:\\nNEURO-Pt sedated on versed and fentanyl drips, also receiving intermittent dosing of IV dilaudid for further pain management. Pt will grimace face but not open eyes. Pt's pupils at 2mm bilaterally and reactive to light. Pt withdraws extremities to nail bed pressure.\\nCV-Pt HR 90s-110s, SR. SBP maintaining 90s-100. Continue phenylephrine drip to maintain MAP >60. Pt with generalized edema present.\\nRESP-LS clear to coarse and very diminished at bases. Pt's sputum now more bloody and remains thick. Dr. aware. Pt continues to be ventilated and initially on CPAP settings, ABG improved however pt requiring 100% fio2 and has been unable to wean fio2 down as pt's sats decrease into the high 80s. Pt changed over to AC mode at 0500 - will monitor ABG but repiratory rate elevated into 40s. CXR done, results pending.\\nGI-OG with no output, now pt with increased output via ileostomy. Abdomen is softly distended with faint, hpoactive bowel sounds present. Midline surgical incision with staples and small amounts of serosanquinous drainaige-DSD applied. drain remains intact with minimal output.\\nGU-foley intact and putting out adequate amounts of urine.\\nLABS-Pt's platelets continue to drop, INR elevated. HIT panel pending. WBC elevated as well- Tmax 102.1, SICU team aware, Pan cultured yesterday. Continues Vancomycin and zosyn.\\nPLAN-Monitor respiratory status, pulmonary toilet. ?bronchoscopy today secondary to thick, bloody secretions. Follow temps, continue antibiotics. Follow GI status/exams. Monitor labs.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445671,\n \"text\": \"Nsg.progress notes:\\nSee flow sheet for specific:\\n\\nNeuro: Pt is alert and oriented x , confused inbetween,but easily reoriented back, c/o pain, dilaudid prn with good effcet, ativan 1mg as pt c/o insomnia with fair effect, pleasant and co op with care.\\n\\nCV: NSR, HR in 60's, SBP 140-170, on po lopressor,ivf kvo only, afebrile, ++PP, + edema scrotum & penis, still on aldactone.CVP 2-4cm.denies Cp or discomfort.\\n\\nResp: Remains on RA, ls clear, ++cough, pt is able to suction it from mouth, using IS appropriately, encouraged deep breath and cough.O2 sat 96-99%.\\n\\nGI: Abd softly distneded, Hypoactive BS, Tf at goal. tolerated well, ileostomy with brown loose stool, banana flakes TID. tube clamped.\\n\\nGU: Foley cath patent with yellow clear urine adq amt.\\n\\nEndo; Bld sug q6h, on SSRI and NPH .\\n\\nID: Afebrile, on anbx.\\n\\nSocial: Visited by wife early shift, aware of \\n\\nAct: turned in bed, skin intact.\\n\\nPlan: Cont monitoring, pulm hygiene, encourage deep breath cough & IS, ? ^ lopressor for SBP 170's, taper hydrocortisone, ambulate as tolerates , support to pt and family.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445672,\n \"text\": \"SICU Nursing Note: See flowsheet for details\\nPt remains on RA, coughing scant secretions, using IS, pivoted with 2 assist to chair, needed heavy 3-assist to return to chair however; motivated to get physical therapy for his sons' weddings upcoming. Added norvasc to his BP regime for better BP control; taking clear liquids without problem, appetite fair. VAC dressing to abd incision changed by surgery, ileostomy appliances changed at same time. Remains slightly confused by pleasant, oriented, cooperative with care. Wife phoned today for update.\\n\\nPLAN: VAC and ileo appliances due to be changed on Sunday (VAC changed by east surgery team only); advance diet as tol; PT/OT; pain management; continue to encourage IS, cough/deep breathe, continue ICU plan of care.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2178-06-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1445673,\n \"text\": \"Nsg.progress notes:\\nSee flow sheet for specific:\\n\\nNeuro:Alert and orinented x3, MAE, c/o abd pain dilaudid x1 and ativan 1mg per pt's request and slightly confused towards late night,\\\" No body told me it is time to go for the wedding\\\"reoriented back,appropriate with answers,aware of palce, time and self.trying to get OOB at times, bed alarm on.\\n\\nCV: HR 60-70, no ectopy noted, SBP 140-170, ++PP,less edema good diuresis with aldectone, K and calcium replaced.\\n\\nResp : On RA O 2sat 99-100%, LS clear, good cough w/ minimal secretion,Deep breath and cough and IS encouraged.\\n\\nGI: Abd soft,Hypoactive BS, Ileostomy w/ more thick stool with gas. can't drain to the bag, banana flakes held last night, vac dressing intact with SS drain.TF at goal, tolerated clears too.\\n\\nGU: Foley cath patent with yellow clear uirne adq amt.\\n\\nEndo; bld sug q6h, on SSRI & NPH.\\n\\nAct: Turned in bed, skin intact.\\n\\nSocial; Called by pt's son last night, updated with him.\\n\\nPlan: Cont monitoring, pulm hygiene, ambulate, ? Advance diet, change pain meds to po., support to pt nad family.\\n\"\n }\n]"}}},{"rowIdx":990,"cells":{"subject_id":{"kind":"number","value":4113,"string":"4,113"},"hadm_id":{"kind":"number","value":146014,"string":"146,014"},"target_text":{"kind":"string","value":"The patient was admitted under the Pulmonary Service, at which time she was followed by Pulmonary and Renal Departments, at which time Cardiology also saw the patient. The patient eventually underwent coronary artery bypass grafting on . The patient underwent coronary artery bypass grafting times four using the left internal mammary artery. On postoperative day zero, after surgery, Renal came by to see the patient. Intraoperatively, the patient had atrial fibrillation for which she was cardioverted and placed on amiodarone. Renal decided to schedule dialysis for the following day without heparin. On postoperative day one, status post coronary artery bypass graft times four, over the last 24 hours the patient was transfused 1 unit of packed red blood cells for a hematocrit of 26. The patient with a low-grade temperature of 100, in sinus rhythm at 85, blood pressure stable at 107/50, central venous pressure of 8, cardiac index of 3.27, with an systemic vascular resistance of 800. Potassium of 3.6, BUN of 23, creatinine of 3.5, with a blood glucose of 155. Ionized calcium of 1.1, magnesium of 2, hematocrit of 30. On physical examination, the patient was awake, following commands. Heart had a regular rate and rhythm. Lungs were clear to auscultation bilaterally. Sternum was dry and stable. Abdomen was benign. Extremities were warm with right ankle with increased color. The patient was on Esmolol, and amiodarone, as well as vancomycin, carafate, and a sliding-scale of insulin. The plan was to change her pain management to Percocet instead of morphine, change the esmolol drip to p.o., continue the amiodarone, wean to extubate, hemodialysis today, continue antibiotics, and to discontinue the chest tubes, and to transfer to the floor. Renal came by to see the patient on as well. The patient was seen at hemodialysis. The patient underwent dialysis for four hours. The patient was found to be acidotic, predominantly metabolic acidosis with no respiratory compensation. They recommended to check the lactate level, check the calcium and potassium, and to increase Epogen to 8000 units. On postoperative day two, the patient was on nitroglycerin at 0.6, a sliding-scale, Lopressor, Epogen, morphine, calcium, and Percocet. The patient was afebrile, in sinus rhythm at 94, blood pressure 140/53, satting at 97% on 4 liters nasal cannula. Potassium of 3, blood glucose ranging between 65 and 150. On physical examination, the patient was wake and alert and oriented times three. Heart had a regular rate and rhythm. Lungs had decreased breath sounds on the left side. The sternum was stable and dry. Abdomen was benign. Extremities were warm and edematous. The plan was to transfer the patient to the floor, follow the potassium, discontinue the Foley, ambulate, and to check a chest x-ray. Renal also came by to see the patient on postoperative day two, which was . Their recommendation was to limit p.o. and intravenous 1 liter to 1.5 liters a day. Check potassium and resume potassium binders when starting p.o. diet, and the plan was to undergo hemodialysis on . Cardiology also came by to see the patient on . They recommended a chest x-ray because of the bronchial breathing over the left lung field. No other recommendations. On postoperative day three, the patient under hemodialysis, was afebrile, in sinus rhythm at 93, blood pressure 114/68, satting at 95% on 4 liters. On physical examination, the patient was in no apparent distress. Had decreased breath sounds. Heart had normal S1 and S2. Dressings were clean, dry and intact. The sternum was stable. Abdomen was nontender, nondistended, and soft. Extremities revealed left lower extremity incision was clean, dry and intact. The plan was to continue Percocet, increase the Lopressor, discontinue the wires, hemodialysis. The patient did undergo hemodialysis for 3.5 hours, 1500 units of heparin were administered during dialysis. On postoperative day four, the patient remained afebrile, in sinus rhythm at 77, blood pressure 120/70, satting at 96% on 2 liters, fingersticks ranging between 87 and 125. On physical examination, the patient was in no apparent distress. Lungs had decreased breath sounds, left greater than right, at the bases. Heart was normal S1 and S2. Chest revealed the sternum was stable, clean, dry and intact. The abdomen was nondistended, nontender, and soft. Extremities revealed left lower extremity was clean, dry and intact. The right lower extremity was with edema. The patient was stable. The plan was to continue current medications, discontinue the wires and chest tube, continue physical therapy, resume calcium carbonate and Nephrocaps, and possible hemodialysis planned for . Cardiology also came by and saw the patient on postoperative day four, which was . Recommendations were to continue aspirin and Lopressor and to add an ACE inhibitor if okay with Renal for mortality benefit for diabetics with coronary artery disease. On postoperative day five, the patient underwent hemodialysis for four hours. Renal came by to check the patient during hemodialysis, at which time the patient was stable with shortness of breath or chest pain."},"extractive_notes_summ":{"kind":"string","value":"The left ventricular inflow pattern suggests delayedrelaxation.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitaton.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:1. Regional left ventricular wall motion isnormal.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Normal sinus rhythm, rate 93Consider Anteroseptal infarct, oldDiffuse Nonspecific ST-T abnormalitiesSince last ECG, no significant changeABNORMAL ECG PATIENT/TEST INFORMATION:Indication: Left ventricular function.Hyportension.Height: (in) 68Weight (lb): 130BSA (m2): 1.70 m2BP (mm Hg): 83/56Status: InpatientDate/Time: at 09:33Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: There is moderate symmetric left ventricular hypertrophy. There is moderate symmetric left ventricular hypertrophy. Discoid atelectasis/scarring is seen in the right middle and right lower lobes, not significantly changed from prior exam. Mild (1+) mitral regurgitation isseen. IMPRESSION: Right middle and lower lobe atelectasis, without pneumonic consolidation. Sinus tachycardia, rate 101Consider Anteroseptal infarct, oldDiffuse Nonspecific ST-T abnormalitiesSince last ECG, no significant changeABNORMAL ECG Normal sinus rhythm, rate 95Diffuse Nonspecific T wave abnormalitiesSince last ECG, no significant changeABNORMAL ECG Mild (1+) mitralregurgitation is seen. There is moderatethickening of the mitral valve chordae. Normal sinus rhythm, rate 82Low voltage throughoutConsider Anteroseptal infarct, oldDiffuse Nonspecific T wave abnormalitiesSince last ECG, no significant changeABNORMAL ECG Regional left ventricular wall motion is normal.2. Normal sinus rhythm, rate 87Low voltage throughoutConsider Anteroseptal infarct, oldDiffuse Nonspecific T wave abnormalitiesSince last ECG, no significant changeABNORMAL ECG The leftventricular cavity size is normal. Theleft ventricular cavity size is normal. Heart size and mediastinal and hilar contours are normal. Overall left ventricular systolicfunction is normal (LVEF>55%). Since the previoustracing of sinus tachycardia and further ST-T wave changes are present.TRACING #1 Overall left ventricular systolic functionis normal (LVEF>55%). The left ventricular inflow pattern suggests delayed relaxation. Slight compression of the lower thoracic vertebral body is again noted. Since the previous tracing of right-sided chestleads are submitted - no ST segment elevation is evident.TRACING #2 Sinus tachycardia, rate 114Abnormal R wave progression (?ASMI or lead location)Diffuse ST-T abnormalities- Consider IschemiaSince last ECG, ST-T abnormalities more markedABNORMAL ECG Sinus tachycardia. Sinus tachycardia. Consider prior anteroseptal myocardial infarction - clinicalcorrelation is suggested. Anterolateral ST-T wave abnormalities - considerischemia and/or possible left ventricular hypertrophy. The mitral valve leaflets are mildly thickened. Pulmonary vasculature is unremarkable. There are no areas of pneumonic consolidation or pleural effusions. There ismoderate thickening of the mitral valve chordae. Comparison to exam from ."},"n_notes":{"kind":"number","value":10,"string":"10"},"notes":{"kind":"list like","value":[{"category":"Echo","chartdate":"2140-05-20 00:00:00.000","description":"Report","row_id":63283,"text":"PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHyportension.\nHeight: (in) 68\nWeight (lb): 130\nBSA (m2): 1.70 m2\nBP (mm Hg): 83/56\nStatus: Inpatient\nDate/Time: at 09:33\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: There is moderate symmetric left ventricular hypertrophy. The\nleft ventricular cavity size is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Regional left ventricular wall motion is\nnormal.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate thickening of the mitral valve chordae. Mild (1+) mitral\nregurgitation is seen. The left ventricular inflow pattern suggests delayed\nrelaxation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitaton.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. There is moderate symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The mitral valve leaflets are mildly thickened. There is moderate\nthickening of the mitral valve chordae. Mild (1+) mitral regurgitation is\nseen. The left ventricular inflow pattern suggests delayed relaxation.\n\n\n"},{"category":"ECG","chartdate":"2140-05-24 00:00:00.000","description":"Report","row_id":126238,"text":"Normal sinus rhythm, rate 95\nDiffuse Nonspecific T wave abnormalities\nSince last ECG, no significant change\nABNORMAL ECG\n\n"},{"category":"ECG","chartdate":"2140-05-25 00:00:00.000","description":"Report","row_id":126239,"text":"Normal sinus rhythm, rate 82\nLow voltage throughout\nConsider Anteroseptal infarct, old\nDiffuse Nonspecific T wave abnormalities\nSince last ECG, no significant change\nABNORMAL ECG\n\n"},{"category":"ECG","chartdate":"2140-05-26 00:00:00.000","description":"Report","row_id":126240,"text":"Normal sinus rhythm, rate 87\nLow voltage throughout\nConsider Anteroseptal infarct, old\nDiffuse Nonspecific T wave abnormalities\nSince last ECG, no significant change\nABNORMAL ECG\n\n"},{"category":"ECG","chartdate":"2140-05-22 00:00:00.000","description":"Report","row_id":126241,"text":"Normal sinus rhythm, rate 93\nConsider Anteroseptal infarct, old\nDiffuse Nonspecific ST-T abnormalities\nSince last ECG, no significant change\nABNORMAL ECG\n\n"},{"category":"ECG","chartdate":"2140-05-23 00:00:00.000","description":"Report","row_id":126242,"text":"Sinus tachycardia, rate 101\nConsider Anteroseptal infarct, old\nDiffuse Nonspecific ST-T abnormalities\nSince last ECG, no significant change\nABNORMAL ECG\n\n"},{"category":"ECG","chartdate":"2140-05-20 00:00:00.000","description":"Report","row_id":126243,"text":"Sinus tachycardia, rate 114\nAbnormal R wave progression (?ASMI or lead location)\nDiffuse ST-T abnormalities- Consider Ischemia\nSince last ECG, ST-T abnormalities more marked\nABNORMAL ECG\n\n"},{"category":"ECG","chartdate":"2140-05-19 00:00:00.000","description":"Report","row_id":126244,"text":"Sinus tachycardia. Since the previous tracing of right-sided chest\nleads are submitted - no ST segment elevation is evident.\nTRACING #2\n\n\n"},{"category":"ECG","chartdate":"2140-05-19 00:00:00.000","description":"Report","row_id":126245,"text":"Sinus tachycardia. Consider prior anteroseptal myocardial infarction - clinical\ncorrelation is suggested. Anterolateral ST-T wave abnormalities - consider\nischemia and/or possible left ventricular hypertrophy. Since the previous\ntracing of sinus tachycardia and further ST-T wave changes are present.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2140-05-19 00:00:00.000","description":"CHEST (PA & LAT)","row_id":739111,"text":" 1:35 PM\n CHEST (PA & LAT) Clip # \n Reason: LOW BP/ WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with low bp\n REASON FOR THIS EXAMINATION:\n ?pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL & LATERAL CHEST:\n\n HISTORY: 36 y/o woman with hypotension, ?pneumonia.\n\n Comparison to exam from .\n\n Heart size and mediastinal and hilar contours are normal. Pulmonary\n vasculature is unremarkable. Discoid atelectasis/scarring is seen in the right\n middle and right lower lobes, not significantly changed from prior exam. There\n are no areas of pneumonic consolidation or pleural effusions. Slight\n compression of the lower thoracic vertebral body is again noted.\n\n IMPRESSION: Right middle and lower lobe atelectasis, without pneumonic\n consolidation.\n\n"}],"string":"[\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2140-05-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 63283,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Left ventricular function.\\nHyportension.\\nHeight: (in) 68\\nWeight (lb): 130\\nBSA (m2): 1.70 m2\\nBP (mm Hg): 83/56\\nStatus: Inpatient\\nDate/Time: at 09:33\\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: There is moderate symmetric left ventricular hypertrophy. The\\nleft ventricular cavity size is normal. Overall left ventricular systolic\\nfunction is normal (LVEF>55%). Regional left ventricular wall motion is\\nnormal.\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal.\\n\\nAORTA: The aortic root is normal in diameter.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\\nmoderate thickening of the mitral valve chordae. Mild (1+) mitral\\nregurgitation is seen. The left ventricular inflow pattern suggests delayed\\nrelaxation.\\n\\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\\ntricuspid regurgitaton.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\\nstructurally normal with physiologic pulmonic regurgitation.\\n\\nPERICARDIUM: There is no pericardial effusion.\\n\\nConclusions:\\n1. There is moderate symmetric left ventricular hypertrophy. The left\\nventricular cavity size is normal. Overall left ventricular systolic function\\nis normal (LVEF>55%). Regional left ventricular wall motion is normal.\\n2. The mitral valve leaflets are mildly thickened. There is moderate\\nthickening of the mitral valve chordae. Mild (1+) mitral regurgitation is\\nseen. The left ventricular inflow pattern suggests delayed relaxation.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-05-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126238,\n \"text\": \"Normal sinus rhythm, rate 95\\nDiffuse Nonspecific T wave abnormalities\\nSince last ECG, no significant change\\nABNORMAL ECG\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-05-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126239,\n \"text\": \"Normal sinus rhythm, rate 82\\nLow voltage throughout\\nConsider Anteroseptal infarct, old\\nDiffuse Nonspecific T wave abnormalities\\nSince last ECG, no significant change\\nABNORMAL ECG\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-05-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126240,\n \"text\": \"Normal sinus rhythm, rate 87\\nLow voltage throughout\\nConsider Anteroseptal infarct, old\\nDiffuse Nonspecific T wave abnormalities\\nSince last ECG, no significant change\\nABNORMAL ECG\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-05-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126241,\n \"text\": \"Normal sinus rhythm, rate 93\\nConsider Anteroseptal infarct, old\\nDiffuse Nonspecific ST-T abnormalities\\nSince last ECG, no significant change\\nABNORMAL ECG\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-05-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126242,\n \"text\": \"Sinus tachycardia, rate 101\\nConsider Anteroseptal infarct, old\\nDiffuse Nonspecific ST-T abnormalities\\nSince last ECG, no significant change\\nABNORMAL ECG\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-05-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126243,\n \"text\": \"Sinus tachycardia, rate 114\\nAbnormal R wave progression (?ASMI or lead location)\\nDiffuse ST-T abnormalities- Consider Ischemia\\nSince last ECG, ST-T abnormalities more marked\\nABNORMAL ECG\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-05-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126244,\n \"text\": \"Sinus tachycardia. Since the previous tracing of right-sided chest\\nleads are submitted - no ST segment elevation is evident.\\nTRACING #2\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2140-05-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 126245,\n \"text\": \"Sinus tachycardia. Consider prior anteroseptal myocardial infarction - clinical\\ncorrelation is suggested. Anterolateral ST-T wave abnormalities - consider\\nischemia and/or possible left ventricular hypertrophy. Since the previous\\ntracing of sinus tachycardia and further ST-T wave changes are present.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2140-05-19 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 739111,\n \"text\": \" 1:35 PM\\n CHEST (PA & LAT) Clip # \\n Reason: LOW BP/ WEAKNESS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 36 year old woman with low bp\\n REASON FOR THIS EXAMINATION:\\n ?pneumonia\\n ______________________________________________________________________________\\n FINAL REPORT\\n FRONTAL & LATERAL CHEST:\\n\\n HISTORY: 36 y/o woman with hypotension, ?pneumonia.\\n\\n Comparison to exam from .\\n\\n Heart size and mediastinal and hilar contours are normal. Pulmonary\\n vasculature is unremarkable. Discoid atelectasis/scarring is seen in the right\\n middle and right lower lobes, not significantly changed from prior exam. There\\n are no areas of pneumonic consolidation or pleural effusions. Slight\\n compression of the lower thoracic vertebral body is again noted.\\n\\n IMPRESSION: Right middle and lower lobe atelectasis, without pneumonic\\n consolidation.\\n\\n\"\n }\n]"}}},{"rowIdx":991,"cells":{"subject_id":{"kind":"number","value":48426,"string":"48,426"},"hadm_id":{"kind":"number","value":108236,"string":"108,236"},"target_text":{"kind":"string","value":"Upon arrival to the floor, goals of care were discussed with the family. They explained that they did not want to have the patient intubated, and preffered to avoid any invasive procedures including a central line. The understood that this would limit out ability to offer optimal care. When discussed with the patient, he requested to have BIPAP mask removed, expressing full understanding that this would hasten his death. The patient and the family agreed to pursue comfort measures directed care. He was given small doses of IV morphine to treat air hunger, and passed comfortably, with his family at his side, within 50 minutes upon arrival to the unit."},"extractive_notes_summ":{"kind":"string","value":"Multi-level thoracic spine degenerative changes are again noted. The aorta is calcified. The underlying rhythm appears to beatrial fibrillation. The left-sided pacer is unchanged with leads terminating in expected location of the right atrium and right ventricle in the setting of cardiomegaly. Max out neo peripherally Pt was alert and want the mask off. Max out neo peripherally Pt was alert and want the mask off. CHEST, PORTABLE FRONTAL VIEW: There is extensive consolidation of the left mid-to-lower lung and increased consolidation of the right lower lung in comparison to , concerning for infection. COMPARISON: Chest radiograph . IMPRESSION: Bilateral airspace consolidation concerning for pneumonia. Evaluate for pneumonia. The cardiac silhouette remains enlarged. MD informed about his condition and pt does not want aggressive treatment but want to be comfortable. MD informed about his condition and pt does not want aggressive treatment but want to be comfortable. There are small bilateral effusions. Small bilateral effusions. Clinician: Nurse YO male admitted from ED @ 0105 w/ non invasive mask ventillation sating 83 to 85% on Fio2 100%. Clinician: Nurse YO male admitted from ED @ 0105 w/ non invasive mask ventillation sating 83 to 85% on Fio2 100%. Ventricular paced rhythm with capture. Compared to the previous tracing of no diagnosticinterim change. Received morphine totall of 4mg to make him comfortable he had ice cream to eat and became asystole @ 0155 family was @ the bedside w/ him. Received morphine totall of 4mg to make him comfortable he had ice cream to eat and became asystole @ 0155 family was @ the bedside w/ him. 10:43 PM CHEST (PORTABLE AP) Clip # Reason: r/o pna MEDICAL CONDITION: year old man with acute dyspnea REASON FOR THIS EXAMINATION: r/o pna FINAL REPORT HISTORY: -year-old male with acute dyspnea. As per pt request BIPAP removed and refused for NRB too."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"General","chartdate":"2108-01-28 00:00:00.000","description":"ICU Event Note","row_id":617096,"text":"Clinician: Nurse\n YO male admitted from ED @ 0105 w/ non invasive mask ventillation\n sating 83 to 85% on Fio2 100%. Max out neo peripherally Pt was alert\n and want the mask off. As per pt request BIPAP removed and refused for\n NRB too. MD informed about his condition and pt does not want\n aggressive treatment but want to be comfortable. Received morphine\n totall of 4mg to make him comfortable he had ice cream to eat and\n became asystole @ 0155 family was @ the bedside w/ him.\n"},{"category":"General","chartdate":"2108-01-28 00:00:00.000","description":"ICU Event Note","row_id":617097,"text":"Clinician: Nurse\n YO male admitted from ED @ 0105 w/ non invasive mask ventillation\n sating 83 to 85% on Fio2 100%. Max out neo peripherally Pt was alert\n and want the mask off. As per pt request BIPAP removed and refused for\n NRB too. MD informed about his condition and pt does not want\n aggressive treatment but want to be comfortable. Received morphine\n totall of 4mg to make him comfortable he had ice cream to eat and\n became asystole @ 0155 family was @ the bedside w/ him.\n"},{"category":"ECG","chartdate":"2108-01-27 00:00:00.000","description":"Report","row_id":231409,"text":"Ventricular paced rhythm with capture. The underlying rhythm appears to be\natrial fibrillation. Compared to the previous tracing of no diagnostic\ninterim change.\n\n"},{"category":"Radiology","chartdate":"2108-01-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1117759,"text":" 10:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with acute dyspnea\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old male with acute dyspnea. Evaluate for pneumonia.\n\n COMPARISON: Chest radiograph .\n\n CHEST, PORTABLE FRONTAL VIEW: There is extensive consolidation of the left\n mid-to-lower lung and increased consolidation of the right lower lung in\n comparison to , concerning for infection. There are small\n bilateral effusions. The cardiac silhouette remains enlarged. The aorta is\n calcified. The left-sided pacer is unchanged with leads terminating in\n expected location of the right atrium and right ventricle in the setting of\n cardiomegaly. Multi-level thoracic spine degenerative changes are again\n noted.\n\n IMPRESSION: Bilateral airspace consolidation concerning for pneumonia. Small\n bilateral effusions.\n\n"}],"string":"[\n {\n \"category\": \"General\",\n \"chartdate\": \"2108-01-28 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 617096,\n \"text\": \"Clinician: Nurse\\n YO male admitted from ED @ 0105 w/ non invasive mask ventillation\\n sating 83 to 85% on Fio2 100%. Max out neo peripherally Pt was alert\\n and want the mask off. As per pt request BIPAP removed and refused for\\n NRB too. MD informed about his condition and pt does not want\\n aggressive treatment but want to be comfortable. Received morphine\\n totall of 4mg to make him comfortable he had ice cream to eat and\\n became asystole @ 0155 family was @ the bedside w/ him.\\n\"\n },\n {\n \"category\": \"General\",\n \"chartdate\": \"2108-01-28 00:00:00.000\",\n \"description\": \"ICU Event Note\",\n \"row_id\": 617097,\n \"text\": \"Clinician: Nurse\\n YO male admitted from ED @ 0105 w/ non invasive mask ventillation\\n sating 83 to 85% on Fio2 100%. Max out neo peripherally Pt was alert\\n and want the mask off. As per pt request BIPAP removed and refused for\\n NRB too. MD informed about his condition and pt does not want\\n aggressive treatment but want to be comfortable. Received morphine\\n totall of 4mg to make him comfortable he had ice cream to eat and\\n became asystole @ 0155 family was @ the bedside w/ him.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2108-01-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 231409,\n \"text\": \"Ventricular paced rhythm with capture. The underlying rhythm appears to be\\natrial fibrillation. Compared to the previous tracing of no diagnostic\\ninterim change.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2108-01-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1117759,\n \"text\": \" 10:43 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o pna\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n year old man with acute dyspnea\\n REASON FOR THIS EXAMINATION:\\n r/o pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: -year-old male with acute dyspnea. Evaluate for pneumonia.\\n\\n COMPARISON: Chest radiograph .\\n\\n CHEST, PORTABLE FRONTAL VIEW: There is extensive consolidation of the left\\n mid-to-lower lung and increased consolidation of the right lower lung in\\n comparison to , concerning for infection. There are small\\n bilateral effusions. The cardiac silhouette remains enlarged. The aorta is\\n calcified. The left-sided pacer is unchanged with leads terminating in\\n expected location of the right atrium and right ventricle in the setting of\\n cardiomegaly. Multi-level thoracic spine degenerative changes are again\\n noted.\\n\\n IMPRESSION: Bilateral airspace consolidation concerning for pneumonia. Small\\n bilateral effusions.\\n\\n\"\n }\n]"}}},{"rowIdx":992,"cells":{"subject_id":{"kind":"number","value":18237,"string":"18,237"},"hadm_id":{"kind":"number","value":109560,"string":"109,560"},"target_text":{"kind":"string","value":"# Pancytopenia: On admission the patient was found to be pancytopenic - Hct 14.5, WBC 2.9, ptl 89. The initial differential included idiopathic, medication-induced aplastic anemia (nifedipine, NSAIDs), viral-induced aplastic anemia (HIV, parvo B19), myelodysplastic syndrome (?lymphoma or other malignancy), TTP (without fever, acute renal dysfunction, with mental status changes, anemia, and thromboctopenia)or DIC with elevated INR. There was evidence of hemolysis with LDH in range and hapto <20, D-dimer 2600. The patient received 3 units PRBC in the ED and was transfered to the MICU for further monitorin of his hypotension. He was given an additional 2 Units of PRBC in the MICU. His Hct rose appropriately to PRBC, being 30.3 after a total of 5 Units given. The peripheral smear was most notable for polychromatophilia and anisocytosis. The obtained additional labs revealed a Vit B12 deficiency (75), Folate normal (6.2), elevated Iron (233) and Ferritin (624) and low TiBC (186). Parameters indicating Hemolysis were low: Hapto(<20), elevated tBili (2.6) and dBili 0.7. The Retic Count of 0.9 showed impaired production in the BM. Given that the pt was Vit B12 deficient and that is presentation could be well explained a possible BM biopsy was postponed. He was started on Cyanocobalamin 1000mcg sc/im daily and Folate 5mg iv daily. The LDH increase persisted initially, and then started to steadily go down, same with tBili. Since his Retic Count did not respond as expected to Vit B12 supplementation (being 0.4 on ) a bone marrow biopsy was obtained (on ) to r/o an additional hemolytic disorder, such as AML, aplastic anemia. The BM biopsy confirmed the diagnosis of Vit B12 deficiency as the underlying disorder and showed no signs of leukemia. The pt was kept inpatient over the weekend because his thrombocytes continously dropped (32 on ) despite the initiated Vit B12 therapy; however, his platelets gradually increased and he was discharged to rehab with all counts trending upwards. . # Hypotension On admission the pt presented with BP of 86/48. He reported light-headnesses and dizziness but denied syncopal episodes, falls, CP or SOB. His physical exam did not reveal signs of HF, such as increased JVD, hepatojugular reflux, ascites or peripheral edema. His hypotension was to dehydration and his BP was successfully elevated by volume resuscitation (3l of IVF and 5 Units of PRBC) and d/c of home BP-meds. He was transfered to the MICU for overnight supervision. His SBPs have remained stable over the rest of his hospital stay (SBP 110-130) and he was put back on Lisinopril 10mg po daily. Before discharge patient's blood pressure improved and he was restarted on atenolol 25 with SBP 100-110 range. . # Lethargy, confusion Pt presented with 5 days h/o worsening confusion, possible baseline dementia, to the ED. He has a PMH for stroke in , with no residual deficits per wife. In the ED a CT of the head was obtained to r/o possible stroke as cause for MS changes. It showed subacute/chronic infarcy in right occipital lobe. Neuro evaluated the patient in the ED and felt that this was most likely consistent with chronic infarct. Pt had waxing and episodes of confusion (disoriented to date, location and context; agitation) when still on the MICU and after he was transfered to the floor. Since the CT had been negative for acute bleeding, the changes in his MS to his hypotension on presentation as well as to the Vit B12 deficiency. A EEG was performed, following neuro recs, which showed widespread encephalopathy. Since the pt MS improved over the course of his hospital stay, and considering the facts presented above, Neuro did not think that a MRI of his head was indicated for further work-up. Patient is likely to have baseline dementia (atrophy seen on initial CT) and (resolving) neurologic manifestation from Vit B12 deficiency. . # EKG changes The EKG drawn in the ED showed the following abnormalities: RBBB, ST-depressions and TWI in V1-V6, which were thought to be a result of demand ischemia. His CK was 43 and his Troponin 0.02. There was only little suspicion for ACS as the etiology for his hypotension, since the pt had no complaints of shortness of breath/chest pain or radiating pain. EKG and Troponin were monitored closely over the following days and resolved after the pt was normotensive and had received PRBC. A repeat EKG on showed RBBB, no remaining ST-depressions or TWI. His Troponin on was 0.04. He was started on Lipitor 10mg daily. Given the pt PMH and his strong FH for CAD, he should receive outpatient work-up of underlying CAD. . # Chronic renal insufficiency Creatinine presented with Creatinine of 1.7 on admission, which was his baseline Crea according to old recs. The chronic renal insufficiency might be due to diabetic nephropathy. However, since the creatinine steadily improved over the course of the hospital stay, being 1.1 on , a prerenal component (secondary to dehydration) was thought to play a key role. . # Pt has a h/o DM, which he is seen for by his PCP at the . On admission he was on oral hypoglycemics, metformin and glyburide, but was changed to a ISS (Humalog). Patient was subsequently restarted on his oral hypoglycemic before discharge with suplemental sliding scale."},"extractive_notes_summ":{"kind":"string","value":"Sinus rhythmRight bundle branch blockLeft atrial abnormalityAnterolateral ST-T wave abnormalities -may be in part primary and arenonspecific - clinical correlation is suggestedSince previous tracing of same date, no significant change Sinus rhythmRight bundle branch blockLeft atrial abnormalityAnterolateral ST-T wave abnormalities - may be in part primary and arenonspecific - clinical correlation is suggestedSince previous tracing of , ST-T wave abnormalities decreased Sinus rhythm with occasional atrial ectopy. Sinus rhythm with occasional atrial ectopy. HEAD CT IN ED SHOWED NON-ACUTE INFARCT TO RT OCCIPITAL LOBE. Left atrial abnormality. ASA ON HOLD FOR NOW.RESP) LS WITH SCATT RHONCHI THROUGHOUT WITH OCC EXP WHEEZES THIS AM. Otherwise, no significant diagnostic change.TRACING #1 1.5-cm hypodense area in the right occipital lobe, which may represent subacute-to-chronic infarction. WHEEZES GONE AFTER LASIX GIVEN. There is continued mild tortuosity of the thoracic aorta with calcification. PT HAS BEEN ORIENTED X2 AND HAS SHORT TERM MEMORY LOSS. PT HAS NOW BEEN DX'D WITH B 12 DEFICENCY. DIET ADVANCED TO REG/DIABETIC DIET AND TOL WELL BY PT. 1.5 cm hyppodense area in the right occipital lobe, which may represent subacute/chronic infarction. REASON FOR THIS EXAMINATION: Eval for ICH or mass No contraindications for IV contrast WET READ: MNIa MON 11:47 PM No bleed. Sinus rhythmRight bundle branch blockLeft atrial abnormalityDiffuse ST-T wave abnormalities -are in part primary and suggest ischemia -clinical correlation is suggestedNo previous tracing available for comparison NEURO C/S DONE.CV) VSS AND WNL'S. Compared to the previous tracing of atrial ectopyis new. PT HAS = PUPILS, BUT RT PUPIL REACTS SL SLUGGISH COMPARE TO LT, MD AWARE. Note is made of 1.5-cm hypodense lesion in the medial portion of right occipital lobe, which may represent subacute-to- chronic infarction. Compared to the previous tracingof no significant diagnostic change.TRACING #2 hemolysis and ? TECHNIQUE: Non-contrast head CT. No comparison. There is mild congestive heart failure with cardiomegaly and small bilateral pleural effusion associated with bibasilar patchy atelectasis. IF PT NEEDS F/U CT SCAN. PT MIGHT NEED A 1:1 SITTER ONCE TRANSFRED. CHEST AP PORTABLE: The heart size is probably top normal. IMPRESSION: Mild congestive heart failure with cardiomegaly and small bilateral pleural effusion. SBP 117-130'S AND HR 70-80'S. Note added at attending review: There also appears to be some evidence of chronic infarction in the postero-medial right temporal lobe. FINDINGS: The evaluation is somewhat limited due to motion artifact. CM IN NSR WITHOUT ANY ECTOPY. Bilateral ventricles are somewhat prominent with brain atrophy. VIT K THIS AM GIVEN INR OF 1.7 . Somewhat limited study due to motion artifact. Heart size top normal. NO N/V/D AT THIS TIME. The pulmonary vasculature is unremarkable. IMPRESSION: Apparent mediastinal widening and prominent aortic contours may be due to AP technique. IVF @ KVO. No acute intracranial hemorrhage. PT HAS = STRENGHT TO ALL EXT'S. IMPRESSION: 1. Clinical correlation is advised. Clinical correlation is recommended. Clinical correlation is recommended. RR 30-40'S BUT IN NO RESP DISTRESS. COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared with the previous study of yesterday. NO EDEMA NOTED. The lungs are grossly clear without focal consolidation, pleural effusion or pneumothorax. The osseous and soft tissue structures are unremarkable. HO TO ASSESS. Rightbundle-branch block. Brain atrophy. The information was communicated with the referring physician, . 9:30 AM CHEST (PORTABLE AP) Clip # Reason: evidence of pulm edema Admitting Diagnosis: HYPOTENSION MEDICAL CONDITION: 71 year old man with ? PT ALSO HAD NON-PROD COUGH THIS AM, BUT NOT AFTER LASIX THIS PM. If there is concern for aortic pathology, chest CT could be performed. PT DENIES ANY CP OR ANY OTHER CARDIAC SYMPTOMS. Pulmonary vascular congestion has progressed but there is no pulmonary edema. If there is a high concern for acute infarct, MRI will be helpful. ABD DIST/SOFT AND NON-TENDER TO TOUCH. COMPARISON: No prior study available. REASON FOR THIS EXAMINATION: evidence of pulm edema FINAL REPORT AP CHEST, 9:41 A.M., HISTORY: Hemolysis, question lymphoma. ORAL DIABETIC MED'S HELD FOR NOW HIS RENAL STATUS (ELEVATED CREATINE).GU) FOLEY CATHETER D/C'D THIS PM AT 15:00 AND HAS THEN VOIDED TWICE VIA URINAL IN GOOD AMOUNTS.PAIN) PT DENIES ANY DISCOMFORT.SKIN) SKIN INTACT WITH OLD SCARS TO BIL LOWER LEGS.SOC) PT IS MARRIED WITH 7 CHILDREN. No pleural effusion. There is apparent mediastinal widening and prominence of the aortic contours which may be due to the AP technique. FINAL REPORT INDICATION: 71-year-old male with fatigue, lethargy, and hypertension. The lungs are clear otherwise. lymphoma (by labs) s/p several units of blood products and IVF after hypotension. 11:17 PM CT HEAD W/O CONTRAST Clip # Reason: Eval for ICH or mass MEDICAL CONDITION: 71 year old man with fatigue, lethargy, and hypotension. (NEURO) PT HAS BEEN CALM AND COOPERATIVE MOST OF THE DAY, BUT IS STARTING TO BECOME AGITATED AT 17:30. Severe degenerative changes of the spine. 7 AM TO 7 PM:PT HAD AN UNEVENTFUL DAY. IMPRESSION: AP chest compared to at 10:04 p.m. O2SAT 93 ON RA THIS AM AND UP TO 96-98% ON 2 LITER."},"n_notes":{"kind":"number","value":10,"string":"10"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2106-05-18 00:00:00.000","description":"Report","row_id":1502236,"text":"7 AM TO 7 PM:\n\nPT HAD AN UNEVENTFUL DAY. PT HAS NOW BEEN DX'D WITH B 12 DEFICENCY. (B12 WAS 75 THIS AM, NORMAL RANGE 240-900).\n\n(NEURO) PT HAS BEEN CALM AND COOPERATIVE MOST OF THE DAY, BUT IS STARTING TO BECOME AGITATED AT 17:30. HO TO ASSESS. PT HAS BEEN ORIENTED X2 AND HAS SHORT TERM MEMORY LOSS. PT HAS = PUPILS, BUT RT PUPIL REACTS SL SLUGGISH COMPARE TO LT, MD AWARE. PT HAS = STRENGHT TO ALL EXT'S. HEAD CT IN ED SHOWED NON-ACUTE INFARCT TO RT OCCIPITAL LOBE. ? IF PT NEEDS F/U CT SCAN. NEURO C/S DONE.\n\nCV) VSS AND WNL'S. SBP 117-130'S AND HR 70-80'S. CM IN NSR WITHOUT ANY ECTOPY. PT DENIES ANY CP OR ANY OTHER CARDIAC SYMPTOMS. NO EDEMA NOTED. VIT K THIS AM GIVEN INR OF 1.7 . ASA ON HOLD FOR NOW.\n\nRESP) LS WITH SCATT RHONCHI THROUGHOUT WITH OCC EXP WHEEZES THIS AM. WHEEZES GONE AFTER LASIX GIVEN. (LASIX 20 MG X2). RR 30-40'S BUT IN NO RESP DISTRESS. O2SAT 93 ON RA THIS AM AND UP TO 96-98% ON 2 LITER. PT ALSO HAD NON-PROD COUGH THIS AM, BUT NOT AFTER LASIX THIS PM. CXR DONE THIS AM.\n\nGI) BS+ TO ALL QUAD'S. ABD DIST/SOFT AND NON-TENDER TO TOUCH. NO N/V/D AT THIS TIME. IVF @ KVO. DIET ADVANCED TO REG/DIABETIC DIET AND TOL WELL BY PT. PT HAS A GOOD APPETITE.\n\nENDO) PT'S FSBS AT 17:00 WAS 147 AND WAS GIVEN 3 UNITS. ORAL DIABETIC MED'S HELD FOR NOW HIS RENAL STATUS (ELEVATED CREATINE).\n\nGU) FOLEY CATHETER D/C'D THIS PM AT 15:00 AND HAS THEN VOIDED TWICE VIA URINAL IN GOOD AMOUNTS.\n\nPAIN) PT DENIES ANY DISCOMFORT.\n\nSKIN) SKIN INTACT WITH OLD SCARS TO BIL LOWER LEGS.\n\nSOC) PT IS MARRIED WITH 7 CHILDREN. PT LIVES WITH WIFE AND ONE SON. WIFE HAS BEEN UPDATED OF PT'S STATUS AND ABOUT TRANSFER TO FLOOR BY MD.\n\nPLAN) TO BE TRANSFERED TO CC7 FOR FURTHER TREATMENT. PT MIGHT NEED A 1:1 SITTER ONCE TRANSFRED.\n"},{"category":"ECG","chartdate":"2106-05-20 00:00:00.000","description":"Report","row_id":178784,"text":"Sinus rhythm with occasional atrial ectopy. Compared to the previous tracing\nof no significant diagnostic change.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2106-05-19 00:00:00.000","description":"Report","row_id":178785,"text":"Sinus rhythm with occasional atrial ectopy. Left atrial abnormality. Right\nbundle-branch block. Compared to the previous tracing of atrial ectopy\nis new. Otherwise, no significant diagnostic change.\nTRACING #1\n\n"},{"category":"ECG","chartdate":"2106-05-18 00:00:00.000","description":"Report","row_id":178786,"text":"Sinus rhythm\nRight bundle branch block\nLeft atrial abnormality\nAnterolateral ST-T wave abnormalities -may be in part primary and are\nnonspecific - clinical correlation is suggested\nSince previous tracing of same date, no significant change\n\n"},{"category":"ECG","chartdate":"2106-05-18 00:00:00.000","description":"Report","row_id":178787,"text":"Sinus rhythm\nRight bundle branch block\nLeft atrial abnormality\nAnterolateral ST-T wave abnormalities - may be in part primary and are\nnonspecific - clinical correlation is suggested\nSince previous tracing of , ST-T wave abnormalities decreased\n\n"},{"category":"ECG","chartdate":"2106-05-17 00:00:00.000","description":"Report","row_id":178788,"text":"Sinus rhythm\nRight bundle branch block\nLeft atrial abnormality\nDiffuse ST-T wave abnormalities -are in part primary and suggest ischemia -\nclinical correlation is suggested\nNo previous tracing available for comparison\n\n"},{"category":"Radiology","chartdate":"2106-05-17 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":913042,"text":" 11:17 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for ICH or mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fatigue, lethargy, and hypotension.\n REASON FOR THIS EXAMINATION:\n Eval for ICH or mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa MON 11:47 PM\n No bleed. 1.5 cm hyppodense area in the right occipital lobe, which may\n represent subacute/chronic infarction. Clinical correlation is recommended. If\n there is a high concern for acute infarct, MRI will be helpful.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male with fatigue, lethargy, and hypertension.\n\n TECHNIQUE: Non-contrast head CT.\n\n No comparison.\n\n FINDINGS: The evaluation is somewhat limited due to motion artifact. No\n evidence of intracranial hemorrhage. Bilateral ventricles are somewhat\n prominent with brain atrophy. Note is made of 1.5-cm hypodense lesion in the\n medial portion of right occipital lobe, which may represent subacute-to-\n chronic infarction. The osseous and soft tissue structures are unremarkable.\n\n IMPRESSION:\n\n 1. No acute intracranial hemorrhage. Somewhat limited study due to motion\n artifact. Brain atrophy.\n\n 2. 1.5-cm hypodense area in the right occipital lobe, which may represent\n subacute-to-chronic infarction. Clinical correlation is recommended. MRI\n will be helpful for further evaluation.\n\n The information was communicated with the referring physician, . , by\n telephone at the time of interpretation.\n\n Note added at attending review: There also appears to be some evidence of\n chronic infarction in the postero-medial right temporal lobe.\n\n"},{"category":"Radiology","chartdate":"2106-05-18 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":913085,"text":" 9:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evidence of pulm edema\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with ? hemolysis and ? lymphoma (by labs) s/p several units of\n blood products and IVF after hypotension.\n\n REASON FOR THIS EXAMINATION:\n evidence of pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:41 A.M., \n\n HISTORY: Hemolysis, question lymphoma.\n\n IMPRESSION: AP chest compared to at 10:04 p.m.\n\n Pulmonary vascular congestion has progressed but there is no pulmonary edema.\n Heart size top normal. No pleural effusion.\n\n\n"},{"category":"Radiology","chartdate":"2106-05-17 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":913035,"text":" 9:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with hypotension\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n 71-year-old male with hypotension.\n\n COMPARISON: No prior study available.\n\n CHEST AP PORTABLE: The heart size is probably top normal. There is apparent\n mediastinal widening and prominence of the aortic contours which may be due to\n the AP technique. The lungs are grossly clear without focal consolidation,\n pleural effusion or pneumothorax. The pulmonary vasculature is unremarkable.\n Severe degenerative changes of the spine.\n\n IMPRESSION: Apparent mediastinal widening and prominent aortic contours may\n be due to AP technique. No prior study available for comparison. Clinical\n correlation is advised. If there is concern for aortic pathology, chest CT\n could be performed.\n\n This was discussed with Dr. at 10:30 p.m. on .\n\n\n\n\n\n"},{"category":"Radiology","chartdate":"2106-05-19 00:00:00.000","description":"CHEST (PA & LAT)","row_id":913241,"text":" 10:56 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for CHF, wide mediastinum\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with DM and B12 deficiency, with previous CXR showing wide\n mediastinum\n REASON FOR THIS EXAMINATION:\n evaluate for CHF, wide mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS\n\n INDICATION: 71-year-old man with diabetes mellitus and B12 deficiency.\n\n COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared\n with the previous study of yesterday.\n\n There is mild congestive heart failure with cardiomegaly and small bilateral\n pleural effusion associated with bibasilar patchy atelectasis. The lungs are\n clear otherwise. There is continued mild tortuosity of the thoracic aorta\n with calcification.\n\n IMPRESSION: Mild congestive heart failure with cardiomegaly and small\n bilateral pleural effusion.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2106-05-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1502236,\n \"text\": \"7 AM TO 7 PM:\\n\\nPT HAD AN UNEVENTFUL DAY. PT HAS NOW BEEN DX'D WITH B 12 DEFICENCY. (B12 WAS 75 THIS AM, NORMAL RANGE 240-900).\\n\\n(NEURO) PT HAS BEEN CALM AND COOPERATIVE MOST OF THE DAY, BUT IS STARTING TO BECOME AGITATED AT 17:30. HO TO ASSESS. PT HAS BEEN ORIENTED X2 AND HAS SHORT TERM MEMORY LOSS. PT HAS = PUPILS, BUT RT PUPIL REACTS SL SLUGGISH COMPARE TO LT, MD AWARE. PT HAS = STRENGHT TO ALL EXT'S. HEAD CT IN ED SHOWED NON-ACUTE INFARCT TO RT OCCIPITAL LOBE. ? IF PT NEEDS F/U CT SCAN. NEURO C/S DONE.\\n\\nCV) VSS AND WNL'S. SBP 117-130'S AND HR 70-80'S. CM IN NSR WITHOUT ANY ECTOPY. PT DENIES ANY CP OR ANY OTHER CARDIAC SYMPTOMS. NO EDEMA NOTED. VIT K THIS AM GIVEN INR OF 1.7 . ASA ON HOLD FOR NOW.\\n\\nRESP) LS WITH SCATT RHONCHI THROUGHOUT WITH OCC EXP WHEEZES THIS AM. WHEEZES GONE AFTER LASIX GIVEN. (LASIX 20 MG X2). RR 30-40'S BUT IN NO RESP DISTRESS. O2SAT 93 ON RA THIS AM AND UP TO 96-98% ON 2 LITER. PT ALSO HAD NON-PROD COUGH THIS AM, BUT NOT AFTER LASIX THIS PM. CXR DONE THIS AM.\\n\\nGI) BS+ TO ALL QUAD'S. ABD DIST/SOFT AND NON-TENDER TO TOUCH. NO N/V/D AT THIS TIME. IVF @ KVO. DIET ADVANCED TO REG/DIABETIC DIET AND TOL WELL BY PT. PT HAS A GOOD APPETITE.\\n\\nENDO) PT'S FSBS AT 17:00 WAS 147 AND WAS GIVEN 3 UNITS. ORAL DIABETIC MED'S HELD FOR NOW HIS RENAL STATUS (ELEVATED CREATINE).\\n\\nGU) FOLEY CATHETER D/C'D THIS PM AT 15:00 AND HAS THEN VOIDED TWICE VIA URINAL IN GOOD AMOUNTS.\\n\\nPAIN) PT DENIES ANY DISCOMFORT.\\n\\nSKIN) SKIN INTACT WITH OLD SCARS TO BIL LOWER LEGS.\\n\\nSOC) PT IS MARRIED WITH 7 CHILDREN. PT LIVES WITH WIFE AND ONE SON. WIFE HAS BEEN UPDATED OF PT'S STATUS AND ABOUT TRANSFER TO FLOOR BY MD.\\n\\nPLAN) TO BE TRANSFERED TO CC7 FOR FURTHER TREATMENT. PT MIGHT NEED A 1:1 SITTER ONCE TRANSFRED.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2106-05-20 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178784,\n \"text\": \"Sinus rhythm with occasional atrial ectopy. Compared to the previous tracing\\nof no significant diagnostic change.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2106-05-19 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178785,\n \"text\": \"Sinus rhythm with occasional atrial ectopy. Left atrial abnormality. Right\\nbundle-branch block. Compared to the previous tracing of atrial ectopy\\nis new. Otherwise, no significant diagnostic change.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2106-05-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178786,\n \"text\": \"Sinus rhythm\\nRight bundle branch block\\nLeft atrial abnormality\\nAnterolateral ST-T wave abnormalities -may be in part primary and are\\nnonspecific - clinical correlation is suggested\\nSince previous tracing of same date, no significant change\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2106-05-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178787,\n \"text\": \"Sinus rhythm\\nRight bundle branch block\\nLeft atrial abnormality\\nAnterolateral ST-T wave abnormalities - may be in part primary and are\\nnonspecific - clinical correlation is suggested\\nSince previous tracing of , ST-T wave abnormalities decreased\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2106-05-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 178788,\n \"text\": \"Sinus rhythm\\nRight bundle branch block\\nLeft atrial abnormality\\nDiffuse ST-T wave abnormalities -are in part primary and suggest ischemia -\\nclinical correlation is suggested\\nNo previous tracing available for comparison\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2106-05-17 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 913042,\n \"text\": \" 11:17 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Eval for ICH or mass\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with fatigue, lethargy, and hypotension.\\n REASON FOR THIS EXAMINATION:\\n Eval for ICH or mass\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n WET READ: MNIa MON 11:47 PM\\n No bleed. 1.5 cm hyppodense area in the right occipital lobe, which may\\n represent subacute/chronic infarction. Clinical correlation is recommended. If\\n there is a high concern for acute infarct, MRI will be helpful.\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 71-year-old male with fatigue, lethargy, and hypertension.\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n No comparison.\\n\\n FINDINGS: The evaluation is somewhat limited due to motion artifact. No\\n evidence of intracranial hemorrhage. Bilateral ventricles are somewhat\\n prominent with brain atrophy. Note is made of 1.5-cm hypodense lesion in the\\n medial portion of right occipital lobe, which may represent subacute-to-\\n chronic infarction. The osseous and soft tissue structures are unremarkable.\\n\\n IMPRESSION:\\n\\n 1. No acute intracranial hemorrhage. Somewhat limited study due to motion\\n artifact. Brain atrophy.\\n\\n 2. 1.5-cm hypodense area in the right occipital lobe, which may represent\\n subacute-to-chronic infarction. Clinical correlation is recommended. MRI\\n will be helpful for further evaluation.\\n\\n The information was communicated with the referring physician, . , by\\n telephone at the time of interpretation.\\n\\n Note added at attending review: There also appears to be some evidence of\\n chronic infarction in the postero-medial right temporal lobe.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2106-05-18 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 913085,\n \"text\": \" 9:30 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: evidence of pulm edema\\n Admitting Diagnosis: HYPOTENSION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with ? hemolysis and ? lymphoma (by labs) s/p several units of\\n blood products and IVF after hypotension.\\n\\n REASON FOR THIS EXAMINATION:\\n evidence of pulm edema\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 9:41 A.M., \\n\\n HISTORY: Hemolysis, question lymphoma.\\n\\n IMPRESSION: AP chest compared to at 10:04 p.m.\\n\\n Pulmonary vascular congestion has progressed but there is no pulmonary edema.\\n Heart size top normal. No pleural effusion.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2106-05-17 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 913035,\n \"text\": \" 9:45 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for acute process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with hypotension\\n REASON FOR THIS EXAMINATION:\\n eval for acute process\\n ______________________________________________________________________________\\n FINAL REPORT\\n 71-year-old male with hypotension.\\n\\n COMPARISON: No prior study available.\\n\\n CHEST AP PORTABLE: The heart size is probably top normal. There is apparent\\n mediastinal widening and prominence of the aortic contours which may be due to\\n the AP technique. The lungs are grossly clear without focal consolidation,\\n pleural effusion or pneumothorax. The pulmonary vasculature is unremarkable.\\n Severe degenerative changes of the spine.\\n\\n IMPRESSION: Apparent mediastinal widening and prominent aortic contours may\\n be due to AP technique. No prior study available for comparison. Clinical\\n correlation is advised. If there is concern for aortic pathology, chest CT\\n could be performed.\\n\\n This was discussed with Dr. at 10:30 p.m. on .\\n\\n\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2106-05-19 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 913241,\n \"text\": \" 10:56 AM\\n CHEST (PA & LAT) Clip # \\n Reason: evaluate for CHF, wide mediastinum\\n Admitting Diagnosis: HYPOTENSION\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 71 year old man with DM and B12 deficiency, with previous CXR showing wide\\n mediastinum\\n REASON FOR THIS EXAMINATION:\\n evaluate for CHF, wide mediastinum\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST TWO VIEWS\\n\\n INDICATION: 71-year-old man with diabetes mellitus and B12 deficiency.\\n\\n COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared\\n with the previous study of yesterday.\\n\\n There is mild congestive heart failure with cardiomegaly and small bilateral\\n pleural effusion associated with bibasilar patchy atelectasis. The lungs are\\n clear otherwise. There is continued mild tortuosity of the thoracic aorta\\n with calcification.\\n\\n IMPRESSION: Mild congestive heart failure with cardiomegaly and small\\n bilateral pleural effusion.\\n\\n\\n\"\n }\n]"}}},{"rowIdx":993,"cells":{"subject_id":{"kind":"number","value":61673,"string":"61,673"},"hadm_id":{"kind":"number","value":180117,"string":"180,117"},"target_text":{"kind":"string","value":"81F with UC, HTN, CAD presenting with hypotension and abdominal pain/diarrhea/pancolitis, consistent with sepsis from abdominal source. See below for discussion of each issue. 1. Hypotension: was related to sepsis. Improved with fluid boluses initially. She was started on broad spectrum abx for presumed intraabdominal sepsis. She then changed her code status to CMO and refused antibiotics for about 12 hours. The next day, she changed her mind and antibiotics were restarted, but she still did not want any aggressive or invasive care. A CT was planned to evaluate her abdomen, but refused by the patient. After about 36 hours since restarting her antibiotics, she again developed hypotension. After talking with the family, pressors were not started and she expired. . 2. Abdominal pain/Pancolitis: Pt with pancolitis on CT scan and malnutrition, failure to thrive. Surgery was consulted and she was not a candidate. GI was consulted and they recommended decreasing her steroids. She remained on steroids until she became CMO. . 3. AF: Not anticoagulated. Was on amio drip initially but pressures did not tolerate. She was switched to PRN metoprolol boluses. . 4. Wheezing/resp distress: Likely related to volume challenge since was not wheezing prior to fluid boluses and has know low EF. Was on supplemental O2 and had no futher shortness of breath. . 5. Goals of care: she was initially DNR/DNI and then refused aggressive and interventional measures. Her sepsis eventually led to shock and she passed away very comfortably with a few doses of morphine for her abdominal pain."},"extractive_notes_summ":{"kind":"string","value":"There is a paucity of gas in the ascending, descending colon and rectum. IMPRESSION: Abnormal appearance to midabdominal loops with relatively a featureless appearance. There is a left-sided PICC line with tip close to midline, not yet crossing to the superior vena cava. T waveinversions in leads V1-V2 of unclear significance. Generalized low QRS voltages. The aorta is mildly calcified. There are bilateral lower lobe infiltrates, left greater than right and a small left effusion. IMPRESSION: Worsening CHF. Consider presence ofpericardial effusion, hypothyroidism, large body habitus or diffusecardiomyopathy. There are few scattered air-fluid levels on the decubitus film. Given history of pancolitis this could represent the abnormal appearing transverse colon. The heart is upper limits normal in size. Sinus rhythm. Baseline artifact. FINDINGS: Supine portable and lateral decubitus films show a few gas-filled loops of relatively a featureless bowel in the mid abdomen measuring up to 5.1 cm. Compared to the study from earlier the same day, there is no significant interval change. No previous tracing available for comparison. FINDINGS: There are no old films available for comparison. REASON FOR THIS EXAMINATION: eval NGT placement FINAL REPORT CHEST ON HISTORY: Ulcerative colitis flare. There is no pneumothorax. An underlying infectious infiltrate cannot be excluded. No evidence of obstruction. HISTORY: Central line. REFERENCE EXAMINATION: at 3:30. REFERENCE EXAM: at 06:30. FINDINGS: Compared to the prior study, there has been some increase in the vascular plethora with ill-defined vasculature and bilateral effusions are slightly larger. 3:23 AM PORTABLE ABDOMEN Clip # Reason: please eval for free air, acute process Admitting Diagnosis: GASTROENTERITIS MEDICAL CONDITION: 81 year old woman with pancolitis, hypotension, sepsis REASON FOR THIS EXAMINATION: please eval for free air, acute process FINAL REPORT ABDOMEN FILMS ON HISTORY: Pancolitis, hypotension. 3:22 AM CHEST (PORTABLE AP) Clip # Reason: please eval placement Admitting Diagnosis: GASTROENTERITIS MEDICAL CONDITION: 81 year old woman with midline REASON FOR THIS EXAMINATION: please eval placement FINAL REPORT CHEST ON . 6:19 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: please eval for acute process Admitting Diagnosis: GASTROENTERITIS MEDICAL CONDITION: 81 year old woman with resp distress REASON FOR THIS EXAMINATION: please eval for acute process FINAL REPORT CHEST HISTORY: Respiratory distress."},"n_notes":{"kind":"number","value":5,"string":"5"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2156-02-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1176642,"text":" 6:19 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval for acute process\n Admitting Diagnosis: GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with resp distress\n REASON FOR THIS EXAMINATION:\n please eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Respiratory distress.\n\n REFERENCE EXAMINATION: at 3:30.\n\n FINDINGS: Compared to the prior study, there has been some increase in the\n vascular plethora with ill-defined vasculature and bilateral effusions are\n slightly larger.\n\n IMPRESSION: Worsening CHF. An underlying infectious infiltrate cannot be\n excluded.\n\n\n"},{"category":"Radiology","chartdate":"2156-02-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1176700,"text":" 2:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval NGT placement\n Admitting Diagnosis: GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with UC here with UC flare and sepsis.\n REASON FOR THIS EXAMINATION:\n eval NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Ulcerative colitis flare.\n\n REFERENCE EXAM: at 06:30.\n\n Compared to the study from earlier the same day, there is no significant\n interval change.\n\n\n"},{"category":"Radiology","chartdate":"2156-02-01 00:00:00.000","description":"PORTABLE ABDOMEN","row_id":1176634,"text":" 3:23 AM\n PORTABLE ABDOMEN Clip # \n Reason: please eval for free air, acute process\n Admitting Diagnosis: GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with pancolitis, hypotension, sepsis\n REASON FOR THIS EXAMINATION:\n please eval for free air, acute process\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN FILMS ON \n\n HISTORY: Pancolitis, hypotension.\n\n FINDINGS: Supine portable and lateral decubitus films show a few gas-filled\n loops of relatively a featureless bowel in the mid abdomen measuring up to 5.1\n cm. Given history of pancolitis this could represent the abnormal appearing\n transverse colon. There is a paucity of gas in the ascending, descending\n colon and rectum. There are few scattered air-fluid levels on the decubitus\n film.\n\n IMPRESSION: Abnormal appearance to midabdominal loops with relatively a\n featureless appearance. No evidence of obstruction.\n\n\n"},{"category":"Radiology","chartdate":"2156-02-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1176626,"text":" 3:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval placement\n Admitting Diagnosis: GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with midline\n REASON FOR THIS EXAMINATION:\n please eval placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON .\n\n HISTORY: Central line.\n\n FINDINGS: There are no old films available for comparison. The heart is\n upper limits normal in size. The aorta is mildly calcified. There are\n bilateral lower lobe infiltrates, left greater than right and a small left\n effusion. There is a left-sided PICC line with tip close to midline, not yet\n crossing to the superior vena cava. There is no pneumothorax.\n\n\n"},{"category":"ECG","chartdate":"2156-02-01 00:00:00.000","description":"Report","row_id":165775,"text":"Baseline artifact. Sinus rhythm. Generalized low QRS voltages. T wave\ninversions in leads V1-V2 of unclear significance. Consider presence of\npericardial effusion, hypothyroidism, large body habitus or diffuse\ncardiomyopathy. No previous tracing available for comparison.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-02-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1176642,\n \"text\": \" 6:19 AM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: please eval for acute process\\n Admitting Diagnosis: GASTROENTERITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with resp distress\\n REASON FOR THIS EXAMINATION:\\n please eval for acute process\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST\\n\\n HISTORY: Respiratory distress.\\n\\n REFERENCE EXAMINATION: at 3:30.\\n\\n FINDINGS: Compared to the prior study, there has been some increase in the\\n vascular plethora with ill-defined vasculature and bilateral effusions are\\n slightly larger.\\n\\n IMPRESSION: Worsening CHF. An underlying infectious infiltrate cannot be\\n excluded.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-02-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1176700,\n \"text\": \" 2:54 PM\\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \\n Reason: eval NGT placement\\n Admitting Diagnosis: GASTROENTERITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with UC here with UC flare and sepsis.\\n REASON FOR THIS EXAMINATION:\\n eval NGT placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST ON \\n\\n HISTORY: Ulcerative colitis flare.\\n\\n REFERENCE EXAM: at 06:30.\\n\\n Compared to the study from earlier the same day, there is no significant\\n interval change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-02-01 00:00:00.000\",\n \"description\": \"PORTABLE ABDOMEN\",\n \"row_id\": 1176634,\n \"text\": \" 3:23 AM\\n PORTABLE ABDOMEN Clip # \\n Reason: please eval for free air, acute process\\n Admitting Diagnosis: GASTROENTERITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with pancolitis, hypotension, sepsis\\n REASON FOR THIS EXAMINATION:\\n please eval for free air, acute process\\n ______________________________________________________________________________\\n FINAL REPORT\\n ABDOMEN FILMS ON \\n\\n HISTORY: Pancolitis, hypotension.\\n\\n FINDINGS: Supine portable and lateral decubitus films show a few gas-filled\\n loops of relatively a featureless bowel in the mid abdomen measuring up to 5.1\\n cm. Given history of pancolitis this could represent the abnormal appearing\\n transverse colon. There is a paucity of gas in the ascending, descending\\n colon and rectum. There are few scattered air-fluid levels on the decubitus\\n film.\\n\\n IMPRESSION: Abnormal appearance to midabdominal loops with relatively a\\n featureless appearance. No evidence of obstruction.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2156-02-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1176626,\n \"text\": \" 3:22 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: please eval placement\\n Admitting Diagnosis: GASTROENTERITIS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 81 year old woman with midline\\n REASON FOR THIS EXAMINATION:\\n please eval placement\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST ON .\\n\\n HISTORY: Central line.\\n\\n FINDINGS: There are no old films available for comparison. The heart is\\n upper limits normal in size. The aorta is mildly calcified. There are\\n bilateral lower lobe infiltrates, left greater than right and a small left\\n effusion. There is a left-sided PICC line with tip close to midline, not yet\\n crossing to the superior vena cava. There is no pneumothorax.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2156-02-01 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 165775,\n \"text\": \"Baseline artifact. Sinus rhythm. Generalized low QRS voltages. T wave\\ninversions in leads V1-V2 of unclear significance. Consider presence of\\npericardial effusion, hypothyroidism, large body habitus or diffuse\\ncardiomyopathy. No previous tracing available for comparison.\\n\\n\"\n }\n]"}}},{"rowIdx":994,"cells":{"subject_id":{"kind":"number","value":56996,"string":"56,996"},"hadm_id":{"kind":"number","value":114004,"string":"114,004"},"target_text":{"kind":"string","value":"67 yom with history of a.fib, on pradaxa, now presenting with worsening BRBPR and hematuria . # GI Bleed: Patient was monitored in the MICU overnight for GIB given pradaxa use. He remained normotensive throughout his MICU stay without drop in Hct. He was evaluated by GI who felt no urgent colonoscopy was needed, and symptoms were likely secondary hemorrhoidal and exacerbated by anticoagulation. He was transferred to the medical floor where he remained stable o/n. After discussion with Dr. the patient's out- patient cardiologist, given the fact that he has been in sinus for the better part of a year and has not flipped into AFIB he was d/c'd on full dose ASA with GI f/u scheduled. . # UTI: Patient was started on ciprofloxacin for UTI as evidenced by UA and dysuria. He was subsequently switched to cefpodoxime given concern for prolonged QTc in combination with amiodarone. Micro showed a sensitive E. Coli. . # Afib: Patient remained in sinus rhythm. Anticoagulation was initially held, then switched to ASA as above."},"extractive_notes_summ":{"kind":"string","value":"The visualized heart and pericardium are unremarkable. The seminal vesicles are unremarkable. retroperitoneal bleed FINAL REPORT (Cont) IMPRESSION: 1. The stomach, small bowel, colon, and rectum are unremarkable. Mild retrocardiac atelectasis. The ureters are unremarkable. The examination of the intra-abdominal organs is limited due to noncontrast technique. These may represent cysts, however, cannot be fully characterized on noncontrast CT scan. Hypodense lesions in each kidney likely represent cysts, however, not fully characterized on nonenhanced CT scan. Bilateral hypodense round lesions in kidneys, likely cysts but cannot fully characterize on non-contrast scan. There are moderate degenerative changes of lower thoracic and lumbar spine, most prominent at L3 through S1 with joint space narrowing and anterior and posterior osteophytes. The intra-abdominal vasculature is unremarkable; however, evaluation is limited due to lack of IV contrast. No retroperitoneal bleed. Given this limitation, the liver, pancreas, spleen and adrenal glands are unremarkable. Normal hilar and mediastinal contours. TECHNIQUE: MDCT images were obtained through the abdomen and pelvis without administration of contrast. No pleural effusions. FINDINGS: As compared to the previous radiograph, the signs indicative of volume overload have decreased but are still clearly present. The bladder wall is thickened and indistinct with some surrounding fat stranding indicating probable cystitis. Compared to prior, there is new central pulmonary vascular engorgement with mild cephalization of the pulmonary vasculature. IMPRESSION: Findings suggestive of mild pulmonary vascular congestion without frank pulmonary edema. There is no retroperitoneal hematoma. Sinus rhythm. There is no free fluid. retroperitoneal bleed CONTRAINDICATIONS for IV CONTRAST: WET READ: PRib WED 2:46 PM Bladder has thick walls with surrounding stranding, likely cystitis. No fractures or suspicious lytic or sclerotic lesions are identified. Thickened bladder wall with surrounding stranding potentially secondary to cystitis and correlation with UA suggested. COMPARISON: None available. There are no hernias identified. Enlarged prostate. Enlarged prostate. retroperitoneal bleed MEDICAL CONDITION: History: 67M with BRB PR, mild diffuse mild low left side pain, new renal failure REASON FOR THIS EXAMINATION: ? The appendix is not visualized; however, there is no evidence of appendicitis. There is a 4-cm round hypodense lesion in the superior pole of the right kidney. Cardiomediastinal silhouette is stable, as are the osseous and soft tissue structures. Coronal and sagittal reformations were performed. There is a 1.5-cm round hypodense lesion in the interpolar region of the left kidney. There is no confluent consolidation or effusion. There is no free air. Q-T interval prolongation. Clinical correlation is suggested. (Over) 1:37 PM CT ABD & PELVIS W/O CONTRAST Clip # Reason: ? 1:37 PM CT ABD & PELVIS W/O CONTRAST Clip # Reason: ? The prostate is enlarged. FINDINGS: The lung bases are clear. FINDINGS: Frontal and lateral views of the chest are compared to previous exam from . 4. COMPARISON: . 3. 2. Compared to the previous tracingof the T wave amplitude has increased while the QTc interval isprolonged. If desired US could help characterize. 11:19 AM CHEST (PA & LAT) Clip # Reason: pls eval ro infectious process MEDICAL CONDITION: History: 67M with hypotension REASON FOR THIS EXAMINATION: pls eval ro infectious process FINAL REPORT CHEST, TWO VIEWS: HISTORY: 67-year-old male with hypotension, rule out infectious process. 7:52 AM CHEST (PORTABLE AP) Clip # Reason: eval for vol overload Admitting Diagnosis: ACUTE RENAL FAILURE MEDICAL CONDITION: 67 year old man with concern for volume overload clinically REASON FOR THIS EXAMINATION: eval for vol overload FINAL REPORT CHEST RADIOGRAPH INDICATION: Volume overload, evaluation."},"n_notes":{"kind":"number","value":4,"string":"4"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2114-02-28 00:00:00.000","description":"CT ABD & PELVIS W/O CONTRAST","row_id":1234640,"text":" 1:37 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? retroperitoneal bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 67M with BRB PR, mild diffuse mild low left side pain, new renal\n failure\n REASON FOR THIS EXAMINATION:\n ? retroperitoneal bleed\n CONTRAINDICATIONS for IV CONTRAST:\n\n ______________________________________________________________________________\n WET READ: PRib WED 2:46 PM\n Bladder has thick walls with surrounding stranding, likely cystitis. No\n retroperitoneal bleed. Bilateral hypodense round lesions in kidneys, likely\n cysts but cannot fully characterize on non-contrast scan. Enlarged prostate.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old male with bright red blood per rectum and left side\n pain and renal failure, question retroperitoneal bleed.\n\n TECHNIQUE: MDCT images were obtained through the abdomen and pelvis without\n administration of contrast. Coronal and sagittal reformations were performed.\n\n COMPARISON: None available.\n\n FINDINGS: The lung bases are clear. The visualized heart and pericardium are\n unremarkable.\n\n The examination of the intra-abdominal organs is limited due to noncontrast\n technique. Given this limitation, the liver, pancreas, spleen and adrenal\n glands are unremarkable. There is a 1.5-cm round hypodense lesion in the\n interpolar region of the left kidney. There is a 4-cm round hypodense lesion\n in the superior pole of the right kidney. These may represent cysts, however,\n cannot be fully characterized on noncontrast CT scan. The ureters are\n unremarkable. The bladder wall is thickened and indistinct with some\n surrounding fat stranding indicating probable cystitis. The prostate is\n enlarged. The seminal vesicles are unremarkable.\n\n\n The stomach, small bowel, colon, and rectum are unremarkable. The appendix is\n not visualized; however, there is no evidence of appendicitis. There is no\n free fluid. There is no free air. The intra-abdominal vasculature is\n unremarkable; however, evaluation is limited due to lack of IV contrast.\n There are no hernias identified.\n\n There are moderate degenerative changes of lower thoracic and lumbar spine,\n most prominent at L3 through S1 with joint space narrowing and anterior and\n posterior osteophytes. No fractures or suspicious lytic or sclerotic lesions\n are identified.\n\n (Over)\n\n 1:37 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? retroperitoneal bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Thickened bladder wall with surrounding stranding potentially secondary to\n cystitis and correlation with UA suggested.\n\n 2. There is no retroperitoneal hematoma.\n\n 3. Hypodense lesions in each kidney likely represent cysts, however, not\n fully characterized on nonenhanced CT scan. If desired US could help\n characterize.\n\n 4. Enlarged prostate.\n\n"},{"category":"Radiology","chartdate":"2114-02-28 00:00:00.000","description":"CHEST (PA & LAT)","row_id":1234623,"text":" 11:19 AM\n CHEST (PA & LAT) Clip # \n Reason: pls eval ro infectious process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 67M with hypotension\n REASON FOR THIS EXAMINATION:\n pls eval ro infectious process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS: \n\n HISTORY: 67-year-old male with hypotension, rule out infectious process.\n\n FINDINGS: Frontal and lateral views of the chest are compared to previous\n exam from . Compared to prior, there is new central pulmonary\n vascular engorgement with mild cephalization of the pulmonary vasculature.\n There is no confluent consolidation or effusion. Cardiomediastinal silhouette\n is stable, as are the osseous and soft tissue structures.\n\n IMPRESSION: Findings suggestive of mild pulmonary vascular congestion without\n frank pulmonary edema.\n\n"},{"category":"Radiology","chartdate":"2114-03-01 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":1234745,"text":" 7:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for vol overload\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with concern for volume overload clinically\n REASON FOR THIS EXAMINATION:\n eval for vol overload\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Volume overload, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the signs indicative of\n volume overload have decreased but are still clearly present. No pleural\n effusions. Mild retrocardiac atelectasis. Normal hilar and mediastinal\n contours.\n\n\n"},{"category":"ECG","chartdate":"2114-02-28 00:00:00.000","description":"Report","row_id":112555,"text":"Sinus rhythm. Q-T interval prolongation. Compared to the previous tracing\nof the T wave amplitude has increased while the QTc interval is\nprolonged. Clinical correlation is suggested.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-02-28 00:00:00.000\",\n \"description\": \"CT ABD & PELVIS W/O CONTRAST\",\n \"row_id\": 1234640,\n \"text\": \" 1:37 PM\\n CT ABD & PELVIS W/O CONTRAST Clip # \\n Reason: ? retroperitoneal bleed\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 67M with BRB PR, mild diffuse mild low left side pain, new renal\\n failure\\n REASON FOR THIS EXAMINATION:\\n ? retroperitoneal bleed\\n CONTRAINDICATIONS for IV CONTRAST:\\n\\n ______________________________________________________________________________\\n WET READ: PRib WED 2:46 PM\\n Bladder has thick walls with surrounding stranding, likely cystitis. No\\n retroperitoneal bleed. Bilateral hypodense round lesions in kidneys, likely\\n cysts but cannot fully characterize on non-contrast scan. Enlarged prostate.\\n\\n WET READ VERSION #1\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 67-year-old male with bright red blood per rectum and left side\\n pain and renal failure, question retroperitoneal bleed.\\n\\n TECHNIQUE: MDCT images were obtained through the abdomen and pelvis without\\n administration of contrast. Coronal and sagittal reformations were performed.\\n\\n COMPARISON: None available.\\n\\n FINDINGS: The lung bases are clear. The visualized heart and pericardium are\\n unremarkable.\\n\\n The examination of the intra-abdominal organs is limited due to noncontrast\\n technique. Given this limitation, the liver, pancreas, spleen and adrenal\\n glands are unremarkable. There is a 1.5-cm round hypodense lesion in the\\n interpolar region of the left kidney. There is a 4-cm round hypodense lesion\\n in the superior pole of the right kidney. These may represent cysts, however,\\n cannot be fully characterized on noncontrast CT scan. The ureters are\\n unremarkable. The bladder wall is thickened and indistinct with some\\n surrounding fat stranding indicating probable cystitis. The prostate is\\n enlarged. The seminal vesicles are unremarkable.\\n\\n\\n The stomach, small bowel, colon, and rectum are unremarkable. The appendix is\\n not visualized; however, there is no evidence of appendicitis. There is no\\n free fluid. There is no free air. The intra-abdominal vasculature is\\n unremarkable; however, evaluation is limited due to lack of IV contrast.\\n There are no hernias identified.\\n\\n There are moderate degenerative changes of lower thoracic and lumbar spine,\\n most prominent at L3 through S1 with joint space narrowing and anterior and\\n posterior osteophytes. No fractures or suspicious lytic or sclerotic lesions\\n are identified.\\n\\n (Over)\\n\\n 1:37 PM\\n CT ABD & PELVIS W/O CONTRAST Clip # \\n Reason: ? retroperitoneal bleed\\n ______________________________________________________________________________\\n FINAL REPORT\\n (Cont)\\n IMPRESSION:\\n 1. Thickened bladder wall with surrounding stranding potentially secondary to\\n cystitis and correlation with UA suggested.\\n\\n 2. There is no retroperitoneal hematoma.\\n\\n 3. Hypodense lesions in each kidney likely represent cysts, however, not\\n fully characterized on nonenhanced CT scan. If desired US could help\\n characterize.\\n\\n 4. Enlarged prostate.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-02-28 00:00:00.000\",\n \"description\": \"CHEST (PA & LAT)\",\n \"row_id\": 1234623,\n \"text\": \" 11:19 AM\\n CHEST (PA & LAT) Clip # \\n Reason: pls eval ro infectious process\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n History: 67M with hypotension\\n REASON FOR THIS EXAMINATION:\\n pls eval ro infectious process\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, TWO VIEWS: \\n\\n HISTORY: 67-year-old male with hypotension, rule out infectious process.\\n\\n FINDINGS: Frontal and lateral views of the chest are compared to previous\\n exam from . Compared to prior, there is new central pulmonary\\n vascular engorgement with mild cephalization of the pulmonary vasculature.\\n There is no confluent consolidation or effusion. Cardiomediastinal silhouette\\n is stable, as are the osseous and soft tissue structures.\\n\\n IMPRESSION: Findings suggestive of mild pulmonary vascular congestion without\\n frank pulmonary edema.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2114-03-01 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 1234745,\n \"text\": \" 7:52 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for vol overload\\n Admitting Diagnosis: ACUTE RENAL FAILURE\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 67 year old man with concern for volume overload clinically\\n REASON FOR THIS EXAMINATION:\\n eval for vol overload\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH\\n\\n INDICATION: Volume overload, evaluation.\\n\\n COMPARISON: .\\n\\n FINDINGS: As compared to the previous radiograph, the signs indicative of\\n volume overload have decreased but are still clearly present. No pleural\\n effusions. Mild retrocardiac atelectasis. Normal hilar and mediastinal\\n contours.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2114-02-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 112555,\n \"text\": \"Sinus rhythm. Q-T interval prolongation. Compared to the previous tracing\\nof the T wave amplitude has increased while the QTc interval is\\nprolonged. Clinical correlation is suggested.\\n\\n\"\n }\n]"}}},{"rowIdx":995,"cells":{"subject_id":{"kind":"number","value":18556,"string":"18,556"},"hadm_id":{"kind":"number","value":117069,"string":"117,069"},"target_text":{"kind":"string","value":"The patient was admitted to the Medical service for radiologic catheterization. This revealed a 70 to 80% distal left main with normal ejection fraction lesion. He was evaluated for a bypass graft. On , the patient underwent coronary artery bypass graft times two with left internal mammary artery to left anterior descending and saphenous vein graft to OM. He tolerated the procedure well and was transferred to the CSRU in intubated condition. He was extubated on postoperative day one. It was noted on postoperative day two that his creatinine had risen to 2.2 from a baseline of 1.6. Renal consultation was obtained, and the impression was a prerenal mild acute renal failure. He was started on a Dopamine infusion. On postoperative day three, he developed atrial fibrillation. He was started on Amiodarone. His creatinine continued to rise over the next day. On postoperative day four, his creatinine started trending down again. He continued to be in atrial fibrillation at this time. He was started on Heparin infusion for the atrial fibrillation. He was transferred to the floor on postoperative day five. At this point, he had converted back into normal sinus rhythm. His Heparin infusion was continued for some time. It was then discontinued. His pacing wires were discontinued on postoperative day six. He was ready for discharge on postoperative day seven in stable condition. He will be discharged home."},"extractive_notes_summ":{"kind":"string","value":"IMPRESSION: S/P CABG surgery noted. AWARE, EKG DONE AND PT. ID: Tmax 98.6, wbc 11.6, 1 more dose of vanco. Renal: BUN/Cr 29/2.2 (20/1.9). Given 2gm Ca gluconate for Ca 1.11. Extub held until rounds this AM. Heme: Hct 27.4, cts dcd. + BS THRU-OUT, CONT. ABG: 7.34 43 63. GOING INTO CONTROLLED RATE OF AFIB, HR 60-90'S, DR. s/p cabgs: \"I'm feeling better\"o: continues in af ventricular response 70-110's. SX FOR SCANT CLEAR SECRETIONS, BS CLEAR THRU OOUT, DIM IN BASES SLIGHTLY. NEW L PERIPH IV PLACED. U/O ALSO FALLING, TREATED WITH ADDITIONAL 1L NS WITH MINIMAL EFFECT. continues to diurese. AP BEDSIDE SUPINE CHEST: Recent CABG with sternal wire sutures and skin staples. IMPRESSION: Atelectatic and pleural changes left base. Tip of right IJ line is poorly visualized in mid SVC. ASSESSMENT:NEURO: A&OX3, MAE TO COMMANDS, C/O STERNAL DISCOMFORT MEDICATED WITH 2 PERCOCETS WITH GOOD EFFECT. BS CONT. HAS KNOWN RENAL STENOSIS AND BASELINE SYS B/P ~160'S. SYS B/P CONT. Pt alert and appropriate however ABGs borderline. SYS B/P CURRENTLY AT 150'S. Hypoxemic. S/P recent CABG surgery again noted. L RAD ALINE AND R IJ MULTILUMEN LINE INTACT.RESP: BS INITIALLY VERY COARSE IN BASES, AFTER RECEIVING PERCOCETS ABLE COUGH AND RAISE TAN SECREATIONS, O2 REMAINS ON AT 4L NP WITH SAT'S ~95%. Renal status worse.P: Cont to monitor closely. Sharp lateral right CP angle. Wt unchanged from (9>preop). TOLERATING REG DIET IN SM. ABG REMAINS UNCHAGED FROM PREVIOUS.GI/GU: HOURLY URINES >50CC OF CLEAR YELLOW WHILE ON DOPA GTT, REPEAT CRE LEVEL CONT. SYS B/P >145, N B/P CORRELATING. u/o 70-100cc/hr overnight. Comparison study dated . sbp 120's-140's. CV: BP up to 190/50, rx with SNP .4 to keep BP 150/40. PACER REMAINS ATTACHED BUT OFF.RESP: BS CONT. The left internal carotid is occluded. percocet 2 tabs x1 for incisional discomfort with good effect. Resp Care Note:Pt cont intub on mech vent as per Carevue. CURRENTLY REMAINS IN AFIB, PACER OFF D/T COMPETETING. CONDITION.PLAN: CONT. BY NOON SYS B/P >200, DOPAMINE OFF X1/HR AND PT. oob x 1. INITIALLY SYS B/P 120-140'S RANGE ON 3MCG/KG/MIN OF DOPAMINE. FOR CONSISTENT HR IN THE 50'S AND HYPOTENSION, GOOD CAPTURE WITH A WIRES, NEO GTT NEEDING TO BE TITRATED UPTO 2MCG/KG/MIN TO MAINTAIN SYS ~150'S. Nsg progress noteBP 140-170/ Hr 88-106 Afib. SHIFT UPDATE.PT. SHIFT UPDATE.PT. TO KEEP SYS >150'S WITH NEO GTT, MONITOR U/O CLOSELY. A right central venous line is in place with its tip at the junction of the superior vena cava and the right atrium. There is evidence of fairly marked cardiac enlargement, mainly left ventricular. The peak systolic velocities on the right common, internal and external carotid arteries are approximately 110, 134 and over 300 cm/second respectively. TO BE VERY LABILE BETWEEN 170-220, GIVEN ADDITIONAL 10MG IVP HYDRALAZINE, 2 PERCOCETS & DOPAMINE GTT DECREASED TO 1.5MCG/KG/MIN AT 1330PM. U/O APPROX 25-30CC/HR, PT WT UP 8.7KGGI: PT WIT POOR APPETITE- REQUESTING H20- WELL, ABD SODT, NON TENDER, BOWEL SOUNDS HYPOACTIVE.SKIN: SMALL REDDENNED AREA AT TOP OF PT STATED THAT IT WAS NOT NEW- THIS A \"REGULAR\" FOR HIM NO OTHER SKIN BREAK DOWN NOTED. Symmetric left ventricularhypertrophy with preserved systolic function and mild resting mid-cavitarygradient. PT APPEARS VERY COMF DESPITE ABG. RESP: PT SOMEWHAT ACIDOTIC ALL NOC 7.32 (AS LOW AS 7.29); WITH O2 73-75. incisions c+d. MOD CT DRG AT TIMES. GU: U/O MARGINAL ALL NOC. ?pericardial effusionHeight: (in) 71Weight (lb): 205BSA (m2): 2.13 m2BP (mm Hg): 202/55Status: InpatientDate/Time: at 13:34Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy withnormal cavity size and systolic function (LVEF>55%). A mid-cavitary gradientis identified.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal. GI: OGT-LCWS. LAB: ION CA RX'D. There is a small pericardial effusion. s/p cabgs: moaning-\"I moan alot\"o: cardiac: afib without vea, ventricular response 111-57,np aware and ? PER DR. . THUS EXTUB. PT UPDATE PT IS S/P CABG X2. hct 32. mag,k and calcium nl. CV: AF 50-110 (on dopa) on po amio load. + bowel sounds. There is paradoxic septal motion consistent with prior cardiacsurgery.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Retrocardiac density is unchanged. 1 episode of dry heaves none further. Therhythm appears to be atrial fibrillation.Conclusions:The left atrium is moderately dilated. Consider prior inferior myocardial infarction. UO 2-45/hr. pp palp. on zantac. A mild (peak 20mmHg) mid-cavitary resting gradient is identified.Right ventricular cavity size and systolic function are normal. CVP UP TO 12NOTE PT U/O IN OR 180CC ONLY WITH 2.3L OF CRYSTALOID GIVEN, POST OP HCT IN OR 24- IN 23--DR. No aorticregurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Finally settled and comfortable @ 2200 p pm care.CV-SBP 170-200 req Hydralazine 10 mg ivp x3 1300-1600. Nsg progress noteBP 150-170/ HR 90-108 afib. The right lateral costophrenic angle is excluded from the film. Multiple change of position w/ slight improvement. Dopa at 3. The aorticvalve leaflets (3) are mildly thickened but not stenotic. ID: Tmax 98.7, wbc 18 (11.6). BUN/Cr cont to rise 43/2.5 (38/2.3). PT. CVP 13-18. There is mild thickening of the mitral valvechordae. sbp 120's to 190 transiently decreases to 140's when @ rest. WANTS TO EXTUB. WANTS TUBE OUT; HAS REMAINED VERY CALM ALL NOC; DESPITE BEING INTUB. is q 2 hours with good effect.bs with expiratory wheeze bibasilar. WANTS TUBE OUT. AT ONE POINT SATS DOWN TO 92-93. Lung sounds decreased at bases L>R. ?attempt diuresis with rising BUN/Cr. There is no significant mitral stenosis.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation. Heme: Blood as above, hct this am between units of blood=26.9. Neo 1-2.5 mcg to keep SBP>150. ALL DSG D&I. NEURO: PT IS CALM. Pt denies pain. DR. Atrial fibrillation with a controlled ventricular response. HELD OFF. Intraventricularconduction defect. 2UPC given, no lasix. Refused Percocet overnigth. cont on Dopamine at 3mcg/kg/min with u/o 80-90cc/hr. Thereare no echocardiographic signs of tamponade.IMPRESSION: Small circumferential pericardial effusion without evidence ofhemodynamic compromise."},"n_notes":{"kind":"number","value":21,"string":"21"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2111-06-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":760135,"text":" 10:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p cabg with low p02\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with severe peripheral vascular disease with 80% left main\n disease to go to CABG\n REASON FOR THIS EXAMINATION:\n s/p cabg with low p02\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61 year old man with severe peripheral vascular disease and coronary\n artery disease status post CABG with low oxygen sats.\n\n Portable AP upright chest at 10:40 PM: Comparison is made to prior\n study on at 8:43 PM. The patient is now post op. He is intubated. The\n tip of the ET tube is seen at the level of the medial ends of the clavicles.\n An NG tube is in place, the tip of which is not clearly seen but is below the\n level of the hemidiaphragms. A right central venous line is in place with its\n tip at the junction of the superior vena cava and the right atrium. Sternotomy\n wires, mediastinal tubes and left chest tube as well as an aortic balloon pump\n are in place. There are increased density of the left base most likely\n representing post op changes. No evidence of failure.\n\n"},{"category":"Radiology","chartdate":"2111-06-12 00:00:00.000","description":"CAROTID SERIES COMPLETE","row_id":760082,"text":" 11:44 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: Asses degree of stenosis on both carotids\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CAD pre op for CABG\n REASON FOR THIS EXAMINATION:\n Asses degree of stenosis on both carotids\n ______________________________________________________________________________\n WET READ: JMBu SAT 12:06 AM\n Left ICA- 100 % (total occlusion)\n Right ICA- 1 - 39% (mild stenosis)\n Antegrade vertebral flow\n WET READ VERSION #1 JMBu FRI 11:56 PM\n Left ICA- 100 % (total occlusion)\n Right ICA- 40 - 59% (moderate stenosis)\n Antegrade vertebral flow\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Assess degree of stenosis in both carotids prior to CABG.\n\n FINDINGS: Pulsed Doppler and color flow studies were performed to evaluate\n the carotid vasculature bilaterally. The peak systolic velocities on the\n right common, internal and external carotid arteries are approximately 110,\n 134 and over 300 cm/second respectively. The left internal carotid is\n occluded. Flow velocities in the left common and external carotid arteries\n are approximately 68 and over 300 cm/second respectively. Antegrade flow is\n noted in both vertebral arteries.\n\n IMPRESSION: Total occlusion of left internal carotid artery. Mild degree of\n stenosis in the right internal carotid artery of less than 40%. Antegrade\n flow in both vertebral arteries.\n\n\n"},{"category":"Radiology","chartdate":"2111-06-15 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":760225,"text":" 6:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: INCREASED O2 REQUIREMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old male s/p CAB w/ hypoxia\n REASON FOR THIS EXAMINATION:\n INCREASED O2 REQUIREMENT\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: A single AP upright image is provided.\n\n Comparison study dated .\n\n There is evidence of fairly marked cardiac enlargement, mainly left\n ventricular. S/P recent CABG surgery again noted. The pulmonary vessels show\n no upper zone redistribution and do not indicate cardiac failure at this time.\n Patchy bibasilar atelectasis is noted, most marked in the left lower zone. No\n significant pleural effusions are identified.\n\n Compared with the previous examination the bibasilar atelectases appear\n slightly more extensive. No other significant change is seen.\n\n IMPRESSION: S/P CABG surgery noted. No evidence of cardiac failure.\n Bibasilar patchy atelectasis, particularly on the left side.\n\n"},{"category":"Radiology","chartdate":"2111-06-16 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":760251,"text":" 8:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old male s/p CAB w/ hypoxia\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post CABG. Hypoxemic.\n\n AP BEDSIDE SUPINE CHEST: Recent CABG with sternal wire sutures and skin\n staples. There is atelectasis in the left lower lobe with associated pleural\n changes but I doubt the presence of consolidation. Right lung clear. Slight\n prominence of the mediastinum and cardiac silhouette are difficult to assess\n in this recumbent exam. No vascular congestion. Tip of right IJ line is\n poorly visualized in mid SVC. Sharp lateral right CP angle. Little change\n from exam one day previous.\n\n IMPRESSION: Atelectatic and pleural changes left base. No CHF, pneumonia or\n short interval change.\n\n"},{"category":"Nursing/other","chartdate":"2111-06-14 00:00:00.000","description":"Report","row_id":1506252,"text":"Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds coarse suct mod th yellow sput. Pt alert and appropriate however ABGs borderline. Extub held until rounds this AM. Plan to extub when ready.\n"},{"category":"Nursing/other","chartdate":"2111-06-14 00:00:00.000","description":"Report","row_id":1506253,"text":"RESP WEAN\nD: PT ON CPAP WITH 5 IPS, 5 PEEP, WELL, PT APPEARS CALM COMFORTABLE, TV >500CC, ABG INTIALLY ACIDOTIC BUT IMPROVED. SX FOR SCANT CLEAR SECRETIONS, BS CLEAR THRU OOUT, DIM IN BASES SLIGHTLY. PT AWAKE, ABLE TO LIFT HEAD OFF BED, FOLLOWS COMMANDS\nA: PT \nR: PLACED ON 40% OPEN FM THEN TOO 4L PT ABG AFTER 1HR (PT WITH LARGE SMOKING HX- QUIT 18MON AGO)\nD: PT PERFORMING ONLY ABLE TO GET METER UP TO 700CC- PT MED FOR PAIN WITH PERCOCET- STATED HE WAS NOT IN PAIN. PTCOUGHING AND EVENTUALLY RAISIED THICJ TAN SECRETIONS IN MOD AMT- NO FURTHER SPUTUM PRODUCTION NOTED.\nA: ABG SENT THIS EVE-\nR: PO2 DOWN, PRIOR TO RETURN OF ABG RESULTS, PT SAT NOTED TO BE DOWN TO 91\nA: CPT DONE, DONE PT COUGHING BUT UNABLE TO RAISE SECRETION SAT REMAIN 90-91- INC NP TO 5L THEN TO 6L.\nR: SAT UP TO 93%\nD: UPON LISTENING TO PT NOTED TO HAVE CRACKLES THRU OUT-\nLASIC GIVEN 2 HOURS EARLIER WITH MIN RESPONSE. AT PT CONT ON NEO TO OBTAIN A SBP >150/--FELT DUE TO RENAL INSUFF AND PROLONGED H/O HYPERTENSION, PT KIDNEYS PROBABLY USE TO HIGHER PRESSURES- THUS INC BP RESULT IN INC U/O.\nR: U/O UP TO APPROX 20CC/HR\nQUESTIONED IF MD WOULD CONSIDER DOPAMINE RENAL- FOR INC RENAL PERFUSION, RATHER THAN NEO WITH ITS\"SQUUZING\" EFFECTS. PT HR 67-69 SR NO ECTOPY, CVP 10, BP 165/46 OFF NEO AT PRESENT.\nPLAN: MONITOR RESP.URINE STATUS CLOSELY.\n\nADDEM: PT MED WITH PERCOCET FOR INC PAIN, DOES NOT LIKE THE EFFECTS OF PERCOCET-- :DROWSY\" BUT AWARE HE NEED TO BE ABLE TO TAKE A DEEP BREATH.\n\nNEURO: WNL\nCARDIAC: HR 60'S SP, SBP 160/50 OFF NEO AT PRESENT.\nRESP : AS NOTED ABOVE\nGU: CREAT 1.9 TODAY, 2 DOSES LASIX 40MG GIVEN WITH MIN EFFECT. U/O APPROX 25-30CC/HR, PT WT UP 8.7KG\nGI: PT WIT POOR APPETITE- REQUESTING H20- WELL, ABD SODT, NON TENDER, BOWEL SOUNDS HYPOACTIVE.\nSKIN: SMALL REDDENNED AREA AT TOP OF PT STATED THAT IT WAS NOT NEW- THIS A \"REGULAR\" FOR HIM NO OTHER SKIN BREAK DOWN NOTED.\n"},{"category":"Nursing/other","chartdate":"2111-06-15 00:00:00.000","description":"Report","row_id":1506254,"text":" Progress Note\nS/O: Neuro: Comf with 2 percocet, slept in long naps.\n CV: BP up to 190/50, rx with SNP .4 to keep BP 150/40.\n Resp: 5L NP with RR 20s, strong prod cough. ABG: 7.34 43 63.\n Renal: BUN/Cr 29/2.2 (20/1.9). UO 25-60/hr. Wt unchanged from (9>preop).\n Heme: Hct 27.4, cts dcd.\n ID: Tmax 98.6, wbc 11.6, 1 more dose of vanco.\n GI: taking pos, on zantac.\n Endo: 4U IV insulin glu 161-135.\n Skin: Intact.\n Rehab: Moving well in bed.\nA: Small dose on SNP controls hypertension. Renal status worse.\nP: Cont to monitor closely. Advance activity as \n"},{"category":"Nursing/other","chartdate":"2111-06-15 00:00:00.000","description":"Report","row_id":1506255,"text":"SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: A&OX3, MAE TO COMMANDS, OOB TO CHAIR WITH ASSIST X1, VERY STEADY ON FEET. C/O STERNAL DISCOMFORT MEDICATED WITH 2 PERCOCETS WITH EXCELLENT RELIEF.\nCARDIAC: INITIALLY HR >90 WITH SYS B/P >150 VIA L RAD ALINE ON .4MCG/KG/MIN, TREATED WITH 12.5MG PO LOPRESSOR, HR FALLING TO 50'S AND SYS B/P DOWN TO 100, REQUIRING NEO GTT TO MAINTAIN SYS >150 FOR RENAL AND CEREBRAL PERFUSION. AS DAY PROGRESSING NEEDING PT. FOR CONSISTENT HR IN THE 50'S AND HYPOTENSION, GOOD CAPTURE WITH A WIRES, NEO GTT NEEDING TO BE TITRATED UPTO 2MCG/KG/MIN TO MAINTAIN SYS ~150'S. U/O ALSO FALLING, TREATED WITH ADDITIONAL 1L NS WITH MINIMAL EFFECT. ~1200PM PT. GOING INTO CONTROLLED RATE OF AFIB, HR 60-90'S, DR. AWARE, EKG DONE AND PT. STARTED ON AMIODARONE 400MG PO TID, NO IV BOLUS GIVEN. PT. CURRENTLY REMAINS IN AFIB, PACER OFF D/T COMPETETING. SYS B/P >145, N B/P CORRELATING. L RAD ALINE AND R IJ MULTILUMEN LINE INTACT.\nRESP: BS INITIALLY VERY COARSE IN BASES, AFTER RECEIVING PERCOCETS ABLE COUGH AND RAISE TAN SECREATIONS, O2 REMAINS ON AT 4L NP WITH SAT'S ~95%. POOR , DOES BETTER WITH COUGHING AND DEEP BREATHING.\nGI/GU: WITH HYPOTENSION U/O DROPPING TO <10CC FOR 3/HR'S, SLOWING MAKEING 25CC/HR WITH SYS B/P AROUND 150'S. PT. HAS KNOWN RENAL STENOSIS AND BASELINE SYS B/P ~160'S. + BS THRU-OUT, CONT. TO TREAT BS WITH S.S. INSULIN. TOLERATING REG DIET IN SM. AMT'S.\nSOCIAL: WIFE AND CHILDREN INTO VISIT, UPDATES GIVEN REGARDING PT. CONDITION.\nPLAN: CONT. TO KEEP SYS >150'S WITH NEO GTT, MONITOR U/O CLOSELY. TREAT ELECTROLYTES AS NEEDED. MONITOR NEURO STATUS.\n"},{"category":"Nursing/other","chartdate":"2111-06-16 00:00:00.000","description":"Report","row_id":1506258,"text":"s/p cabg\ns: \"I'm feeling better\"\no: continues in af ventricular response 70-110's. no vea. sbp 120's-140's. continues to diurese. pulm toilet. oob x 1. 100ml liquid brown stool. open face tent @ 50 % 4lnp with o2 sats > 96%. percocet 2 tabs x1 for incisional discomfort with good effect. lopressor held np .\na: continues to diurese,loose brown stool.\np: monitor comfort, hr and rythym, sbp, i+O goal to keep i=o,labs, pulm toilet, as per orders.\n\n"},{"category":"Nursing/other","chartdate":"2111-06-17 00:00:00.000","description":"Report","row_id":1506259,"text":" Nsg progress note\nBP 140-170/ Hr 88-106 Afib. Given 2gm Ca gluconate for Ca 1.11. Renal function improving with creat down to 1.6 today. u/o 70-100cc/hr overnight. Cont on renal range Dopamine.\nO2 sats 97-100%. Face tent d/c'd and pt kept on 4L nc with sats unchanged. Initial ABG with PO2 58 this morning (?O2 off just prior to ABG drawn) Repeat ABG 7.41/37/69. Pt coughing and deep breathing - cough productive for thick yellow secretions.\nPt given Percocet x2 overnight with good effect. Pt sleeping through most of night.\n"},{"category":"Nursing/other","chartdate":"2111-06-17 00:00:00.000","description":"Report","row_id":1506260,"text":"SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: A&OX3, MAE TO COMMANDS, C/O STERNAL DISCOMFORT MEDICATED WITH 2 PERCOCETS WITH GOOD EFFECT. OOB TO CHAIR X4/HR'S, AMBULATING IN HALLWAY WITH PT AND NSG, VERY STEADY ON FEET. PT. C/O FEELING \"VERY TIRED\" & \"LETHARGIC\".\nCARDIAC: REMAINS IN A-FIB THIS AM, HR 90-105. INITIALLY SYS B/P 120-140'S RANGE ON 3MCG/KG/MIN OF DOPAMINE. BY NOON SYS B/P >200, DOPAMINE OFF X1/HR AND PT. GIVEN 40MG IVP LASIX & 10MG IVP HYDRALAZINE. SYS B/P CONT. TO BE VERY LABILE BETWEEN 170-220, GIVEN ADDITIONAL 10MG IVP HYDRALAZINE, 2 PERCOCETS & DOPAMINE GTT DECREASED TO 1.5MCG/KG/MIN AT 1330PM. SYS B/P CURRENTLY AT 150'S. L RAD ALINE INTACT. NEW L PERIPH IV PLACED. PACER REMAINS ATTACHED BUT OFF.\nRESP: BS CONT. TO BE VERY DIMINISHED IN BILT. BASES. STRONG PRODUCTIVE COUGH. O2 REMAINS AT 5L NP WITH SAT'S >97%. ABG REMAINS UNCHAGED FROM PREVIOUS.\nGI/GU: HOURLY URINES >50CC OF CLEAR YELLOW WHILE ON DOPA GTT, REPEAT CRE LEVEL CONT. TO HOLD AT 1.5. + BS THRU-OUT, SEVERAL BOUTS OF LOOSE LIQUID STOOL, APPEPITITE REMAINS POOR, NEEDS LOTS OF ENCOURAGEMENT FOR EATING. BS CONT. TO BE TREATED WITH S.S. INSULIN.\nSOCIAL: BROTHER AND INTO VISIT, UPDATE GIVEN. CONT. TO MONITOR B/P CLOSELY AND TREAT IF SYS SUSTAINED OVER 180 WITH HYDRALAZINE, GOAL OF SYS B/P 140-180'S (NEEDED FOR RENAL STENOSIS AND PREVIOUS CVA).\n"},{"category":"Nursing/other","chartdate":"2111-06-17 00:00:00.000","description":"Report","row_id":1506261,"text":" Nursing Progress Note 3p-11p\n Neuro- A&O x3, , , ambulatory, OOB to chair/commode w/ minimal assist.Slightly restless/anxious, unable to get comfortable for most of evening after getting back to bed @ 1800. Multiple change of position w/ slight improvement. Finally settled and comfortable @ 2200 p pm care.\nCV-SBP 170-200 req Hydralazine 10 mg ivp x3 1300-1600. Lopressor ^ 25mg , 1st dose @1700 w/ good response of SBP 140-160, HR 80's afib.\nRenal- u/o 'd to 5cc/hr x2hr 1900- on Dopa @1.5 mcg/kg/min. MD aware @ ; ^ Dopa to 3mcg/kg/min w/ good response of 50-60cc/hr -2230.\nSocial- Visiting w/ wife and daughter today. Pt and family informed of present status and progress. Informed of probable transfer to floort .\n\n"},{"category":"Nursing/other","chartdate":"2111-06-13 00:00:00.000","description":"Report","row_id":1506250,"text":"update\nPT S/P CABG X 2- LIMA-LAD, SVG TO OM.\nD: PT TO ON PROPOFOL- ON AND OFF NTG DEPENDING ON SBP-\nNEURO: ONCE , PT FOLLOWING COMMANDS, MAE TO COMMAND, NODDING APPROP.-\nPLAN: ONCE AWAKE, WEAN TO EXTUBATE AS TOL.\n\nRESP: PT SMOKING HX SIGNIFICANT, QUIT 18MON AGO.- INITIAL ABG GOOD WEANED TO 50% THEN AFTER WATCHING SAT >99% WEANED TO FIO2 40%, BS INTIALLY COARSE BUT CLEARED WITH SX.\nPLAN: AS NOTED ABOVE, WEAN TO EXTUBATE--BE AWARE--SMOKING HX.\n\nCARDIAC: SR 70'S SR, A WIRES ONLY, MA 11 TO CAPTURE. NO ECTOPY NOTED.\n\nGI: NPO, OGT REPLACED- NOT IN PLACE UPON ADM TO - DRAINING CL SECRETIONS- CARAFATE GIVEN, ABD SOFT, ABSENT BOWEL SOUNDS\n\nGU: U/O APPROX 30CC/HR, CVP INITALLY 6, PT GIVEN REMAINING 50CC LR FROM OR THEN GIVEN ADDITIONAL LR 1000CC OVER NEXT HOUR. CVP UP TO 12\nNOTE PT U/O IN OR 180CC ONLY WITH 2.3L OF CRYSTALOID GIVEN, POST OP HCT IN OR 24- IN 23--DR. AWARE, AS IS DR .\n\nPLAN: WEAN TO EXTUBATE, MONIOTOR FLUID STATUS, FOLLOW FAST TRACK PROTOCOL.\n"},{"category":"Nursing/other","chartdate":"2111-06-14 00:00:00.000","description":"Report","row_id":1506251,"text":"PT UPDATE\n PT IS S/P CABG X2.\n\n NEURO: PT IS CALM. PROP OFF LAST EVE. PT DOZES WHEN LEFT ALONE; BUT AWAKENS AS SOON AS HE IS SPOKEN TO OR CARE DONE. VERY APPROPRIATE AND SEEMS TO UNDERSTAND ALL THAT IS SAID. FOLLOWS ALL COMMANDS. HAS REMAINED CALM THROUGHOUT NOC; DESPITE REMAINING INTUB. WANTS TUBE OUT.\n\n RESP: PT SOMEWHAT ACIDOTIC ALL NOC 7.32 (AS LOW AS 7.29); WITH O2 73-75. THUS EXTUB. HELD OFF. AT ONE POINT SATS DOWN TO 92-93. NOW BAKC UP TO 95. PT HAS REMAINED ON CPAP ALL NIGHT-APPEARS VERY COMF-PEEP UP TO 7.5. BUT GOOD TV AND RR MID 20'S. PT APPEARS VERY COMF DESPITE ABG. CXR DONE LAST NIGHT-O.K. PER DR. . AWAITING AM ROUNDS TO SEE IF PT CAN BE EXTUB.\n\n CARDIAC: HR 70'S ALL NIGHT. NO ECTOPY. PACER HAS REMAINED OFF. INITIALLY PT ON NTG; OFF LAST NIGHT, AS DR. THOUGHT HIGHER BP WOULD HELP U/O. CVP 13-16. PT HAS RECEIVED 2 PC. DOES NOT APPEAR TO BE DRY. PT ON NO GTTS ALL NIGHT.\n\n GU: U/O MARGINAL ALL NOC. MOST OF THE TIME 30/HR. DR. AWARE. U/O DID SEEM TO PICK UP AFTER RECEIVING PC AND WITH HIGHER BP.\n\n GI: OGT-LCWS.\n\n LAB: ION CA RX'D. DID NOT NEED K REPLACMEENT. HCT 24-RX WITH 2 PC. UP TO 28. BS 170-200- SS INSULIN COVERAGE.\n\n OTHER: PT SHAKES HIS HEAD HE HAS NO PAIN. HAS APPEARED TO GET REST DURING NIGHT. WANTS TUBE OUT; HAS REMAINED VERY CALM ALL NOC; DESPITE BEING INTUB. ALL DSG D&I. MOD CT DRG AT TIMES. WILL AWAIT AM ROUNDS TO SEE IF DR. WANTS TO EXTUB. PT. OTHERWISE VERY STABLE NIGHT.\n"},{"category":"Nursing/other","chartdate":"2111-06-16 00:00:00.000","description":"Report","row_id":1506256,"text":" Progress Note\nS/O: Neuro: Comf with percocet q 4-6 hrs. Slept well.\n CV: AF 50-110 (on dopa) on po amio load. Neo 1-2.5 mcg to keep SBP>150. Dopa at 3. CVP 13-18.\n Resp: RR 14-18, strong cough. Exp wheezes clear with cough/albuterol inhaler. Now on 70% face mask and 6lnp with sao2 96%. Last abg on 40% face mask and 6lnp: 7.27 45 68.\n Renal: Wt up 4.5 kg (12>preop). UO 2-45/hr. BUN/Cr cont to rise 43/2.5 (38/2.3). K 4.8. 2UPC given, no lasix.\n Heme: Blood as above, hct this am between units of blood=26.9.\n ID: Tmax 98.7, wbc 18 (11.6).\n GI: taking pos. on zantac.\n Endo: No insulin required.\n Skin: Intact.\nA: Worsening renal failure causing met acidosis and marginal oxygenation (also hx smoking).\nP: Cont to monitor closely. ?attempt diuresis with rising BUN/Cr.\n"},{"category":"Nursing/other","chartdate":"2111-06-16 00:00:00.000","description":"Report","row_id":1506257,"text":"s/p cabg\ns: moaning-\"I moan alot\"\no: cardiac: afib without vea, ventricular response 111-57,np aware and ? next dose of po lopressor and amiodarone to discuss on rounds. sbp 120's to 190 transiently decreases to 140's when @ rest. incisions c+d. pp palp. temp 97.8-96.5 pt denies being cold. hct 32. mag,k and calcium nl. rij dlc dc'd and tip sent for culture.\n resp: presently on 50 % open face mask and 4 l np with o2 sats >97%. rr 13-20. c+r green thick sputum sent for c+s. is q 2 hours with good effect.bs with expiratory wheeze bibasilar.\n neuro: sleepy easily arousable, oriented x 3, mae, following commands, pleasant, perl.\n gi: refusing solids requesting fluids , pt reminded of fluid restriction. + bowel sounds. 1 episode of dry heaves none further.\n gu: marginal uo, recieved 40 mg ivp lasix with good diuresis >120 ml/hr. 12 noon k 4.7\n endo: glucose 146 has not recieved any sliding scale insulin this shift.\n id: wbc 18,blood cultures via aline and rij sent, rij tip sent for c+s. sputum sent for c+s, urine also sent fo c+s.\n pain: recieved 1 percocet @ 1230 , pt got oob with assist of 2 tolerated well, 1345 requested another percocet which he recieved with better relief of inciisional discomfort.\n skin: buttock crease very red and tender, area cleansed .\na: beginning to diurese, ventricular response decreasing,cultured, c+r thick green sputum,\np: monitor comfort, hr and np to reevalute lopressor and amiodarone, sbp, pp, incisions, resp status-pulm toilet, neuro status, i+o-uo dopa continues @ 3 mcq, labs, as per orders.\n"},{"category":"Nursing/other","chartdate":"2111-06-18 00:00:00.000","description":"Report","row_id":1506262,"text":" Nsg progress note\nBP 150-170/ HR 90-108 afib. K+ 3.8 this morning, KCl given. cont on Dopamine at 3mcg/kg/min with u/o 80-90cc/hr. Pt denies pain. Refused Percocet overnigth. Lung sounds decreased at bases L>R. Pt coughting and deep breathing. O2 sats 96-99% on 2L NC.\n"},{"category":"Echo","chartdate":"2111-06-17 00:00:00.000","description":"Report","row_id":71519,"text":"PATIENT/TEST INFORMATION:\nIndication: H/O cardiac surgery with recent CABG. ?pericardial effusion\nHeight: (in) 71\nWeight (lb): 205\nBSA (m2): 2.13 m2\nBP (mm Hg): 202/55\nStatus: Inpatient\nDate/Time: at 13:34\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and systolic function (LVEF>55%). A mid-cavitary gradient\nis identified.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal. There is paradoxic septal motion consistent with prior cardiac\nsurgery.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. A mitral valve\nannuloplasty ring is present. There is mild thickening of the mitral valve\nchordae. There is no significant mitral stenosis.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. The pulmonary artery systolic pressure could not be\ndetermined.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. The\nrhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size and systolic function\n(LVEF>55%). A mild (peak 20mmHg) mid-cavitary resting gradient is identified.\nRight ventricular cavity size and systolic function are normal. The aortic\nvalve leaflets (3) are mildly thickened but not stenotic. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. A\nmitral valve annuloplasty ring is present. The pulmonary artery systolic\npressure could not be determined. There is a small pericardial effusion. There\nare no echocardiographic signs of tamponade.\n\nIMPRESSION: Small circumferential pericardial effusion without evidence of\nhemodynamic compromise. Aortic sclerosis. Symmetric left ventricular\nhypertrophy with preserved systolic function and mild resting mid-cavitary\ngradient.\n\n\n"},{"category":"ECG","chartdate":"2111-06-15 00:00:00.000","description":"Report","row_id":175965,"text":"Atrial fibrillation with a controlled ventricular response. Intraventricular\nconduction defect. Consider prior inferior myocardial infarction. T wave\ninversions in leads I, aVL and V4-V6 may be due to underlying atrial\nfibrillation or myocardial ischemic process. No previous tracing available for\ncomparison. Clinical correlation is suggested.\n\n"},{"category":"Radiology","chartdate":"2111-06-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":760078,"text":" 8:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pre-op\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with severe peripheral vascular disease with 80% left main\n disease to go to CABG\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative evaluation for coronary artery bypass.\n\n PORTABLE CHEST: An upright view obtained at 8:43 P.M. shows a normal heart\n size. There is no pulmonary vasculature congestion. The lungs are clear, and\n there is no pleural effusion. The right lateral costophrenic angle is\n excluded from the film. The skeletal structures are unremarkable.\n\n There are no prior studies available for comparison.\n\n IMPRESSION: No CHF or pneumonia.\n\n"},{"category":"Radiology","chartdate":"2111-06-14 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":760188,"text":" 9:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube removal\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with severe peripheral vascular disease with 80% left main\n disease to go to CABG\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 61 y/o man with severe peripheral vascular disease, S/P chest\n tube removal.\n\n AP UPRIGHT PORTABLE CHEST AT 9:40 P.M.: Since prior study on , the\n left chest tube has been removed. No evidence of pneumothorax. Retrocardiac\n density is unchanged. Patchy opacity at the right base may represent\n atelectasis or infiltrate.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-06-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 760135,\n \"text\": \" 10:29 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p cabg with low p02\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with severe peripheral vascular disease with 80% left main\\n disease to go to CABG\\n REASON FOR THIS EXAMINATION:\\n s/p cabg with low p02\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 61 year old man with severe peripheral vascular disease and coronary\\n artery disease status post CABG with low oxygen sats.\\n\\n Portable AP upright chest at 10:40 PM: Comparison is made to prior\\n study on at 8:43 PM. The patient is now post op. He is intubated. The\\n tip of the ET tube is seen at the level of the medial ends of the clavicles.\\n An NG tube is in place, the tip of which is not clearly seen but is below the\\n level of the hemidiaphragms. A right central venous line is in place with its\\n tip at the junction of the superior vena cava and the right atrium. Sternotomy\\n wires, mediastinal tubes and left chest tube as well as an aortic balloon pump\\n are in place. There are increased density of the left base most likely\\n representing post op changes. No evidence of failure.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-06-12 00:00:00.000\",\n \"description\": \"CAROTID SERIES COMPLETE\",\n \"row_id\": 760082,\n \"text\": \" 11:44 PM\\n CAROTID SERIES COMPLETE Clip # \\n Reason: Asses degree of stenosis on both carotids\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with CAD pre op for CABG\\n REASON FOR THIS EXAMINATION:\\n Asses degree of stenosis on both carotids\\n ______________________________________________________________________________\\n WET READ: JMBu SAT 12:06 AM\\n Left ICA- 100 % (total occlusion)\\n Right ICA- 1 - 39% (mild stenosis)\\n Antegrade vertebral flow\\n WET READ VERSION #1 JMBu FRI 11:56 PM\\n Left ICA- 100 % (total occlusion)\\n Right ICA- 40 - 59% (moderate stenosis)\\n Antegrade vertebral flow\\n ______________________________________________________________________________\\n FINAL REPORT *ABNORMAL!\\n INDICATION: Assess degree of stenosis in both carotids prior to CABG.\\n\\n FINDINGS: Pulsed Doppler and color flow studies were performed to evaluate\\n the carotid vasculature bilaterally. The peak systolic velocities on the\\n right common, internal and external carotid arteries are approximately 110,\\n 134 and over 300 cm/second respectively. The left internal carotid is\\n occluded. Flow velocities in the left common and external carotid arteries\\n are approximately 68 and over 300 cm/second respectively. Antegrade flow is\\n noted in both vertebral arteries.\\n\\n IMPRESSION: Total occlusion of left internal carotid artery. Mild degree of\\n stenosis in the right internal carotid artery of less than 40%. Antegrade\\n flow in both vertebral arteries.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-06-15 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 760225,\n \"text\": \" 6:52 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: INCREASED O2 REQUIREMENT\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old male s/p CAB w/ hypoxia\\n REASON FOR THIS EXAMINATION:\\n INCREASED O2 REQUIREMENT\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST:\\n\\n INDICATION: A single AP upright image is provided.\\n\\n Comparison study dated .\\n\\n There is evidence of fairly marked cardiac enlargement, mainly left\\n ventricular. S/P recent CABG surgery again noted. The pulmonary vessels show\\n no upper zone redistribution and do not indicate cardiac failure at this time.\\n Patchy bibasilar atelectasis is noted, most marked in the left lower zone. No\\n significant pleural effusions are identified.\\n\\n Compared with the previous examination the bibasilar atelectases appear\\n slightly more extensive. No other significant change is seen.\\n\\n IMPRESSION: S/P CABG surgery noted. No evidence of cardiac failure.\\n Bibasilar patchy atelectasis, particularly on the left side.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-06-16 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 760251,\n \"text\": \" 8:42 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: r/o effusion\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old male s/p CAB w/ hypoxia\\n REASON FOR THIS EXAMINATION:\\n r/o effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: Post CABG. Hypoxemic.\\n\\n AP BEDSIDE SUPINE CHEST: Recent CABG with sternal wire sutures and skin\\n staples. There is atelectasis in the left lower lobe with associated pleural\\n changes but I doubt the presence of consolidation. Right lung clear. Slight\\n prominence of the mediastinum and cardiac silhouette are difficult to assess\\n in this recumbent exam. No vascular congestion. Tip of right IJ line is\\n poorly visualized in mid SVC. Sharp lateral right CP angle. Little change\\n from exam one day previous.\\n\\n IMPRESSION: Atelectatic and pleural changes left base. No CHF, pneumonia or\\n short interval change.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506252,\n \"text\": \"Resp Care Note:\\n\\nPt cont intub on mech vent as per Carevue. Lung sounds coarse suct mod th yellow sput. Pt alert and appropriate however ABGs borderline. Extub held until rounds this AM. Plan to extub when ready.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506253,\n \"text\": \"RESP WEAN\\nD: PT ON CPAP WITH 5 IPS, 5 PEEP, WELL, PT APPEARS CALM COMFORTABLE, TV >500CC, ABG INTIALLY ACIDOTIC BUT IMPROVED. SX FOR SCANT CLEAR SECRETIONS, BS CLEAR THRU OOUT, DIM IN BASES SLIGHTLY. PT AWAKE, ABLE TO LIFT HEAD OFF BED, FOLLOWS COMMANDS\\nA: PT \\nR: PLACED ON 40% OPEN FM THEN TOO 4L PT ABG AFTER 1HR (PT WITH LARGE SMOKING HX- QUIT 18MON AGO)\\nD: PT PERFORMING ONLY ABLE TO GET METER UP TO 700CC- PT MED FOR PAIN WITH PERCOCET- STATED HE WAS NOT IN PAIN. PTCOUGHING AND EVENTUALLY RAISIED THICJ TAN SECRETIONS IN MOD AMT- NO FURTHER SPUTUM PRODUCTION NOTED.\\nA: ABG SENT THIS EVE-\\nR: PO2 DOWN, PRIOR TO RETURN OF ABG RESULTS, PT SAT NOTED TO BE DOWN TO 91\\nA: CPT DONE, DONE PT COUGHING BUT UNABLE TO RAISE SECRETION SAT REMAIN 90-91- INC NP TO 5L THEN TO 6L.\\nR: SAT UP TO 93%\\nD: UPON LISTENING TO PT NOTED TO HAVE CRACKLES THRU OUT-\\nLASIC GIVEN 2 HOURS EARLIER WITH MIN RESPONSE. AT PT CONT ON NEO TO OBTAIN A SBP >150/--FELT DUE TO RENAL INSUFF AND PROLONGED H/O HYPERTENSION, PT KIDNEYS PROBABLY USE TO HIGHER PRESSURES- THUS INC BP RESULT IN INC U/O.\\nR: U/O UP TO APPROX 20CC/HR\\nQUESTIONED IF MD WOULD CONSIDER DOPAMINE RENAL- FOR INC RENAL PERFUSION, RATHER THAN NEO WITH ITS\\\"SQUUZING\\\" EFFECTS. PT HR 67-69 SR NO ECTOPY, CVP 10, BP 165/46 OFF NEO AT PRESENT.\\nPLAN: MONITOR RESP.URINE STATUS CLOSELY.\\n\\nADDEM: PT MED WITH PERCOCET FOR INC PAIN, DOES NOT LIKE THE EFFECTS OF PERCOCET-- :DROWSY\\\" BUT AWARE HE NEED TO BE ABLE TO TAKE A DEEP BREATH.\\n\\nNEURO: WNL\\nCARDIAC: HR 60'S SP, SBP 160/50 OFF NEO AT PRESENT.\\nRESP : AS NOTED ABOVE\\nGU: CREAT 1.9 TODAY, 2 DOSES LASIX 40MG GIVEN WITH MIN EFFECT. U/O APPROX 25-30CC/HR, PT WT UP 8.7KG\\nGI: PT WIT POOR APPETITE- REQUESTING H20- WELL, ABD SODT, NON TENDER, BOWEL SOUNDS HYPOACTIVE.\\nSKIN: SMALL REDDENNED AREA AT TOP OF PT STATED THAT IT WAS NOT NEW- THIS A \\\"REGULAR\\\" FOR HIM NO OTHER SKIN BREAK DOWN NOTED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506254,\n \"text\": \" Progress Note\\nS/O: Neuro: Comf with 2 percocet, slept in long naps.\\n CV: BP up to 190/50, rx with SNP .4 to keep BP 150/40.\\n Resp: 5L NP with RR 20s, strong prod cough. ABG: 7.34 43 63.\\n Renal: BUN/Cr 29/2.2 (20/1.9). UO 25-60/hr. Wt unchanged from (9>preop).\\n Heme: Hct 27.4, cts dcd.\\n ID: Tmax 98.6, wbc 11.6, 1 more dose of vanco.\\n GI: taking pos, on zantac.\\n Endo: 4U IV insulin glu 161-135.\\n Skin: Intact.\\n Rehab: Moving well in bed.\\nA: Small dose on SNP controls hypertension. Renal status worse.\\nP: Cont to monitor closely. Advance activity as \\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506255,\n \"text\": \"SHIFT UPDATE.\\nPT. ASSESSMENT:\\n\\nNEURO: A&OX3, MAE TO COMMANDS, OOB TO CHAIR WITH ASSIST X1, VERY STEADY ON FEET. C/O STERNAL DISCOMFORT MEDICATED WITH 2 PERCOCETS WITH EXCELLENT RELIEF.\\nCARDIAC: INITIALLY HR >90 WITH SYS B/P >150 VIA L RAD ALINE ON .4MCG/KG/MIN, TREATED WITH 12.5MG PO LOPRESSOR, HR FALLING TO 50'S AND SYS B/P DOWN TO 100, REQUIRING NEO GTT TO MAINTAIN SYS >150 FOR RENAL AND CEREBRAL PERFUSION. AS DAY PROGRESSING NEEDING PT. FOR CONSISTENT HR IN THE 50'S AND HYPOTENSION, GOOD CAPTURE WITH A WIRES, NEO GTT NEEDING TO BE TITRATED UPTO 2MCG/KG/MIN TO MAINTAIN SYS ~150'S. U/O ALSO FALLING, TREATED WITH ADDITIONAL 1L NS WITH MINIMAL EFFECT. ~1200PM PT. GOING INTO CONTROLLED RATE OF AFIB, HR 60-90'S, DR. AWARE, EKG DONE AND PT. STARTED ON AMIODARONE 400MG PO TID, NO IV BOLUS GIVEN. PT. CURRENTLY REMAINS IN AFIB, PACER OFF D/T COMPETETING. SYS B/P >145, N B/P CORRELATING. L RAD ALINE AND R IJ MULTILUMEN LINE INTACT.\\nRESP: BS INITIALLY VERY COARSE IN BASES, AFTER RECEIVING PERCOCETS ABLE COUGH AND RAISE TAN SECREATIONS, O2 REMAINS ON AT 4L NP WITH SAT'S ~95%. POOR , DOES BETTER WITH COUGHING AND DEEP BREATHING.\\nGI/GU: WITH HYPOTENSION U/O DROPPING TO <10CC FOR 3/HR'S, SLOWING MAKEING 25CC/HR WITH SYS B/P AROUND 150'S. PT. HAS KNOWN RENAL STENOSIS AND BASELINE SYS B/P ~160'S. + BS THRU-OUT, CONT. TO TREAT BS WITH S.S. INSULIN. TOLERATING REG DIET IN SM. AMT'S.\\nSOCIAL: WIFE AND CHILDREN INTO VISIT, UPDATES GIVEN REGARDING PT. CONDITION.\\nPLAN: CONT. TO KEEP SYS >150'S WITH NEO GTT, MONITOR U/O CLOSELY. TREAT ELECTROLYTES AS NEEDED. MONITOR NEURO STATUS.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506258,\n \"text\": \"s/p cabg\\ns: \\\"I'm feeling better\\\"\\no: continues in af ventricular response 70-110's. no vea. sbp 120's-140's. continues to diurese. pulm toilet. oob x 1. 100ml liquid brown stool. open face tent @ 50 % 4lnp with o2 sats > 96%. percocet 2 tabs x1 for incisional discomfort with good effect. lopressor held np .\\na: continues to diurese,loose brown stool.\\np: monitor comfort, hr and rythym, sbp, i+O goal to keep i=o,labs, pulm toilet, as per orders.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506259,\n \"text\": \" Nsg progress note\\nBP 140-170/ Hr 88-106 Afib. Given 2gm Ca gluconate for Ca 1.11. Renal function improving with creat down to 1.6 today. u/o 70-100cc/hr overnight. Cont on renal range Dopamine.\\nO2 sats 97-100%. Face tent d/c'd and pt kept on 4L nc with sats unchanged. Initial ABG with PO2 58 this morning (?O2 off just prior to ABG drawn) Repeat ABG 7.41/37/69. Pt coughing and deep breathing - cough productive for thick yellow secretions.\\nPt given Percocet x2 overnight with good effect. Pt sleeping through most of night.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506260,\n \"text\": \"SHIFT UPDATE.\\nPT. ASSESSMENT:\\n\\nNEURO: A&OX3, MAE TO COMMANDS, C/O STERNAL DISCOMFORT MEDICATED WITH 2 PERCOCETS WITH GOOD EFFECT. OOB TO CHAIR X4/HR'S, AMBULATING IN HALLWAY WITH PT AND NSG, VERY STEADY ON FEET. PT. C/O FEELING \\\"VERY TIRED\\\" & \\\"LETHARGIC\\\".\\nCARDIAC: REMAINS IN A-FIB THIS AM, HR 90-105. INITIALLY SYS B/P 120-140'S RANGE ON 3MCG/KG/MIN OF DOPAMINE. BY NOON SYS B/P >200, DOPAMINE OFF X1/HR AND PT. GIVEN 40MG IVP LASIX & 10MG IVP HYDRALAZINE. SYS B/P CONT. TO BE VERY LABILE BETWEEN 170-220, GIVEN ADDITIONAL 10MG IVP HYDRALAZINE, 2 PERCOCETS & DOPAMINE GTT DECREASED TO 1.5MCG/KG/MIN AT 1330PM. SYS B/P CURRENTLY AT 150'S. L RAD ALINE INTACT. NEW L PERIPH IV PLACED. PACER REMAINS ATTACHED BUT OFF.\\nRESP: BS CONT. TO BE VERY DIMINISHED IN BILT. BASES. STRONG PRODUCTIVE COUGH. O2 REMAINS AT 5L NP WITH SAT'S >97%. ABG REMAINS UNCHAGED FROM PREVIOUS.\\nGI/GU: HOURLY URINES >50CC OF CLEAR YELLOW WHILE ON DOPA GTT, REPEAT CRE LEVEL CONT. TO HOLD AT 1.5. + BS THRU-OUT, SEVERAL BOUTS OF LOOSE LIQUID STOOL, APPEPITITE REMAINS POOR, NEEDS LOTS OF ENCOURAGEMENT FOR EATING. BS CONT. TO BE TREATED WITH S.S. INSULIN.\\nSOCIAL: BROTHER AND INTO VISIT, UPDATE GIVEN. CONT. TO MONITOR B/P CLOSELY AND TREAT IF SYS SUSTAINED OVER 180 WITH HYDRALAZINE, GOAL OF SYS B/P 140-180'S (NEEDED FOR RENAL STENOSIS AND PREVIOUS CVA).\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506261,\n \"text\": \" Nursing Progress Note 3p-11p\\n Neuro- A&O x3, , , ambulatory, OOB to chair/commode w/ minimal assist.Slightly restless/anxious, unable to get comfortable for most of evening after getting back to bed @ 1800. Multiple change of position w/ slight improvement. Finally settled and comfortable @ 2200 p pm care.\\nCV-SBP 170-200 req Hydralazine 10 mg ivp x3 1300-1600. Lopressor ^ 25mg , 1st dose @1700 w/ good response of SBP 140-160, HR 80's afib.\\nRenal- u/o 'd to 5cc/hr x2hr 1900- on Dopa @1.5 mcg/kg/min. MD aware @ ; ^ Dopa to 3mcg/kg/min w/ good response of 50-60cc/hr -2230.\\nSocial- Visiting w/ wife and daughter today. Pt and family informed of present status and progress. Informed of probable transfer to floort .\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506250,\n \"text\": \"update\\nPT S/P CABG X 2- LIMA-LAD, SVG TO OM.\\nD: PT TO ON PROPOFOL- ON AND OFF NTG DEPENDING ON SBP-\\nNEURO: ONCE , PT FOLLOWING COMMANDS, MAE TO COMMAND, NODDING APPROP.-\\nPLAN: ONCE AWAKE, WEAN TO EXTUBATE AS TOL.\\n\\nRESP: PT SMOKING HX SIGNIFICANT, QUIT 18MON AGO.- INITIAL ABG GOOD WEANED TO 50% THEN AFTER WATCHING SAT >99% WEANED TO FIO2 40%, BS INTIALLY COARSE BUT CLEARED WITH SX.\\nPLAN: AS NOTED ABOVE, WEAN TO EXTUBATE--BE AWARE--SMOKING HX.\\n\\nCARDIAC: SR 70'S SR, A WIRES ONLY, MA 11 TO CAPTURE. NO ECTOPY NOTED.\\n\\nGI: NPO, OGT REPLACED- NOT IN PLACE UPON ADM TO - DRAINING CL SECRETIONS- CARAFATE GIVEN, ABD SOFT, ABSENT BOWEL SOUNDS\\n\\nGU: U/O APPROX 30CC/HR, CVP INITALLY 6, PT GIVEN REMAINING 50CC LR FROM OR THEN GIVEN ADDITIONAL LR 1000CC OVER NEXT HOUR. CVP UP TO 12\\nNOTE PT U/O IN OR 180CC ONLY WITH 2.3L OF CRYSTALOID GIVEN, POST OP HCT IN OR 24- IN 23--DR. AWARE, AS IS DR .\\n\\nPLAN: WEAN TO EXTUBATE, MONIOTOR FLUID STATUS, FOLLOW FAST TRACK PROTOCOL.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506251,\n \"text\": \"PT UPDATE\\n PT IS S/P CABG X2.\\n\\n NEURO: PT IS CALM. PROP OFF LAST EVE. PT DOZES WHEN LEFT ALONE; BUT AWAKENS AS SOON AS HE IS SPOKEN TO OR CARE DONE. VERY APPROPRIATE AND SEEMS TO UNDERSTAND ALL THAT IS SAID. FOLLOWS ALL COMMANDS. HAS REMAINED CALM THROUGHOUT NOC; DESPITE REMAINING INTUB. WANTS TUBE OUT.\\n\\n RESP: PT SOMEWHAT ACIDOTIC ALL NOC 7.32 (AS LOW AS 7.29); WITH O2 73-75. THUS EXTUB. HELD OFF. AT ONE POINT SATS DOWN TO 92-93. NOW BAKC UP TO 95. PT HAS REMAINED ON CPAP ALL NIGHT-APPEARS VERY COMF-PEEP UP TO 7.5. BUT GOOD TV AND RR MID 20'S. PT APPEARS VERY COMF DESPITE ABG. CXR DONE LAST NIGHT-O.K. PER DR. . AWAITING AM ROUNDS TO SEE IF PT CAN BE EXTUB.\\n\\n CARDIAC: HR 70'S ALL NIGHT. NO ECTOPY. PACER HAS REMAINED OFF. INITIALLY PT ON NTG; OFF LAST NIGHT, AS DR. THOUGHT HIGHER BP WOULD HELP U/O. CVP 13-16. PT HAS RECEIVED 2 PC. DOES NOT APPEAR TO BE DRY. PT ON NO GTTS ALL NIGHT.\\n\\n GU: U/O MARGINAL ALL NOC. MOST OF THE TIME 30/HR. DR. AWARE. U/O DID SEEM TO PICK UP AFTER RECEIVING PC AND WITH HIGHER BP.\\n\\n GI: OGT-LCWS.\\n\\n LAB: ION CA RX'D. DID NOT NEED K REPLACMEENT. HCT 24-RX WITH 2 PC. UP TO 28. BS 170-200- SS INSULIN COVERAGE.\\n\\n OTHER: PT SHAKES HIS HEAD HE HAS NO PAIN. HAS APPEARED TO GET REST DURING NIGHT. WANTS TUBE OUT; HAS REMAINED VERY CALM ALL NOC; DESPITE BEING INTUB. ALL DSG D&I. MOD CT DRG AT TIMES. WILL AWAIT AM ROUNDS TO SEE IF DR. WANTS TO EXTUB. PT. OTHERWISE VERY STABLE NIGHT.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506256,\n \"text\": \" Progress Note\\nS/O: Neuro: Comf with percocet q 4-6 hrs. Slept well.\\n CV: AF 50-110 (on dopa) on po amio load. Neo 1-2.5 mcg to keep SBP>150. Dopa at 3. CVP 13-18.\\n Resp: RR 14-18, strong cough. Exp wheezes clear with cough/albuterol inhaler. Now on 70% face mask and 6lnp with sao2 96%. Last abg on 40% face mask and 6lnp: 7.27 45 68.\\n Renal: Wt up 4.5 kg (12>preop). UO 2-45/hr. BUN/Cr cont to rise 43/2.5 (38/2.3). K 4.8. 2UPC given, no lasix.\\n Heme: Blood as above, hct this am between units of blood=26.9.\\n ID: Tmax 98.7, wbc 18 (11.6).\\n GI: taking pos. on zantac.\\n Endo: No insulin required.\\n Skin: Intact.\\nA: Worsening renal failure causing met acidosis and marginal oxygenation (also hx smoking).\\nP: Cont to monitor closely. ?attempt diuresis with rising BUN/Cr.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-16 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506257,\n \"text\": \"s/p cabg\\ns: moaning-\\\"I moan alot\\\"\\no: cardiac: afib without vea, ventricular response 111-57,np aware and ? next dose of po lopressor and amiodarone to discuss on rounds. sbp 120's to 190 transiently decreases to 140's when @ rest. incisions c+d. pp palp. temp 97.8-96.5 pt denies being cold. hct 32. mag,k and calcium nl. rij dlc dc'd and tip sent for culture.\\n resp: presently on 50 % open face mask and 4 l np with o2 sats >97%. rr 13-20. c+r green thick sputum sent for c+s. is q 2 hours with good effect.bs with expiratory wheeze bibasilar.\\n neuro: sleepy easily arousable, oriented x 3, mae, following commands, pleasant, perl.\\n gi: refusing solids requesting fluids , pt reminded of fluid restriction. + bowel sounds. 1 episode of dry heaves none further.\\n gu: marginal uo, recieved 40 mg ivp lasix with good diuresis >120 ml/hr. 12 noon k 4.7\\n endo: glucose 146 has not recieved any sliding scale insulin this shift.\\n id: wbc 18,blood cultures via aline and rij sent, rij tip sent for c+s. sputum sent for c+s, urine also sent fo c+s.\\n pain: recieved 1 percocet @ 1230 , pt got oob with assist of 2 tolerated well, 1345 requested another percocet which he recieved with better relief of inciisional discomfort.\\n skin: buttock crease very red and tender, area cleansed .\\na: beginning to diurese, ventricular response decreasing,cultured, c+r thick green sputum,\\np: monitor comfort, hr and np to reevalute lopressor and amiodarone, sbp, pp, incisions, resp status-pulm toilet, neuro status, i+o-uo dopa continues @ 3 mcq, labs, as per orders.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2111-06-18 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1506262,\n \"text\": \" Nsg progress note\\nBP 150-170/ HR 90-108 afib. K+ 3.8 this morning, KCl given. cont on Dopamine at 3mcg/kg/min with u/o 80-90cc/hr. Pt denies pain. Refused Percocet overnigth. Lung sounds decreased at bases L>R. Pt coughting and deep breathing. O2 sats 96-99% on 2L NC.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2111-06-17 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 71519,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: H/O cardiac surgery with recent CABG. ?pericardial effusion\\nHeight: (in) 71\\nWeight (lb): 205\\nBSA (m2): 2.13 m2\\nBP (mm Hg): 202/55\\nStatus: Inpatient\\nDate/Time: at 13:34\\nTest: Portable TTE(Complete)\\nDoppler: Complete pulse and color flow\\nContrast: None\\nTechnical Quality: Suboptimal\\n\\n\\nINTERPRETATION:\\n\\nFindings:\\n\\nLEFT ATRIUM: The left atrium is moderately dilated.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\\n\\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with\\nnormal cavity size and systolic function (LVEF>55%). A mid-cavitary gradient\\nis identified.\\n\\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\\nnormal. There is paradoxic septal motion consistent with prior cardiac\\nsurgery.\\n\\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. No aortic\\nregurgitation is seen.\\n\\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. A mitral valve\\nannuloplasty ring is present. There is mild thickening of the mitral valve\\nchordae. There is no significant mitral stenosis.\\n\\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\\ntricuspid regurgitation. The pulmonary artery systolic pressure could not be\\ndetermined.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\\n\\nPERICARDIUM: There is a small pericardial effusion. There are no\\nechocardiographic signs of tamponade.\\n\\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. The\\nrhythm appears to be atrial fibrillation.\\n\\nConclusions:\\nThe left atrium is moderately dilated. There is mild symmetric left\\nventricular hypertrophy with normal cavity size and systolic function\\n(LVEF>55%). A mild (peak 20mmHg) mid-cavitary resting gradient is identified.\\nRight ventricular cavity size and systolic function are normal. The aortic\\nvalve leaflets (3) are mildly thickened but not stenotic. No aortic\\nregurgitation is seen. The mitral valve leaflets are mildly thickened. A\\nmitral valve annuloplasty ring is present. The pulmonary artery systolic\\npressure could not be determined. There is a small pericardial effusion. There\\nare no echocardiographic signs of tamponade.\\n\\nIMPRESSION: Small circumferential pericardial effusion without evidence of\\nhemodynamic compromise. Aortic sclerosis. Symmetric left ventricular\\nhypertrophy with preserved systolic function and mild resting mid-cavitary\\ngradient.\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2111-06-15 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 175965,\n \"text\": \"Atrial fibrillation with a controlled ventricular response. Intraventricular\\nconduction defect. Consider prior inferior myocardial infarction. T wave\\ninversions in leads I, aVL and V4-V6 may be due to underlying atrial\\nfibrillation or myocardial ischemic process. No previous tracing available for\\ncomparison. Clinical correlation is suggested.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-06-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 760078,\n \"text\": \" 8:46 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: pre-op\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with severe peripheral vascular disease with 80% left main\\n disease to go to CABG\\n REASON FOR THIS EXAMINATION:\\n pre-op\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Preoperative evaluation for coronary artery bypass.\\n\\n PORTABLE CHEST: An upright view obtained at 8:43 P.M. shows a normal heart\\n size. There is no pulmonary vasculature congestion. The lungs are clear, and\\n there is no pleural effusion. The right lateral costophrenic angle is\\n excluded from the film. The skeletal structures are unremarkable.\\n\\n There are no prior studies available for comparison.\\n\\n IMPRESSION: No CHF or pneumonia.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2111-06-14 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 760188,\n \"text\": \" 9:22 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p chest tube removal\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 61 year old man with severe peripheral vascular disease with 80% left main\\n disease to go to CABG\\n REASON FOR THIS EXAMINATION:\\n s/p chest tube removal\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATIONS: 61 y/o man with severe peripheral vascular disease, S/P chest\\n tube removal.\\n\\n AP UPRIGHT PORTABLE CHEST AT 9:40 P.M.: Since prior study on , the\\n left chest tube has been removed. No evidence of pneumothorax. Retrocardiac\\n density is unchanged. Patchy opacity at the right base may represent\\n atelectasis or infiltrate.\\n\\n\"\n }\n]"}}},{"rowIdx":996,"cells":{"subject_id":{"kind":"number","value":22085,"string":"22,085"},"hadm_id":{"kind":"number","value":182828,"string":"182,828"},"target_text":{"kind":"string","value":"Admitted on pre-operatively, taken to OR on day of admission. Underwent CABG X 5 (please see operative report for details of surgical procedure) Required phenylephrine & vasopressin post-op for hypotension. These were weaned off by POD # 2, and he was transferred from the ICU in stable condition. His epicardial wires were removed on POD # 4. He has progressed with physical therapy, and has remained hemodynamically stable, and is ready for discharge home on ."},"extractive_notes_summ":{"kind":"string","value":"Cont on neo & vasopressin gtts. labile BP in csru.neuro: now off propofol. bld tinge ogt dng. titrate neo. Pt on vasopressin and neo gtts. good min volume.gi/gu: lg amt uop. csru adm/updates/p cabg x5. ROS:Neuro: A+O x's 3. C&DB. Now weaning down neo. reversals given.cv: refer to flowsheet for vs. BP labile. PERRLA. PERRLA. EXTREMITIES W/D; AFEBRILE. Chest tubes as noted above.GI: Abd soft w/hypo BS. Current ABG: 7.37/42/298/25. Once tolerating neo off attempt to wean vasopressin gtt. perl. Resp CarePt from OR intubated s/p CABG. CVP 8-15. a-line dampened, removed NP .Resp: NC 4L. Sternal, mediastinal, and left leg drsgs CDI. tol wean fio2 to .4. presently on cpap + ips. booklet given.assess: labile bp post-op cabg x 5.plan: wean to extubation. Generalized edema.Resp: O2 NP, sats 95% or >. on off neo/ntg though mostly neosynephrine dependent. BUN 13, CREATININE 0.8. ABD SOFT, NT, ND. Monitor, tx, support, and comfort. Steady gait.CV: NSR-ST 90-105. Nursing 7a-3pNeuro: A&Ox3. hct upon arrival to csru 31.resp: lungs clear. MAE x's 4. Pulm toilet. Mobilize, OOB. insulin gtt per protocol. HCT STABLE=28.RESP: LS CLR, BASES DIM; O2SATS 92-95% ON 3L NC, RESP RATE 20S-30S; GOOD COUGH, BUT PT NEEDS ENCOURAGEMENT; USES I.S. BP marginally low even w/titrating neo ^. Several fluid bolus given w/minimal effect on BP. CVP 11->20 F/U bs cont >200. 3 units PRBCs ordered. 3 units PRBCs ordered. IM TORADOL GIVEN FOR INCISIONAL PAIN W/GOOD EFFECT; +PERRL.CV: ST LOW 100s INITIALLY TO SR 90S; PACER OFF, A-WIRES DO NOT S/C APPROPRIATELY, V-WIRES S/C APPROP-SEE CAREVUE FOR THRESHOLDS; K REPLETED; BP STABLE 90S-120S, PALPABLE PERIPHERAL PULSES. Lytes repleated. No impaired skin.Gi: Tol reg diet. MAE. Plan is to continue weaning to extubate. Mostly for line management. Lungs cta, dim in bases.Endo: Blood sugars increased. MSO4 IV and PO dilaudid for pain mngt w/good effect.CV: RSR/ST w/o ectopy. Afternoon bs >200, tx per CSRU riss protocol. abd soft. NA 143. RR: 22-30 HR:103 Sa02 96%. Tol thin liquids. Sats >93%. NP aware. Initially asked that meds be crushed. o2 sats 97-100%. No resp distress noted, = rise and fall of chest. Pulmonary toileting. Increase diet & act as tol. OOB to chair w/2 assist. Suctioned prior to extubation for scant white sectretions.Plan: Monitor respiratory status. Insulin gtt started.Skin: See carevue for incisions. nods to questions asked. k+ repleted.social: wife in and updated. Addendum: Nursing Progress Note:Assumed care at 1600. Lungs clear. +BS, NO BM. However swallowing meds whole fine in afternoon.Gu: Min-adequate HUO.Pain: PO dilaudid w/good effect.Social: Family into visit, updated by RN.Plan: Wean neo to off as tol to keep map >60. HUO CLR YELLOW, DIURESED UP TO 450cc/HR. Uses IS weakly to 500 w/encouragement. Current vent settings are: SIMV 600 X 12 60% 5/5. nsr to st. A & V wires present and functioning. cvp mid teens after 3L crystalloid. NO C/O NAUSEA. Weaning neo to keep map >60, unable to wean off. Has 2 mediastinal and 1 pleural chest tubes Y connected together and to 20 cm sx draing sang fluid. Noaortic regurgitation is seen. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. The ascending, transverse and descending thoracic aorta arenormal in diameter and free of atherosclerotic plaque. IMPRESSION: Stable postoperative chest. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Atelectasis and pleural effusion at the left base are unchanged. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). There is no pericardial effusion.POST-BypASS:preserved biventricular systolic function. Three right-sided chest tubes and a right IJ central venous catheter are unchanged in position. Small left apical pneumothorax. No spontaneous echo contrast or thrombus in theLA/LAA or the RA/RAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Rule out pneumothorax. PATIENT/TEST INFORMATION:Indication: Coronary artery disease.Weight (lb): 180BP (mm Hg): 120/70HR (bpm): 72Status: InpatientDate/Time: at 14:38Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. Wean neo as BP tolerates. Right jugular CV line is in right atrium, unchanged since prior films. There is normal postoperative widening of the mediastinum. Patient reports hx of low lung capacity.GI: Abd soft w/active bs. The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. There is a small left apical pneumothorax. Postoperative appearance of the mediastinum is stable. Has two mediastinal and one pleural chest tube Y connected together draining serosang fluid and connected to 20 cm sx.Resp: Lungs clear and diminished in bases. There are low lung volumes, with retrocardiac atelectasis. IMPRESSION: Right jugular CV line in right atrium. PERRLA.CV: ST/RSR w/o ectopy. The remainder of the chest radiograph is stable. Compared to theprevious tracing of no significant diagnostic change. Left leg drsg and /steri strips, ACE wrap reapplied. Fluid bolus also given for hypotension and Low HUO w/minimal effect. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Peripheral pulses palpable w/ease. Two mediastinal drains and a left-sided chest tube is present. A right IJ central venous catheter has been placed with tip in the expected location of the atrial caval junction. Portable AP chest radiograph compared to . Non-specific inferolateral ST-T wave changes. Heart size and mediastinal width are unchanged when compared with a prior film of the same date. Right ventricular chamber size and free wallmotion are normal. Sternal and mediastinal drsg . Three left-sided chest tubes are present. Neuro: A+O x's 3. Status post-CABG. There are low lung volumes with no evidence of consolidation. Has RIJ cath w/distal port transduced for CVP = 10 to 16/18 after fluid bolus. Sinus rhythm. FINDINGS: Compared to prior radiograph obtained on , patient is status post CABG procedure with a median sternotomy."},"n_notes":{"kind":"number","value":22,"string":"22"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2118-01-13 00:00:00.000","description":"Report","row_id":1552025,"text":"Endo: Insulin gtt resumed d/t rapidly rising FSGsLabs: K, Ca+, and Mag all repleted this AM\n\nHeme: Hct 21.6 after recheck from 21.4, down from yesterday's of 31. 3 units PRBCs ordered.\n"},{"category":"Nursing/other","chartdate":"2118-01-13 00:00:00.000","description":"Report","row_id":1552026,"text":"NEURO: Alert, awake, oriented x3, transfer from bed to chair and vice versa with 2 person assist, incisional pain treated with recurring Toradol IM with good effect, Pt states pain free.\n\nRESP: Wean O2 to 2L via NC, Sats in 97%, lung sounds clear at apicals/dim at bases, Pt able to cough/deep breath and uses IS, also states that \"his lungs are not that good\" resp in 30s and reg/unlabored\n\nCV: NSR with HRs in 80-90s, keep MAP >60, wean off Vasopressin, given 3 units of PRBCs for a Hct of 21, post-transfusion Hct was 29, with improved BP and O2 Sats, pacer is off (tested As and not sensing/capturing appropiately, did not test Vs), pedal pulses palpable\n\nGI/GU: Pt on diet with good appetite, Pt tolerates PO meds, has large, formed stool today; Foley draining yellow-amber/clear urine, urine outputs slowly diminished to 20-30cc/hr but responds well to recurring Lasix\n\nENDO: Started on daily Glyburide and Lantus 20units today with SSRI\n\nSOCIAL: Wife and children visited throughout the afternoon.\n\nPLAN: Continue to monitor resp, hemodynamics, urine output, LABS, deline trauma line and start PIV, increase activity as tolerated, ? transfer to floor tomorrow\n"},{"category":"Nursing/other","chartdate":"2118-01-14 00:00:00.000","description":"Report","row_id":1552027,"text":"NEURO: PT IS A&OX3-APPROPRIATE; SLEPT ON/OFF OVERNIGHT; MAES EQUALLY TO COMMAND-NO DEFICITS, THOUGH RELUCTANT TO MOVE. IM TORADOL GIVEN FOR INCISIONAL PAIN W/GOOD EFFECT; +PERRL.\n\nCV: ST LOW 100s INITIALLY TO SR 90S; PACER OFF, A-WIRES DO NOT S/C APPROPRIATELY, V-WIRES S/C APPROP-SEE CAREVUE FOR THRESHOLDS; K REPLETED; BP STABLE 90S-120S, PALPABLE PERIPHERAL PULSES. EXTREMITIES W/D; AFEBRILE. HCT STABLE=28.\n\nRESP: LS CLR, BASES DIM; O2SATS 92-95% ON 3L NC, RESP RATE 20S-30S; GOOD COUGH, BUT PT NEEDS ENCOURAGEMENT; USES I.S. UP TO 750.\n\nGI/GU/ENDO: PT SAYS TOLERATED SM AMTS OF FOOD PREVIOUS SHIFT, H20 W/PO MEDS TOL OVERNIGHT. NO C/O NAUSEA. +BS, NO BM. ABD SOFT, NT, ND. HUO CLR YELLOW, DIURESED UP TO 450cc/HR. BUN 13, CREATININE 0.8. NA 143. BS MONITORED PER CSRU SS, REQUIRED RSSI COVERAGE X1 THIS SHIFT, PT STARTED ON GLYBURIDE & GLARGINE PREVIOUS SHIFT.\n\nSOCIAL: NO PHONE CALLS FROM FAMILY THIS SHIFT.\n\nPLAN: CONTINUE MONITORING CARDIORESP STATUS; MONITOR LABS, PULM TOILET, INCREASE ACTIVITY & PO INTAKE AS TOLERATED; TRANSFER TO 2.\n\n\n"},{"category":"Nursing/other","chartdate":"2118-01-12 00:00:00.000","description":"Report","row_id":1552019,"text":"Nursing 7a-3p\nNeuro: A&Ox3. PERRLA. MAE. OOB to chair w/2 assist. Mostly for line management. Steady gait.\nCV: NSR-ST 90-105. No ectopy. Lytes repleated. Cont on neo & vasopressin gtts. Weaning neo to keep map >60, unable to wean off. NP aware. CVP 8-15. a-line dampened, removed NP .\nResp: NC 4L. Sats >93%. Uses IS weakly to 500 w/encouragement. C&DB. No sputum. Lungs cta, dim in bases.\nEndo: Blood sugars increased. Afternoon bs >200, tx per CSRU riss protocol. F/U bs cont >200. Insulin gtt started.\nSkin: See carevue for incisions. No impaired skin.\nGi: Tol reg diet. Eating sm amts. Tol thin liquids. Initially asked that meds be crushed. However swallowing meds whole fine in afternoon.\nGu: Min-adequate HUO.\nPain: PO dilaudid w/good effect.\nSocial: Family into visit, updated by RN.\nPlan: Wean neo to off as tol to keep map >60. Once tolerating neo off attempt to wean vasopressin gtt. Monitor blood sugars, wean insulin. Pulm toilet. Increase diet & act as tol.\n"},{"category":"Nursing/other","chartdate":"2118-01-12 00:00:00.000","description":"Report","row_id":1552020,"text":"Addendum: Nursing Progress Note:\nAssumed care at 1600. Pt on vasopressin and neo gtts. Insulin gtt restarted for glucose >250.\n"},{"category":"Nursing/other","chartdate":"2118-01-13 00:00:00.000","description":"Report","row_id":1552021,"text":"Endo: Insulin gtt resumed d/t rapidly rising FSGsLabs: K, Ca+, and Mag all repleted this AM\n\nHeme: Hct 21.6 after recheck from 21.4, down from yesterday's of 31. 3 units PRBCs ordered.\n"},{"category":"Nursing/other","chartdate":"2118-01-11 00:00:00.000","description":"Report","row_id":1552013,"text":"Resp Care\nPt from OR intubated s/p CABG. Current vent settings are: SIMV 600 X 12 60% 5/5. Current ABG: 7.37/42/298/25. Plan is to continue weaning to extubate. No other changes noted.\n"},{"category":"Nursing/other","chartdate":"2118-01-11 00:00:00.000","description":"Report","row_id":1552014,"text":"csru adm/update\ns/p cabg x5. labile BP in csru.\n\nneuro: now off propofol. alert and following commands. mae in bed. nods to questions asked. perl. reversals given.\n\ncv: refer to flowsheet for vs. BP labile. on off neo/ntg though mostly neosynephrine dependent. nsr to st. A & V wires present and functioning. cvp mid teens after 3L crystalloid. hct upon arrival to csru 31.\n\nresp: lungs clear. o2 sats 97-100%. tol wean fio2 to .4. presently on cpap + ips. good min volume.\n\ngi/gu: lg amt uop. abd soft. bld tinge ogt dng. insulin gtt per protocol. k+ repleted.\n\nsocial: wife in and updated. booklet given.\n\nassess: labile bp post-op cabg x 5.\n\nplan: wean to extubation. monitor bp,labs, cvp closely. titrate neo.\n\n\n"},{"category":"Nursing/other","chartdate":"2118-01-11 00:00:00.000","description":"Report","row_id":1552015,"text":"Respiratory care:\nPatient extubated to a 4 l NC without incident. Voice strong. RR: 22-30 HR:103 Sa02 96%. Suctioned prior to extubation for scant white sectretions.\nPlan: Monitor respiratory status.\n"},{"category":"Nursing/other","chartdate":"2118-01-12 00:00:00.000","description":"Report","row_id":1552016,"text":"CVP 11->20\n"},{"category":"Nursing/other","chartdate":"2118-01-12 00:00:00.000","description":"Report","row_id":1552017,"text":"ROS:\n\nNeuro: A+O x's 3. MAE x's 4. PERRLA. MSO4 IV and PO dilaudid for pain mngt w/good effect.\n\nCV: RSR/ST w/o ectopy. BP marginally low even w/titrating neo ^. Several fluid bolus given w/minimal effect on BP. Vasopresson 2.4 units hr initiated and albumin 5% given w/good effects on BP. Now weaning down neo. Sternal, mediastinal, and left leg drsgs CDI. Has 2 mediastinal and 1 pleural chest tubes Y connected together and to 20 cm sx draing sang fluid. Has 2 A and 2 V epicardial pacing wires, sense and capt not checked d/t ^ HR. Generalized edema.\n\nResp: O2 NP, sats 95% or >. Lungs clear. No resp distress noted, = rise and fall of chest. Chest tubes as noted above.\n\nGI: Abd soft w/hypo BS. Taking sips of clear liquids. No c/o N/V. H2 blocker to start this Am for GI prophylaxis.\n\nGU: foley patent draining clear yellow urine in QS.\n\nEndo: Insulin gtt converted to SQ RSSI\n\nLabs: Stable and WNL\n\nsocial: No contact from family or friends this 8 hr shift.\n\nPlan: Wean neo as BP allows. Pulmonary toileting. Mobilize, OOB. Monitor, tx, support, and comfort.\n"},{"category":"Nursing/other","chartdate":"2118-01-12 00:00:00.000","description":"Report","row_id":1552018,"text":"CVP 11->20\n"},{"category":"Nursing/other","chartdate":"2118-01-13 00:00:00.000","description":"Report","row_id":1552022,"text":"Neuro: A+O x's 3. MAE x's 4 ='ly. Pain mngt w/IM ketorolac w/good effect. PERRLA.\n\nCV: ST/RSR w/o ectopy. On vasopresson 2.4 units/hr and neo which has been titrated to maintain MAP > 60. Fluid bolus also given for hypotension and Low HUO w/minimal effect. Peripheral pulses palpable w/ease. Has RIJ cath w/distal port transduced for CVP = 10 to 16/18 after fluid bolus. Sternal and mediastinal drsg . Left leg drsg and /steri strips, ACE wrap reapplied. Has 2 A and 2 V epicardial pacing wires, A wires do not sense but do capture. V wires sense and capture. Has two mediastinal and one pleural chest tube Y connected together draining serosang fluid and connected to 20 cm sx.\n\nResp: Lungs clear and diminished in bases. O2 4L NP. Sats 92-95%. Does fair w/deep breathing and poor w/IS and coughing. Patient reports hx of low lung capacity.\n\nGI: Abd soft w/active bs. Taking po's w/o complaints of N/V. H2 blocker for GI prophylaxis.\n\nGU: Foley patent draining dark yellow -> amber cloudy w/sediment in marginal amt even after fluid bolus. UA obtained.\n\nEndo: Insulin gtt off. SQ RSSI for glucose control\n\nLabs: Pending at time of this note.\n\nSocial: Wife phoned at HS for update.\n\nPlan: Mobilize, OOB to chair. Pulmonary toileting. Wean neo as BP tolerates. Ketorolac IM for pain mngt ATC. Resmume home po antihyperglycemics??? Monitor, tx, support, and comfort.\n"},{"category":"Nursing/other","chartdate":"2118-01-13 00:00:00.000","description":"Report","row_id":1552023,"text":"Endo: Insulin gtt resumed d/t rapidly rising FSGsLabs: K, Ca+, and Mag all repleted this AM\n\nHeme: Hct 21.6 after recheck from 21.4, down from yesterday's of 31. 3 units PRBCs ordered.\n"},{"category":"Nursing/other","chartdate":"2118-01-13 00:00:00.000","description":"Report","row_id":1552024,"text":"Endo: Insulin gtt resumed d/t rapidly rising FSGsLabs: K, Ca+, and Mag all repleted this AM\n\nHeme: Hct 21.6 after recheck from 21.4, down from yesterday's of 31. 3 units PRBCs ordered.\n"},{"category":"Echo","chartdate":"2118-01-11 00:00:00.000","description":"Report","row_id":82426,"text":"PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nWeight (lb): 180\nBP (mm Hg): 120/70\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 14:38\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 or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. The ascending, transverse and descending thoracic aorta are\nnormal in diameter and free of atherosclerotic plaque. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. There is no pericardial effusion.\nPOST-BypASS:\npreserved biventricular systolic function. Overall LVEF 55%.\nMild MR>\nAortic contour is preserved.\nTrace TR\n\n\n"},{"category":"ECG","chartdate":"2118-01-11 00:00:00.000","description":"Report","row_id":208537,"text":"Sinus rhythm. Non-specific inferolateral ST-T wave changes. Compared to the\nprevious tracing of no significant diagnostic change.\n\n\n"},{"category":"Radiology","chartdate":"2118-01-11 00:00:00.000","description":"CHEST PORT. LINE PLACEMENT","row_id":939696,"text":" 5:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 60-year-old male status post CABG. Postoperative film.\n\n COMPARISON: .\n\n TECHNIQUE: Portable chest radiograph.\n\n FINDINGS: Compared to prior radiograph obtained on , patient\n is status post CABG procedure with a median sternotomy. ET tube is seen\n terminating approximately 3.8 cm above the carina. A right IJ central venous\n catheter has been placed with tip in the expected location of the atrial caval\n junction. Tip of the NG tube is in the expected region of the fundus of the\n stomach. Two mediastinal drains and a left-sided chest tube is present. No\n pneumothorax is apparent. There are low lung volumes, with retrocardiac\n atelectasis. No pleural effusions is seen. There is normal postoperative\n widening of the mediastinum.\n\n IMPRESSION: Stable postoperative chest.\n\n\n"},{"category":"Radiology","chartdate":"2118-01-12 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":939741,"text":" 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/hypotension-r/o PTX\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p cabg\n\n REASON FOR THIS EXAMINATION:\n s/p CABG w/hypotension-r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after CABG.\n\n Portable AP chest radiograph compared to .\n\n No obvious change. No evidence of pneumothorax is present. No\n consolidations, pulmonary edema, or pneumomediastinum is demonstrated.\n\n"},{"category":"Radiology","chartdate":"2118-01-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":939991,"text":" 2:42 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess effusion/infiltrates/chf\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p cabg hct drop\n\n REASON FOR THIS EXAMINATION:\n assess effusion/infiltrates/chf\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of CABG and hematocrit drop.\n\n Status post-CABG. Right jugular CV line is in right atrium, unchanged since\n prior films. Three left-sided chest tubes are present. There is a small left\n apical pneumothorax. Heart size and mediastinal width are unchanged when\n compared with a prior film of the same date. There is atelectasis at the left\n lung base.\n\n IMPRESSION: Right jugular CV line in right atrium. Small left apical\n pneumothorax.\n\n"},{"category":"Radiology","chartdate":"2118-01-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":939881,"text":" 7:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for effusions/infiltrates\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p cabg\n\n REASON FOR THIS EXAMINATION:\n assess for effusions/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old post CABG.\n\n Portable semi-upright frontal radiograph compared to and 13, .\n\n The lung volumes are reduced. Atelectasis and pleural effusion at the left\n base are unchanged. Pulmonary vascularity is normal. Three right-sided chest\n tubes and a right IJ central venous catheter are unchanged in position.\n Postoperative appearance of the mediastinum is stable.\n\n IMPRESSION: No change compared to one day earlier.\n\n\n"},{"category":"Radiology","chartdate":"2118-01-13 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":940014,"text":" 5:05 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p cabg and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man status post CABG and CT removal. Rule out\n pneumothorax.\n\n COMPARISON: Two hours prior.\n\n There has been removal of three left-sided chest tubes. There is no evidence\n of pneumothorax. There are low lung volumes with no evidence of\n consolidation. The remainder of the chest radiograph is stable.\n\n IMPRESSION:\n\n No evidence of pneumothorax.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552025,\n \"text\": \"Endo: Insulin gtt resumed d/t rapidly rising FSGsLabs: K, Ca+, and Mag all repleted this AM\\n\\nHeme: Hct 21.6 after recheck from 21.4, down from yesterday's of 31. 3 units PRBCs ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552026,\n \"text\": \"NEURO: Alert, awake, oriented x3, transfer from bed to chair and vice versa with 2 person assist, incisional pain treated with recurring Toradol IM with good effect, Pt states pain free.\\n\\nRESP: Wean O2 to 2L via NC, Sats in 97%, lung sounds clear at apicals/dim at bases, Pt able to cough/deep breath and uses IS, also states that \\\"his lungs are not that good\\\" resp in 30s and reg/unlabored\\n\\nCV: NSR with HRs in 80-90s, keep MAP >60, wean off Vasopressin, given 3 units of PRBCs for a Hct of 21, post-transfusion Hct was 29, with improved BP and O2 Sats, pacer is off (tested As and not sensing/capturing appropiately, did not test Vs), pedal pulses palpable\\n\\nGI/GU: Pt on diet with good appetite, Pt tolerates PO meds, has large, formed stool today; Foley draining yellow-amber/clear urine, urine outputs slowly diminished to 20-30cc/hr but responds well to recurring Lasix\\n\\nENDO: Started on daily Glyburide and Lantus 20units today with SSRI\\n\\nSOCIAL: Wife and children visited throughout the afternoon.\\n\\nPLAN: Continue to monitor resp, hemodynamics, urine output, LABS, deline trauma line and start PIV, increase activity as tolerated, ? transfer to floor tomorrow\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-14 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552027,\n \"text\": \"NEURO: PT IS A&OX3-APPROPRIATE; SLEPT ON/OFF OVERNIGHT; MAES EQUALLY TO COMMAND-NO DEFICITS, THOUGH RELUCTANT TO MOVE. IM TORADOL GIVEN FOR INCISIONAL PAIN W/GOOD EFFECT; +PERRL.\\n\\nCV: ST LOW 100s INITIALLY TO SR 90S; PACER OFF, A-WIRES DO NOT S/C APPROPRIATELY, V-WIRES S/C APPROP-SEE CAREVUE FOR THRESHOLDS; K REPLETED; BP STABLE 90S-120S, PALPABLE PERIPHERAL PULSES. EXTREMITIES W/D; AFEBRILE. HCT STABLE=28.\\n\\nRESP: LS CLR, BASES DIM; O2SATS 92-95% ON 3L NC, RESP RATE 20S-30S; GOOD COUGH, BUT PT NEEDS ENCOURAGEMENT; USES I.S. UP TO 750.\\n\\nGI/GU/ENDO: PT SAYS TOLERATED SM AMTS OF FOOD PREVIOUS SHIFT, H20 W/PO MEDS TOL OVERNIGHT. NO C/O NAUSEA. +BS, NO BM. ABD SOFT, NT, ND. HUO CLR YELLOW, DIURESED UP TO 450cc/HR. BUN 13, CREATININE 0.8. NA 143. BS MONITORED PER CSRU SS, REQUIRED RSSI COVERAGE X1 THIS SHIFT, PT STARTED ON GLYBURIDE & GLARGINE PREVIOUS SHIFT.\\n\\nSOCIAL: NO PHONE CALLS FROM FAMILY THIS SHIFT.\\n\\nPLAN: CONTINUE MONITORING CARDIORESP STATUS; MONITOR LABS, PULM TOILET, INCREASE ACTIVITY & PO INTAKE AS TOLERATED; TRANSFER TO 2.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552019,\n \"text\": \"Nursing 7a-3p\\nNeuro: A&Ox3. PERRLA. MAE. OOB to chair w/2 assist. Mostly for line management. Steady gait.\\nCV: NSR-ST 90-105. No ectopy. Lytes repleated. Cont on neo & vasopressin gtts. Weaning neo to keep map >60, unable to wean off. NP aware. CVP 8-15. a-line dampened, removed NP .\\nResp: NC 4L. Sats >93%. Uses IS weakly to 500 w/encouragement. C&DB. No sputum. Lungs cta, dim in bases.\\nEndo: Blood sugars increased. Afternoon bs >200, tx per CSRU riss protocol. F/U bs cont >200. Insulin gtt started.\\nSkin: See carevue for incisions. No impaired skin.\\nGi: Tol reg diet. Eating sm amts. Tol thin liquids. Initially asked that meds be crushed. However swallowing meds whole fine in afternoon.\\nGu: Min-adequate HUO.\\nPain: PO dilaudid w/good effect.\\nSocial: Family into visit, updated by RN.\\nPlan: Wean neo to off as tol to keep map >60. Once tolerating neo off attempt to wean vasopressin gtt. Monitor blood sugars, wean insulin. Pulm toilet. Increase diet & act as tol.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552020,\n \"text\": \"Addendum: Nursing Progress Note:\\nAssumed care at 1600. Pt on vasopressin and neo gtts. Insulin gtt restarted for glucose >250.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552021,\n \"text\": \"Endo: Insulin gtt resumed d/t rapidly rising FSGsLabs: K, Ca+, and Mag all repleted this AM\\n\\nHeme: Hct 21.6 after recheck from 21.4, down from yesterday's of 31. 3 units PRBCs ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552013,\n \"text\": \"Resp Care\\nPt from OR intubated s/p CABG. Current vent settings are: SIMV 600 X 12 60% 5/5. Current ABG: 7.37/42/298/25. Plan is to continue weaning to extubate. No other changes noted.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552014,\n \"text\": \"csru adm/update\\ns/p cabg x5. labile BP in csru.\\n\\nneuro: now off propofol. alert and following commands. mae in bed. nods to questions asked. perl. reversals given.\\n\\ncv: refer to flowsheet for vs. BP labile. on off neo/ntg though mostly neosynephrine dependent. nsr to st. A & V wires present and functioning. cvp mid teens after 3L crystalloid. hct upon arrival to csru 31.\\n\\nresp: lungs clear. o2 sats 97-100%. tol wean fio2 to .4. presently on cpap + ips. good min volume.\\n\\ngi/gu: lg amt uop. abd soft. bld tinge ogt dng. insulin gtt per protocol. k+ repleted.\\n\\nsocial: wife in and updated. booklet given.\\n\\nassess: labile bp post-op cabg x 5.\\n\\nplan: wean to extubation. monitor bp,labs, cvp closely. titrate neo.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552015,\n \"text\": \"Respiratory care:\\nPatient extubated to a 4 l NC without incident. Voice strong. RR: 22-30 HR:103 Sa02 96%. Suctioned prior to extubation for scant white sectretions.\\nPlan: Monitor respiratory status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552016,\n \"text\": \"CVP 11->20\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552017,\n \"text\": \"ROS:\\n\\nNeuro: A+O x's 3. MAE x's 4. PERRLA. MSO4 IV and PO dilaudid for pain mngt w/good effect.\\n\\nCV: RSR/ST w/o ectopy. BP marginally low even w/titrating neo ^. Several fluid bolus given w/minimal effect on BP. Vasopresson 2.4 units hr initiated and albumin 5% given w/good effects on BP. Now weaning down neo. Sternal, mediastinal, and left leg drsgs CDI. Has 2 mediastinal and 1 pleural chest tubes Y connected together and to 20 cm sx draing sang fluid. Has 2 A and 2 V epicardial pacing wires, sense and capt not checked d/t ^ HR. Generalized edema.\\n\\nResp: O2 NP, sats 95% or >. Lungs clear. No resp distress noted, = rise and fall of chest. Chest tubes as noted above.\\n\\nGI: Abd soft w/hypo BS. Taking sips of clear liquids. No c/o N/V. H2 blocker to start this Am for GI prophylaxis.\\n\\nGU: foley patent draining clear yellow urine in QS.\\n\\nEndo: Insulin gtt converted to SQ RSSI\\n\\nLabs: Stable and WNL\\n\\nsocial: No contact from family or friends this 8 hr shift.\\n\\nPlan: Wean neo as BP allows. Pulmonary toileting. Mobilize, OOB. Monitor, tx, support, and comfort.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-12 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552018,\n \"text\": \"CVP 11->20\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552022,\n \"text\": \"Neuro: A+O x's 3. MAE x's 4 ='ly. Pain mngt w/IM ketorolac w/good effect. PERRLA.\\n\\nCV: ST/RSR w/o ectopy. On vasopresson 2.4 units/hr and neo which has been titrated to maintain MAP > 60. Fluid bolus also given for hypotension and Low HUO w/minimal effect. Peripheral pulses palpable w/ease. Has RIJ cath w/distal port transduced for CVP = 10 to 16/18 after fluid bolus. Sternal and mediastinal drsg . Left leg drsg and /steri strips, ACE wrap reapplied. Has 2 A and 2 V epicardial pacing wires, A wires do not sense but do capture. V wires sense and capture. Has two mediastinal and one pleural chest tube Y connected together draining serosang fluid and connected to 20 cm sx.\\n\\nResp: Lungs clear and diminished in bases. O2 4L NP. Sats 92-95%. Does fair w/deep breathing and poor w/IS and coughing. Patient reports hx of low lung capacity.\\n\\nGI: Abd soft w/active bs. Taking po's w/o complaints of N/V. H2 blocker for GI prophylaxis.\\n\\nGU: Foley patent draining dark yellow -> amber cloudy w/sediment in marginal amt even after fluid bolus. UA obtained.\\n\\nEndo: Insulin gtt off. SQ RSSI for glucose control\\n\\nLabs: Pending at time of this note.\\n\\nSocial: Wife phoned at HS for update.\\n\\nPlan: Mobilize, OOB to chair. Pulmonary toileting. Wean neo as BP tolerates. Ketorolac IM for pain mngt ATC. Resmume home po antihyperglycemics??? Monitor, tx, support, and comfort.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552023,\n \"text\": \"Endo: Insulin gtt resumed d/t rapidly rising FSGsLabs: K, Ca+, and Mag all repleted this AM\\n\\nHeme: Hct 21.6 after recheck from 21.4, down from yesterday's of 31. 3 units PRBCs ordered.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2118-01-13 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1552024,\n \"text\": \"Endo: Insulin gtt resumed d/t rapidly rising FSGsLabs: K, Ca+, and Mag all repleted this AM\\n\\nHeme: Hct 21.6 after recheck from 21.4, down from yesterday's of 31. 3 units PRBCs ordered.\\n\"\n },\n {\n \"category\": \"Echo\",\n \"chartdate\": \"2118-01-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 82426,\n \"text\": \"PATIENT/TEST INFORMATION:\\nIndication: Coronary artery disease.\\nWeight (lb): 180\\nBP (mm Hg): 120/70\\nHR (bpm): 72\\nStatus: Inpatient\\nDate/Time: at 14:38\\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 or thrombus in the\\nLA/LAA or the RA/RAA.\\n\\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\\nDoppler.\\n\\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\\n(LVEF>55%).\\n\\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\\n\\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\\natherosclerotic plaque.\\n\\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\\n\\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\\n\\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\\n\\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\\nphysiologic PR.\\n\\nPERICARDIUM: No pericardial effusion.\\n\\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\\nI was present in compliance with HCFA regulations. No TEE related\\ncomplications. The patient was under general anesthesia throughout the\\nprocedure. The patient appears to be in sinus rhythm. Results were personally\\nreviewed with the MD caring for the patient.\\n\\nConclusions:\\nPRE-BYPASS:\\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\\nseen in the body of the left atrium/left atrial appendage or the body of the\\nright atrium/right atrial appendage. No atrial septal defect is seen by 2D or\\ncolor Doppler. Left ventricular wall thickness, cavity size, and systolic\\nfunction are normal (LVEF>55%). Right ventricular chamber size and free wall\\nmotion are normal. The ascending, transverse and descending thoracic aorta are\\nnormal in diameter and free of atherosclerotic plaque. The aortic valve\\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\\nMild (1+) mitral regurgitation is seen. There is no pericardial effusion.\\nPOST-BypASS:\\npreserved biventricular systolic function. Overall LVEF 55%.\\nMild MR>\\nAortic contour is preserved.\\nTrace TR\\n\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2118-01-11 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 208537,\n \"text\": \"Sinus rhythm. Non-specific inferolateral ST-T wave changes. Compared to the\\nprevious tracing of no significant diagnostic change.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2118-01-11 00:00:00.000\",\n \"description\": \"CHEST PORT. LINE PLACEMENT\",\n \"row_id\": 939696,\n \"text\": \" 5:16 PM\\n CHEST PORT. LINE PLACEMENT Clip # \\n Reason: postop film\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man s/p cabg\\n REASON FOR THIS EXAMINATION:\\n postop film\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 60-year-old male status post CABG. Postoperative film.\\n\\n COMPARISON: .\\n\\n TECHNIQUE: Portable chest radiograph.\\n\\n FINDINGS: Compared to prior radiograph obtained on , patient\\n is status post CABG procedure with a median sternotomy. ET tube is seen\\n terminating approximately 3.8 cm above the carina. A right IJ central venous\\n catheter has been placed with tip in the expected location of the atrial caval\\n junction. Tip of the NG tube is in the expected region of the fundus of the\\n stomach. Two mediastinal drains and a left-sided chest tube is present. No\\n pneumothorax is apparent. There are low lung volumes, with retrocardiac\\n atelectasis. No pleural effusions is seen. There is normal postoperative\\n widening of the mediastinum.\\n\\n IMPRESSION: Stable postoperative chest.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2118-01-12 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 939741,\n \"text\": \" 3:16 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: s/p CABG w/hypotension-r/o PTX\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man s/p cabg\\n\\n REASON FOR THIS EXAMINATION:\\n s/p CABG w/hypotension-r/o PTX\\n ______________________________________________________________________________\\n FINAL REPORT\\n REASON FOR EXAMINATION: Followup of a patient after CABG.\\n\\n Portable AP chest radiograph compared to .\\n\\n No obvious change. No evidence of pneumothorax is present. No\\n consolidations, pulmonary edema, or pneumomediastinum is demonstrated.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2118-01-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 939991,\n \"text\": \" 2:42 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: assess effusion/infiltrates/chf\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man s/p cabg hct drop\\n\\n REASON FOR THIS EXAMINATION:\\n assess effusion/infiltrates/chf\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, SINGLE AP FILM\\n\\n History of CABG and hematocrit drop.\\n\\n Status post-CABG. Right jugular CV line is in right atrium, unchanged since\\n prior films. Three left-sided chest tubes are present. There is a small left\\n apical pneumothorax. Heart size and mediastinal width are unchanged when\\n compared with a prior film of the same date. There is atelectasis at the left\\n lung base.\\n\\n IMPRESSION: Right jugular CV line in right atrium. Small left apical\\n pneumothorax.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2118-01-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 939881,\n \"text\": \" 7:23 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess for effusions/infiltrates\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man s/p cabg\\n\\n REASON FOR THIS EXAMINATION:\\n assess for effusions/infiltrates\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 60-year-old post CABG.\\n\\n Portable semi-upright frontal radiograph compared to and 13, .\\n\\n The lung volumes are reduced. Atelectasis and pleural effusion at the left\\n base are unchanged. Pulmonary vascularity is normal. Three right-sided chest\\n tubes and a right IJ central venous catheter are unchanged in position.\\n Postoperative appearance of the mediastinum is stable.\\n\\n IMPRESSION: No change compared to one day earlier.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2118-01-13 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 940014,\n \"text\": \" 5:05 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: r/o ptx\\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\\\CORONARY ARTERY BYPASS GRAFT /SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 60 year old man s/p cabg and ct removal\\n REASON FOR THIS EXAMINATION:\\n r/o ptx\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 60-year-old man status post CABG and CT removal. Rule out\\n pneumothorax.\\n\\n COMPARISON: Two hours prior.\\n\\n There has been removal of three left-sided chest tubes. There is no evidence\\n of pneumothorax. There are low lung volumes with no evidence of\\n consolidation. The remainder of the chest radiograph is stable.\\n\\n IMPRESSION:\\n\\n No evidence of pneumothorax.\\n\\n\"\n }\n]"}}},{"rowIdx":997,"cells":{"subject_id":{"kind":"number","value":7784,"string":"7,784"},"hadm_id":{"kind":"number","value":118746,"string":"118,746"},"target_text":{"kind":"string","value":"Impression: 70 yo f w/ h/o ESLD and grade I varices who p/w weakness, LE edema, and anemia. . 1) anemia- felt likely slow GIB given guiac + stool. Egd showed gastritis and grade I varices, and GI consult felt this was the explanation for the patient's hct drop. H. pylori negative. The patient was transfused 2U PRBC, and her hct remained stable throughout her hospital course. She should have a f/u EGD which is already scheduled with Dr. in . She was also started on iron supplementation and protonix. . 2) thrombocytopenia- likely liver dz +/- splenomegaly. Seemed unlikely to be related to med effect and there was no evidence of ongoing infection. Also could be related to acute etoh effect (particularly given elevated AST). Very low suspicion for diffuse marrow process or malignancy. Platelets remained stable and were actually trending up during this hospital course. . 3) ischemia - mild troponin and ecg changes c/w low grade ischemia. No evidence of ACS. Ecg changes resolved w/ support of her hct. . 4) copd- no pfts on record but exam on HD3 and 4 c/w flair and patient has significant smoking history. started on nebs and completed a 5d course of steroids. On transfer to the floor, the patient had clear lungs and did not require O2, nebs or endorse SOB. Discharged patient on combivent inhaler. . 5) esld- initially held lasix/aldactone while in house and this was then resumed. She was also given lactulose for hepatic encephalopathy which was d/c'd when her mental status cleared. She was started back on lasix/aldactone at home dose on but became hypernatremic so subsequently held again. We restarted these medications on discharge and patient should have her electrolytes rechecked within the next week at rehab. She was also started on thiamine and folate. . 6) encephalopathy- likely esld and etoh w/d. Head ct performed given that pt had recent fall and it was negative for ICH. She was treated w/ 3d iv thiamine for possible Wernicke's. Mental status changes resolved w/ aggressive lactulose and clearing of benzodiazepenes. We stopped lactulose when patient's mental status cleared and her NH4 was normal. On discharge, she was at her mental status baseline. . 7) etoh w/d with DTs- req'd extremely large doses of ativan (chosen over valium due to impaired liver fxn), on HD 2 the patient req'd 60 mg ativan througout the day. Titrated off over the subsequent 6 days. On transfer to floor on , patient has not req'd any ativan and was in the clear in terms of ETOH withdrawl. Patient is to be discharged to rehab center. We had a family meeting and discussed all the issues and patient wants treatment for alcoholism and will be discharged to Rehab. . 8) ppx- maintained on pneumoboots given thrombocytopenia initially, then sub q heparin. ppi "},"extractive_notes_summ":{"kind":"string","value":"K repleated in AM w/ 60mEq, INR 1.6.Resp: remains on 4L NC, rr 19-28, o2sat 92-98, LS coarse upper diminished lower. NS IV bolus or additional x1 IV lasix for decreased UO.ID: Temp 97.0-98.4, WBC 17 (up from 9, md's aware). MICU 7 RN Note 0700-1900Events: Hypernatremia Free H20 bolus, Speech eval, ^PTT, CIWA monitoring.Neuro: Awake lethargic, voice slurred with noted improved level of orientation. recieved lactalose encephalopathyCV: HR 78-90 NSR no ectopy, BP 112-140/40-60. Lactulose continues.GU: Foley to gravity with marginal output, HO aware - no intervention at this time.Endo: No RISSSkin: Stage I pressure area on coccyx/buttocks. Na 153 Free H20 repeat Na trending down.Heme: Hct 31.8 trending down from previous days, Ptt 90 INR 1.7 Heparin SQ d/cResp: RR 22-26 Reg O2 3L/Min NC Sats 95-97% Lungs clear Dim @ bases.ID: low grade temp 100, WBC 10.9, Abx Flagyl/vancoGI/liver: Ads soft distended + BS +stool Mushroom cath in place. Respiratory Care: Pt seen for albuterol and atrovent nebs today. Patient on albuterolQ6 PRN,Atrovent Q6.last Rx done @ 18 0clock.Hard to understand patient,BS diminished without wheezes.Being treated prophylactically for SOB. Hemodynamically stable.Resp: Remains on 3L NC, RR 15-30, O2sat 89-100, LS coarse upper and crackles lower. npn micu 7 westallergies: SulfaFull CodeNeuro: pt is minimally arousable, opens eyes to speech, pupils 3mm brisk, speech is garbled and slurred, pt. CIWA scale 5-10 recieved Ativan 1mg x3 and Haldol 1mg x2. tp has stroung/productive cough, but swallow back.cv: HR 90-116, NSR/ST, no ectopy. CLAMPED WITH BILIOUS DRNG, HEME-. CXR DONE THIS MORNING.GI/GU: ABD SOFT WITH +BS. LACTULOSE AS ORDERED, HELD AM DOSE AS SHE WAS STOOLING.CARDIAC: HR 88-105 SR/ST WITH RARE PVC'S. Wean O2 to maintain sats>95%.Cv: 1 left peripheral/right single lumen PICC placed today in IR, LE edema present, UE bruising/ edematous, HR 90-100 NS-ST, no ectopy, pulses palpable in all four extremeties. PICC with KVO IVF.Resp: Switched to 3LNC, maintains SPO2 high 90's. PT WITH LOW GRADE TEMP OF 99.6 PO. LS coarse to clear with occas ins wheezing. INR 1.7, PTT and PT slightly elevated as well, Hep dose changed to and DIC labs sent, but mostly likely caused by impaired liver function.Resp: started shift on 4L NC, mouth has been very dry and sat's were lower, changed to cool neb @ 40% for moisture and increased o2, tolerating well. Treating w/ standing dose ativan 1mg Q4H and Haldol 0.5-1mg PRN (low dose for liver issues MD). PLEASE SEE CAREVIEW FOR CIWA SCALE.CV: PT IN NSR WHEN ASLEEP BUT WHEN AWAKE HR UP TO THE 120'S. 1900-0700 rn notes micuneuro: in the beggining shift pt very lethargic, minimal withdraw to sternal rub, minimal attempt to open eyes and move in the bed, MD aware, dose of Ativam held, stopped Ativan 1mg q4hr, change Halodol PRN 0.5mg q4hr. RECEIVING LACTULOSE FOR ESLD.CARDIAC: HR 78-91 SR WITH NO ECTOPY. MD AWARE AND DECREASED ATIVAN TO 3MG Q2HRS. d/c'd rectal . Right pleural effusion is incompletely assessed. Single-lumen PICC to R brachial is patent and WNL. Since the previous tracing of minimal slowing ofthe heart rate is seen. ON LEVOFLOX.SKIN: W/D/I. FINDINGS: There is a new small left pleural effusion. COMPARISON: Radiograph dated . A right pleural effusion is incompletely evaluated on this study. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided PICC line placement via the right brachial vein with the tip positioned in SVC. LYTES PER CAREVUE. now w/ new hypoxemia and coarse breath sounds REASON FOR THIS EXAMINATION: eval for pulm edema or pna FINAL REPORT CHEST, SINGLE VIEW, ON HISTORY: New hypoxemia and coarse breath sounds. Since the previous tracing of the heart rate isfaster. Afebrile.GI: Pt. More centrally, there is considerable peribronchial opacification in a region that previously showed abnormality. now w/ new oxygen requirement. MICU NPN 7P-7ANEURO: INITIALLY PATIENT DIFFICULT TO AROUSE. MEDS CHANGED TO IV/SC AS ALLOWED.ID: TMAX 99.4 WITH WBC 11.2. oriented to person, place, and time but when left alone has d/c'd rectal , NGT, and takes off 02. There continues to be mild cardiomegaly. IMPRESSION: Mild penetration which cleared during the swallow. Most likely, this findings are due to CHF. CONTINUE TO TREAT DT'S. As demonstrated on , there is reversal of flow in the main, right, and left portal veins as well as superior mesenteric vein. now w/ PNA and O2 requirement REASON FOR THIS EXAMINATION: eval for improvement FINAL REPORT INDICATION: Pneumonia and decreased oxygen requirement. Normal flow and appropriate waveforms are demonstrated in the main, left, and right hepatic arteries. now w/ PNA and O2 requirement REASON FOR THIS EXAMINATION: interval change FINAL REPORT CHEST RADIOGRAPH. OCCASIONAL CONGESTED NONPRODUCTIVE COUGH.GI/GU: ABD SOFT WITH +BS. HCT @ 24.9, GIVEN 1UPRBC'S WITH AM HCT 32.3. Able to take lactulose po. WHEN CALM LS CLEAR WITH DIMINISHED LEFT BASE. Lungs are clear, bases are diminished at times. Nursing Progress Note:Pt. Nursing Progress Note:Pt. 9:32 AM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOPP ABD/PEL Reason: assess ascites, mark for tap, ? Sinus rhythm, rate 98. IMPRESSION: AP chest compared to and : Heart size is top normal. BP 98-150/45-80. Significant interval improvement of the multifocal pneumonia. can have thickened liquids until further eval of swallow is performed (pt."},"n_notes":{"kind":"number","value":32,"string":"32"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2127-08-25 00:00:00.000","description":"Report","row_id":1366523,"text":"npn micu 7 west\nallergies: Sulfa\nFull Code\n\nNeuro: pt is minimally arousable, opens eyes to speech, pupils 3mm brisk, speech is garbled and slurred, pt. lethargic and sleeping most of day, ativan 4mg q 2hrs for DTs.\n\nResp: 3L NC, LS clear, CXR + pNA/r pleural effusion for which she is receiving abx flagyl and ceftriaxone, O2 sats>95%. Wean O2 to maintain sats>95%.\n\nCv: 1 left peripheral/right single lumen PICC placed today in IR, LE edema present, UE bruising/ edematous, HR 90-100 NS-ST, no ectopy, pulses palpable in all four extremeties. IV fluid D5W @ 30cc/hr. Of note: past ECHO normal.\n\ngu\r: foley output >30cc/hr, standing Lasix 40mg IV and Spirolactone PO for end stage liver failure.\n\ngi: Please start TF after midnight via NG, NG patent & clamped, 50 cc residual yellow bile, BS present, last BM (black stool), abd neg for ascites, Lactulose given for encephalopathy. Endoscopy on showed grade 1+2 varices/gastritis, NG lavage negative.\n\nid: T=96.8, WBC 9.3, urine sent, Flagl/Cef for pNA, PO prednisone for possible COPD\n\nsocial: daughter visited today, she was very helpful and supportive of her mother\n\nplan: Start TF, advance as tolerated\n Cont Ativan 4mg IV for DT\n Monitor mental status\n Cont Lactulose\n\n"},{"category":"Nursing/other","chartdate":"2127-08-26 00:00:00.000","description":"Report","row_id":1366524,"text":"MICU NPN 7P-7A\nNEURO: INITIALLY SEDATED AND DIFFICULT TO AROUSE. DID OPEN EYES TO VOICE BUT ONLY MAKING SOUNDS. MD AWARE AND DECREASED ATIVAN TO 3MG Q2HRS. A BIT MORE RESTLESS AS NIGHT WORE ON TRYING TO PICK SELF UP. THIS MORNING MORE AWAKE WITH EYES OPEN. STATED NAME AND WAS ABLE TO SAY THAT SHE WAS IN A HOSPITAL. FOLLOWED SIMPLE COMMANDS. MOVING ALL EXTREMITIES. RESTRAINED FOR SAFETY. LACTULOSE AS ORDERED, HELD AM DOSE AS SHE WAS STOOLING.\n\nCARDIAC: HR 88-105 SR/ST WITH RARE PVC'S. BP 105-128/49-66. HCT STABLE @32.6. PPP.\n\nRESP: ON 3L N/C WITH RR 15-24 AND SATS 95-100%. LS COARSE WITH DIMINISHED BASES, BUT THIS MORNING WITH A FEW FINE CRACKLES BIBASILAR. FREQUENT CONGESTED PRODUCTIVE COUGH BUT SWALLOWING. CXR FROM SHOWED MULTIFOCAL PNA BUT NO EFFUSIONS. NO SIGNS OD SOB, NEBS AND STEROIDS AS ORDERED.\n\nGI/GU: ABD SOFT WITH +BS. MED LOOSE BLACK TO BROWN STOOL X2. NGT IN PLACE AND PATENT. MARGINAL UOP 15-30CC/HR, 250CC FLUID BOLUS WITH SLIGHT INREASE IN OUTPUT. AMBER AND CLEAR.\n\nFEN: D5W D/C'D. FEEDS STARTED, GOAL 40CC/HR, MODERATE RESIDUALS. LYTES PER CAREVUE. RECEIVED 60MEQ KCL LAST NOC FOR K+ 3.4, NOW 4.1.\n\nID: TMAX 98.4 WITH JUMP IN WBC FROM 9.3 TO 17. CONTINUES ON FLAGYL AND CEFTRIAXONE FOR PNA COVERAGE. NGTD ON CX'S.\n\nSKIN: W/D/I, SEVERAL ECCHYMOTIC AREAS ON ARMS.\n\nACCESS: PIV X1, RIGHT BRACHIAL PICC.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY. CONTINUE TO TITRAE DOWN DOSAGE OF ATIVAN TO BETTER ASSESS MS. FEEDS AS TOLERATED.\n"},{"category":"Nursing/other","chartdate":"2127-08-26 00:00:00.000","description":"Report","row_id":1366525,"text":"Nursing Progress Note 0700-1900\n*Full Code\n\n*Access: 2 PIV's (R and L)\n\n*Allergies: Sulfa\n\nNeuro: Pt agitated at times, trying to lift self in bed, putting legs over railings, pulling at restraints. Treating w/ standing dose ativan 1mg Q4H and Haldol 0.5-1mg PRN (low dose for liver issues MD). not be enough for her as behavior continues, however VS remain stable at this time. Follows commands infrequently, insensible words, unable to assess orientation, PERRL 3mm/, (moving in bed).\n\nCardiac: NSR/ST w/o ectopy, HR 93-108, SBP 124-140, Hct stable @ 32.6. Hemodynamically stable.\n\nResp: Remains on 3L NC, RR 15-30, O2sat 89-100, LS coarse upper and crackles lower. CXR shows slightly worsened bilateral infiltrates slightly worse on right than left. Lasix changed from IV to PO QD to remove fluid and help increase Urine output as well. Also ? aspiration aspect to this picture (not new, but prior to hospitalization).\n\nGI/GU: TF @ 30cc increased after residual 10cc, was 110 this AM so did not advance TF til this afternoon (goal 40cc/hr, advance if tolerating). +BS, med stool brown, loose this AM, cont lactulose for goal 3 stools per day. Urine out foley yellow/amber and clear, 40-1100cc/hr w/ higher doses following 20mg IV Lasix, no PO. ? NS IV bolus or additional x1 IV lasix for decreased UO.\n\nID: Temp 97.0-98.4, WBC 17 (up from 9, md's aware). Cont flagyl and ceftriaxone. IV sites wnl.\n\nPsychosocial: Husband visited today, updated on POC and current condition by MD's. Daughter visited later and also updated on POC and condition and ICU environment. Sister also called and told by unit coordinator it would be best to contact her husband or daughter for updates.\n\nDispo: cont to monitor mental status, treat agitation w/ ativan and haldol, cont to monitor resp status, cont med regimen.\n"},{"category":"Nursing/other","chartdate":"2127-08-27 00:00:00.000","description":"Report","row_id":1366526,"text":"1900-0700 rn notes micu\n\nneuro: in the beggining shift pt very lethargic, minimal withdraw to sternal rub, minimal attempt to open eyes and move in the bed, MD aware, dose of Ativam held, stopped Ativan 1mg q4hr, change Halodol PRN 0.5mg q4hr. overnight became more responsive, opens eyes half way, trying to lift self in the bed, moving all extremeties in the bed, but does not follow commands, incomp sounds, unable to assess orientation.\n\nresp: receievd on NC 3L, pt deast to 90-91%,O2 up to 4L, given nebs for wheezing. LS coarse to clear with occas ins wheezing. tp has stroung/productive cough, but swallow back.\n\ncv: HR 90-116, NSR/ST, no ectopy. SBP 113-135/60-70's. HCT 33.9\n\ngi/gu: foley in place, pr received fluid bolus NS 250ccx2 for u/o 2-17cc/hr with good response. ABD soft/dist, BS +. cont , pt start passing liquid brown stool, mushroom cath placed. cont TF at goal 40cc/hr residual 10-40cc.\n\nid: tmax 99.8 rectal, cont ABX.\n\nsocial: full code, no conatct from family.\n\nplan: cont monitoring neuro/mental status\n repleted lytes as needed.\n\n"},{"category":"Nursing/other","chartdate":"2127-08-24 00:00:00.000","description":"Report","row_id":1366520,"text":"Respiratory Care: Pt seen for albuterol and atrovent nebs today. Pt's breath sounds coarse/wheezes, diminished aeration. Suctioned x 1 by Rt for moderate thick white secretions, pt tolerated well. will continue to monitor.\n"},{"category":"Nursing/other","chartdate":"2127-08-24 00:00:00.000","description":"Report","row_id":1366521,"text":"Micu nursing note \n\nNeuro, pt very restless at 7 am hr 115 ST, pt all over bed, had removed both Iv's\nhands remains in soft restraints, on ciwa scale recieveing ativan q2 hr throught the day, pt had # 22 placed in L hand, pt given iv ativan q1 hr for the first 3hrs, also at the time pt wheezy, with crackles in bases and tacky. pt given resp tx and 20 lasix Iv, pt had good response of 800 plus over 2 hrs, and sounds much better this afternoon\nresp o2^ 4L with sob, and throught day have been able to drop o2 back to 3l sats 100%, previously to getting lasix sats 90-93%, lungs now deminished in bases but no crackles, pt also suctioned for lg amount of secreation nasal/orally x2 now pt much clearer. chest xray also thanken this am with ^ sob, showed some failer ? pneumonia,pt also febrile at that time to 101, pt started back on cefriaxone, and flagly\ncv Pt had a short peried of dropping bp in high 80's sbp after lasix, not treated at that time and bp returned to now BP 90-104/50-60\nGi pt still npo, but ngt dropped in order to give oral meds, pt asperates hem pos, pt also having smearing of stool which is also heme pos,\n pt has foley passing clear yellow urine, started on lasix and sparolactone today.\nId tmax 101.0 this am started anitbiotics, cultures pending\nheme 32.7\nskin intact\nsocial husband in this afternoon\nIV pt has # 22 in hand will consult iv therapy for ? picc placement.\nA/P Continue with ativan as ordered, pul toilet suction prn, follow up on cultures\n"},{"category":"Nursing/other","chartdate":"2127-08-25 00:00:00.000","description":"Report","row_id":1366522,"text":"MICU NPN 7P-7A\nNEURO: RESTLESS AT BEGINNING OF SHIFT BUT SETTLED DOWN. PERIODS OF RESTLESSNESS AND SLIGHT AGITATION THROUGHOUT THE SHIFT. CONTINUES ON ATIVAN 5MG Q2HRS WITH EFFECT. INITIALLY AROUSABLE TO STIMULI (MOUTHCARE, SXTING), WAS RAISING EYEBROWS BUT NOT OPENING EYES AND MAKING A FEW INCOMPREHENSIBLE SOUNDS. NOT FOLL0WING COMMANDS BUT CONTINUED TO MOVE ALL EXTREMITIES. TOWARDS THE AM WAKING UP A LITTLE, OPENING EYES AND INCONSISTENTLY FOLLOWING COMMANDS. ABLE TO STATE NAME BUT NOT BALE TO ANSWER ORIENTATION QUESTIONS. REMAINS RESTRAINED FOR SAFETY. RECEIVING LACTULOSE FOR ESLD.\n\nCARDIAC: HR 78-91 SR WITH NO ECTOPY. BP 98-157/41-62. HCT STABLE @32.6. UNABLE TO TEST STOOL FOR HEME, THOUGH IT WAS BLACK. PPP.\n\nRESP: RECEIVED ON 3L N/C AND INITIALLY WITH RESTLESSNESS SPONTANEOUSLY DESATTED TO 88%. INCREASED TO 5L AND AS PATIENT SETTLED DOWN HER SATS RETURNED TO UPPER 90'S. RR 14-34 WITH SATS 88-100%. LS WITH EXP WHEEZES TO CLEAR WITH A FEW FINE CRACKLES IN RIGHT BASE. NOTED RIGHT PLEURAL EFFUSION ON U/S. NEBS AND STEROIDS AS ORDERED. OCCASIONAL CONGESTED NONPRODUCTIVE COUGH. CXR DONE THIS MORNING.\n\nGI/GU: ABD SOFT WITH +BS. SMEARS OF BLACK LOOSE STOOL. NGT IN PLACE AND PATENT. CLAMPED WITH BILIOUS DRNG, HEME-. UOP 30-110CC/HR AMBER AND CLEAR.\n\nFEN: D5W @30CC/HR. NO EDEMA. -1.1L LOS. ON LASIX AND SPIRONOLACTONE. LYTES PER CAREVUE. NPO FOR NOW.\n\nID: TMAX 96.8 WITH WBC 9.3. ON FLAGYL AND CEFTRIAXONE FOR EMPIRIC ASPIRATION PNA COVERAGE. NGTD ON CX'S.\n\nSKIN: W/D/I.\n\nACCESS: PIV X1.\n\nSOCIAL/DISPO: FULL CODE. PLAN TO GO TO IR TODAY FOR PICC PLACEMENT. CONTINUE ATIVAN AS NEEDED FOR DT'S.\n"},{"category":"Nursing/other","chartdate":"2127-08-27 00:00:00.000","description":"Report","row_id":1366527,"text":"Nursing Progress Note 0700-1900\n*Full Code\n\n*Access: 2 PIV's R and L arms\n\n*Allergies: Sulfa\n\nNeuro: remains difficult to orient, garbled speech, able to say year is but difficult to understand, reorient frequently. Moving around in bed, MAE, PERRL 3mm/, says \"no\" when asked if uncomfortable. No haldol or ativan given this shift. Slowly more , MD's feel she is not clearing lg doses of ativan that were given in previous days for withdrawl d/t decreased liver function.\n\nCardiac: NSR w/o ectopy, HR 100-111, SBP 112-153. Hct stable @ 33.9. K repleated in AM w/ 60mEq, INR 1.6.\n\nResp: remains on 4L NC, rr 19-28, o2sat 92-98, LS coarse upper diminished lower. Cough occassionally, appears to be productive and swallows. CXR today slightly improved but still abnormal compared to yesterday MD's.\n\nGI/GU: TF (promote w/fiber)@ goal 55cc/hr, stop for residual >100. +BS, brown liquid stool out mushroom cath. Urine out foley 20-690cc/hr w/ larger amts following PO lasix 20mg, now DC'd. PRN bolus for decreased U/O. FS 109.\n\nID: Temp 97.7-98.3, WBC 12.0. ?aspiration as source of PNA. Cont ceftriaxone, flagyl. IV sites wnl.\n\nPsychosocial: Daughter called this AM updated on status and , husband visited also updated.\n\nDispo: Cont to monitor mental status, cont lactulose, cont to hold sedatives if VS stable, monitor I&O request bolus for decreased U/O, cont med regimen.\n"},{"category":"Nursing/other","chartdate":"2127-08-27 00:00:00.000","description":"Report","row_id":1366528,"text":"Patient on albuterolQ6 PRN,Atrovent Q6.last Rx done @ 18 0clock.Hard to understand patient,BS diminished without wheezes.Being treated prophylactically for SOB.\n"},{"category":"Nursing/other","chartdate":"2127-08-28 00:00:00.000","description":"Report","row_id":1366529,"text":"micu npn 1900-0700\nPlease see carevue flowsheet for all objective data\n\nPatient continues to be agitated and restless through the night. bilateral soft wrist restraints present, also this am, hand mitts added after pt self d/c'd her mushroom catheter x2. opens eyes, shaky and agitated for the most part. Occ follows commands, does not participate in talking or answering questions unless she is angry and yelling. received 2 doses of ativan 2mg w/o much effect. HR has been 1teens-120this am. bp 1teens-140's sys. Pt did not receive ativan during the day yesterday. Pt remains on 4l nasal cannula, sats 92-97%. l/s diminished/coarse. She has lots of dry oral secretions requiring frequent mouth care.\n feeds remain at goal, toelrating well. held overnight as pt put out >500cc last evening. uop remains marginal but adequate, no bolus' given overnight.\npt's daughter calling for update at beginning of shift.\n\nPlan to cont to follow mental status, keep pt safe. asses for s+s of bleeding, follow temp curve/wbc, fluid status. Ativan prn for s+s of withdrawal.\n"},{"category":"Nursing/other","chartdate":"2127-08-28 00:00:00.000","description":"Report","row_id":1366530,"text":"Resp Care\n\nPt followed by respiratory for bronchodilator tx Q6. Currently wearing 40% cool aerosol with spo2 in the mid to upper 90s. BS essentially clear with no changes noted post treatment therapy. Pt needs some encouragement keeping mask on at times. Alb/atro given x2 via aerosol mask. Will cont to follow as needed.\n"},{"category":"Nursing/other","chartdate":"2127-08-28 00:00:00.000","description":"Report","row_id":1366531,"text":"Nursing Progress Note 0700-1900\n*Full Code\n\n*Access: R PICC, L PIV\n\n*Allergies: Sulfa\n\nNeuro: agitated this AM, HR 140's, SBP 150's, hanging over bedside, was given 4 mg Ativan in previous shift w/ poor effect, this nurse gave 1mg haldol w/ good effect, Pt stable most of the day but difficult to arouse at times; may want to try 0.5mg if additional sedation is required. At this time, still moving around in the bed, asking to go outside, wants to get out of bed, wants a plum, want milk, and at this point still not oriented. No complaints or signs of pain, PERRL 3mm / . MD's feel she may still be having some withdrawl symptoms even though she is 7 days in hospital.\n\nCardiac: NSR/ST w/o ectopy, HR 92-125, SBP 108-155. Hct stable @ 36.3, no s/s of bleeding. INR 1.7, PTT and PT slightly elevated as well, Hep dose changed to and DIC labs sent, but mostly likely caused by impaired liver function.\n\nResp: started shift on 4L NC, mouth has been very dry and sat's were lower, changed to cool neb @ 40% for moisture and increased o2, tolerating well. O2sat 90-98%, rr 15-22, LS clear upper and coarse lower, no cxr today though yesterdays showed some improvement but still abnormal (PNA).\n\nGI/GU: TF @ goal 55cc/hr w/ residual 30cc, stop TF if >100. FWB 250cc thru NGT Q6H for Na 148 this AM. +BS, stool through mushroom cath brown/liquid, 250cc then bag emptied, cont lactulose TID. Urine out foley amber/clear 20-40cc/hr, 500cc NS bolus x2 this shift to try and increase UO, no significant change in output.\n\nID: Temp 97.4Ax - 98.6oral, WBC 13.2. Ceftriaxone to be dc'd tomorrow which will be 7th day. Continue flagyl.\n\nPsychosocial: Husband() and Daughter (), both called this AM and updated on condition and . PCP also visited this afternoon, visits everyday he said.\n\nDispo: cont to monitor mental status (attempt lesser doses of haldol such as 0.5mg if necessary), monitor UO, cont lactulose and awaiting DIC labs, cont med regimen.\n"},{"category":"Nursing/other","chartdate":"2127-08-29 00:00:00.000","description":"Report","row_id":1366532,"text":"MICU Nursing 19-07\nNeuro: Gradually more awake through course of night. A&Ox3 at latest, however not appropriately interactive and does not answer many questions correctly beyond basic orientation exam. Frequently calling out, yelling, etc. Gave 0.5mg haldol IM once with no effect.\n\nPain: Denies, and appears comfortable. Screams out with any movement in bed.\n\nCV: Sinus rhythm rate 91-112 BP 118-140/46-69 Palpable pulses in all extremities. HR elevated when more alert. P-boots on, sc heparin. PICC with KVO IVF.\n\nResp: Switched to 3LNC, maintains SPO2 high 90's. Desat's to low 90's on room air. Nebs q6 as ordered. Lungs are clear, diminished bibasilar with upper airway congestion. Swallows sputum.\n\nGI: Abdomen soft, non-tender. TF at goal, minimal residuals. Flushed as ordered. Mushroom cath with lg amounts of brown liquid stool. Lactulose continues.\n\nGU: Foley to gravity with marginal output, HO aware - no intervention at this time.\n\nEndo: No RISS\n\nSkin: Stage I pressure area on coccyx/buttocks. Turned and positioned frequently, barrier cream applied liberally.\n\nID: Tmax 99.9, on antibiotics, known improving PNA.\n\nSocial: Husband called, updated on pt's condition and nursing overnight.\n\nPlan:\nMaintain safety\nPain management\nMinimize sedatives\nFrequent reorientation\nAggressive bowel regimen with lactulose\nNotify team of acute changes\n transfer to floor if mental status continues to improve\n"},{"category":"Nursing/other","chartdate":"2127-08-29 00:00:00.000","description":"Report","row_id":1366533,"text":"MICU 7 RN Note 0700-1900\n\nEvents: Hypernatremia Free H20 bolus, Speech eval, ^PTT, CIWA monitoring.\n\nNeuro: Awake lethargic, voice slurred with noted improved level of orientation. wax and wanes. Pupils/cataract 3mm equal react , tracks surroundings, MAE random and to command equal strength, intermitent tremors of UE. CIWA scale 5-10 recieved Ativan 1mg x3 and Haldol 1mg x2. periods of restlessness/calm agitation requesting somthing to drink. moves about in the bed. no c/o pain. recieved lactalose encephalopathy\n\nCV: HR 78-90 NSR no ectopy, BP 112-140/40-60. Maps>60. Peripheral pulses 3+DP/DT neg peripheral edema. IV access R brachial PICC IV d5W 100cc/hr. K+4.0, mag 2.2. Na 153 Free H20 repeat Na trending down.\nHeme: Hct 31.8 trending down from previous days, Ptt 90 INR 1.7 Heparin SQ d/c\n\nResp: RR 22-26 Reg O2 3L/Min NC Sats 95-97% Lungs clear Dim @ bases.\n\nID: low grade temp 100, WBC 10.9, Abx Flagyl/vanco\n\nGI/liver: Ads soft distended + BS +stool Mushroom cath in place. recieved Lactalose Liq brown trace + stool. NGT R nares TF promte with fiber 55cc/hr @ goal. Speech eval failed Pt remains NPO\n\nGU: foley u/o 20-50cc/h icteric urine.\n\nDerm : skin impaired Dry Coccyx red skin irritaion from stool emollient cream appleid.\n\nSocial: Full code status, Family visited, updated on plan of care.\n\nPlan: called out to floor\n Monitor for dT's CIWA scale med Ativan/Haldol\n To start diuretic \n cont Free H20 Hypernatremia.\n\n\n"},{"category":"Nursing/other","chartdate":"2127-08-23 00:00:00.000","description":"Report","row_id":1366517,"text":"NURSING PROGRESS NOTE:\nTHIS IS A 70 YR OLD FEMALE WHO CAME IN THROUGH THE ED WITH C/O PAIN IN HER LOWER EXTREMETIES. AFTER DRAWING HER BLOODS THEY FOUND THAT HER HCT WAS ONLY 14 AND HER K+ WAS 2.6. PT WAS TREATED IN THE ED WITH 2UNITS OF PACKED RBC'S, POTASSIUM SUPPL, AND PROTONIX. PT THEN BROUGHT TO MICU FOR FURTHER TREATMENT AND FIND SOURCE OF HER BLEED.\n\nNEURO: ON ARRIVAL TO THE UNIT PT SEEMED TO BE ORIENTED X 3 BUT AS THE NIGHT WORE ON PT BECAME INCREASINGLY MORE CONFUSED AND AGITATED. PT VERY RESTLESS IN THE BED AND PICKING AT EVERYTHING. PT GOT OOB AND PULLING EVERYTHING OFF. PT ALSO HAS TREMORS AMD HER EXTREMETIES ARE VERY RIGID. PT STATES THAT THE LAST TIME SHE HAD A DRINK WAS OVER LABOR DAY WEEKEND. PT HAS BEEN STARTED ON THE CIWA SCALE AND HAS RECEIVED ATIVAN PO/IV AND ONE DOSE OF VALIUM BEFORE IT WAS D/C'D. PLEASE SEE CAREVIEW FOR CIWA SCALE.\n\nCV: PT IN NSR WHEN ASLEEP BUT WHEN AWAKE HR UP TO THE 120'S. PT HAS RECEIVED ONE UNIT OF PACKED CELLS WHILE IN THE MICU FOR A HCT OF 16. PT HAS RECEIVED A DOSE OF LACTULOSE WHICH HAS NOT IMROVED HER ENCEPHALOPATHY. PT TO CT SCAN OF HER HEAD FOR POSSIBLE HEAD BLEED BECAUSE OF HER NEURO SYMPTOMS AND HER SLURRED SPEECH. PT WITH LOW GRADE TEMP OF 99.6 PO. BOTH LOWER EXTREMTIES ARE REDDENED/SWOLLEN AND VERY TENDER. PT STARTED ON CEFAZOLIN FOR CELLULITIS.\n\nGI: PT WITH POSSIBLE SLOW GI BLEED. PT HAS HAD ONE STOOL AFTER RECEIVING LACTULOSE. STOOL LOOSE/BROWN AND GUIAIC POS. ABD SOFT WITH POS BOWEL SOUNDS. ORAL CAVITY WITH VERY FOUL ODOR. DENTURES REMOVED AND UPPER GUMS VERY SORE LOOKING WITH HER OWN TEETH GROUND DOWN TO THE NUB. GUMS BLEEDING WITH MOUTH CARE. DENTURES TAKEN OUT TO BE CLEANED AND TO OBSERVE MOUTH.\n\nGU: PT HAD RECEIVED A DOSE OF LASIX IN THE ED AND HAS BEEN PUTTING OUT LRG AMT'S OF CLEAR YELLOW URINE.\n\nACCESS: PT WITH TWO PERIPH IV'S BUT HAS LOST THE ONE IN HER LEFT AC.\n\nSKIN: PT'S LOWER EXTREMETIES VERY RED AND SORE, LOOKS LIKE CELLUTLITS.\nPT HAS A LRG HEMATOMA ON RIGHT UPPER BACK. PT DOES NOT KNOW HOW SHE GOT IT..\n\nSOCIAL: PT LIVES WITH SPOUSE AND HAS A DAUGHTER. DAUGHTER CALLED LAST EVENING FOR AN UPDATE. PT IS A FULL CODE.\n"},{"category":"Nursing/other","chartdate":"2127-08-23 00:00:00.000","description":"Report","row_id":1366518,"text":"MIcu Nursing note \n\nNeuro pt very restless, orient to person only, pt in soft restraints for saftey reasons, cwai 35, and ativan ^ pt recieved 4 mg iv ativan q1 hr for the first 3 hrs before she was calm, pt was tacky and hypertensive when I arrived at 7 am, now has not received ativan since 2 pm and cwai is now 10\n\nCv Pt hemodynamically stable pulses palp bilaterally, both shins still slightly reddened and firm, pt now sr hr 80-90\n\nResp pt remains on 2L n/c sats 98&% when on ra sats drop tp 90%, pt ^ 4L while having endo this am but has be able to be placed back to 2L n/c, lung clear.\n\nGi pt npo, had endo this am, no beleeding, pt has grade I varices in esph, sever gastritic, gastic varicies and a polyp pt does c/o RUG tenderness, no stool, and bowel sound x4\n\ngu pt passing yellow unine but u/o low house staff aware and after blood if u/o doesn't ^ the will consider ^ ivf\nat present ivf at kvo\n\nId pt tmax 100.3 ax pt was cultured x2 blood and urine , pt started on levoflox this afternoon, tylenol given x2 pr\n\nsocial spoke with husband and daughter which were updates about pt's condition, husband notified that I removed pt's jewlery and credit cards and money sent to be locked up.\n\nheme, hct this afternoon down to 19.9 form 24.5 pt transfused with 1unit prbc's, so of bleeding.\n\nA/P repeat cht this evening, follow cwai scale and prn ativan for dt's per scale, follow up with house staff reguarding ^ ivf because of npo status.\n"},{"category":"Nursing/other","chartdate":"2127-08-24 00:00:00.000","description":"Report","row_id":1366519,"text":"MICU NPN 7P-7A\nNEURO: INITIALLY PATIENT DIFFICULT TO AROUSE. NAME CALLED REPEATEDLY BEFORE SHE STARTED TO OPEN EYES. PATIENT UNABLE TO ANSWER QUESTIONS AND MAKING INCOMPREHENSIBLE SOUNDS. LOCALIZING PAIN. LATER WAKING UP BUT FALLING BACK TO SLEEP AFTER SHE WAS AROUSED. WAS ATTEMPTING TO ANSWER QUESTIONS BUT APPEARS SHE BE ONLY ORIENTED TO SELF. CIWA 4 @, 7 @2200. DIFFICULT TO ASSESS CIWA AS SHE WAS UNABLE TO ANSWER ?'S. ~12AM MORE AGITATED, PULLING @SHEETS/GOWN. ATTEMPTING TO SIT UP. CIWA AS SHE WAS C/O MILD HEADACHE. FOLLOWING COMMANDS INCONSISTENTLY. GIVEN 4MG ATIVAN IV WITH MOD EFFECT. AS NIGHT HAS GONE ON PATIENT BECOMING MORE AND MORE AGITATED, CIWA 9-11HAS RECEIVED A TOTAL OF 26MG (4-6MG Q1-2HRS) OF ATIVAN IV SINCE MIDNOC WITH EFFECT NOT LASTING MORE THAN 45MIN. RESTRAINED FOR SAFETY OF LINES, RISK FOR FALLING OUT OF BED.\n\nCARDIAC: HR 76-120 SR/ST WITH NO ECTOPY. BP 98-150/45-80. HCT @ 24.9, GIVEN 1UPRBC'S WITH AM HCT 32.3. PLTS 96. NO SIGNS OF BLEEDING. PPP.\n\nRESP: ON 2L N/C WITH RR 19-40 AND SATS 89-100%. WHEN AGITATED DROPPING SATS AND AUDIBLY WHEEZY. WHEN CALM LS CLEAR WITH DIMINISHED LEFT BASE. OCCASIONAL CONGESTED NONPRODUCTIVE COUGH.\n\nGI/GU: ABD SOFT WITH +BS. SMALL SMEARS OF STOOL, APPEAR BLACK. UOP 25-45CC/HR AMBER AND CLEAR.\n\nFEN: RECEIVING MVI, FOLATE, THIAMINE VIA 500CC D5W. LYTES PER CAREVUE. NOT SAFE AT THIS TIME TO ATTEMPT ANYTHING PO AND WITH GRADE ESOPHAGEAL VARICIES A NGT IS RISKY. MEDS CHANGED TO IV/SC AS ALLOWED.\n\nID: TMAX 99.4 WITH WBC 11.2. ON LEVOFLOX.\n\nSKIN: W/D/I. HEMATOMA TO RIGHT UPPER BACK.\n\nACCESS: PIV X1.\n\nSOCIAL/DISPO: FULL CODE. SON FROM CALLED FOR UPDATE. CONTINUE TO TREAT DT'S.\n"},{"category":"Nursing/other","chartdate":"2127-08-30 00:00:00.000","description":"Report","row_id":1366534,"text":"Nursing Progress Note:\n\nPt. is called out but still waiting for bed.\n\nNeuro: Pt. remains confused, at times knows where she is but at others thought she was at home. She was not agitated during the night, slept fairly well, and was not given any Ativan or Haldol.She did appear to be trying to get out of bed a couple times but was easily reoriented.\n\nCV: HR 70s-90s NST with no ectopy, NBP 110s-130s/40s-60s. Single-lumen PICC to R brachial is patent and WNL. IV fluids d/c'd and running at KVO now.\n\nResp: Lung sounds are clear to all lobes with diminished bases. RR teens, 02 sats high 90s except when on room air when it drops to low 90s. No wheezes or crackles noted. Neb txs could probably be changed to PRN as pt. has no hx of use prior to admission.\n\nGI: feeds at goal of 55cc/hour, BSX4, liquid, brown stool via mushroom catheter. MN dose of Lactulose held due to copious liquid stool.\n\nGU: UO is marginal (between 20-30cc/hour). Team is aware and will order bolus if UO drops to <20cc/hour.\n\nSkin: Pt. has a rash which appears to be fungal to perineal area and labia. Anti-fungal ointment applied.\n"},{"category":"Nursing/other","chartdate":"2127-08-30 00:00:00.000","description":"Report","row_id":1366535,"text":"NPN 7a-7p\nNeuro: Pt. oriented to person, place, and time but when left alone has d/c'd rectal , NGT, and takes off 02. Got out of chair and tried to ambulate in room, unsteady gait. Taking lactulose po.\n\nResp: 02 sat 95-96% on room air. Bibasilar crackles. Mild cough with minimal sputum.\n\nCV: HR 80's NSR no ectopy. BP 110-120/60's. Has PIC line which was KVO but stopped KVO so there would be less for her to pull at.\n\nID: Completed course of IV antibiotics for presumed aspiration PNA. Afebrile.\n\nGI: Pt. d/c'd rectal . Small amounts of stool since then-liquid. Able to take lactulose po. Has her dentures in.\n\nGU: Foley intact-urine output approx 20-30cc/hr.\n\nSkin: Rash over perineal area. Nystatin applied.\n\nSocial: Husband in to visit most of the day.\n\nplan:\n-transfer to floor when sitter available.\n-monitor pt. when eating\n-? repeat formal swallowing study\n"},{"category":"Nursing/other","chartdate":"2127-08-31 00:00:00.000","description":"Report","row_id":1366536,"text":"Nursing Progress Note:\n\nPt. is called out to floor and has a bed but was not transferred due to needing a sitter (this may change as pt's mental status is improving).\n\nNeuro: Pt. has been alert, oriented, pleasant, and cooperative. She was appropriate and slept well for most of the night. She was found standing by the bed once but was easily reoriented and told to use call light rather than getting out of bed herself. She appeared to understand and there were no further incidents.\n\nCV: HR 70s-90s, NBP 100s-120s/40s-50s. Pt. has single-lumen PICC which is patent and draws well. Area around PICC is ecchymotic.\n\nResp: RR teens, 02 sats in 90s on room air. Lungs are clear, bases are diminished at times. No wheezes or cough, Neb txs held.\n\nGI: BSX4, pt. can have thickened liquids until further eval of swallow is performed (pt. did poorly yesterday). Pt. seems to be fine with thickened liquids, no coughing noted. Pt. initially stooling somewhat formed stool but this changed to thin enough so that mushroom catheter reinserted. Stool is now liquid brown. Lactulose given at MN, held at 0600.\n\nGU: UO remained marginal until 20mg PO Lasix q day ordered and given. UO after thsi increased to 60cc/hour for several hours.\n\nSkin: Rash to perineal area and labia, Aloe Vesta antifungal applied. Scattered ecchymotic areas on extreamities and blood blister to L FA.\n\nSocial: Pt. spoke to family on phone today.\n"},{"category":"ECG","chartdate":"2127-08-25 00:00:00.000","description":"Report","row_id":144073,"text":"Sinus rhythm\nProlonged Q-Tc interval - clinical correlation is suggested\nSince previous tracing of , Q-Tc interval appears longer\n\n"},{"category":"ECG","chartdate":"2127-08-23 00:00:00.000","description":"Report","row_id":144074,"text":"Sinus rhythm, rate 89. Since the previous tracing of minimal slowing of\nthe heart rate is seen. No other changes are noted.\nTRACING #2\n\n"},{"category":"ECG","chartdate":"2127-08-22 00:00:00.000","description":"Report","row_id":144075,"text":"Sinus rhythm, rate 98. Since the previous tracing of the heart rate is\nfaster. Increased ST-T wave abnormalities are seen particularly over the\nlateral precordium.\nTRACING #1\n\n"},{"category":"Radiology","chartdate":"2127-08-25 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":927381,"text":" 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for improvement\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ETOH cirrhosis here w GIB. now w/ PNA and O2\n requirement\n REASON FOR THIS EXAMINATION:\n eval for improvement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia and decreased oxygen requirement. Eval for\n improvement.\n\n Comparison is made to .\n\n PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: There has been interval placement\n of an NG tube with the tip projecting over the body of the stomach. The side\n hole is located above the gastroesophageal junction. Patchy opacities are\n again seen predominantly in the right upper lobe, but also in the right middle\n and lower lobes and left lower lobe. The right upper lobe opacity is slightly\n improved in the interval. Also, the left lower lobe opacity is less\n prominent. No pleural effusions are seen. No new consolidations are seen.\n\n IMPRESSION:\n 1. Multifocal pneumonia with interval improvement in the right upper lobe\n opacity and left lower lobe opacity.\n 2. Placement of NG tube with the tip in gastric fundus, side hole above GE\n junction. Advancement of approximately 10 cm is recommended.\n\n"},{"category":"Radiology","chartdate":"2127-08-27 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":927697,"text":" 9:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ETOH cirrhosis here w GIB. now w/ PNA and O2\n requirement\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n INDICATION: 70-year-old woman with cirrhosis and shortness of breath.\n\n COMPARISON: Radiograph dated .\n\n FINDINGS: When compared to the prior study, there has been significant\n interval improvement of the multifocal pneumonia. Interval placement of a\n right PICC line with its tip projecting over the SVC near the atrial junction.\n There is no evidence of pneumothorax or pneumoperitoneum. NG tube appears\n stable.\n\n IMPRESSION:\n\n 1. Significant interval improvement of the multifocal pneumonia.\n\n 2. Interval placement of a right PICC line with its tip projecting over the\n SVC, near the atrial junction.\n\n\n"},{"category":"Radiology","chartdate":"2127-08-23 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":927209,"text":" 3:17 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracranial hemorrhage\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ESLD, encephalopathic\n REASON FOR THIS EXAMINATION:\n r/o intracranial hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage liver disease with encephalopathy. Evaluate for\n intracranial hemorrhage.\n\n There are no prior studies for comparison.\n\n NON-CONTRAST HEAD CT SCAN: There is no evidence of acute intracranial\n hemorrhage or shift of the normally midline structures. The ventricles and\n cisterns are normal. There is hypodensity of the cerebral periventricular\n white matter, particularly in the left frontal region, consistent with chronic\n microvascular ischemia. There is also hypodensity of the left subinsular\n white matter consistent with the same process. The visualized paranasal\n sinuses and mastoid air cells are clear. The osseous and soft tissue\n structures are unremarkable.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage. Chronic\n microvascular ischemic changes.\n\n\n"},{"category":"Radiology","chartdate":"2127-08-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":927140,"text":" 2:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ETOH cirrhosis\n REASON FOR THIS EXAMINATION:\n CHF?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:10 P.M., \n\n HISTORY: Alcoholics cirrhosis. Shortness of breath.\n\n IMPRESSION: AP chest compared to and :\n\n Heart size is top normal. Pulmonary vasculature is engorged and there is mild\n interstitial edema at the base of the right lung laterally. More centrally,\n there is considerable peribronchial opacification in a region that previously\n showed abnormality. This may therefore represent deposition of edema in the\n region of previous lung injury, but we could also be seeing right lower lobe\n pneumonia with secondary cardiac decompensation. There is no appreciable\n pleural effusion.\n\n Dr. was paged to discuss these findings, at the time of dictation.\n\n\n"},{"category":"Radiology","chartdate":"2127-08-23 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":927239,"text":" 10:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion/pna\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ETOH cirrhosis here w GIB. now w/ new oxygen\n requirement.\n REASON FOR THIS EXAMINATION:\n eval for effusion/pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: New oxygen requirement, question effusion pneumonia.\n\n REFERENCE EXAM: .\n\n FINDINGS: There is a new small left pleural effusion. There continues to be\n mild cardiomegaly. There continues to be hazy pulmonary vasculature and\n increased interstitial edema most marked on the right. There is also an area\n of focal consolidation in the retrocardiac region. Most likely, this findings\n are due to CHF. An underlying infectious infiltrate cannot be excluded.\n\n IMPRESSION: Likely increased CHF.\n\n\n"},{"category":"Radiology","chartdate":"2127-08-25 00:00:00.000","description":"PICC W/O PORT","row_id":927391,"text":" 7:19 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: SEVER ANEMIA\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ESLD here w/ GIB. now c/b EtOH withdrawal\n REASON FOR THIS EXAMINATION:\n please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: 70-year-old woman with end-stage liver disease, needs long-term\n IV access.\n\n RADIOLOGISTS: Dr. , and Dr. . Dr. , staff radiologist,\n was present for the entire procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia the right brachial\n vein was localized with ultrasound and punctured under direct ultrasound\n guidance using a micropuncture set. Ultrasound images were obtained before\n and immediately after obtaining intravenous access. A micropuncture sheath\n was then placed over the wire. A single-lumen PICC line was then advanced\n through the sheath over the wire and its tip positioned in SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by chest x-ray\n in one view. Guidewire and the peel-away sheath were then removed. The\n catheter was secured to the skin.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided PICC line\n placement via the right brachial vein with the tip positioned in SVC. Total\n length of the catheter is 34 cm. The catheter is ready for use.\n\n"},{"category":"Radiology","chartdate":"2127-08-24 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":927318,"text":" 8:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema or pna\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ETOH cirrhosis here w GIB. now w/ new hypoxemia and\n coarse breath sounds\n REASON FOR THIS EXAMINATION:\n eval for pulm edema or pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW, ON \n\n HISTORY: New hypoxemia and coarse breath sounds.\n\n FINDINGS: There is a new right upper lobe infiltrate and patchy areas of\n increased opacity in the right lower lobe and left lower lobe as well. Heart\n is moderately enlarged.\n\n IMPRESSION: Probable multifocal pneumonia. CHF with an atypical presentation\n cannot be totally excluded.\n\n\n"},{"category":"Radiology","chartdate":"2127-08-24 00:00:00.000","description":"LIVER OR GALLBLADDER US (SINGLE ORGAN)","row_id":927325,"text":" 9:32 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: assess ascites, mark for tap, ? liver changes\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with alcoholic ascites, now with fever, tender abdomen\n REASON FOR THIS EXAMINATION:\n assess ascites, mark for tap, ? liver changes\n ______________________________________________________________________________\n FINAL REPORT\n 70-year-old female with alcoholic cirrhosis, now with fever and tender\n abdomen.\n\n COMPARISON: .\n\n FINDINGS: Again demonstrated is the shrunken nodular appearance of the liver\n consistent with cirrhosis. No focal hepatic lesion is identified. There is\n no intra- or extra-hepatic biliary ductal dilatation. The common duct\n measures normal caliber of 4 mm. No ascites is identified. The gallbladder\n is unremarkable without stones, wall thickening, or pericholecystic fluid. A\n right pleural effusion is incompletely evaluated on this study.\n\n As demonstrated on , Doppler evaluation of the liver again\n shows reversal of flow (hepatofugal) of the main, right and left portal veins\n as well as superior mesenteric vein. The splenic vein demonstrates normal\n directionality of flow. The main, left, and right hepatic veins are patent\n with appropriate color flow and waveform. Normal flow and appropriate\n waveforms are demonstrated in the main, left, and right hepatic arteries. The\n IVC is patent.\n\n IMPRESSION:\n 1. Cirrhotic liver, without focal hepatic lesion identified.\n 2. No ascites.\n 3. As demonstrated on , there is reversal of flow in the\n main, right, and left portal veins as well as superior mesenteric vein. The\n hepatic veins and arteries demonstrate appropriate directionality of flow and\n waveform.\n 4. Right pleural effusion is incompletely assessed.\n\n"},{"category":"Radiology","chartdate":"2127-09-01 00:00:00.000","description":"VIDEO OROPHARYNGEAL SWALLOW","row_id":928307,"text":" 2:13 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval for aspirations with thin liquids\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ESLD etoh abuse\n REASON FOR THIS EXAMINATION:\n eval for aspirations with thin liquids\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old female with end-stage liver disease, evaluate for\n aspiration.\n\n OROPHARYNGEAL VIDEO FLUOROSCOPIC SWALLOWING EVALUATION: An oropharyngeal\n swallowing video fluoroscopy study was performed today in collaboration with\n speech pathology. Barium of varying consistencies as well as solids coated\n with barium and a barium pill were administered. There was moderate\n impairment in bolus formation with no premature spillover seen. There was\n mild penetration with no aspiration.\n\n IMPRESSION: Mild penetration which cleared during the swallow.\n\n Please see the speech pathology note under CareWeb for further details.\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366523,\n \"text\": \"npn micu 7 west\\nallergies: Sulfa\\nFull Code\\n\\nNeuro: pt is minimally arousable, opens eyes to speech, pupils 3mm brisk, speech is garbled and slurred, pt. lethargic and sleeping most of day, ativan 4mg q 2hrs for DTs.\\n\\nResp: 3L NC, LS clear, CXR + pNA/r pleural effusion for which she is receiving abx flagyl and ceftriaxone, O2 sats>95%. Wean O2 to maintain sats>95%.\\n\\nCv: 1 left peripheral/right single lumen PICC placed today in IR, LE edema present, UE bruising/ edematous, HR 90-100 NS-ST, no ectopy, pulses palpable in all four extremeties. IV fluid D5W @ 30cc/hr. Of note: past ECHO normal.\\n\\ngu\\r: foley output >30cc/hr, standing Lasix 40mg IV and Spirolactone PO for end stage liver failure.\\n\\ngi: Please start TF after midnight via NG, NG patent & clamped, 50 cc residual yellow bile, BS present, last BM (black stool), abd neg for ascites, Lactulose given for encephalopathy. Endoscopy on showed grade 1+2 varices/gastritis, NG lavage negative.\\n\\nid: T=96.8, WBC 9.3, urine sent, Flagl/Cef for pNA, PO prednisone for possible COPD\\n\\nsocial: daughter visited today, she was very helpful and supportive of her mother\\n\\nplan: Start TF, advance as tolerated\\n Cont Ativan 4mg IV for DT\\n Monitor mental status\\n Cont Lactulose\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366524,\n \"text\": \"MICU NPN 7P-7A\\nNEURO: INITIALLY SEDATED AND DIFFICULT TO AROUSE. DID OPEN EYES TO VOICE BUT ONLY MAKING SOUNDS. MD AWARE AND DECREASED ATIVAN TO 3MG Q2HRS. A BIT MORE RESTLESS AS NIGHT WORE ON TRYING TO PICK SELF UP. THIS MORNING MORE AWAKE WITH EYES OPEN. STATED NAME AND WAS ABLE TO SAY THAT SHE WAS IN A HOSPITAL. FOLLOWED SIMPLE COMMANDS. MOVING ALL EXTREMITIES. RESTRAINED FOR SAFETY. LACTULOSE AS ORDERED, HELD AM DOSE AS SHE WAS STOOLING.\\n\\nCARDIAC: HR 88-105 SR/ST WITH RARE PVC'S. BP 105-128/49-66. HCT STABLE @32.6. PPP.\\n\\nRESP: ON 3L N/C WITH RR 15-24 AND SATS 95-100%. LS COARSE WITH DIMINISHED BASES, BUT THIS MORNING WITH A FEW FINE CRACKLES BIBASILAR. FREQUENT CONGESTED PRODUCTIVE COUGH BUT SWALLOWING. CXR FROM SHOWED MULTIFOCAL PNA BUT NO EFFUSIONS. NO SIGNS OD SOB, NEBS AND STEROIDS AS ORDERED.\\n\\nGI/GU: ABD SOFT WITH +BS. MED LOOSE BLACK TO BROWN STOOL X2. NGT IN PLACE AND PATENT. MARGINAL UOP 15-30CC/HR, 250CC FLUID BOLUS WITH SLIGHT INREASE IN OUTPUT. AMBER AND CLEAR.\\n\\nFEN: D5W D/C'D. FEEDS STARTED, GOAL 40CC/HR, MODERATE RESIDUALS. LYTES PER CAREVUE. RECEIVED 60MEQ KCL LAST NOC FOR K+ 3.4, NOW 4.1.\\n\\nID: TMAX 98.4 WITH JUMP IN WBC FROM 9.3 TO 17. CONTINUES ON FLAGYL AND CEFTRIAXONE FOR PNA COVERAGE. NGTD ON CX'S.\\n\\nSKIN: W/D/I, SEVERAL ECCHYMOTIC AREAS ON ARMS.\\n\\nACCESS: PIV X1, RIGHT BRACHIAL PICC.\\n\\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY. CONTINUE TO TITRAE DOWN DOSAGE OF ATIVAN TO BETTER ASSESS MS. FEEDS AS TOLERATED.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366525,\n \"text\": \"Nursing Progress Note 0700-1900\\n*Full Code\\n\\n*Access: 2 PIV's (R and L)\\n\\n*Allergies: Sulfa\\n\\nNeuro: Pt agitated at times, trying to lift self in bed, putting legs over railings, pulling at restraints. Treating w/ standing dose ativan 1mg Q4H and Haldol 0.5-1mg PRN (low dose for liver issues MD). not be enough for her as behavior continues, however VS remain stable at this time. Follows commands infrequently, insensible words, unable to assess orientation, PERRL 3mm/, (moving in bed).\\n\\nCardiac: NSR/ST w/o ectopy, HR 93-108, SBP 124-140, Hct stable @ 32.6. Hemodynamically stable.\\n\\nResp: Remains on 3L NC, RR 15-30, O2sat 89-100, LS coarse upper and crackles lower. CXR shows slightly worsened bilateral infiltrates slightly worse on right than left. Lasix changed from IV to PO QD to remove fluid and help increase Urine output as well. Also ? aspiration aspect to this picture (not new, but prior to hospitalization).\\n\\nGI/GU: TF @ 30cc increased after residual 10cc, was 110 this AM so did not advance TF til this afternoon (goal 40cc/hr, advance if tolerating). +BS, med stool brown, loose this AM, cont lactulose for goal 3 stools per day. Urine out foley yellow/amber and clear, 40-1100cc/hr w/ higher doses following 20mg IV Lasix, no PO. ? NS IV bolus or additional x1 IV lasix for decreased UO.\\n\\nID: Temp 97.0-98.4, WBC 17 (up from 9, md's aware). Cont flagyl and ceftriaxone. IV sites wnl.\\n\\nPsychosocial: Husband visited today, updated on POC and current condition by MD's. Daughter visited later and also updated on POC and condition and ICU environment. Sister also called and told by unit coordinator it would be best to contact her husband or daughter for updates.\\n\\nDispo: cont to monitor mental status, treat agitation w/ ativan and haldol, cont to monitor resp status, cont med regimen.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366526,\n \"text\": \"1900-0700 rn notes micu\\n\\nneuro: in the beggining shift pt very lethargic, minimal withdraw to sternal rub, minimal attempt to open eyes and move in the bed, MD aware, dose of Ativam held, stopped Ativan 1mg q4hr, change Halodol PRN 0.5mg q4hr. overnight became more responsive, opens eyes half way, trying to lift self in the bed, moving all extremeties in the bed, but does not follow commands, incomp sounds, unable to assess orientation.\\n\\nresp: receievd on NC 3L, pt deast to 90-91%,O2 up to 4L, given nebs for wheezing. LS coarse to clear with occas ins wheezing. tp has stroung/productive cough, but swallow back.\\n\\ncv: HR 90-116, NSR/ST, no ectopy. SBP 113-135/60-70's. HCT 33.9\\n\\ngi/gu: foley in place, pr received fluid bolus NS 250ccx2 for u/o 2-17cc/hr with good response. ABD soft/dist, BS +. cont , pt start passing liquid brown stool, mushroom cath placed. cont TF at goal 40cc/hr residual 10-40cc.\\n\\nid: tmax 99.8 rectal, cont ABX.\\n\\nsocial: full code, no conatct from family.\\n\\nplan: cont monitoring neuro/mental status\\n repleted lytes as needed.\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366520,\n \"text\": \"Respiratory Care: Pt seen for albuterol and atrovent nebs today. Pt's breath sounds coarse/wheezes, diminished aeration. Suctioned x 1 by Rt for moderate thick white secretions, pt tolerated well. will continue to monitor.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366521,\n \"text\": \"Micu nursing note \\n\\nNeuro, pt very restless at 7 am hr 115 ST, pt all over bed, had removed both Iv's\\nhands remains in soft restraints, on ciwa scale recieveing ativan q2 hr throught the day, pt had # 22 placed in L hand, pt given iv ativan q1 hr for the first 3hrs, also at the time pt wheezy, with crackles in bases and tacky. pt given resp tx and 20 lasix Iv, pt had good response of 800 plus over 2 hrs, and sounds much better this afternoon\\nresp o2^ 4L with sob, and throught day have been able to drop o2 back to 3l sats 100%, previously to getting lasix sats 90-93%, lungs now deminished in bases but no crackles, pt also suctioned for lg amount of secreation nasal/orally x2 now pt much clearer. chest xray also thanken this am with ^ sob, showed some failer ? pneumonia,pt also febrile at that time to 101, pt started back on cefriaxone, and flagly\\ncv Pt had a short peried of dropping bp in high 80's sbp after lasix, not treated at that time and bp returned to now BP 90-104/50-60\\nGi pt still npo, but ngt dropped in order to give oral meds, pt asperates hem pos, pt also having smearing of stool which is also heme pos,\\n pt has foley passing clear yellow urine, started on lasix and sparolactone today.\\nId tmax 101.0 this am started anitbiotics, cultures pending\\nheme 32.7\\nskin intact\\nsocial husband in this afternoon\\nIV pt has # 22 in hand will consult iv therapy for ? picc placement.\\nA/P Continue with ativan as ordered, pul toilet suction prn, follow up on cultures\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366522,\n \"text\": \"MICU NPN 7P-7A\\nNEURO: RESTLESS AT BEGINNING OF SHIFT BUT SETTLED DOWN. PERIODS OF RESTLESSNESS AND SLIGHT AGITATION THROUGHOUT THE SHIFT. CONTINUES ON ATIVAN 5MG Q2HRS WITH EFFECT. INITIALLY AROUSABLE TO STIMULI (MOUTHCARE, SXTING), WAS RAISING EYEBROWS BUT NOT OPENING EYES AND MAKING A FEW INCOMPREHENSIBLE SOUNDS. NOT FOLL0WING COMMANDS BUT CONTINUED TO MOVE ALL EXTREMITIES. TOWARDS THE AM WAKING UP A LITTLE, OPENING EYES AND INCONSISTENTLY FOLLOWING COMMANDS. ABLE TO STATE NAME BUT NOT BALE TO ANSWER ORIENTATION QUESTIONS. REMAINS RESTRAINED FOR SAFETY. RECEIVING LACTULOSE FOR ESLD.\\n\\nCARDIAC: HR 78-91 SR WITH NO ECTOPY. BP 98-157/41-62. HCT STABLE @32.6. UNABLE TO TEST STOOL FOR HEME, THOUGH IT WAS BLACK. PPP.\\n\\nRESP: RECEIVED ON 3L N/C AND INITIALLY WITH RESTLESSNESS SPONTANEOUSLY DESATTED TO 88%. INCREASED TO 5L AND AS PATIENT SETTLED DOWN HER SATS RETURNED TO UPPER 90'S. RR 14-34 WITH SATS 88-100%. LS WITH EXP WHEEZES TO CLEAR WITH A FEW FINE CRACKLES IN RIGHT BASE. NOTED RIGHT PLEURAL EFFUSION ON U/S. NEBS AND STEROIDS AS ORDERED. OCCASIONAL CONGESTED NONPRODUCTIVE COUGH. CXR DONE THIS MORNING.\\n\\nGI/GU: ABD SOFT WITH +BS. SMEARS OF BLACK LOOSE STOOL. NGT IN PLACE AND PATENT. CLAMPED WITH BILIOUS DRNG, HEME-. UOP 30-110CC/HR AMBER AND CLEAR.\\n\\nFEN: D5W @30CC/HR. NO EDEMA. -1.1L LOS. ON LASIX AND SPIRONOLACTONE. LYTES PER CAREVUE. NPO FOR NOW.\\n\\nID: TMAX 96.8 WITH WBC 9.3. ON FLAGYL AND CEFTRIAXONE FOR EMPIRIC ASPIRATION PNA COVERAGE. NGTD ON CX'S.\\n\\nSKIN: W/D/I.\\n\\nACCESS: PIV X1.\\n\\nSOCIAL/DISPO: FULL CODE. PLAN TO GO TO IR TODAY FOR PICC PLACEMENT. CONTINUE ATIVAN AS NEEDED FOR DT'S.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366527,\n \"text\": \"Nursing Progress Note 0700-1900\\n*Full Code\\n\\n*Access: 2 PIV's R and L arms\\n\\n*Allergies: Sulfa\\n\\nNeuro: remains difficult to orient, garbled speech, able to say year is but difficult to understand, reorient frequently. Moving around in bed, MAE, PERRL 3mm/, says \\\"no\\\" when asked if uncomfortable. No haldol or ativan given this shift. Slowly more , MD's feel she is not clearing lg doses of ativan that were given in previous days for withdrawl d/t decreased liver function.\\n\\nCardiac: NSR w/o ectopy, HR 100-111, SBP 112-153. Hct stable @ 33.9. K repleated in AM w/ 60mEq, INR 1.6.\\n\\nResp: remains on 4L NC, rr 19-28, o2sat 92-98, LS coarse upper diminished lower. Cough occassionally, appears to be productive and swallows. CXR today slightly improved but still abnormal compared to yesterday MD's.\\n\\nGI/GU: TF (promote w/fiber)@ goal 55cc/hr, stop for residual >100. +BS, brown liquid stool out mushroom cath. Urine out foley 20-690cc/hr w/ larger amts following PO lasix 20mg, now DC'd. PRN bolus for decreased U/O. FS 109.\\n\\nID: Temp 97.7-98.3, WBC 12.0. ?aspiration as source of PNA. Cont ceftriaxone, flagyl. IV sites wnl.\\n\\nPsychosocial: Daughter called this AM updated on status and , husband visited also updated.\\n\\nDispo: Cont to monitor mental status, cont lactulose, cont to hold sedatives if VS stable, monitor I&O request bolus for decreased U/O, cont med regimen.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366528,\n \"text\": \"Patient on albuterolQ6 PRN,Atrovent Q6.last Rx done @ 18 0clock.Hard to understand patient,BS diminished without wheezes.Being treated prophylactically for SOB.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366529,\n \"text\": \"micu npn 1900-0700\\nPlease see carevue flowsheet for all objective data\\n\\nPatient continues to be agitated and restless through the night. bilateral soft wrist restraints present, also this am, hand mitts added after pt self d/c'd her mushroom catheter x2. opens eyes, shaky and agitated for the most part. Occ follows commands, does not participate in talking or answering questions unless she is angry and yelling. received 2 doses of ativan 2mg w/o much effect. HR has been 1teens-120this am. bp 1teens-140's sys. Pt did not receive ativan during the day yesterday. Pt remains on 4l nasal cannula, sats 92-97%. l/s diminished/coarse. She has lots of dry oral secretions requiring frequent mouth care.\\n feeds remain at goal, toelrating well. held overnight as pt put out >500cc last evening. uop remains marginal but adequate, no bolus' given overnight.\\npt's daughter calling for update at beginning of shift.\\n\\nPlan to cont to follow mental status, keep pt safe. asses for s+s of bleeding, follow temp curve/wbc, fluid status. Ativan prn for s+s of withdrawal.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366530,\n \"text\": \"Resp Care\\n\\nPt followed by respiratory for bronchodilator tx Q6. Currently wearing 40% cool aerosol with spo2 in the mid to upper 90s. BS essentially clear with no changes noted post treatment therapy. Pt needs some encouragement keeping mask on at times. Alb/atro given x2 via aerosol mask. Will cont to follow as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366531,\n \"text\": \"Nursing Progress Note 0700-1900\\n*Full Code\\n\\n*Access: R PICC, L PIV\\n\\n*Allergies: Sulfa\\n\\nNeuro: agitated this AM, HR 140's, SBP 150's, hanging over bedside, was given 4 mg Ativan in previous shift w/ poor effect, this nurse gave 1mg haldol w/ good effect, Pt stable most of the day but difficult to arouse at times; may want to try 0.5mg if additional sedation is required. At this time, still moving around in the bed, asking to go outside, wants to get out of bed, wants a plum, want milk, and at this point still not oriented. No complaints or signs of pain, PERRL 3mm / . MD's feel she may still be having some withdrawl symptoms even though she is 7 days in hospital.\\n\\nCardiac: NSR/ST w/o ectopy, HR 92-125, SBP 108-155. Hct stable @ 36.3, no s/s of bleeding. INR 1.7, PTT and PT slightly elevated as well, Hep dose changed to and DIC labs sent, but mostly likely caused by impaired liver function.\\n\\nResp: started shift on 4L NC, mouth has been very dry and sat's were lower, changed to cool neb @ 40% for moisture and increased o2, tolerating well. O2sat 90-98%, rr 15-22, LS clear upper and coarse lower, no cxr today though yesterdays showed some improvement but still abnormal (PNA).\\n\\nGI/GU: TF @ goal 55cc/hr w/ residual 30cc, stop TF if >100. FWB 250cc thru NGT Q6H for Na 148 this AM. +BS, stool through mushroom cath brown/liquid, 250cc then bag emptied, cont lactulose TID. Urine out foley amber/clear 20-40cc/hr, 500cc NS bolus x2 this shift to try and increase UO, no significant change in output.\\n\\nID: Temp 97.4Ax - 98.6oral, WBC 13.2. Ceftriaxone to be dc'd tomorrow which will be 7th day. Continue flagyl.\\n\\nPsychosocial: Husband() and Daughter (), both called this AM and updated on condition and . PCP also visited this afternoon, visits everyday he said.\\n\\nDispo: cont to monitor mental status (attempt lesser doses of haldol such as 0.5mg if necessary), monitor UO, cont lactulose and awaiting DIC labs, cont med regimen.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366532,\n \"text\": \"MICU Nursing 19-07\\nNeuro: Gradually more awake through course of night. A&Ox3 at latest, however not appropriately interactive and does not answer many questions correctly beyond basic orientation exam. Frequently calling out, yelling, etc. Gave 0.5mg haldol IM once with no effect.\\n\\nPain: Denies, and appears comfortable. Screams out with any movement in bed.\\n\\nCV: Sinus rhythm rate 91-112 BP 118-140/46-69 Palpable pulses in all extremities. HR elevated when more alert. P-boots on, sc heparin. PICC with KVO IVF.\\n\\nResp: Switched to 3LNC, maintains SPO2 high 90's. Desat's to low 90's on room air. Nebs q6 as ordered. Lungs are clear, diminished bibasilar with upper airway congestion. Swallows sputum.\\n\\nGI: Abdomen soft, non-tender. TF at goal, minimal residuals. Flushed as ordered. Mushroom cath with lg amounts of brown liquid stool. Lactulose continues.\\n\\nGU: Foley to gravity with marginal output, HO aware - no intervention at this time.\\n\\nEndo: No RISS\\n\\nSkin: Stage I pressure area on coccyx/buttocks. Turned and positioned frequently, barrier cream applied liberally.\\n\\nID: Tmax 99.9, on antibiotics, known improving PNA.\\n\\nSocial: Husband called, updated on pt's condition and nursing overnight.\\n\\nPlan:\\nMaintain safety\\nPain management\\nMinimize sedatives\\nFrequent reorientation\\nAggressive bowel regimen with lactulose\\nNotify team of acute changes\\n transfer to floor if mental status continues to improve\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366533,\n \"text\": \"MICU 7 RN Note 0700-1900\\n\\nEvents: Hypernatremia Free H20 bolus, Speech eval, ^PTT, CIWA monitoring.\\n\\nNeuro: Awake lethargic, voice slurred with noted improved level of orientation. wax and wanes. Pupils/cataract 3mm equal react , tracks surroundings, MAE random and to command equal strength, intermitent tremors of UE. CIWA scale 5-10 recieved Ativan 1mg x3 and Haldol 1mg x2. periods of restlessness/calm agitation requesting somthing to drink. moves about in the bed. no c/o pain. recieved lactalose encephalopathy\\n\\nCV: HR 78-90 NSR no ectopy, BP 112-140/40-60. Maps>60. Peripheral pulses 3+DP/DT neg peripheral edema. IV access R brachial PICC IV d5W 100cc/hr. K+4.0, mag 2.2. Na 153 Free H20 repeat Na trending down.\\nHeme: Hct 31.8 trending down from previous days, Ptt 90 INR 1.7 Heparin SQ d/c\\n\\nResp: RR 22-26 Reg O2 3L/Min NC Sats 95-97% Lungs clear Dim @ bases.\\n\\nID: low grade temp 100, WBC 10.9, Abx Flagyl/vanco\\n\\nGI/liver: Ads soft distended + BS +stool Mushroom cath in place. recieved Lactalose Liq brown trace + stool. NGT R nares TF promte with fiber 55cc/hr @ goal. Speech eval failed Pt remains NPO\\n\\nGU: foley u/o 20-50cc/h icteric urine.\\n\\nDerm : skin impaired Dry Coccyx red skin irritaion from stool emollient cream appleid.\\n\\nSocial: Full code status, Family visited, updated on plan of care.\\n\\nPlan: called out to floor\\n Monitor for dT's CIWA scale med Ativan/Haldol\\n To start diuretic \\n cont Free H20 Hypernatremia.\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366517,\n \"text\": \"NURSING PROGRESS NOTE:\\nTHIS IS A 70 YR OLD FEMALE WHO CAME IN THROUGH THE ED WITH C/O PAIN IN HER LOWER EXTREMETIES. AFTER DRAWING HER BLOODS THEY FOUND THAT HER HCT WAS ONLY 14 AND HER K+ WAS 2.6. PT WAS TREATED IN THE ED WITH 2UNITS OF PACKED RBC'S, POTASSIUM SUPPL, AND PROTONIX. PT THEN BROUGHT TO MICU FOR FURTHER TREATMENT AND FIND SOURCE OF HER BLEED.\\n\\nNEURO: ON ARRIVAL TO THE UNIT PT SEEMED TO BE ORIENTED X 3 BUT AS THE NIGHT WORE ON PT BECAME INCREASINGLY MORE CONFUSED AND AGITATED. PT VERY RESTLESS IN THE BED AND PICKING AT EVERYTHING. PT GOT OOB AND PULLING EVERYTHING OFF. PT ALSO HAS TREMORS AMD HER EXTREMETIES ARE VERY RIGID. PT STATES THAT THE LAST TIME SHE HAD A DRINK WAS OVER LABOR DAY WEEKEND. PT HAS BEEN STARTED ON THE CIWA SCALE AND HAS RECEIVED ATIVAN PO/IV AND ONE DOSE OF VALIUM BEFORE IT WAS D/C'D. PLEASE SEE CAREVIEW FOR CIWA SCALE.\\n\\nCV: PT IN NSR WHEN ASLEEP BUT WHEN AWAKE HR UP TO THE 120'S. PT HAS RECEIVED ONE UNIT OF PACKED CELLS WHILE IN THE MICU FOR A HCT OF 16. PT HAS RECEIVED A DOSE OF LACTULOSE WHICH HAS NOT IMROVED HER ENCEPHALOPATHY. PT TO CT SCAN OF HER HEAD FOR POSSIBLE HEAD BLEED BECAUSE OF HER NEURO SYMPTOMS AND HER SLURRED SPEECH. PT WITH LOW GRADE TEMP OF 99.6 PO. BOTH LOWER EXTREMTIES ARE REDDENED/SWOLLEN AND VERY TENDER. PT STARTED ON CEFAZOLIN FOR CELLULITIS.\\n\\nGI: PT WITH POSSIBLE SLOW GI BLEED. PT HAS HAD ONE STOOL AFTER RECEIVING LACTULOSE. STOOL LOOSE/BROWN AND GUIAIC POS. ABD SOFT WITH POS BOWEL SOUNDS. ORAL CAVITY WITH VERY FOUL ODOR. DENTURES REMOVED AND UPPER GUMS VERY SORE LOOKING WITH HER OWN TEETH GROUND DOWN TO THE NUB. GUMS BLEEDING WITH MOUTH CARE. DENTURES TAKEN OUT TO BE CLEANED AND TO OBSERVE MOUTH.\\n\\nGU: PT HAD RECEIVED A DOSE OF LASIX IN THE ED AND HAS BEEN PUTTING OUT LRG AMT'S OF CLEAR YELLOW URINE.\\n\\nACCESS: PT WITH TWO PERIPH IV'S BUT HAS LOST THE ONE IN HER LEFT AC.\\n\\nSKIN: PT'S LOWER EXTREMETIES VERY RED AND SORE, LOOKS LIKE CELLUTLITS.\\nPT HAS A LRG HEMATOMA ON RIGHT UPPER BACK. PT DOES NOT KNOW HOW SHE GOT IT..\\n\\nSOCIAL: PT LIVES WITH SPOUSE AND HAS A DAUGHTER. DAUGHTER CALLED LAST EVENING FOR AN UPDATE. PT IS A FULL CODE.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366518,\n \"text\": \"MIcu Nursing note \\n\\nNeuro pt very restless, orient to person only, pt in soft restraints for saftey reasons, cwai 35, and ativan ^ pt recieved 4 mg iv ativan q1 hr for the first 3 hrs before she was calm, pt was tacky and hypertensive when I arrived at 7 am, now has not received ativan since 2 pm and cwai is now 10\\n\\nCv Pt hemodynamically stable pulses palp bilaterally, both shins still slightly reddened and firm, pt now sr hr 80-90\\n\\nResp pt remains on 2L n/c sats 98&% when on ra sats drop tp 90%, pt ^ 4L while having endo this am but has be able to be placed back to 2L n/c, lung clear.\\n\\nGi pt npo, had endo this am, no beleeding, pt has grade I varices in esph, sever gastritic, gastic varicies and a polyp pt does c/o RUG tenderness, no stool, and bowel sound x4\\n\\ngu pt passing yellow unine but u/o low house staff aware and after blood if u/o doesn't ^ the will consider ^ ivf\\nat present ivf at kvo\\n\\nId pt tmax 100.3 ax pt was cultured x2 blood and urine , pt started on levoflox this afternoon, tylenol given x2 pr\\n\\nsocial spoke with husband and daughter which were updates about pt's condition, husband notified that I removed pt's jewlery and credit cards and money sent to be locked up.\\n\\nheme, hct this afternoon down to 19.9 form 24.5 pt transfused with 1unit prbc's, so of bleeding.\\n\\nA/P repeat cht this evening, follow cwai scale and prn ativan for dt's per scale, follow up with house staff reguarding ^ ivf because of npo status.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366519,\n \"text\": \"MICU NPN 7P-7A\\nNEURO: INITIALLY PATIENT DIFFICULT TO AROUSE. NAME CALLED REPEATEDLY BEFORE SHE STARTED TO OPEN EYES. PATIENT UNABLE TO ANSWER QUESTIONS AND MAKING INCOMPREHENSIBLE SOUNDS. LOCALIZING PAIN. LATER WAKING UP BUT FALLING BACK TO SLEEP AFTER SHE WAS AROUSED. WAS ATTEMPTING TO ANSWER QUESTIONS BUT APPEARS SHE BE ONLY ORIENTED TO SELF. CIWA 4 @, 7 @2200. DIFFICULT TO ASSESS CIWA AS SHE WAS UNABLE TO ANSWER ?'S. ~12AM MORE AGITATED, PULLING @SHEETS/GOWN. ATTEMPTING TO SIT UP. CIWA AS SHE WAS C/O MILD HEADACHE. FOLLOWING COMMANDS INCONSISTENTLY. GIVEN 4MG ATIVAN IV WITH MOD EFFECT. AS NIGHT HAS GONE ON PATIENT BECOMING MORE AND MORE AGITATED, CIWA 9-11HAS RECEIVED A TOTAL OF 26MG (4-6MG Q1-2HRS) OF ATIVAN IV SINCE MIDNOC WITH EFFECT NOT LASTING MORE THAN 45MIN. RESTRAINED FOR SAFETY OF LINES, RISK FOR FALLING OUT OF BED.\\n\\nCARDIAC: HR 76-120 SR/ST WITH NO ECTOPY. BP 98-150/45-80. HCT @ 24.9, GIVEN 1UPRBC'S WITH AM HCT 32.3. PLTS 96. NO SIGNS OF BLEEDING. PPP.\\n\\nRESP: ON 2L N/C WITH RR 19-40 AND SATS 89-100%. WHEN AGITATED DROPPING SATS AND AUDIBLY WHEEZY. WHEN CALM LS CLEAR WITH DIMINISHED LEFT BASE. OCCASIONAL CONGESTED NONPRODUCTIVE COUGH.\\n\\nGI/GU: ABD SOFT WITH +BS. SMALL SMEARS OF STOOL, APPEAR BLACK. UOP 25-45CC/HR AMBER AND CLEAR.\\n\\nFEN: RECEIVING MVI, FOLATE, THIAMINE VIA 500CC D5W. LYTES PER CAREVUE. NOT SAFE AT THIS TIME TO ATTEMPT ANYTHING PO AND WITH GRADE ESOPHAGEAL VARICIES A NGT IS RISKY. MEDS CHANGED TO IV/SC AS ALLOWED.\\n\\nID: TMAX 99.4 WITH WBC 11.2. ON LEVOFLOX.\\n\\nSKIN: W/D/I. HEMATOMA TO RIGHT UPPER BACK.\\n\\nACCESS: PIV X1.\\n\\nSOCIAL/DISPO: FULL CODE. SON FROM CALLED FOR UPDATE. CONTINUE TO TREAT DT'S.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366534,\n \"text\": \"Nursing Progress Note:\\n\\nPt. is called out but still waiting for bed.\\n\\nNeuro: Pt. remains confused, at times knows where she is but at others thought she was at home. She was not agitated during the night, slept fairly well, and was not given any Ativan or Haldol.She did appear to be trying to get out of bed a couple times but was easily reoriented.\\n\\nCV: HR 70s-90s NST with no ectopy, NBP 110s-130s/40s-60s. Single-lumen PICC to R brachial is patent and WNL. IV fluids d/c'd and running at KVO now.\\n\\nResp: Lung sounds are clear to all lobes with diminished bases. RR teens, 02 sats high 90s except when on room air when it drops to low 90s. No wheezes or crackles noted. Neb txs could probably be changed to PRN as pt. has no hx of use prior to admission.\\n\\nGI: feeds at goal of 55cc/hour, BSX4, liquid, brown stool via mushroom catheter. MN dose of Lactulose held due to copious liquid stool.\\n\\nGU: UO is marginal (between 20-30cc/hour). Team is aware and will order bolus if UO drops to <20cc/hour.\\n\\nSkin: Pt. has a rash which appears to be fungal to perineal area and labia. Anti-fungal ointment applied.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366535,\n \"text\": \"NPN 7a-7p\\nNeuro: Pt. oriented to person, place, and time but when left alone has d/c'd rectal , NGT, and takes off 02. Got out of chair and tried to ambulate in room, unsteady gait. Taking lactulose po.\\n\\nResp: 02 sat 95-96% on room air. Bibasilar crackles. Mild cough with minimal sputum.\\n\\nCV: HR 80's NSR no ectopy. BP 110-120/60's. Has PIC line which was KVO but stopped KVO so there would be less for her to pull at.\\n\\nID: Completed course of IV antibiotics for presumed aspiration PNA. Afebrile.\\n\\nGI: Pt. d/c'd rectal . Small amounts of stool since then-liquid. Able to take lactulose po. Has her dentures in.\\n\\nGU: Foley intact-urine output approx 20-30cc/hr.\\n\\nSkin: Rash over perineal area. Nystatin applied.\\n\\nSocial: Husband in to visit most of the day.\\n\\nplan:\\n-transfer to floor when sitter available.\\n-monitor pt. when eating\\n-? repeat formal swallowing study\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2127-08-31 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1366536,\n \"text\": \"Nursing Progress Note:\\n\\nPt. is called out to floor and has a bed but was not transferred due to needing a sitter (this may change as pt's mental status is improving).\\n\\nNeuro: Pt. has been alert, oriented, pleasant, and cooperative. She was appropriate and slept well for most of the night. She was found standing by the bed once but was easily reoriented and told to use call light rather than getting out of bed herself. She appeared to understand and there were no further incidents.\\n\\nCV: HR 70s-90s, NBP 100s-120s/40s-50s. Pt. has single-lumen PICC which is patent and draws well. Area around PICC is ecchymotic.\\n\\nResp: RR teens, 02 sats in 90s on room air. Lungs are clear, bases are diminished at times. No wheezes or cough, Neb txs held.\\n\\nGI: BSX4, pt. can have thickened liquids until further eval of swallow is performed (pt. did poorly yesterday). Pt. seems to be fine with thickened liquids, no coughing noted. Pt. initially stooling somewhat formed stool but this changed to thin enough so that mushroom catheter reinserted. Stool is now liquid brown. Lactulose given at MN, held at 0600.\\n\\nGU: UO remained marginal until 20mg PO Lasix q day ordered and given. UO after thsi increased to 60cc/hour for several hours.\\n\\nSkin: Rash to perineal area and labia, Aloe Vesta antifungal applied. Scattered ecchymotic areas on extreamities and blood blister to L FA.\\n\\nSocial: Pt. spoke to family on phone today.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2127-08-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 144073,\n \"text\": \"Sinus rhythm\\nProlonged Q-Tc interval - clinical correlation is suggested\\nSince previous tracing of , Q-Tc interval appears longer\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2127-08-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 144074,\n \"text\": \"Sinus rhythm, rate 89. Since the previous tracing of minimal slowing of\\nthe heart rate is seen. No other changes are noted.\\nTRACING #2\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2127-08-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 144075,\n \"text\": \"Sinus rhythm, rate 98. Since the previous tracing of the heart rate is\\nfaster. Increased ST-T wave abnormalities are seen particularly over the\\nlateral precordium.\\nTRACING #1\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-08-25 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 927381,\n \"text\": \" 4:09 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for improvement\\n Admitting Diagnosis: SEVER ANEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with ETOH cirrhosis here w GIB. now w/ PNA and O2\\n requirement\\n REASON FOR THIS EXAMINATION:\\n eval for improvement\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Pneumonia and decreased oxygen requirement. Eval for\\n improvement.\\n\\n Comparison is made to .\\n\\n PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: There has been interval placement\\n of an NG tube with the tip projecting over the body of the stomach. The side\\n hole is located above the gastroesophageal junction. Patchy opacities are\\n again seen predominantly in the right upper lobe, but also in the right middle\\n and lower lobes and left lower lobe. The right upper lobe opacity is slightly\\n improved in the interval. Also, the left lower lobe opacity is less\\n prominent. No pleural effusions are seen. No new consolidations are seen.\\n\\n IMPRESSION:\\n 1. Multifocal pneumonia with interval improvement in the right upper lobe\\n opacity and left lower lobe opacity.\\n 2. Placement of NG tube with the tip in gastric fundus, side hole above GE\\n junction. Advancement of approximately 10 cm is recommended.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-08-27 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 927697,\n \"text\": \" 9:59 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: interval change\\n Admitting Diagnosis: SEVER ANEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with ETOH cirrhosis here w GIB. now w/ PNA and O2\\n requirement\\n REASON FOR THIS EXAMINATION:\\n interval change\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST RADIOGRAPH.\\n\\n INDICATION: 70-year-old woman with cirrhosis and shortness of breath.\\n\\n COMPARISON: Radiograph dated .\\n\\n FINDINGS: When compared to the prior study, there has been significant\\n interval improvement of the multifocal pneumonia. Interval placement of a\\n right PICC line with its tip projecting over the SVC near the atrial junction.\\n There is no evidence of pneumothorax or pneumoperitoneum. NG tube appears\\n stable.\\n\\n IMPRESSION:\\n\\n 1. Significant interval improvement of the multifocal pneumonia.\\n\\n 2. Interval placement of a right PICC line with its tip projecting over the\\n SVC, near the atrial junction.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-08-23 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 927209,\n \"text\": \" 3:17 AM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: r/o intracranial hemorrhage\\n Admitting Diagnosis: SEVER ANEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with ESLD, encephalopathic\\n REASON FOR THIS EXAMINATION:\\n r/o intracranial hemorrhage\\n No contraindications for IV contrast\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: End-stage liver disease with encephalopathy. Evaluate for\\n intracranial hemorrhage.\\n\\n There are no prior studies for comparison.\\n\\n NON-CONTRAST HEAD CT SCAN: There is no evidence of acute intracranial\\n hemorrhage or shift of the normally midline structures. The ventricles and\\n cisterns are normal. There is hypodensity of the cerebral periventricular\\n white matter, particularly in the left frontal region, consistent with chronic\\n microvascular ischemia. There is also hypodensity of the left subinsular\\n white matter consistent with the same process. The visualized paranasal\\n sinuses and mastoid air cells are clear. The osseous and soft tissue\\n structures are unremarkable.\\n\\n IMPRESSION: No evidence of acute intracranial hemorrhage. Chronic\\n microvascular ischemic changes.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-08-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 927140,\n \"text\": \" 2:00 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: CHF?\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with ETOH cirrhosis\\n REASON FOR THIS EXAMINATION:\\n CHF?\\n ______________________________________________________________________________\\n FINAL REPORT\\n AP CHEST, 2:10 P.M., \\n\\n HISTORY: Alcoholics cirrhosis. Shortness of breath.\\n\\n IMPRESSION: AP chest compared to and :\\n\\n Heart size is top normal. Pulmonary vasculature is engorged and there is mild\\n interstitial edema at the base of the right lung laterally. More centrally,\\n there is considerable peribronchial opacification in a region that previously\\n showed abnormality. This may therefore represent deposition of edema in the\\n region of previous lung injury, but we could also be seeing right lower lobe\\n pneumonia with secondary cardiac decompensation. There is no appreciable\\n pleural effusion.\\n\\n Dr. was paged to discuss these findings, at the time of dictation.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-08-23 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 927239,\n \"text\": \" 10:02 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for effusion/pna\\n Admitting Diagnosis: SEVER ANEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with ETOH cirrhosis here w GIB. now w/ new oxygen\\n requirement.\\n REASON FOR THIS EXAMINATION:\\n eval for effusion/pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, SINGLE VIEW ON \\n\\n HISTORY: New oxygen requirement, question effusion pneumonia.\\n\\n REFERENCE EXAM: .\\n\\n FINDINGS: There is a new small left pleural effusion. There continues to be\\n mild cardiomegaly. There continues to be hazy pulmonary vasculature and\\n increased interstitial edema most marked on the right. There is also an area\\n of focal consolidation in the retrocardiac region. Most likely, this findings\\n are due to CHF. An underlying infectious infiltrate cannot be excluded.\\n\\n IMPRESSION: Likely increased CHF.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-08-25 00:00:00.000\",\n \"description\": \"PICC W/O PORT\",\n \"row_id\": 927391,\n \"text\": \" 7:19 AM\\n PICC LINE PLACMENT SCH Clip # \\n Reason: please place PICC\\n Admitting Diagnosis: SEVER ANEMIA\\n ********************************* CPT Codes ********************************\\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\\n ****************************************************************************\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with ESLD here w/ GIB. now c/b EtOH withdrawal\\n REASON FOR THIS EXAMINATION:\\n please place PICC\\n ______________________________________________________________________________\\n FINAL REPORT\\n PICC LINE PLACEMENT\\n\\n INDICATION: 70-year-old woman with end-stage liver disease, needs long-term\\n IV access.\\n\\n RADIOLOGISTS: Dr. , and Dr. . Dr. , staff radiologist,\\n was present for the entire procedure.\\n\\n TECHNIQUE: Using sterile technique and local anesthesia the right brachial\\n vein was localized with ultrasound and punctured under direct ultrasound\\n guidance using a micropuncture set. Ultrasound images were obtained before\\n and immediately after obtaining intravenous access. A micropuncture sheath\\n was then placed over the wire. A single-lumen PICC line was then advanced\\n through the sheath over the wire and its tip positioned in SVC under\\n fluoroscopic guidance. Position of the catheter was confirmed by chest x-ray\\n in one view. Guidewire and the peel-away sheath were then removed. The\\n catheter was secured to the skin.\\n\\n The patient tolerated the procedure well. There were no immediate\\n complications.\\n\\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided PICC line\\n placement via the right brachial vein with the tip positioned in SVC. Total\\n length of the catheter is 34 cm. The catheter is ready for use.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-08-24 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 927318,\n \"text\": \" 8:21 AM\\n CHEST (PORTABLE AP) Clip # \\n Reason: eval for pulm edema or pna\\n Admitting Diagnosis: SEVER ANEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with ETOH cirrhosis here w GIB. now w/ new hypoxemia and\\n coarse breath sounds\\n REASON FOR THIS EXAMINATION:\\n eval for pulm edema or pna\\n ______________________________________________________________________________\\n FINAL REPORT\\n CHEST, SINGLE VIEW, ON \\n\\n HISTORY: New hypoxemia and coarse breath sounds.\\n\\n FINDINGS: There is a new right upper lobe infiltrate and patchy areas of\\n increased opacity in the right lower lobe and left lower lobe as well. Heart\\n is moderately enlarged.\\n\\n IMPRESSION: Probable multifocal pneumonia. CHF with an atypical presentation\\n cannot be totally excluded.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-08-24 00:00:00.000\",\n \"description\": \"LIVER OR GALLBLADDER US (SINGLE ORGAN)\",\n \"row_id\": 927325,\n \"text\": \" 9:32 AM\\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \\n DUPLEX DOPP ABD/PEL\\n Reason: assess ascites, mark for tap, ? liver changes\\n Admitting Diagnosis: SEVER ANEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with alcoholic ascites, now with fever, tender abdomen\\n REASON FOR THIS EXAMINATION:\\n assess ascites, mark for tap, ? liver changes\\n ______________________________________________________________________________\\n FINAL REPORT\\n 70-year-old female with alcoholic cirrhosis, now with fever and tender\\n abdomen.\\n\\n COMPARISON: .\\n\\n FINDINGS: Again demonstrated is the shrunken nodular appearance of the liver\\n consistent with cirrhosis. No focal hepatic lesion is identified. There is\\n no intra- or extra-hepatic biliary ductal dilatation. The common duct\\n measures normal caliber of 4 mm. No ascites is identified. The gallbladder\\n is unremarkable without stones, wall thickening, or pericholecystic fluid. A\\n right pleural effusion is incompletely evaluated on this study.\\n\\n As demonstrated on , Doppler evaluation of the liver again\\n shows reversal of flow (hepatofugal) of the main, right and left portal veins\\n as well as superior mesenteric vein. The splenic vein demonstrates normal\\n directionality of flow. The main, left, and right hepatic veins are patent\\n with appropriate color flow and waveform. Normal flow and appropriate\\n waveforms are demonstrated in the main, left, and right hepatic arteries. The\\n IVC is patent.\\n\\n IMPRESSION:\\n 1. Cirrhotic liver, without focal hepatic lesion identified.\\n 2. No ascites.\\n 3. As demonstrated on , there is reversal of flow in the\\n main, right, and left portal veins as well as superior mesenteric vein. The\\n hepatic veins and arteries demonstrate appropriate directionality of flow and\\n waveform.\\n 4. Right pleural effusion is incompletely assessed.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2127-09-01 00:00:00.000\",\n \"description\": \"VIDEO OROPHARYNGEAL SWALLOW\",\n \"row_id\": 928307,\n \"text\": \" 2:13 PM\\n VIDEO OROPHARYNGEAL SWALLOW Clip # \\n Reason: eval for aspirations with thin liquids\\n Admitting Diagnosis: SEVER ANEMIA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 70 year old woman with ESLD etoh abuse\\n REASON FOR THIS EXAMINATION:\\n eval for aspirations with thin liquids\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: 70-year-old female with end-stage liver disease, evaluate for\\n aspiration.\\n\\n OROPHARYNGEAL VIDEO FLUOROSCOPIC SWALLOWING EVALUATION: An oropharyngeal\\n swallowing video fluoroscopy study was performed today in collaboration with\\n speech pathology. Barium of varying consistencies as well as solids coated\\n with barium and a barium pill were administered. There was moderate\\n impairment in bolus formation with no premature spillover seen. There was\\n mild penetration with no aspiration.\\n\\n IMPRESSION: Mild penetration which cleared during the swallow.\\n\\n Please see the speech pathology note under CareWeb for further details.\\n\\n\"\n }\n]"}}},{"rowIdx":998,"cells":{"subject_id":{"kind":"number","value":22933,"string":"22,933"},"hadm_id":{"kind":"number","value":127043,"string":"127,043"},"target_text":{"kind":"string","value":""},"extractive_notes_summ":{"kind":"string","value":"remaines intubated and vented, weaned to PSV tol ok at this time. OXYGENATING WELL & FI02 WEANED DOWN, SEE FLOWSHEET FOR ABG. care note - Pt. INTUBATED AND ON ASSIST CONTROL, BREATHING OVER SET RESP RATE MINIMALLY. Visualized paranasal sinuses are normally aerated. Again demonstrated in the right hepatic lobe is a TIPS stent catheter, which appears unchanged in position. Pt tolerating well. IMPRESSION: Endotracheal only 1 cm above the carina, and angled towards the right mainstem bronchus. AM LABS PENDING.GI: ABDOMEN SOFT. NGT TO LCWS, SCANT BILIOUS OUTPUT. COMPARISON: Head CTA from . LS clear bilat. LCTAB. Nasogastric tube is in place. GI: Abd soft, pos bs. K+ repleted in am, PM lytes pnd. TECHNIQUE: Non-contrast head CT. ABDOMEN SOFTLY DISTENDED. There is fecalization of the small bowel consistent with resolving obstruction. FLEXI-SEAL CURRENTLY IN PLACE. Endotracheal tube is in place, positioned approximately 1 cm above the carina, and angled towards the right main stem bronchus. REASON FOR THIS EXAMINATION: NOTE: TO BE PERFORMED WITH DOPPLER! Fecalization of the small bowel consistent with slowly resolving small bowel obstruction. Resp. IMPRESSION: Patent TIPS stent with flow velocities within similar range to recent evaluations. FINDINGS: Portable supine chest radiograph is reviewed. Sinus rhythm. Nsg.progress notes:See flow sheet for specific:Neuro: Alert and oriented x3,pleasant and co op with care,c/o head achae,oxicodone prn started with good effect,MAE.CV: NSR,HR in 70-80,no ectopy noted,SBP 110-130,IVF KVO denies CP or discomfort.40mmol kcl replaced this am,pending evening labs.Resp: Remains on RA with O 2sat 99-100%,LS clear.GI:Abd soft,+ BS,liq stool to FIB,flexiseal removed as not draining to the bag,on lactulose q4h.regular diet started and tolerated.GU: Foely cath patent with yellow clear urine adq amt.Endo: Bld sug wnl.Act: Turning alone in bed,skin intact,except redness around rectum from frequent stooling.Social: Husband called x2,updated with him,MICU team also talked to him.Plan: cont monitoring,neuro checks,transfer to floor when bed available. Please assess tube placement. NGT clamped. ASSITING IN CARE, COOPERATIVE. FINDINGS: This was a limited Doppler evaluation of the TIPS stent. Uneventful shift.Tolerating advanced diet. CV: Remains NSR, no ectopy noted. Patient intubated. NURSING PROGRESS NOTEPLEASE SEE CAREVUE FOR DETAILSRESP: EXTUBATED WELL W/NO EVENTS, DR AT BS. Suctioned prn for small amounts of thick brow sputum. NON DISTENDED. Overall, these are in similar range to the prior studies of and . IMPRESSION: 1. Pt denies SOB. Diffuse non-specific ST-T wave changes. NSR HR 90S. IVF kvo, revieved 1.5L NS as ordered. PEERLA. COMPARISON: . SICU NPNS-\"I feel much better, thank you. Flexiseal remains intact, draining lg aounts of golden loose stool secondary to frequent lactulose. Again seen is a vascular coil in the region of the right MCA bifurcation aneurysm (there is no evidence of craniotomy), and surrounding encephalomalacia and ex vacuo dilatation of the frontal of the right lateral ventricle, unchanged from prior exam. CALL MICU HO W/ANY CHANGES. IMPRESSION: Endotracheal tube is 6.4 cm from carinal angle. The ventricles and basal cisterns are otherwise normal and unchanged since prior exam. Scout image demonstrates TIPS stent and cholecystectomy clips within the right upper quadrant. The nasogastric tube remains in a satisfactory position. DENIES PAIN. HEART RATE 90'S NORMAL SINUS. Flow velocities within the TIPS stent in the proximal, mid, and distal portions are 127, 173, and 175 cm/sec respectively. PRODUCTIVE COUGH FOR THIN WHITE SECRETIONS.NEURO: A&OX3. BLOOD GLUCOSE WITHIN NORMAL RANGE. NPO.GU: FOLEY PATENT, >30CC CYU HOURLY.SKIN: INTACT, NO BREAKDOWN NOTED. \"SEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.O-VSS. Resp Care: Pt recieved on mechanical ventilation. SAT'S 100%. SBP 115-140. REASON FOR THIS EXAMINATION: Evaluate placement of ETT, OGT. Tube withdrawal of approximately 2 to 3 cm is recommended for appropriate positioning. MAINTAIN SKIN INTEGRITY. 11:00 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Evaluate placement of ETT, OGT. LUNG SOUNDS CLEARED, SUCTIONED ONCE FOR THICK BROWN/YELLOW SPUTUM. TRANSFER TO FLOOR. Evaluate portal flow, TIPS flow. FOLLOWING COMMANDS. SBP 120-140. Streak artifact from the aneurysm clips does slightly limit evaluation of the right infratemporal region. Recommend withdrawing tube at least 2-3 cm. MONITOR OUTPUT. AWAITING AM LAB RESULTS & REPEAT AMMONIA LEVEL. MAE. 10:54 PM DUPLEX DOP ABD/PEL LIMITED Clip # Reason: NOTE: TO BE PERFORMED WITH DOPPLER! Resp: pt placed on CPAP, PEEP 5, PS 10, FiO2 40%, following O2 sats per MICU, pt without aline. GIVEN LACTULOSE PR AND PNGT FOR ELEVATED AMMONIA LEVEL IN ED. LOW GRADE FEVER. Condition UpdateAssessment:Please see carevue for details Neuro: Pt encephalopathic, lactulose cont Q4hrs with much noted improvement in neuro exam over the course of the day. SBP RANGING 100-130'S. Compared to theprevious tracing of there is no significant diagnostic change. FINAL REPORT CLINICAL HISTORY: Cirrhosis, encephalopathy. Denies CP. Color Doppler evaluation shows wall-to-wall color Doppler signal within the TIPS stent. NO FAMILY CONTACT OVERNIGHT.PLAN: CONTINUE WITH LACTULOSE, TITRATE TO BOWEL MOVEMENTS. ? SLIGHTLY RED ON COCCYX.POC: MONITOR RESP, NEURO. NO ECTOPY. No edema noted. 2. MICU TEAM ATTEMPTED TO PLACE ARTERIAL LINE, UNABLE. CVP ~ 10. There is appropriate hepatopetal blood flow in the main portal vein. IMPRESSION: No acute intracranial process. FINDINGS: There is no intracranial hemorrhage. PATIENT RARELY OPENING EYES WITH REPOSITIONING & STIMULI. FLEXISEAL REMAINS INTACT W/LG AMOUNTS LIQUID GOLDEN BROWN, CONT W/FAIR AMOUNT OF DRAINAGE AROUND FLEXISEAL AS WELL. CURRENTLY ON 40% FIO2 COOL NEB FACE MASK. Heart and mediastinal contours are unremarkable. COMPARISON: Duplex Doppler ultrasound evaluation of the liver and TIPS on and . NURSING NOTEASSESSMENT: PATIENT ARRIVED FROM APPROX 10 PM, UNRESPONSIVE & MINIMALLY WITHDRAWING TO PAIN (PATIENT CURRENTLY DOES NOT WITHDRAW ANY EXTREMITIES)."},"n_notes":{"kind":"number","value":13,"string":"13"},"notes":{"kind":"list like","value":[{"category":"Radiology","chartdate":"2110-02-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":994959,"text":" 3:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess tube placement pt in \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with delta MS \n REASON FOR THIS EXAMINATION:\n assess tube placement pt in \n ______________________________________________________________________________\n WET READ: DSsd SAT 4:07 PM\n ETT at or near origin of right mainstem bronchus. Recommend withdrawing tube\n at least 2-3 cm.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old female with altered mental status, now . Please\n assess tube placement.\n\n COMPARISON: .\n\n FINDINGS: Portable supine chest radiograph is reviewed. Endotracheal tube is\n in place, positioned approximately 1 cm above the carina, and angled towards\n the right main stem bronchus. Enteric feeding tube extends below the diaphragm\n and into the stomach. Heart and mediastinal contours are unremarkable. The\n lungs are clear and well expanded. There is no pleural effusion or\n pneumothorax.\n\n IMPRESSION: Endotracheal only 1 cm above the carina, and angled towards the\n right mainstem bronchus. Tube withdrawal of approximately 2 to 3 cm is\n recommended for appropriate positioning.\n\n"},{"category":"Radiology","chartdate":"2110-02-22 00:00:00.000","description":"CT HEAD W/O CONTRAST","row_id":994960,"text":" 3:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with hepatic sarcoid w/ cirrhosis who p/w MS changes,\n responsive only to pain.\n REASON FOR THIS EXAMINATION:\n Eval for ICH\n CONTRAINDICATIONS for IV CONTRAST:\n RF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old female with hepatic sarcoid and cirrhosis, presenting\n with mental status changes, and responsive only to pain.\n\n COMPARISON: Head CTA from .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage. There is no mass, mass\n effect, or evidence of acute vascular territorial infarction. Again seen is\n a vascular coil in the region of the right MCA bifurcation aneurysm (there is\n no evidence of craniotomy), and surrounding encephalomalacia and ex vacuo\n dilatation of the frontal of the right lateral ventricle, unchanged from\n prior exam. The ventricles and basal cisterns are otherwise normal and\n unchanged since prior exam. Streak artifact from the aneurysm clips does\n slightly limit evaluation of the right infratemporal region.\n\n There is no fracture. Visualized paranasal sinuses are normally aerated.\n Nasogastric tube is in place.\n\n IMPRESSION: No acute intracranial process. No change from study.\n\n\n\n"},{"category":"Nursing/other","chartdate":"2110-02-24 00:00:00.000","description":"Report","row_id":1562265,"text":"Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Alert and oriented x3,pleasant and co op with care,c/o head achae,oxicodone prn started with good effect,MAE.\n\nCV: NSR,HR in 70-80,no ectopy noted,SBP 110-130,IVF KVO denies CP or discomfort.40mmol kcl replaced this am,pending evening labs.\n\nResp: Remains on RA with O 2sat 99-100%,LS clear.\n\nGI:Abd soft,+ BS,liq stool to FIB,flexiseal removed as not draining to the bag,on lactulose q4h.regular diet started and tolerated.\n\nGU: Foely cath patent with yellow clear urine adq amt.\n\nEndo: Bld sug wnl.\n\nAct: Turning alone in bed,skin intact,except redness around rectum from frequent stooling.\n\nSocial: Husband called x2,updated with him,MICU team also talked to him.\n\nPlan: cont monitoring,neuro checks,transfer to floor when bed available.\n"},{"category":"Nursing/other","chartdate":"2110-02-25 00:00:00.000","description":"Report","row_id":1562266,"text":"SICU NPN\nS-\"I feel much better, thank you.\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-VSS. Uneventful shift.Tolerating advanced diet. Sleeping most of night. Awaiting floor bed.\n\nA/P:\nTransfer to floor when bed available.\n"},{"category":"Nursing/other","chartdate":"2110-02-23 00:00:00.000","description":"Report","row_id":1562260,"text":"NURSING NOTE\nASSESSMENT:\n PATIENT ARRIVED FROM APPROX 10 PM, UNRESPONSIVE & MINIMALLY WITHDRAWING TO PAIN (PATIENT CURRENTLY DOES NOT WITHDRAW ANY EXTREMITIES). PATIENT RARELY OPENING EYES WITH REPOSITIONING & STIMULI.\n INTUBATED AND ON ASSIST CONTROL, BREATHING OVER SET RESP RATE MINIMALLY. OXYGENATING WELL & FI02 WEANED DOWN, SEE FLOWSHEET FOR ABG. MICU TEAM ATTEMPTED TO PLACE ARTERIAL LINE, UNABLE. LUNG SOUNDS CLEARED, SUCTIONED ONCE FOR THICK BROWN/YELLOW SPUTUM.\n HEART RATE 90'S NORMAL SINUS. SBP RANGING 100-130'S. LOW GRADE FEVER. PATIENT MAKING 30-50 CC URINE HOURLY, IV FLUIDS STARTED. CVP ~ 10.\n ABDOMEN SOFTLY DISTENDED. GIVEN LACTULOSE PR AND PNGT FOR ELEVATED AMMONIA LEVEL IN ED. FLEXI-SEAL CURRENTLY IN PLACE. BLOOD GLUCOSE WITHIN NORMAL RANGE.\n NO FAMILY CONTACT OVERNIGHT.\nPLAN:\n CONTINUE WITH LACTULOSE, TITRATE TO BOWEL MOVEMENTS. WILL NEED SOCIAL WORK CONSULT. AWAITING AM LAB RESULTS & REPEAT AMMONIA LEVEL.\n"},{"category":"Nursing/other","chartdate":"2110-02-23 00:00:00.000","description":"Report","row_id":1562261,"text":"Resp. care note - Pt. remaines intubated and vented, weaned to PSV tol ok at this time.\n"},{"category":"Nursing/other","chartdate":"2110-02-23 00:00:00.000","description":"Report","row_id":1562262,"text":"Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt encephalopathic, lactulose cont Q4hrs with much noted improvement in neuro exam over the course of the day. Pt now open eys to voice, tracking, nods appropriately to questions, MAE, follows all commands, assists with turning and repositioning.\n\n Resp: pt placed on CPAP, PEEP 5, PS 10, FiO2 40%, following O2 sats per MICU, pt without aline. O2 sat 96-99%. Pt denies SOB. LS clear bilat. Suctioned prn for small amounts of thick brow sputum.\n\n CV: Remains NSR, no ectopy noted. SBP 120-140. No edema noted. Denies CP. IVF kvo, revieved 1.5L NS as ordered. K+ repleted in am, PM lytes pnd.\n\n GI: Abd soft, pos bs. NGT clamped. Flexiseal remains intact, draining lg aounts of golden loose stool secondary to frequent lactulose.\n\n GU: Adequate amounts of clear yellow urine via foley cath.\n\nPlan: Continue with lactulose, monitor labs, monitor hemodynamics, monitor neuro exam, wean vent as tol, pulm toileting, provide pt and family with emotional support.\n"},{"category":"Nursing/other","chartdate":"2110-02-24 00:00:00.000","description":"Report","row_id":1562263,"text":"NURSING PROGRESS NOTE\n\nPLEASE SEE CAREVUE FOR DETAILS\n\nRESP: EXTUBATED WELL W/NO EVENTS, DR AT BS. CURRENTLY ON 40% FIO2 COOL NEB FACE MASK. SAT'S 100%. LCTAB. PRODUCTIVE COUGH FOR THIN WHITE SECRETIONS.\n\nNEURO: A&OX3. MAE. FOLLOWING COMMANDS. ASSITING IN CARE, COOPERATIVE. PEERLA. DENIES PAIN. CONT RECEIVING LACTULOSE EVERY 4 HOURS W/MUCH EFFECT.\n\nCV: AFEBRILE. NSR HR 90S. NO ECTOPY. SBP 115-140. AM LABS PENDING.\n\nGI: ABDOMEN SOFT. NON DISTENDED. FLEXISEAL REMAINS INTACT W/LG AMOUNTS LIQUID GOLDEN BROWN, CONT W/FAIR AMOUNT OF DRAINAGE AROUND FLEXISEAL AS WELL. NGT TO LCWS, SCANT BILIOUS OUTPUT. NPO.\n\nGU: FOLEY PATENT, >30CC CYU HOURLY.\n\nSKIN: INTACT, NO BREAKDOWN NOTED. SLIGHTLY RED ON COCCYX.\n\nPOC: MONITOR RESP, NEURO. MONITOR OUTPUT. MAINTAIN SKIN INTEGRITY. ? TRANSFER TO FLOOR. CALL MICU HO W/ANY CHANGES.\n"},{"category":"Nursing/other","chartdate":"2110-02-24 00:00:00.000","description":"Report","row_id":1562264,"text":"Resp Care: Pt recieved on mechanical ventilation. Pt extubated to 40% cool aerosol. Pt tolerating well.\n"},{"category":"Radiology","chartdate":"2110-02-22 00:00:00.000","description":"DUPLEX DOP ABD/PEL LIMITED","row_id":994999,"text":" 10:54 PM\n DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: NOTE: TO BE PERFORMED WITH DOPPLER! Evaluate portal flow,\n Admitting Diagnosis: DELTA MS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with hepatic sarcoid, cirrhosis, varices, s/p TIPs,\n idiopathic cardiomyopathy p/w altered mental status now for airway\n protection.\n REASON FOR THIS EXAMINATION:\n NOTE: TO BE PERFORMED WITH DOPPLER! Evaluate portal flow, TIPS flow.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old female with history of hepatic sarcoidosis, cirrhosis,\n varices and TIPS placement, now with change in mental status and concern for\n TIPS occlusion or stenosis.\n\n COMPARISON: Duplex Doppler ultrasound evaluation of the liver and TIPS on\n and .\n\n FINDINGS: This was a limited Doppler evaluation of the TIPS stent. Again\n demonstrated in the right hepatic lobe is a TIPS stent catheter, which appears\n unchanged in position. Color Doppler evaluation shows wall-to-wall color\n Doppler signal within the TIPS stent. Flow velocities within the TIPS stent\n in the proximal, mid, and distal portions are 127, 173, and 175 cm/sec\n respectively. Overall, these are in similar range to the prior studies of\n and . There is appropriate hepatopetal blood flow in the\n main portal vein. As before, no definite flow is identified within the left\n portal vein.\n\n IMPRESSION: Patent TIPS stent with flow velocities within similar range to\n recent evaluations.\n\n\n"},{"category":"Radiology","chartdate":"2110-02-22 00:00:00.000","description":"CHEST (PORTABLE AP)","row_id":995000,"text":" 11:00 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluate placement of ETT, OGT.\n Admitting Diagnosis: DELTA MS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with cirrhosis, hepatic encephalopathy, intubated for airway\n protection.\n REASON FOR THIS EXAMINATION:\n Evaluate placement of ETT, OGT.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Cirrhosis, encephalopathy. Patient intubated.\n\n CHEST:\n\n The endotracheal tube lies 6.4 cm from the carinal angle and has been\n withdrawn since the prior chest x-ray of seven hours earlier. The nasogastric\n tube remains in a satisfactory position. The lung fields are clear.\n\n IMPRESSION: Endotracheal tube is 6.4 cm from carinal angle.\n\n\n"},{"category":"Radiology","chartdate":"2110-02-26 00:00:00.000","description":"SMALL BOWEL ONLY (BARIUM)","row_id":995398,"text":" 9:14 AM\n SMALL BOWEL ONLY (BARIUM) Clip # \n Reason: small bowel with follow-through\n Admitting Diagnosis: DELTA MS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with hepatic sarcoid\n REASON FOR THIS EXAMINATION:\n small bowel with follow-through\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 54-year-old female with hepatic sarcoid.\n\n SMALL BOWEL FOLLOW-THROUGH: Contrast passes freely through the small bowel\n entering the colon within 50 minutes. There is fecalization of the small\n bowel consistent with resolving obstruction. Note is made of thickening of\n jejunal and ileal folds which is likely related to resolving obstruction and\n chronic liver disease. Scout image demonstrates TIPS stent and\n cholecystectomy clips within the right upper quadrant.\n\n IMPRESSION:\n 1. No evidence of mechanical obstruction. Fecalization of the small bowel\n consistent with slowly resolving small bowel obstruction.\n\n 2. Small bowel fold thickening likely related to resolving obstruction and\n chronic liver disease.\n\n"},{"category":"ECG","chartdate":"2110-02-22 00:00:00.000","description":"Report","row_id":148378,"text":"Sinus rhythm. Diffuse non-specific ST-T wave changes. Compared to the\nprevious tracing of there is no significant diagnostic change.\n\n"}],"string":"[\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2110-02-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 994959,\n \"text\": \" 3:12 PM\\n CHEST (PORTABLE AP) Clip # \\n Reason: assess tube placement pt in \\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old woman with delta MS \\n REASON FOR THIS EXAMINATION:\\n assess tube placement pt in \\n ______________________________________________________________________________\\n WET READ: DSsd SAT 4:07 PM\\n ETT at or near origin of right mainstem bronchus. Recommend withdrawing tube\\n at least 2-3 cm.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 54-year-old female with altered mental status, now . Please\\n assess tube placement.\\n\\n COMPARISON: .\\n\\n FINDINGS: Portable supine chest radiograph is reviewed. Endotracheal tube is\\n in place, positioned approximately 1 cm above the carina, and angled towards\\n the right main stem bronchus. Enteric feeding tube extends below the diaphragm\\n and into the stomach. Heart and mediastinal contours are unremarkable. The\\n lungs are clear and well expanded. There is no pleural effusion or\\n pneumothorax.\\n\\n IMPRESSION: Endotracheal only 1 cm above the carina, and angled towards the\\n right mainstem bronchus. Tube withdrawal of approximately 2 to 3 cm is\\n recommended for appropriate positioning.\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2110-02-22 00:00:00.000\",\n \"description\": \"CT HEAD W/O CONTRAST\",\n \"row_id\": 994960,\n \"text\": \" 3:22 PM\\n CT HEAD W/O CONTRAST Clip # \\n Reason: Eval for ICH\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old woman with hepatic sarcoid w/ cirrhosis who p/w MS changes,\\n responsive only to pain.\\n REASON FOR THIS EXAMINATION:\\n Eval for ICH\\n CONTRAINDICATIONS for IV CONTRAST:\\n RF\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 54-year-old female with hepatic sarcoid and cirrhosis, presenting\\n with mental status changes, and responsive only to pain.\\n\\n COMPARISON: Head CTA from .\\n\\n TECHNIQUE: Non-contrast head CT.\\n\\n FINDINGS: There is no intracranial hemorrhage. There is no mass, mass\\n effect, or evidence of acute vascular territorial infarction. Again seen is\\n a vascular coil in the region of the right MCA bifurcation aneurysm (there is\\n no evidence of craniotomy), and surrounding encephalomalacia and ex vacuo\\n dilatation of the frontal of the right lateral ventricle, unchanged from\\n prior exam. The ventricles and basal cisterns are otherwise normal and\\n unchanged since prior exam. Streak artifact from the aneurysm clips does\\n slightly limit evaluation of the right infratemporal region.\\n\\n There is no fracture. Visualized paranasal sinuses are normally aerated.\\n Nasogastric tube is in place.\\n\\n IMPRESSION: No acute intracranial process. No change from study.\\n\\n\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2110-02-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562265,\n \"text\": \"Nsg.progress notes:\\nSee flow sheet for specific:\\n\\nNeuro: Alert and oriented x3,pleasant and co op with care,c/o head achae,oxicodone prn started with good effect,MAE.\\n\\nCV: NSR,HR in 70-80,no ectopy noted,SBP 110-130,IVF KVO denies CP or discomfort.40mmol kcl replaced this am,pending evening labs.\\n\\nResp: Remains on RA with O 2sat 99-100%,LS clear.\\n\\nGI:Abd soft,+ BS,liq stool to FIB,flexiseal removed as not draining to the bag,on lactulose q4h.regular diet started and tolerated.\\n\\nGU: Foely cath patent with yellow clear urine adq amt.\\n\\nEndo: Bld sug wnl.\\n\\nAct: Turning alone in bed,skin intact,except redness around rectum from frequent stooling.\\n\\nSocial: Husband called x2,updated with him,MICU team also talked to him.\\n\\nPlan: cont monitoring,neuro checks,transfer to floor when bed available.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2110-02-25 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562266,\n \"text\": \"SICU NPN\\nS-\\\"I feel much better, thank you.\\\"\\n\\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\\n\\nO-VSS. Uneventful shift.Tolerating advanced diet. Sleeping most of night. Awaiting floor bed.\\n\\nA/P:\\nTransfer to floor when bed available.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2110-02-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562260,\n \"text\": \"NURSING NOTE\\nASSESSMENT:\\n PATIENT ARRIVED FROM APPROX 10 PM, UNRESPONSIVE & MINIMALLY WITHDRAWING TO PAIN (PATIENT CURRENTLY DOES NOT WITHDRAW ANY EXTREMITIES). PATIENT RARELY OPENING EYES WITH REPOSITIONING & STIMULI.\\n INTUBATED AND ON ASSIST CONTROL, BREATHING OVER SET RESP RATE MINIMALLY. OXYGENATING WELL & FI02 WEANED DOWN, SEE FLOWSHEET FOR ABG. MICU TEAM ATTEMPTED TO PLACE ARTERIAL LINE, UNABLE. LUNG SOUNDS CLEARED, SUCTIONED ONCE FOR THICK BROWN/YELLOW SPUTUM.\\n HEART RATE 90'S NORMAL SINUS. SBP RANGING 100-130'S. LOW GRADE FEVER. PATIENT MAKING 30-50 CC URINE HOURLY, IV FLUIDS STARTED. CVP ~ 10.\\n ABDOMEN SOFTLY DISTENDED. GIVEN LACTULOSE PR AND PNGT FOR ELEVATED AMMONIA LEVEL IN ED. FLEXI-SEAL CURRENTLY IN PLACE. BLOOD GLUCOSE WITHIN NORMAL RANGE.\\n NO FAMILY CONTACT OVERNIGHT.\\nPLAN:\\n CONTINUE WITH LACTULOSE, TITRATE TO BOWEL MOVEMENTS. WILL NEED SOCIAL WORK CONSULT. AWAITING AM LAB RESULTS & REPEAT AMMONIA LEVEL.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2110-02-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562261,\n \"text\": \"Resp. care note - Pt. remaines intubated and vented, weaned to PSV tol ok at this time.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2110-02-23 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562262,\n \"text\": \"Condition Update\\nAssessment:\\nPlease see carevue for details\\n\\n Neuro: Pt encephalopathic, lactulose cont Q4hrs with much noted improvement in neuro exam over the course of the day. Pt now open eys to voice, tracking, nods appropriately to questions, MAE, follows all commands, assists with turning and repositioning.\\n\\n Resp: pt placed on CPAP, PEEP 5, PS 10, FiO2 40%, following O2 sats per MICU, pt without aline. O2 sat 96-99%. Pt denies SOB. LS clear bilat. Suctioned prn for small amounts of thick brow sputum.\\n\\n CV: Remains NSR, no ectopy noted. SBP 120-140. No edema noted. Denies CP. IVF kvo, revieved 1.5L NS as ordered. K+ repleted in am, PM lytes pnd.\\n\\n GI: Abd soft, pos bs. NGT clamped. Flexiseal remains intact, draining lg aounts of golden loose stool secondary to frequent lactulose.\\n\\n GU: Adequate amounts of clear yellow urine via foley cath.\\n\\nPlan: Continue with lactulose, monitor labs, monitor hemodynamics, monitor neuro exam, wean vent as tol, pulm toileting, provide pt and family with emotional support.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2110-02-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562263,\n \"text\": \"NURSING PROGRESS NOTE\\n\\nPLEASE SEE CAREVUE FOR DETAILS\\n\\nRESP: EXTUBATED WELL W/NO EVENTS, DR AT BS. CURRENTLY ON 40% FIO2 COOL NEB FACE MASK. SAT'S 100%. LCTAB. PRODUCTIVE COUGH FOR THIN WHITE SECRETIONS.\\n\\nNEURO: A&OX3. MAE. FOLLOWING COMMANDS. ASSITING IN CARE, COOPERATIVE. PEERLA. DENIES PAIN. CONT RECEIVING LACTULOSE EVERY 4 HOURS W/MUCH EFFECT.\\n\\nCV: AFEBRILE. NSR HR 90S. NO ECTOPY. SBP 115-140. AM LABS PENDING.\\n\\nGI: ABDOMEN SOFT. NON DISTENDED. FLEXISEAL REMAINS INTACT W/LG AMOUNTS LIQUID GOLDEN BROWN, CONT W/FAIR AMOUNT OF DRAINAGE AROUND FLEXISEAL AS WELL. NGT TO LCWS, SCANT BILIOUS OUTPUT. NPO.\\n\\nGU: FOLEY PATENT, >30CC CYU HOURLY.\\n\\nSKIN: INTACT, NO BREAKDOWN NOTED. SLIGHTLY RED ON COCCYX.\\n\\nPOC: MONITOR RESP, NEURO. MONITOR OUTPUT. MAINTAIN SKIN INTEGRITY. ? TRANSFER TO FLOOR. CALL MICU HO W/ANY CHANGES.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2110-02-24 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1562264,\n \"text\": \"Resp Care: Pt recieved on mechanical ventilation. Pt extubated to 40% cool aerosol. Pt tolerating well.\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2110-02-22 00:00:00.000\",\n \"description\": \"DUPLEX DOP ABD/PEL LIMITED\",\n \"row_id\": 994999,\n \"text\": \" 10:54 PM\\n DUPLEX DOP ABD/PEL LIMITED Clip # \\n Reason: NOTE: TO BE PERFORMED WITH DOPPLER! Evaluate portal flow,\\n Admitting Diagnosis: DELTA MS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old woman with hepatic sarcoid, cirrhosis, varices, s/p TIPs,\\n idiopathic cardiomyopathy p/w altered mental status now for airway\\n protection.\\n REASON FOR THIS EXAMINATION:\\n NOTE: TO BE PERFORMED WITH DOPPLER! Evaluate portal flow, TIPS flow.\\n ______________________________________________________________________________\\n FINAL REPORT\\n HISTORY: 54-year-old female with history of hepatic sarcoidosis, cirrhosis,\\n varices and TIPS placement, now with change in mental status and concern for\\n TIPS occlusion or stenosis.\\n\\n COMPARISON: Duplex Doppler ultrasound evaluation of the liver and TIPS on\\n and .\\n\\n FINDINGS: This was a limited Doppler evaluation of the TIPS stent. Again\\n demonstrated in the right hepatic lobe is a TIPS stent catheter, which appears\\n unchanged in position. Color Doppler evaluation shows wall-to-wall color\\n Doppler signal within the TIPS stent. Flow velocities within the TIPS stent\\n in the proximal, mid, and distal portions are 127, 173, and 175 cm/sec\\n respectively. Overall, these are in similar range to the prior studies of\\n and . There is appropriate hepatopetal blood flow in the\\n main portal vein. As before, no definite flow is identified within the left\\n portal vein.\\n\\n IMPRESSION: Patent TIPS stent with flow velocities within similar range to\\n recent evaluations.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2110-02-22 00:00:00.000\",\n \"description\": \"CHEST (PORTABLE AP)\",\n \"row_id\": 995000,\n \"text\": \" 11:00 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: Evaluate placement of ETT, OGT.\\n Admitting Diagnosis: DELTA MS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old woman with cirrhosis, hepatic encephalopathy, intubated for airway\\n protection.\\n REASON FOR THIS EXAMINATION:\\n Evaluate placement of ETT, OGT.\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: Cirrhosis, encephalopathy. Patient intubated.\\n\\n CHEST:\\n\\n The endotracheal tube lies 6.4 cm from the carinal angle and has been\\n withdrawn since the prior chest x-ray of seven hours earlier. The nasogastric\\n tube remains in a satisfactory position. The lung fields are clear.\\n\\n IMPRESSION: Endotracheal tube is 6.4 cm from carinal angle.\\n\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2110-02-26 00:00:00.000\",\n \"description\": \"SMALL BOWEL ONLY (BARIUM)\",\n \"row_id\": 995398,\n \"text\": \" 9:14 AM\\n SMALL BOWEL ONLY (BARIUM) Clip # \\n Reason: small bowel with follow-through\\n Admitting Diagnosis: DELTA MS\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 54 year old woman with hepatic sarcoid\\n REASON FOR THIS EXAMINATION:\\n small bowel with follow-through\\n ______________________________________________________________________________\\n FINAL REPORT\\n CLINICAL HISTORY: 54-year-old female with hepatic sarcoid.\\n\\n SMALL BOWEL FOLLOW-THROUGH: Contrast passes freely through the small bowel\\n entering the colon within 50 minutes. There is fecalization of the small\\n bowel consistent with resolving obstruction. Note is made of thickening of\\n jejunal and ileal folds which is likely related to resolving obstruction and\\n chronic liver disease. Scout image demonstrates TIPS stent and\\n cholecystectomy clips within the right upper quadrant.\\n\\n IMPRESSION:\\n 1. No evidence of mechanical obstruction. Fecalization of the small bowel\\n consistent with slowly resolving small bowel obstruction.\\n\\n 2. Small bowel fold thickening likely related to resolving obstruction and\\n chronic liver disease.\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2110-02-22 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 148378,\n \"text\": \"Sinus rhythm. Diffuse non-specific ST-T wave changes. Compared to the\\nprevious tracing of there is no significant diagnostic change.\\n\\n\"\n }\n]"}}},{"rowIdx":999,"cells":{"subject_id":{"kind":"number","value":24149,"string":"24,149"},"hadm_id":{"kind":"number","value":132161,"string":"132,161"},"target_text":{"kind":"string","value":"Patient was admitted to the preoperative holding area on . He underwent an open abdominal aortic repair with a tube graft. He tolerated the procedure well. Was transferred to the SICU intubated in stable condition. Postoperatively, the patient was monitored by the anesthesia acute pain service secondary to his epidural. Patient was also evaluated by the electrophysiology service to check pacer. The pacer mode was set at a DDD at 60- 120. It was sensing and pacing AV. The P-R interval was adjusted to allow for sinus rhythm instead of V-pacing. Postoperative day 1 overnight events, the patient had 3 episodes of hypotension requiring 4 units of FFP, 4 units of pack red blood cells, and 5 liters of lactated Ringer. The epidural was held secondary to the hypotension. Postoperative hematocrit was 31.1 with a white count of 18.3, platelets 54 K. BUN 23, creatinine 1.0. Postoperative day 2, the epidural was instituted with morphine sulfate as analgesic . A HIT panel was sent secondary to persistent low platelet count, and he continued with aggressive fluid boluses. His troponin was 0.11. His pulse exam remained unchanged. He remained on ventilator support. Postoperative day 4, the patient was extubated. His Swan catheter was replaced with a triple lumen. His Lopressor was increased for rate control. His white count which peaked at 21.5 showed a decreasing count of 16.4, hematocrit remains stable at 30.7. BUN and creatinine were stable at 32 and 0.9. Patient was neurologically intact and oriented x3. He continued to remain NPO. Patient did have bowel sounds, but had not passed flatus. Patient's intrathecal catheter was discontinued. His HIT panel was negative. His platelet count continued to show improvement. Patient was transferred to the VICU for continued monitoring and care. On postoperative day 5, patient had bowel sounds, but no flatus. His diet was advanced. NG tube was removed. He was evaluated by physical therapy who felt that he would benefit from rehab when medically stable for discharge. The patient continued to progress. Postoperative day 7, the Foley was removed. The patient failed to void. A Foley was replaced. An informal consult with urology service determined that the patient should maintain the catheter until he is transferred to rehab, and then they can begin a q.6h. intermittent straight catheterization. Patient then should follow up with the urology clinic and call for an appointment. Patient's remaining hospital course was unremarkable. Patient continued to do well. He was transferred to rehab on in stable condition, tolerating POs."},"extractive_notes_summ":{"kind":"string","value":"focus: Dondition Update.please see flowsheet for specific values.Neuro: Pt lightly sedated on Propofol. Plan to extubate pt today.GI: Very faint bowel sounds noted. BS slightly course with minimal secretions noted. Received fluid boluses for low u/o yesterday. ABD soft and distended + hypo BS. cause epidural d/c'd and BP stable since. Follow up abg 7.40/33/100/22. Pt with cool/cyanotic extremities. ABGs acceptable. Incision with small amt old serosanguinous drainage at midpoint of incision. BS are clear, but diminished in the bases bilaterally. BP stable via Arterial line. Resp CarePt had CPAP/PSV trial on %. SICU team aware.Heme: Platelet low. Lung sounds clear, diminished at bases. Lungs Clear to diminished at the bases w/ faint crackle in L base. PT tolerating SBT well.Plan: continue with SBT and possible extubation. Plan is to rest overnite Pt placed back on IMV. Wean on CPAP as tolerated, will placed back on SMIV if needed. SICU NN: See carevue for specifics. 2U FFP given for INR 1.7. pt did desat to 91-93 while on SBT despite adequate ABG.GI/GU: Currently NPO. Resp CarePt admitted to SICU this AM s/p AAA repair. Cleaned with sterile H20 and sxd oral cavity. Respiratory Care NotePt received on PSV as noted. Foley intact and patent. Suctioning small amts of sputum and bs are generally clear with scatter rhonchi. Follows commands, MAE left side stronger than right.CV: afebrile, HR 60-100's SR/ Paced. Remains intubated on full support with increasing fio2 and peep requirement t/o course of the shift. Blood pressure well controlled this am. skin pink, warm, and dry.Plan: Keep CVP 10-14--give fluid as needed when drops or u/o less that 20 cc hr. CVP=. Cont wean vent. IMPRESSION: Lines and tubes in satisfactory position. BP very labile at start of shift. abd inc intact with noted shadow staining.Soc: Supportive family. BP wnl. extubation this am \"B\" Nsg Progress Note:CVS: T=98.8-99.7, HR=66-90 NSR with some episodes of paced beats. Heart size and mediastinal contours are unchanged. Cont to monitor lytes and replete as needed. HIT sent.skin: No breakdown is noted. VR PVC noted. RESP CARE: pt remains intubated/on vent on PS 5/5/.50. Plan is for extubation 02 sat current 96-97 on .70% Fi02. RSBI-62. Abdomen with staples, clean, dry and intact. Baseline artifactAtrial sensed ventricular paced rhythmSince previous tracing of , atrial sensing SBP by Aline=90-153. Pt placed on SBT - tolerated well with good follow up ABG's. Afebrile. CI=2.3-2.75. Plan is to extubate in the am. creat=0.8-0.9.Neuro: Pt nods appropriately,follows commands,moves all extremities. NPNN: PAtient is awake and alert, following commands moves all extremeties weakly.nodding appropriately.CV: Patient low grade temp all day, hemodynamically stable pulses unchanged. Swann not wedged this shift, pressures adequate. Pt has positive cuff leak. Pt placed on CPAP this afternoon, and appears to be tolerating well. Feet cool,pale but capillary refill adequate. PT rechecked this am with SBT which pt did tolerate initially but did begin to drop sats. Pulses unchanged. with marginal oxygenation. Will cont to monitor oxygenation per ABG and titrate fio2 accordingly. Sinus rhythmProbable left atrial abnormalityIntraventricular conduction delay - may be atypical right bundle branch blockConsider inferoposterolateral myocardial infarct, age indeterminateLeft ventricular hypertrophyDiffuse ST-T wave abnormalities - Cannot exclude in part ischemiaClinical correlation is suggestedSince previous tracing of , paced rhythm now absent RESP CARE: pt rested overnight on SIMV SEE CAREVUE. Lopressor restarted, however, pressure rising now that patient is weaning on CPAP. PP no dopplerable can doppler PT. Pt with low grade temp T-max 38.4 tylenol with effect current temp 37.6. RSBI-63. Pt requiring mult fluid bolus for hypotension and currently for inadequate u/o. with systolic around 140/. Patient follows commands. HCT stable.Resp: patient remains on PSV 50% 5 5 with adeqaute oxygenation occasionally tachypnic when in pain.GI: Very faint bowel sounds no BM or flatus this shift.GU: patient given lasix this am with adequate urine output.Skin: intact. Lungs dim bilat. Will continue to monitor as indicated. change swan to TLCL. Increase urine output to normal range. A pacemaking device overlying the right chest is in unchanged position with stable appearance of electrodes. continue to monitor lytes and replete as needed 8pm troponin=0.11, EKG done, no changes noted. Pt has permanent DDD pacer, rate set at 60. BS- diminished at bases. SBPby cuff=95-140. Thank you Thank you Thank you Patient nods head and mouths words around et tube. Nursing Progress NotePlease see carvue for specifics:Neuro: Lightly sedated on prop and fent for pain. CO 3.7-5.4 with SVR 700's-1200's. ICU team and primary team aware.Resp: Current on SIMV 600X14 with Fi02 70%. Placed on .50 at 0500 with acceptable ABGS. Strong cough noted. No plans to extubate at this point, still receiving fluid for low urines, will check gas on cpap .CV: Pt in NSR with occassional paced beats (pacer set for demand of 60) regular. Pt extubated to cool aerosol w/o incident. 19/07 PT ALERT RELAXED TALKATIVE OCC SHORT PERIODS OF COFUSION EASILY RE DIRECTED SLEEPS LONG PERIODS IN GOOD SPIRITS RESP PLACED ON 6 L NP TOL WELL SAT 97 TO 100 PRODUCTIVE COUGH HEART S1S2 NSR WITH OCC PACED 100 PERSENT CAPTURED POOR PULSES NOTED PLEASE SEE CAREVIEW FOR DETAILS ABD FIRM HYPOACTIVE B/S NPO MAINTAINED WOUND HEALING PLAN PROGRESSIVE AMBULATION ROM P/T FAMILY SUPPORT Patient denies pain. Patient is alert, received morphine intrathecally (administered by anesthesia resident) and appears comfortable. Pt received lasix today and had good return. Abdomen soft. Pt not wedged d/t coags. Will check with Dr. re: more specific parameters and perhaps adding another antihypertensive . Bilateral PT pulses present with doppler, Left DP present with doppler, unable to locate rt DP. Dressing clean and dry. No redness noted.GU: U/O=23-37cc/h amber clear urine. Going by cvp for fluid management, goal to keep cvp 10-14, urines will drop when cvp around 10.GI: No bowel sounds, abd is soft and nontender."},"n_notes":{"kind":"number","value":20,"string":"20"},"notes":{"kind":"list like","value":[{"category":"Nursing/other","chartdate":"2176-11-26 00:00:00.000","description":"Report","row_id":1577100,"text":"Resp Care\n\nPt admitted to SICU this AM s/p AAA repair. Remains intubated on full support with increasing fio2 and peep requirement t/o course of the shift. BS slightly course with minimal secretions noted. Will cont to monitor oxygenation per ABG and titrate fio2 accordingly.\n"},{"category":"Nursing/other","chartdate":"2176-11-26 00:00:00.000","description":"Report","row_id":1577101,"text":"NPN Admitt NOOTE\nPatient is an 85 year old male who was admitted direct fromthe OR S/P AAA. Patient originally stable however patient became increasingly more hypotensive-- HCT dropping oxygenation MD's at bedside. Patient received large amounts of fluid and blood products. Patients daughter in law called early in shift and was updated. Please see care view for all other information. Thank you\n"},{"category":"Nursing/other","chartdate":"2176-11-27 00:00:00.000","description":"Report","row_id":1577102,"text":"Respiratory Care\nPt changed to SIMV 12 PEEP/PS +5/+5 Vt 600 and O2 has been weaned throughout the night.RSBI done this AM and pt placed on SBT. BLBS coarse @ times, sx small to moderate amt thick white secretions.ABGs looked throughout the night. PT tolerating SBT well.\n\nPlan: continue with SBT and possible extubation.\n"},{"category":"Nursing/other","chartdate":"2176-11-27 00:00:00.000","description":"Report","row_id":1577103,"text":"Respiratory Care\nSBT canceled due to rise in HR >20% above baseline.\n"},{"category":"Nursing/other","chartdate":"2176-11-30 00:00:00.000","description":"Report","row_id":1577115,"text":" 19/07\n PT ALERT RELAXED TALKATIVE OCC SHORT PERIODS OF COFUSION EASILY RE DIRECTED SLEEPS LONG PERIODS IN GOOD SPIRITS\n RESP PLACED ON 6 L NP TOL WELL SAT 97 TO 100 PRODUCTIVE COUGH\n HEART S1S2 NSR WITH OCC PACED 100 PERSENT CAPTURED POOR PULSES NOTED PLEASE SEE CAREVIEW FOR DETAILS\n ABD FIRM HYPOACTIVE B/S NPO MAINTAINED WOUND HEALING\n PLAN PROGRESSIVE AMBULATION ROM P/T FAMILY SUPPORT\n"},{"category":"Nursing/other","chartdate":"2176-11-30 00:00:00.000","description":"Report","row_id":1577116,"text":"SICU nursing progress note\nPlease refer to flowsheet for specific info. and to the nursing transfer note.\n"},{"category":"Nursing/other","chartdate":"2176-11-28 00:00:00.000","description":"Report","row_id":1577108,"text":"RESP CARE: pt rested overnight on SIMV SEE CAREVUE. Placed on .50 at 0500 with acceptable ABGS. RSBI-62. Lungs dim bilat. Sxd thick yellow sputum. ? extubation this am\n"},{"category":"Nursing/other","chartdate":"2176-11-28 00:00:00.000","description":"Report","row_id":1577109,"text":"RESPIRATORY CARE:\nPt remains on PSV 5 peep 5 50% with SPO2 99%. Pt received lasix today and had good return. BS- diminished at bases. Plan is to extubate in the am. Will continue to monitor as indicated.\n"},{"category":"Nursing/other","chartdate":"2176-11-28 00:00:00.000","description":"Report","row_id":1577110,"text":"NPN\nN: PAtient is awake and alert, following commands moves all extremeties weakly.nodding appropriately.\nCV: Patient low grade temp all day, hemodynamically stable pulses unchanged. HCT stable.\nResp: patient remains on PSV 50% 5 5 with adeqaute oxygenation occasionally tachypnic when in pain.\nGI: Very faint bowel sounds no BM or flatus this shift.\nGU: patient given lasix this am with adequate urine output.\nSkin: intact. Please see flowsheets for all other information. Thank you\n"},{"category":"Nursing/other","chartdate":"2176-11-29 00:00:00.000","description":"Report","row_id":1577111,"text":"SICU NN: See carevue for specifics. Patient is alert, received morphine intrathecally (administered by anesthesia resident) and appears comfortable. Patient denies pain. Patient moves all extremities, right arm weaker than left. Patient nods head and mouths words around et tube. Patient follows commands. ET to vent no issues, o2 sat 94-97% however po2 >100 by abg. Secretions tan and very thick. RSR on cardiac monitor with occasional paced beats. BP wnl. RIJ with cco swan maintained as per policy, no issues. Afebrile. NPO. No bm. Foley intact and patent. Skin intact. Abdomen with staples, clean, dry and intact. No drainage from incision. Patient resting comfortably. Spoke with daughter in law on phone.\n"},{"category":"Nursing/other","chartdate":"2176-11-29 00:00:00.000","description":"Report","row_id":1577112,"text":"RESP CARE: pt remains intubated/on vent on PS 5/5/.50. Rested a short time overnight on SIMV to prepare for extubation. Lungs coarse. Sxd for thick tan sputum. Foul smelling odor from oropharynx. Cleaned with sterile H20 and sxd oral cavity. ABGs acceptable. Strong cough noted. RSBI-63. Plan is for extubation\n"},{"category":"Nursing/other","chartdate":"2176-11-29 00:00:00.000","description":"Report","row_id":1577113,"text":"Respiratory Care Note\nPt received on PSV as noted. FiO2 weaned to 40%. BS are clear, but diminished in the bases bilaterally. Pt placed on SBT - tolerated well with good follow up ABG's. Pt has positive cuff leak. Pt has a strong cough. Pt extubated to cool aerosol w/o incident.\n"},{"category":"Nursing/other","chartdate":"2176-11-29 00:00:00.000","description":"Report","row_id":1577114,"text":"NPN\nN: Patient awake and alert, only oriented to self, not time or place. Follows commands, MAE left side stronger than right.\n\nCV: afebrile, HR 60-100's SR/ Paced. BP stable via Arterial line. Pulses unchanged. Patient with blueness at capillary bed-- Dr aware. PA catheter changed to TLC.\n\nResp: Patient extubated to shovel mask- currently at 70%. with marginal oxygenation. Patient given Chest PT three times since extubation. Using insentive spirometer when instructed.\n\nGI: abdomen NTND with no bowel sounds no bowel movements.\n\nGU: foley patent voiding adeqaute amounts of urine. Patient diuresing from two doses of lasix. Please see flowsheets for all other information. Thank you\n"},{"category":"Nursing/other","chartdate":"2176-11-27 00:00:00.000","description":"Report","row_id":1577104,"text":"Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Lightly sedated on prop and fent for pain. Arousable to voice. Pt does follow commands and nods appropriately. Pupils and brisk.\nCV: Pt with large crit drop to 19 on days received 2units of PRBCs over noc which stablized crit. 2U FFP given for INR 1.7. Pt with low grade temp T-max 38.4 tylenol with effect current temp 37.6. BP very labile at start of shift. Pt with episodes of severe hypotension which required levo and fluid. PT also would have episodes of rebound HTN which required some nipride and ^^prop and fent. ? cause epidural d/c'd and BP stable since. SBP 100-120's HR-NSR will AV pace at 60. Pacer interrogated last noc by cardioloy (see cards note for changes). PAD's 15-20. CO 3.7-5.4 with SVR 700's-1200's. Pt not wedged d/t coags. Pt requiring mult fluid bolus for hypotension and currently for inadequate u/o. Pt receive 3L on LR in addition to products. Current wt ^^ 7kgs. Pt with cool/cyanotic extremities. PP no dopplerable can doppler PT. ICU team and primary team aware.\nResp: Current on SIMV 600X14 with Fi02 70%. Pt attemted to wean to cpap early in shift did not tolerated. PT rechecked this am with SBT which pt did tolerate initially but did begin to drop sats. Pt placed back on IMV. Lungs Clear to diminished at the bases w/ faint crackle in L base. 02 sat current 96-97 on .70% Fi02. pt did desat to 91-93 while on SBT despite adequate ABG.\nGI/GU: Currently NPO. NO NGT/OGT in place. ABD soft and distended + hypo BS. Foley patent drng amber colored urine.\nEndo: RISS\nInteg: No drains. abd inc intact with noted shadow staining.\nSoc: Supportive family. Dtr in law is RN in a hospital.\nPlan: Cont with current plan of care. ? change swan to TLCL. Cont wean vent. Cont to monitor lytes and replete as needed.\n"},{"category":"Nursing/other","chartdate":"2176-11-27 00:00:00.000","description":"Report","row_id":1577105,"text":"focus: Dondition Update.\nplease see flowsheet for specific values.\n\nNeuro: Pt lightly sedated on Propofol. He opens his eyes spontaneously, and follows commands consistently. He is receiving Fentanyl for pain, with boluses given for breakthrough pn when turning. Pain service in this am, eipdural cath idenfitied as being intrathecal by dr. and team, no pain med to be give via cath at this time, will assess pain management with ICU team later this p.m.\n\nResp: Lungs clear in the upper lobes, and crackles heard in the bases. Pt on AC this a.m. with Fi02 at 70%, weaned to 50% with sats at 100%. Pt placed on CPAP this afternoon, and appears to be tolerating well. No plans to extubate at this point, still receiving fluid for low urines, will check gas on cpap .\n\nCV: Pt in NSR with occassional paced beats (pacer set for demand of 60) regular. Blood pressure well controlled this am. with systolic around 140/. Lopressor restarted, however, pressure rising now that patient is weaning on CPAP. Will check with Dr. re: more specific parameters and perhaps adding another antihypertensive . Poor pulses in LE's, can hear post tib with the doppler, pedal pulses difficult to hear. Pt has permanent DDD pacer, rate set at 60. Swann not wedged this shift, pressures adequate. Going by cvp for fluid management, goal to keep cvp 10-14, urines will drop when cvp around 10.\n\nGI: No bowel sounds, abd is soft and nontender. Dressing clean and dry. No NGT at this time, will check with team re: placement becasue platlets remain low.\n\nGU: Urine output low, have been giving fluid boluses with little effect. SICU team aware.\n\n\nHeme: Platelet low. HIT sent.\n\nskin: No breakdown is noted. skin pink, warm, and dry.\n\nPlan: Keep CVP 10-14--give fluid as needed when drops or u/o less that 20 cc hr.\n Increase urine output to normal range.\n Wean on CPAP as tolerated, will placed back on SMIV if needed.\n continue to monitor lytes and replete as needed\n\n"},{"category":"Nursing/other","chartdate":"2176-11-27 00:00:00.000","description":"Report","row_id":1577106,"text":"Resp Care\n\nPt had CPAP/PSV trial on %. MV in the 10L range with rr in the mid 20's. Follow up abg 7.40/33/100/22. Suctioning small amts of sputum and bs are generally clear with scatter rhonchi. Plan is to rest overnite\n"},{"category":"Nursing/other","chartdate":"2176-11-28 00:00:00.000","description":"Report","row_id":1577107,"text":" \"B\" Nsg Progress Note:\n\nCVS: T=98.8-99.7, HR=66-90 NSR with some episodes of paced beats. VR PVC noted. SBPby cuff=95-140. SBP by Aline=90-153. PAD= most of night but up to 16 at 5am. CVP=. CI=2.3-2.75. IV Fentanyl drip at 25mcg. IV Propofol drip at 5-15mcg. IV LR at 125cc/h. Bilateral PT pulses present with doppler, Left DP present with doppler, unable to locate rt DP. Feet cool,pale but capillary refill adequate. 8pm troponin=0.11, EKG done, no changes noted. Repeat troponin done at 3am.\n\nResp: Rested on IMV overnight. 5am placed on CPAP+PSV 5/5, FIO2 50%. Sats=97-100%. Lung sounds clear, diminished at bases. Plan to extubate pt today.\n\nGI: Very faint bowel sounds noted. Abdomen soft. Incision with small amt old serosanguinous drainage at midpoint of incision. No redness noted.\n\nGU: U/O=23-37cc/h amber clear urine. Received fluid boluses for low u/o yesterday. creat=0.8-0.9.\n\nNeuro: Pt nods appropriately,follows commands,moves all extremities. Pupils=+.\n\nSkin: Edema noted, no open areas, face red.\n\nPain: No c/o pain.\n\nSocial: Family visited this eve and will be back today.\n\nPlan: Extubate today.\n"},{"category":"ECG","chartdate":"2176-11-27 00:00:00.000","description":"Report","row_id":177345,"text":"Sinus rhythm\nProbable left atrial abnormality\nIntraventricular conduction delay - may be atypical right bundle branch block\nConsider inferoposterolateral myocardial infarct, age indeterminate\nLeft ventricular hypertrophy\nDiffuse ST-T wave abnormalities - Cannot exclude in part ischemia\nClinical correlation is suggested\nSince previous tracing of , paced rhythm now absent\n\n"},{"category":"ECG","chartdate":"2176-11-26 00:00:00.000","description":"Report","row_id":177346,"text":"Baseline artifact\nAtrial sensed ventricular paced rhythm\nSince previous tracing of , atrial sensing\n\n"},{"category":"Radiology","chartdate":"2176-11-26 00:00:00.000","description":"BY DIFFERENT PHYSICIAN","row_id":893018,"text":" 4:40 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for PTX, effusion\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with CAD s/p AAA repair w/desats and hypotension\n\n REASON FOR THIS EXAMINATION:\n eval for PTX, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease, AAA repair, hypoxia, and hypotension.\n\n FINDINGS: Comparison made with radiograph from earlier the same day.\n\n An endotracheal tube ends below the thoracic inlet, approximately 5 cm from\n the carina. A right IJ Swan-Ganz catheter ends in the proximal right\n pulmonary artery. A pacemaking device overlying the right chest is in\n unchanged position with stable appearance of electrodes. Heart size and\n mediastinal contours are unchanged. No pulmonary parenchymal consolidation,\n failure, effusion, or pneumothorax is seen.\n\n IMPRESSION: Lines and tubes in satisfactory position. No evidence of\n pneumothorax or effusion.\n\n\n"}],"string":"[\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577100,\n \"text\": \"Resp Care\\n\\nPt admitted to SICU this AM s/p AAA repair. Remains intubated on full support with increasing fio2 and peep requirement t/o course of the shift. BS slightly course with minimal secretions noted. Will cont to monitor oxygenation per ABG and titrate fio2 accordingly.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577101,\n \"text\": \"NPN Admitt NOOTE\\nPatient is an 85 year old male who was admitted direct fromthe OR S/P AAA. Patient originally stable however patient became increasingly more hypotensive-- HCT dropping oxygenation MD's at bedside. Patient received large amounts of fluid and blood products. Patients daughter in law called early in shift and was updated. Please see care view for all other information. Thank you\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577102,\n \"text\": \"Respiratory Care\\nPt changed to SIMV 12 PEEP/PS +5/+5 Vt 600 and O2 has been weaned throughout the night.RSBI done this AM and pt placed on SBT. BLBS coarse @ times, sx small to moderate amt thick white secretions.ABGs looked throughout the night. PT tolerating SBT well.\\n\\nPlan: continue with SBT and possible extubation.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577103,\n \"text\": \"Respiratory Care\\nSBT canceled due to rise in HR >20% above baseline.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577115,\n \"text\": \" 19/07\\n PT ALERT RELAXED TALKATIVE OCC SHORT PERIODS OF COFUSION EASILY RE DIRECTED SLEEPS LONG PERIODS IN GOOD SPIRITS\\n RESP PLACED ON 6 L NP TOL WELL SAT 97 TO 100 PRODUCTIVE COUGH\\n HEART S1S2 NSR WITH OCC PACED 100 PERSENT CAPTURED POOR PULSES NOTED PLEASE SEE CAREVIEW FOR DETAILS\\n ABD FIRM HYPOACTIVE B/S NPO MAINTAINED WOUND HEALING\\n PLAN PROGRESSIVE AMBULATION ROM P/T FAMILY SUPPORT\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-30 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577116,\n \"text\": \"SICU nursing progress note\\nPlease refer to flowsheet for specific info. and to the nursing transfer note.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577108,\n \"text\": \"RESP CARE: pt rested overnight on SIMV SEE CAREVUE. Placed on .50 at 0500 with acceptable ABGS. RSBI-62. Lungs dim bilat. Sxd thick yellow sputum. ? extubation this am\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577109,\n \"text\": \"RESPIRATORY CARE:\\nPt remains on PSV 5 peep 5 50% with SPO2 99%. Pt received lasix today and had good return. BS- diminished at bases. Plan is to extubate in the am. Will continue to monitor as indicated.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577110,\n \"text\": \"NPN\\nN: PAtient is awake and alert, following commands moves all extremeties weakly.nodding appropriately.\\nCV: Patient low grade temp all day, hemodynamically stable pulses unchanged. HCT stable.\\nResp: patient remains on PSV 50% 5 5 with adeqaute oxygenation occasionally tachypnic when in pain.\\nGI: Very faint bowel sounds no BM or flatus this shift.\\nGU: patient given lasix this am with adequate urine output.\\nSkin: intact. Please see flowsheets for all other information. Thank you\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577111,\n \"text\": \"SICU NN: See carevue for specifics. Patient is alert, received morphine intrathecally (administered by anesthesia resident) and appears comfortable. Patient denies pain. Patient moves all extremities, right arm weaker than left. Patient nods head and mouths words around et tube. Patient follows commands. ET to vent no issues, o2 sat 94-97% however po2 >100 by abg. Secretions tan and very thick. RSR on cardiac monitor with occasional paced beats. BP wnl. RIJ with cco swan maintained as per policy, no issues. Afebrile. NPO. No bm. Foley intact and patent. Skin intact. Abdomen with staples, clean, dry and intact. No drainage from incision. Patient resting comfortably. Spoke with daughter in law on phone.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577112,\n \"text\": \"RESP CARE: pt remains intubated/on vent on PS 5/5/.50. Rested a short time overnight on SIMV to prepare for extubation. Lungs coarse. Sxd for thick tan sputum. Foul smelling odor from oropharynx. Cleaned with sterile H20 and sxd oral cavity. ABGs acceptable. Strong cough noted. RSBI-63. Plan is for extubation\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577113,\n \"text\": \"Respiratory Care Note\\nPt received on PSV as noted. FiO2 weaned to 40%. BS are clear, but diminished in the bases bilaterally. Pt placed on SBT - tolerated well with good follow up ABG's. Pt has positive cuff leak. Pt has a strong cough. Pt extubated to cool aerosol w/o incident.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-29 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577114,\n \"text\": \"NPN\\nN: Patient awake and alert, only oriented to self, not time or place. Follows commands, MAE left side stronger than right.\\n\\nCV: afebrile, HR 60-100's SR/ Paced. BP stable via Arterial line. Pulses unchanged. Patient with blueness at capillary bed-- Dr aware. PA catheter changed to TLC.\\n\\nResp: Patient extubated to shovel mask- currently at 70%. with marginal oxygenation. Patient given Chest PT three times since extubation. Using insentive spirometer when instructed.\\n\\nGI: abdomen NTND with no bowel sounds no bowel movements.\\n\\nGU: foley patent voiding adeqaute amounts of urine. Patient diuresing from two doses of lasix. Please see flowsheets for all other information. Thank you\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577104,\n \"text\": \"Nursing Progress Note\\nPlease see carvue for specifics:\\nNeuro: Lightly sedated on prop and fent for pain. Arousable to voice. Pt does follow commands and nods appropriately. Pupils and brisk.\\nCV: Pt with large crit drop to 19 on days received 2units of PRBCs over noc which stablized crit. 2U FFP given for INR 1.7. Pt with low grade temp T-max 38.4 tylenol with effect current temp 37.6. BP very labile at start of shift. Pt with episodes of severe hypotension which required levo and fluid. PT also would have episodes of rebound HTN which required some nipride and ^^prop and fent. ? cause epidural d/c'd and BP stable since. SBP 100-120's HR-NSR will AV pace at 60. Pacer interrogated last noc by cardioloy (see cards note for changes). PAD's 15-20. CO 3.7-5.4 with SVR 700's-1200's. Pt not wedged d/t coags. Pt requiring mult fluid bolus for hypotension and currently for inadequate u/o. Pt receive 3L on LR in addition to products. Current wt ^^ 7kgs. Pt with cool/cyanotic extremities. PP no dopplerable can doppler PT. ICU team and primary team aware.\\nResp: Current on SIMV 600X14 with Fi02 70%. Pt attemted to wean to cpap early in shift did not tolerated. PT rechecked this am with SBT which pt did tolerate initially but did begin to drop sats. Pt placed back on IMV. Lungs Clear to diminished at the bases w/ faint crackle in L base. 02 sat current 96-97 on .70% Fi02. pt did desat to 91-93 while on SBT despite adequate ABG.\\nGI/GU: Currently NPO. NO NGT/OGT in place. ABD soft and distended + hypo BS. Foley patent drng amber colored urine.\\nEndo: RISS\\nInteg: No drains. abd inc intact with noted shadow staining.\\nSoc: Supportive family. Dtr in law is RN in a hospital.\\nPlan: Cont with current plan of care. ? change swan to TLCL. Cont wean vent. Cont to monitor lytes and replete as needed.\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577105,\n \"text\": \"focus: Dondition Update.\\nplease see flowsheet for specific values.\\n\\nNeuro: Pt lightly sedated on Propofol. He opens his eyes spontaneously, and follows commands consistently. He is receiving Fentanyl for pain, with boluses given for breakthrough pn when turning. Pain service in this am, eipdural cath idenfitied as being intrathecal by dr. and team, no pain med to be give via cath at this time, will assess pain management with ICU team later this p.m.\\n\\nResp: Lungs clear in the upper lobes, and crackles heard in the bases. Pt on AC this a.m. with Fi02 at 70%, weaned to 50% with sats at 100%. Pt placed on CPAP this afternoon, and appears to be tolerating well. No plans to extubate at this point, still receiving fluid for low urines, will check gas on cpap .\\n\\nCV: Pt in NSR with occassional paced beats (pacer set for demand of 60) regular. Blood pressure well controlled this am. with systolic around 140/. Lopressor restarted, however, pressure rising now that patient is weaning on CPAP. Will check with Dr. re: more specific parameters and perhaps adding another antihypertensive . Poor pulses in LE's, can hear post tib with the doppler, pedal pulses difficult to hear. Pt has permanent DDD pacer, rate set at 60. Swann not wedged this shift, pressures adequate. Going by cvp for fluid management, goal to keep cvp 10-14, urines will drop when cvp around 10.\\n\\nGI: No bowel sounds, abd is soft and nontender. Dressing clean and dry. No NGT at this time, will check with team re: placement becasue platlets remain low.\\n\\nGU: Urine output low, have been giving fluid boluses with little effect. SICU team aware.\\n\\n\\nHeme: Platelet low. HIT sent.\\n\\nskin: No breakdown is noted. skin pink, warm, and dry.\\n\\nPlan: Keep CVP 10-14--give fluid as needed when drops or u/o less that 20 cc hr.\\n Increase urine output to normal range.\\n Wean on CPAP as tolerated, will placed back on SMIV if needed.\\n continue to monitor lytes and replete as needed\\n\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577106,\n \"text\": \"Resp Care\\n\\nPt had CPAP/PSV trial on %. MV in the 10L range with rr in the mid 20's. Follow up abg 7.40/33/100/22. Suctioning small amts of sputum and bs are generally clear with scatter rhonchi. Plan is to rest overnite\\n\"\n },\n {\n \"category\": \"Nursing/other\",\n \"chartdate\": \"2176-11-28 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 1577107,\n \"text\": \" \\\"B\\\" Nsg Progress Note:\\n\\nCVS: T=98.8-99.7, HR=66-90 NSR with some episodes of paced beats. VR PVC noted. SBPby cuff=95-140. SBP by Aline=90-153. PAD= most of night but up to 16 at 5am. CVP=. CI=2.3-2.75. IV Fentanyl drip at 25mcg. IV Propofol drip at 5-15mcg. IV LR at 125cc/h. Bilateral PT pulses present with doppler, Left DP present with doppler, unable to locate rt DP. Feet cool,pale but capillary refill adequate. 8pm troponin=0.11, EKG done, no changes noted. Repeat troponin done at 3am.\\n\\nResp: Rested on IMV overnight. 5am placed on CPAP+PSV 5/5, FIO2 50%. Sats=97-100%. Lung sounds clear, diminished at bases. Plan to extubate pt today.\\n\\nGI: Very faint bowel sounds noted. Abdomen soft. Incision with small amt old serosanguinous drainage at midpoint of incision. No redness noted.\\n\\nGU: U/O=23-37cc/h amber clear urine. Received fluid boluses for low u/o yesterday. creat=0.8-0.9.\\n\\nNeuro: Pt nods appropriately,follows commands,moves all extremities. Pupils=+.\\n\\nSkin: Edema noted, no open areas, face red.\\n\\nPain: No c/o pain.\\n\\nSocial: Family visited this eve and will be back today.\\n\\nPlan: Extubate today.\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-11-27 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 177345,\n \"text\": \"Sinus rhythm\\nProbable left atrial abnormality\\nIntraventricular conduction delay - may be atypical right bundle branch block\\nConsider inferoposterolateral myocardial infarct, age indeterminate\\nLeft ventricular hypertrophy\\nDiffuse ST-T wave abnormalities - Cannot exclude in part ischemia\\nClinical correlation is suggested\\nSince previous tracing of , paced rhythm now absent\\n\\n\"\n },\n {\n \"category\": \"ECG\",\n \"chartdate\": \"2176-11-26 00:00:00.000\",\n \"description\": \"Report\",\n \"row_id\": 177346,\n \"text\": \"Baseline artifact\\nAtrial sensed ventricular paced rhythm\\nSince previous tracing of , atrial sensing\\n\\n\"\n },\n {\n \"category\": \"Radiology\",\n \"chartdate\": \"2176-11-26 00:00:00.000\",\n \"description\": \"BY DIFFERENT PHYSICIAN\",\n \"row_id\": 893018,\n \"text\": \" 4:40 PM\\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \\n Reason: eval for PTX, effusion\\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\\n ______________________________________________________________________________\\n MEDICAL CONDITION:\\n 85 year old man with CAD s/p AAA repair w/desats and hypotension\\n\\n REASON FOR THIS EXAMINATION:\\n eval for PTX, effusion\\n ______________________________________________________________________________\\n FINAL REPORT\\n INDICATION: Coronary artery disease, AAA repair, hypoxia, and hypotension.\\n\\n FINDINGS: Comparison made with radiograph from earlier the same day.\\n\\n An endotracheal tube ends below the thoracic inlet, approximately 5 cm from\\n the carina. A right IJ Swan-Ganz catheter ends in the proximal right\\n pulmonary artery. A pacemaking device overlying the right chest is in\\n unchanged position with stable appearance of electrodes. Heart size and\\n mediastinal contours are unchanged. No pulmonary parenchymal consolidation,\\n failure, effusion, or pneumothorax is seen.\\n\\n IMPRESSION: Lines and tubes in satisfactory position. No evidence of\\n pneumothorax or effusion.\\n\\n\\n\"\n }\n]"}}}],"truncated":false,"partial":false},"paginationData":{"pageIndex":9,"numItemsPerPage":100,"numTotalItems":24993,"offset":900,"length":100}},"jwt":"eyJhbGciOiJFZERTQSJ9.eyJyZWFkIjp0cnVlLCJwZXJtaXNzaW9ucyI6eyJyZXBvLmNvbnRlbnQucmVhZCI6dHJ1ZX0sImlhdCI6MTczMDMyNDMzNiwic3ViIjoiL2RhdGFzZXRzL2RtYWNyZXMvbWltaWNpaWktaG9zcGl0YWxjb3Vyc2UtbWV0YSIsImV4cCI6MTczMDMyNzkzNiwiaXNzIjoiaHR0cHM6Ly9odWdnaW5nZmFjZS5jbyJ9.rDZCOfzP7YaLXeWooO-wiAGzOufWIUScgJkOXsxh8jd9w9WI-nFEzyE7SLOAjN7KF7j4prisEDHJsYxF71oGAQ","displayUrls":true},"discussionsStats":{"closed":0,"open":1,"total":1},"fullWidth":true,"hasGatedAccess":true,"hasFullAccess":true,"isEmbedded":false}">
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94,785 | 121,800 | He was admitted for same day surgery and underwent aortic valve replacement and coronary artery bypass graft surgery. He received cefazolin for perioperative antibiotics. On he went to the Operating Room where aortic valve replacement was preformed. He remained stable and transferred to the ICU where he awoke, was hemodynamically stable on extubated. Postoperatively he was very confused and disoriented. He moaned, called out and was somewhat uncooperative. Haldol and Ativan were given and over the course of several days he improved and cleared neurologically returned to baseline. He was restarted on propafranone, but atrial fibrillation developed and persisited. CTs and pacing wires were removed per protocol. He was begun on Coumadin and after two days of 3mg the INR rose to 2.4. Coumadin was held for a day and the INR fell to 2.2 and 1mg of Coumadin was given on . The INR was 1.8 on and he should receive 1 mg again with a target INR of 1.8-2. The ventricular response rate in atrial fibrillation was 110 for several days despite 50 mg of Lopressor three times daily. BP was low at 95, although he felt well. He received a 1mg total load of Digoxin and Lopressor was decreased to . 0.125mg of Digoxin daily was then begun and the ventricular rate decreased to 60-80 for the most part and the BP was ~100 systolic. On he felt well, his exam was unremarkable and he transferred to Nursing and Rehab for further recovery. | Sinus bradycardia with A-V conduction delay and ventricular premature beats.Left atrial abnormality. The descendingthoracic aorta is mildly dilated. Consider left ventricularhypertrophy. Left ventricular function. Since theprevious tracing of sinus bradycardia, ventricular ectopy and furtherleft axis deviation are all now present. LV systolic function appears depressed.Right ventricular chamber size and free wall motion are normal. Mitral valve disease. Moderate thickening of mitral valve chordae.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. A left-to-right shunt across theinteratrial septum is seen at rest. Right ventricular function. Howec\ couldnot exclude with certainty due to limited access to RA/RV junctionConclusions:PRE-BYPASS: The left atrium is moderately dilated. There are complex (mobile) atheroma in thedescending aorta. Intraventricular conduction delay. Non-specific septal and lateral repolarizationchanges. Probable leftventricular hypertrophy. Mild to moderate(+) aortic regurgitation is seen. Mildly dilated descending aorta.Complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed.There is critical aortic valve stenosis (valve area <0.8cm2). Complex (mobile)atheroma in the descending aorta.AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Moderate mitralannular calcification. Atrial fibrillation with ventricular response approximately 120-130. A patent foramen ovale is present. Demonstrated systolic and diastolic flow, and typical S and Dwaves and atrial wave reversal wave seen on PWD. The mitral valve leaflets are moderatelythickened. There are complex (>4mm) atheroma in thedescending thoracic aorta. The rhythm remainsatrial fibrillation with ventricular response of approximately 120.TRACING #2 Congenital heart disease. Depressed LVEF.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -hypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -hypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -hypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending aorta diameter. Coronary artery disease. PATIENT/TEST INFORMATION:Indication: Aortic valve disease. Mild to moderate (+) AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. A SVO2 sample demonstrated aslight step-up of aspirated blood from the RA, but of questionablesignificance in the presence of PFO.Surgical team informedLEFT ATRIUM: Moderate LA enlargement. There is moderate thickening of the mitral valve chordae. Left-to-right shunt across the interatrialseptum at rest.LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2Dimages. Prosthetic valve function. Leftanterior hemiblock. Critical AS(area <0.8cm2). Valvular heart disease.Status: InpatientDate/Time: at 12:10Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:A possible anomalous pulmonary vein visualized in the ME windows, entering theRA-IVC junction. Lateral lead ST-T wave changes are non-specific. Left axis deviation may be due to left anteriorfascicular block although is non-diagnostic. No PS.Physiologic PR.GENERAL COMMENTS: A TEE was performed in the location listed above. Compared to the previous tracing of sinus bradycardia withleft atrial abnormality and first degree A-V block has given way to atrialfibrillation with rapid ventricular rate and the ventricular rate has doubled.Also, ventricular ectopy is no longer evident.TRACING #1 Compared to the previous tracing no significant change. Suboptimal image quality - poor echo windows.Surgical team unable to visualize the APV after sternotomy. A catheter or pacing wire isseen in the RA. All four pulmonary veins identified and enterthe left atrium.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. I certifyI was present in compliance with HCFA regulations. PFO is present. No TEE relatedcomplications. No spontaneous echo contrast or thrombusin the body of the LAA. | 4 | [
{
"category": "Echo",
"chartdate": "2197-06-27 00:00:00.000",
"description": "Report",
"row_id": 96994,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Congenital heart disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Prosthetic valve function. Right ventricular function. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 12:10\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nA possible anomalous pulmonary vein visualized in the ME windows, entering the\nRA-IVC junction. Demonstrated systolic and diastolic flow, and typical S and D\nwaves and atrial wave reversal wave seen on PWD. A SVO2 sample demonstrated a\nslight step-up of aspirated blood from the RA, but of questionable\nsignificance in the presence of PFO.\nSurgical team informed\nLEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus\nin the body of the LAA. All four pulmonary veins identified and enter\nthe left atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA. PFO is present. Left-to-right shunt across the interatrial\nseptum at rest.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid anteroseptal -\nhypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -\nhypo; mid inferior - hypo; basal inferolateral - hypo; mid inferolateral -\nhypo; basal anterolateral - hypo; mid anterolateral - hypo; anterior apex -\nhypo; septal apex - hypo; inferior apex - hypo; lateral apex - hypo; apex -\nhypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Mildly dilated descending aorta.\nComplex (>4mm) atheroma in the descending thoracic aorta. Complex (mobile)\natheroma in the descending aorta.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS\n(area <0.8cm2). Mild to moderate (+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Moderate thickening of mitral valve chordae.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. Suboptimal image quality - poor echo windows.\nSurgical team unable to visualize the APV after sternotomy. Howec\\ could\nnot exclude with certainty due to limited access to RA/RV junction\n\nConclusions:\nPRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo\ncontrast or thrombus is seen in the body of the left atrium or left atrial\nappendage. A patent foramen ovale is present. A left-to-right shunt across the\ninteratrial septum is seen at rest. LV systolic function appears depressed.\nRight ventricular chamber size and free wall motion are normal. The descending\nthoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the\ndescending thoracic aorta. There are complex (mobile) atheroma in the\ndescending aorta. The aortic valve leaflets are severely thickened/deformed.\nThere is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate\n(+) aortic regurgitation is seen. The mitral valve leaflets are moderately\nthickened. There is moderate thickening of the mitral valve chordae.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2197-07-02 00:00:00.000",
"description": "Report",
"row_id": 288032,
"text": "Atrial fibrillation with ventricular response approximately 120-130. Left\nanterior hemiblock. Intraventricular conduction delay. Probable left\nventricular hypertrophy. Non-specific septal and lateral repolarization\nchanges. Compared to the previous tracing of sinus bradycardia with\nleft atrial abnormality and first degree A-V block has given way to atrial\nfibrillation with rapid ventricular rate and the ventricular rate has doubled.\nAlso, ventricular ectopy is no longer evident.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2197-07-03 00:00:00.000",
"description": "Report",
"row_id": 288031,
"text": "Compared to the previous tracing no significant change. The rhythm remains\natrial fibrillation with ventricular response of approximately 120.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2197-06-27 00:00:00.000",
"description": "Report",
"row_id": 288033,
"text": "Sinus bradycardia with A-V conduction delay and ventricular premature beats.\nLeft atrial abnormality. Left axis deviation may be due to left anterior\nfascicular block although is non-diagnostic. Consider left ventricular\nhypertrophy. Lateral lead ST-T wave changes are non-specific. Since the\nprevious tracing of sinus bradycardia, ventricular ectopy and further\nleft axis deviation are all now present.\n\n"
}
] |
9,341 | 181,810 | 70 year old woman with a history of hypertension, stage III CKD, and COPD is admitted for nausea/vomiting and found to have NSTEMI with hypoxia and tachycardia requiring admission to the CCU. #NSTEMI - Initial troponin T was 0.90 and peak was 2.27. EKG showed STD in V3-V5 consistnt with anterior septal MI. Repeat EKG showed resolution of previously seen STD and new PR depressions in II, III and aVF, which can be seen in RV infarct. Nitro was therefore held. Her initial N/V may have been related to myocardial ischemia. She was started on heparin drip, ASA, loaded with plavix. Started on metoprolol which was titrated to 100 mg . Echo showed evidence of mild LV dysfunction (EF 40-45%) c/w CAD, moderate mitral regurgitation. Cardiac catheterization was deferred given respiratory distress likely secondary to heart failure and/or pneumonia, as well as the fact that she had persistent tachycardia equivalent to a stress test which she tolerated without recurrence of symptoms. consider outpatient cardiac catheterization. Simvastatin was changed to atorvastatin at 80 mg, aspirin and plavix were started to minimize coronary artery thrombus. Pt should have nitroglycerin at home to take for chest pain. #Hypoxia - On arrival to CCU, CXR showed evidence of worsening pulmonary edema since admission after receiving fluids. Pt with labored breathing and pursed lips. ABG showed 77/59/7.28/29. Hypoxia thought to be due to volume overload as result of NSTEMI vs COPD exacerbation. Pt treated with albuterol/ipratripium nebs and advair. Also initially started on prednisone. She was diuresed with lasix. Repeat CXR concerning for early infiltrate vs. aspiration pnuemonia. Given recent hospitalization, fever, and elevated white count coverage for HAP was also initiated with vanc/cefepime and azithromycin for atypical coverage. Pulmonary service was consulted and recommended further diuresis and to stop the steroids as they felt SOB was more likely due to combination of UTI, lung inflammation/aspiration pneumonia, and/or low EF and MR /ACS. Pt completed antibiotics on . At the time of discharge, she was comfortable on RA and denied cough or sputum production. She was not discharged on diuretics because of her , but this may be considered in the future if she has evidence of fluid retention. Lisinopril was held because of but should be restarted once creat < 1.5. | Stable small right pleural effusion. Stable small right pleural effusion. Stable small right pleural effusion. A small right pleural effusion is stable. The cardiac and mediastinal silhouettes are normal. Small right pleural effusion is presumed. Previous asymmetric pulmonary edema has improved, with only a right lung residual. Continued faint R pulm opacity. Cardiomediastinal contours are normal. IMPRESSION: Mild increase in CHF. IMPRESSION: Slight progression of mild-to-moderate pulmonary edema. Visualized portion of the bowel shows a nonspecific gas pattern. Aeration of the right lung has improved. Minimal atelectasis at both bases. Heart size normal. Mediastinum is normal. Left lung is clear. The right hemidiaphragm is slightly elevated. The aorta is minimally unfolded. IMPRESSION: Mild improvement of right lung pneumonia. The left lung is clear. The left lung is clear. Imaged lung bases appear clear. Heart size is normal. Heart size is normal. Heart size is normal. Heart size is normal. No definite sign of free air below the right hemidiaphragm. Right upper quadrant surgical clips noted. There is upper zone redistribution and mild vascular prominence. FINDINGS: Supine and upright views of the abdomen and pelvis was provided. FINDINGS: Mild-to-moderate pulmonary edema is stable to slightly increased since the prior study. There is no appreciable left pleural effusion. Trace right effusion. IMPRESSION: No definite signs of obstruction. There are no new lung abnormalities. early pneumonic infiltrate versus aspiration. The bowel gas pattern is nonspecific with no dilated loops of small or large bowel. FINAL REPORT INDICATION: COPD, tachypnea and tachycardia. FINDINGS: Right lung opacity due to pneumonia has mildly improved since . The asymmetric opacification of the right lung which occurred on , attributed to aspiration, is probably responsible for the disparity in radiodensity today. IMPRESSION: AP chest compared to through 7: Mild pulmonary edema and pulmonary vascular congestion have worsened slightly since . CHEST, SINGLE AP PORTABLE VIEW. CHEST, SINGLE AP PORTABLE VIEW. IMPRESSION: AP chest compared to at 1:38 a.m.: Mild pulmonary edema which worsened since has improved slightly since earlier in the day, despite deposition of a new small right pleural effusion. Increased right hilear density reflects edema. IMPRESSION: No acute pulmonary process identified. A right PIC line ends low in the right atrium at least 5 cm beyond the estimated location of the superior cavoatrial junction. Follow-up CXR after resolution of the acute episode is recommended to confirm resolution and exclude a hilar abnormality. Linear calcification overlying the right lung apex likely represents vascular calcification. There is asymmetric prominence of interstitial markings at right greater than left bases, with new prominence of the right inferior hilum. The heart is not enlarged. The heart is not enlarged. No pleural effusion or pneumothorax. While this could represent asymmetric CHF, the differential diagnosis includes an early pneumonic infiltrate at the right base and possible changes due to aspiration. REASON FOR THIS EXAMINATION: assess interval change FINAL REPORT REASON FOR EXAMINATION: Evaluation of the patient with COPD after non-ST elevation MI. There is mildregional left ventricular systolic dysfunction with hypokinesis of thebasal-mid inferior and inferolateral walls. No AR.MITRAL VALVE: Moderate (2+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Resting tachycardia (HR>100bpm).Conclusions:The left atrium is mildly dilated. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.TRICUSPID VALVE: Tricuspid valve not well visualized. There is mild regional left ventricular systolicdysfunction with hypokinesis of the basal inferior, inferolateral andinferoseptal segments. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basalinferolateral - hypo; mid inferolateral - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: No AS. No resting LVOT gradient.LV WALL MOTION: Regional LV wall motion abnormalities include: basalinferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basalinferolateral - hypo; mid inferolateral - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: No AS. Scattered diverticula without diverticulitis. There is moderate pulmonary artery systolic hypertension.There is no pericardial effusion.Compared to the study dated (images reviewed), the patient is moretachycardic. Small hiatal hernia. There is no pericardialeffusion.IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.Moderate mitral regurgitation.Compared with the report of the prior study (images unavailable for review) of, regional left ventricular systolic dysfunction is new. Mild regional LVsystolic dysfunction. Mild regional LVsystolic dysfunction. Scattered diverticula are seen in the sigmoid colon without inflammatory changes. Non-specific anterolateral ST segment depression. Mild [1+] TR. Normal appendix. Normal appendix. The gallbladder is surgically absent. Elongated LA.LEFT VENTRICLE: Normal LV wall thickness and cavity size. Atherosclerotic calcifications are seen throughout the aorta without aneurysmal dilatation. Suboptimalimage quality - body habitus.Conclusions:The left atrium is mildly dilated. Pulmonary pressures are now in the moderate range (undeterminedon the prior study). Right ventricular chamber size and free wall motionare normal. Compared to the previous tracing of there is no significantdifference.TRACING #1 Comparedto the previous tracing of the anterolateral ST segment abnormality isnew.TRACING #1 3. no acute intra-abdominal process. Left ventricular wall thicknesses andcavity size are normal. Increasing sob.Height: (in) 65Weight (lb): 127BSA (m2): 1.63 m2BP (mm Hg): 148/86HR (bpm): 126Status: InpatientDate/Time: at 16:20Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. Moderate (2+) mitralregurgitation is seen. Left ventricular function. Moderate (2+)mitral regurgitation is seen; it is likely ischemic in nature. Right ventricular chamber size and free wall motion are normal. Leftventricular wall thicknesses and cavity size are normal. Bilateral small renal hypodensities are too small to characterize and likely represent cysts. No significant differencecompared with previous tracing.TRACING #2 Sinus tachycardia with premature ventricular complex. Otherwise, no diagnostic interim change. Otherwise, normaltracing. PATIENT/TEST INFORMATION:Indication: Hypoxia Pulm edemaHeight: (in) 65Weight (lb): 140BSA (m2): 1.70 m2BP (mm Hg): 115/71HR (bpm): 101Status: InpatientDate/Time: at 12:21Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness and cavity size. | 24 | [
{
"category": "Radiology",
"chartdate": "2119-07-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197297,
"text": ", E. 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with COPD, tachypnea, tachycardia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n Mild improvement of right lung pneumonia. No new consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-07-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197110,
"text": " 7:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with COPD s/p NSTEMI tachycardic and dyspneic.\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with COPD after non-ST\n elevation MI.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n Heart size is normal. Mediastinum is normal. There continues progression of\n the right lung consolidation, extensive most likely consistent with gradual\n development of infectious process. The left lung is clear. Heart size is\n normal. Mediastinum is unremarkable.\n\n The asymmetric appearance of the consolidation on the current study with\n fever, infectious process over pulmonary edema as was originally suggested.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-07-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197296,
"text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with COPD, tachypnea, tachycardia\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:02 PM\n Mild improvement of right lung pneumonia. No new consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, tachypnea and tachycardia.\n\n COMPARISON: , , .\n\n FINDINGS: Right lung opacity due to pneumonia has mildly improved since\n . No new consolidation is seen. The left lung is clear. No pleural\n effusion or pneumothorax. The cardiac and mediastinal silhouettes are normal.\n\n\n IMPRESSION: Mild improvement of right lung pneumonia. No new consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-07-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197498,
"text": " 7:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluation for interval change, CHF exac\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with NSTEMI, CHF, COPD, hx of aspiration PNA with continued\n oxygen requirement\n REASON FOR THIS EXAMINATION:\n evaluation for interval change, CHF exac\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 8:37 A.M., \n\n HISTORY: MI, CHF, COPD. Aspiration pneumonia.\n\n IMPRESSION: AP chest compared to through 7:\n\n Mild pulmonary edema and pulmonary vascular congestion have worsened slightly\n since . The asymmetric opacification of the right lung which occurred\n on , attributed to aspiration, is probably responsible for the disparity\n in radiodensity today. Small right pleural effusion is presumed. There is no\n appreciable left pleural effusion. Heart size normal. A right PIC line ends\n low in the right atrium at least 5 cm beyond the estimated location of the\n superior cavoatrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-07-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1197423,
"text": " 4:52 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please check PICC tip right cephalic 50 cm please page IV w\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with new line placement\n REASON FOR THIS EXAMINATION:\n please check PICC tip right cephalic 50 cm please page IV with wet read thanks\n \n ______________________________________________________________________________\n WET READ: 11:40 PM\n R PICC 1 cm beyond cavoatrial jctn. Continued faint R pulm opacity.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:25 P.M \n\n HISTORY: New line placement. Check PIC.\n\n IMPRESSION: AP chest compared to at 7:43 a.m.:\n\n The wire in the new right PIC line passes nearly as far as the superior\n cavoatrial junction. Whether the catheter tip extends further is known to the\n operator. Previous asymmetric pulmonary edema has improved, with only a right\n lung residual. Left lung is clear. Heart size is normal. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-07-02 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1196747,
"text": " 5:15 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval for e/o obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with severe N/V, unable to tolerate POs\n REASON FOR THIS EXAMINATION:\n eval for e/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL RADIOGRAPH PERFORMED ON \n\n Comparison is made with a prior CT abdomen and pelvis from as well as\n a prior abdominal radiograph from .\n\n CLINICAL HISTORY: Severe nausea and vomiting, unable to tolerate p.o., assess\n obstruction.\n\n FINDINGS: Supine and upright views of the abdomen and pelvis was provided.\n Clips in the right upper quadrant related to prior cholecystectomy. The bowel\n gas pattern is nonspecific with no dilated loops of small or large bowel. A\n lucency is seen in the right upper quadrant on the upright projection which\n could represent a loop of gas-filled large bowel, though is somewhat unusual.\n No definite sign of free air below the right hemidiaphragm. Bony structures\n appear intact. Imaged lung bases appear clear.\n\n IMPRESSION: No definite signs of obstruction. Gas lucency projecting over\n the right upper quadrant could represent a gas-filled loop of large bowel. If\n there is strong clinical concern for acute abnormality, CT is advised.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-07-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197667,
"text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate interval change of pulmonary edema and RLL opacity\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with CHF exacerbation and aspiration PNA.\n REASON FOR THIS EXAMINATION:\n Evaluate interval change of pulmonary edema and RLL opacity\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: CHF exacerbation and aspiration pneumonia.\n\n Comparison is made with prior study performed a day earlier.\n\n Cardiomediastinal contours are normal. Aeration of the right lung has\n improved. There are no new lung abnormalities. Right PICC remains in place.\n The tip is difficult to visualize, can be followed at least to the cavoatrial\n junction. There is no pneumothorax or pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197022,
"text": ", E. 2:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval evaluation of edema/infiltrate\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent NSTEMI, CHF exac, COPD, rales at R base\n REASON FOR THIS EXAMINATION:\n interval evaluation of edema/infiltrate\n ______________________________________________________________________________\n PFI REPORT\n Slight progression of mild-to-moderate pulmonary edema. Stable small right\n pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-07-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1196776,
"text": " 11:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: rule out pneumonia/diaphragm irration\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with nausea/vomiting\n REASON FOR THIS EXAMINATION:\n rule out pneumonia/diaphragm irration\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Nausea, vomiting, rule out pneumonia.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n The heart is not enlarged. There is no CHF, focal infiltrate, or effusion.\n The right hemidiaphragm is slightly elevated. Minimal atelectasis at both\n bases. Linear calcification overlying the right lung apex likely represents\n vascular calcification.\n\n Right upper quadrant surgical clips noted. No free air is seen beneath the\n diaphragm. Visualized portion of the bowel shows a nonspecific gas pattern.\n\n IMPRESSION: No acute pulmonary process identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-07-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1196860,
"text": " 5:57 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluation for pulmonary edema, new onset vomiting and short\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent NSTEMI, CHF, COPD\n REASON FOR THIS EXAMINATION:\n evaluation for pulmonary edema, new onset vomiting and shortness of breath\n ______________________________________________________________________________\n WET READ: YGd MON 6:30 PM\n Vascular congestion, lines, c/w pulmonary edema. Trace right effusion.\n Persistent streaky opacities in the right cardiophrenic angle, given history\n and persistence, likely aspiration. - x \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:03 P.M. ON \n\n HISTORY: Evaluate pulmonary edema, vomiting and shortness of breath.\n\n IMPRESSION: AP chest compared to at 1:38 a.m.:\n\n Mild pulmonary edema which worsened since has improved slightly since\n earlier in the day, despite deposition of a new small right pleural effusion.\n Heart size is normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-07-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1196781,
"text": " 1:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for fluid overload\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with hypoxia\n REASON FOR THIS EXAMINATION:\n eval for fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia, question fluid overload.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n The heart is not enlarged. The aorta is minimally unfolded. There is upper\n zone redistribution and mild vascular prominence. There is asymmetric\n prominence of interstitial markings at right greater than left bases, with new\n prominence of the right inferior hilum. While this could represent asymmetric\n CHF, the differential diagnosis includes an early pneumonic infiltrate at the\n right base and possible changes due to aspiration. Changes at the left base\n are less specific.\n\n IMPRESSION:\n\n Mild increase in CHF. More pronounced increased markings at right base, with\n new prominence of the right inferior hilum -- ? early pneumonic infiltrate\n versus aspiration.\n\n Follow-up CXR after resolution of the acute episode is recommended to confirm\n resolution and exclude a hilar abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197021,
"text": " 2:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval evaluation of edema/infiltrate\n Admitting Diagnosis: VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with recent NSTEMI, CHF exac, COPD, rales at R base\n REASON FOR THIS EXAMINATION:\n interval evaluation of edema/infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MDAg TUE 5:35 PM\n Slight progression of mild-to-moderate pulmonary edema. Stable small right\n pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Recent STEMI, CHF exacerbation, right basilar rales.\n\n COMPARISON: , , at 1:38 a.m. and 6:03 p.m.\n\n FINDINGS: Mild-to-moderate pulmonary edema is stable to slightly increased\n since the prior study. Increased right hilear density reflects edema. A small\n right pleural effusion is stable. No pneumothorax.\n\n IMPRESSION: Slight progression of mild-to-moderate pulmonary edema. Stable\n small right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-07-02 00:00:00.000",
"description": "CT ABD & PELVIS WITH CONTRAST",
"row_id": 1196754,
"text": " 6:44 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: R/O obstruction, volvulus.\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with N/V/D - unable to tolerate PO. Xray concerned for\n possible loop of gas filled large bowel. Past history of bloody stools.\n REASON FOR THIS EXAMINATION:\n R/O obstruction, volvulus.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MDAg SUN 8:40 PM\n 1. radiographic lucency is bowel interposed between liver and diaphragm\n 2. fluid in the cecum and ascending colon is c/w history of diarrhea.\n 3. no acute intra-abdominal process. no obstruction or volvulus.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Nausea, vomiting, diarrhea, gas-filled large bowel on AXR.\n\n COMPARISON: AXR and CT .\n\n TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic\n symphysis were displayed with 5-mm slice thickness with 130 mL of Optiray\n intravenous contrast. Coronal and sagittal reformats were displayed with 5-mm\n slice thickness.\n\n CT ABDOMEN: The lung bases are clear aside from scarring at the right lung\n base from prior pneumonia. There is no pleural or pericardial effusion. Small\n hiatal hernia.\n\n The liver, spleen, pancreas, and bilateral adrenal glands are normal. The\n gallbladder is surgically absent. The kidneys enhance symmetrically and\n excrete contrast promptly without hydronephrosis. Bilateral small renal\n hypodensities are too small to characterize and likely represent cysts. The\n small bowel is normal in course and caliber without obstruction. Fluid in the\n cecum and ascending colon with distal decompression are compatible with\n history of diarrhea. Normal appendix. The radiographic lucency corresponds to\n large bowel interposed between the liver and diaphragm. Atherosclerotic\n calcifications are seen throughout the aorta without aneurysmal dilatation. No\n pathologically enlarged mesenteric or retroperitoneal lymph nodes are present.\n There is no free fluid and no free air.\n\n CT PELVIS: The rectum, bladder and uterus are normal. Scattered diverticula\n are seen in the sigmoid colon without inflammatory changes. No adnexal mass\n identified. There is no free fluid and no pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: No lytic or sclerotic lesion suspicious for malignancy is seen.\n\n IMPRESSION:\n 1. Radiographic lucency corresponds to colon interposed between the liver and\n diaphragm.\n (Over)\n\n 6:44 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: R/O obstruction, volvulus.\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Fluid-filled cecum and ascending colon is compatible with history of\n diarrhea. Normal appendix.\n 3. Scattered diverticula without diverticulitis.\n\n"
},
{
"category": "Echo",
"chartdate": "2119-07-05 00:00:00.000",
"description": "Report",
"row_id": 96576,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Increasing sob.\nHeight: (in) 65\nWeight (lb): 127\nBSA (m2): 1.63 m2\nBP (mm Hg): 148/86\nHR (bpm): 126\nStatus: Inpatient\nDate/Time: at 16:20\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\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal\ninferolateral - hypo; mid inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR. Eccentric\nTR jet. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Resting tachycardia (HR>100bpm).\n\nConclusions:\nThe left atrium is mildly dilated. The left atrium is elongated. Left\nventricular wall thicknesses and cavity size are normal. There is mild\nregional left ventricular systolic dysfunction with hypokinesis of the\nbasal-mid inferior and inferolateral walls. The remaining segments contract\nnormally (LVEF = 40-45 %). Right ventricular chamber size and free wall motion\nare normal. There is no aortic valve stenosis. No aortic regurgitation is\nseen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen. The tricuspid regurgitation jet is eccentric and may be\nunderestimated. There is moderate pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\nCompared to the study dated (images reviewed), the patient is more\ntachycardic. Pulmonary pressures are now in the moderate range (undetermined\non the prior study). Other findings are similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2119-07-03 00:00:00.000",
"description": "Report",
"row_id": 96577,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypoxia Pulm edema\nHeight: (in) 65\nWeight (lb): 140\nBSA (m2): 1.70 m2\nBP (mm Hg): 115/71\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 12:21\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 report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; basal inferior - hypo; mid inferior - hypo; basal\ninferolateral - hypo; mid inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: No AS. No AR.\n\nMITRAL VALVE: Moderate (2+) 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. Suboptimal\nimage quality - body habitus.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with hypokinesis of the basal inferior, inferolateral and\ninferoseptal segments. The remaining segments contract normally (LVEF =\n40-45%). Right ventricular chamber size and free wall motion are normal. There\nis no aortic valve stenosis. No aortic regurgitation is seen. Moderate (2+)\nmitral regurgitation is seen; it is likely ischemic in nature. The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\nIMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD.\nModerate mitral regurgitation.\n\nCompared with the report of the prior study (images unavailable for review) of\n, regional left ventricular systolic dysfunction is new.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2119-07-02 00:00:00.000",
"description": "Report",
"row_id": 263286,
"text": "Sinus rhythm with premature atrial contractions. Normal tracing. Compared to\nthe previous tracing no diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2119-07-07 00:00:00.000",
"description": "Report",
"row_id": 263278,
"text": "Sinus tachycardia. Compared to the previous tracing of there is no\nsignificant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-07-06 00:00:00.000",
"description": "Report",
"row_id": 263279,
"text": "Sinus tachycardia. Otherwise, normal tracing. No significant difference\ncompared with previous tracing.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2119-07-05 00:00:00.000",
"description": "Report",
"row_id": 263280,
"text": "Sinus tachycardia with premature ventricular complex. Otherwise, normal\ntracing. Compared to the previous tracing of there is no significant\ndifference.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2119-07-05 00:00:00.000",
"description": "Report",
"row_id": 263281,
"text": "Sinus tachycardia with increase in rate as compared to the previous tracing\nof . Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-07-04 00:00:00.000",
"description": "Report",
"row_id": 263282,
"text": "Sinus rhythm. Compared to the previous tracing of there has been slowing\nof the sinus rate and the previously described ST segment abnormality has\nresolved.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2119-07-03 00:00:00.000",
"description": "Report",
"row_id": 263283,
"text": "Sinus tachycardia. Non-specific anterolateral ST segment depression. Compared\nto the previous tracing of the anterolateral ST segment abnormality is\nnew.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2119-07-03 00:00:00.000",
"description": "Report",
"row_id": 263284,
"text": "Sinus rhythm. ST segment elevations in the inferior leads as previously\ndescribed. Clinical correlation for signs of acute inferior myocardial\ninfarction and a repeat tracing are suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2119-07-03 00:00:00.000",
"description": "Report",
"row_id": 263285,
"text": "Sinus rhythm. One and a half millimeter of ST segment elevations\nin leads II, III and aVF raising consideration of inferior transmural\nischemia. Compared to the previous tracing ST segment elevations are new.\nTRACING #2\n\n"
}
] |
3,566 | 122,167 | He arrived to the ED minimally responsive, withdrawing to pain with attempts to externally pace continuing. He was intubated, and R SC cordis and R a-line placed, and was started on dopamine gtt. Cardiology fellow performed carotid massage, after which pt spontaneously reverted to NSR with HR 60s. Subsequent ECG demonstrated new ST depressions in V2-V6 (most notable in V3-V5), with 1mm STE in III, 0.5mm STE in II and AVF, and some suggestion of possible STE in AVR. Initial CK was 112 with MB 2, and tropT of <0.01. He was given ASA 600mg PR. Initial labs were notable for BUN/Cr of 37/3.1, from likely baseline around 1.4. wbc was 9.9 with no left shift. K was elevated to 5.6. Bicarb was 15, with initial ABG 7.17/37/286/14, lactate 4.0. Pt remained hypotensive on Dopamine 50mcg/kg/min, and was switched to Levophed 0.05mcg/kg/min. Pupils were noted to be fixed and dilated. Had stat head CT, which did not show any evidence of acute hemorrhage or mass effect, with probable maintenance of -white differentiation. CXR at 10pm suggested possible increasing pulmonary vasculature which was not present on initial 9pm CXR. He also had a non-contrast chest/abd CT, which was notable for bilateral dependent consolidations and small pleural effusions, with increased ground glass opacities bilaterally. There was possible peripancreatic stranding, but no dilated loops of bowel and a normal-appearing appendix. Initial LFTs, amylase, and lipase were unremarkable. He was transferred to the CCU intubated on Levophed for further management. Given concern for sepsis, borad spectrum antibiotics were initiated. In the CCU, a bedside TTE was done by cardiology fellow which demonstrated relatively preserved EF. Cardiac enzymes eventually rose, peaking at Troponin of 3.0 and CK-MB of 103. Subsequent cardiac cath on showed proximal 40% LAD lesion, 70% ostial lesion in the circumflex and a diffusely diseased RCA. PCI of the RCA was considered but due to the small caliber vessel, renal failure and possible septic process, it was initially decided to continue with medical therapy. Patient remained intubated and required full ventilatory support. Septic workup eventually returned negative. Over several days, his renal function normalized and he was eventually extubated. Despite aggressive medical therapy, he continued to experience anginal symptoms with lateral ST depressions which improved with Nitro drip. Cardiac surgery was therefore consulted for coronary revascularization surgery and further evaluation was performed. Carotid ultrasound revealed moderate disease of his left internal carotid artery. Workup was otherwise benign. Given his improving renal function and no evidence of sepsis, he was eventually cleared for surgery. On , Dr. performed off pump coronary artery bypass grafting. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics as he weaned from inotropic support. On postoperative day one, he transferred to the SDU. Beta blockade was slowly advanced as tolerated. He remained in a normal sinus rhythm without evidence of atrial or ventricular arrhythmias. Empiric antibiotics were eventually discontinued. Over several days, he continued to make clinical improvements with medical therapy and made steady progress with physical therapy. The rest of his postop course was unremarkable and he was medically cleared for discharge on postoperative day five. | Noaortic regurgitation is seen. Simpleatheroma in ascending aorta. Mild (1+) to moderate{ 2+}mitral regurgitation is seen. D/T HX OF STROKE KEEP SBP APPROX. Normal ascending aorta diameter. Normal descending aorta diameter. Mild mitral annularcalcification. BUN/Cr 37/3.1.ID: Hypothermic. Initial enzymes flat.Resp: Mechanically ventilated. remains intubated on A/C . Minimal spontaneous mvmt noted. Resp Care,Pt. Simple atheroma inaortic arch. latest gas 7.43 41 181 3 28 98. Mild tomoderate (+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Cont Imdur/ Metoprolol and Captopril. Updated in condition and POC. BILATERAL BS CLEAR, PATIENT WAS ON FLAGYL/LEVOFLOXACIN PREOP WILL MAKE , PRESENTLY ON VANCOMYCIN.. GU GREAT UO!! NIBP correlating w/in mm HG. Hemodymanics = CO 9.0 CI 4.37. Resp CarePt returned Post Op, placed on SIMV/PS, ABGs slight resp acidosis, inc rate, FiO2. Normal aortic arch diameter. SWAN LEFT IN PLACE VIA R GROIN. ABD SOFT + BS. Resting regionalwall motion abnormalities include inferior/inferolateral akinesis/hypokinesis.Right ventricular chamber size and free wall motion are normal. CP resolved upon completion of EKG. Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. LS clear upper, crackles at bases.GI: no stool, hypoactive bs. Resting regional wall motionabnormalities include mild hypokinesia of the mid and apical portions of theinferior wall and the inferolateral walls.3.. ABP dampened and positional. There is mild regionalleft ventricular systolic dysfunction. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 69Weight (lb): 187BSA (m2): 2.01 m2BP (mm Hg): 122/43HR (bpm): 63Status: InpatientDate/Time: at 10:13Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Normal LV cavity size. There are simple atheromain the aortic arch. The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. DSG ALL D/I. Mild regional LV systolic dysfunction. There is moderate pulmonary artery systolic hypertension.There is a trivial/physiologic pericardial effusion.Compared to the prior study (images reviewed) of earlier today, leftventricular systolic function appears similar. CIWA scale instituted d/t hx of ETOH. BS hypoactive. Most recent ABG 7.48/70/108GI/GU: Abd soft. Pulses per doppler. Remains on Flagyl q 8hrs, Levofloxacin q 48hrs and Vancomycin q12 hrs. abxs dosed as ordered.Access-R subclavian introducer WNL. Repositioned q3hrs. CO/CI/SVR 5.8/2.82/1159 following Dopamine wean. Carotid US done. Vanco d/c'd. Started on po Metoprolol and tolerating . Last ABG 7.43/46/76/32. Updated in pt condition. ARF resolving. Update pt per POC/multidisiplanary rounds. CHF worstening on CXR. Autodiuresis upon initial assessemnt UOP decreasing but cont HUOP of 70-210cc q 1-2hrs. HR 57-79 NSR. EKG done ST depresions V3-V6 (previously c elvations when pain free). sepsis/ asp pna. This am 20/1.2.ID: Afebrile. HCT stable. LLL pna. Nml CO andfilling pressures. Cortisol test completed this am. MAE, PERRL, follows commands, cooperative c care.CV-NSR 60s-80s c rare PACs. start TF. Rating ~2.ID: T max 99.8 po, on levoflox, vanco and flagyl. tolerating po's. f/u morning lytes. Short P-R interval. Short P-R interval. Short P-R interval. Right femoral site CDI. Probable sinus rhythmSlight ST-T wave changes - are nonspecific and within normal limitsSince previous tracing of same date, ST-T wave changes decreased Baseline artifact. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Sinus rhythm. Assess for CP, follow HR/BP. Adequate CYU via foley. Continue to assess HD/increase BB/ACE as tolerated. Probable sinus rhythm.Diffuse ST-T wave abnormalities - suggsts ischemia - clinical correlation issuggestedSince previous tracing of , ST-T wave abnormalities decreased K 3.8--> 20 IV KCL. +369 LOS. This am 140s c nitro off. LS clr in apexes. Borderline short P-R interval. Changes resolved post pain. Tolerating well. Tmax 99.3 per core temp. Nitro gradually weaned off. Contined ST segment depression in theinferolateral leads. NSR. Updated on plan of care.A: stable without CP today. Placement confirmed by auscultation. Repeat this am 6.9/3.35/545. BUN/CR cont to improve. ST segment depressions inleads I, II, III, aVF and V4-V6 compared to the previous tracing of without diagnostic interim change. Tolerating increased ACE-I and BB. New left renal hypodensity. The aortic knob is calcified. Previously present interstitial edema has resolved. Resolution of interstitial edema. Small bilateral fat-containing inguinal hernias are identified. The mediastinal contours appear unremarkable, with some calcification at the aortic knob. Right- and left-sided chest tube and mediastinal drain in place. IMPRESSION: AP chest compared to : Pulmonary edema and pleural effusions have cleared. Nonspecific stranding in the region of the pancreas. Status post right carotid endarterectomy. There is continued small bilateral pleural effusion. There is a sclerotic focus in the right femoral head. Note is made of pneumopericardium. An endotracheal tube terminates 7.3 cm from the carina, just at the level of the thoracic inlet. The pericardium has resolved in the interval. IMPRESSION: Endotracheal tube in appropriate position. Probable sinus rhythmDiffuse ST-T wave abnormalities - consistent with ischemiaClinical correlation is suggestedSince previous tracing of same date, ectopic atrial/? Pneumopericardium, consistent with patient's postoperative state. There is antegrade vertebral flow bilaterally. SEMI-UPRIGHT AP VIEW OF THE CHEST: Endotracheal tube and nasogastric tube remain in standard positions. FINDINGS: Duplex evaluation was performed of bilateral carotid arteries. Sinus opacification, as described. CT OF THE CHEST: The pericardium appears unremarkable. INDICATION: Chest tube removal. The airways are patent to the level of the segmental bronchi bilaterally. Pleural calcifications are identified. The lungs demonstrate bilateral dependent consolidative opacities as well as bilateral small pleural effusions. HISTORY: Bradycardia and hypotension. The patient has prior CABG and median sternotomy. Right subclavian central venous catheter tip is at the junction of the brachiocephalic vein and the superior vena cava. Slight worsening of bibasilar atelectasis. The endotracheal tube and nasogastric tube are in unchanged positions. There are bibasilar atelectatic changes which are slightly worse in the interval, and there is a possible small left pleural effusion. Cardiomegaly and mild congestive heart failure. There is evidence of mucosal thickening within the ethmoid airspaces and possible small fluid level within the right maxillary sinus. | 47 | [
{
"category": "Echo",
"chartdate": "2148-05-20 00:00:00.000",
"description": "Report",
"row_id": 63461,
"text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABG procedure\nHeight: (in) 68\nWeight (lb): 140\nBSA (m2): 1.76 m2\nBP (mm Hg): 145/67\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 16:07\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the \nLAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. No LV\naneurysm. Mild regional LV systolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid inferior -\nhypo; mid inferolateral - hypo; inferior apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter. Simple\natheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in\naortic arch. Normal descending aorta diameter. There are complex (>4mm)\natheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. No MS. Mild to\nmoderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nPre revascularization\n\n1.No spontaneous echo contrast or thrombus is seen in the body of the left\natrium or left atrial appendage. No atrial septal defect is seen by 2D or\ncolor Doppler.\n\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. No left ventricular aneurysm is seen. There is mild regional\nleft ventricular systolic dysfunction. Resting regional wall motion\nabnormalities include mild hypokinesia of the mid and apical portions of the\ninferior wall and the inferolateral walls.\n\n3.. Right ventricular chamber size and free wall motion are normal.\n\n4.There are simple atheroma in the ascending aorta. There are simple atheroma\nin the aortic arch. There are complex (>4mm) atheroma in the descending\nthoracic aorta.\n\n5.There are three aortic valve leaflets. The aortic valve leaflets are mildly\nthickened. There is no aortic valve stenosis. Trace aortic regurgitation is\nseen.\n\n6.The mitral valve leaflets are mildly thickened. Mild (1+) to moderate{ 2+}\nmitral regurgitation is seen. There is no pericardial effusion.\n\nPost revascularization\n\n1. Biventricular systolic function remains unchanged.\n\n2. Mild to moderate mitral regurgitation persists.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2148-05-15 00:00:00.000",
"description": "Report",
"row_id": 63462,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 69\nWeight (lb): 187\nBSA (m2): 2.01 m2\nBP (mm Hg): 122/43\nHR (bpm): 63\nStatus: Inpatient\nDate/Time: at 10:13\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Normal LV cavity size. Mild regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; basal inferolateral - akinetic; mid inferolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\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: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. The left ventricular cavity size is normal.\nThere is mild regional left ventricular systolic dysfunction. Resting regional\nwall motion abnormalities include inferior/inferolateral akinesis/hypokinesis.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. There is moderate pulmonary artery systolic hypertension.\nThere is a trivial/physiologic pericardial effusion.\n\nCompared to the prior study (images reviewed) of earlier today, left\nventricular systolic function appears similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2148-05-15 00:00:00.000",
"description": "Report",
"row_id": 63480,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 68\nWeight (lb): 200\nBSA (m2): 2.05 m2\nBP (mm Hg): 110/60\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 01:59\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.\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets.\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 focal inferolateral\nhypokinesis but image quality is technically suboptimal for assessment of\nregional wall motion. Right ventricular chamber size is normal. Right\nventricular systolic function is grossly preserved. The mitral valve leaflets\nare mildly thickened and there is probably mild mitral regurgitation.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-15 00:00:00.000",
"description": "Report",
"row_id": 1308271,
"text": "Respiratory Care\nPt remains intubated and on vent support. Current settings are A/C 600/14/70/5. Vent changes were in FiO2 and PEEP. PEEP was dropped from 10 -> 5 and FiO2 was dropped from 100% -> 70%. Pt lung sounds were course in the bases that cleared after suction. He was suction for moderate amounts of thick tan secretions. Care plan is to remain unchanged and conutinue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-15 00:00:00.000",
"description": "Report",
"row_id": 1308272,
"text": "CCU NPN 0700-1900\n\nS/O: Pt intubated & sedated.\nPlease see carevue for COMPLETE objective data.\n\nneuro: Pupils equal and reactive, 3mm/brisk. Pt responds to all painful stimuli, ++ facial grimace, and withdraws from stimuli. Propofol increased to 50 mcgs/kg/min w/ adequate sedation.\nMAE on bed, some purposeful movements noted w/ lighter sedation. SWR maintained for ETT.\n\nCV: NIBP 130's on 5.0mcg/kg/min of dopamine. (aline rt radial d/c'd).\nHR 60'-70's nsr. CK's added on to 7am labs=1327, MB 103, INDEX 7.8, TROP 2.73. Pt to cath lab today, Right and left heart cath done. No intervention, see cath report. RA 8, RV 31/6, PA 26/8, WEDGE 11. SWAN LEFT IN PLACE VIA R GROIN. SHEATH PULLED IN CATH. Pedal Pulses by doppler, no evidence of hematoma. CVP 11, PAP 26/8. Hemodymanics = CO 9.0 CI 4.37. A-line replaced lft radial.\n\nResp: Current Vent settings AC 70% 600X14 5 peep. latest gas 7.43 41 181 3 28 98. Sxn'd for large amount of tan secretions on return from lab. LS clear upper, crackles at bases.\n\nGI: no stool, hypoactive bs. og tube in place.\nGU: auto diuresis, > 250-300 cc hr light yellow urine. Rec'd only 55cc contrast dye in lab. NaBicarb given bolus then gtt at 103cc/hr for 600cc. Mucomyst ordered x's 2. K+/bun/creat pending from pm labs.\nSkin: intact\nEndo: bs wnl\nAccess: Cordis introducer Rscv, Vip Swan r fem, left AC #18, Right wrist #18.\nID: on Levofloxacin, Flagyl, and Started Vanco. Temp 97.8 core.\nSocial; family in to visit, upated on progress.\n\nA: 76 y/o male w/ CHF post Bradycardic episode. + cardiac enzymes, no culprit lesion found via cath. RH cath numbers not elevated. ++Hyperdynamic co/ci. ? Non-Cardiogenic Pulm Edema/Sepsis.\nP: Vent support, dompamine, iv abx, monitor hemodynamics. Follow temp and bld cx's. Support to family and update on plan of care.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-15 00:00:00.000",
"description": "Report",
"row_id": 1308269,
"text": "Respiratory Care Note:\n received patient this shift from ED, intubated with a 7.0, 22 at the lip. On 100%, ABG returned a PO2 of 88, peep raised to 10 and a resultant PO2 of 249. SX for a moderate amount of frothy pink tinged sputum. Sample obtained and sent for analysis. CXR showed failure. No RSBI this am due to peep level of 10, with FIO2 of 100%. Plan is to wean FIO2 as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-15 00:00:00.000",
"description": "Report",
"row_id": 1308270,
"text": "CCU Nursing Progress Note 1900-0700\nS: Intubated.\n\nO: Please see careview for complete VS/additional objective data.\n\n76yo male admitted from EW after presenting to OSH after experiencing SSCP w/ assoc pale, cool extremeties, n/v and diaphoresis. Junctional rhythm w/ HR 37 and SBP 60s. Uneffective atropine. Transcutaneously paced in field. Tx to . Converted NSR after carotid massage. No further need for pacing. Intubated. Started on Levophed gtt after Dopamine gtt was ineffective. Transferred to CCU for further mgmt.\n\nMS: Per report unresponsive and pupils fixed and dilated. After arriving to CCU notable for response to stimuli and withdraws to pain. Pupillary response 4 mm in size. Brisk in response. Minimal spontaneous mvmt noted. Propofol gtt started and remains at 20 mcg/kg/min. Soft wrist restraints applied to maintain integrity of ETT and invasive lines.\n\nCV: Received pt on 0.05 mcg/kg/min Levophed gtt. HR trending down to 40s and ^ 30s. External pacer pads placed and remain intact. SB/junctional/ NSR. Changed to Dopamine gtt and titrated to 7.5 mcg/kg/min. HR improved to 69. ABP dampened and positional. Difficulty in obtaining ABG. HO aware. NIBP correlating w/in mm HG. HCT stable at 38. Bicarb 11. Received 3 amps Na Bicarb. Mg 1.6 and Ion Ca 1.0. Repleted w/ 4 gm MGSO4 and 3 gm CaGluc. Lactate initially 4.8 but improved to 1.6 by am. Initial enzymes flat.\n\nResp: Mechanically ventilated. No vent changes . Pt remains on AC 100% / 600*14/ 10 peep. Initially overbreathing by 11 breaths prior to sedation. O2 sats 100%. ABG improved 7.37/39/249 (7.17/37/286). Suctioned for pink, frothy sputum. Worstening CHF on CXR as well as bilateral pleural effusions and posterior consolidation ? atelectasis versus asp pna.\n\nGI/GU: NPO. OGT placement confirmed. Abd obese. +BS. No stool. F/C to gravity. F/C to gravity. Draining light yellow urine. -100cc LOS. BUN/Cr 37/3.1.\n\nID: Hypothermic. Temp unmeasurable PR. Bair hugger applied until 0600 when temp 98.3 axillary. WBC 9.9. Started on Levofloxacin IV and Flagyl IV for broad coverage and ? asp pna. Pt pan cultured . Results still pending.\n\nEndo: BS wnl. No coverage indicated per RISS.\n\nSocial: Wife and children into visit. Updated in condition and POC. Will return this am. No other calls or visitors .\n\nA/P: 76 yo male w/ h/o HTn and CVA presented w/ hypotension, ARF and junctional bradycardia resolving to NSR w/ lateral ST depressions and Inferior STEMI requiring intubation and pressor support. Cont to wean pressors and ventilatory support as tolerated. Remains on Dopamine for ^ HR and perfusion of kidneys. CHF on CXR. Diuresis gently once indicated. ? cardiac catheterization for further diagnosis pt experienced CP and EKG changes at OSH. Cont supportive care. Keep family updated in POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-20 00:00:00.000",
"description": "Report",
"row_id": 1308284,
"text": "Resp Care\nPt returned Post Op, placed on SIMV/PS, ABGs slight resp acidosis, inc rate, FiO2. Advanced ET tube 3 cm 2nd to CXR and NP. Plan to wean as tolerated 2nd to getting blood press stable. Presently on Fi02 40%\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-20 00:00:00.000",
"description": "Report",
"row_id": 1308285,
"text": "PATIENT ADMIITED WITH LABILE SBP 70'S -170'S IN A MINUTE, NEO/NTG UP/DOWN, SVO2 60% OR BETTER, HCT 26 AT TRANSFUSING WITH IUPRBC. SEDATED WITH PROPOFOL/MORPHINE 2MG APPROX. Q2HRS. D/T HX OF STROKE KEEP SBP APPROX. 120'S. ONCE PATIENT REVERSED SBP MORE STABLE, PROPFOL OFF, SHIVERING RECEIVED TOTAL OF 25MG DEMEROL IV. SR TO ST 80-105 , NO ECTOPY, PATIENT ON 1MG/MIN LIDO DRIP FOR VE IN OR.. NO VE IN CSRU, CA/K REPLETED. NEURO AWAKENED AT MAE BUT VERY WEAK,OPENS EYES TO VOICE. RESP INTIALLY POOR ABG, TUBE ADVANCED INCREASED RATE, INCREASED PEEP. NOW PATIENT VERY SLEEPY TO WEAN, ATTEMPT IN AM. BILATERAL BS CLEAR, PATIENT WAS ON FLAGYL/LEVOFLOXACIN PREOP WILL MAKE , PRESENTLY ON VANCOMYCIN.. GU GREAT UO!!!GI NO BS, OGT DRAINING MINIMAL DRAINAGE , ON RANITIDINE/CARAFATE. DSG ALL D/I. WIFE VISITED EARLY IN EVENING, CALLED AT 2200 UPDATE GIVEN\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-21 00:00:00.000",
"description": "Report",
"row_id": 1308286,
"text": "Resp: pt on simv 14/600/5/+5/40%. Bs are clear bilaterally. Suctioned for small amount of thin white secretions. AM ABG 7.40/40/90/26. Placed pt on PSV 10/5/40%. VT's 800, VE 11 with 02 sats to 98%. Plan to continue to wean to extubate today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-21 00:00:00.000",
"description": "Report",
"row_id": 1308287,
"text": "Neuro: pt sedated overnight with propofol weaned off this am and pt awake following commonds.\nResp: pt weaned and extubated this am without difficulty to a 50% face mask with o2 sats running 95%.\nC/V: vss svo2 int he 70's with CI of 2.4-3 pt requiring neo 0.25-0.75 for SBP of 80-90. pt heart rate varying, to rate of 100 to junctional rate of 60. pacing wires A\"s not sensing andthis am not capturing, V wires sensing and capturing. junctional rhythm was brief 5mins at most then pt would go back into sinus and pick up rate. Lidocaine d/c'd this am.\nGI: pt npo over night 2nd to intubation will advance diet later today.\nEndo: blood sugars controlled wtih sliding scale insulin./\nGU: adequate urine outputs.\nPain: pt nods head yes to pain medicated with 2mg morphine.\nSkin: dsg clean and dry no drainage.\nPlan: deline , oob to chair and trransfer to floor later today\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-18 00:00:00.000",
"description": "Report",
"row_id": 1308280,
"text": "CCU NPN\n\nCV: REMAINS IN NSR WITH HR 56-79. SBP ON EVES 180-190. IV NTG INCREASED WITH NO SIGNIFICANT CHG IN BP, EKG COMPLETED NO CHG NOTED. DR NOTIFIED. ADDITIONAL CAPTOPRIL 25MG GIVEN AND CAPTOPRIL DOSE INCREASED TO 75MG TID. SBP IMPROVED 120-130. IV NTG TITRATED DOWN FROM 1.0MCG/KG TO 0.50MCG/KG/MIN. CON'T ON LOPRESSOR 50MG AS WELL.\n\nRESP: O2 SATS 98-100% ON 4L NP. C&R THICK BLD TINGE SECRETIONS. BS CL/DIMINISH WITH SL CRACKLES AT THE BASES. RR- . DENIES SOB\n\nGI: TAKING MEDS WITH SIPS OF CL'S. ABD SOFT + BS. UP TO THE COMMODE, NO STOOL, + FLATUS. APPETITE FAIR.\n\nGU: U/O 50-100CC/HR 1 LITER.\n\nSKIN: R GROIN C&D PULSES 3+/2+\n\nNEURO: A/O X3 COOPERATIVE, FOLLOWS ALL COMMNADS. MAE CIWA -. C/O DIFFICULTY SLEEPING. REFUSING SLEEPER, BUT TOOK TWO TYLENOL PRIOR TO HS AND SLEPT ALL NOC.\n\nID: AFEBRILE. CON'T ON FLAGYL. HAD DIARRHEA PRIOR TO ADMISSION. LEVO FOR ? ASP PNA\n\nLABS; K+ 4.0\n BS 88\n\nSOCIAL: WIFE CALLED FOR UPDATE. POC REVIEWED WITH FAMILY\n\nP: 76 YR OLD WITH H/O HTN,CVA, ETHO, HX OF CAROTID STENOSIS WITH STEMI, S/P CATH WITH SEVERE DIFFUSE DISEASE. FOR CABG ON MONDAY. REVIEW PRE-OP ORDERS. CON'T WITH CURRENT MED REGIME. WILL SEND T&C THIS AM. FOLLOW BP'S\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-18 00:00:00.000",
"description": "Report",
"row_id": 1308281,
"text": "ADDENDUM: T&C SENT FOR PRE-OP. PRE-OP UA C/S SENT AS WELL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-18 00:00:00.000",
"description": "Report",
"row_id": 1308282,
"text": "CCU NPN 0700-1900\n\nS/O: \"ANOTHER PILL!??\"\nPLEASE SEE CAREVUE FOR COMPLETE OBJ DATA.\n\nCV: A-LINE D/C'D THIS AFTERNOON. SBP IN LEFT ARM CONSISTANTLY 20-30 POINTS GREATER THAN BP IN RIGHT ARM. THIS CONFIRMED BY INVASIVE A-LINE ON LEFT, AND MANUAL READINGS BILATERALLY. GOAL BP MANAGMENT SBP=120 OR LESS IN RIGHT, 140 OR LESS IN LEFT. IV NTG TITRATED UP TO 3MCQ/KG FOR SBP 190 (MAP 110). LOPRESSOR 50MG TID, CAPTOPRIL 75MG TID,\nIMDUR STARTED AT 30MG, INCREASED TO 60MG. BP TRENDING DOWN, NIBP 120/60 ON RIGHT ARM, W/ IV NTG TITRATED DOWN TO 1MCQ/KG.\nATTEMPTED TO D/C IVNTG THIS AM, PT DEVELOPED CP, RESOLVED W/ RESTARTED IVNTG, EKG DONE BUT PT PAIN FREE.\nHR 50-70 BPM.\n\nRESP: O2 SAT 98 % RA, NO COUGH. LSCTA, DIMINISHED AT BASES.\nGI: TOLERATING PO'S, STOOL SOFTNER GIVEN\nGU: VOIDING 200-400 CC'S/HR. CREAT 1.1\nID: CONT FLAGYL AND LEVOQUIN COURSE, NO WC, NO FEVER.\nACCESS: LEFT AC #18. CORDIS D/C'D THIS AM.\n\nA/P: 75 Y/O MALE W/ SEVERE DIFFUSE CAD, PLAN FOR CATH ON MONDAY. ONLY PRE-OP NEED STILL PENDING IS PA LAT CHEST XRAY. WILL F/U TOMORROW.\nBP CONTROL W/ PO MEDS, CAPTOPRIL/LOPRESSOR/IMDUR. TITRATE IV NTG TO GOAL SBP 120 IN RIGHT ARM (SBP 140 IN LEFT), AND PAIN FREE.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-18 00:00:00.000",
"description": "Report",
"row_id": 1308283,
"text": "CCU Nursing Note\nReceived pt at 1900. Weaned Nitro gtt off per instruction of HO. While preparing pt for transfer pt called for RN. Approximately 30 minutes after Nitro gtt was turned off pt experienced CP after reaching for newspaper at bedside table. HO notified. CP resolved upon completion of EKG. Nitroglycerin gtt resumed and titrated to 1.5 mcg/kg/min. After speaking with fellow pt will continue to be transferred to F6. POC is to titrate/ wean Nitro gtt as tolerated to maintain SBP goal. Cont Imdur/ Metoprolol and Captopril. Awaiting CABG on Monday for treatment of severe 2VD\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-16 00:00:00.000",
"description": "Report",
"row_id": 1308273,
"text": "Resp Care,\nPt. remains intubated on A/C . Fio2 weaned down to 50% this shift, ABG acceptable. RSBI not completed, apnea. See carevue.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-16 00:00:00.000",
"description": "Report",
"row_id": 1308274,
"text": "CCU Nursing Progress Note 1900-0700\nS: Intubated and sedated.\n\nO: Please see careview for complete VS/additional objective data.\n\nMS: Remains sedated on Propofol at 50-75 mcg/kg/min to maintain comfort. No spontaneous movement noted. PEARL. Approximately 3 mm in size. Brisk in response. Soft wrist restraints remain applied to maintain integrity of invasive lines/ ETT.\n\nCV: HR 66-83. NSR. No vea. Weaned off of Dopamine gtt at 2200. ABP via Left radial arterial line 108-162/56. MAPs>80. PAP 24-26/11-14. CVP 4-11. Unable to obtain PCWP. CO/CI/SVR 5.8/2.82/1159 following Dopamine wean. Repeat this am 6.9/3.35/545. Started on po Metoprolol and tolerating . HCT stable. K+ this am 3.6. Awaiting orders for repletion. Ion Ca 1.09 last pm received 1 gm Ca Gluc . Repeat this am 1.17. Other labs wnl. CK this am 571. Peak 1327. Right femoral site CDI. Pulses dopplerable.\n\nResp: Remains mechanically ventilated. Weaned FIO2 from 70% to 50%. No further vent changes noted. Remains on AC 50%/600*14/ 5peep. RR 16. O2 sats 100% throughout night. LS clr in apexes. Diminished in bases. LLL pna. CHF worstening on CXR. Most recent ABG 7.48/70/108\n\nGI/GU: Abd soft. Slightly distended. NPO at present. Meds via OGT. Placement confirmed by auscultation. BS hypoactive. No stool. F/C to gravity. Autodiuresis upon initial assessemnt UOP decreasing but cont HUOP of 70-210cc q 1-2hrs. Remains -132 for 24hrs. +369 LOS. ARF resolving. BUN/CR cont to improve. This am 20/1.2.\n\nID: Afebrile. Tmax 99.3 per core temp. Remains on Flagyl q 8hrs, Levofloxacin q 48hrs and Vancomycin q12 hrs. WBC this am 8.8. ? GPC growth in sputum in pairs and clusters. BC still pending. Additional surveillance cultures sent this am from L radial arterial line.\n\nSkin: Intact. No noteable breakdown. Repositioned q3hrs. Barrier cream applied prophylactively to coccyx.\n\nEndo: BS 83-107. No coverage indicated per HISS.\n\nSocial: Wife called last pm. Updated in pt condition. Will visit this am.\n\nA/P: 76 yo male w/ h/o HTN, ^ lipids and CVA presented w/ hypotension, ARF and junctional bradycardia w/ ST depressions and Inferior STEMI required intubation and pressor support. CPK leak yesterday am resulting in cardiac catheterization revealing 2VD involving LCX/ RCA. D/t concerns for ARF, sm caliber distal vessel and ?sepsis process no stent placement and cont medical managment. Nml CO andfilling pressures. Weaned off Dopamine and cont HTN requiring Metoprolol po. Tolerating well. Cortisol test completed this am. Cont triple abx for ? sepsis/ asp pna. ? start TF. Cont supportive care. Keep family updated in POC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-16 00:00:00.000",
"description": "Report",
"row_id": 1308275,
"text": "Respiratory Care\nPt was extubated today at 1330. Upon extubation patient had a HR 81, RR 16 (non-labored), SpO2 100% on 40% OFM. Pt had a good cough and no stridor. While on the ventilator patient had no MDI's. Lung sounds were clear after coughing. Pt coughed up moderate amount of thick tanish secretions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-17 00:00:00.000",
"description": "Report",
"row_id": 1308278,
"text": "CCU Nursing note\ns-\"I haven't slept all night.\"\nO-see flowsheet for additonal details.\n\nN-A/ox2 at beggining of shift c reorientation pt now a/ox3. CIWA initally 7. pt c noticable tremors, mild HA, disoriented. This am CIWA 0, although pt has been unable to sleep most of night. Team aware and into assess pt-denied need to give pt sleeping aide in order to monitor CIWA closely. MAE, PERRL, follows commands, cooperative c care.\n\nCV-NSR 60s-80s c rare PACs. BP elevated most of shift despite increases in Lopressor (37.5mg) and captopril(25mg) as well as one time captopril dose (25mg). Nitro gradually weaned off. SBP 136-170 via a-line/NBP about 15mmHg lower. This am 140s c nitro off. Consider increasing doses as tolerated. MAPs>60. Pulses per doppler. right groin WNL. Denies any CP this shift.\n\nResp-3L NC c sats >98%. Last ABG 7.43/46/76/32. LS clear c bibaslar faint crackles.\n\nGI/GU/endo- +BS, -BM. Currently NPO except for meds. Difficulty swallowing pills c thin liquid. Dosed c apple sauce this am-tolerated well. Consider swallow eval. Adequate CYU via foley. BS WNL-no coverave needed.\n\nID-afebrile. abxs dosed as ordered.\n\nAccess-R subclavian introducer WNL. R 20g PIV. a-line wnl.\n\na/p-76y.o c h/o HTN and CVA presenting c hypotension, RF, junctional brady resolving to NSR c lateral ST depressions and inferior STE, s/p cath c no clear culprit lession/although c severe diffuse calcified disease. Managing medically for now. Continue to assess HD/increase BB/ACE as tolerated. f/u morning lytes. Update pt per POC/multidisiplanary rounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-17 00:00:00.000",
"description": "Report",
"row_id": 1308279,
"text": "CCU Nursing Progress Note 0700-1900\nS: denies CP\n\nO: see CCU flow sheet for complete objective data\n\nCV: Captopril ^ to 50 mg tid and lopressor ^ to 50 mg tid. HR 57-79 NSR. SBP 107-169/47-60 MAP 75-95, good correlation of a-line and NBP when SBP in the 120's, when SBP higher, there is a 20-30 point difference between a-line and NBP (a-line being higher). K 3.8--> 20 IV KCL. Evaluated by cardiac surger. To have CABG, second case . Carotid US done. To have PA/Lat CXR saturday or sunday (needs to be done within 48 hours of OR).\n\nResp: O2 titrated down to 2LNP, with O2 sats 97-100%, lungs clear.\n\nGI: swallowing pills when placed in custard. Good appetite. No SS insulin coverage required. Abdomen flat, (+) bowel sounds.\n\nGU: u/o 60-140cc/hour clear yellow urine, BUN 29, Cr 1.1\n\nNeuro: CIWA score remains at 0.\n\nSkin: skin intact.\n\nID: afebrile, WBC 6.6. Vanco d/c'd. Flagyl and levoflox changed to po. IV sites and introducer site clean.\n\nAccess: left radial a-line, R subclavian introducer, R PIV.\n\nSocial: family into visit. Updated on plan of care.\n\nA: stable without CP today. Tolerating increased ACE-I and BB. tolerating po's. Pre-op for Monday. No signs of withdrawal.\n\nP: continue to monitor HR/BP, follow CIWA score. Pre-op orders in progress. Check K and other lytes at .\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-16 00:00:00.000",
"description": "Report",
"row_id": 1308276,
"text": "CCU Nursing Progress Note\nS: c/o SSCP radiating down both arms. CP initially (had to clarify this with patient because he initially thought 10 was the best), when scale re-explained to pt, he rated pain to be a .\n\nO: see CCU flow sheet for complete objective data\n\nCV: HR 70-80 NSR with rare PVC up to 90's with CP. SBP 93-130/ (with lower SBP when asleep), up to SBP of 190 with CP. Lopressor increased to 25 mg tid and started on 12.5 mg captopril. With c/o CP, EKG with ST depression, resolving when pain free. For c/o CP, started on IV NTG, given 5mg IV lopressor X2, and 2 mg IV Morphine. HR slowed to 70's and SBP down to 120's. PA cath d/c'd, last PAD 12. Right femoral venous sheath pulled. No oozing at site, distal pulses palpable.\n\nResp: vent weaned over coarse of morning. Extubated at 1330. ABG on 40% mask: 7.45/39/99/28/-2. Changed to 6 LNP for pt. comfort with O2 sat 98-100%. Sat falling to low 90's with CP, therefore placed back on mask, currently at 50%. Lungs with bibasilar crackles posteriorly, clear anteriorly. ETS had--> thick tan secretions. + cough and gag since extubation.\n\nGU: foley draining clear yellow urine 35-100cc/hour, BUN 20, Cr 1.2\n\nNeuro: propofol gtt off @ 1310. Follows requests, MAE. CIWA scale instituted d/t hx of ETOH. Rating ~2.\n\nID: T max 99.8 po, on levoflox, vanco and flagyl. WBC 8.8\n\nAccess: PIV L AC #18, R PIV #18, R subclavian introducer, left radial a-line.\n\nSocial: wife and son in to visit. Updated on patient's condition.\n\nA: resp status stable post extubation. CP assoc with ST depression, resolved with beta blocker, nitrates and Morphine. Changes resolved post pain. No signs of ETOH withdrawal at present.\n\nP: continue to monitor resp status. Assess for CP, follow HR/BP. Monitor for signs of withdrawal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-05-17 00:00:00.000",
"description": "Report",
"row_id": 1308277,
"text": "CCU Nursing note\n0700-pt awoke c HA and CP c SBP 180s and HR ^90. IV nitro restarted @ 3mcg/kg. Sats decreased to 88%-placed on 50% face tent. EKG done ST depresions V3-V6 (previously c elvations when pain free). Team notified and into evaluate pt. Dosed 2mg morphine c desired effect. Now pain free -ntg @ 1.5mcg/kg c sBP 120s. Continue to monitor closely.\n"
},
{
"category": "ECG",
"chartdate": "2148-05-16 00:00:00.000",
"description": "Report",
"row_id": 127734,
"text": "Baseline artifact. Sinus rhythm. Relatively short P-R interval without other\nevidence of pre-excitation. Low limb lead voltage. Non-diagnostic Q waves in\nlead III. Non-specific ST-T wave changes with lateral ST segment depression\nwhich could be due to ischemia, drug effect, etc. Compared to the previous\ntracing of lateral ST segment sagging may be somewhat more apparent.\nClinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-16 00:00:00.000",
"description": "Report",
"row_id": 127735,
"text": "Sinus rhythm\nModest nonspecific ST-T wave changes\nSince previous tracing of , probably no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-15 00:00:00.000",
"description": "Report",
"row_id": 127736,
"text": "Probable sinus rhythm\nSlight ST-T wave changes - are nonspecific and within normal limits\nSince previous tracing of same date, ST-T wave changes decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-15 00:00:00.000",
"description": "Report",
"row_id": 127737,
"text": "Probable sinus rhythm.\nDiffuse ST-T wave abnormalities - suggsts ischemia - clinical correlation is\nsuggested\nSince previous tracing of , ST-T wave abnormalities decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-20 00:00:00.000",
"description": "Report",
"row_id": 127728,
"text": "Normal sinus rhythm. Short P-R interval. T wave inversions in leads III and aVF\nwith downsloping ST segments in leads V4-V6 suggest possible inferolateral\nischemia. Compared to the previous tracing of no diagnostic interim\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-19 00:00:00.000",
"description": "Report",
"row_id": 127729,
"text": "Sinus rhythm. Short P-R interval. Contined ST segment depression in the\ninferolateral leads. No diagnostic interim change compared to the previous\ntracing of .\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-19 00:00:00.000",
"description": "Report",
"row_id": 127730,
"text": "Sinus rhythm. Short P-R interval. Continued ST segment depressions especially\nin the inferolateral leads, which may be slightly more prominent but without\ndiagnostic interim change compared to the previous tracing of . Clinical\ncorrelation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-18 00:00:00.000",
"description": "Report",
"row_id": 127731,
"text": "Sinus rhythm. Borderline short P-R interval. ST segment depressions in\nleads I, II, III, aVF and V4-V6 compared to the previous tracing of \nwithout diagnostic interim change. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-18 00:00:00.000",
"description": "Report",
"row_id": 127732,
"text": "Sinus rhythm. Relatively short P-R interval without other evidence of\npre-excitation. Compared to the previous tracing of inferior and\nanterolateral ischemic appearing ST segment depressions are less marked at a\nslower heart rate. Clinical correlation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-17 00:00:00.000",
"description": "Report",
"row_id": 127733,
"text": "Sinus rhythm. Compared to the previous tracing of findings are as noted\nwith markedly more prominent inferior and anterolateral ST segment depressions\nwhich are now downsloping consistent with ischemia. Clinical correlation is\nsuggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-14 00:00:00.000",
"description": "Report",
"row_id": 127783,
"text": "Probable sinus rhythm\nDiffuse ST-T wave abnormalities - consistent with ischemia\nClinical correlation is suggested\nSince previous tracing of same date, ectopic atrial/? Accelerated junctional\nrhythm absent\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-14 00:00:00.000",
"description": "Report",
"row_id": 127784,
"text": "Probable ectopic atrial or Accelerated junctional rhythm\nDiffuse ST-T wave abnormalities consistent with ischemia\nClinical correlation is suggested\nSince previous tracing of same date, faster rate and further ST-T wave\nabnormalities present\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-14 00:00:00.000",
"description": "Report",
"row_id": 127785,
"text": "Junctional rhythm with probable \"echo\" beat\nProminent precordial lead T waves - are nonspecific and cannot exclude in part\nischemia or possible hyperkalemia\nClinical correlation is suggested\nSince previous tracing of same date, junctional rhythm rate faster\n\n"
},
{
"category": "ECG",
"chartdate": "2148-05-14 00:00:00.000",
"description": "Report",
"row_id": 127786,
"text": "Probable A-V junctional rhythm\nProminent precordial lead T waves - are nonspecific and cannot exclude in part\nischemia or possible htyperkalemia\nClinical correlation is suggested\nSince previous tracing of , changes as described now present and less\nsuggestive of prior inferior myocardial infarction\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916706,
"text": " 10:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx s/p ct's removed\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with\n REASON FOR THIS EXAMINATION:\n r/o ptx s/p ct's removed\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST :\n\n COMPARISON: .\n\n INDICATION: Chest tube removal.\n\n Since the recent study, various lines and tubes have been removed, with no\n evidence of pneumothorax. Cardiac and mediastinal contours are stable. The\n pericardium has resolved in the interval. There are bibasilar atelectatic\n changes which are slightly worse in the interval, and there is a possible\n small left pleural effusion.\n\n Previously present interstitial edema has resolved.\n\n IMPRESSION:\n No pneumothorax.\n Resolution of interstitial edema.\n Slight worsening of bibasilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916428,
"text": " 2:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: this is a pre-op film (pre-CABG, patient unable to go for PA\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with bradycardia and hypotension, pulmonary edema on chest\n CT, now improving, going for CABG on \n REASON FOR THIS EXAMINATION:\n this is a pre-op film (pre-CABG, patient unable to go for PA abd lat as is on\n nitro and heparin gtt and cannot leave the floor\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:16 .\n\n HISTORY: Bradycardia and hypotension. Pulmonary edema improving.\n\n IMPRESSION: AP chest compared to :\n\n Pulmonary edema and pleural effusions have cleared. Lungs are largely clear.\n Left-sided pleural thickening is probably calcified and long-standing. Heart\n size normal. No adenopathy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-20 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 916596,
"text": " 3:00 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion/Tamponade\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with CAD s/p off-pump CABG.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CAD, status post CABG.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable supine chest.\n\n FINDINGS: Since the previous examination, multiple lines and tubes have been\n placed. An endotracheal tube terminates 7.3 cm from the carina, just at the\n level of the thoracic inlet. Left internal jugular venous access sheath is in\n place with PA catheter traversing the sheath. The tip of the PA catheter is\n coiled within the main pulmonary artery, with the catheter tip directed\n inferiorly. Right- and left-sided chest tube and mediastinal drain in place.\n Nasogastric tube with tip in gastric fundus. Stable cardiomegaly. Note is\n made of pneumopericardium. There is no pneumothorax. Mild prominence of the\n pulmonary vasculature is consistent with mild congestive heart failure.\n Minimal left lower lobe atelectasis versus consolidation.\n\n IMPRESSION:\n 1. Pulmonary artery catheter is coiled within the main pulmonary artery.\n Endotracheal tube at thoracic inlet. Other lines and tubes in satisfactory\n position.\n 2. Cardiomegaly and mild congestive heart failure.\n 3. Pneumopericardium, consistent with patient's postoperative state.\n\n Findings discussed with at 4 p.m..\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 915848,
"text": " 10:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man w/ change in MS\n REASON FOR THIS EXAMINATION:\n ? ICH\n CONTRAINDICATIONS for IV CONTRAST:\n renal function\n ______________________________________________________________________________\n WET READ: KCLd TUE 11:33 PM\n study limited by patient motion\n no evidence of acute ich seen\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Change in mental status. Evaluate for intracranial hemorrhage.\n\n COMPARISON: Comparison is made to report from MR of the head dated , as images from this study were not immediately available for direct\n comparison.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: Study limited by patient motion. Allowing for this, there is no\n evidence of acute intracranial hemorrhage, shift of normally structures, or\n hydrocephalus. -white differentiation grossly appears intact. There is\n evidence of mucosal thickening within the ethmoid airspaces and possible small\n fluid level within the right maxillary sinus.\n\n IMPRESSION: Limited study secondary to patient motion. No evidence of acute\n intracranial hemorrhage. Sinus opacification, as described. Follow-up\n examination should be performed when the patient is able to lie still, if\n clinical signs persist.\n DFDgf\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-14 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 915849,
"text": " 10:57 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? catastrophe in chest/abd\n Field of view: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with bradycardia,hypotension,\n REASON FOR THIS EXAMINATION:\n ? catastrophe in chest/abd\n CONTRAINDICATIONS for IV CONTRAST:\n renal fxn\n ______________________________________________________________________________\n WET READ: KLMn TUE 11:51 PM\n Bilateral moderate pleural effusions and bilateral dependent airspace\n consolidation -- pneumonia vs aspiration.\n\n Extensive coronary artery and aortic calcifications, no aneurismal dilation of\n aorta.\n\n Stranding around pancreas. Please correlate with labs.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypotension and bradycardia, evaluate for catastrophe.\n\n COMPARISON: Chest x-ray from the same day.\n\n TECHNIQUE: Multidetector CT scanning of the chest, abdomen and pelvis was\n performed without oral or intravenous contrast. Coronal and sagittal\n reformations were obtained.\n\n CT OF THE CHEST: The pericardium appears unremarkable. There are extensive\n calcifications of the coronary arteries. The heart is not enlarged. There are\n also extensive calcifications of the thoracic aorta, which does not\n demonstrate aneurysmal dilation. An endotracheal tube and a nasogastric tube\n are seen within the trachea and esophagus, respectively. The lungs\n demonstrate bilateral dependent consolidative opacities as well as bilateral\n small pleural effusions. There is increased central ground-glass opacity\n bilaterally as well. Pleural calcifications are identified. The airways are\n patent to the level of the segmental bronchi bilaterally. Shotty mediastinal\n lymphadenopathy is incompletely evaluated on this non-contrast study, but\n there do not appear to be any clearly pathologically enlarged lymph nodes.\n\n CT OF THE ABDOMEN: The examination is limited by lack of intravenous\n contrast. The liver, adrenal glands, and spleen appear unremarkable. The\n gallbladder is not distended, but its wall cannot be well assessed on the\n current study. There is higher density within its lumen centrally. There\n appears to be some stranding in the retroperitoneum surrounding the pancreas,\n most prominently in the region of the pancreatic head. The kidneys are\n symmetric in size without evidence of hydronephrosis. A new hypodensity is\n seen in the left kidney, measuring 20 in attenuation. There is mild\n nonspecific stranding around the kidneys. No dilated loops of small or large\n bowel are identified. No free intraperitoneal air is identified. The vascular\n (Over)\n\n 10:57 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: ? catastrophe in chest/abd\n Field of view: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n structures demonstrate extensive calcification of the abdominal aorta and all\n of its major branches; in the mid aorta there is some more central\n calcification, incompletely evaluated. There is a small amount of ascites in\n the left upper quadrant.\n\n CT OF THE PELVIS: The bladder, prostate, seminal vesicles and rectum appear\n unremarkable. Scattered diverticula are seen within the colon. None appear\n acutely inflamed. No obvious pathologically enlarged pelvic or inguinal\n lymphadenopathy is identified. The appendix is visualized and is normal.\n Small bilateral fat-containing inguinal hernias are identified. There is a\n small right-sided hydrocele.\n\n The osseous structures do not demonstrate any fractures. There are\n degenerative changes of the spine, and grade 1 anterolisthesis of L5 on S1.\n There is a sclerotic focus in the right femoral head.\n\n IMPRESSION:\n 1. Evidence of congestive heart failure with bilateral pleural effusions. In\n addition, there are consolidative opacities posteriorly, which could represent\n atelectasis or possibly aspiration. The congestive heart failure has\n progressed dramatically since the prior study of one and a half hours prior.\n 2. Extensive calcifications of the coronary arteries, the aorta, and its\n major branches. No evidence of aneurysmal dilation.\n 3. Nonspecific stranding in the region of the pancreas. Please correlate\n with lab values.\n 4. Colonic diverticula without clear evidence of diverticulitis.\n 5. New left renal hypodensity. Please further evaluate with ultrasound.\n 6. High density material within gallbladder lumen. Please correlate with\n ultrasound.\n\n Findings were communicated to the Emergency Department dashboard and discussed\n with the clinical team.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 916016,
"text": " 2:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pulmonary edema, infiltrates\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with bradycardia and hypotension, pulmonary edema on chest\n CT, now improving, s/p autodiuresis\n REASON FOR THIS EXAMINATION:\n eval pulmonary edema, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of patient with pulmonary edema.\n\n Portable AP chest radiograph compared to .\n\n IMPRESSION: The tip of the right subclavian sheath is at the level of the\n junction between the right subclavian vein and right internal jugular vein.\n The bilateral pulmonary edema is grossly unchanged, but there is increase in\n the fluid in the major fissure on the left. The left lower lobe consolidation\n is due to atelectasis. There is no sizable amount of right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915838,
"text": " 9:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with s/p intubation\n REASON FOR THIS EXAMINATION:\n assess for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate endotracheal tube position.\n\n COMPARISON: Chest x-ray from .\n\n PORTABLE AP UPRIGHT CHEST RADIOGRAPH: An endotracheal tube is seen 6.2 cm\n above the carina. A nasogastric tube tip is coiled in the fundus of the\n stomach. The heart is not enlarged. The mediastinal contours appear\n unremarkable, with some calcification at the aortic knob. The hila are\n slightly prominent bilaterally. The lungs are grossly clear. No pleural\n effusions or pneumothoraces are identified. Surrounding osseous and soft\n tissue structures appear unremarkable.\n\n IMPRESSION: Endotracheal tube in appropriate position. Slightly prominent\n pulmonary vasculature without frank congestive heart failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915842,
"text": " 9:59 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: LINE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n COMPARISON: Chest x-ray from 15 minutes earlier.\n\n SINGLE PORTABLE AP SEMI-UPRIGHT CHEST RADIOGRAPH: There is a new right\n subclavian central venous catheter with its tip at the junction of the\n brachiocephalic vein and the superior vena cava. The endotracheal tube and\n nasogastric tube are in unchanged positions. No pneumothorax is identified.\n Pulmonary vasculature is prominent, more so than the prior study, which may be\n positional, or may relate to slightly worsening volume overload.\n\n IMPRESSION:\n 1. Right subclavian central venous catheter tip is at the junction of the\n brachiocephalic vein and the superior vena cava. No pneumothorax.\n 2. Mild congestive heart failure. Please correlate clinically.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-17 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 916227,
"text": " 3:46 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: r/o stenosis\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with CAD\n REASON FOR THIS EXAMINATION:\n r/o stenosis\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Carotid series complete.\n\n REASON: Coronary artery disease. Preop CABG. Status post right carotid\n endarterectomy.\n\n FINDINGS: Duplex evaluation was performed of bilateral carotid arteries.\n There is no plaque noted in the right carotid. On the left, there is a\n moderate amount of plaque in the proximal and mid ICA.\n\n On the right, peak systolic velocities are 111, 108, and 115 in the ICA, CCA,\n and ECA respectively. This is consistent with no stenosis.\n\n On the left, peak velocities are 160, 102, and 332 in the ICA, CCA, and ECA\n respectively. The ICA end-diastolic velocity is 35. The ICA/CCA ratio is\n 1.5. This is consistent with 60-69% stenosis.\n\n There is antegrade vertebral flow bilaterally.\n\n IMPRESSION: No stenosis of the right carotid. 60-69% left carotid stenosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 915870,
"text": " 8:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with bradycardia and hypotension, pulmonary edema on chest CT\n REASON FOR THIS EXAMINATION:\n Assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bradycardia and hypotension.\n\n COMPARISON: Chest radiograph from and chest CT from .\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: Endotracheal tube and nasogastric tube\n remain in standard positions. A right subclavian central venous catheter tip\n lies within the junction of the internal jugular and right subclavian vein.\n Heart is top normal in size. The aortic knob is calcified. Increased\n bilateral interstitial opacities indicate worsening pulmonary edema. Confluent\n opacity within the left lower lobe likely represents superimposed aspiration\n or pneumonia. No effusions or pneumothorax is present.\n\n IMPRESSION:\n\n 1. Worsening pulmonary edema.\n\n 2. Left lower lobe consolidation, likely representing superimposed pneumonia\n or aspiration.\n DFDdp\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-05-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 917222,
"text": " 2:22 PM\n CHEST (PA & LAT) Clip # \n Reason: eval post op\n Admitting Diagnosis: BRADYCARDIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval post op\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS\n\n INDICATION: 76-year-old man status post CABG.\n\n COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared\n with previous study of .\n\n The previously identified congestive heart failure has been markedly\n improving. There is improving left lower lobe opacity indicating atelectasis\n versus pneumonia. There is continued small bilateral pleural effusion. The\n patient has prior CABG and median sternotomy.\n\n IMPRESSION: Improving congestive heart failure. Improving left lower lobe\n opacity, probably atelectasis.\n\n\n"
}
] |
6,027 | 181,593 | 80 y/o female with recent diagnosis of acute cholecystitis who present from rehab with dyspnea found to have PE on CTA and thrombocytopenia. . 1. PE/DVT and thrombocytopenia: The patient presented with multiple thrombi in lungs and legs. She was found to have HIT type 1 which was thought to be the main driver of the clotting. Complicating her treatment was her simultaneous DIC which was felt to be driven by her likely (although never biopsy proven) locally advanced gallbladder cancer. The patient was treated with empiric antibiotics directed at acute cholecystitis but further imaging was not consistent with active infection or gallbladder inflammation. The patient was felt to have both DIC and HIT as she had a significantly positive PF4 antibody and evidence of hemolysis and a consumptive coagulopathy. In discussions with the patient's family, given that the underlying DIC cause (i.e. gallbladder cancer) was not treatable and therapies for the HIT driven thromboembolic disease would put her at significant risk for bleeding, comfort was made the prime goal of care. Over the course of the next day, her consumptive coagulopathy progressed with resulting oliguria and depressed mental status. The patient's condition continued to deteriorate and she expired in the early morning of . The family (son and daughter-in-law) was . The family declined autopsy. . 2. Hypercalcemia - Patient with elevated calcium, appears to have elevated CA at baseline. Most likely secondary to hyperparathyroidism as this has been noted in OMR worsened by the thiazide diuretic. . 3. Diabetes - BS elevated, will cover patient with RISS . 4. CAD - Patient with history of fixed defect on stress-MIBI. - Will hold ASA given thrombocytopenia - Continue BBlocker and statin once po . 5. PPx - supratheraputic INR, tylenol, bowel regimin . FEN - NPO . Code - DNI/DNR, later changed to CMO following extensive discussions with her next of and his wife. . Dispo: expired | FINDINGS: The left common femoral, superficial femoral and popliteal veins are partially compressible, indicative of intraluminal thrombus. FINDINGS: Two views with the frontal view labeled "AP upright stretcher" limited by patient rotation and chin overlying the right lung apex, are compared with most recent examination dated . FINAL REPORT STUDY: BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND. There is a focal area of rounded hypodensity within the lower thoracic aortic lumen measuring approximately 1.1 cm in diameter seen on multiple images (series 3, image 69) which appears to correlate with intraluminal thrombus. There are prominent, non-pathologic mediastinal and hilar lymph nodes. progressive decline in neuro status to unresponsive.CV: HR 118-140 Afib freq PVC. Dampened waveforms were obtained within the right popliteal and right superficial femoral veins, respectively. TECHNIQUE: Non-contrast MDCT axial images of the chest were acquired. Sinus rhythm with ventricular and atrial premature beats. There is a small, associated right pleural effusion and diffuse ground-glass opacity distal to the obstruction which could be consistent with early pulmonary infarction. Small intra-aortic thrombus, unchanged compared to a CT from . The aorta is diffusely calcified. There is diffuse osteopenia with slight anterior wedging of multiple thoracic vertebrae and resultant kyphosis, as before. Dopper analysis reveals dampened waveforms of the left common femoral, superficial femoral, and popliteal veins, respectively. CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: Within the distal portion of the right main pulmonary artery, there is a filling defect that extends into the major artery to the right lower lobe of the lung almost completely fills the lumen and extending into multiple distal vessels. Ground-glass opacity and small right pleural effusion distal to the major portion of pulmonary embolism could reflect small pulmonary infarction. Allowing for the persistently low lung volumes, there is cardiomegaly with left ventricular enlargement. lungs clear dim bases.GI: abd soft distended Hypoactive BS. There are diffuse degenerative changes of the thoracic spine. Downsloping ST segmentdepression in leads I and aVL suggest possible anterolateral ischemia. Patient is pale and diaphoretic. Limited views (Over) 3:38 PM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: assess for PE, pneumonia FINAL REPORT (Cont) of the upper abdomen demonstrate a few rounded areas of hypodensity that likely correspond with intrahepatic biliary ductal dilatation that was present on the previous CT scan from . In ED patient found to have elevated WBC, hypercalcemia and given IVF and thrombocytopenia, may be due to unasyn induced. Intraluminal thrombus extending from the left common femoral vein to the popliteal vein, nonocclusive. The right popliteal vein, difficult to assess, is likely not completely compressible and may contain intraluminal thrombus as well. Pt progressived to , apnea. Wanted to make sure it was documented that she was dnr/dnia. FINAL REPORT STUDY: CTA of the chest with and without contrast. Intraluminal thrombus extending from the right superficial femoral vein distally, possibly to the popliteal vein, also nonocclusive. Downsloping ST segmentdepressions also noted in the anterior precordial leads. Clot also within RUL segmental artery and tiny filling defect with left upper lobe branch. The right superficial femoral proximal to distal veins are also noncompressible, indicative of intraluminal thrombus as well. Normal waveforms were obtained in the right common femoral vein. There has been interval placement of a left-sided PICC with tip in the distal SVC. RIGHT UPPER QUADRANT ULTRASOUND: Again seen is a gallbladder which demonstrates wall thickening. Peripheral cool clammy mottled pulsed +doppler. Cholelithiasis is also again noted. This area is unchanged compared to the patient's CT of the abdomen from . Cannotexclude prior inferior myocardial infarction. Pt expired and pronounced @0320.recieved pt cool clammy LE mottled, lethargic but arousable.neuro: @ start of shift responsive to verbal stimulation, nods yes/no/ language barrier. NPOGU: foley u/o 0-10cc/hr rising Creat.Social: DNR/DNI, comfort. Prominent, ectatic ascending thoracic aorta. IMPRESSION: Cardiomegaly and low lung volumes but no CHF. IVF NS at 200cc qhrPedal pulses + dopplerableresp 4lnp o2 sats 94-97% lungs clear diminished basesGI Had US of gallbladder which showed persistent areas of thickening within the gallbladder wall and an enlarged perportal lymph node concerning for cancer. There is a small filling defect within the segmental branch to the left upper lobe that could also be pulmonary embolism. Afib to SB to idioventricular @ 0320 Resp ceases assystolic Pronounced by MD.. Family notified and arrived s/p expired. REASON FOR THIS EXAMINATION: assess for PE, pneumonia No contraindications for IV contrast WET READ: 5:29 PM Large filling defect just distal to lobar branching point from right main pulmonary artery within segmental branch to RLL and associated right pleural effusion and ground glass changes - pulmonary infarct is possible. starting labetolol gtt or esmolal gtt for tachyarrthymia, medicate pt prn pain, monitor coag, hct, bair hugger prn, antibx as ordered Coronal, sagittal, and oblique reformatted images were then obtained. correct inr ^4.9, monitor neuro status for lethargy, watch for signs of bleeding, emotional support patient and family. \@0300 tachypneic rr 40 to agonal moaning resp status. COMPARISON: CT scan from . Within the posterior-inferior portion of the left upper lobe, there is an area of diffuse streaky opacity. | 9 | [
{
"category": "Radiology",
"chartdate": "2116-05-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 960555,
"text": " 3:49 PM\n CHEST (PA & LAT) Clip # \n Reason: assess for infiltrate, effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman p/w N/V, abd pain, h/o cholecystitis (d/ced ), also w/\n hypoxia\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS DATED \n\n HISTORY: 80-year-old woman with nausea, vomiting, and abdominal pain, history\n of cholecystitis, also with hypoxia; evaluate for infiltrate or effusion.\n\n FINDINGS: Two views with the frontal view labeled \"AP upright stretcher\"\n limited by patient rotation and chin overlying the right lung apex, are\n compared with most recent examination dated . There has been interval\n placement of a left-sided PICC with tip in the distal SVC. Allowing for the\n persistently low lung volumes, there is cardiomegaly with left ventricular\n enlargement. No evidence of CHF. There is right basilar linear atelectasis,\n but no focal consolidation is seen. There is diffuse osteopenia with slight\n anterior wedging of multiple thoracic vertebrae and resultant kyphosis, as\n before.\n\n IMPRESSION: Cardiomegaly and low lung volumes but no CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-05-28 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 960552,
"text": " 3:38 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: assess for PE, pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with h/o DVT, surgery several wks ago, minimally ambulatory,\n p/w dypsnea, tachypnea.\n REASON FOR THIS EXAMINATION:\n assess for PE, pneumonia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:29 PM\n Large filling defect just distal to lobar branching point from right main\n pulmonary artery within segmental branch to RLL and associated right pleural\n effusion and ground glass changes - pulmonary infarct is possible. Clot also\n within RUL segmental artery and tiny filling defect with left upper lobe\n branch. Pulmonary embolism.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CTA of the chest with and without contrast.\n\n INDICATION: 80-year-old female with history of surgery times several weeks\n ago presenting with dyspnea, tachypnea. Assess for pulmonary embolism.\n\n COMPARISONS: None.\n\n TECHNIQUE: Non-contrast MDCT axial images of the chest were acquired.\n Following the administration of 90 cc of Optiray intravenous contrast, MDCT\n axial images were acquired from the thoracic inlet to the upper abdomen.\n Coronal, sagittal, and oblique reformatted images were then obtained.\n\n CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: Within the distal portion of\n the right main pulmonary artery, there is a filling defect that extends into\n the major artery to the right lower lobe of the lung almost completely\n fills the lumen and extending into multiple distal vessels. There is a small,\n associated right pleural effusion and diffuse ground-glass opacity distal to\n the obstruction which could be consistent with early pulmonary infarction.\n There are multiple filling defects in the major segmental branches to the\n right upper lobe as well. There is a small filling defect within the\n segmental branch to the left upper lobe that could also be pulmonary embolism.\n The left main pulmonary artery is clear. There are no filling defects within\n the left lower lobe segemental arteries. The thoracic aorta is prominent\n measuring approximately 4.7 cm in diameter. The aorta is diffusely calcified.\n There is a focal area of rounded hypodensity within the lower thoracic\n aortic lumen measuring approximately 1.1 cm in diameter seen on multiple\n images (series 3, image 69) which appears to correlate with intraluminal\n thrombus. This area is unchanged compared to the patient's CT of the abdomen\n from . There is no evidence of acute aortic dissection. There are\n prominent, non-pathologic mediastinal and hilar lymph nodes. There are no\n pathologic axillary lymph nodes. There is minimal, bibasilar dependent\n atelectasis. There are a few linear areas of atelectasis within the right\n middle lobe along the periphery. Within the posterior-inferior portion of the\n left upper lobe, there is an area of diffuse streaky opacity. Limited views\n (Over)\n\n 3:38 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: assess for PE, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of the upper abdomen demonstrate a few rounded areas of hypodensity that\n likely correspond with intrahepatic biliary ductal dilatation that was present\n on the previous CT scan from .\n\n Bone windows demonstrate no suspicious lytic or blastic lesions. There are\n diffuse degenerative changes of the thoracic spine.\n\n IMPRESSION:\n\n 1. Bilateral pulmonary emboli, greatest within the distal right main\n pulmonary artery extending into the right upper and right lower lobes. Small\n pulmonary embolus within the arteries to the left upper lobe. Ground-glass\n opacity and small right pleural effusion distal to the major portion of\n pulmonary embolism could reflect small pulmonary infarction.\n\n 2. Prominent, ectatic ascending thoracic aorta.\n\n 3. Small intra-aortic thrombus, unchanged compared to a CT from .\n\n Findings were discussed with Dr. by Dr. over the telephone\n at 11:30 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-05-29 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 960688,
"text": " 1:13 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: please assess any progression of cholecystitis\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with CAD, HTN, DM2, with acute cholecystitis, now in DIC\n REASON FOR THIS EXAMINATION:\n please assess any progression of cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old woman with coronary artery disease and hypertension,\n now with gallbladder mass, and possible acute cholecystitis. Evaluate for\n interval change.\n\n COMPARISON: CT scan from .\n\n RIGHT UPPER QUADRANT ULTRASOUND: Again seen is a gallbladder which\n demonstrates wall thickening. Again seen are several gallstones within the\n gallbladder. There is also evidence of soft tissue thickening within the\n lumen of the gallbladder, and the lung wall, which is assessed on the prior\n study of . No pericholecystic free fluid is seen. There is a large\n round 2.6 x 3.1 x 2.3 cm hypoechoic nodule within the periportal region, which\n is seen on the recent CT scan as well. The remainder of the liver is normal\n in appearance. No free fluid is seen.\n\n IMPRESSION: Persistent areas of thickening within the gallbladder wall, and\n soft tissue within the lumen, with an enlarged periportal lymph node. These\n findings are concerning for gallbladder carcinoma. Cholelithiasis is also\n again noted. No free fluid is seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2116-05-28 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 960576,
"text": " 6:25 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: Evaluate for DVT\n Admitting Diagnosis: PULMONARY EMBOLIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with dyspnea and PE\n REASON FOR THIS EXAMINATION:\n Evaluate for DVT\n ______________________________________________________________________________\n WET READ: 7:27 PM\n Bilateral DVT - on right SFV to distal SFV - poss extending into popliteal. On\n the left - clot extends from SFV to popliteal.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND.\n\n INDICATION: 80-year-old female presenting with dyspnea. Assess for DVT.\n\n COMPARISONS: None.\n\n FINDINGS: The left common femoral, superficial femoral and popliteal veins\n are partially compressible, indicative of intraluminal thrombus. The right\n superficial femoral proximal to distal veins are also noncompressible,\n indicative of intraluminal thrombus as well. The right popliteal vein,\n difficult to assess, is likely not completely compressible and may contain\n intraluminal thrombus as well. Dopper analysis reveals dampened waveforms of\n the left common femoral, superficial femoral, and popliteal veins,\n respectively. Normal waveforms were obtained in the right common femoral vein.\n Dampened waveforms were obtained within the right popliteal and right\n superficial femoral veins, respectively.\n\n IMPRESSION:\n\n 1. Intraluminal thrombus extending from the left common femoral vein to the\n popliteal vein, nonocclusive.\n\n 2. Intraluminal thrombus extending from the right superficial femoral vein\n distally, possibly to the popliteal vein, also nonocclusive.\n\n Findings discussed with. Dr. by Dr. over the telephone at 12\n am on .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-30 00:00:00.000",
"description": "Report",
"row_id": 1341652,
"text": "MICU 6 RN Note 1900-0500\n\nEvents: DNR/DNI Interned called Family to update prognosis. Goals of care to make comfortable. Pt expired and pronounced @0320.\nrecieved pt cool clammy LE mottled, lethargic but arousable.\nneuro: @ start of shift responsive to verbal stimulation, nods yes/no/ language barrier. opens eyes, pupils 3mm equal react brisk. MAE random. progressive decline in neuro status to unresponsive.\nCV: HR 118-140 Afib freq PVC. NBP 123-100/60-48 MAPS ^60. IV access L Brachial PICC NS 200cc/hr. Peripheral cool clammy mottled pulsed +doppler. Labs Ca ^INR 5.0 DIC.\nResp: tachypneic RR 30-40 @ times agonal moaning recieved Morphine 2mg x3. O2 4l/min NC. Sats 95-100%. lungs clear dim bases.\nGI: abd soft distended Hypoactive BS. no stool. NPO\nGU: foley u/o 0-10cc/hr rising Creat.\nSocial: DNR/DNI, comfort. Family notified @ start of shift pt prognosis and wanted to honor pt wishes comfort measures. \\\n@0300 tachypneic rr 40 to agonal moaning resp status. Intern notified of status change and Family called. Pt progressived to , apnea. Afib to SB to idioventricular @ 0320 Resp ceases assystolic Pronounced by MD.. Family notified and arrived s/p expired. yellow band ring removed by son and taken by family. No personal belongings. Post mortem care completed and body taken to morgue by transport.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-29 00:00:00.000",
"description": "Report",
"row_id": 1341650,
"text": "Nursing progress Notes (1900-0700)\nReview carevue for all other objective data\nAllergy : NKDA\nCode: DNR/DNI\n\n86 yo female with PMH/o CAD,HTN, TIAs Hyperparathyroidism on unasyn at rehab for acute cholecystitis presented to ED with lethargy and on CTA found to have PE in the Rt pulmonary artery and left upper lobe branch. In ED patient found to have elevated WBC, hypercalcemia and given IVF and thrombocytopenia, may be due to unasyn induced. Patient seen by surgery and not a candidate for surgery now until patient is more stable. Patient diagnosed with bilateral DVT\"s on LE and treated with coumadin and inr is 3.5 and all heparin products are held.\n\nNeuro: Patient is russian speaking, and per family patient is progressively lethargic and confused. Patient is lethargic but easily arousable, not following any commands. Lives alone one month before and since 1 month resident of rehab.\n\nCv: Patient is in a fib with rate of 90-120 with occasional pvc's, po lopressor is on hold as patient is lethargic and unable to take po meds. SBP 120-170's. Patient's fibrinogen is 85 and need to observe for signs of bleeding. with am labs fibrinogen 79 from 85 and inr 4.9 from 3.5, no signs bleeding noted, and LDH is also elevated.\n\nResp: Up on admission patient was on NRB and changed to 4L nasal canula and o2 sats 98-100%. Bilateral lung sound clear and diminished at the base.\n\nGI: NPO, and abd soft distended and positive bowel sounds,no bm this shift and sample need to be send for c diff.\n\nGu: with h/o renal insuffiency, UO 20-80ml/hr via foley's catheter.\n\nEndo: insulin on ss\nskin: intact\nAccess: PIV on rt hand and PICC on lt lt hand\nSocial: visited by son last night and updated by MD with care and plan\n\nId: t- 95.4 and bair hugger on for 2hrs, continued on antibiotics, vanco/levo and flagyl.\n\nPLan: Monitor cardio/resp status, ? IVC filter in IR for emboli and dvt's, ? correct inr ^4.9, monitor neuro status for lethargy, watch for signs of bleeding, emotional support patient and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2116-05-29 00:00:00.000",
"description": "Report",
"row_id": 1341651,
"text": "Neuro lethagic to alert family in stating patient is confused. They stated she denied pain. Pupil equal reactive, localizes to pain\ncvs HR 70- with freq pvc and pac given lopressor 5mg IV x1 with good response an ekg taken team notified that she again went into rate 150 briefly but cont to be tachycardic >110. bp 122/55-176/80 hct 24.2 INR 4.8 no obvious signs of bleeding. Patient is pale and diaphoretic. Calicium level is 13.1. IVF NS at 200cc qhr\nPedal pulses + dopplerable\nresp 4lnp o2 sats 94-97% lungs clear diminished bases\nGI Had US of gallbladder which showed persistent areas of thickening within the gallbladder wall and an enlarged perportal lymph node concerning for cancer. Abd soft nontender + bowel sounds no stool\ngu urine output 20-30cc ivf 200cc qhr\nID temp 95.5 axillary wbc 18.2 flagyl, levofloxacin and vanco given\naccess rtw 20g and picc ltantecub\nsocial son and daughter in law in do not want any invasive procedures done. Wanted to make sure it was documented that she was dnr/dni\na. admitted for acute cholecystitis US concerning for gallbladder cancer\nSVT\nDIC\np. Need family meeting to discuss plan of care, family voicing that their main goal is comfort. Pt is dnr/dni\n? starting labetolol gtt or esmolal gtt for tachyarrthymia, medicate pt prn pain, monitor coag, hct, bair hugger prn, antibx as ordered\n"
},
{
"category": "ECG",
"chartdate": "2116-05-29 00:00:00.000",
"description": "Report",
"row_id": 114461,
"text": "Atrial fibrillation with a rapid ventricular response. Downsloping ST segment\ndepression in leads I and aVL suggest possible anterolateral ischemia. Cannot\nexclude prior inferior myocardial infarction. Downsloping ST segment\ndepressions also noted in the anterior precordial leads. Compared to the\nprevious tracing of no diagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2116-05-28 00:00:00.000",
"description": "Report",
"row_id": 114462,
"text": "Sinus rhythm with ventricular and atrial premature beats. No significant change\nfrom the tracing of .\n\n"
}
] |
25,196 | 195,924 | 52year old gentleman with background of diabetes, and hypercholesterolaemia, with HTN diagnosed in , admitted with a L thalamic bleed with extension to ventricular system. . Neuro: Pt was initially admitted to Neurosurgery service. L thalamic hemorrhage was about 10cc with extension to lateral and 3rd ventricles on imaging (see results above). Bilateral EVDs were placed on and revised . Cefazolin prophylaxis was continued while EVDs in place. Mental status improved and pt was extubated without incident on , and transferred to Neurology step down unit on . EVD was clamped and pt. developed increased ICPs to 30s, so VP shunt was placed with no complications on . Post-op Head CT showed decrease in ventricle size after shunt placement (see results above). He had no seizures in house. He was initially given phenytoin for seizure prophylaxis, which was titrated down prior to discharge. He should continue to be titrated off over the next 2 weeks (100 mg through , then 100 QD through , then off). BP was cotrolled with Metoprolol IV -> PO and Hydralazine IV PRN to maintain MAPs < 110. Angiogram was performed and showed no evidence of aneurysm, but did show a small arteriovenous fistula from the distal branches of the right internal maxillary artery / ethmoidal arteries with drainage into the ophthalmic vein and cavernous sinus. ENT was consulted about this and felt that it needed no acute intervention. This should be revisited by Neurology in follow up. The location of the hemorrhage was most consistent with a hypertensive bleed and as angiogram showed no other lesion this was felt to be the most likely cause of the hemorrhage. . On the floor pt. was evaluated by PT and OT, who recommended rehab, and speech, who felt that pt. was safe for advancement from tube feeds to a soft solid diet with thin liquids, which he tolerated well. Pt. should be reassessed by speech at rehab and advanced to a full diet if appropriate. . On day of discharge pt. had grip strength on the right, increased tone in his right arm, and some flexion of his right arm with pain, although he was unable to lift the R arm off the bed. He had decreased tone and UMN pattern weakness in his right leg but was able to lift it against gravity. He had R facial droop. He was awake and alert and conversing with his family in Cantonese. | pain dilaudid 1mg IV x1 given. OGT in place to LCWS with minimal amts drg. Pboots in place.RESP: Intubated. Last ABG was WNL with hyperoxygenation. Pt with foley in place, putting out adequate amts. tends to to bite down on the tube.B/S are ess. of clear urine.ID: Tmax 99.4 axillaryPLAN: Pt to have cerebral angio today and is to remain NPO for that procedure and ? Normal ECG except for rate. Pt went to CT x2 and OR for drain placement fix. Poor gag reflex.CV-HCT stable, HR 100-115 ST no ectopy, MAP goal 90-110, labetalol & hydralazine prn to meet goal. DC VENT DRAINS..CONTINUE WITH FREQ NEURO CHECKS LS coarse, lots of secretion suctioned in mouth.CV: Afebrile, HR NSR w/no ectopy. Med w/ dilaudid 1mg for discomfort so between the dilaudid and labetalol, BP down to 130s-140s and HR 100s. Admitted to SICU from OR @0100 S/P bilateral Burr Holes and ventricular drain placement. Sinus rhythmModest T wave inversion in lead V2 - may be in part positional/normal variantSince previous tracing of , sinus tachycardia absent and T waveinversion in leads V1 and V2 now seen Repeat CT this AMCV: NSR. SICU HO and Neuro Sx notified and in to eval. HR sinus tachy to 120s max. BLS CTA.GI: NPO. +PPGI: Soft abd, BS+. 0300 BUE w/intermittent slight tremors. Pt with 2 vent drains in place with the right drain putting out more than the left (see carevue for outputs).CV: Pt HR has been in ST with rate ranging 110-120s. Covered per RISS. DSD's to vent drains intact.Please refer to carevue for further details. drg noted on flatsheet. repleted Ca and K.GI: BS+,soft abd, OG LCS w/coffee ground drainage.GU: Foley patent ye/clea urine o/p.ENDO: On slidig scale. Withdraws to nailbed pressure. Pt opens eyes spontaneoulsy. STATUSD: FOLLOWS SOME SIMPLE COMMANDS MIN MOVEMENT OF RT SIDE..LF SIDE STRONG..P=REACT SLUGGISH..RESPONDS TO FAMILYA: HEAD CT DONE..ANGIO ON HOLD UNTIL THURSDAY..VENT DRAINS WITH SM AMT SEROUS SANG DRAINAGE..10CM AT TRAGUS..GOOD HUO..MED X2 WITH DILAUDID FOR RESTLESSNESS/HEAD PAIN..HYDRALIZINE X1 FOR MAP >110 WITH GOOD EFFECTR: STABLEP: AWAITING ANGIO ON THURSDAY..? Neuro MD possible baseline deficit to RUE where pt. ?Clamp trial today and angio tommorrow.CV/GU: good urine output. repeat head CT today. ?need 1:1 when transferred out. Resp. VEntricular drain managment, ? Sinus tachycardiaOtherwise normal ECGSince previous tracing of , sinus tachycardia rate faster Intuabted with a #7.5 ETT 22@lip. Went to the OR after first CT to little pull back the drains.RESP: On CMV,FiO2 .40, Peep 5,TV 600, no vent changes w/acceptable ABG"s.Suctioned for small amount of yel/thin secretions.LS are clear.CV: HR NSR w/no ectopy. Last 3hours urine o/p up to 220-260-280, HO Aware.ENDO: Labile blood glucose, o sliding scale.SKIN: Intact.Drain incision sides red, no drainage, intact.PLAN:Monitor respiratory status, needs more chest PT. HCt stable @29.6. HR 90-110's Sinus tach with rare PVC. SICU and Neuro Sx teams aware of rising BG. TF at 50cc, appears to be tol well, no N&V noted.GU-Foley with adequate u/oEndo-BS qid with SC coverage, scale tightened today d/t BS in 200sSkin-Vent drain sites C/D/I, no drng noted from site.A/p-Stable, Neuro checks q1hr, continue dilantin, continue IVFs untilTF goal met, monitor vent drain sites and drainage, MAP goal 90-110. repeat Head CT am, Pulmonary toileting. There is unchanged intraventricular hemorrhage. Overall unchanged appearance of the left frontal hemorrhage and the left basal ganglia hemorrhage surrounded by vasogenic edema, with slight decrease of the size of the left thalamic hematoma. Stable interval appearance of left thalamic hemorrhage and trace left to right shift of the third ventricle. Again note is made of hemorrhage in the left thalamus, measuring 3 x 0.3 cm surrounded by vasogenic edema, with small hyperdense foci in the left basal ganglia, overall unchanged since prior study. IMPRESSION: Unchanged right ventricular drain with further decrease of the ventricular size. Stable appearance to the thalamic hemorrhage with extension into the ventricles. IMPRESSION: Left thalamic and intraventricular hemorrhage. Again note is made of right intraventricular drain, unchanged since prior study, with further decrease of the ventricular size. IMPRESSION: Interval replacement of the right intraventricular drain as described above with resultant decrease in ventricular prominence. There are bilateral intraventricular drains as before. Imaging of the paranasal sinuses is unchanged with moderate mucosal thickening and bilateral sphenoid sinuses, scattered ethmoid air cells bilaterally, and mild mucosal thickening in the maxillary sinuses, left greater than right. Relatively small arteriovenous fistula is noted from the distal branches of the right internal maxillary artery / ethmoidal arteries with drainage into the ophthalmic vein and cavernous sinus. Again demonstrated is a large left thalamic hemorrhage, which has not changed appreciably in size measuring 2.4 x 1.8 cm (transverse, AP, with significant and somewhat worsened surrounding vasogenic edema). There remains a large left thalamic hemorrhage with surrounding vasogenic edema and a small amount of midline shift at this level. FINDINGS: The patient is status post removal of a left-sided intraventricular drain with foci of hemorrhage and gas along the former tract. IMPRESSION: S/p bilateral ventriculostomy tube placement, malpositioned as described above. Slightly decreased hemorrhage within the ventricle. FINAL REPORT INDICATION: Intracranial hemorrhage, Dobhoff placement. INDICATION: Intracranial hemorrhage, status post Dobbhoff line placement. Overall unchanged appearance of left thalamic bleed with small bleed in left basal ganglia and vasogenic edema. IMPRESSION: Significant interval change in left thalamic hemorrhage with mild shift of normally midline structures and dissemination of hemorrhage into bilateral anterior horns, third ventricle and fourth ventricle. FINAL REPORT HISTORY: Left thalamic hemorrhage. Bilateral intraventricular drains via a right frontal approach with their tips terminating in the anterior horns of the lateral ventricles bilaterally are unchanged in satisfactory position. Status post removal of left intraventricular drain with interval development of communicating hydrocephalus. However, inferior to the center of the hemorrhage, within the left hippocampus, there is an asymmetric prominent area of vasculature, likely veins. HEAD CT WITHOUT CONTRAST: Comparison is made to the prior head CT taken on . FINDINGS: There has been interval repositioning of bilateral intraventricular drains via a frontal approach with their tips now residing in the anterior horns of the lateral ventricles bilaterally, in satisfactory position. | 30 | [
{
"category": "Nursing/other",
"chartdate": "2145-12-18 00:00:00.000",
"description": "Report",
"row_id": 1591149,
"text": "NPN\nPlease see CareVue for full assessments\nPt. is a 52y.o Cantonese speaking male transferred to from with thalamic bleed. Admitted to SICU from OR @0100 S/P bilateral Burr Holes and ventricular drain placement. Pt. arrived intubated, paralyzed and sedated. Pupils 3mm and equal. Sluggish reaction to light. Bilateral drains to measure 10cc above middle of head per NeuroSx. Right drain>Left and darker in color. Left fluid lt pink and Right lt. red. Scant sang. drg noted on flatsheet. No futher episodes. Puncture area @left temporal from stabilizer in OR. team aware. Cleaned and left open to air. Not following commands or moving extremities. Delayed withdrawal response to nailbed pressure. Left extremities responding greater than right. Neuro MD possible baseline deficit to RUE where pt. has limited ROM. Also noted approx. 0300 BUE w/intermittent slight tremors. Neuromed in evaling at this time and aware. SICU HO and Neuro Sx notified and in to eval. Cont. to monitor. Repeat CT this AM\n\nCV: NSR. No ectopy noted. HR 90's Maintained goal SBP 100-140. Nimodipine dose held MD due to SBP 100 at time of dose. HCt stable @29.6. WBC 11.0. Afebrile. PPP. Pboots in place.\n\nRESP: Intubated. AC. No vent changes through noc. BLS CTA.\nGI: NPO. OGT in place to LCWS with minimal amts drg. To start TF possibly this AM per SICU team.\nENDO: BG 170-202. Covered per RISS. SICU and Neuro Sx teams aware of rising BG. Possible insulin gtt this AM per team.\nGU: 16Fr foley patent and draining QS clr yellow urine. Amt noted to dip off this AM to @35cc/Hr. SICU team aware.\nINTEG: Skin intact.\nPSYCHOSOCIAL: Family at bedside after admitted to SICU. HCP info explained and at bedside. Son to be contact. Family updated by attending and will be in late this AM. Family asked to please call with any concerns.\nPLAN: Neuros Q1H, maintain ventricular drains, administer Dilantin, repeat CT, monitor CV, maintain SBP goal 100-140, decrease IVF and initiate TF per SICU team, ?initiate Heparin SC, monitor labs, rplete electrolytes, previde support to pt/family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-18 00:00:00.000",
"description": "Report",
"row_id": 1591150,
"text": "Respiratory Care\nPt remains intubated and on vent support. Intuabted with a #7.5 ETT 22@lip. No vent changes were made during shift. Lung sounds were clear t/o. Suctioned for scant-small thick yellow. Pt went to CT x2 and OR for drain placement fix. Last ABG was WNL with hyperoxygenation. Care plan is to continue current therapy. Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-21 00:00:00.000",
"description": "Report",
"row_id": 1591157,
"text": "7pm-7am Nursing Note\nSee CarVue for objective data and trends:\n\nNEURO: Pt alert, Cantonese speaking. Pt with both calm, resting periods as well as periods of increased agitation and restlessness. Pupils at 3mm bilaterally and are very sluggish to react to light. Pt with minimal movement on right side and full strength on left. Pt verbalizing in Cantonese and, per family, pt is aware that he is in the hospital. Pt with 2 vent drains in place with the right drain putting out more than the left (see carevue for outputs).\n\nCV: Pt HR has been in ST with rate ranging 110-120s. BP ranging 140s-190s/80s-100s. Pt received a PRN dose of both IV hydralazine and IV labetolol at 0300 when pt's BP/MAP elevated. Pt also very agitated when BP increased as well. MAP back to goal of 90-110 at present.\n\nRESP: Pt on 50% shovel mask with humidification. POx 97-100%, LS clear to coarse and diminished at bases. Pt able to cough and raise small amounts of sputum overnoc.\n\nGI/GU: Pt with dobhoff tube in place. TF up to goal rate of 75 cc/hr however TF put on hold at midnight for Cerebral angiogram to be done . Abdomen soft with positive BS. Pt with foley in place, putting out adequate amts. of clear urine.\n\nID: Tmax 99.4 axillary\n\nPLAN: Pt to have cerebral angio today and is to remain NPO for that procedure and ? repeat head CT today. Continue to monitor neuro status closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-21 00:00:00.000",
"description": "Report",
"row_id": 1591158,
"text": "STATUS\nD: FOLLOWS SOME SIMPLE COMMANDS MIN MOVEMENT OF RT SIDE..LF SIDE STRONG..P=REACT SLUGGISH..RESPONDS TO FAMILY\nA: HEAD CT DONE..ANGIO ON HOLD UNTIL THURSDAY..VENT DRAINS WITH SM AMT SEROUS SANG DRAINAGE..10CM AT TRAGUS..GOOD HUO..MED X2 WITH DILAUDID FOR RESTLESSNESS/HEAD PAIN..HYDRALIZINE X1 FOR MAP >110 WITH GOOD EFFECT\nR: STABLE\nP: AWAITING ANGIO ON THURSDAY..? DC VENT DRAINS..CONTINUE WITH FREQ NEURO CHECKS\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-22 00:00:00.000",
"description": "Report",
"row_id": 1591160,
"text": "FULL CODE Universal Precautions\n\n\nPt is responsive, MEAx4 on command/spont. Cantonese speaking resident in this am to communicate w/ pt. He does not respond verbally, but does speak occ (\"ok. Thank you\") but it has been reported he's not all that verbal w/ his family. Pupils 3mm/sluggish. Bilat vent drains intact - not transduced. L has put out 50cc since 7am and R has put out 1cc. Drains now at 15cm at tragus from 10. Daughter called and updated.\n\nBP 130-150/60-80s - labetalol and hydralazine prn - no scheduled anti-HTN yet. HR=100-130s. Med w/ dilaudid 1mg for discomfort so between the dilaudid and labetalol, BP down to 130s-140s and HR 100s. + periph pulses, extrems warm. TF via dobhoff at 50cc/hr (goal=75cc) and IVF to be maintained at rate to equal 100cc/hr intake. Foley cath w/ clear yellow urine. Afebrile.\n\nTx to at 1100 via bed on monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-19 00:00:00.000",
"description": "Report",
"row_id": 1591154,
"text": "PLEASE SEE CAREVUE FOR SPECIFICS.\n\nNEURO:Not on any sedation. Alert, disorinted, inconsistly follow commands, interpreter and family help for communication, moves his left side, withdraws w/pain.PERRLA sluggish, right pupil's more reactive than left.On dilaudid PRN for pain. Two brain drains intact, drains 10cc/hr every one. After extibation right brain drain color changed to bright red, HO and neurosurgery resident aware.\nRESP: Extubated @2pm w/no accident. On %50 O2 w/face tent, post extubation ABG is acceptable. LS coarse, lots of secretion suctioned in mouth.\nCV: Afebrile, HR NSR w/no ectopy. After extubation HR went up to 100-110, SBP 160-170's, labetolol and hydralazine given. Goal SBP<150. +PP\nGI: Soft abd, BS+. Doboff tube placed by resident, started tube feeding 10cc/hr, goal 40cc/hr.\nGU: Foley patent yel/cle urine o/p. Last 3hours urine o/p up to 220-260-280, HO Aware.\nENDO: Labile blood glucose, o sliding scale.\nSKIN: Intact.Drain incision sides red, no drainage, intact.\nPLAN:Monitor respiratory status, needs more chest PT. Monitor blood pressure and urine o/p for diabetes insipidus. Check dilantin level and blood glucose closely. Increase tube feeding rate per order.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-20 00:00:00.000",
"description": "Report",
"row_id": 1591155,
"text": "Nursing Progress Note:\nNeuro: Pt alert, unable to assess orientation. Moving LUE and RUE. Otherwise not moving r side. Withdraws to nailbed pressure. BUt unable\nto follow and commands for Neuro MD, whom speaks chinese.\n\nCV:low grade temp. HR 110's, recieved several doses of labatol with little effect. Extremities warm with +PP.\nresp; Lung coarse, with mod amount of oral secretions. Attempting to\n\nsuction several times. Pt biting yankauer and would not accept VAP.\nGI: tol tube feed to continue with advancing pt goal of 50.\n\nGU: foley draining adequate clear yellow urine\n\nENDO: blood sugars WNL\n.\nPLAN: cont to monitor neuro exam. Keep Vent drain from >10-15cc/hr\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-20 00:00:00.000",
"description": "Report",
"row_id": 1591156,
"text": "7a-7p\nSee carevue for specifics:\nNeuro-Cantonese speaking only. Pupils equal at 3mm with sluggish reaction. L side strong, lifts and holds LUE/LLE. RUE initally no movement did not respond to pain, currently withdraws to nail bed pressure, RLE withdraws to pain. Increased alertness throughout day, attempting to speak to family, diff to assess orientatin d/t language barrier, appears to follow simple commands from daughter \n vent drains intact 10cm abouve the tragus with blood tinged drainage (goal 10-20cc). Tmax 100.4 tylenol 650mg given per NMED team. ? pain dilaudid 1mg IV x1 given. No obvious sz activity noted, continued on dilantin. Poor gag reflex.\nCV-HCT stable, HR 100-115 ST no ectopy, MAP goal 90-110, labetalol & hydralazine prn to meet goal. Hypotensive episode x1 NS bolus 500cc x2 given with good effect.\nResp-Spo2 95-100% on FT, LS coarse & diminished,(+)upper airway congestion, weak cough unable to clear, NT sxn multiple tiems for mod amts of thick, blood tinged sputum.\nGI-NPO, ABD soft NT/ND, (+)BSx4, No BM this shift. TF at 50cc, appears to be tol well, no N&V noted.\nGU-Foley with adequate u/o\nEndo-BS qid with SC coverage, scale tightened today d/t BS in 200s\nSkin-Vent drain sites C/D/I, no drng noted from site.\nA/p-Stable, Neuro checks q1hr, continue dilantin, continue IVFs until\nTF goal met, monitor vent drain sites and drainage, MAP goal 90-110. repeat Head CT am, Pulmonary toileting. Provide emotional support to PT and Family\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-22 00:00:00.000",
"description": "Report",
"row_id": 1591159,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nNeuro: Pt's family in earlier in evening and able to translate. Pt c/o pain in leg occasionally and medicated with dilaudid prn with good effect. Pt's family stated that pt less confused than the day before. Pt frequently agitated throughout night and attempting oob and pulling at catheter. Restraints in place. Pt following most commands, but unable to be left alone without restraints. ?need 1:1 when transferred out. Tmax 99.4. Bilat vent drains in place with blood tinged drainage. ?Clamp trial today and angio tommorrow.\n\nCV/GU: good urine output. HR sinus tachy to 120s max. BP elevated often and treated with hydralazine and labetolol prn with good effect. Discussed with team to add po antihypertensives to medical regime for a most consistent effect.\n\nGI: abdomen soft and bowel sounds present. Tube feeds restarted and to be held again at midnight tonight for angio on thursday.\n\nSKin: leg skin tears noted. spotted bruising to bilat legs and pt c/o itchiness of legs with dry skin. Lotion applied. DSD's to vent drains intact.\n\nPlease refer to carevue for further details. Pain management. Neuro checks q 1 hour. VEntricular drain managment, ? clamp today. Keep family updated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-18 00:00:00.000",
"description": "Report",
"row_id": 1591151,
"text": "PLEASE SEE CAREVUE FOR SPECIFICS.\n\nNEURO: Sedated w/Propofol, withdraws his right ext w/pain, moves his left upper and lower ext when awakened, opened his eyes spontaneously during daily wake up, doesn't follow commands. Pupils reactive, sluggish, no corneal reflex, cough and gag reflex intact. Two ventricular drains intact. 2 CT scan done. Went to the OR after first CT to little pull back the drains.\n\nRESP: On CMV,FiO2 .40, Peep 5,TV 600, no vent changes w/acceptable ABG\"s.Suctioned for small amount of yel/thin secretions.LS are clear.\n\nCV: HR NSR w/no ectopy. Goal 100<SBP<150, on PRN 10mg Labetolol w/really good effects. In the morning, his SBP dropped to the88-90mmHg, NEO started for BP, given only one hour, shut it off Now, SBP 130-140's. repleted Ca and K.\nGI: BS+,soft abd, OG LCS w/coffee ground drainage.\nGU: Foley patent ye/clea urine o/p.\nENDO: On slidig scale. BG was 55 in the morning, given 1/2amp D50. Very labile BG.\nSKIN: mostly intact.\nPLAN: Closely monitor blood pressure, keep SBP <150, closely monitor urine o/p and ventricular drains.Tube feeding ? tomorrow,support family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-19 00:00:00.000",
"description": "Report",
"row_id": 1591152,
"text": "Resp. Care\nPt remains on mech vent. No changes made during shift. Pt sx for mod amts of purelent thick yellow,but pt. tends to to bite down on the tube.B/S are ess. clear with few scat rhonchi.No planned trip to CT today.Plan is to monitor neuro status.No RSBI due to bilat vent drains.\n"
},
{
"category": "Nursing/other",
"chartdate": "2145-12-19 00:00:00.000",
"description": "Report",
"row_id": 1591153,
"text": "Nursing Progress Note:\n Neuro : pt sedated on propofol. Turned off last eve and this am for neuro exam. Pt opens eyes spontaneoulsy. Able to lift and hold LUE, moving on bed LLE, rare occasion of RUE & RLE with movement. Pupils 3mm sluggish. Vent drain 10 above tragus, occasionally have >10ml per hour of blood tinged CSF, but noted to be due to hyper cough and gag reflex.\n\n CV: low grade temp99.6. HR 90-110's Sinus tach with rare PVC. SBP 110-130's. Occasionally SBP >150 when coughing but returned to <150 with out intervention. extremities warm with +PP.\n\nRESP: lungs clear through out. Remains on AC 40%, 600X12 peep of 5. Breathing over at times. requiring occasional suctioning of thick yellow secretions.\n\nGI: abd soft with + BS, No stool today. NGT draining minimal coffee ground drg.\n\nGU: foley draining adequate clear yellow urine.\n\nENDO: blood sugars elevated requiring coverage per RISS.\n\nPLAN: Cont to monitor neuro exam. Vent drain to drain approx 10cc/hr.\n"
},
{
"category": "ECG",
"chartdate": "2145-12-31 00:00:00.000",
"description": "Report",
"row_id": 185810,
"text": "Sinus rhythm\nModest T wave inversion in lead V2 - may be in part positional/normal variant\nSince previous tracing of , sinus tachycardia absent and T wave\ninversion in leads V1 and V2 now seen\n\n"
},
{
"category": "ECG",
"chartdate": "2145-12-22 00:00:00.000",
"description": "Report",
"row_id": 185811,
"text": "Sinus tachycardia\nOtherwise normal ECG\nSince previous tracing of , sinus tachycardia rate faster\n\n"
},
{
"category": "ECG",
"chartdate": "2145-12-17 00:00:00.000",
"description": "Report",
"row_id": 185812,
"text": "Sinus tachycardia. Normal ECG except for rate. No previous tracing available\nfor comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-17 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 940161,
"text": " 8:16 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: eval for AVM, SAH\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with L thalamic bleed on CT with extension to ventricles\n REASON FOR THIS EXAMINATION:\n eval for AVM, SAH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KLMn FRI 9:52 PM\n No evidence of AVM. Stable appearance to the thalamic hemorrhage with\n extension into the ventricles.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left thalamic hemorrhage.\n\n COMPARISON: at 18:57.\n\n TECHNIQUE: Axial non-contrast head CT. Axial contrast images through the\n brain with multiplanar reformats were then performed.\n\n FINDINGS: There is continued evidence of the left thalamic and\n intraventricular hemorrhage. There is a small amount of edema surrounding the\n thalamic hemorrhage.\n\n There are no pathologic vessels in the region of the hemorrhage.\n However, inferior to the center of the hemorrhage, within the left\n hippocampus, there is an asymmetric prominent area of vasculature, likely\n veins.\n\n There is no definite aneurysm.\n\n Again seen are multiple air-fluid levels within the ethmoid, sphenoid, and\n maxillary sinuses bilaterally. There are no acute fractures.\n\n IMPRESSION: Left thalamic and intraventricular hemorrhage. Prominent veins\n in the left hippocampus, could represent a developmental venous anomaly.\n If this patient is not felt to have a hypertensive hemorrhage, an angiogram\n should be performed to evaluate for arteriovenous shunting, in which case, an\n arteriovenous malformation could be considered. This was discussed with Dr.\n , attending neurosurgeon- in- chief, on the morning of .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 940300,
"text": " 8:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: L THALAMIC BLEED, BILATERAL EVD , FOLLOW UP\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with L thalamic bleed, s/p bilat EVD and adjustment \n REASON FOR THIS EXAMINATION:\n follow-up CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup left thalamic bleed.\n\n COMPARISON: .\n\n TECHNIQUE: Axial MDCT images through the brain without IV contrast.\n\n FINDINGS: Again demonstrated is a large left thalamic hemorrhage which has\n not changed in size measuring approximately 2.4 x 1.7 cm. There is midline\n shift adjacent to the thalamic hemorrhage of approximately 5 mm, not changed\n from the prior study. There remains high-density material consistent with\n hemorrhage within the lateral ventricles as well as in the third and fourth\n ventricle. No new intra- or extra-axial hemorrhage is appreciated. The\n ventricles are not dilated. -white matter differentiation appears\n preserved. Bilateral intraventricular drains via a right frontal approach\n with their tips terminating in the anterior horns of the lateral ventricles\n bilaterally are unchanged in satisfactory position. Severe sinus disease\n including fluid levels and mucosal thickening within the ethmoid, sphenoid,\n maxillary and frontal sinuses is again noted.\n\n IMPRESSION: Significant interval change in left thalamic hemorrhage with mild\n shift of normally midline structures and dissemination of hemorrhage into\n bilateral anterior horns, third ventricle and fourth ventricle. There are two\n multiple air-fluid levels in the paranasal sinuses representing sinus disease.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 940240,
"text": " 4:33 PM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: post-op CT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with thalamic hemoorhage, s/p bilat intraventricular drains\n , drain adjustment \n REASON FOR THIS EXAMINATION:\n post-op CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man status post thalamic hemorrhage with\n intraventricular extent with repositioning of the bilateral intraventricular\n drains.\n\n COMPARISONS: CT head of earlier in the same day.\n\n TECHNIQUE: Axial MDCT images through the brain without IV contrast.\n\n FINDINGS: There has been interval repositioning of bilateral intraventricular\n drains via a frontal approach with their tips now residing in the anterior\n horns of the lateral ventricles bilaterally, in satisfactory position. There\n remains a large left thalamic hemorrhage with surrounding vasogenic edema and\n a small amount of midline shift at this level. There remains intraventricular\n hemorrhage seen within the anterior horns, third ventricle, dependently in the\n occipital horns, as well as in the fourth ventricle. This is not\n significantly changed. No new intra- or extra-axial hemorrhage is\n appreciated. -white matter differentiation appears preserved. There is\n severe and diffuse sinus disease as described previously, with multiple air-\n fluid levels.\n\n IMPRESSION: Successful repositioning of the bilateral intraventricular\n drains.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-23 00:00:00.000",
"description": "SEL CATH 3RD ORDER THOR",
"row_id": 940867,
"text": " 8:45 AM\n CAROT/CEREB Clip # \n Reason: ?Cerebral AVM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 173\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CERVICAL UNILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with thalamic bleed on CT scan with ? of AVM\n\n REASON FOR THIS EXAMINATION:\n ?Cerebral AVM\n ______________________________________________________________________________\n FINAL REPORT\n CEREBRAL ANGIOGRAM\n\n HISTORY: 52-year-old male with left thalamic and intraventricular bleed,\n assess for underlying cerebral AVM.\n\n RADIOLOGISTS: Drs. and , the Attending Neuroradiologist, present and\n supervising throughout.\n\n TECHNIQUE:\n\n Informed consent was obtained from the patient and the patient's family\n utilizing a Cantonese interpreter. The risks, benefits, and alternative\n management therapies were discussed. The risks discussed included cerebral\n infarcts, blindness both temporary and permanent, dissections, and death.\n\n The patient was brought to the fluoroscopy suite and a timeout was performed,\n confirming the patient's identification and procedure to be performed. The\n patient was placed on the biplane fluoroscopy table in the supine position.\n General anesthesia was provided by the anesthesiology team. The patient was\n prepped and draped in the usual sterile fashion. The skin and subcutaneous\n tissues of the right groin were infiltrated with 1% lidocaine buffered with\n bicarbonate. A small skin incision was made with a #2 scalpel. A 19-gauge\n needle was used to access the right common femoral artery via a single wall\n puncture. Through the needle, a 0.035 wire was introduced and the\n needle taken out. Over the wire, 4 French vascular sheath was placed and\n connected to a saline infusion (heparin 500 units in 500 cc of normal saline)\n with a continuous drip. Through the sheath, 4-French Berenstein catheter was\n introduced and connected to continuous saline infusion (1000 units of heparin\n in 1000 cc of normal saline). The following vessels were selectively\n catheterized and arteriograms were performed from these locations.\n\n (Over)\n\n 8:45 AM\n CAROT/CEREB Clip # \n Reason: ?Cerebral AVM\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 173\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. AP and lateral of the right vertebral artery.\n 2. AP and lateral of the right internal carotid artery as well as a 3D spin\n of the right internal carotid artery.\n 3. AP and lateral of the right external carotid artery.\n 4. AP and lateral of the right common carotid artery.\n 5. AP, lateral, and 3D spin of the left internal carotid artery.\n 6. AP, lateral, and 3D spin of the left external carotid artery.\n 7. AP and lateral of the left vertebral artery.\n\n After review of films, the catheter and sheath were withdrawn and manual\n compression was used to obtain hemostasis. The procedure was uneventful and\n there were no complications. The patient was sent to the ICU with orders.\n\n FINDINGS: No intraparenchymal arteriovenous malformations were seen. There\n are no aneurysms, stenoses, or occlusions.\n Right external carotid artery injection demonstrates an arteriovenous fistula\n from the distal branches of the right internal maxillary artery / ethmoidal\n arteries are seen to the ophthalmic veins and the cavernous sinuses\n bilaterally.\n\n IMPRESSION: No intraparenchymal arteriovenous malformations.\n\n Relatively small arteriovenous fistula is noted from the distal branches of\n the right internal maxillary artery / ethmoidal arteries with drainage into\n the ophthalmic vein and cavernous sinus.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 940153,
"text": " 6:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess extent of bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with ich\n REASON FOR THIS EXAMINATION:\n assess extent of bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa FRI 6:51 PM\n 2.5X2.1 cm hemorhage in the left thalamus with mild shift of midline structure\n (4 mm) with vasogenic edema, and dissemination of the blood into bilateral\n anterior horns of the ventricles, 3rd and 4th ventricles.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old woman with known intracranial hemorrhage.\n\n HEAD CT WITHOUT CONTRAST: There is no prior study for comparison in our\n system. Note is made of 2.5 x 2.1 cm acute hemorrhage in the left thalamus\n with surrounding vasogenic edema and mild shift of normally midline structures\n towards the right measuring 4 mm, with dissemination of the hemorrhage into\n the bilateral anterior horns of the ventricle, third ventricle, aqueduct, and\n into the fourth ventricle. There is mild mass effect due to the hemorrhage at\n the level of thalamus. There are multiple air fluid levels in bilateral\n ethmoid, sphenoid and maxillary sinuses, probably representing sinus disease.\n The visualized portion of mastoid air cells are clear, and osseous structures\n are unremarkable.\n\n IMPRESSION:\n 1. Acute hemorrhage in the left thalamus with surrounding vasogenic edema,\n mass effect, and mild shift of normally midline structures, and dissemination\n of the hemorrhage into bilateral anterior horns, third ventricle, aqueduct,\n and fourth ventricle.\n\n The wet read was flagged to ED dashboard.\n\n 2. Multiple air fluid levels in paranasal sinuses as described above,\n representing sinus disease.\n\n The findings were discussed with neurosurgeoun in person on the day of the\n exam.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 940201,
"text": " 7:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: EVALUATE FOR INTERVAL CHANGE, INTRAVENTRICULAR HEMORRHAGE, VENTRICULOSTOMY TUBE PLACEMENT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with intraventricular hemorrhage s/p b/l ventriculostomy tube\n placement\n REASON FOR THIS EXAMINATION:\n eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old with intraventricular hemorrhage status post\n bilateral ventriculostomy tube placement. Evaluate for interval change.\n\n COMPARISONS: CT head of and CTA head of the same day.\n TECHNIQUE: Axial MDCT images through the brain without IV contrast.\n\n FINDINGS: There has been placement of bilateral ventriculostomy tubes, both\n via frontal approach. The right drain enters the anterior of the right\n lateral ventricle, crosses the midline, and terminates within the inferior\n left basilar cistern. The left drain courses lateral to the anterior of\n the left lateral ventricle and enters the temporal , however, appears to\n pass through the temporal with its tip either residing within the extra-\n axial space anterior to the left cerebellar hemisphere or within the\n parenchyma just anterior to this. Again demonstrated is a large left thalamic\n hemorrhage, which has not changed appreciably in size measuring 2.4 x 1.8 cm\n (transverse, AP, with significant and somewhat worsened surrounding vasogenic\n edema). Additionally, there is midline shift adjacent to the thalamic\n hemorrhage of approximately 6 mm, also slightly increased from the prior\n study. There remains hemorrhage seen in the anterior and occipital horns of\n the lateral ventricles as well as in the third and fourth ventricle.\n Ventricular size does not appear significantly changed. There is a small\n amount of hemorrhage seen along the tract of the left ventricular drain,\n however, there has not been progression of significant new intra- or extra-\n axial hemorrhage. There remains sinus disease in air-fluid levels throughout\n the visualized paranasal sinuses, not significantly changed from the prior\n study.\n\n IMPRESSION: S/p bilateral ventriculostomy tube placement, malpositioned as\n described above. Slight interval increase in vasogenic edema and midline\n shift adjacent to the dominant left thalamic hemorrhage. D/w covering resident\n Dr. .\n\n\n\n\n\n (Over)\n\n 7:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: EVALUATE FOR INTERVAL CHANGE, INTRAVENTRICULAR HEMORRHAGE, VENTRICULOSTOMY TUBE PLACEMENT\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-18 00:00:00.000",
"description": "SKULL (CALDWELL, LFT LAT, TOWNES & BASE)",
"row_id": 940241,
"text": " 4:44 PM\n SKULL (, LFT LAT, & BASE); SKULL FLUORO Clip # \n Reason: REVISION OF CRANIAL DRAIN\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Revision of drain.\n\n Two lateral intraoperative fluoroscopic views of the skull obtained without\n radiologist present. These demonstrate tubing projecting over the oropharynx\n and cranium. For additional details, please consult the operative report.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 940335,
"text": " 2:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm dobhoff placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with intracranial hemmorhage, s/p dobhoff placement, intubated,\n increased secretions\n REASON FOR THIS EXAMINATION:\n confirm dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n HISTORY: Intracranial hemorrhage status post Dobbhoff placement.\n\n FINDINGS: The endotracheal tube tip is 4 cm above the carina. The feeding\n tube is coiled in the stomach with the tip pointed downward in the fundus of\n the stomach. The lungs are clear without infiltrate or effusion. The heart\n is upper limits normal in size. There is no focal infiltrate.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 941390,
"text": " 8:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Tolerating EVD clamping in prep for removal ie?hydrocephalus\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with Lthalamic bleed\n REASON FOR THIS EXAMINATION:\n Tolerating EVD clamping in prep for removal ie?hydrocephalus\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 42-year-old man with left thalamic hemorrhage. Evaluate for\n interval change prior to removal of right intraventricular drain.\n\n COMPARISON: Non-contrast head CT dated .\n\n TECHNIQUE: Routine non-contrast head CT.\n\n FINDINGS: The patient is status post removal of a left-sided intraventricular\n drain with foci of hemorrhage and gas along the former tract. Vasogenic edema\n in the left frontal lobe surrounds the prior tract path. A right\n intraventricular drain traverses the anterior of the right lateral\n ventricle via a right frontal approach. The tip of the catheter abuts the\n right caudate lobe. There has been a significant interval increase in the\n size of the lateral ventricles bilaterally, now measuring up to 9 mm\n bilaterally in the anterior horns, previously 3 mm. The third ventricle,\n previously collapsed now appears patent, and there is a slight interval\n increase in size of the fourth ventricle. Hemorrhage layering in the temporal\n horns bilaterally is decreased. A left thalamic intraparenchymal hemorrhage\n is slightly decreased in size. There is a stable amount of surrounding edema,\n and minimal shift of the third ventricle to the right. The remaining brain\n parenchyma appears unchanged. Imaging of the paranasal sinuses is unchanged\n with moderate mucosal thickening and bilateral sphenoid sinuses, scattered\n ethmoid air cells bilaterally, and mild mucosal thickening in the maxillary\n sinuses, left greater than right. Bilateral mastoid air cells are normally\n aerated.\n\n IMPRESSION:\n 1. Status post removal of left intraventricular drain with interval\n development of communicating hydrocephalus.\n 2. Stable interval appearance of left thalamic hemorrhage and trace left to\n right shift of the third ventricle.\n 3. Stable sinus disease as detailed above.\n\n These findings were paged to Dr. covering for Dr. \n at 2:30 p.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-31 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 941924,
"text": " 8:41 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: hemorrhage\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with shunt and drowsy\n REASON FOR THIS EXAMINATION:\n hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man with shunt and drowsy.\n\n HEAD CT WITHOUT CONTRAST: Comparison is made to the prior head CT taken on\n . Again note is made of right intraventricular drain,\n unchanged since prior study, with further decrease of the ventricular size.\n Again note is made of foci of hemorrhage in the left frontal lobe at the\n location of previous intraventricular drain placement surrounded by vasogenic\n edema, as well as heterogeneous high density in the left corona radiata and\n basal ganglia, and hematoma measuring 1.8 x 1.3 cm in the left thalamus\n surrounded by vasogenic edema. The size of the hematoma in the left thalamus\n has slightly decreased in size since prior study. There is no significant\n shift of normally midline structures. The appearance of surrounding soft\n tissues and osseous structures are unchanged.\n\n IMPRESSION: Unchanged right ventricular drain with further decrease of the\n ventricular size. Overall unchanged appearance of the left frontal hemorrhage\n and the left basal ganglia hemorrhage surrounded by vasogenic edema, with\n slight decrease of the size of the left thalamic hematoma.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-25 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 941119,
"text": " 1:54 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: follow-up CT head\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with L thalamic bleed\n REASON FOR THIS EXAMINATION:\n follow-up CT head\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man with left thalamic bleed, followup CT.\n\n HEAD CT WITHOUT CONTRAST: Comparison is made with a prior head CT dated\n . Again note is made of hemorrhage in the left thalamus,\n measuring 3 x 0.3 cm surrounded by vasogenic edema, with small hyperdense foci\n in the left basal ganglia, overall unchanged since prior study. The\n hemorrhage within the anterior horns of the ventricles is somewhat decreased\n especially on the right. There is small amount of air in the left anterior\n of the ventricle, which was not seen in the prior study, with two\n ventricular catheters unchanged since prior study. There is no significant\n shift of normally midline structures. There is opacification of bilateral\n ethmoid and sphenoid sinuses and mucosal thickening in maxillary sinus. The\n intraventricular hemorrhage is also seen in the posterior horns with layering,\n overall unchanged since prior study. The hemorrhage in the third and fourth\n ventricle has decreased and is not clearly identified on this study.\n\n IMPRESSION:\n\n 1. Overall unchanged appearance of left thalamic bleed with small bleed in\n left basal ganglia and vasogenic edema. Slightly decreased hemorrhage within\n the ventricle.\n\n 2. Small foci of air in the anterior of the left ventricular, new since\n prior study, in this patient with bilateral ventricular catheters.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 941730,
"text": " 3:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Shunt placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with thalamic hemorrhage and s/p VP shunt\n REASON FOR THIS EXAMINATION:\n Shunt placement\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man with known thalamic hemorrhage status post\n ventriculoperitoneal shunt replacement.\n\n COMPARISON: Non-contrast head CT dated and .\n\n FINDINGS: An intraventricular drain enters the brain via a right frontal burr\n hole, traversing the septum pellucidum and terminating at the level of the\n left cerebellar peduncle. The ventricles appear smaller than on prior CT\n scan. The amount of blood layering in bilateral occipital horns is unchanged.\n The appearance of the brain and paranasal sinuses is otherwise unchanged.\n\n IMPRESSION: Interval replacement of the right intraventricular drain as\n described above with resultant decrease in ventricular prominence.\n\n These findings were discussed with Dr. at 5:00 p.m. on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 941450,
"text": " 2:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval NGT placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with intracranial hemmorhage, s/p dobhoff placement,\n intubated, increased secretions\n REASON FOR THIS EXAMINATION:\n eval NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: Intracranial hemorrhage, status post Dobbhoff line placement.\n Intubated.\n\n FINDINGS: AP single view of the chest obtained with the patient in supine\n position is analyzed in direct comparison with a similar preceding study of\n . During the interval, the patient has been extubated. The\n NG tube remains and is seen to terminate in the body of the stomach.\n Comparison with the previous study suggests that the type of the tube has been\n switched. There is no evidence of pneumothorax or any other placement related\n complication. The lungs remain clear. No evidence of CHF or acute\n infiltrates.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 940586,
"text": " 10:18 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man w/thalamic bleed - and ? AVM\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 52-year-old man with left thalamic bleed, evaluate for change\n from prior examination.\n\n FINDINGS: There has been no change from the prior examination of . Again, there is a large left thalamic hemorrhage. There is unchanged\n midline shift. There is unchanged intraventricular hemorrhage. There are\n bilateral intraventricular drains as before. There are no new hemorrhages or\n change in the appearance of the -white matter differentiation.\n\n The fluid within the visualized paranasal sinuses is also unchanged.\n\n IMPRESSION: No change in the left thalamic hemorrhage with mild midline shift\n and intraventricular hemorrhage.\n\n Bifrontal ventriculostomy catheters.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2145-12-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 941622,
"text": " 8:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Replacement dobhoff -position ok?\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with intracranial hemmorhage, s/p dobhoff\n REASON FOR THIS EXAMINATION:\n Replacement dobhoff -position ok?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage, Dobhoff placement.\n\n CHEST, ONE VIEW: Comparison with . Nasogastric tube has\n been removed. No feeding tube is seen in its place. There is interval\n placement of a ventriculoperitoneal shunt. No pleural effusion. No\n pneumothorax. Cardiac, mediastinal, and hilar contours are unchanged. Osseous\n structures also unchanged.\n\n IMPRESSION: No Dobbhoff tube seen. By report the patient's feeding tube had\n been removed before this study was performed.\n\n Findings discussed with Dr. at 10:30 a.m., .\n\n"
}
] |
18,952 | 112,722 | Due to the clinical findings the patient was admitted on the morning of the to the Neurosurgical Service and to the care of Dr. who took the patient to the angiography suite where under monitored anesthesia care the patient underwent a diagnostic cerebral angiogram followed by a placement of a right vertebral artery stent for treatment of a severely narrowed right vertebral artery origin. The patient was also noted to have multiple sites of intracranial stenosis which will be followed for now. The patient tolerated the procedure well. Postoperatively, the patient was admitted to the Post Anesthesia Recovery Room overnight for monitoring and subsequently transferred on the first postoperative day to the Neurosurgical Intensive Care Unit where he remained for approximately 24 to 48 hours, but was stable throughout that time. He was subsequently transferred to the Medical Hospital Floor where the remainder of his postoperative hospitalization was unremarkable and he was discharged home on the morning of the with follow up to see Dr. in the clinic in approximately four weeks time. He was also instructed to resume his aspirin 325 mg po q day and Plavix 75 mg po q.d. and return to use of all of his preoperative medications. , M.D. Dictated By: MEDQUIST36 D: 10:34 T: 09:11 JOB#: | FINAL REPORT (REVISED) PRE-OP DIAGNOSIS: Vertebral basilar insufficiency. IMPRESSION: Severe stenosis of the origin of the right vertebral artery treated using stent angioplasty as well as moderate less than 60% stenosis of the origin of the left vertebral artery at its takeoff from the left subclavian artery as well as a focal site of intracranial atherosclerosis of the left vertebral artery at the level of the origin of the left PICA as well as a mid basilar focal stenosis of approximately 60%. R ANGIO SITE WITH PRESSURE DRESSING C,D&ICV: TMAX 98.2, HR 70-90 NSR WITH NOTED OCCASIONAL PVC DURING THE AM. Post angioplasty a series of angiographic runs were performed of the right subclavian artery which showed a significantly decreased transit time in the right vertebral artery in its cervical segment and showed improved flow distally. In the intracranial portion the right vertebral artery appears to taper to a stenosis proximal to its junction with the basilar artery at the vertebral basilar junction. The right and left groin areas were prepped and draped in usual sterile fashion and a 5 FR vascular sheath was inserted into the right common femoral artery. Accordingly, the decision was made to treat the least high risk lesion which at this point would be the origin of the right vertebral artery in order to improve posterior circulation flow and to that end a 7 FR guide catheter was placed into the right common femoral artery after exchange and a 7 FR guide catheter was placed into the right vertebral artery facing the origin of the right vertebral artery which was crossed with a stabilizer 300 cm micro wire. POST-OP DIAGNOSIS: Multiple sites of intracranial atherosclerosis in the basilar and vertebral arteries and severe stenosis of the right vertebral artery origin status post stent angioplasty. Evaluation of the right vertebral artery at its origin reveals a stenosis of approximately greater than 80% with delayed filling of the right vertebral artery in its cervical segment. At this point a decision was made to proceed with further intracranial revascularization and the catheter was removed from the patient and the patient was sent to the recovery room in stable condition. Over the micro wire was a BX velocity stent measuring 4 mm x 8 mm which was carefully placed at the origin of the right vertebral artery and deployed carefully to prevent an endosection. PRESENLTY ON 1.124MCG/KG/MIN.PT STARTED ON LABETALOL 10MG Q4 WITH SHORT TERM EFFECT. MED WITH ZOFRAN AND PROTONIX. The mid cervical section of the left vertebral artery is free of stenosis or disease, however, the intracranial portion is characterized by a significant stenosis approximately greater than 70% which involves the origin of the takeoff of the posterior inferior cerebellar artery. At this point a 5 FR Berenstein 2 catheter was used to catheterize the left subclavian artery followed by catheterization of the right subclavian artery. Contrast: OPTIRAY Amt: 180 ********************************* CPT Codes ******************************** * TRANSCATH PLCT STENTS, INITIAL SEL CATH 3RD ORDER * * -51 MULTI-PROCEDURE SAME DAY SEL CATH 1ST ORDER * * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH INTRO STENT * * VERT/CAROTID A-GRAM VERT/CAROTID A-GRAM * * -59 DISTINCT PROCEDURAL SERVICE EXT BILAT A-GRAM * * -52 REDUCED SERVICES * **************************************************************************** MEDICAL CONDITION: 65 year old man with High grade stenosis who will need to undergo a cerebral angiogram w/possible stent angioplasty. In addition, the mid (Over) 10:53 AM /CERB UNI Clip # Reason: vertebrobasilar insufficiency. PT STATES TO BE MORE COMFORTABLE WITH 02 ON.GI: PT HAVING EPISODE OF NAUSEA WITH APPROX 50CC OF EMESIS. 10:53 AM /CERB UNI Clip # Reason: vertebrobasilar insufficiency. With the catheter in each of these positions, a series of angiographic runs were performed of the cervical as well as intracranial circulation by use of a cuff to divert the angiographic dye into the right and left vertebral arteries. PT C/O POST-NASAL DRIP. NEURO; ALERT & ORIENTED X 3, SPEECH CLEAR, C/O PAIN ON ARRIVAL FROM PACU, MEDIC WITH MORPHINE 2 MGM IV, PERL #2 BRISK, NO PRONATOR DRIST, ABLE TO KEEP LEGS LIFTED AT 45 DEGREES OFF BED AND OFFER RESISTANCE TO FLEXION AND EXTENSION, STRONG BILAT HANDGRASP,, NIPRIDE AT 1.044 MCG/KG/MIN TO KEEP SYS 160-180'SCARDIOVASCULAR; HR 70'S SR, EXTREMITIES SL COOL, PEDAL AND PT PULSES ,RT GROIN DSG D/I, NO HEMATOMARESPIR; FEW CRACKLES ON AUSCULTATION, 02 SAT 98%, ON R/APAIN; C/O INCISIONAL DISCOMFORT, AND NAUSEA, MEDIC WITH MORPHINE (HAD RECEIVED ZOFRAN PRIOR TO TRANSFER) COMFORTABLE AT PRESENT, | 5 | [
{
"category": "Radiology",
"chartdate": "2172-10-06 00:00:00.000",
"description": "TRANSCATH PLCT STENTS, INITIAL VESSEL",
"row_id": 769695,
"text": " 10:53 AM\n /CERB UNI Clip # \n Reason: vertebrobasilar insufficiency.\n Contrast: OPTIRAY Amt: 180\n ********************************* CPT Codes ********************************\n * TRANSCATH PLCT STENTS, INITIAL SEL CATH 3RD ORDER *\n * -51 MULTI-PROCEDURE SAME DAY SEL CATH 1ST ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE TRANSCATH INTRO STENT *\n * VERT/CAROTID A-GRAM VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE EXT BILAT A-GRAM *\n * -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with High grade stenosis who will need to undergo a cerebral\n angiogram w/possible stent angioplasty.\n REASON FOR THIS EXAMINATION:\n vertebrobasilar insufficiency.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n PRE-OP DIAGNOSIS: Vertebral basilar insufficiency.\n\n POST-OP DIAGNOSIS: Multiple sites of intracranial atherosclerosis in the\n basilar and vertebral arteries and severe stenosis of the right vertebral\n artery origin status post stent angioplasty.\n\n INDICATION: 65 y/o man complaining of significant symptoms of vertebral\n basilar insufficiency. Patient has been referred for possible endovascular\n treatment using possible angioplasty and/or stent mediated angioplasty.\n\n ANESTHESIA: Monitored anesthesia care provided by anesthesia department.\n\n CONSENT: The patient was given full explanation of the procedure including\n risks, benefits, and possible complications including but not limited to\n stroke, infection, death by vessel rupture, vessel injury as well as other\n unforeseen complications. He understood and wished to proceed with the\n operation.\n\n PROCEDURE: The patient was brought into the angiographic suite and placed o\n the table in supine position. The right and left groin areas were prepped and\n draped in usual sterile fashion and a 5 FR vascular sheath was inserted into\n the right common femoral artery. At this point a 5 FR Berenstein 2 catheter\n was used to catheterize the left subclavian artery followed by catheterization\n of the right subclavian artery. With the catheter in each of these positions,\n a series of angiographic runs were performed of the cervical as well as\n intracranial circulation by use of a cuff to divert the angiographic dye into\n the right and left vertebral arteries. Injection of these vessels and\n evaluation revealed the presence of approximately 50% stenosis at the origin\n of the left vertebral artery that has takeoff from the left subclavian artery.\n The mid cervical section of the left vertebral artery is free of stenosis or\n disease, however, the intracranial portion is characterized by a significant\n stenosis approximately greater than 70% which involves the origin of the\n takeoff of the posterior inferior cerebellar artery. In addition, the mid\n (Over)\n\n 10:53 AM\n /CERB UNI Clip # \n Reason: vertebrobasilar insufficiency.\n Contrast: OPTIRAY Amt: 180\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n basilar segment appears to have a focal site of stenosis of approximately 50%.\n Evaluation of the right vertebral artery at its origin reveals a stenosis of\n approximately greater than 80% with delayed filling of the right vertebral\n artery in its cervical segment. In the intracranial portion the right\n vertebral artery appears to taper to a stenosis proximal to its junction with\n the basilar artery at the vertebral basilar junction. Accordingly, the\n decision was made to treat the least high risk lesion which at this point\n would be the origin of the right vertebral artery in order to improve\n posterior circulation flow and to that end a 7 FR guide catheter was placed\n into the right common femoral artery after exchange and a 7 FR guide catheter\n was placed into the right vertebral artery facing the origin of the right\n vertebral artery which was crossed with a stabilizer 300 cm micro wire. Over\n the micro wire was a BX velocity stent measuring 4 mm x 8 mm which was\n carefully placed at the origin of the right vertebral artery and deployed\n carefully to prevent an endosection. Post angioplasty a series of\n angiographic runs were performed of the right subclavian artery which showed a\n significantly decreased transit time in the right vertebral artery in its\n cervical segment and showed improved flow distally. At this point a decision\n was made to proceed with further intracranial revascularization and the\n catheter was removed from the patient and the patient was sent to the recovery\n room in stable condition.\n\n IMPRESSION:\n\n Severe stenosis of the origin of the right vertebral artery treated using\n stent angioplasty as well as moderate less than 60% stenosis of the origin of\n the left vertebral artery at its takeoff from the left subclavian artery as\n well as a focal site of intracranial atherosclerosis of the left vertebral\n artery at the level of the origin of the left PICA as well as a mid basilar\n focal stenosis of approximately 60%.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-10-08 00:00:00.000",
"description": "Report",
"row_id": 1511111,
"text": "nursing progress note\nPLEASE SEE NURSING TRANSFER NOTE FOR DETAILS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-10-07 00:00:00.000",
"description": "Report",
"row_id": 1511109,
"text": "NEURO; ALERT & ORIENTED X 3, SPEECH CLEAR, C/O PAIN ON ARRIVAL FROM PACU, MEDIC WITH MORPHINE 2 MGM IV, PERL #2 BRISK, NO PRONATOR DRIST, ABLE TO KEEP LEGS LIFTED AT 45 DEGREES OFF BED AND OFFER RESISTANCE TO FLEXION AND EXTENSION, STRONG BILAT HANDGRASP,, NIPRIDE AT 1.044 MCG/KG/MIN TO KEEP SYS 160-180'S\n\nCARDIOVASCULAR; HR 70'S SR, EXTREMITIES SL COOL, PEDAL AND PT PULSES ,\nRT GROIN DSG D/I, NO HEMATOMA\nRESPIR; FEW CRACKLES ON AUSCULTATION, 02 SAT 98%, ON R/A\n\nPAIN; C/O INCISIONAL DISCOMFORT, AND NAUSEA, MEDIC WITH MORPHINE (HAD RECEIVED ZOFRAN PRIOR TO TRANSFER) COMFORTABLE AT PRESENT,\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2172-10-08 00:00:00.000",
"description": "Report",
"row_id": 1511110,
"text": "NEURO: PT ALERT AND ORIENTED X3, PUPILS 2MM BRISK. MAE, FOLLOWS ALL COMMANDS. R ANGIO SITE WITH PRESSURE DRESSING C,D&I\nCV: TMAX 98.2, HR 70-90 NSR WITH NOTED OCCASIONAL PVC DURING THE AM. EKG OBTAINED. SBP 150-190'S. CONT ON NIPRIDE FOR GOAL 160-180'S. PRESENLTY ON 1.124MCG/KG/MIN.PT STARTED ON LABETALOL 10MG Q4 WITH SHORT TERM EFFECT. RECIEVED HYDRALAZINE X1 WITH MINIMAL EFFECT. EXTREMITIES WARM WITH PULSES. LYTES WNL. CONT ON IVF NS WITH 20KCL AT 125CC/HR.\nRESP: LUNGS WITH FAINT CRACKLES AT BASES. O2 SATS 96% ROOM AIR. PT C/O POST-NASAL DRIP. O2 APPLIED AT 2L VIA N/C. PT STATES TO BE MORE COMFORTABLE WITH 02 ON.\nGI: PT HAVING EPISODE OF NAUSEA WITH APPROX 50CC OF EMESIS. MED WITH ZOFRAN AND PROTONIX. NO FURTHER N/V. DR. AWARE.\nGU: U/O 30-50CC/HR CLEAR YELLOW URINE.\nENDOCRINE: PT REQUIRING SSRI FOR INCREASED BLOOD SUGARS\n"
},
{
"category": "ECG",
"chartdate": "2172-10-08 00:00:00.000",
"description": "Report",
"row_id": 171251,
"text": "Sinus rhythm\nLeft axis deviation\nLow QRS voltages in limb leads\nSince last ECG, no significant change\n\n"
}
] |
31,705 | 122,950 | Patient underwent ERCP with stenting for biliary obstruction due to pancreatic mass with liver and lung lesions, most likely reflecting metastases of pancreatic neoplasm. Biopsy was not obtained. On day after ERCP patient developed intermittent ventricular tachycardia with hypotension. An emergent femoral line was placed for access. Patient was started on pressors for hypotension, he was mentating and complaining of pain which was treated with IV morphine. Family was called and came to the hospital for meeting. Patient clearly stated that he did not wish to be shocked or intubated. Supportive therapy was continued. On at 1.45 PM he went into asystole. Per patient's and family wish no resuscitation was attempted and the patient expired. Family declined post-mortem exam. | Within the limits of lack of contrast administration, there is probably intrahepatic biliary dilatation. Probable low-attenuation area within the head of the pancreas consistent with reported history of pancreatic mass. EVENTS: Pt with ^HR and episode of hypotension. Evidence of inferior wall myocardial infarction was presentpreviously. A low-attenuation area is noted within the head of the pancreas. Overall the appearance is suggestive of a partially calcified meningioma. NURSING MICU NOTE 7P-7ANEURO: PT , CONFUSED AT TIMES, OX1-2. Markedly distended gall bladder worriesome for biliary obstruction versus cholecysitis. Probable intra- and extra- hepatic biliary dilatation. Less likely this represents a focus of chronic encephalomalacia due to prior infarction. Heterogenous low attenuation lesion within left kidney, unable to be characterized further without IV contrast. Sinus rhythm with a single right-sided ventricular premature beat. if pt would want to be intubated (pt deferred). Mild postobstructive dilation is present. Pt expired and Dr. in to pronounce. Old inferior myocardialinfarction. The gallbladder is significantly distended. OSSEOUS STRUCTURES: There is mild degenerative disease of the lower thoracic and lumbar spines. No (Over) 9:58 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: eval for obstruction, po contrast only FINAL REPORT (Cont) gallstones are specifically identified. PT C/O NAUSEA WITH SHORT RELIEF FROM ZOLFRAN. There are degenerative calcifications of the basal ganglia bilaterally. There is mild hypodensity of the periventricular white matter consistent with chronic microvascular infarction. TECHNIQUE: Non-contrast head CT. A moderate amount of perihepatic and perisplenic fluid is noted. TECHNIQUE: Non-contrast MDCT axial images were acquired from the lung bases to the pubic symphysis. Moderate abdominal and pelvic ascites. Sinus rhythm and A-V conduction delay. Patient with reported history of pancreatic mass. itubated for ERCP. This lesion probably represents a simple cyst. Intrahepatic biliary dilatation although detailed evaluation is limited without intravenous contrast administration. There is fluid about a small spleen and trace fluid in the right lower quadrant. INDICATIONS: Nasogastric tube placement. 8:26 AM LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # Reason: ABN CT EXAM, DISTENTED GB SEEM ON CT EXAM. CT ABD and Pelvis ~ pancreatic malignancy with metastatic involvement of lungs and liver, pulmonoary nodules at the lung bases, distended gallbladder, ascites, probable low attenuation area within the head of the pancreas c/w reported history of pancreatic mass, numerous moderate to severe sigmoid diverticulosis. Frequent ventricular ectopy andventricular tachycardia. Last image demonstrates a biliary stent in place. Intraventricular conduction defect. The patient is status post sternotomy and CABG. Cardiology consulted. CT OF THE PELVIS WITH IV CONTRAST: Fluid is noted to track along the left paracolic gutter and layers significantly within the pelvis. The spleen is otherwise unremarkable. Moderate-to-severe sigmoid diverticulosis. Moderate sigmoid diverticulosis - no direct evidence of diverticulitis. Multiple median sternotomy wires are seen, likely reflecting evidence of previous CABG. There is moderate-to-severe sigmoid diverticulosis. A 5-mm hyperattenuating lesion is noted at the superior pole of the left kidney is too small to characterize (2:30). There is mild bibasilar atelectasis, left greater than right. Pt in and out of VTACH. Coronal and sagittal reformatted images were then obtained. The common bile duct is poorly visualized. AP PORTABLE CHEST: The heart is mildly enlarged but unchanged. Distended gallbladder with gallbladder wall thickening, pericholecystic fluid may all be secondary to third spacing, ascites, and a fasting state, but given presence of pancreatic head mass, a ductal obstruction cannot be excluded and a HIDA scan should be considered for this patient. Mild-moderate abdominal and pelvic ascites. care note - Pt. An area of stenosis was seen in the middle and upper third of the common bile duct. Distended gallbladder without evidence of gallstones. The gallbladder is distended and there is a small sludge but no shadowing stones. updated by GI team regarding results on ERCPPLAN: ?more procedures, if not will turn off Propofol and extubate.monitor resp/CV status. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are innumerable, subcentimeter pulmonary nodules present at both lung bases. PMICU Nsg Admit Note84 y.o. Free fluid is noted to track down the left paracolic gutter into the pelvis. THIS AM PT C/O NAUSEA, GIVEN WITH GOOD EFFECT. FINAL REPORT STUDY: CT of the abdomen and pelvis without contrast. A 2.8 x 2.0 cm low-attenuation lesion at the lower pole of the right kidney is also present (2:40). Nasogastric tube loops in the proximal stomach with distal tip directed cephalad in the fundus. IMPRESSION: Stricture at the middle and upper third of the common bile duct. 4:36 PM ERCP BILIARY ONLY PORTABLY BY TECH Clip # Reason: HEPATIC DUCT STENT PLACEMENT IN THE MICU Admitting Diagnosis: PANCREATIC MASS FINAL REPORT TECHNIQUE: Endoscopic retrograde cholangiopancreatography by GI unit. | 15 | [
{
"category": "Radiology",
"chartdate": "2159-07-22 00:00:00.000",
"description": "ERCP BILIARY ONLY PORTABLY BY TECH",
"row_id": 975628,
"text": " 4:36 PM\n ERCP BILIARY ONLY PORTABLY BY TECH Clip # \n Reason: HEPATIC DUCT STENT PLACEMENT IN THE MICU\n Admitting Diagnosis: PANCREATIC MASS\n ______________________________________________________________________________\n FINAL REPORT\n\n TECHNIQUE: Endoscopic retrograde cholangiopancreatography by GI unit.\n\n FINDINGS: Six views from ERCP are submitted for review. No radiologist was\n present during the procedure. An area of stenosis was seen in the middle and\n upper third of the common bile duct. Mild postobstructive dilation is\n present. Last image demonstrates a biliary stent in place.\n\n IMPRESSION: Stricture at the middle and upper third of the common bile duct.\n Stent placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-07-23 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 975693,
"text": " 8:26 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: ABN CT EXAM, DISTENTED GB SEEM ON CT EXAM.\n Admitting Diagnosis: PANCREATIC MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with MMP including new pancreatic mass, s/p ERCP with plastic\n stent placement\n REASON FOR THIS EXAMINATION:\n assess gallbladder to r/o acute cholycystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New pancreatic mass status post ERCP with plastic stent and right\n upper quadrant pain, please rule out acute cholecystitis.\n\n FINDINGS: Comparison is made to abdominal CT . Innumerable\n hypodense lesions are present in liver, most measuring 1.5 cm, the largest\n measuring 2.7 cm in the right lobe consistent with metastases. The\n gallbladder is distended and there is a small sludge but no shadowing stones.\n Son sign is present. The gallbladder wall measures 6 mm and\n there is a pericholecystic fluid. The common bile duct measures 9 mm. The\n common bile duct is poorly visualized. The portal vein is patent with\n hepatopetal flow and there is no intrahepatic biliary ductal dilation. There\n is fluid about a small spleen and trace fluid in the right lower quadrant.\n\n IMPRESSION:\n 1. Distended gallbladder with gallbladder wall thickening, pericholecystic\n fluid may all be secondary to third spacing, ascites, and a fasting state, but\n given presence of pancreatic head mass, a ductal obstruction cannot be\n excluded and a HIDA scan should be considered for this patient.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-07-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 975567,
"text": " 5:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for mass v. bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with h/o metastatic pancreatic ca with AMS and hallucinations\n for 2 days\n REASON FOR THIS EXAMINATION:\n eval for mass v. bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MPtb SUN 5:55 AM\n 3.7 x 1.7 cm broad-based dural based mass of the left frontal region with\n heterogeneous areas of internal hyperattentuation is more likely a partially\n calcified meningioma. No priors for comparison. No evidence of intracranial\n hemorrhage or acute major vascular territorial infarction.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old male with history of metastatic pancreatic cancer, now\n with change in mental status.\n\n COMPARISON: No prior imaging of the head available.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is a 3.7 x 1.7 cm extra-axial mass with broad base along the\n left frontal skull which exerts mass effect upon the adjacent left frontal\n cortex. The mass is heterogeneous with multiple areas of internal\n hyperattenuation thought more likely to represent calcification. It does not\n frankly invade the cerebral cortex but appears simply to displace it. There\n is no evidence of adjacent bone destruction. There is no evidence of\n intracranial hemorrhage, shift of normally midline structures or major\n vascular territorial infarction. Circumscribed hypodensity in the region of\n the left cerebellar hemisphere is more likely due to volume averaging with a\n cisterna magna that is slightly larger than typically seen. Less likely this\n represents a focus of chronic encephalomalacia due to prior infarction. There\n is mild hypodensity of the periventricular white matter consistent with\n chronic microvascular infarction. There are degenerative calcifications of\n the basal ganglia bilaterally. The visualized paranasal sinuses and mastoid\n air cells are clear.\n\n IMPRESSION: 3.7 x 1.7 cm dural-based mass of the left frontal region with\n areas of increased hyperattenuation probably due to calcification. Overall\n the appearance is suggestive of a partially calcified meningioma. No prior\n studies available for comparison. This would be helpful to assess the\n chronicity of the mass. Given the patient's history of malignancy, further\n evaluation with MRI with gadolinium is to be considered to assess for\n possible metastatic disease.\n\n ER dashboard wet read placed 5:50 a.m. on .\n\n Dr. reviewed the study and edited the report.\n (Over)\n\n 5:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for mass v. bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-07-22 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 975587,
"text": " 9:58 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for obstruction, po contrast only\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with abdominal distension and vomiting, hx of pancreatic mass\n REASON FOR THIS EXAMINATION:\n eval for obstruction, po contrast only\n CONTRAINDICATIONS for IV CONTRAST:\n renal insufficiency\n ______________________________________________________________________________\n WET READ: DMFj SUN 10:52 AM\n Limited evaluation without IV contrast. Markedly distended gall bladder\n worriesome for biliary obstruction versus cholecysitis. Ultrasound recommended\n for further evaluation. Probable intra- and extra- hepatic biliary\n dilatation.\n\n No evidence of bowel obstruction.\n\n Innumerable sub-centimeter nodules present at both lung bases high concerning\n for metastatic disease.\n\n Mild-moderate abdominal and pelvic ascites.\n\n Moderate sigmoid diverticulosis - no direct evidence of diverticulitis.\n\n Heterogenous low attenuation lesion within left kidney, unable to be\n characterized further without IV contrast. Ultrasound could be performed for\n further assessment.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the abdomen and pelvis without contrast.\n\n INDICATION: 84-year-old male presenting with abdominal pain and distention,\n vomiting. Patient with reported history of pancreatic mass. Assess for\n obstruction.\n\n COMPARISONS: There are no prior images available here for comparison.\n\n TECHNIQUE: Non-contrast MDCT axial images were acquired from the lung bases\n to the pubic symphysis. Coronal and sagittal reformatted images were then\n obtained.\n\n CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are innumerable, subcentimeter\n pulmonary nodules present at both lung bases. The largest is located at the\n right lung base along the lateral pleural surface and measures 1.0 x 1.1 cm\n (2:10). There is mild bibasilar atelectasis, left greater than right. There\n is no pleural effusion. Multiple median sternotomy wires are seen, likely\n reflecting evidence of previous CABG. Please note, lack of intravenous\n contrast administration significantly limits detailed evaluation of the intra-\n abdominal and pelvic organs. Within the limits of lack of contrast\n administration, there is probably intrahepatic biliary dilatation. No focal\n lesions is identified. The gallbladder is significantly distended. No\n (Over)\n\n 9:58 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for obstruction, po contrast only\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n gallstones are specifically identified. A low-attenuation area is noted\n within the head of the pancreas. There is no evidence of pancreatic duct\n dilatation (2:29). A moderate amount of perihepatic and perisplenic fluid is\n noted. The spleen is otherwise unremarkable. The adrenal glands are normal\n in appearance. A 5-mm hyperattenuating lesion is noted at the superior pole\n of the left kidney is too small to characterize (2:30). Mildly heterogeneous\n lower attenuation lesion at the mid pole of the left kidney measures 1.6 x 1.6\n cm is difficult to assess with lack of intravenous contrast administration\n (2:40). A 2.8 x 2.0 cm low-attenuation lesion at the lower pole of the right\n kidney is also present (2:40). This lesion probably represents a simple cyst.\n Several mildly dilated loops of small bowel are noted within the mid abdomen,\n the largest measuring approximately 4 cm in diameter. However, there is no\n evidence of obstruction. Free fluid is noted to track down the left paracolic\n gutter into the pelvis. Multiple prominent peripancreatic lymph nodes are\n present. There is no significant pathologic retroperitoneal lymphadenopathy.\n\n CT OF THE PELVIS WITH IV CONTRAST: Fluid is noted to track along the left\n paracolic gutter and layers significantly within the pelvis. There is\n moderate-to-severe sigmoid diverticulosis. Although there is no direct\n evidence of diverticulitis, a significant amount of fluid within the lower\n pelvis obscures detailed evaluation of the sigmoid colon. The bladder appears\n unremarkable. Note is made of several prostatic calcifications. There is no\n inguinal or pelvic lymphadenopathy.\n\n OSSEOUS STRUCTURES: There is mild degenerative disease of the lower thoracic\n and lumbar spines. No suspicious lytic or blastic lesions are identified.\n\n IMPRESSION:\n\n 1. Innumerable subcentimeter pulmonary nodules at the lung bases, worrisome\n for metastatic disease.\n\n 2. Distended gallbladder without evidence of gallstones. Intrahepatic biliary\n dilatation although detailed evaluation is limited without intravenous\n contrast administration. There may be a component of extrahepatic biliary\n dilatation as well, related to known pancreatic mass.\n\n 3. Moderate abdominal and pelvic ascites.\n\n 4. Probable low-attenuation area within the head of the pancreas consistent\n with reported history of pancreatic mass. Numerous peripancreatic lymph nodes\n are worrisome for carcinoma process. An MRCP could be performed for further\n characterization.\n\n 5. Moderate-to-severe sigmoid diverticulosis.\n\n Findings were discussed over the telephone with Dr. adn the GI fellow\n (Over)\n\n 9:58 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for obstruction, po contrast only\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n by Dr. at approximately on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 975645,
"text": " 9:32 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p NGT placement\n Admitting Diagnosis: PANCREATIC MASS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with AMS and elevated wbc count, now s/p NGT placement\n\n REASON FOR THIS EXAMINATION:\n s/p NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY AT 2152\n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATIONS: Nasogastric tube placement.\n\n Nasogastric tube loops in the proximal stomach with distal tip directed\n cephalad in the fundus. Within the chest, apparent diffuse haziness in the\n left hemithorax compared to the right is probably due to technical artifact,\n but layering left pleural effusion may produce a similar appearance and\n attention to this area on followup chest x-ray may be helpful in this regard.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-07-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 975563,
"text": " 5:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with AMS and elevated wbc count\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old male with change in mental status and elevated white\n count, concern for pneumonia.\n\n COMPARISON: .\n\n AP PORTABLE CHEST: The heart is mildly enlarged but unchanged. The patient\n is status post sternotomy and CABG. No chf, focal infiltrate, pleural\n effusion or pneumothorax.\n\n IMPRESSION: No acute pulmonary process identified.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-07-22 00:00:00.000",
"description": "Report",
"row_id": 1665663,
"text": "Resp. care note - Pt. itubated for ERCP. Pt. intubated with # 8 OET 22 at the lip, placed on the vent without incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-07-22 00:00:00.000",
"description": "Report",
"row_id": 1665664,
"text": "PMICU Nsg Admit Note\n84 y.o. male admitted to MICU from EW with Pancreatic Mass, change in Mental status.\n\nPMH: pancreatic mass, (pt presented to NEBH with several weeks of abd pain, N/V, poor po intake, increased fatigue, 15# wt loss), CAD s/p 2V CABG , type 2 DM, HTN, Hyperlipidemia, GERD, Anemia, PVD, RAS, CRI baseline creat of 1.7\n\nALLERGIES: PCN, IVP dye, iodine containing.\n\nROS:\n\nRESP: pt electively intubated for ERCP at the bedside. pt intubated with #8 ETT, taped @ 22 cm lips, received 160 mg Sux, 10 mg Etiomidate. pt placed on AC 100% TV~600 x12, 5 peep, after procedure pt placed on 50% FIO2, lungs clear,\n\nCV/FLUIDS: bp stable 100-140/60-70 HR 80's SR no vea noted.\nIVF NS @ 75 cc/hr\n\nGI: pt had bedside ERCP, received a total of 2 mg IV Versed, 50 mcg Fentanyl, on a Propofol gtt @ 68 mcg/kg/min. pt tolerated procedure well. stent placed in common bile duct - draining bile, no pus. VSS q 5 minutes, stable throughout the procedure (see carevue)\nNPO, belly distended, firm, no bowel sounds.\n\nGU: foley inserted in EW, UO~ 20-30 cc/hr amber colored urine.\n\nID: urine cx sent in EW, blood cultures sent in MICU. afebreile WBC 23.9 pt on Flagyl and Levofloxacin.\n\nENDO: FS qid, and cover with Humalog insulin sliding scale.\n\nIV ACCESS: 2 peripheral lines\n\nSOCIAL: full code, lives with wife and dtr. updated by GI team regarding results on ERCP\n\nPLAN: ?more procedures, if not will turn off Propofol and extubate.\nmonitor resp/CV status. NPO, follow labs, GI to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-07-22 00:00:00.000",
"description": "Report",
"row_id": 1665665,
"text": "addendum PMICU Nsg Note\nNEURO: pt oriented to person, year, not place. , \n"
},
{
"category": "Nursing/other",
"chartdate": "2159-07-22 00:00:00.000",
"description": "Report",
"row_id": 1665666,
"text": "CT ABD and Pelvis ~ pancreatic malignancy with metastatic involvement of lungs and liver, pulmonoary nodules at the lung bases, distended gallbladder, ascites, probable low attenuation area within the head of the pancreas c/w reported history of pancreatic mass, numerous moderate to severe sigmoid diverticulosis. CT Head ~ mass of the left frontal region with areas of increased hyperattenuation probably due to calcification\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-07-23 00:00:00.000",
"description": "Report",
"row_id": 1665667,
"text": "Addendum:\nTHIS AM PT MORE CLEAR, LESS CONFUSED. OOB TO CHAIR FOR 1 HOUR. TOLERATED WELL WITH ASSISTX1. PT C/O NAUSEA WITH SHORT RELIEF FROM ZOLFRAN. 10MG IVP COMPAZINE GIVEN AT 0630. URINE LYTES SENT AS WELL AT O630. PT IS BACK INTO BED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-07-23 00:00:00.000",
"description": "Report",
"row_id": 1665668,
"text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT , CONFUSED AT TIMES, OX1-2. PT MAE, FOLLOWS COMMANDS. PT DENIES ANY PAIN.\n\nRESP: PT REMAINS ON 2L NC, RR 20-40.\n\nCV: HR 100-120'S ST, SBP 90-120'S. AFEBRILE. IVF NS @75CC/HR.\n\nGI/GU: ABD FIRM DISTENDED, NO BS, NO BM. PT C/O NAUSEA, VOMITTING EARLY IN NIGHT. PT GIVEN WILL LITTLE EFFECT. NGT PLACED FOR 300CC BILE. DID HELP PT FEEL BETTER, BUT PT PULLED IT OUT 2HRS LATER DUE TO CONFUSION. NGT WAS NOT REPLACED. THIS AM PT C/O NAUSEA, GIVEN WITH GOOD EFFECT. PT IS NPO THIS AM. FOLEY INPLACE DRAINING DARK BROWN URINE SMALL AMT. TEAM AWARE.\n\nACCESS: PT HAS 2 PIV'S.\n\nDISPO: PLAN IS FOR ENDOSCOPIC ULTRASOUND TO RECHECK BILLIARY STENT THAT WAS PLACED. CONT TO MONITOR MS, PAIN AND COMFORT. PLAN IS FOR PT TO BE TRANSFERED TO ONCOLOGY WHEN ABLE TO LEAVE ICU. PT'S DAUGHTER WAS UPDATED BY DR.. PT'S DAUGHTER, OVER THE PHONE, IS HCP. PT IS A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2159-07-23 00:00:00.000",
"description": "Report",
"row_id": 1665669,
"text": "EVENTS: Pt with ^HR and episode of hypotension. Widened QRS complex noted on monitor...ekg obtained and labs sent. Required total of 3l NS bolus and maxed on double pressors. L femoral aline placed at bedside by dr. . Cardiology consulted. Discussion with pt, pt's family, this rn and micu team about poor prognosis and ? if pt would want to be intubated (pt deferred). Pt in and out of VTACH. Pt with c/o severe chestpain, requesting pain medication and no further escalation of care. Morphine 0.5 mg IVP given with no relief. Social work notified and emotional support provided to family. Priest called to bedside and sacraments of the sick administered. Pt expired and Dr. in to pronounce.\n"
},
{
"category": "ECG",
"chartdate": "2159-07-23 00:00:00.000",
"description": "Report",
"row_id": 154673,
"text": "Sinus rhythm and A-V conduction delay. Frequent ventricular ectopy and\nventricular tachycardia. These findings are new as compared with tracing\nof . The QRS interval has widened. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2159-07-22 00:00:00.000",
"description": "Report",
"row_id": 154674,
"text": "Sinus rhythm with a single right-sided ventricular premature beat. Biatrial\nabnormality. Intraventricular conduction defect. Old inferior myocardial\ninfarction. Compared to the previous tracing of the ventricular\npremature beat is new and the heart rate has accelerated from 54 to 96 beats\nper minute. Evidence of inferior wall myocardial infarction was present\npreviously.\n\n"
}
] |
94,232 | 184,806 | In summary, Mr. is a 51 year old male with a history of liver disease secondary to hemachromatosis, alcoholic liver disease, and HCV ad with history of EtoH abuse/withdrawal, history of seizures, history of esophageal varices admitted with upper GI bleeding Upper GI Bleed. Patient admitted for GI bleed. EGD showed grade esophageal varices s/p banding as well as esophagitis. He was treated initially with octreotide drip and IV PPI . He required 5 units of PRBCs during hospital stay. He was treated with sucralafate. Nadolol was initiated due to history of varices. Alcohol withdrawal. Patient reportedly drinks pint of alcohol per day. He went into alcohol withdrawal requiring benzox and haldol. Hypertension. Patient on lisinopril and lopressor at home at unknown doses. Nadolol initiated during hospital stay due to history of varices. Patient had ongoing hypertension during hospital stay likely due to withdrawal from alcohol plus baseline hypertension. Liver disease. Patient has a history of hemochromatosis, alcohol abuse, and HCV with stigmata of chronic liver disease on physical exam. Abdominal ultrasound did not show cirrhosis, but showed splenomegaly and no ascites. He was followed by liver during his hospital stay. Thrombocytopenia. Patient had stable thrombocytopenia likely secondary to splenic sequestration. Diabetes Mellitus. Patient has history diabetes, on unknown dose of glyburide at home. Was monitored on RISS while in house. Full Code | Anti smooth muscle Ab pos, neg >HTN/tachycardia:likely related in part to underlying HTN and exacerbated by withdrawl - Lisiniopril >EtOH abuse: Now largely improved, lucid will cont PO valium CIWA scale - CIWA scale: valium and haldol prn - thiamine and folate (change to PO) - Check QTc >Thrombocytopenia: Probably a combination of splenic sequestration (on U/S) and EtOh abuse. >HTN/tachycardia:likely related in part to underlying HTN and exacerbated by withdrawl - Will add back lisinopril (home dose) >EtOH abuse: Improvement compared to , increasingly oriented. >HTN/tachycardia:likely related in part to underlying HTN and exacerbated by withdrawl - Will add back lisinopril (home dose) >EtOH abuse: Improvement compared to , increasingly oriented. >HTN/tachycardia:likely related in part to underlying HTN and exacerbated by withdrawl - Will add back lisinopril (home dose) >EtOH abuse: Improvement compared to , increasingly oriented. >HTN/tachycardia:likely related in part to underlying HTN and exacerbated by withdrawl - Will add back lisinopril (home dose) >EtOH abuse: Improvement compared to , increasingly oriented. Alcohol abuse/withdraw Assessment: A/ox3, restless, , H 120-130s, ST, Action: Start on valium PRN, changed to Ativan 2mg Iv, given Ativan 2mg for 13 Response: Remains A/ox3, appropriate,HR remains on 119-120,ST Plan: Cont follow signs of alcohol withdrawn, given Ativan per Pt noncomplain with meds. At 1015 lever/gallbladeer US Alcohol abuse/withdraw Assessment: A/ox3, restless, Action: Start on valium PRN, changed to Ativan 2mg Iv, given Ativan 2mg for 13 Response: Plan: Cont follow signs of alcohol withdrawn, given Ativan per Pt noncomplain with meds. Chief Complaint: GI Bleed 24 Hour Events: Allergies: Last dose of Antibiotics: Ciprofloxacin - 04:52 AM Infusions: Other ICU medications: Pantoprazole (Protonix) - 03:57 AM Lorazepam (Ativan) - 05:35 AM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 07:07 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 37.1C (98.8 Tcurrent: 37.1C (98.8 HR: 122 (115 - 127) bpm BP: 172/93(112) {137/70(88) - 172/93(112)} mmHg RR: 16 (12 - 19) insp/min SpO2: 97% Heart rhythm: ST (Sinus Tachycardia) Wgt (current): 94.8 kg (admission): 94.8 kg Height: 72 Inch Total In: 1,760 mL PO: TF: IVF: 1,760 mL Blood products: Total out: 0 mL 495 mL Urine: 345 mL NG: 150 mL Stool: Drains: Balance: 0 mL 1,265 mL Respiratory support O2 Delivery Device: None SpO2: 97% ABG: //// Physical Examination Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Labs / Radiology 51 K/uL 8.8 g/dL 25.6 % 6.6 K/uL [image002.jpg] 05:36 AM WBC 6.6 Hct 25.6 Plt 51 Other labs: Differential-Neuts:81.5 %, Lymph:13.1 %, Mono:5.1 %, Eos:0.3 % Assessment and Plan 51 y/oM with h/o hemachromatosis and alcoholic liver disease with history of EtoH abuse/withdrawal, history of seizures, history of esophageal varices admitted with upper GI bleeding GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB - Noted to be erosive esophagitis, though has reported history of varices. Chief Complaint: upper GI bleed 24 Hour Events: - EGD performed; grade II-III & gastritis/esophagitis; 4 bands placed - Carafate and nadolol started - 1 bag platelets given for plt ct 47 --> 71 - hematocrit not appropriately bumping to transfusion; total 4 units given since admission to (25.6 --> 2units --> 28 --> 1 unit --> 26.8 --> 1 unit). Chief Complaint: upper GI bleed 24 Hour Events: - EGD performed; grade II-III & gastritis/esophagitis; 4 bands placed - Carafate and nadolol started - 1 bag platelets given for plt ct 47 --> 71 - hematocrit not appropriately bumping to transfusion; total 4 units given since admission to (25.6 --> 2units --> 28 --> 1 unit --> 26.8 --> 1 unit). - fluid repletion with D5 , thiamine and folate - Advance diet as tolerated Thrombocytopenia: unclear etiology possible partial component of marrow suppression (from EtOh although odd that MCV is low) vs hemachromatosis marrow infiltrate) and dilutional effect given transfusions. EGD showed grade esophageal varices s/p banding as well as esophagitisWas started on IV PPI and octreotide drip. At OSH had a EGD which reportedly showedesophagitis He was started on octreotide and protonix. At OSH had a EGD which reportedly showedesophagitis He was started on octreotide and protonix. - fluid repletion with D5 , thiamine and folate - Advance diet as tolerated Thrombocytopenia: unclear etiology possible partial component of marrow suppression (from EtOh although odd that MCV is low) vs hemachromatosis marrow infiltrate) and dilutional effect given transfusions. - fluid repletion with D5 , thiamine and folate - Advance diet as tolerated Thrombocytopenia: unclear etiology possible partial component of marrow suppression (from EtOh although odd that MCV is low) vs hemachromatosis marrow infiltrate) and dilutional effect given transfusions. Repeat lytes EtOH abuse: - CIWA scale using haldol for hallucination, benzo for agitation and metop/labet IVP for HTN/tachy. Repeat lytes EtOH abuse: - CIWA scale using haldol for hallucination, benzo for agitation and metop/labet IVP for HTN/tachy. FINAL REPORT LIMITED ABDOMINAL ULTRASOUND. Alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt A&Ox3 at beginning of shift with no s/s ETOH withdrawal. Alcohol withdrawal (including delirium tremens, DTs, seizures) Assessment: Pt A&Ox3 at beginning of shift with no s/s ETOH withdrawal. COMPARISON: Abdominal ultrasound dated . THROMBOCYTOPENIA. Noted to have splenomegaly on abdominal ultrasound. REASON FOR THIS EXAMINATION: evaluate for splenomegaly, ascites PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 6:44 PM Splenomegaly. Patent hepatic vasculature. REASON FOR THIS EXAMINATION: ?cirrhosis, ascites, clots. REASON FOR THIS EXAMINATION: ?cirrhosis, ascites, clots. PFI REPORT Patent hepatic vasculature. - ativan per CIWA scale - haldol as needed while monitoring QTc - thiamine, folate, mvi 3. EGD showed grade esophageal varices s/p banding as well as esophagitis. He received 16mg ativan and 5mg haldol for active s/s ETOH withdrawal. He received 16mg ativan and 5mg haldol for active s/s ETOH withdrawal. FINDINGS: There is rotation of the patient, which limits full evaluation of the chest. FINDINGS: There has been interval placement of a right-sided PICC catheter whose tip terminates in the right atrium. | 84 | [
{
"category": "Physician ",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 423161,
"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 Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:12 AM\n Pantoprazole (Protonix) - 04:29 PM\n Haloperidol (Haldol) - 12:04 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.6\nC (99.7\n Tcurrent: 36.9\nC (98.5\n HR: 72 (59 - 95) bpm\n BP: 155/81(97) {115/63(68) - 179/99(132)} mmHg\n RR: 16 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 3,560 mL\n 78 mL\n PO:\n 1,500 mL\n TF:\n IVF:\n 2,060 mL\n 78 mL\n Blood products:\n Total out:\n 3,362 mL\n 470 mL\n Urine:\n 3,362 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 198 mL\n -392 mL\n Respiratory support\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x2, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 12.0 g/dL\n 69 K/uL\n 134 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 9 mg/dL\n 105 mEq/L\n 138 mEq/L\n 34.7 %\n 6.2 K/uL\n [image002.jpg]\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n 06:31 PM\n 05:31 AM\n WBC\n 7.2\n 5.4\n 8.8\n 6.6\n 6.2\n Hct\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n 35.3\n 34.7\n Plt\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n 69\n Cr\n 0.8\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 145\n 163\n 197\n 137\n 134\n Other labs: PT / PTT / INR:15.2/27.2/1.3, ALT / AST:35/73, Alk Phos / T\n Bili:122/2.9, Amylase / Lipase:31/23, Differential-Neuts:66.7 %,\n Lymph:19.7 %, Mono:9.5 %, Eos:3.8 %, Albumin:3.2 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.6 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n TACHYCARDIA, OTHER\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n ALCOHOL ABUSE\n ICU Care\n Nutrition:\n Comments: Reg diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 422950,
"text": "Chief Complaint: alcohol withdrawal, upper gi bleed\n 24 Hour Events:\n Octreotide gtt stopped\n Ciprofloxacin stopped to no abdominal fluid on U/S\n Intermittent agitation - IV ativan, then attempted valium (haldol held\n due to prolonged qtc) with good effect.\n SBPs to 180s - treated with iv labetalol 10mg x2\n (-), other hepatic serolgies pending\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:30 PM\n Labetalol - 01:30 AM\n Lorazepam (Ativan) - 01:36 AM\n Pantoprazole (Protonix) - 03:30 AM\n Other medications:\n Labetolol 10 mg IV prn\n Diazepam prn ciwa\n Haldol PRN\n Ativan PRN\n Nadolol 40 daily\n Sucralafate po QID\n Folic Acid\n Thiamine\n Insulin Sliding Scale\n Zofran\n Pantoprazole\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 77 (64 - 91) bpm\n BP: 139/94(106) {139/69(92) - 187/127(138)} mmHg\n RR: 22 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,699 mL\n 194 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,210 mL\n 194 mL\n Blood products:\n 8 mL\n Total out:\n 5,135 mL\n 792 mL\n Urine:\n 5,135 mL\n 792 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,436 mL\n -598 mL\n Respiratory support\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 66 K/uL\n 12.0 g/dL\n 137 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 100 mEq/L\n 136 mEq/L\n 33.7 %\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n 6.6\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n 197\n 137\n Other labs: PT / PTT / INR:15.3/28.3/1.3, ALT / AST:38/101, Alk Phos /\n T Bili:114/3.4, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL\n Abdominal ultrasound: .\n IMPRESSION:\n 1. Splenomegaly.\n 2. No ascites.\n IMPRESSION:\n 1. Patent hepatic vasculature.\n 2. Echogenic liver, compatible with fatty liver, however, other forms\n of\n liver disease and more advanced liver disease, including significant\n hepatic\n cirrhosis/fibrosis cannot be excluded.\n HCV genotype: pending\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\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": "Physician ",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 422951,
"text": "Chief Complaint: alcohol withdrawal, upper gi bleed\n 24 Hour Events:\n Octreotide gtt stopped\n Ciprofloxacin stopped to no abdominal fluid on U/S\n Intermittent agitation - IV ativan, then attempted valium (haldol held\n due to prolonged qtc) with good effect.\n SBPs to 180s - treated with iv labetalol 10mg x2\n (-), other hepatic serolgies pending\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:30 PM\n Labetalol - 01:30 AM\n Lorazepam (Ativan) - 01:36 AM\n Pantoprazole (Protonix) - 03:30 AM\n Other medications:\n Labetolol 10 mg IV prn\n Diazepam prn ciwa\n Haldol PRN\n Ativan PRN\n Nadolol 40 daily\n Sucralafate po QID\n Folic Acid\n Thiamine\n Insulin Sliding Scale\n Zofran\n Pantoprazole\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 77 (64 - 91) bpm\n BP: 139/94(106) {139/69(92) - 187/127(138)} mmHg\n RR: 22 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,699 mL\n 194 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,210 mL\n 194 mL\n Blood products:\n 8 mL\n Total out:\n 5,135 mL\n 792 mL\n Urine:\n 5,135 mL\n 792 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,436 mL\n -598 mL\n Respiratory support\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 66 K/uL\n 12.0 g/dL\n 137 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 100 mEq/L\n 136 mEq/L\n 33.7 %\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n 6.6\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n 197\n 137\n Other labs: PT / PTT / INR:15.3/28.3/1.3, ALT / AST:38/101, Alk Phos /\n T Bili:114/3.4, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL\n Abdominal ultrasound: .\n IMPRESSION:\n 1. Splenomegaly.\n 2. No ascites.\n IMPRESSION:\n 1. Patent hepatic vasculature.\n 2. Echogenic liver, compatible with fatty liver, however, other forms\n of\n liver disease and more advanced liver disease, including significant\n hepatic\n cirrhosis/fibrosis cannot be excluded.\n HCV genotype: pending\n Assessment and Plan\n In summary, Mr. is a 51 year old male with h/o\n hemachromatosis, alcoholic liver disease, HCV, and alcohol abuse, and\n history of esophageal varices admitted for UGIB now in alcohol\n withdrawal.\n 1. Alcohol withdrawal. Patient now 48 hours from last drink with\n evidence of alcohol withdrawal. Requiring large amounts of benzos to\n control symptoms and haldol.\n - ativan per CIWA scale\n - haldol as needed while monitoring QTc\n - thiamine, folate, mvi\n - daily EKG for QTc evaluation\n 2. Upper GI Bleed. EGD showed grade esophageal varices s/p\n banding as well as esophagitis. Was started on IV PPI and\n octreotide drip. No BMs or hematemasis in last 24 hours. Currently\n has two peripheral (22, 18) and a PICC line for access. Received 5\n units of PRBCs since admission without appropriate increase in hct (25\n 34.5). Hct of 35-40 per PCP.\n Hcts\n - octreotide drip for three days (until AM of )\n - IV PPI \n - type and cross 2 units\n - d/c cipro given that patient has no evidence of ascites\n - sucralafate for two weeks\n - Liver team following\n - regular diet\n - nadolol 40 mg daily given presence of varices\n 3. Hypertension. Patient on lisinopril and lopressor at home at\n unknown doses. Nadolol initiated during hospital stay due to history\n of varices. Patinet has ongoing hypertension likely due to withdrawal\n from alcohol plus hypertension.\n - tolerate SBP < 160, prn IV antihypertensives\n - continue nadolol (though patient unlikely to tolerate Pos given\n sedation)\n .\n 4. Liver disease. Patient has a history of hemochromatosis, alcohol\n abuse, and HCV. Evidence of stigmata of chronic liver disease.\n Elevated Iron noted. Abdominal ultrasound did not show cirrhosis, but\n showed splenomegaly and no ascites. Patient state prior workup for\n liver disease including liver biopsy occurred at many years ago,\n but no record of this. Outpatient GI doctor is unclear of prior workup\n given that patient does not follow up regularly.\n - f/u final read of abdominal ultrasound\n - f/u anti smooth muscle , , hep A, B, C antibodies, HFE,\n to evaluate for other etiology of cirrhosis\n 5. ELEVATED INR. Likely secondary to combination of liver disease and\n poor PO intake. Minimal effect with oral vitamin K.\n - follow INR\n 6. THROMBOCYTOPENIA. be secondary to marrow suppression from\n alcohol abuse or splenic sequestration. Noted to have splenomegaly on\n abdominal ultrasound. Per PCP, Plt is in 70s. Unclear from\n PCP what prior workup has occurred. No schistocytes on peripheral\n smear.\n - trend plts, transfuse for <50 while having GIB\n 7. DIABETES MELLITUS\n - RISS for now, hold glyburide for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\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": "Physician ",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 422952,
"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 Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:30 PM\n Labetalol - 01:30 AM\n Lorazepam (Ativan) - 01:36 AM\n Pantoprazole (Protonix) - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 77 (64 - 91) bpm\n BP: 139/94(106) {139/69(92) - 187/127(138)} mmHg\n RR: 22 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,699 mL\n 231 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,210 mL\n 231 mL\n Blood products:\n 8 mL\n Total out:\n 5,135 mL\n 792 mL\n Urine:\n 5,135 mL\n 792 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,436 mL\n -561 mL\n Respiratory support\n SpO2: 97%\n ABG: ///27/\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: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bases )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: 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 12.0 g/dL\n 66 K/uL\n 137 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 100 mEq/L\n 136 mEq/L\n 33.7 %\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n 6.6\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n 197\n 137\n Other labs: PT / PTT / INR:15.3/28.3/1.3, ALT / AST:38/101, Alk Phos /\n T Bili:114/3.4, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause of\n cirrhosis. His Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding and octreotide course with stable Hct\n - IV PPI\n - Follow q 12hr Hct\n - cont Beta blocker (uptitrate)\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n Cirrhosis: ongoing evaluation for cirrhosis including hemachromatosis\n and Hep C as well as EtOH abuse, as well as other potential etiologies\n of cirrhosis.\n HTN/tachycardia:likely related in part to underlying HTN and\n exacerbated by withdrawl\n - beta blocker\n EtOH abuse: now progressing into withdrawl\n - CIWA scale using haldol for hallucination, benzo for agitation and\n metop/labet IVP for HTN/tachy.\n - fluid repletion with D5 , thiamine and folate\n - Advance diet as tolerated\n - Check ECG\n - Will probably need lactulose (but do not want to place NG tube\n blindly given varices)\n Thrombocytopenia: unclear etiology possible partial component of\n marrow suppression (from EtOh although odd that MCV is low) vs\n hemachromatosis with marrow infiltrate) . By report this is chronic.\n Does not appear to be a med related toxic component. Appears to have\n significant splenomegaly on US () which likely explains the\n thrombocytopenia at least in part.\n -Plt goal of> 50\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 423033,
"text": "54yo male with hx HTN, ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring of GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs and PLTs since admission, and\n has been transfused with 5 units PRBCs and 1 unit PLTs. His HCT is now\n stable at 34.5 and his PLTs are 70. Pts last drink was Sunday, .\n From the time of admission up until the early morning of , the pt\n was without s/s ETOH withdrawal. Around MN , the pt began to\n exhibit signs of alcohol withdrawal.\n Events:no acute events today.ativan has been changed to po valium,pt\n agitated intermittently\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt aox2,fluctuating mental status,trying to get oob many times,ciwa\n \n Action:\n Received ativan 4 mg iv in am.changed to valium .valium 2 mgx2 ,recvd\n Haldol 2.5 mg iv x1,contd wrist restraints intermittently\n Response:\n Pt sleeping intermittently but trying to get oob in between,currently\n sleeping after haldol,all restraints off since 4pm.\n Plan:\n Cont to follow the ciwa scale and dose with valium.follow Qtc with\n haldol,daily EKG\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 423083,
"text": "54yo male with hx HTN, ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring of GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs and PLTs since admission, and\n has been transfused with 5 units PRBCs and 1 unit PLTs. His HCT is now\n stable at 34.5 and his PLTs are 70. Pts last drink was Sunday, .\n From the time of admission up until the early morning of , the pt\n was without s/s ETOH withdrawal. Around MN , the pt began to\n exhibit signs of alcohol withdrawal.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt aox2,fluctuating mental status,trying to get oob many times. BP\n 140\ns to 180\ns systolic.\n Action:\n Pt. receiving PRN Haldol and PRN Valium per CIWA scale. Reoriented\n frequently to time of day.\n Response:\n Pt sleeping intermittently but trying to get oob in between. Responds\n well to Valium.\n Plan:\n Cont to follow the ciwa scale and dose with valium.follow Qtc with\n haldol,daily EKG. Per MICu resident, will tolerate BP below 190\n systolic. Was restarted on PO anithypertensives on day shift.\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 423141,
"text": "Chief Complaint: alcohol withdrawal, upper gi bleed\n 24 Hour Events:\n - Rare agitation, getting out of bed, haldol 2.5 x 1.\n - Lisinopril started at 10 mg.\n - Liver: check AFP, ?repeat Fe/TIBC (hard to read the note...)\n - Hct stable (34.7\n 35.3\n 33.7 )\n - positive anti smooth muscle antibody\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:12 AM\n Pantoprazole (Protonix) - 04:29 PM\n Haloperidol (Haldol) - 12:04 AM\n Other medications:\n Valium prn\n Lisinopril 10 mg daily\n Haldol prn\n Nadolol 40\n Sucralafate\n Folate\n Thiamine\n Insulin sliding scale\n Zofran prn\n Pantoprazole 40 IV q 12\n Changes to medical and 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: 37.6\nC (99.7\n Tcurrent: 36.9\nC (98.5\n HR: 72 (59 - 95) bpm\n BP: 155/81(97) {115/63(68) - 179/99(132)} mmHg\n RR: 16 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 3,560 mL\n 76 mL\n PO:\n 1,500 mL\n TF:\n IVF:\n 2,060 mL\n 76 mL\n Blood products:\n Total out:\n 3,362 mL\n 470 mL\n Urine:\n 3,362 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 198 mL\n -395 mL\n Respiratory support\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 69 K/uL\n 12.0 g/dL\n 134 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 9 mg/dL\n 105 mEq/L\n 138 mEq/L\n 34.7 %\n 6.2 K/uL\n [image002.jpg]\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n 06:31 PM\n 05:31 AM\n WBC\n 7.2\n 5.4\n 8.8\n 6.6\n 6.2\n Hct\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n 35.3\n 34.7\n Plt\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n 69\n Cr\n 0.8\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 145\n 163\n 197\n 137\n 134\n Other labs: PT / PTT / INR:15.2/27.2/1.3, ALT / AST:35/73, Alk Phos / T\n Bili:122/2.9, Amylase / Lipase:31/23, Differential-Neuts:66.7 %,\n Lymph:19.7 %, Mono:9.5 %, Eos:3.8 %, Albumin:3.2 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.6 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n TACHYCARDIA, OTHER\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n ALCOHOL ABUSE\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 423143,
"text": "Chief Complaint: alcohol withdrawal, upper gi bleed\n 24 Hour Events:\n - Rare agitation, getting out of bed, haldol 2.5 x 1.\n - Lisinopril started at 10 mg.\n - Liver: check AFP, ?repeat Fe/TIBC (hard to read the note...)\n - Hct stable (34.7\n 35.3\n 33.7 )\n - positive anti smooth muscle antibody\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:12 AM\n Pantoprazole (Protonix) - 04:29 PM\n Haloperidol (Haldol) - 12:04 AM\n Other medications:\n Valium prn\n Lisinopril 10 mg daily\n Haldol prn\n Nadolol 40\n Sucralafate\n Folate\n Thiamine\n Insulin sliding scale\n Zofran prn\n Pantoprazole 40 IV q 12\n Changes to medical and 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: 37.6\nC (99.7\n Tcurrent: 36.9\nC (98.5\n HR: 72 (59 - 95) bpm\n BP: 155/81(97) {115/63(68) - 179/99(132)} mmHg\n RR: 16 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 3,560 mL\n 76 mL\n PO:\n 1,500 mL\n TF:\n IVF:\n 2,060 mL\n 76 mL\n Blood products:\n Total out:\n 3,362 mL\n 470 mL\n Urine:\n 3,362 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 198 mL\n -395 mL\n Respiratory support\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 69 K/uL\n 12.0 g/dL\n 134 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 9 mg/dL\n 105 mEq/L\n 138 mEq/L\n 34.7 %\n 6.2 K/uL\n [image002.jpg]\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n 06:31 PM\n 05:31 AM\n WBC\n 7.2\n 5.4\n 8.8\n 6.6\n 6.2\n Hct\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n 35.3\n 34.7\n Plt\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n 69\n Cr\n 0.8\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 145\n 163\n 197\n 137\n 134\n Other labs: PT / PTT / INR:15.2/27.2/1.3, ALT / AST:35/73, Alk Phos / T\n Bili:122/2.9, Amylase / Lipase:31/23, Differential-Neuts:66.7 %,\n Lymph:19.7 %, Mono:9.5 %, Eos:3.8 %, Albumin:3.2 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.6 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n In summary, Mr. is a 51 year old male with h/o liver\n disease secondary to hemachromatosis, alcoholic liver disease, HCV, and\n history of esophageal varices admitted for UGIB now in alcohol\n withdrawal.\n 1. Alcohol withdrawal. Requiring large amounts of benzos to control\n symptoms and haldol (with limited use due to qt prolongation). Better\n effect with valium than ativan so will transition to valium.\n - switch to valium per CIWA scale\n - haldol as needed while monitoring QTc\n - thiamine, folate, mvi\n - daily EKG for QTc evaluation\n 2. Upper GI Bleed. EGD showed grade esophageal varices s/p\n banding as well as esophagitis. Was started on IV PPI . Was on\n octreotide drip for 3 days, now completed. No BMs or hematemasis in\n last 24 hours. S/p 5 units of PRBC during hospitalization. Hct now\n stable. Baseline Hct of 35-40 per PCP.\n Hcts\n - IV PPI \n - type and cross 2 units\n - sucralafate for two weeks\n - Liver team following\n - regular diet\n - nadolol 40 mg daily given presence of varices\n 3. Hypertension. Patient on lisinopril and lopressor at home at\n unknown doses. Nadolol initiated during hospital stay due to history\n of varices. Patinet has ongoing hypertension likely due to withdrawal\n from alcohol plus baseline hypertension.\n - tolerate SBP < 160, prn IV antihypertensives\n - continue nadolol\n - initiate lisinopril\n .\n 4. Liver disease. Patient has a history of hemochromatosis, alcohol\n abuse, and HCV. Evidence of stigmata of chronic liver disease.\n Elevated Iron noted. Abdominal ultrasound did not show cirrhosis, but\n showed splenomegaly and no ascites. Patient state prior workup for\n liver disease including liver biopsy occurred at many years ago,\n but no record of this. Outpatient GI doctor is unclear of prior workup\n given that patient does not follow up regularly. History of Hep B\n vaccination. History of hep A infection in past. negative\n - f/u final read of abdominal ultrasound\n - f/u anti smooth muscle antibiody HFE, to evaluate for other etiology\n of cirrhosis\n 5. THROMBOCYTOPENIA. Likely secondary to splenic sequestration. At\n baseline platelet count.\n - trend plts, transfuse for <50 while having GIB\n 7. DIABETES MELLITUS\n - RISS for now, hold glyburide for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Family meeting held Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 423145,
"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 Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:12 AM\n Pantoprazole (Protonix) - 04:29 PM\n Haloperidol (Haldol) - 12:04 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.6\nC (99.7\n Tcurrent: 36.9\nC (98.5\n HR: 72 (59 - 95) bpm\n BP: 155/81(97) {115/63(68) - 179/99(132)} mmHg\n RR: 16 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 3,560 mL\n 78 mL\n PO:\n 1,500 mL\n TF:\n IVF:\n 2,060 mL\n 78 mL\n Blood products:\n Total out:\n 3,362 mL\n 470 mL\n Urine:\n 3,362 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 198 mL\n -392 mL\n Respiratory support\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x2, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 12.0 g/dL\n 69 K/uL\n 134 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 9 mg/dL\n 105 mEq/L\n 138 mEq/L\n 34.7 %\n 6.2 K/uL\n [image002.jpg]\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n 06:31 PM\n 05:31 AM\n WBC\n 7.2\n 5.4\n 8.8\n 6.6\n 6.2\n Hct\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n 35.3\n 34.7\n Plt\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n 69\n Cr\n 0.8\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 145\n 163\n 197\n 137\n 134\n Other labs: PT / PTT / INR:15.2/27.2/1.3, ALT / AST:35/73, Alk Phos / T\n Bili:122/2.9, Amylase / Lipase:31/23, Differential-Neuts:66.7 %,\n Lymph:19.7 %, Mono:9.5 %, Eos:3.8 %, Albumin:3.2 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.6 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN\n ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES)\n TACHYCARDIA, OTHER\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n ALCOHOL ABUSE\n ICU Care\n Nutrition:\n Comments: Reg diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 423162,
"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 Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:12 AM\n Pantoprazole (Protonix) - 04:29 PM\n Haloperidol (Haldol) - 12:04 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.6\nC (99.7\n Tcurrent: 36.9\nC (98.5\n HR: 72 (59 - 95) bpm\n BP: 155/81(97) {115/63(68) - 179/99(132)} mmHg\n RR: 16 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 3,560 mL\n 78 mL\n PO:\n 1,500 mL\n TF:\n IVF:\n 2,060 mL\n 78 mL\n Blood products:\n Total out:\n 3,362 mL\n 470 mL\n Urine:\n 3,362 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 198 mL\n -392 mL\n Respiratory support\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x2, Movement: Purposeful,\n Labs / Radiology\n 12.0 g/dL\n 69 K/uL\n 134 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 9 mg/dL\n 105 mEq/L\n 138 mEq/L\n 34.7 %\n 6.2 K/uL\n [image002.jpg]\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n 06:31 PM\n 05:31 AM\n WBC\n 7.2\n 5.4\n 8.8\n 6.6\n 6.2\n Hct\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n 35.3\n 34.7\n Plt\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n 69\n Cr\n 0.8\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 145\n 163\n 197\n 137\n 134\n Other labs: PT / PTT / INR:15.2/27.2/1.3, ALT / AST:35/73, Alk Phos / T\n Bili:122/2.9, Amylase / Lipase:31/23, Differential-Neuts:66.7 %,\n Lymph:19.7 %, Mono:9.5 %, Eos:3.8 %, Albumin:3.2 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.6 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause\n of cirrhosis. His baseline Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding and octreotide course with stable Hct\n - change PPI to PO\n - cont Beta blocker for varices\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n >Cirrhosis: ongoing evaluation for cirrhosis including hemachromatosis\n and Hep C as well as EtOH abuse, as well as other potential etiologies\n of cirrhosis. Anti smooth muscle Ab pos, neg\n >HTN/tachycardia:likely related in part to underlying HTN and\n exacerbated by withdrawl\n - Lisiniopril\n >EtOH abuse: Now largely improved, lucid will cont PO valium CIWA scale\n - CIWA scale: valium and haldol prn\n - thiamine and folate (change to PO)\n - Check QTc\n >Thrombocytopenia: Probably a combination of splenic sequestration (on\n U/S) and EtOh abuse.\n -Plt goal of> 50\n ICU Care\n Nutrition:\n Comments: Reg diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 423302,
"text": "51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with admitted with UGIB in the\n setting of grad esoph varices s/p banding . ETOH withdrawl\n requiring Haldol and Valium.\n Hypertension, benign\n Assessment:\n BP- 170-160/90\ns, HR 80- with no ectopy noted. No CP.\n Action:\n Was restarted back on PO Anti-hypertensives.\n Response:\n BP-to 150\ns/80, HR 70-80\ns SR.\n Plan:\n Continue to assess BP\ns and administer anti-hypertensive meds.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Is alert but still mildly confused, is cooperative today, CIWA scale\n , no need for Haldol or Valium today. Had been requiring high amts.\n Action:\n Assessing MS, OOB to chair, has poor short term memory @ times.\n Response:\n Happy to be OOB and eating, wants to go home.\n Plan:\n Assess MS, continue CIWA scale Valium/Haldol if needed. Social Services\n involved.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n HCT\ns stable @ 34.0, No n/v, no stool, taking PO\ns well. No c/o\ns pain.\n Action:\n Taking PO\ns well, checking HCt\ns ,\n Response:\n GIB resolved.\n Plan:\n Monitor HCT\ns assess VS\ns and s/s of re-bleed.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n UPPER GI BLEED\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 94.8 kg\n Daily weight:\n 94.8 kg\n Allergies/Reactions:\n Precautions: Contact\n PMH: Diabetes - Oral , ETOH, Hepatitis\n CV-PMH: Hypertension\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:153\n D:83\n Temperature:\n 98.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 24 insp/min\n Heart Rate:\n 80 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,287 mL\n 24h total out:\n 2,235 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 05:31 AM\n Potassium:\n 3.4 mEq/L\n 05:31 AM\n Chloride:\n 105 mEq/L\n 05:31 AM\n CO2:\n 24 mEq/L\n 05:31 AM\n BUN:\n 9 mg/dL\n 05:31 AM\n Creatinine:\n 0.8 mg/dL\n 05:31 AM\n Glucose:\n 134 mg/dL\n 05:31 AM\n Hematocrit:\n 34.7 %\n 05:31 AM\n Finger Stick Glucose:\n 181\n 10:00 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": "2148-12-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 423287,
"text": "51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with admitted with UGIB in the\n setting of grad esoph varices s/p banding . ETOH withdrawl\n requiring Haldol and Valium.\n Hypertension, benign\n Assessment:\n BP- 170-160/90\ns, HR 80- with no ectopy noted. No CP.\n Action:\n Was restarted back on PO Anti-hypertensives.\n Response:\n BP-to 150\ns/80, HR 70-80\ns SR.\n Plan:\n Continue to assess BP\ns and administer anti-hypertensive meds.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Is alert but still mildly confused, is cooperative today, CIWA scale\n , no need for Haldol or Valium today. Had been requiring high amts.\n Action:\n Assessing MS, OOB to chair, has poor short term memory @ times.\n Response:\n Happy to be OOB and eating, wants to go home.\n Plan:\n Assess MS, continue CIWA scale Valium/Haldol if needed. Social Services\n involved.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n HCT\ns stable @ 34.0, No n/v, no stool, taking PO\ns well. No c/o\ns pain.\n Action:\n Taking PO\ns well, checking HCt\ns ,\n Response:\n GIB resolved.\n Plan:\n Monitor HCT\ns assess VS\ns and s/s of re-bleed.\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 422965,
"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 > continued EtOH withdrawl\n > Increasing QTc\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:30 PM\n Labetalol - 01:30 AM\n Lorazepam (Ativan) - 01:36 AM\n Pantoprazole (Protonix) - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 77 (64 - 91) bpm\n BP: 139/94(106) {139/69(92) - 187/127(138)} mmHg\n RR: 22 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,699 mL\n 231 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,210 mL\n 231 mL\n Blood products:\n 8 mL\n Total out:\n 5,135 mL\n 792 mL\n Urine:\n 5,135 mL\n 792 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,436 mL\n -561 mL\n Respiratory support\n SpO2: 97%\n ABG: ///27/\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: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bases )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: A+Ox 2\n (markedly improved from )\n Labs / Radiology\n 12.0 g/dL\n 66 K/uL\n 137 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 100 mEq/L\n 136 mEq/L\n 33.7 %\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n 6.6\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n 197\n 137\n Other labs: PT / PTT / INR:15.3/28.3/1.3, ALT / AST:38/101, Alk Phos /\n T Bili:114/3.4, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL. neg\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause\n of cirrhosis. His baseline Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding and octreotide course with stable Hct\n - IV PPI\n - Follow q 12hr Hct\n - cont Beta blocker (uptitrate)\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n >Cirrhosis: ongoing evaluation for cirrhosis including hemachromatosis\n and Hep C as well as EtOH abuse, as well as other potential etiologies\n of cirrhosis.\n >HTN/tachycardia:likely related in part to underlying HTN and\n exacerbated by withdrawl\n - Will add back lisinopril (home dose)\n >EtOH abuse: Improvement compared to , increasingly oriented.\n - CIWA scale using haldol for hallucination, seems to have responded\n well to valium (prob longer half life)\n - fluid repletion with D5 , thiamine and folate\n - Advance diet as tolerated\n - Prolonged QT on ECG, holding haldol.\n >Thrombocytopenia: unclear etiology possible partial component of\n marrow suppression (from EtOh although odd that MCV is low) vs\n hemachromatosis with marrow infiltrate) . By report this is chronic.\n Does not appear to be a med related toxic component. Appears to have\n significant splenomegaly on US () which likely explains the\n thrombocytopenia at least in part.\n -Plt goal of> 50\n ICU Care\n Nutrition:\n OK to trial clears\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: Keep HOB elevated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 422990,
"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 > continued EtOH withdrawl\n > Increasing QTc\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:30 PM\n Labetalol - 01:30 AM\n Lorazepam (Ativan) - 01:36 AM\n Pantoprazole (Protonix) - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 77 (64 - 91) bpm\n BP: 139/94(106) {139/69(92) - 187/127(138)} mmHg\n RR: 22 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,699 mL\n 231 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,210 mL\n 231 mL\n Blood products:\n 8 mL\n Total out:\n 5,135 mL\n 792 mL\n Urine:\n 5,135 mL\n 792 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,436 mL\n -561 mL\n Respiratory support\n SpO2: 97%\n ABG: ///27/\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: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bases )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: A+Ox 2\n (markedly improved from )\n Labs / Radiology\n 12.0 g/dL\n 66 K/uL\n 137 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 100 mEq/L\n 136 mEq/L\n 33.7 %\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n 6.6\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n 197\n 137\n Other labs: PT / PTT / INR:15.3/28.3/1.3, ALT / AST:38/101, Alk Phos /\n T Bili:114/3.4, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL. neg\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause\n of cirrhosis. His baseline Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding and octreotide course with stable Hct\n - IV PPI\n - Follow q 12hr Hct\n - cont Beta blocker (uptitrate)\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n >Cirrhosis: ongoing evaluation for cirrhosis including hemachromatosis\n and Hep C as well as EtOH abuse, as well as other potential etiologies\n of cirrhosis.\n >HTN/tachycardia:likely related in part to underlying HTN and\n exacerbated by withdrawl\n - Will add back lisinopril (home dose)\n >EtOH abuse: Improvement compared to , increasingly oriented.\n - CIWA scale using haldol for hallucination, seems to have responded\n well to valium (prob longer half life)\n - fluid repletion with D5 , thiamine and folate\n - Advance diet as tolerated\n - Prolonged QT on ECG, holding haldol.\n >Thrombocytopenia: unclear etiology possible partial component of\n marrow suppression (from EtOh although odd that MCV is low) vs\n hemachromatosis with marrow infiltrate) . By report this is chronic.\n Does not appear to be a med related toxic component. Appears to have\n significant splenomegaly on US () which likely explains the\n thrombocytopenia at least in part.\n -Plt goal of> 50\n ICU Care\n Nutrition:\n OK to trial clears\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: Keep HOB elevated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 422993,
"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 > continued EtOH withdrawl\n > Increasing QTc\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:30 PM\n Labetalol - 01:30 AM\n Lorazepam (Ativan) - 01:36 AM\n Pantoprazole (Protonix) - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 77 (64 - 91) bpm\n BP: 139/94(106) {139/69(92) - 187/127(138)} mmHg\n RR: 22 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,699 mL\n 231 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,210 mL\n 231 mL\n Blood products:\n 8 mL\n Total out:\n 5,135 mL\n 792 mL\n Urine:\n 5,135 mL\n 792 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,436 mL\n -561 mL\n Respiratory support\n SpO2: 97%\n ABG: ///27/\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: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bases )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: A+Ox 2\n (markedly improved from )\n Labs / Radiology\n 12.0 g/dL\n 66 K/uL\n 137 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 100 mEq/L\n 136 mEq/L\n 33.7 %\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n 6.6\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n 197\n 137\n Other labs: PT / PTT / INR:15.3/28.3/1.3, ALT / AST:38/101, Alk Phos /\n T Bili:114/3.4, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL. neg\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause\n of cirrhosis. His baseline Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding and octreotide course with stable Hct\n - IV PPI\n - Follow q 12hr Hct\n - cont Beta blocker (uptitrate)\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n >Cirrhosis: ongoing evaluation for cirrhosis including hemachromatosis\n and Hep C as well as EtOH abuse, as well as other potential etiologies\n of cirrhosis.\n >HTN/tachycardia:likely related in part to underlying HTN and\n exacerbated by withdrawl\n - Will add back lisinopril (home dose)\n >EtOH abuse: Improvement compared to , increasingly oriented.\n - CIWA scale using haldol for hallucination, seems to have responded\n well to valium (prob longer half life)\n - fluid repletion with D5 , thiamine and folate\n - Advance diet as tolerated\n - Prolonged QT on ECG, holding haldol.\n >Thrombocytopenia: unclear etiology possible partial component of\n marrow suppression (from EtOh although odd that MCV is low) vs\n hemachromatosis with marrow infiltrate) . By report this is chronic.\n Does not appear to be a med related toxic component. Appears to have\n significant splenomegaly on US () which likely explains the\n thrombocytopenia at least in part.\n -Plt goal of> 50\n ICU Care\n Nutrition:\n OK to trial clears\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: Keep HOB elevated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 422995,
"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: GI bleed, ETOH withdrawal\n 24 Hour Events:\n > continued EtOH withdrawal\n > Increasing QTc\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:30 PM\n Labetalol - 01:30 AM\n Lorazepam (Ativan) - 01:36 AM\n Pantoprazole (Protonix) - 03:30 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 77 (64 - 91) bpm\n BP: 139/94(106) {139/69(92) - 187/127(138)} mmHg\n RR: 22 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,699 mL\n 231 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,210 mL\n 231 mL\n Blood products:\n 8 mL\n Total out:\n 5,135 mL\n 792 mL\n Urine:\n 5,135 mL\n 792 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,436 mL\n -561 mL\n Respiratory support\n SpO2: 97%\n ABG: ///27/\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: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bases )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: A+Ox 2\n (markedly improved from )\n Labs / Radiology\n 12.0 g/dL\n 66 K/uL\n 137 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 100 mEq/L\n 136 mEq/L\n 33.7 %\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n 6.6\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n 197\n 137\n Other labs: PT / PTT / INR:15.3/28.3/1.3, ALT / AST:38/101, Alk Phos /\n T Bili:114/3.4, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL. neg\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause\n of cirrhosis. His baseline Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding and octreotide course with stable Hct\n - IV PPI\n - Follow q 12hr Hct\n - cont Beta blocker (uptitrate)\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n >Cirrhosis: ongoing evaluation for cirrhosis including hemachromatosis\n and Hep C as well as EtOH abuse, as well as other potential etiologies\n of cirrhosis.\n >HTN/tachycardia:likely related in part to underlying HTN and\n exacerbated by withdrawl\n - Will add back lisinopril (home dose)\n >EtOH abuse: Improvement compared to , increasingly oriented.\n - CIWA scale using haldol for hallucination, seems to have responded\n well to valium (prob longer half life)\n - fluid repletion with D5 , thiamine and folate\n - Advance diet as tolerated\n - Prolonged QT on ECG, holding haldol.\n >Thrombocytopenia: unclear etiology possible partial component of\n marrow suppression (from EtOh although odd that MCV is low) vs\n hemachromatosis with marrow infiltrate) . By report this is chronic.\n Does not appear to be a med related toxic component. Appears to have\n significant splenomegaly on US () which likely explains the\n thrombocytopenia at least in part.\n -Plt goal of> 50\n ICU Care\n Nutrition:\n OK to trial clears\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: Keep HOB elevated\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 422974,
"text": "Chief Complaint: alcohol withdrawal, upper gi bleed\n 24 Hour Events:\n Octreotide gtt stopped\n Ciprofloxacin stopped to no abdominal fluid on U/S\n Intermittent agitation - IV ativan, then attempted valium (haldol held\n due to prolonged qtc) with good effect.\n SBPs to 180s - treated with iv labetalol 10mg x2\n (-), other hepatic serolgies pending\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 09:30 PM\n Labetalol - 01:30 AM\n Lorazepam (Ativan) - 01:36 AM\n Pantoprazole (Protonix) - 03:30 AM\n Other medications:\n Labetolol 10 mg IV prn\n Diazepam prn ciwa\n Haldol PRN\n Ativan PRN\n Nadolol 40 daily\n Sucralafate po QID\n Folic Acid\n Thiamine\n Insulin Sliding Scale\n Zofran\n Pantoprazole\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.2\nC (98.9\n HR: 77 (64 - 91) bpm\n BP: 139/94(106) {139/69(92) - 187/127(138)} mmHg\n RR: 22 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,699 mL\n 194 mL\n PO:\n 480 mL\n TF:\n IVF:\n 2,210 mL\n 194 mL\n Blood products:\n 8 mL\n Total out:\n 5,135 mL\n 792 mL\n Urine:\n 5,135 mL\n 792 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,436 mL\n -598 mL\n Respiratory support\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 66 K/uL\n 12.0 g/dL\n 137 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.3 mEq/L\n 8 mg/dL\n 100 mEq/L\n 136 mEq/L\n 33.7 %\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n 6.6\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n Cr\n 1.0\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n 197\n 137\n Other labs: PT / PTT / INR:15.3/28.3/1.3, ALT / AST:38/101, Alk Phos /\n T Bili:114/3.4, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL\n Abdominal ultrasound: .\n IMPRESSION:\n 1. Splenomegaly.\n 2. No ascites.\n IMPRESSION:\n 1. Patent hepatic vasculature.\n 2. Echogenic liver, compatible with fatty liver, however, other forms\n of\n liver disease and more advanced liver disease, including significant\n hepatic\n cirrhosis/fibrosis cannot be excluded.\n HCV genotype: pending\n Assessment and Plan\n In summary, Mr. is a 51 year old male with h/o liver\n disease secondary to hemachromatosis, alcoholic liver disease, HCV, and\n history of esophageal varices admitted for UGIB now in alcohol\n withdrawal.\n 1. Alcohol withdrawal. Requiring large amounts of benzos to control\n symptoms and haldol (with limited use due to qt prolongation). Better\n effect with valium than ativan so will transition to valium.\n - switch to valium per CIWA scale\n - haldol as needed while monitoring QTc\n - thiamine, folate, mvi\n - daily EKG for QTc evaluation\n 2. Upper GI Bleed. EGD showed grade esophageal varices s/p\n banding as well as esophagitis. Was started on IV PPI . Was on\n octreotide drip for 3 days, now completed. No BMs or hematemasis in\n last 24 hours. S/p 5 units of PRBC during hospitalization. Hct now\n stable. Baseline Hct of 35-40 per PCP.\n Hcts\n - IV PPI \n - type and cross 2 units\n - sucralafate for two weeks\n - Liver team following\n - regular diet\n - nadolol 40 mg daily given presence of varices\n 3. Hypertension. Patient on lisinopril and lopressor at home at\n unknown doses. Nadolol initiated during hospital stay due to history\n of varices. Patinet has ongoing hypertension likely due to withdrawal\n from alcohol plus baseline hypertension.\n - tolerate SBP < 160, prn IV antihypertensives\n - continue nadolol\n - initiate lisinopril\n .\n 4. Liver disease. Patient has a history of hemochromatosis, alcohol\n abuse, and HCV. Evidence of stigmata of chronic liver disease.\n Elevated Iron noted. Abdominal ultrasound did not show cirrhosis, but\n showed splenomegaly and no ascites. Patient state prior workup for\n liver disease including liver biopsy occurred at many years ago,\n but no record of this. Outpatient GI doctor is unclear of prior workup\n given that patient does not follow up regularly. History of Hep B\n vaccination. History of hep A infection in past. negative\n - f/u final read of abdominal ultrasound\n - f/u anti smooth muscle antibiody HFE, to evaluate for other etiology\n of cirrhosis\n 5. THROMBOCYTOPENIA. Likely secondary to splenic sequestration. At\n baseline platelet count.\n - trend plts, transfuse for <50 while having GIB\n 7. DIABETES MELLITUS\n - RISS for now, hold glyburide for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\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": "2148-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 423022,
"text": "54yo male with hx HTN, ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring of GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs and PLTs since admission, and\n has been transfused with 5 units PRBCs and 1 unit PLTs. His HCT is now\n stable at 34.5 and his PLTs are 70. Pts last drink was Sunday, .\n From the time of admission up until the early morning of , the pt\n was without s/s ETOH withdrawal. Around MN , the pt began to\n exhibit signs of alcohol withdrawal.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt aox2,fluctuating mental status,trying to get oob many times,ciwa\n \n Action:\n Received ativan 4 mg iv in am.changed to valium .valium 2 mgx2 ,recvd\n Haldol 2.5 mg iv x1,contd wrist restraints intermittently\n Response:\n Pt sleeping intermittently but trying to get oob in between,currently\n sleeping after haldol\n Plan:\n Cont to follow the ciwa scale and dose with valium,Haldol is deferred\n due to prolonged QTc .481\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 422486,
"text": "Chief Complaint: GI Bleed\n 24 Hour Events:\n - had melena overnight, nausea, and small coffee ground emesis\n - got ativan per CIWA scale x 2\n - ongoing tachycardia, minimal improvement with 1L NS\n - awaiting sono\n - Hct fell to 25\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 04:52 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 03:57 AM\n Lorazepam (Ativan) - 05:35 AM\n Other medications:\n Vitamin K 10 mg PO x 3 days\n Folic acid 1 mg daily\n Thiamine 100 IV daily\n Cipro 400 mg x 1\n Insulin Sliding Scale\n Ativan 2 mg daily\n Zofran PRN\n Pantoprazole 40 mg \n Octreotide Drip\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 122 (115 - 127) bpm\n BP: 172/93(112) {137/70(88) - 172/93(112)} mmHg\n RR: 16 (12 - 19) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 1,760 mL\n PO:\n TF:\n IVF:\n 1,760 mL\n Blood products:\n Total out:\n 0 mL\n 495 mL\n Urine:\n 345 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n Gen: well appearing obese gentleman, NAD, tremulous\n HEENT: EOMI, o/p clear\n CV: Tachycardic, no m/r/g\n Lungs: CTA bilaterally\n Abd: Obese, soft, NT, distended, bowel sounds present\n Ext: no peripherally edema, + asterixus, tremulous\n Skin: +spiders\n Labs / Radiology\n 51 K/uL\n 8.8 g/dL\n 25.6 %\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n WBC\n 6.6\n Hct\n 25.6\n Plt\n 51\n Other labs: Differential-Neuts:81.5 %, Lymph:13.1 %, Mono:5.1 %,\n Eos:0.3 %\n PT 16.3\n PTT 26.9\n INR 1.5\n Micro:\n HCV VL pending \n Imaging:\n EGD .\n Varices at the lower third of the esophagus (ligation)\n Erythema and friability in the middle third of the esophagus and lower\n third of the esophagus compatible with esophagitis\n Erythema, friability, granularity and mosaic appearance in the stomach\n body and fundus compatible with portal hypertensive gastropathy\n Otherwise normal EGD to second part of the duodenum\n Assessment and Plan\n In summary, Mr. is a 51 year old male with h/o\n hemachromatosis, alcoholic liver disease, HCV, and alcohol abuse, and\n history of esophageal varices admitted for UGIB.\n 1. Upper GI Bleed. EGD today showed grade esophageal varices\n s/p banding as well as esophagitis. OSH EGD showed gastritis but did\n not comment on varices. Was started on IV PPI and octreotide\n drip. Had melena and bright red hematemasis overnight. Currently has\n two peripheral (22, 18) and a PICC line for access. Received 2 units\n of PRBCs this morning and 1.5 of emergency release blood at OSH. Per\n PCP, had a few admissions for GIBs. Hct of 35-40 per PCP.\n 6 hour Hcts, transfuse to 30 given active bleeding\n - octreotide drip, IV PPI \n - type and cross 2 units\n - cipro prophylaxis for SBP prophylaxis in patient with history of\n cirrhosis\n - sucralafate for two weeks\n - Liver team following\n - advance to clears\n - initiate nadolol 20 mg daily in PM if stable from standpoint of\n ongoing bleed\n 2. Tachycardia. HR currently in the 130s and BP increasing,\n likely secondary to combination of alcohol withdrawal, GI bleed, and\n ?dehydration. HR did not respond to fluid boluses, but mild\n improvement with ativan for CIWA scale and blood transfusion. Also,\n normally on home BB and ACIE, which is being held.\n - monitor on tele\n - blood transfusions, to keep hct > 30\n - ativan per CIWA scale\n 3. Liver disease. Patient has a history of hemochromatosis, alcohol\n abuse, and HCV. Evidence of stigmata of chronic liver disease.\n - abdominal ultrasound\n - f/u iron studies\n - f/u HCV viral load\n 4. Alcohol abuse. Physical exam and vitals suggestive of alcohol\n withdrawal.\n - ativan CIWA scale\n - Thiamine, folate, MVI\n 5. ELEVATED INR. Likely secondary to combination of liver disease and\n poor PO intake.\n - attempt reversal with vitamin k 10mg PO x3 days\n 6. THROMBOCYTOPENIA. be secondary to marrow suppression from\n alcohol abuse or splenic sequestration. Per PCP, Plt is in\n 70s. Unclear from PCP what prior workup has occurred.\n - obtain OSH records for previous workup and for prior Plt\n count\n - trend plts, transfuse for <50 while having GIB\n - check peripheral smear to r/o schistocytes\n 7. DIABETES MELLITUS\n - RISS for now, hold glyburide for now\n 8. HYPERTENSION. Likely secondary to alcohol withdrawal and not being\n on home antihypertensives. Given history of varices, will consider\n resuming antihypertensives in PM if hemodynamically stable and no\n further ongoing bleeding.\n - hold lopressor in setting of GIB, but consider starting nadolol in\n PM\n 9. Anion gap. Patient has an elevated anion gap, with unclear\n etiology.\n - check u tox, s tox\n PCP: Ph \n ICU Care\n Nutrition: NPO\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 02:00 AM\n 16 Gauge - 02:01 AM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: IV PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU care\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 422459,
"text": "Chief Complaint: Hematemesis\n HPI:\n Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match.\n In the ED, He had a HR of 120 and BP of 150/70 RR 16 and satting\n 100% on RA. He was continued on medications and admitted to the medical\n ICU.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lopressor\n Lisinopril\n Glyburide\n - unknown doses\n Past medical history:\n Family history:\n Social History:\n Hemachromatosis c/b diabetes\n Hypertension\n Liver Disease , reported c/b varices\n HCV per notes\n Occupation:\n Drugs: denies\n Tobacco: denies\n Alcohol:\n pt/day\n Other:\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, denies CP\n Respiratory: No(t) Cough, Dyspnea, mild dyspnea recently, worse when\n walking, supine\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, Diarrhea,\n melena\n Genitourinary: Dysuria, Foley\n Flowsheet Data as of 04:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 120 (115 - 120) bpm\n BP: 137/93(103) {137/70(88) - 143/93(103)} mmHg\n RR: 12 (12 - 14) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 518 mL\n PO:\n TF:\n IVF:\n 518 mL\n Blood products:\n Total out:\n 0 mL\n 210 mL\n Urine:\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 308 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\n SM at base\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 : , No(t) Crackles : )\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n ALT: 39\n AP: 114\n Tbili: 1.6\n Alb: 3.8\n AST: 86\n LDH: 231\n Dbili:\n TProt:\n :\n Lip:\n 79\n 258\n 0.9\n 28\n 29\n 94\n 3.5\n 137\n 30.0\n 7.1\n [image002.jpg]\n PT: 17.0\n PTT: 28.4\n INR: 1.5\n Iron studies pending\n Other labs: PT / PTT / INR://1.5\n Assessment and Plan\n 51 y/oM with h/o hemachromatosis and alcoholic liver disease with\n history of EtoH abuse/withdrawal, history of seizures, history of\n esophageal varices admitted with upper GI bleeding\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n - Noted to be erosive esophagitis, though has reported history\n of varices. A non-bleeding ulcer was seen, and he was transferred on IV\n PPI infusion and octreotide infusion\n - Given no bleeding ulcer seen, change protonix to 40mg IV BID\n - Discontinue octreotide gtt for now\n - Q6h HCTs, transfuse <30 or falling HCT\n - Bolus 1L/1h now\n - Cipro 400mg IV x1 given unclear h/o ascites/portal\n hypertension\n - Gi aware from , see in the morning. Involve GI and\n hepatology service for further investigation, and possible repeat EGD\n for evaluation of varices\n - Maintain 3 PIV (16g, 18g, 20g)\nHEMOCHROMATOSIS\n - Check current iron studies\n - Check RUQ ultrasound for eval of ascites, cirrhosis\n - f/u Bilirubin, trend, obtain direct\n ALCOHOL ABUSE/ Withdrawal\n - CIWA with Ativan while taking only IV 2mg IV q1h PRN CIWA >\n 10\n - Thiamine, folate, MVI\n - SW consult in morning\n HEPATITIS C VIRUS\n - Check HCV Viral load\n - RUQ also to assess for focal lesions\n ELEVATED INR\n - presumably from poor po intake, liver disease\n - attempt reversal with vitamin k 10mg PO x3 days\n THROMBOCYTOPENIA\n - unknown baseline, possible contribution from liver (\n thrombopoietin), spleen\n - trend plts, transfuse for <50 while having GIB.\nDIABETES MELLITUS\n - RISS for now, hold glyburide for now\nHYPERTENSION\n - hold lopressor in setting of GIB\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 02:02 AM\n 18 Gauge - 02:03 AM\n 20 Gauge - 02:03 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: contact: (sister)\n status: Full code\n Disposition: ICU\n ------ Protected Section ------\n For Inc SOB recently, could consider CHF. CXR ordered for this am\n though lungs grossly clear on exam. Potential cardiomyopathy from\n hemochromatosis, consider echocardiogram.\n ------ Protected Section Addendum Entered By: , MD\n on: 07:07 ------\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 422460,
"text": "Chief Complaint: GI Bleed\n 24 Hour Events:\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 04:52 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 03:57 AM\n Lorazepam (Ativan) - 05:35 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 122 (115 - 127) bpm\n BP: 172/93(112) {137/70(88) - 172/93(112)} mmHg\n RR: 16 (12 - 19) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 1,760 mL\n PO:\n TF:\n IVF:\n 1,760 mL\n Blood products:\n Total out:\n 0 mL\n 495 mL\n Urine:\n 345 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 51 K/uL\n 8.8 g/dL\n 25.6 %\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n WBC\n 6.6\n Hct\n 25.6\n Plt\n 51\n Other labs: Differential-Neuts:81.5 %, Lymph:13.1 %, Mono:5.1 %,\n Eos:0.3 %\n Assessment and Plan\n 51 y/oM with h/o hemachromatosis and alcoholic liver disease with\n history of EtoH abuse/withdrawal, history of seizures, history of\n esophageal varices admitted with upper GI bleeding\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB\n - Noted to be erosive esophagitis, though has reported history\n of varices. A non-bleeding ulcer was seen, and he was transferred on IV\n PPI infusion and octreotide infusion\n - Given no bleeding ulcer seen, change protonix to 40mg IV BID\n - Discontinue octreotide gtt for now\n - Q6h HCTs, transfuse <30 or falling HCt\n - Bolus 1L/1h now\n - Cipro 400mg IV x1 given unclear h/o ascites/portal\n hypertension\n - Gi aware from , see in the morning. Involve GI and\n hepatology service for further investigation, and possible repeat EGD\n for evaluation of varices\n - Maintain 3 PIV (16g, 18g, 20g)\nHEMOCHROMATOSIS\n - Check current iron studies\n - Check RUQ ultrasound for eval of ascites, cirrhosis\n - f/u Bilirubin, trend, obtain direct\n ALCOHOL ABUSE/ Withdrawal\n - CIWA with Ativan while taking only IV 2mg IV q1h PRN CIWA >\n 10\n - Thiamine, folate, MVI\n - SW consult in morning\n HEPATITIS C VIRUS\n - Check HCV Viral load\n - RUQ also to assess for focal lesions\n ELEVATED INR\n - presumably from poor po intake, liver disease\n - attempt reversal with vitamin k 10mg PO x3 days\n THROMBOCYTOPENIA\n - unknown baseline, possible contribution from liver (\n thrombopoietin), spleen\n - trend plts, transfuse for <50 while having GIB.\nDIABETES MELLITUS\n - RISS for now, hold glyburide for now\nHYPERTENSION\n - hold lopressor in setting of GIB\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:00 AM\n 16 Gauge - 02:01 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": "2148-12-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 422461,
"text": "Chief Complaint: GI Bleed\n 24 Hour Events:\n Had melena overnight, nausea, and small coffee ground emesis\n - got ativan for CIWA scale\n - ongoing tachycardia, minimal improvement with 1L NS\n - awaiting sono\n - Hct fell to 25\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 04:52 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 03:57 AM\n Lorazepam (Ativan) - 05:35 AM\n Other medications:\n Vitamin K 10 mg PO x 3 days\n Folic acid 1 mg daily\n Thiamine 100 IV daily\n Cipro 400 mg x 1\n Insulin Sliding Scale\n Ativan 2 mg daily\n Zofran PRN\n Pantoprazole 40 mg \n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.1\nC (98.8\n Tcurrent: 37.1\nC (98.8\n HR: 122 (115 - 127) bpm\n BP: 172/93(112) {137/70(88) - 172/93(112)} mmHg\n RR: 16 (12 - 19) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 1,760 mL\n PO:\n TF:\n IVF:\n 1,760 mL\n Blood products:\n Total out:\n 0 mL\n 495 mL\n Urine:\n 345 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,265 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 51 K/uL\n 8.8 g/dL\n 25.6 %\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n WBC\n 6.6\n Hct\n 25.6\n Plt\n 51\n Other labs: Differential-Neuts:81.5 %, Lymph:13.1 %, Mono:5.1 %,\n Eos:0.3 %\n PT 16.3\n PTT 26.9\n INR 1.5\n Micro:\n HCV VL pending \n Imaging:\n CXR\n \n sono\n -\n Assessment and Plan\n 51 y/oM with h/o hemachromatosis and alcoholic liver disease with\n history of EtoH abuse/withdrawal, history of seizures, history of\n esophageal varices admitted with upper GI bleeding\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB\n - Noted to be erosive esophagitis, though has reported history\n of varices. A non-bleeding ulcer was seen, and he was transferred on IV\n PPI infusion and octreotide infusion\n - Given no bleeding ulcer seen, change protonix to 40mg IV BID\n - Discontinue octreotide gtt for now\n - Q6h HCTs, transfuse <30 or falling HCt\n - Bolus 1L/1h now\n - Cipro 400mg IV x1 given unclear h/o ascites/portal\n hypertension\n - Gi aware from , see in the morning. Involve GI and\n hepatology service for further investigation, and possible repeat EGD\n for evaluation of varices\n - Maintain 3 PIV (16g, 18g, 20g)\n Tachycardia. GI Bleed, withdrawal, ?dehydration, holding home BB\nHEMOCHROMATOSIS\n - Check current iron studies\n - Check ultrasound for eval of ascites, cirrhosis\n - f/u Bilirubin, trend, obtain direct\n ALCOHOL ABUSE/ Withdrawal\n - CIWA with Ativan while taking only IV 2mg IV q1h PRN CIWA >\n 10\n - Thiamine, folate, MVI\n - SW consult in morning\n HEPATITIS C VIRUS\n - Check HCV Viral load\n - also to assess for focal lesions\n ELEVATED INR\n - presumably from poor po intake, liver disease\n - attempt reversal with vitamin k 10mg PO x3 days\n THROMBOCYTOPENIA\n - unknown baseline, possible contribution from liver (\n thrombopoietin), spleen\n - trend plts, transfuse for <50 while having GIB.\nDIABETES MELLITUS\n - RISS for now, hold glyburide for now\nHYPERTENSION\n - hold lopressor in setting of GIB\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n 20 Gauge - 02:00 AM\n 16 Gauge - 02:01 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": "2148-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422452,
"text": "Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match.\n In the ED, He had a HR of 120 and BP of 150/70 RR 16 and satting\n 100% on RA. He was continued on medications and admitted to the medical\n ICU.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Upon arrival no c/o nausea, no stool. Around 0400 pt vomited coffee\n ground and had melena\n Action:\n Start on Protonix iv q12hr, HCq8hr. given zofran Iv\n Response:\n Good response after zofran\n Plan:\n Follow HCT q8hr and signs of bleeding. At 1015 lever/gallbladeer US,\n possible endoscopy during day.\n Alcohol abuse/withdraw\n Assessment:\n A/ox3, restless, , H 120-130\ns, ST,\n Action:\n Start on valium PRN, changed to Ativan 2mg Iv, given Ativan 2mg for\n 13\n Response:\n Remains A/ox3, appropriate,HR remains on 119-120,ST\n Plan:\n Cont follow signs of alcohol withdrawn, given Ativan per \n Pt non\ncomplain with meds. Constantly asking for water or soda,\n despite explanation that he can not have any drinks.\n Pt received fluid bolus 500ccx2 NS\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 422467,
"text": "Chief Complaint: hematemesis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 51 yo with hx of UGIB, EtOH abuse who had episode of h\n 1.5 units of PRBC at OSH\n Patient admitted from: Transfer from other hospital\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 04:52 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 03:57 AM\n Lorazepam (Ativan) - 05:35 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Hemachromatosis\n Liver disease (? varices)\n Htn\n Occupation:\n Drugs: no\n Tobacco: no\n Alcohol: pint of EtOH\n Other:\n Review of systems:\n Flowsheet Data as of 09:21 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: 126 (115 - 127) bpm\n BP: 178/102(117) {137/70(88) - 178/102(117)} mmHg\n RR: 19 (12 - 19) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,156 mL\n PO:\n TF:\n IVF:\n 1,806 mL\n Blood products:\n 350 mL\n Total out:\n 0 mL\n 495 mL\n Urine:\n 345 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,661 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bases b/l, No(t)\n Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, stigmata of chronic\n liver dz\n Extremities: Right: Trace, Left: Trace\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 51 K/uL\n 25.6 %\n 8.8 g/dL\n 241 mg/dL\n 1.0 mg/dL\n 28 mg/dL\n 26 mEq/L\n 98 mEq/L\n 3.8 mEq/L\n 139 mEq/L\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n WBC\n 6.6\n Hct\n 25.6\n Plt\n 51\n Cr\n 1.0\n Glucose\n 241\n Other labs: PT / PTT / INR:16.3/26.9/1.5, ALT / AST:34/66, Alk Phos / T\n Bili:97/1.1, Differential-Neuts:81.5 %, Lymph:13.1 %, Mono:5.1 %,\n Eos:0.3 %, Albumin:3.3 g/dL, LDH:231 IU/L, Ca++:7.6 mg/dL, Mg++:1.1\n mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 51 yo male with hx of UGIB\n GIB: hx of EtOH abuse, hemachromatosis and ? of cirrhosis. His\n baseline Hct is not known, although his Hct has fallen from 30->25.\n Plan for endoscopy today. Will also\n - octreotide and IV PPI\n - Ciprofloxacin prophylaxis\n - PICC vs CVC\n - Abd U/S\n - check lactate\n HTN/tachycardia: hold on treatment for now\n AG acidosis: check lactate, UA for ketones, serum ketones. Repeat lytes\n EtOH abuse:\n - CIWA scale using haldol, benzos\n - thiamine and folate\n Thrombocytopenia: unclear etiology possible partial component of marrow\n suppression and dilutional effect.\n - Abd U/S\n -Peripheral smear\n - OSH records for hx of previous evaluation\n -Plt goal of> 50\n Cirrhosis: with poor synthetic function\n - OSH records for etiology of cirrhosis.\n NPO for now: check lipase\n ICU Care\n Nutrition:\n Glycemic Control: Comments: no indication\n Lines / Intubation:\n 16 Gauge - 02:01 AM\n 18 Gauge - 03:07 AM\n 22 Gauge - 08:35 AM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 423220,
"text": "51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with admitted with UGIB in the\n setting of grad esoph varices s/p banding . ETOH withdrawl\n requiring Haldol and Valium.\n Hypertension, benign\n Assessment:\n BP- 170-160/90\ns, HR 80- with no ectopy noted. No CP.\n Action:\n Was restarted back on PO Anti-hypertensives.\n Response:\n BP-to 150\ns/80, HR 70-80\ns SR.\n Plan:\n Continue to assess BP\ns and administer anti-hypertensive meds.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Is alert but still mildly confused, is cooperative today, CIWA scale\n , no need for Haldol or Valium today. Had been requiring high amts.\n Action:\n Assessing MS, OOB to chair, has poor short term memory @ times.\n Response:\n Happy to be OOB and eating, wants to go home.\n Plan:\n Assess MS, continue CIWA scale Valium/Haldol if needed. Social Services\n involved.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n HCT\ns stable @ 34.0, No n/v, no stool, taking PO\ns well. No c/o\ns pain.\n Action:\n Taking PO\ns well, checking HCt\ns ,\n Response:\n GIB resolved.\n Plan:\n Monitor HCT\ns assess VS\ns and s/s of re-bleed.\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422435,
"text": "Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match.\n In the ED, He had a HR of 120 and BP of 150/70 RR 16 and satting\n 100% on RA. He was continued on medications and admitted to the medical\n ICU.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Upon arrival no c/o nausea, no stool. Around 0400 pt vomited coffee\n ground and had melena\n Action:\n Start on Protonix iv q12hr, HCq8hr. given zofran Iv\n Response:\n Good response after zofran\n Plan:\n Follow HCT q8hr and signs of bleeding. At 1015 lever/gallbladeer US\n Alcohol abuse/withdraw\n Assessment:\n A/ox3, restless, \n Action:\n Start on valium PRN, changed to Ativan 2mg Iv, given Ativan 2mg for\n 13\n Response:\n Plan:\n Cont follow signs of alcohol withdrawn, given Ativan per \n Pt non\ncomplain with meds. Constantly asking for water or soda,\n despite explanation that he can not have any drinks.\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422860,
"text": "54yo male with hx HTN, ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs and PLTs since admission, and\n has been transfused with 5 units PRBCs and 1 unit PLTs. His HCT this AM\n is 34.5 and his PLTs are 70. Pts last drink was Sunday, . From\n the time of admission up until the early morning of , the pt was\n without s/s ETOH withdrawal. Around MN , the pt began to exhibit\n signs of confusion. Throughout the course of the early morning, the pt\n became increasingly anxious/agitated/paranoid and began hallucinating.\n He received 16mg ativan and 5mg haldol for active s/s ETOH withdrawal\n on night shift while receiving 16mg IV ativan during the day shift..\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt remains confused throughout this shift with s/s ETOH withdrawal.\n CIWA has ranged 10-33. Pt. has been anxious/agitated/paranoid\n throughout this shift. He began continuously hallucinating and\n attempting to get OOB.\n Action:\n Pt given total of 16mg ativan and Haldol ordered PRN. Pt was placed in\n a posy and wrist restraints for safety and was monitored frequently\n with much 1:1 time spent with pt.\n Response:\n Pt slightly less anxious post ativan but continues to hallucinate and\n still a fall risk so continued in restraints for safety. Pt. has not\n received Haldol due to elevated QTC of .5-.49.\n Plan:\n Cont with CIWA Q1hr and medicate as necessary with ativan/haldol.\n Maintain safety.\n Pt. has received, Calcium gluconate, and Magnesium, with PM labs\n pending at present.\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422537,
"text": "Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match. Pt\n transferred to micu for further care.\n Events:contd small amount of coffee ground emesis,with drop in HCT,pt\n had upper endoscopy done at bedside,usg abdomen done,received 2U prbc.\n IV picc line was placed ,1episode of asymptamatic NSVT ,(10 beat)Mg\n repleted\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Known alcoholic,h/o gi bleed 1 month back,currently with coffee ground\n emesis,small amount in this shift ,no melena noted,hct 25,last coffee\n ground emesis @2pm\n Action:\n Pt had upper Gi scopoy done,received 2u prbc,had abd ultrasound,started\n on octeretide drip,cont iv protonix and cipro prophylaxis,npo status\n changed to clear liquid after usg abdomen,started on karafate, on\n nadalol for portal htn,recvd zofran iv\n Response:\n Endoscopy s/o eosophageal varices and eosophagitis,with\n bleeding,banding done,hct improved to 28 ,receiving 3^rd unit of\n prbc,no vomiting since 2pm\n Plan:\n Cont follow hct q6h, ,goal hct >30, next hct @ hrs,cont cear\n liquids now.\n Alcohol abuse\n Assessment:\n Known alcohol abuse,as per the pt last drink yesterday(~24 hrs),now\n with ciwa ,tachycardic to 130\ns and hypertensive to 190\n Action:\n Pt received 250 mcg fentanyl and 5 mg versed prior to endoscopy,no\n ativan so far in this shfit\n Response:\n Currently resting comfortably hr 90\ns bp 160\ns,ciwa \n Plan:\n Will cont to watch for withdrawal,prn ativan for\n withdrawal(diaphoresis,tachycardic,tremer,hypertension,and iv haldol\n for agitation\n Tachycardia, Other\n Assessment:\n Received the pt in Hr 130\ns sbp 170\ns,as per report pt received fluid\n bolus overnight with minimal effect,pt takes lopressor at home,1\n episode of NSVT(10 beat) ,serum mg level 1.1\n Action:\n Over the course of the day pt received 3 unit of prbc,5 mg versed,also\n started on nadalol.4gm magnesium sulfate\n Response:\n Hr in 90\ns sbp 160-170\n Plan:\n Will cont to monitor,follow ciwa scale ,prn Ativan on board,\n"
},
{
"category": "Social Work",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 422707,
"text": "Family Information\n Next of : sister\n Health Proxy appointed: Proxy\n Family Spokesperson designated: \n Communication or visitation restriction: none\n Patient Information:\n Previous living situation: Pt lives alone in his own home in\n . Until recently he was living with girlfriend, but she\n moved out d/t pt\ns drinking.\n Previous level of functioning: Independent\n Previous or other hospital admissions: Previous admit at \n medical center\n Past psychiatric history:\n Past addictions history: Pt has long hx of etoh abuse, beginning in his\n teens. He reports he has been a daily drinker for many years, drinking\n a fifth of vodka daily. He notes no significant periods of sobriety,\n but reports he was section 35'd by his family this past summer and\n spent 30 days in . He reports he relapsed after 5 days of\n being home. Pt shares he has been involved in AA and currently has a\n sponsor who has been very supportive.\n Employment status: Unemployed - works in construction but out d/t back\n injury.\n Legal involvement: Pt had DUI back in and was due to be in court\n this week but unable d/t hospitalization. This is his second DUI.\n Mandated Reporting Information: N/A\n Additional Information:\n Patient / Family Assessment:\n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422898,
"text": "54yo male with hx HTN, ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring of GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs and PLTs since admission, and\n has been transfused with 5 units PRBCs and 1 unit PLTs. His HCT is now\n stable at 34.5 and his PLTs are 70. Pts last drink was Sunday, .\n From the time of admission up until the early morning of , the pt\n was without s/s ETOH withdrawal. Around MN , the pt began to\n exhibit signs of confusion. Throughout the course of the early morning,\n the pt became increasingly anxious/agitated/paranoid and began\n hallucinating. He is currently receiving large amts of ativan for ETOH\n withdrawal.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Confused/agitated/paranoid throughout noc. Continuously hallucinating\n and attempting to get OOB.\n Action:\n Pt given ativan and valium. Unable to give haldol high QTc\n interval. Pt in a posy and wrist restraints for safety and monitored\n frequently with much 1:1 time spent with pt.\n Response:\n Pt much less agitated tonite than last noc. Ativan/valium lasts 1-2hrs,\n then pt gets restless. He is continuously hallucinating and still a\n fall risk so continued in restraints for safety.\n Plan:\n Cont with CIWA Q1hr and medicate as necessary with ativan. Minimize\n valium long half life and poor liver function. Hold haldol until\n QTc WNL. Maintain safety.\n Hypertension, benign\n Assessment:\n BP consistently ranging 170s-180s/110s-120s. Unclear if HTN ETOH\n withdrawal or baseline HTN. Goal SBP <170.\n Action:\n Pt given 10mg IV labetalol x2.\n Response:\n Pt with SBP 150s-160s at times, 170s-180s at times, very inconsistent.\n Plan:\n Cont to monitor. Possible addition of antihypertensive to daily meds,\n possible need for IV gtt to control BP.\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 423218,
"text": "51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with admitted with UGIB in the\n setting of grad esoph varices s/p banding . ETOH withdrawl\n requiring Haldol and Valium.\n Hypertension, benign\n Assessment:\n BP- 170-160/90\ns, HR 80- with no ectopy noted. No CP.\n Action:\n Was restarted back on PO Anti-hypertensives.\n Response:\n BP-to 150\ns/80, HR 70-80\ns SR.\n Plan:\n Continue to assess BP\ns and administer anti-hypertensive meds.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Is alert but still mildly confused, is cooperative today, CIWA scale\n , no need for Haldol or Valium today. Had been requiring high amts.\n Action:\n Assessing MS, OOB to chair, has poor short term memory @ times.\n Response:\n Happy to be OOB and eating, wants to go home.\n Plan:\n Assess MS, continue CIWA scale Valium/Haldol if needed. Social Services\n involved.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n HCT\ns stable @ 34.0, No n/v, no stool, taking PO\ns well. No c/o\ns pain.\n Action:\n Taking PO\ns well, checking HCt\ns ,\n Response:\n GIB resolved.\n Plan:\n Monitor HCT\ns assess VS\ns and s/s of re-bleed.\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 423007,
"text": "54yo male with hx HTN, ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring of GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs and PLTs since admission, and\n has been transfused with 5 units PRBCs and 1 unit PLTs. His HCT is now\n stable at 34.5 and his PLTs are 70. Pts last drink was Sunday, .\n From the time of admission up until the early morning of , the pt\n was without s/s ETOH withdrawal. Around MN , the pt began to\n exhibit signs of alcohol withdrawal.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt aox2,fluctuating mental status,trying to get oob many times,ciwa\n \n Action:\n Received ativan 4 mg iv in am.changed to valium po per ciwa scale\n Response:\n Pt sleeping intermittently but trying to get oob in between,\n wants to\n go for the meeting\n Plan:\n Cont to follow the ciwa scale and dose with valium,Haldol is deferred\n due to prolonged QTc .481\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 422845,
"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: UGI bleed, ETO abuse\n 24 Hour Events:\n > increasing EtOH withdrawl symptoms\n > Ativan 20 mg over the PM shift for agitation\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 03:30 AM\n Haloperidol (Haldol) - 04:56 AM\n Lorazepam (Ativan) - 07:04 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:32 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: 77 (72 - 86) bpm\n BP: 165/102(119) {141/76(93) - 185/125(119)} mmHg\n RR: 23 (11 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,803 mL\n 670 mL\n PO:\n 770 mL\n 120 mL\n TF:\n IVF:\n 1,350 mL\n 542 mL\n Blood products:\n 683 mL\n 8 mL\n Total out:\n 3,015 mL\n 1,245 mL\n Urine:\n 3,015 mL\n 1,245 mL\n NG:\n Stool:\n Drains:\n Balance:\n -212 mL\n -575 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: No(t) Well nourished, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: diminished\n at the based\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: agitated, Responds to: verbal, Movement: moving all exts\n A+O x 0\n Labs / Radiology\n 12.4 g/dL\n 70 K/uL\n 163 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 98 mEq/L\n 131 mEq/L\n 34.5 %\n 8.8 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n Cr\n 1.0\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n Other labs: PT / PTT / INR:15.4/26.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:1.8 mg/dL\n Abd US :\n FINDINGS: Limited evaluation of the abdomen was performed. The spleen\n is\n enlarged, measuring 15.4 cm. No perisplenic varices are identified.\n There is\n no ascites.\n IMPRESSION:\n 1. Splenomegaly.\n 2. No ascites.\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause of\n cirrhosis. His baseline Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding with stable Hct\n - octreotide (until ) and IV PPI\n - Follow q 12hr Hct\n - cont Beta blocker (uptitrate)\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n Cirrhosis: ongoing evaluation for cirrhosis including hemachromatosis\n and Hep C as well as EtOH abuse, as well as other potential etiologies\n of cirrhosis.\n HTN/tachycardia: beta blocker\n EtOH abuse: now progressing into withdrawl\n - CIWA scale using haldol for hallucination, benzo for agitation and\n metop/labet IVP for HTN/tachy.\n - fluid repletion with D5 , thiamine and folate\n - Advance diet as tolerated\n - Check ECG\n - Will probably need lactulose (but do not want to place NG tube\n blindly given varices)\n Thrombocytopenia: unclear etiology possible partial component of\n marrow suppression (from EtOh although odd that MCV is low) vs\n hemachromatosis with marrow infiltrate) . By report this is chronic.\n Does not appear to be a med related toxic component. Appears to have\n significant splenomegaly on US () which likely explains the\n thrombocytopenia at least in part.\n -Plt goal of> 50\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: will need close assessment of airway with\n sedation\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422897,
"text": "54yo male with hx HTN, ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs and PLTs since admission, and\n has been transfused with 5 units PRBCs and 1 unit PLTs. His HCT this AM\n is 34.5 and his PLTs are 70. Pts last drink was Sunday, . From\n the time of admission up until the early morning of , the pt was\n without s/s ETOH withdrawal. Around MN , the pt began to exhibit\n signs of confusion. Throughout the course of the early morning, the pt\n became increasingly anxious/agitated/paranoid and began hallucinating.\n He received 16mg ativan and 5mg haldol for active s/s ETOH withdrawal.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Confused/agitated/paranoid throughout noc. Continuously hallucinating\n and attempting to get OOB.\n Action:\n Pt given ativan and valium. Unable to give haldol high QTc\n interval. Pt in a posy and wrist restraints for safety and monitored\n frequently with much 1:1 time spent with pt.\n Response:\n Pt much less agitated tonite than last noc. Ativan/valium lasts 1-2hrs,\n then pt gets restless. He is continuously hallucinating and still a\n fall risk so continued in restraints for safety.\n Plan:\n Cont with CIWA Q1hr and medicate as necessary with ativan. Minimize\n valium long half life and poor liver function. Hold haldol until\n QTc WNL. Maintain safety.\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 423198,
"text": "Chief Complaint: alcohol withdrawal, upper gi bleed\n 24 Hour Events:\n - Rare agitation, getting out of bed, haldol 2.5 x 1.\n - Lisinopril started at 10 mg.\n - Liver: check AFP, ?repeat Fe/TIBC (hard to read the note...)\n - Hct stable (34.7\n 35.3\n 33.7 )\n - positive anti smooth muscle antibody\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:12 AM\n Pantoprazole (Protonix) - 04:29 PM\n Haloperidol (Haldol) - 12:04 AM\n Other medications:\n Valium prn\n Lisinopril 10 mg daily\n Haldol prn\n Nadolol 40\n Sucralafate\n Folate\n Thiamine\n Insulin sliding scale\n Zofran prn\n Pantoprazole 40 IV q 12\n Changes to medical and 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: 37.6\nC (99.7\n Tcurrent: 36.9\nC (98.5\n HR: 72 (59 - 95) bpm\n BP: 155/81(97) {115/63(68) - 179/99(132)} mmHg\n RR: 16 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 3,560 mL\n 76 mL\n PO:\n 1,500 mL\n TF:\n IVF:\n 2,060 mL\n 76 mL\n Blood products:\n Total out:\n 3,362 mL\n 470 mL\n Urine:\n 3,362 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 198 mL\n -395 mL\n Respiratory support\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 69 K/uL\n 12.0 g/dL\n 134 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 9 mg/dL\n 105 mEq/L\n 138 mEq/L\n 34.7 %\n 6.2 K/uL\n [image002.jpg]\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n 06:31 PM\n 05:31 AM\n WBC\n 7.2\n 5.4\n 8.8\n 6.6\n 6.2\n Hct\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n 35.3\n 34.7\n Plt\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n 69\n Cr\n 0.8\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 145\n 163\n 197\n 137\n 134\n Other labs: PT / PTT / INR:15.2/27.2/1.3, ALT / AST:35/73, Alk Phos / T\n Bili:122/2.9, Amylase / Lipase:31/23, Differential-Neuts:66.7 %,\n Lymph:19.7 %, Mono:9.5 %, Eos:3.8 %, Albumin:3.2 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.6 mg/dL, PO4:4.7 mg/dL\n Anti smooth muscle antibody - positive\n Assessment and Plan\n In summary, Mr. is a 51 year old male with h/o liver\n disease secondary to hemachromatosis, alcoholic liver disease, HCV, and\n history of esophageal varices admitted for UGIB now in alcohol\n withdrawal.\n 1. Alcohol withdrawal. Benzo requirements are improving. Haldol use\n limited due to qt prolongation.\n - valium per ciwa scale\n - haldol as needed while monitoring QTc\n - thiamine, folate, mvi\n - daily EKG for QTc evaluation\n - switch meds to PO now that taking adequate POs\n 2. Upper GI Bleed. EGD showed grade esophageal varices s/p\n banding as well as esophagitis. Continues on PPI (orally). Was on\n octreotide drip for 3 days, now completed. S/p 5 units of PRBC during\n hospitalization. Hct now stable. Baseline Hct of 35-40 per PCP.\n Hcts\n - PPI \n - type and cross 2 units\n - sucralafate for two weeks\n - Liver team following\n - regular diet\n - nadolol 40 mg daily given presence of varices\n 3. Hypertension. Patient on lisinopril and lopressor at home at\n unknown doses. Nadolol initiated during hospital stay due to history\n of varices. Patinet has ongoing hypertension likely due to withdrawal\n from alcohol plus baseline hypertension.\n - tolerate SBP < 160, prn IV antihypertensives\n - continue nadolol\n - increase lisinopril to 40 mg daily\n .\n 4. Liver disease. Patient has a history of hemochromatosis, alcohol\n abuse, and HCV. Evidence of stigmata of chronic liver disease.\n Elevated Iron noted. Abdominal ultrasound did not show cirrhosis, but\n showed splenomegaly and no ascites. Patient state prior workup for\n liver disease including liver biopsy occurred at many years ago,\n but no record of this. Outpatient GI doctor is unclear of prior workup\n given that patient does not follow up regularly. History of Hep B\n vaccination. History of hep A infection in past. negative, but\n anti smooth muscle antibody positive.\n - f/u HFE\n 5. THROMBOCYTOPENIA. Likely secondary to splenic sequestration. At\n baseline platelet count.\n - trend plts, transfuse for <50 while having GIB\n 7. DIABETES MELLITUS\n - RISS for now, hold glyburide for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: patient\n Code status: Full code\n Disposition: transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 423206,
"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: ETOH withdrawal, GI bleed\n 24 Hour Events:\n Improved mental status\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 08:12 AM\n Pantoprazole (Protonix) - 04:29 PM\n Haloperidol (Haldol) - 12:04 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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: 37.6\nC (99.7\n Tcurrent: 36.9\nC (98.5\n HR: 72 (59 - 95) bpm\n BP: 155/81(97) {115/63(68) - 179/99(132)} mmHg\n RR: 16 (12 - 21) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 3,560 mL\n 78 mL\n PO:\n 1,500 mL\n TF:\n IVF:\n 2,060 mL\n 78 mL\n Blood products:\n Total out:\n 3,362 mL\n 470 mL\n Urine:\n 3,362 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 198 mL\n -392 mL\n Respiratory support\n SpO2: 95%\n ABG: ///24/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : , Diminished: bases)\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x2, Movement: Purposeful,\n Labs / Radiology\n 12.0 g/dL\n 69 K/uL\n 134 mg/dL\n 0.8 mg/dL\n 24 mEq/L\n 3.4 mEq/L\n 9 mg/dL\n 105 mEq/L\n 138 mEq/L\n 34.7 %\n 6.2 K/uL\n [image002.jpg]\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n 05:30 PM\n 03:28 AM\n 06:31 PM\n 05:31 AM\n WBC\n 7.2\n 5.4\n 8.8\n 6.6\n 6.2\n Hct\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n 34.5\n 33.7\n 35.3\n 34.7\n Plt\n 47\n 71\n 60\n 56\n 53\n 70\n 66\n 69\n Cr\n 0.8\n 0.8\n 0.8\n 0.8\n 0.8\n Glucose\n 145\n 163\n 197\n 137\n 134\n Other labs: PT / PTT / INR:15.2/27.2/1.3, ALT / AST:35/73, Alk Phos / T\n Bili:122/2.9, Amylase / Lipase:31/23, Differential-Neuts:66.7 %,\n Lymph:19.7 %, Mono:9.5 %, Eos:3.8 %, Albumin:3.2 g/dL, LDH:236 IU/L,\n Ca++:8.2 mg/dL, Mg++:1.6 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause\n of cirrhosis. His baseline Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding and octreotide course with stable Hct\n - change PPI to PO\n - cont Beta blocker for varices\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n >Cirrhosis: ongoing evaluation for cirrhosis including hemachromatosis\n and Hep C as well as EtOH abuse, as well as other potential etiologies\n of cirrhosis. Anti smooth muscle Ab pos, neg\n >HTN/tachycardia:likely related in part to underlying HTN and\n exacerbated by withdrawl\n - Lisinopril\n >EtOH abuse: Now largely improved, lucid will cont PO valium CIWA scale\n - CIWA scale: valium and haldol prn\n - thiamine and folate (change to PO)\n - Check QTc\n >Thrombocytopenia: Probably a combination of splenic sequestration (on\n U/S) and EtOh abuse.\n -Plt goal of> 50\n ICU Care\n Nutrition:\n Comments: Reg diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 422642,
"text": "Chief Complaint: upper GI bleed\n 24 Hour Events:\n - EGD performed; grade II-III & gastritis/esophagitis; 4 bands placed\n - Carafate and nadolol started\n - 1 bag platelets given for plt ct 47 --> 71\n - hematocrit not appropriately bumping to transfusion; total 4 units\n given since admission to (25.6 --> 2units --> 28 --> 1 unit -->\n 26.8 --> 1 unit).\n - PICC line placed\n - abdominal ultrasound showed fatty infiltration of liver, final\n results pending\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:06 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:18 AM\n Fentanyl - 11:18 AM\n Lorazepam (Ativan) - 08:39 PM\n Pantoprazole (Protonix) - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:37 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: 36.4\nC (97.5\n HR: 88 (83 - 128) bpm\n BP: 145/92(104) {143/62(84) - 178/112(133)} mmHg\n RR: 20 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 4,542 mL\n 765 mL\n PO:\n 600 mL\n TF:\n IVF:\n 2,315 mL\n 448 mL\n Blood products:\n 1,627 mL\n 317 mL\n Total out:\n 1,580 mL\n 640 mL\n Urine:\n 1,380 mL\n 640 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,962 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///31/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, time, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 60 K/uL\n 10.4 g/dL\n 145 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.1 mEq/L\n 17 mg/dL\n 99 mEq/L\n 135 mEq/L\n 29.7 %\n 5.4 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n WBC\n 6.6\n 7.2\n 5.4\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n Plt\n 51\n 47\n 71\n 60\n Cr\n 1.0\n 0.8\n Glucose\n 241\n 145\n Other labs: PT / PTT / INR:15.5/29.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:73.7 %,\n Lymph:16.3 %, Mono:6.3 %, Eos:3.2 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.0 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 03:07 AM\n 22 Gauge - 08:35 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\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": "2148-12-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 422643,
"text": "Chief Complaint: upper GI bleed\n 24 Hour Events:\n - EGD performed; grade II-III & gastritis/esophagitis; 4 bands placed\n - Carafate and nadolol started\n - 1 bag platelets given for plt ct 47 --> 71\n - hematocrit not appropriately bumping to transfusion; total 4 units\n given since admission to (25.6 --> 2units --> 28 --> 1 unit -->\n 26.8 --> 1 unit).\n - PICC line placed\n - abdominal ultrasound showed fatty infiltration of liver, final\n results pending\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:06 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:18 AM\n Fentanyl - 11:18 AM\n Lorazepam (Ativan) - 08:39 PM\n Pantoprazole (Protonix) - 04:26 AM\n Other medications:\n Nadolol 20 mg daily\n Sucralafate QID\n Octreotide Drip\n Vitamin K 10 mg PO x 3 days\n Folic Acid 1 mg daily\n Thiamine 100 mg daily\n Cipro 400 mg \n Insulin Sliding Scale\n Ativan PRN CIWA\n Zofran PRN\n Pantoprazole 40 IV BID\n Changes to medical and 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: 37.2\nC (98.9\n Tcurrent: 36.4\nC (97.5\n HR: 88 (83 - 128) bpm\n BP: 145/92(104) {143/62(84) - 178/112(133)} mmHg\n RR: 20 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 4,542 mL\n 765 mL\n PO:\n 600 mL\n TF:\n IVF:\n 2,315 mL\n 448 mL\n Blood products:\n 1,627 mL\n 317 mL\n Total out:\n 1,580 mL\n 640 mL\n Urine:\n 1,380 mL\n 640 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,962 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///31/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, time, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 60 K/uL\n 10.4 g/dL\n 145 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.1 mEq/L\n 17 mg/dL\n 99 mEq/L\n 135 mEq/L\n 29.7 %\n 5.4 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n WBC\n 6.6\n 7.2\n 5.4\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n Plt\n 51\n 47\n 71\n 60\n Cr\n 1.0\n 0.8\n Glucose\n 241\n 145\n Other labs: PT / PTT / INR:15.5/29.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:73.7 %,\n Lymph:16.3 %, Mono:6.3 %, Eos:3.2 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.0 mg/dL, PO4:1.8 mg/dL\n Micro: HCV VL pending\n Abdominal Ultrasound . Wet read: Patent hepatic vasculature,\n echogenic liver compatibile with fatty infiltration, however, other\n forms of liver disease and more advanced liver disease cannot be\n excluded\n Assessment and Plan\n In summary, Mr. is a 51 year old male with h/o\n hemachromatosis, alcoholic liver disease, HCV, and alcohol abuse, and\n history of esophageal varices admitted for UGIB.\n 1. Upper GI Bleed. EGD today showed grade esophageal varices\n s/p banding as well as esophagitis. OSH EGD showed gastritis but did\n not comment on varices. Was started on IV PPI and octreotide\n drip. Had melena and bright red hematemasis overnight. Currently has\n two peripheral (22, 18) and a PICC line for access. Received 2 units\n of PRBCs this morning and 1.5 of emergency release blood at OSH. Per\n PCP, had a few admissions for GIBs. Hct of 35-40 per PCP.\n 6 hour Hcts, transfuse to 30 given active bleeding\n - octreotide drip, IV PPI \n - type and cross 2 units\n - cipro prophylaxis for SBP prophylaxis in patient with history of\n cirrhosis\n - sucralafate for two weeks\n - Liver team following\n - advance to clears\n - initiate nadolol 20 mg daily in PM if stable from standpoint of\n ongoing bleed\n 2. Tachycardia. HR currently in the 130s and BP increasing,\n likely secondary to combination of alcohol withdrawal, GI bleed, and\n ?dehydration. HR did not respond to fluid boluses, but mild\n improvement with ativan for CIWA scale and blood transfusion. Also,\n normally on home BB and ACIE, which is being held.\n - monitor on tele\n - blood transfusions, to keep hct > 30\n - ativan per CIWA scale\n 3. Liver disease. Patient has a history of hemochromatosis, alcohol\n abuse, and HCV. Evidence of stigmata of chronic liver disease.\n - abdominal ultrasound\n - f/u iron studies\n - f/u HCV viral load\n 4. Alcohol abuse. Physical exam and vitals suggestive of alcohol\n withdrawal.\n - ativan CIWA scale\n - Thiamine, folate, MVI\n 5. ELEVATED INR. Likely secondary to combination of liver disease and\n poor PO intake.\n - attempt reversal with vitamin k 10mg PO x3 days\n 6. THROMBOCYTOPENIA. be secondary to marrow suppression from\n alcohol abuse or splenic sequestration. Per PCP, Plt is in\n 70s. Unclear from PCP what prior workup has occurred.\n - obtain OSH records for previous workup and for prior Plt\n count\n - trend plts, transfuse for <50 while having GIB\n - check peripheral smear to r/o schistocytes\n 7. DIABETES MELLITUS\n - RISS for now, hold glyburide for now\n 8. HYPERTENSION. Likely secondary to alcohol withdrawal and not being\n on home antihypertensives. Given history of varices, will consider\n resuming antihypertensives in PM if hemodynamically stable and no\n further ongoing bleeding.\n - hold lopressor in setting of GIB, but consider starting nadolol in\n PM\n 9. Anion gap. Patient has an elevated anion gap, with unclear\n etiology.\n - check u tox, s tox\n PCP: Ph \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 03:07 AM\n 22 Gauge - 08:35 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\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": "2148-12-10 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 422648,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n PICC LINE - START 11:00 AM\n ENDOSCOPY - At 11:14 AM\n ULTRASOUND - At 02:09 PM\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:06 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:18 AM\n Fentanyl - 11:18 AM\n Lorazepam (Ativan) - 08:39 PM\n Pantoprazole (Protonix) - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 90 (83 - 128) bpm\n BP: 145/92(127) {143/62(84) - 177/112(133)} mmHg\n RR: 23 (12 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 4,542 mL\n 801 mL\n PO:\n 600 mL\n TF:\n IVF:\n 2,315 mL\n 484 mL\n Blood products:\n 1,627 mL\n 317 mL\n Total out:\n 1,580 mL\n 640 mL\n Urine:\n 1,380 mL\n 640 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,962 mL\n 162 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///31/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.4 g/dL\n 60 K/uL\n 145 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.1 mEq/L\n 17 mg/dL\n 99 mEq/L\n 135 mEq/L\n 29.7 %\n 5.4 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n WBC\n 6.6\n 7.2\n 5.4\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n Plt\n 51\n 47\n 71\n 60\n Cr\n 1.0\n 0.8\n Glucose\n 241\n 145\n Other labs: PT / PTT / INR:15.5/29.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:73.7 %,\n Lymph:16.3 %, Mono:6.3 %, Eos:3.2 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.0 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C as risk factors for cirrhosis and\n possible varices.\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause of\n cirrhosis. His baseline Hct is apparently in the mid 30\ns. Plan for\n endoscopy today. Will also need to obtain OSH records to more fully\n evaluate his hx /treatment of Hep C and hemachromatosis.\n - octreotide and IV PPI\n - if varices likely pindalol/nadolol\n - Ciprofloxacin prophylaxis\n - Abd U/S with Doppler imaging to eval patency of portal system\n - check lactate\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - check lipase\n HTN/tachycardia: hold on treatment for now\n AG acidosis: check lactate, UA for ketones, serum ketones. Repeat lytes\n EtOH abuse:\n - CIWA scale using haldol for hallucination, benzo for agitation and\n metop/labet IVP for HTN/tachy.\n - fluid repletion with D5 , thiamine and folate\n Thrombocytopenia: unclear etiology possible partial component of marrow\n suppression (from EtOh although odd that MCV is low) vs hemachromatosis\n marrow infiltrate) and dilutional effect given transfusions. By report\n this is chronic. Does not appear to be a med related toxic component.\n - Abd U/S\n -Peripheral smear\n - OSH records for hx of previous evaluation\n -Plt goal of> 50\n ICU Care\n Nutrition:\n Comments: clears\n Glycemic Control: Regular insulin sliding scale, Comments: as needed\n Lines:\n 18 Gauge - 03:07 AM\n 22 Gauge - 08:35 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 422665,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n PICC LINE - START 11:00 AM\n ENDOSCOPY - At 11:14 AM: grade varices with small\n bleeding, s/p banding\n > 4 units of PRBC with inappropriate rise.\n ULTRASOUND - At 02:09 PM: patent hepatic vasculature,\n echogenic liver (prelim)\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:06 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:18 AM\n Fentanyl - 11:18 AM\n Lorazepam (Ativan) - 08:39 PM\n Pantoprazole (Protonix) - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 90 (83 - 128) bpm\n BP: 145/92(127) {143/62(84) - 177/112(133)} mmHg\n RR: 23 (12 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 4,542 mL\n 801 mL\n PO:\n 600 mL\n TF:\n IVF:\n 2,315 mL\n 484 mL\n Blood products:\n 1,627 mL\n 317 mL\n Total out:\n 1,580 mL\n 640 mL\n Urine:\n 1,380 mL\n 640 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,962 mL\n 162 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///31/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.4 g/dL\n 60 K/uL\n 145 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.1 mEq/L\n 17 mg/dL\n 99 mEq/L\n 135 mEq/L\n 29.7 %\n 5.4 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n WBC\n 6.6\n 7.2\n 5.4\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n Plt\n 51\n 47\n 71\n 60\n Cr\n 1.0\n 0.8\n Glucose\n 241\n 145\n Other labs: PT / PTT / INR:15.5/29.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:73.7 %,\n Lymph:16.3 %, Mono:6.3 %, Eos:3.2 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.0 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause of\n cirrhosis. His baseline Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding.\n - octreotide and IV PPI\n - Follow q 8hr Hct\n - cont Beta blocker (uptitrate)\n - Ciprofloxacin prophylaxis\n - Abd U/S with Doppler imaging to eval patency of portal system: await\n final read\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n HTN/tachycardia: beta blocker\n EtOH abuse:\n - CIWA scale using haldol for hallucination, benzo for agitation and\n metop/labet IVP for HTN/tachy.\n - fluid repletion with D5 , thiamine and folate\n - Advance diet as tolerated\n Thrombocytopenia: unclear etiology possible partial component of marrow\n suppression (from EtOh although odd that MCV is low) vs hemachromatosis\n marrow infiltrate) and dilutional effect given transfusions. By report\n this is chronic. Does not appear to be a med related toxic component.\n Awaiting US for spleen evaluation. Peripheral smear does not reveal\n evidence of schistos\n - Abd U/S: ? splenic sequestration.\n -Plt goal of> 50\n ICU Care\n Nutrition:\n Comments: clears\n Glycemic Control: Regular insulin sliding scale, Comments: as needed\n Lines:\n 18 Gauge - 03:07 AM\n 22 Gauge - 08:35 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI IV\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU (unstable Hct)\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422799,
"text": "54yo male with hx HTN, ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs and PLTs since admission, and\n has been transfused with 5 units PRBCs and 1 unit PLTs. His HCT this AM\n is 34.5 and his PLTs are 70.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422801,
"text": "54yo male with hx HTN, ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs and PLTs since admission, and\n has been transfused with 5 units PRBCs and 1 unit PLTs. His HCT this AM\n is 34.5 and his PLTs are 70. Pts last drink was Sunday, . From\n the time of admission up until the early morning of , the pt was\n without s/s ETOH withdrawal. Around MN , the pt began to exhibit\n signs of confusion. Throughout the course of the early morning, the pt\n became increasingly anxious/agitated/paranoid and began hallucinating.\n He received 16mg ativan and 5mg haldol for active s/s ETOH withdrawal.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt tx from Hospital with episodes hematemesis and melena. S/P\n 4 units PRBCs but HCT 28.9 last evening and PLTs 53. Also s/p\n esophageal banding x4 and no further bleeding since.\n Action:\n Pt transfused with 1 unit PRBCs.\n Response:\n HCT up to 34.5 this AM, PLTs 70.\n Plan:\n Cont with frequent HCT checks, follow labs. Transfuse per team orders.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt A&Ox3 at beginning of shift with no s/s ETOH withdrawal. Then noted\n around MN to be confused and pt became increasingly\n anxious/agitated/paranoid throughout the noc. He began continuously\n hallucinating around 04 and attempting to get OOB.\n Action:\n Pt given total of 16mg ativan and 5mg haldol from 00-06 Pt was placed\n in a posy and wrist restraints for safety.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422497,
"text": "Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match. Pt\n transferred to micu for further care.\n Events:contd small amount of coffee ground emesis,with drop in HCT,pt\n had upper endoscopy done at bedside,usg abdomen done,received 2U prbc.\n Iv picc line was plaved had episode of asymptamatic NSVt 10 beat,Mg\n repleted.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Known alcoholic,h/o gi bleed 1 month back,currently with coffee ground\n emesis,small amount in this shift ,no melena noted,hct 25\n Action:\n Pt had upper Gi scopoy done,received 2u prbc,had abd ultrasound,started\n on octeretide drip,cont iv protonix and cipro prophylaxis,npo status\n changed to clear liquid after usg abdomen,started on karafate\n Response:\n Scopy s/o eosophageal varices and eosophagitis,with bleeding,banding\n done,hct improved to 28\n Plan:\n Cont follow hct q6h,plan for 1 more unit prbc,goal hct >30,\n Alcohol abuse\n Assessment:\n Known alcohol abuse,as per the pt last drink yesterday(~24 hrs),now\n with ciwa ,tachycardic to 130\ns and hypertensive to 190\n Action:\n Pt received 250 mcg fentanyl and 5 mg versed prior to scopy,no ativan\n so fsr in this shfit\n Response:\n Currently sleeping comfirtbaly hr 100\ns bp 160\n Plan:\n Will cont to watch for waithdrawal,prn ativan for\n withdrawal(diaphoresis,tachycardic,tremer,hypertension,and iv haldol\n for agitation\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422794,
"text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422919,
"text": "54yo male with hx HTN, ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring of GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs and PLTs since admission, and\n has been transfused with 5 units PRBCs and 1 unit PLTs. His HCT is now\n stable at 34.5 and his PLTs are 70. Pts last drink was Sunday, .\n From the time of admission up until the early morning of , the pt\n was without s/s ETOH withdrawal. Around MN , the pt began to\n exhibit signs of confusion. Throughout the course of the early morning,\n the pt became increasingly anxious/agitated/paranoid and began\n hallucinating. He is currently receiving large amts of ativan for ETOH\n withdrawal.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Confused/agitated/paranoid; continuously hallucinating and attempting\n to get OOB throughout beginning of shift.\n Action:\n Pt given ativan and valium x1. Unable to give haldol high QTc\n interval. Pt in a posy and wrist restraints for safety and monitored\n frequently with much 1:1 time spent with pt.\n Response:\n Pt much less agitated tonite than last noc. Fell asleep around 0230!!\n Continued in posy/wrist restraints for safety.\n Plan:\n Cont with CIWA Q1hr and medicate as necessary with ativan. Minimize\n valium long half life and poor liver function. Hold haldol until\n QTc WNL. Maintain safety.\n Hypertension, benign\n Assessment:\n BP consistently ranging 170s-180s/110s-120s. Unclear if HTN ETOH\n withdrawal or baseline HTN. Goal SBP <170.\n Action:\n Pt given 10mg IV labetalol x2.\n Response:\n Pt with SBP ranging 130s-150s post second dose of labetalol.\n Plan:\n Cont to monitor for HTN. Give labetalol if needed for SBP>170.\n"
},
{
"category": "Social Work",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Social Work Admission Note",
"row_id": 422729,
"text": "Family Information\n Next of : (sister) \n Health Care Proxy appointed: Proxy\n Family Spokesperson designated: \n Communication or visitation restriction: none\n Patient Information:\n Previous living situation: Pt lives alone in his own home in\n . Until recently he was living with girlfriend, but she\n moved out d/t pt\ns drinking.\n Previous level of functioning: Independent\n Previous or other hospital admissions: Previous admit at \n medical center\n Past psychiatric history: Pt with likely long-standing depression but\n unable to sort out d/t chronic etoh abuse.\n Past addictions history: Pt has long hx of etoh abuse, beginning in his\n teens. He reports he has been a daily drinker for 30 years, most\n recently drinking a fifth of vodka daily. He notes no significant\n periods of sobriety, but reports he was section 35'd by his family this\n past summer and spent 30 days in . He reports he relapsed\n after 5 days of being home. Pt shares he has been involved in AA and\n currently has a sponsor who has been very supportive, but pt reluctant\n to return.\n Employment status: Unemployed - works in construction but has been out\n on unemployment d/t back injury.\n Legal involvement: Pt had DUI back in and was due to be in court\n this week but unable d/t hospitalization. This is his second DUI.\n Mandated Reporting Information: N/A\n Additional Information:\n Patient / Family Assessment: Pt referred to sw for etoh assessment\n and referral for etoh tx. Met with pt at bedside this am. Pt alert\n and oriented, with somewhat irritated affect and reporting congruent\n mood. Pt forthcoming with info re: etoh abuse. Pt shares that this\n admit is directly related to his etoh abuse and that he has been told\n that if he continues to drink he will likely die. Pt stated\nI have to\n stop\n but acknowledged that this will not be easy for him. Pt shares\n he is one of seven children, none of whom are alcoholic but notes\n father (now deceased) abused etoh. Pt reports family is very concerned\n about his drinking and persistently encourage him to get tx. Pt notes\n he is beginning to have significant loses due to his etoh abuse\n including intimate relationships, his license, friendships, relates\n with family, ability to work, financial stability and now his health\n and potentially could lose his life. Pt reports to be motivated for\n txc. He shares past involvement with AA, but notes feeling ashamed\n about going back to meetings and facing his sponsor and others who have\n supported him. Pt states he is open to tx, but is concerned b/c he\n currently cannot drive. Pt inquired about out pt program\n and wanting sw to explore for him.\n SW provided support to pt, psycho-ed re: alcoholism, and motivational\n interviewing. Pt shares he is amenable to Tx, but also\n still seems quite ambivalent. Pt acknowledged this ambivalence but\n continued to reiterate,\nI need to stop.\n Pt seems to be in contemplative phase of change. Hope is that having\n concrete plan in place for tx upon d/c as well as continued emphasis on\n likely fatal consequences should pt continue to drink could help pt to\n move into action phase of change.\n Communication with Team: Discussed with resident, .\n Plan / Follow up:\n SW has contact partial tx program. They report pt\n has been referred there in the past, but never showed for tx. They are\n willing to take pt again if he meets admission criteria. SW will fax\n referral form and necessary PMH to in AM.\n Will f/up with pt and team tomorrow\n , LICSW #\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422796,
"text": "54yo male with hx ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs since admission, and has been\n transfused\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Action:\n Response:\n Plan:\n Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422431,
"text": "Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match.\n In the ED, He had a HR of 120 and BP of 150/70 RR 16 and satting\n 100% on RA. He was continued on medications and admitted to the medical\n ICU.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Upon arrival no c/o nausea, no stool. Around 0400 pt vomited coffee\n ground and had melena\n Action:\n Start on Protonix iv q12hr, HCq8hr. given zofran Iv\n Response:\n Good response after zofran\n Plan:\n Follow HCT q8hr and signs of bleeding. At 1015 lever/gallbladeer US\n Alcohol abuse/withdraw\n Assessment:\n A/ox3, restless, CIWA \n Action:\n Start on valium PRN, changed to Ativan 2mg Iv, given Ativan 2mg for\n CIWA 13\n Response:\n Plan:\n Cont follow signs of alcohol withdrawn, given Ativan per CIWA\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 422429,
"text": "Chief Complaint: Hematemesis\n HPI:\n Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match.\n In the ED, He had a HR of 120 and BP of 150/70 RR 16 and satting\n 100% on RA. He was continued on medications and admitted to the medical\n ICU.\n Allergies:\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Lopressor\n Lisinopril\n Glyburide\n - unknown doses\n Past medical history:\n Family history:\n Social History:\n Hemachromatosis c/b diabetes\n Hypertension\n Liver Disease , reported c/b varices\n HCV per notes\n Occupation:\n Drugs: denies\n Tobacco: denies\n Alcohol:\n pt/day\n Other:\n Review of systems:\n Constitutional: Fever\n Cardiovascular: No(t) Chest pain, denies CP\n Respiratory: No(t) Cough, Dyspnea, mild dyspnea recently, worse when\n walking, supine\n Gastrointestinal: No(t) Abdominal pain, Nausea, Emesis, Diarrhea,\n melena\n Genitourinary: Dysuria, Foley\n Flowsheet Data as of 04:24 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.9\nC (98.4\n HR: 120 (115 - 120) bpm\n BP: 137/93(103) {137/70(88) - 143/93(103)} mmHg\n RR: 12 (12 - 14) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 518 mL\n PO:\n TF:\n IVF:\n 518 mL\n Blood products:\n Total out:\n 0 mL\n 210 mL\n Urine:\n 210 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 308 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI\n SM at base\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 : , No(t) Crackles : )\n Abdominal: Soft, Non-tender, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n ALT: 39\n AP: 114\n Tbili: 1.6\n Alb: 3.8\n AST: 86\n LDH: 231\n Dbili:\n TProt:\n :\n Lip:\n 79\n 258\n 0.9\n 28\n 29\n 94\n 3.5\n 137\n 30.0\n 7.1\n [image002.jpg]\n PT: 17.0\n PTT: 28.4\n INR: 1.5\n Iron studies pending\n Other labs: PT / PTT / INR://1.5\n Assessment and Plan\n 51 y/oM with h/o hemachromatosis and alcoholic liver disease with\n history of EtoH abuse/withdrawal, history of seizures, history of\n esophageal varices admitted with upper GI bleeding\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n - Noted to be erosive esophagitis, though has reported history\n of varices. A non-bleeding ulcer was seen, and he was transferred on IV\n PPI infusion and octreotide infusion\n - Given no bleeding ulcer seen, change protonix to 40mg IV BID\n - Discontinue octreotide gtt for now\n - Q6h HCTs, transfuse <30 or falling HCT\n - Bolus 1L/1h now\n - Cipro 400mg IV x1 given unclear h/o ascites/portal\n hypertension\n - Gi aware from , see in the morning. Involve GI and\n hepatology service for further investigation, and possible repeat EGD\n for evaluation of varices\n - Maintain 3 PIV (16g, 18g, 20g)\nHEMOCHROMATOSIS\n - Check current iron studies\n - Check RUQ ultrasound for eval of ascites, cirrhosis\n - f/u Bilirubin, trend, obtain direct\n ALCOHOL ABUSE/ Withdrawal\n - CIWA with Ativan while taking only IV 2mg IV q1h PRN CIWA >\n 10\n - Thiamine, folate, MVI\n - SW consult in morning\n HEPATITIS C VIRUS\n - Check HCV Viral load\n - RUQ also to assess for focal lesions\n ELEVATED INR\n - presumably from poor po intake, liver disease\n - attempt reversal with vitamin k 10mg PO x3 days\n THROMBOCYTOPENIA\n - unknown baseline, possible contribution from liver (\n thrombopoietin), spleen\n - trend plts, transfuse for <50 while having GIB.\nDIABETES MELLITUS\n - RISS for now, hold glyburide for now\nHYPERTENSION\n - hold lopressor in setting of GIB\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 02:02 AM\n 18 Gauge - 02:03 AM\n 20 Gauge - 02:03 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: contact: (sister)\n status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422430,
"text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Upon arrival no c/o nausea, no stool. Around 0400 pt vomited coffee\n ground and had melena\n Action:\n Start on Protonix iv q12hr, HCq8hr. given zofran Iv\n Response:\n Good response after zofran\n Plan:\n Follow HCT q8hr and signs of bleeding\n Alcohol abuse\n Assessment:\n A/ox3, restless, CIWA \n Action:\n Start on valium PRN, changed to Ativan 2mg Iv, given Ativan 2mg for\n CIWA 13\n Response:\n Plan:\n Cont follow signs of alcohol withdrawn\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422531,
"text": "Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match. Pt\n transferred to micu for further care.\n Events:contd small amount of coffee ground emesis,with drop in HCT,pt\n had upper endoscopy done at bedside,usg abdomen done,received 2U prbc.\n IV picc line was placed ,1episode of asymptamatic NSVT ,(10 beat)Mg\n repleted\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Known alcoholic,h/o gi bleed 1 month back,currently with coffee ground\n emesis,small amount in this shift ,no melena noted,hct 25,last coffee\n ground emesis @2pm\n Action:\n Pt had upper Gi scopoy done,received 2u prbc,had abd ultrasound,started\n on octeretide drip,cont iv protonix and cipro prophylaxis,npo status\n changed to clear liquid after usg abdomen,started on karafate, on\n nadalol for portal htn\n Response:\n Endoscopy s/o eosophageal varices and eosophagitis,with\n bleeding,banding done,hct improved to 28 ,receiving 3^rd unit of prbc\n Plan:\n Cont follow hct q6h, ,goal hct >30, next hct @ hrs,cont cear\n liquids now.\n Alcohol abuse\n Assessment:\n Known alcohol abuse,as per the pt last drink yesterday(~24 hrs),now\n with ciwa ,tachycardic to 130\ns and hypertensive to 190\n Action:\n Pt received 250 mcg fentanyl and 5 mg versed prior to endoscopy,no\n ativan so far in this shfit\n Response:\n Currently resting comfortably hr 90\ns bp 160\ns,ciwa \n Plan:\n Will cont to watch for withdrawal,prn ativan for\n withdrawal(diaphoresis,tachycardic,tremer,hypertension,and iv haldol\n for agitation\n Tachycardia, Other\n Assessment:\n Received the pt in Hr 130\ns sbp 170\ns,as per report pt received fluid\n bolus overnight with minimal effect,pt takes lopressor at home,1\n episode of NSVT(10 beat) ,serum mg level 1.1\n Action:\n Over the course of the day pt received 3 unit of prbc,5 mg versed,also\n started on nadalol.4gm magnesium sulfate\n Response:\n Hr in 90\ns sbp 160-170\n Plan:\n Will cont to monitor,watch for alcohol withdrawal,prn Ativan on board,\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422426,
"text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Upon arrival no c/o nausea, no stool. Around 0400 pt vomited coffee\n ground and had melena\n Action:\n Start on Protonix iv q12hr, HCq8hr. given zofran Iv\n Response:\n Good response after zofran\n Plan:\n Follow HCT q8hr and signs of bleeding\n Alcohol abuse\n Assessment:\n A/ox3, restless, CIWA \n Action:\n Start on valium PRN, changed to Ativan 2mg Iv, given Ativan 2mg for\n CIWA 13\n Response:\n Plan:\n Cont follow signs of alcohol withdrawn\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422518,
"text": "Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match. Pt\n transferred to micu for further care.\n Events:contd small amount of coffee ground emesis,with drop in HCT,pt\n had upper endoscopy done at bedside,usg abdomen done,received 2U prbc.\n IV picc line was placed ,1episode of asymptamatic NSVT ,(10 beat)Mg\n repleted\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Known alcoholic,h/o gi bleed 1 month back,currently with coffee ground\n emesis,small amount in this shift ,no melena noted,hct 25,last coffee\n ground emesis @2pm\n Action:\n Pt had upper Gi scopoy done,received 2u prbc,had abd ultrasound,started\n on octeretide drip,cont iv protonix and cipro prophylaxis,npo status\n changed to clear liquid after usg abdomen,started on karafate, on\n nadalol for portal htn\n Response:\n Endoscopy s/o eosophageal varices and eosophagitis,with\n bleeding,banding done,hct improved to 28 ,receiving 3^rd unit of prbc\n Plan:\n Cont follow hct q6h,plan for 1 more unit prbc,goal hct >30, next hct\n @ hrs\n Alcohol abuse\n Assessment:\n Known alcohol abuse,as per the pt last drink yesterday(~24 hrs),now\n with ciwa ,tachycardic to 130\ns and hypertensive to 190\n Action:\n Pt received 250 mcg fentanyl and 5 mg versed prior to scopy,no ativan\n so fsr in this shfit\n Response:\n Currently sleeping comfortably hr 90\ns bp 160\n Plan:\n Will cont to watch for waithdrawal,prn ativan for\n withdrawal(diaphoresis,tachycardic,tremer,hypertension,and iv haldol\n for agitation\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 422520,
"text": "Chief Complaint: hematemesis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 51 yo with hx of UGIB, heavy EtOH abuse, with EtOH related cirrhosis\n who had episode of hematemesis at home followed by several episodes of\n melena. Went to OSH and received a 1.5 units of PRBC (emergency\n transfusion). At OSH had a EGD which reportedly showed\nesophagitis\n He was started on octreotide and protonix. Notably baseline Hct is\n apparently iin the high 30\n Patient admitted from: Transfer from other hospital\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 04:52 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 03:57 AM\n Lorazepam (Ativan) - 05:35 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Hemachromatosis\n Liver disease (? varices)\n Htn\n Hep C\n Occupation: used to sell construction equipment\n Drugs: no\n Tobacco: no\n Alcohol: pint of EtOH/day\n Other:\n Review of systems:\n Flowsheet Data as of 09:21 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: 126 (115 - 127) bpm\n BP: 178/102(117) {137/70(88) - 178/102(117)} mmHg\n RR: 19 (12 - 19) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,156 mL\n PO:\n TF:\n IVF:\n 1,806 mL\n Blood products:\n 350 mL\n Total out:\n 0 mL\n 495 mL\n Urine:\n 345 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,661 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bases b/l, No(t)\n Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, stigmata of chronic\n liver dz\n Extremities: Right: Trace, Left: Trace\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 51 K/uL\n 25.6 %\n 8.8 g/dL\n 241 mg/dL\n 1.0 mg/dL\n 28 mg/dL\n 26 mEq/L\n 98 mEq/L\n 3.8 mEq/L\n 139 mEq/L\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n WBC\n 6.6\n Hct\n 25.6\n Plt\n 51\n Cr\n 1.0\n Glucose\n 241\n Other labs: PT / PTT / INR:16.3/26.9/1.5, ALT / AST:34/66, Alk Phos / T\n Bili:97/1.1, Differential-Neuts:81.5 %, Lymph:13.1 %, Mono:5.1 %,\n Eos:0.3 %, Albumin:3.3 g/dL, LDH:231 IU/L, Ca++:7.6 mg/dL, Mg++:1.1\n mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C as risk factors for cirrhosis and\n possible varices.\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause of\n cirrhosis. His baseline Hct is apparently in the mid 30\ns. Plan for\n endoscopy today. Will also need to obtain OSH records to more fully\n evaluate his hx /treatment of Hep C and hemachromatosis.\n - octreotide and IV PPI\n - if varices likely pindalol/nadolol\n - Ciprofloxacin prophylaxis\n - PICC vs CVC\n - Abd U/S with Doppler imaging to eval patency of portal system\n - check lactate\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - check lipase\n HTN/tachycardia: hold on treatment for now\n AG acidosis: check lactate, UA for ketones, serum ketones. Repeat lytes\n EtOH abuse:\n - CIWA scale using haldol for hallucination, benzo for agitation and\n metop/labet IVP for HTN/tachy.\n - fluid repletion with D5 , thiamine and folate\n Thrombocytopenia: unclear etiology possible partial component of marrow\n suppression (from EtOh although odd that MCV is low) vs hemachromatosis\n marrow infiltrate) and dilutional effect given transfusions. By report\n this is chronic. Does not appear to be a med related toxic component.\n - Abd U/S\n -Peripheral smear\n - OSH records for hx of previous evaluation\n -Plt goal of> 50\n ICU Care\n Nutrition:\n Glycemic Control: Comments: no indication\n Lines / Intubation:\n 16 Gauge - 02:01 AM\n 18 Gauge - 03:07 AM\n 22 Gauge - 08:35 AM\n Comments:\n Prophylaxis:\n DVT: Boots (low plts)\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"
},
{
"category": "Nursing",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422526,
"text": "Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match. Pt\n transferred to micu for further care.\n Events:contd small amount of coffee ground emesis,with drop in HCT,pt\n had upper endoscopy done at bedside,usg abdomen done,received 2U prbc.\n IV picc line was placed ,1episode of asymptamatic NSVT ,(10 beat)Mg\n repleted\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Known alcoholic,h/o gi bleed 1 month back,currently with coffee ground\n emesis,small amount in this shift ,no melena noted,hct 25,last coffee\n ground emesis @2pm\n Action:\n Pt had upper Gi scopoy done,received 2u prbc,had abd ultrasound,started\n on octeretide drip,cont iv protonix and cipro prophylaxis,npo status\n changed to clear liquid after usg abdomen,started on karafate, on\n nadalol for portal htn\n Response:\n Endoscopy s/o eosophageal varices and eosophagitis,with\n bleeding,banding done,hct improved to 28 ,receiving 3^rd unit of prbc\n Plan:\n Cont follow hct q6h, ,goal hct >30, next hct @ hrs,cont cear\n liquids now.\n Alcohol abuse\n Assessment:\n Known alcohol abuse,as per the pt last drink yesterday(~24 hrs),now\n with ciwa ,tachycardic to 130\ns and hypertensive to 190\n Action:\n Pt received 250 mcg fentanyl and 5 mg versed prior to endoscopy,no\n ativan so far in this shfit\n Response:\n Currently resting comfortably hr 90\ns bp 160\ns,ciwa \n Plan:\n Will cont to watch for withdrawal,prn ativan for\n withdrawal(diaphoresis,tachycardic,tremer,hypertension,and iv haldol\n for agitation\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422415,
"text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Upon arrival no c/o nausea, no stool\n Action:\n Start on Protonix iv q12hr, HCq8hr\n Response:\n Plan:\n Follow HCT q8hr and signs of bleeding\n Alcohol abuse\n Assessment:\n A/ox3, restless, CIWA\n Action:\n Start on valium PRN\n Response:\n Plan:\n Cont follow signs of alcohol withdrawn\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422416,
"text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Upon arrival no c/o nausea, no stool\n Action:\n Start on Protonix iv q12hr, HCq8hr\n Response:\n Plan:\n Follow HCT q8hr and signs of bleeding\n Alcohol abuse\n Assessment:\n A/ox3, restless, CIWA\n Action:\n Start on valium PRN\n Response:\n Plan:\n Cont follow signs of alcohol withdrawn\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 422508,
"text": "Chief Complaint: hematemesis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 51 yo with hx of UGIB, heavy EtOH abuse, with EtOH related cirrhosis\n who had episode of hematemesis at home followed by several episodes of\n melena. Went to OSH and received a 1.5 units of PRBC (emergency\n transfusion). At OSH had a EGD which reportedly showed\nesophagitis\n He was started on octreotide and protonix. Notably baseline Hct is\n apparently iin the high 30\n Patient admitted from: Transfer from other hospital\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 04:52 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 03:57 AM\n Lorazepam (Ativan) - 05:35 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Hemachromatosis\n Liver disease (? varices)\n Htn\n Hep C\n Occupation: used to sell construction equipment\n Drugs: no\n Tobacco: no\n Alcohol: pint of EtOH/day\n Other:\n Review of systems:\n Flowsheet Data as of 09:21 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: 126 (115 - 127) bpm\n BP: 178/102(117) {137/70(88) - 178/102(117)} mmHg\n RR: 19 (12 - 19) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,156 mL\n PO:\n TF:\n IVF:\n 1,806 mL\n Blood products:\n 350 mL\n Total out:\n 0 mL\n 495 mL\n Urine:\n 345 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,661 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///26/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Breath Sounds: Crackles : bases b/l, No(t)\n Wheezes : )\n Abdominal: Soft, Non-tender, Bowel sounds present, stigmata of chronic\n liver dz\n Extremities: Right: Trace, Left: Trace\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 51 K/uL\n 25.6 %\n 8.8 g/dL\n 241 mg/dL\n 1.0 mg/dL\n 28 mg/dL\n 26 mEq/L\n 98 mEq/L\n 3.8 mEq/L\n 139 mEq/L\n 6.6 K/uL\n [image002.jpg]\n 05:36 AM\n WBC\n 6.6\n Hct\n 25.6\n Plt\n 51\n Cr\n 1.0\n Glucose\n 241\n Other labs: PT / PTT / INR:16.3/26.9/1.5, ALT / AST:34/66, Alk Phos / T\n Bili:97/1.1, Differential-Neuts:81.5 %, Lymph:13.1 %, Mono:5.1 %,\n Eos:0.3 %, Albumin:3.3 g/dL, LDH:231 IU/L, Ca++:7.6 mg/dL, Mg++:1.1\n mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C as risk factors for cirrhosis and\n possible varices.\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause of\n cirrhosis. His baseline Hct is apparently in the mid 30\ns. Plan for\n endoscopy today. Will also need to obtain OSH records to more fully\n evaluate his hx /treatment of Hep C and hemachromatosis.\n - octreotide and IV PPI\n - if varices likely pindalol/nadolol\n - Ciprofloxacin prophylaxis\n - PICC vs CVC\n - Abd U/S with Doppler imaging to eval patency of portal system\n - check lactate\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - check lipase\n HTN/tachycardia: hold on treatment for now\n AG acidosis: check lactate, UA for ketones, serum ketones. Repeat lytes\n EtOH abuse:\n - CIWA scale using haldol for hallucination, benzo for agitation and\n metop/labet IVP for HTN/tachy.\n - fluid repletion with D5 , thiamine and folate\n Thrombocytopenia: unclear etiology possible partial component of marrow\n suppression (from EtOh although odd that MCV is low) vs hemachromatosis\n marrow infiltrate) and dilutional effect given transfusions. By report\n this is chronic. Does not appear to be a med related toxic component.\n - Abd U/S\n -Peripheral smear\n - OSH records for hx of previous evaluation\n -Plt goal of> 50\n ICU Care\n Nutrition:\n Glycemic Control: Comments: no indication\n Lines / Intubation:\n 16 Gauge - 02:01 AM\n 18 Gauge - 03:07 AM\n 22 Gauge - 08:35 AM\n Comments:\n Prophylaxis:\n DVT: Boots (low plts)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422573,
"text": "Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Hct 26.8 from 28 after transfusion, no signs of bleeding\n Action:\n Received additional 1 unit PRBCs\n Response:\n Awaiting post transfusion Hct\n Plan:\n Cont Q6H Hcts, monitor for bleeding\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422574,
"text": "Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Hct 26.8 from 28 after transfusion, no signs of bleeding\n Action:\n Received additional 1 unit PRBCs\n Response:\n Awaiting post transfusion Hct\n Plan:\n Cont Q6H Hcts, monitor for bleeding\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 422673,
"text": "Chief Complaint: upper GI bleed\n 24 Hour Events:\n - EGD performed; grade II-III & gastritis/esophagitis; 4 bands placed\n - Carafate and nadolol started\n - 1 bag platelets given for plt ct 47 --> 71\n - hematocrit not appropriately bumping to transfusion; total 4 units\n given since admission to (25.6 --> 2units --> 28 --> 1 unit -->\n 26.8 --> 1 unit).\n - PICC line placed\n - abdominal ultrasound showed fatty infiltration of liver, final\n results pending\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:06 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:18 AM\n Fentanyl - 11:18 AM\n Lorazepam (Ativan) - 08:39 PM\n Pantoprazole (Protonix) - 04:26 AM\n Other medications:\n Nadolol 20 mg daily\n Sucralafate QID\n Octreotide Drip\n Vitamin K 10 mg PO x 3 days\n Folic Acid 1 mg daily\n Thiamine 100 mg daily\n Cipro 400 mg \n Insulin Sliding Scale\n Ativan PRN CIWA\n Zofran PRN\n Pantoprazole 40 IV BID\n Changes to medical and 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: 37.2\nC (98.9\n Tcurrent: 36.4\nC (97.5\n HR: 88 (83 - 128) bpm\n BP: 145/92(104) {143/62(84) - 178/112(133)} mmHg\n RR: 20 (12 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 4,542 mL\n 765 mL\n PO:\n 600 mL\n TF:\n IVF:\n 2,315 mL\n 448 mL\n Blood products:\n 1,627 mL\n 317 mL\n Total out:\n 1,580 mL\n 640 mL\n Urine:\n 1,380 mL\n 640 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,962 mL\n 125 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///31/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): person, place, time, Movement: Not assessed,\n Tone: Not assessed\n Labs / Radiology\n 60 K/uL\n 10.4 g/dL\n 145 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.1 mEq/L\n 17 mg/dL\n 99 mEq/L\n 135 mEq/L\n 29.7 %\n 5.4 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n WBC\n 6.6\n 7.2\n 5.4\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n Plt\n 51\n 47\n 71\n 60\n Cr\n 1.0\n 0.8\n Glucose\n 241\n 145\n Other labs: PT / PTT / INR:15.5/29.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:73.7 %,\n Lymph:16.3 %, Mono:6.3 %, Eos:3.2 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.0 mg/dL, PO4:1.8 mg/dL\n Micro: HCV VL pending\n Abdominal Ultrasound . Wet read: Patent hepatic vasculature,\n echogenic liver compatibile with fatty infiltration, however, other\n forms of liver disease and more advanced liver disease cannot be\n excluded\n Assessment and Plan\n In summary, Mr. is a 51 year old male with h/o\n hemachromatosis, alcoholic liver disease, HCV, and alcohol abuse, and\n history of esophageal varices admitted for UGIB.\n 1. Upper GI Bleed. EGD showed grade esophageal varices s/p\n banding as well as esophagitisWas started on IV PPI and octreotide\n drip. No BMs or hematemasis in last 24 hours. Currently has two\n peripheral (22, 18) and a PICC line for access. Received 4 units of\n PRBCs since admission without appropriate increase in hct (25\n 29).\n Hct of 35-40 per PCP.\n TID Hcts, transfuse to 30 given active bleeding\n - octreotide drip, IV PPI \n - type and cross 2 units\n - cipro prophylaxis for SBP prophylaxis in patient with history of\n cirrhosis\n - sucralafate for two weeks\n - Liver team following\n - clears diet\n - increase nadolol to 40 mg daily given presence of varices\n 2. Tachycardia. Tachycardia is improved. Likely secondary to\n combination of GI bleed, right sided rib pain, and ?withdrawal (though\n clinically does not appear to be withdrawing at present.\n - monitor on tele\n - blood transfusions, to keep hct > 30\n - ativan per CIWA scale\n 3. Liver disease. Patient has a history of hemochromatosis, alcohol\n abuse, and HCV. Evidence of stigmata of chronic liver disease.\n Elevated Iron noted. Abdominal ultrasound did not show cirrhosis.\n - abdominal ultrasound\n - f/u HCV viral load\n 4. Alcohol abuse. Physical exam and vitals do not currently suggest\n withdrawal though has significant alcohol history.\n - ativan CIWA scale\n - Thiamine, folate, MVI\n 5. ELEVATED INR. Likely secondary to combination of liver disease and\n poor PO intake.\n - attempt reversal with vitamin k 10mg PO x3 days\n 6. THROMBOCYTOPENIA. be secondary to marrow suppression from\n alcohol abuse or splenic sequestration. Per PCP, Plt is in\n 70s. Unclear from PCP what prior workup has occurred. No schistocytes\n on peripheral smear.\n - trend plts, transfuse for <50 while having GIB\n 7. DIABETES MELLITUS\n - RISS for now, hold glyburide for now\n 8. HYPERTENSION. Likely secondary to ?alcohol withdrawal, not\n being on home antihypertensives, and pain.\n - increase nadolol to 40 mg daily\n 9. Anion gap. Unclear etiology, but now closed. S tox negative,\n urine ketones negative.\n PCP: Ph \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 03:07 AM\n 22 Gauge - 08:35 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\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": "2148-12-10 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 422678,
"text": "Chief Complaint: UGI bleed\n HPI: ETCOH abuse, hematemesis\n 24 Hour Events:\n PICC LINE - START 11:00 AM\n ENDOSCOPY - At 11:14 AM: grade varices with small\n bleeding, s/p banding\n > 4 units of PRBC with inappropriate rise.\n ULTRASOUND - At 02:09 PM: patent hepatic vasculature,\n echogenic liver (prelim)\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:06 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Midazolam (Versed) - 11:18 AM\n Fentanyl - 11:18 AM\n Lorazepam (Ativan) - 08:39 PM\n Pantoprazole (Protonix) - 04:26 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37\nC (98.6\n Tcurrent: 36.3\nC (97.4\n HR: 90 (83 - 128) bpm\n BP: 145/92(127) {143/62(84) - 177/112(133)} mmHg\n RR: 23 (12 - 23) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 4,542 mL\n 801 mL\n PO:\n 600 mL\n TF:\n IVF:\n 2,315 mL\n 484 mL\n Blood products:\n 1,627 mL\n 317 mL\n Total out:\n 1,580 mL\n 640 mL\n Urine:\n 1,380 mL\n 640 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 2,962 mL\n 162 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///31/\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Clear : )\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right: 1+, Left: 1+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.4 g/dL\n 60 K/uL\n 145 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.1 mEq/L\n 17 mg/dL\n 99 mEq/L\n 135 mEq/L\n 29.7 %\n 5.4 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n WBC\n 6.6\n 7.2\n 5.4\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n Plt\n 51\n 47\n 71\n 60\n Cr\n 1.0\n 0.8\n Glucose\n 241\n 145\n Other labs: PT / PTT / INR:15.5/29.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:73.7 %,\n Lymph:16.3 %, Mono:6.3 %, Eos:3.2 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.4 mg/dL, Mg++:2.0 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause of\n cirrhosis. His baseline Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding.\n - octreotide and IV PPI\n - Follow q 8hr Hct\n - cont Beta blocker (uptitrate)\n - Ciprofloxacin prophylaxis\n - Abd U/S with Doppler imaging to eval patency of portal system: await\n final read\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n If hct declines or becomes unstable hemodynamically, may need relook\n EGD/ colonoscopy\n HTN/tachycardia: beta blocker\n EtOH abuse:\n - CIWA scale using haldol for hallucination, benzo for agitation and\n metop/labet IVP for HTN/tachy.\n - fluid repletion with D5 , thiamine and folate\n - Advance diet as tolerated\n Thrombocytopenia: unclear etiology possible partial component of marrow\n suppression (from EtOh although odd that MCV is low) vs hemachromatosis\n marrow infiltrate) and dilutional effect given transfusions. By report\n this is chronic. Does not appear to be a med related toxic component.\n Awaiting US for spleen evaluation. Peripheral smear does not reveal\n evidence of schistos\n - Abd U/S: ? splenic sequestration.\n -Plt goal of> 50\n ICU Care\n Nutrition:\n Comments: clears\n Glycemic Control: Regular insulin sliding scale, Comments: as needed\n Lines:\n 18 Gauge - 03:07 AM\n 22 Gauge - 08:35 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI IV\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU (unstable Hct)\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 422811,
"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 Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 03:30 AM\n Haloperidol (Haldol) - 04:56 AM\n Lorazepam (Ativan) - 07:04 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:32 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: 77 (72 - 86) bpm\n BP: 165/102(119) {141/76(93) - 185/125(119)} mmHg\n RR: 23 (11 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,803 mL\n 670 mL\n PO:\n 770 mL\n 120 mL\n TF:\n IVF:\n 1,350 mL\n 542 mL\n Blood products:\n 683 mL\n 8 mL\n Total out:\n 3,015 mL\n 1,245 mL\n Urine:\n 3,015 mL\n 1,245 mL\n NG:\n Stool:\n Drains:\n Balance:\n -212 mL\n -575 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: No(t) Well nourished, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.4 g/dL\n 70 K/uL\n 163 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 98 mEq/L\n 131 mEq/L\n 34.5 %\n 8.8 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n Cr\n 1.0\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n Other labs: PT / PTT / INR:15.4/26.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause of\n cirrhosis. His baseline Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding.\n - octreotide and IV PPI\n - Follow q 8hr Hct\n - cont Beta blocker (uptitrate)\n - Ciprofloxacin prophylaxis\n - Abd U/S with Doppler imaging to eval patency of portal system: await\n final read\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n If hct declines or becomes unstable hemodynamically, may need relook\n EGD/ colonoscopy\n HTN/tachycardia: beta blocker\n EtOH abuse:\n - CIWA scale using haldol for hallucination, benzo for agitation and\n metop/labet IVP for HTN/tachy.\n - fluid repletion with D5 , thiamine and folate\n - Advance diet as tolerated\n Thrombocytopenia: unclear etiology possible partial component of marrow\n suppression (from EtOh although odd that MCV is low) vs hemachromatosis\n marrow infiltrate) and dilutional effect given transfusions. By report\n this is chronic. Does not appear to be a med related toxic component.\n Awaiting US for spleen evaluation. Peripheral smear does not reveal\n evidence of schistos\n - Abd U/S: ? splenic sequestration.\n -Plt goal of> 50\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 422816,
"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 > increasing EtOH withdrawl symptoms\n > Ativan 20 mg over the PM shift for agitation\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 03:30 AM\n Haloperidol (Haldol) - 04:56 AM\n Lorazepam (Ativan) - 07:04 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:32 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: 77 (72 - 86) bpm\n BP: 165/102(119) {141/76(93) - 185/125(119)} mmHg\n RR: 23 (11 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,803 mL\n 670 mL\n PO:\n 770 mL\n 120 mL\n TF:\n IVF:\n 1,350 mL\n 542 mL\n Blood products:\n 683 mL\n 8 mL\n Total out:\n 3,015 mL\n 1,245 mL\n Urine:\n 3,015 mL\n 1,245 mL\n NG:\n Stool:\n Drains:\n Balance:\n -212 mL\n -575 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: No(t) Well nourished, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: agitated, Responds to: Not assessed, Movement: moving all\n exts A+O x 0\n Labs / Radiology\n 12.4 g/dL\n 70 K/uL\n 163 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 98 mEq/L\n 131 mEq/L\n 34.5 %\n 8.8 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n Cr\n 1.0\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n Other labs: PT / PTT / INR:15.4/26.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:1.8 mg/dL\n Abd US :\n FINDINGS: Limited evaluation of the abdomen was performed. The spleen\n is\n enlarged, measuring 15.4 cm. No perisplenic varices are identified.\n There is\n no ascites.\n IMPRESSION:\n 1. Splenomegaly.\n 2. No ascites.\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause of\n cirrhosis. His baseline Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding with stable Hct\n - octreotide (until ) and IV PPI\n - Follow q 12hr Hct\n - cont Beta blocker (uptitrate)\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n Cirrhosis: ongoing evaluation for cirrhosis including hemachromatosis\n and Hep C as well as EtOH abuse\n HTN/tachycardia: beta blocker\n EtOH abuse: now progressing into withdrawl\n - CIWA scale using haldol for hallucination, benzo for agitation and\n metop/labet IVP for HTN/tachy.\n - fluid repletion with D5 , thiamine and folate\n - Advance diet as tolerated\n - Check ECG\n - Will probably need lactulose (but do not want to place NG tube\n blindly given varices)\n Thrombocytopenia: unclear etiology possible partial component of\n marrow suppression (from EtOh although odd that MCV is low) vs\n hemachromatosis marrow infiltrate) . By report this is chronic. Does\n not appear to be a med related toxic component. Appears to have\n significant splenomegaly on US () which likely explains the\n thrombocytopenia\n -Plt goal of> 50\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 422818,
"text": "Chief Complaint: upper Gi bleed\n 24 Hour Events:\n - Patient began withdrawing from alcohol, requiring frequent benzos,\n haldol\n - abdominal ultrasound showed splenomegaly\n - outpatient GI doctor does not know of prior liver workup; per\n patient, prior liver workup (including biopsy) occured at though\n no record of this in OMR\n - nadolol increased to 40 mg daily\n - 1 unit of PRBC transfused (Hct 29.7 --> 29.9 --> 28.9 --> 34.5)\n - Platelets stable at 70\n - HCV VL > 3 million\n - seen by social work who recommend outpatient alcohol treatment\n program\n - seen by liver who recommends labs for evaluation of other etiologies\n of cirrhosis, octreotide drip to be continued for 3 days\n History obtained from Patient\n Patient unable to provide history: Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 03:30 AM\n Haloperidol (Haldol) - 04:56 AM\n Other medications:\n Ativan IV PRN ciwa\n Nadolol 40 mg daily\n Sucralafate 1 gm PO QID\n Octreotide drip\n Folate daily\n Thiamine 100 IV daily\n Cipro 400 mg IV q 12\n Insulin Sliding Scale\n Zofran prn\n Pantoprazole 40 IV q 12 hour\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.7\nC (98.1\n HR: 80 (72 - 90) bpm\n BP: 169/89(112) {145/76(93) - 185/98(127)} mmHg\n RR: 19 (11 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,803 mL\n 496 mL\n PO:\n 770 mL\n 120 mL\n TF:\n IVF:\n 1,350 mL\n 368 mL\n Blood products:\n 683 mL\n 8 mL\n Total out:\n 3,015 mL\n 1,025 mL\n Urine:\n 3,015 mL\n 1,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n -212 mL\n -529 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: No(t) PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Tender:\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Oriented (to): person only,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 70 K/uL\n 12.4 g/dL\n 163 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 98 mEq/L\n 131 mEq/L\n 34.5 %\n 8.8 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n Cr\n 1.0\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n Other labs: PT / PTT / INR:15.4/26.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:1.8 mg/dL\nHCV VL. . 3,730,000 IU/mL.\nHep A, Hep B, Hep C antibodies pending.\nIgA 513 (elevated)\n\n pending\nAnti-smooth muscle antibody\n pending\nHemochromatosis mutation analysis - pending\n Assessment and Plan\n In summary, Mr. is a 51 year old male with h/o\n hemachromatosis, alcoholic liver disease, HCV, and alcohol abuse, and\n history of esophageal varices admitted for UGIB.\n 1. Alcohol withdrawal. Patient now 48 hours from last drink with\n evidence of alcohol withdrawal. Requiring large amounts of benzos to\n control symptoms and haldol.\n - ativan per CIWA scale\n - haldol as needed while monitoring QTc\n - thiamine, folate, mvi\n - daily EKG for QTc evaluation\n 2. Upper GI Bleed. EGD showed grade esophageal varices s/p\n banding as well as esophagitis. Was started on IV PPI and\n octreotide drip. No BMs or hematemasis in last 24 hours. Currently\n has two peripheral (22, 18) and a PICC line for access. Received 5\n units of PRBCs since admission without appropriate increase in hct (25\n 34.5). Hct of 35-40 per PCP.\n Hcts\n - octreotide drip for three days (until AM of )\n - IV PPI \n - type and cross 2 units\n - d/c cipro given that patient has no evidence of ascites\n - sucralafate for two weeks\n - Liver team following\n - regular diet\n - nadolol 40 mg daily given presence of varices\n 3. Hypertension. Patient on lisinopril and lopressor at home at\n unknown doses. Nadolol initiated during hospital stay due to history\n of varices. Patinet has ongoing hypertension likely due to withdrawal\n from alcohol plus hypertension.\n - tolerate SBP < 160, prn IV antihypertensives\n - continue nadolol (though patient unlikely to tolerate Pos given\n sedation)\n .\n 4. Liver disease. Patient has a history of hemochromatosis, alcohol\n abuse, and HCV. Evidence of stigmata of chronic liver disease.\n Elevated Iron noted. Abdominal ultrasound did not show cirrhosis, but\n showed splenomegaly and no ascites. Patient state prior workup for\n liver disease including liver biopsy occurred at many years ago,\n but no record of this. Outpatient GI doctor is unclear of prior workup\n given that patient does not follow up regularly.\n - f/u final read of abdominal ultrasound\n - f/u anti smooth muscle , , hep A, B, C antibodies, HFE,\n to evaluate for other etiology of cirrhosis\n 5. ELEVATED INR. Likely secondary to combination of liver disease and\n poor PO intake. Minimal effect with oral vitamin K.\n - follow INR\n 6. THROMBOCYTOPENIA. be secondary to marrow suppression from\n alcohol abuse or splenic sequestration. Noted to have splenomegaly on\n abdominal ultrasound. Per PCP, Plt is in 70s. Unclear from\n PCP what prior workup has occurred. No schistocytes on peripheral\n smear.\n - trend plts, transfuse for <50 while having GIB\n 7. DIABETES MELLITUS\n - RISS for now, hold glyburide for now\n PCP: Ph \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 03:07 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 422823,
"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 > increasing EtOH withdrawl symptoms\n > Ativan 20 mg over the PM shift for agitation\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 03:30 AM\n Haloperidol (Haldol) - 04:56 AM\n Lorazepam (Ativan) - 07:04 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:32 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: 77 (72 - 86) bpm\n BP: 165/102(119) {141/76(93) - 185/125(119)} mmHg\n RR: 23 (11 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,803 mL\n 670 mL\n PO:\n 770 mL\n 120 mL\n TF:\n IVF:\n 1,350 mL\n 542 mL\n Blood products:\n 683 mL\n 8 mL\n Total out:\n 3,015 mL\n 1,245 mL\n Urine:\n 3,015 mL\n 1,245 mL\n NG:\n Stool:\n Drains:\n Balance:\n -212 mL\n -575 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///29/\n Physical Examination\n General Appearance: No(t) Well nourished, Diaphoretic\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: diminished\n at the based\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: agitated, Responds to: verbal, Movement: moving all exts\n A+O x 0\n Labs / Radiology\n 12.4 g/dL\n 70 K/uL\n 163 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 98 mEq/L\n 131 mEq/L\n 34.5 %\n 8.8 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n Cr\n 1.0\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n Other labs: PT / PTT / INR:15.4/26.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:1.8 mg/dL\n Abd US :\n FINDINGS: Limited evaluation of the abdomen was performed. The spleen\n is\n enlarged, measuring 15.4 cm. No perisplenic varices are identified.\n There is\n no ascites.\n IMPRESSION:\n 1. Splenomegaly.\n 2. No ascites.\n Assessment and Plan\n 51 yo male with hx of UGIB in the setting of a hx of heavy EtOH,\n hemachromatosis and Hepatitis C with UGIB in the setting of grad \n esoph varices s/p banding .\n GIB: hx of EtOH abuse, hemachromatosis and ?Hep C as possible cause of\n cirrhosis. His baseline Hct is apparently in the mid 30\ns. Now s/p\n variceal bleed with banding with stable Hct\n - octreotide (until ) and IV PPI\n - Follow q 12hr Hct\n - cont Beta blocker (uptitrate)\n - Goal HCT > 30 in the setting of bleeding, Goal Plt> 50 and INR < 1.5\n - Oral vitamin K\n Cirrhosis: ongoing evaluation for cirrhosis including hemachromatosis\n and Hep C as well as EtOH abuse, as well as other potential etiologies\n of cirrhosis.\n HTN/tachycardia: beta blocker\n EtOH abuse: now progressing into withdrawl\n - CIWA scale using haldol for hallucination, benzo for agitation and\n metop/labet IVP for HTN/tachy.\n - fluid repletion with D5 , thiamine and folate\n - Advance diet as tolerated\n - Check ECG\n - Will probably need lactulose (but do not want to place NG tube\n blindly given varices)\n Thrombocytopenia: unclear etiology possible partial component of\n marrow suppression (from EtOh although odd that MCV is low) vs\n hemachromatosis with marrow infiltrate) . By report this is chronic.\n Does not appear to be a med related toxic component. Appears to have\n significant splenomegaly on US () which likely explains the\n thrombocytopenia at least in part.\n -Plt goal of> 50\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422575,
"text": "Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match.\n s/p EGD with findings of esophagitis and 4 cords of stage II and\n III varices, 4 bands were placed.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Hct 26.8 from 28 after transfusion, no signs of bleeding, no melena, no\n emesis.\n Action:\n Received additional 1 unit PRBCs\n Response:\n Awaiting post transfusion Hct\n Plan:\n Cont Q6H Hcts, monitor for bleeding, f/u with repeat banding in 3weeks.\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422737,
"text": "Mr. is a 51 y/oM with h/o hemachromatosis, h/o EtOH abuse,\n h/o recent UGIB last month now admitted via transfer from ED with UGIB. Yesterday, he developed hematemesis and\n 2-3 episodes of melena. He went to the ED where his BP was\n 127/96, HR 130, RR 20, and sat was 96% on RA. He was placed on PPI gtt\n and octeotide gtt. A history of varices was in his record. He underwent\n EGD which showed UGIB from \"Barrett's\" and erosive\n esophagitis/gastritis, no active bleeding, but without mention of\n varices. He received 1 and\n units of pRBC, emergency release blood\n that was stopped because of multiple antibodies and difficult match.\n s/p EGD with findings of esophagitis and 4 cords of stage II and\n III varices, 4 bands were placed.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n HR 80-90 NSR, Hypertensive SBP>150 received nadolo per routine. Abd\n soft distended + BS , No active bleed no stool. Denies Nausea. Tol\n clear liq diet adv to reg this evening. c/o LUQ /rib chest pain \n intermittent more pronounced on palpation and when lying on L side. (pt\n states had fallen 1month ago hitting ribs no followup. K+ 3.1 phos 1.8\n Action:\n Seriel Hct 29.5/29.7. plts 60. Cont octreotide 50mcg/hr and IV\n protonix, nadolol ^for BP control. Had U/S spleen and abd. Electrolyte\n repletion K+ 60meq and Kphos infusion. Received Multivits/folic\n acid/thiamine.\n Response:\n U/S result pending. Hct stable\n Plan:\n Seriel Hct q6hr, labs @ 1900\n Followup blood discrasia labs (hemachromatosis)\n Liver team consult.\n Alcohol abuse\n Assessment:\n Awake alert oriented x3,periods of anxiety about being in hosp\n discussed with MICU team and GI team resiults of EGD and liver status.\n CIWA<5.\n Action:\n No signs of withdrawal, Social services met w/ pt who is open about\n need for ETOH support.\n Response:\n Comfotabe @ present.\n Plan:\n Monitor CIWA, ativan PN\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 422803,
"text": "Chief Complaint: upper Gi bleed\n 24 Hour Events:\n - Patient began withdrawing from alcohol, requiring frequent benzos,\n haldol\n - abdominal ultrasound showed splenomegaly\n - outpatient GI doctor does not know of prior liver workup; per\n patient, prior liver workup (including biopsy) occured at though\n no record of this in OMR\n - nadolol increased to 40 mg daily\n - 1 unit of PRBC transfused (Hct 29.7 --> 29.9 --> 28.9 --> 34.5)\n - Platelets stable at 70\n - HCV VL > 3 million\n History obtained from Patient\n Patient unable to provide history: Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 03:30 AM\n Haloperidol (Haldol) - 04:56 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.7\nC (98.1\n HR: 80 (72 - 90) bpm\n BP: 169/89(112) {145/76(93) - 185/98(127)} mmHg\n RR: 19 (11 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,803 mL\n 496 mL\n PO:\n 770 mL\n 120 mL\n TF:\n IVF:\n 1,350 mL\n 368 mL\n Blood products:\n 683 mL\n 8 mL\n Total out:\n 3,015 mL\n 1,025 mL\n Urine:\n 3,015 mL\n 1,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n -212 mL\n -529 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: No(t) PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Tender:\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Oriented (to): person only,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 70 K/uL\n 12.4 g/dL\n 163 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 98 mEq/L\n 131 mEq/L\n 34.5 %\n 8.8 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n Cr\n 1.0\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n Other labs: PT / PTT / INR:15.4/26.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:1.8 mg/dL\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 03:07 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422806,
"text": "54yo male with hx HTN, ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs and PLTs since admission, and\n has been transfused with 5 units PRBCs and 1 unit PLTs. His HCT this AM\n is 34.5 and his PLTs are 70. Pts last drink was Sunday, . From\n the time of admission up until the early morning of , the pt was\n without s/s ETOH withdrawal. Around MN , the pt began to exhibit\n signs of confusion. Throughout the course of the early morning, the pt\n became increasingly anxious/agitated/paranoid and began hallucinating.\n He received 16mg ativan and 5mg haldol for active s/s ETOH withdrawal.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt tx from Hospital with episodes hematemesis and melena. S/P\n 4 units PRBCs but HCT 28.9 last evening and PLTs 53. Also s/p\n esophageal banding x4 and no further bleeding since.\n Action:\n Pt transfused with 1 unit PRBCs.\n Response:\n HCT up to 34.5 this AM, PLTs 70.\n Plan:\n Cont with frequent HCT checks, follow labs. Transfuse per team orders.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt A&Ox3 at beginning of shift with no s/s ETOH withdrawal. Then noted\n around MN to be confused and pt became increasingly\n anxious/agitated/paranoid throughout the noc. He began continuously\n hallucinating around 04 and attempting to get OOB.\n Action:\n Pt given total of 16mg ativan and 5mg haldol from 00-06. Pt was placed\n in a posy and wrist restraints for safety and was monitored frequently\n with much 1:1 time spent with pt.\n Response:\n Pt slightly less anxious post ativan/haldol but continues to\n hallucinate and still a fall risk so continued in restraints for\n safety.\n Plan:\n Cont with CIWA Q1hr and medicate as necessary with ativan/haldol.\n Maintain safety.\n"
},
{
"category": "Nursing",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 422807,
"text": "54yo male with hx HTN, ETOH abuse, GI bleeds, esophageal varicies who\n presented to OSH with hematemesis and melena. Transferred here for\n further monitoring GI bleed. EGD performed which showed grade\n II-III varicies now s/p 4 bands and no further episodes of bleeding\n since. Pt has had consistently low HCTs and PLTs since admission, and\n has been transfused with 5 units PRBCs and 1 unit PLTs. His HCT this AM\n is 34.5 and his PLTs are 70. Pts last drink was Sunday, . From\n the time of admission up until the early morning of , the pt was\n without s/s ETOH withdrawal. Around MN , the pt began to exhibit\n signs of confusion. Throughout the course of the early morning, the pt\n became increasingly anxious/agitated/paranoid and began hallucinating.\n He received 16mg ativan and 5mg haldol for active s/s ETOH withdrawal.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Pt tx from Hospital with episodes hematemesis and melena. S/P\n 4 units PRBCs but HCT 28.9 last evening and PLTs 53. Also s/p\n esophageal banding x4 and no further bleeding since.\n Action:\n Pt transfused with 1 unit PRBCs.\n Response:\n HCT up to 34.5 this AM, PLTs 70.\n Plan:\n Cont with frequent HCT checks, follow labs. Transfuse per team orders.\n Alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt A&Ox3 at beginning of shift with no s/s ETOH withdrawal. Then noted\n around MN to be confused and pt became increasingly\n anxious/agitated/paranoid throughout the noc. He began continuously\n hallucinating around 04 and attempting to get OOB.\n Action:\n Pt given total of 16mg ativan and 5mg haldol from 00-06. Pt was placed\n in a posy and wrist restraints for safety and was monitored frequently\n with much 1:1 time spent with pt.\n Response:\n Pt slightly less anxious post ativan/haldol but continues to\n hallucinate and still a fall risk so continued in restraints for\n safety.\n Plan:\n Cont with CIWA Q1hr and medicate as necessary with ativan/haldol.\n Maintain safety.\n"
},
{
"category": "Physician ",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 422808,
"text": "Chief Complaint: upper Gi bleed\n 24 Hour Events:\n - Patient began withdrawing from alcohol, requiring frequent benzos,\n haldol\n - abdominal ultrasound showed splenomegaly\n - outpatient GI doctor does not know of prior liver workup; per\n patient, prior liver workup (including biopsy) occured at though\n no record of this in OMR\n - nadolol increased to 40 mg daily\n - 1 unit of PRBC transfused (Hct 29.7 --> 29.9 --> 28.9 --> 34.5)\n - Platelets stable at 70\n - HCV VL > 3 million\n History obtained from Patient\n Patient unable to provide history: Encephalopathy\n Allergies:\n Last dose of Antibiotics:\n Ciprofloxacin - 06:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 03:30 AM\n Haloperidol (Haldol) - 04:56 AM\n Other medications:\n Ativan IV PRN ciwa\n Nadolol 40 mg daily\n Sucralafate 1 gm PO QID\n Octreotide drip\n Folate daily\n Thiamine 100 IV daily\n Cipro 400 mg IV q 12\n Insulin Sliding Scale\n Zofran prn\n Pantoprazole 40 IV q 12 hour\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 36.7\nC (98.1\n HR: 80 (72 - 90) bpm\n BP: 169/89(112) {145/76(93) - 185/98(127)} mmHg\n RR: 19 (11 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 94.8 kg (admission): 94.8 kg\n Height: 72 Inch\n Total In:\n 2,803 mL\n 496 mL\n PO:\n 770 mL\n 120 mL\n TF:\n IVF:\n 1,350 mL\n 368 mL\n Blood products:\n 683 mL\n 8 mL\n Total out:\n 3,015 mL\n 1,025 mL\n Urine:\n 3,015 mL\n 1,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n -212 mL\n -529 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: No(t) PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Tender:\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Oriented (to): person only,\n Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 70 K/uL\n 12.4 g/dL\n 163 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 98 mEq/L\n 131 mEq/L\n 34.5 %\n 8.8 K/uL\n [image002.jpg]\n 05:36 AM\n 01:30 PM\n 07:54 PM\n 04:04 AM\n 11:15 AM\n 06:53 PM\n 03:22 AM\n WBC\n 6.6\n 7.2\n 5.4\n 8.8\n Hct\n 25.6\n 28.0\n 26.8\n 29.7\n 29.9\n 28.9\n 34.5\n Plt\n 51\n 47\n 71\n 60\n 56\n 53\n 70\n Cr\n 1.0\n 0.8\n 0.8\n Glucose\n 241\n 145\n 163\n Other labs: PT / PTT / INR:15.4/26.3/1.4, ALT / AST:26/62, Alk Phos / T\n Bili:85/1.9, Amylase / Lipase:31/23, Differential-Neuts:78.8 %,\n Lymph:12.3 %, Mono:4.2 %, Eos:4.3 %, Albumin:3.1 g/dL, LDH:244 IU/L,\n Ca++:7.9 mg/dL, Mg++:1.8 mg/dL, PO4:1.8 mg/dL\nHCV VL. . 3,730,000 IU/mL.\nHep A, Hep B, Hep C antibodies pending.\nIgA 513 (elevated)\n\n pending\nAnti-smooth muscle antibody\n pending\nHemochromatosis mutation analysis - pending\n Assessment and Plan\n In summary, Mr. is a 51 year old male with h/o\n hemachromatosis, alcoholic liver disease, HCV, and alcohol abuse, and\n history of esophageal varices admitted for UGIB.\n 1. Upper GI Bleed. EGD showed grade esophageal varices s/p\n banding as well as esophagitis. Was started on IV PPI and\n octreotide drip. No BMs or hematemasis in last 24 hours. Currently\n has two peripheral (22, 18) and a PICC line for access. Received 5\n units of PRBCs since admission without appropriate increase in hct (25\n 34.5). Hct of 35-40 per PCP.\n TID Hcts, transfuse to 30 given active bleeding\n - octreotide drip for three days (until AM of )\n - IV PPI \n - type and cross 2 units\n - cipro prophylaxis for SBP prophylaxis in patient with history of\n cirrhosis for 7 day course\n - sucralafate for two weeks\n - Liver team following\n - regular diet\n - nadolol 40 mg daily given presence of varices\n 2. Alcohol withdrawal. Patient now 48 hours from last drink with\n evidence of alcohol withdrawal. Requiring large amounts of benzos to\n control symptoms.\n - ativan per CIWA scale\n - haldol as needed while monitoring QTc\n - thiamine, folate, mvi\n 3. Hypertension. Patient on lisinopril and lopressor at home at\n unknown doses. Nadolol initiated during hospital stay due to history\n of varices. Patinet has ongoing hypertension likely due to withdrawal\n from alcohol plus hypertension.\n - resume lisinpril today\n - continue nadolol\n .\n 4. Liver disease. Patient has a history of hemochromatosis, alcohol\n abuse, and HCV. Evidence of stigmata of chronic liver disease.\n Elevated Iron noted. Abdominal ultrasound did not show cirrhosis, but\n showed splenomegaly and no ascites. Patient state prior workup for\n liver disease including liver biopsy occurred at many years ago,\n but no record of this. Outpatient GI doctor is unclear of prior workup\n given that patient does not follow up regularly.\n - f/u final read of abdominal ultrasound\n - f/u anti smooth muscle , , hep A, B, C antibodies, HFE,\n to evaluate for other etiology of cirrhosis\n 5. ELEVATED INR. Likely secondary to combination of liver disease and\n poor PO intake. Minimal effect with oral vitamin K.\n - follow INR\n 6. THROMBOCYTOPENIA. be secondary to marrow suppression from\n alcohol abuse or splenic sequestration. Noted to have splenomegaly on\n abdominal ultrasound. Per PCP, Plt is in 70s. Unclear from\n PCP what prior workup has occurred. No schistocytes on peripheral\n smear.\n - trend plts, transfuse for <50 while having GIB\n 7. DIABETES MELLITUS\n - RISS for now, hold glyburide for now\n PCP: Ph \n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 03:07 AM\n PICC Line - 11:00 AM\n Prophylaxis:\n DVT: Boots, LMW Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:ICU\n"
},
{
"category": "Radiology",
"chartdate": "2148-12-10 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 1043933,
"text": ", MED MICU-7 3:17 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: evaluate for splenomegaly, ascites\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hemochromatosis, HCV, etoh abuse.\n REASON FOR THIS EXAMINATION:\n evaluate for splenomegaly, ascites\n ______________________________________________________________________________\n PFI REPORT\n Splenomegaly. No ascites.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-12-10 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 1043932,
"text": " 3:17 PM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: evaluate for splenomegaly, ascites\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hemochromatosis, HCV, etoh abuse.\n REASON FOR THIS EXAMINATION:\n evaluate for splenomegaly, ascites\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf TUE 6:44 PM\n Splenomegaly. No ascites.\n ______________________________________________________________________________\n FINAL REPORT\n LIMITED ABDOMINAL ULTRASOUND.\n\n INDICATION: 51-year-old man with hemachromatosis, hepatitis C, alcohol use,\n evaluate for splenomegaly and ascites.\n\n COMPARISON: Abdominal ultrasound dated .\n\n FINDINGS: Limited evaluation of the abdomen was performed. The spleen is\n enlarged, measuring 15.4 cm. No perisplenic varices are identified. There is\n no ascites.\n\n IMPRESSION:\n 1. Splenomegaly.\n\n 2. No ascites.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-12-09 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1043714,
"text": ", MED MICU-7 1:22 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: ?cirrhosis, ascites, clots\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hemachromatosis, ?portal hypertension, clot changes.\n REASON FOR THIS EXAMINATION:\n ?cirrhosis, ascites, clots. Please perform dopplers.\n ______________________________________________________________________________\n PFI REPORT\n Patent hepatic vasculature. Echogenic liver, compatible with fatty\n infiltration, however, other forms of liver disease and more advanced liver\n disease cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-12-09 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1043713,
"text": " 1:22 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: ?cirrhosis, ascites, clots\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with hemachromatosis, ?portal hypertension, clot changes.\n REASON FOR THIS EXAMINATION:\n ?cirrhosis, ascites, clots. Please perform dopplers.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): YMf MON 9:21 PM\n Patent hepatic vasculature. Echogenic liver, compatible with fatty\n infiltration, however, other forms of liver disease and more advanced liver\n disease cannot be excluded.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT UPPER QUADRANT ULTRASOUND\n\n INDICATION: 51-year-old male with hemachromatosis, evaluate hepatic\n vasculature.\n\n COMPARISON: Not available at .\n\n FINDINGS: Limited evaluation of the right upper quadrant demonstrates\n diffusely increased echogenicity of the hepatic parenchyma.\n\n Doppler interrogation of the main, left anterior and posterior right portal\n veins, middle, left, and right hepatic veins, and main hepatic artery\n demonstrates normal directionality of the flow and normal waveforms.\n\n There is no ascites.\n\n IMPRESSION:\n 1. Patent hepatic vasculature.\n\n 2. Echogenic liver, compatible with fatty liver, however, other forms of\n liver disease and more advanced liver disease, including significant hepatic\n cirrhosis/fibrosis cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-12-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1043673,
"text": " 10:25 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 5 Fr DL Picc placed in right basilic vein, need Picc tip pla\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 5 Fr DL Picc placed in right basilic vein, need Picc tip placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 12:58 PM\n There has been an interval placement of a right-sided PICC catheter whose tip\n could be withdrawn approximately 4 cm.\n ______________________________________________________________________________\n FINAL REPORT\n Portable AP chest radiograph.\n\n HISTORY: 51-year-old man with new PICC. Evaluate for tip placement.\n\n COMPARISON: Chest radiograph from at 4:41 a.m.\n\n FINDINGS: There has been interval placement of a right-sided PICC catheter\n whose tip terminates in the right atrium. The tip of the PICC could be\n withdrawn approximately 4 cm. Otherwise, the cardiac silhouette, and hilar\n and mediastinal contours are unchanged. The lungs are clear without areas of\n consolidation or effusion.\n\n IMPRESSION: Right-sided PICC catheter whose tip is in the right atrium and\n could be withdrawn approximately 4 cm to be positioned in low SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-12-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1043674,
"text": ", MED MICU-7 10:25 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: 5 Fr DL Picc placed in right basilic vein, need Picc tip pla\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 5 Fr DL Picc placed in right basilic vein, need Picc tip placement\n ______________________________________________________________________________\n PFI REPORT\n There has been an interval placement of a right-sided PICC catheter whose tip\n could be withdrawn approximately 4 cm.\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1043619,
"text": " 4:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: aspiration,\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with GIB\n REASON FOR THIS EXAMINATION:\n aspiration,\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw MON 11:57 AM\n No areas of consolidation are identified.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SUPINE CHEST RADIOGRAPH\n\n COMPARISON: None.\n\n HISTORY: 51-year-old man with GI bleed. Evaluate for an aspiration.\n\n FINDINGS: There is rotation of the patient, which limits full evaluation of\n the chest. However, given these limitations, the cardiac silhouette is normal\n in appearance. The hilar and mediastinal contours are unremarkable. There is\n slightly low lung volume, however, the lungs are clear without areas of\n consolidation. There are no pleural effusions, nor is there pneumothorax.\n The osseous and soft tissue structures appear grossly unremarkable.\n\n IMPRESSION: No areas of consolidation. Would recommend repeat chest\n radiograph to achieve better symmetry.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-12-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1043620,
"text": ", MED MICU-7 4:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: aspiration,\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with GIB\n REASON FOR THIS EXAMINATION:\n aspiration,\n ______________________________________________________________________________\n PFI REPORT\n No areas of consolidation are identified.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Report",
"row_id": 221052,
"text": "Sinus tachycardia, rate 135. Slight non-specific ST segment changes in\nleads V3-V6 are non-specific. No previous tracing available for comparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2148-12-12 00:00:00.000",
"description": "Report",
"row_id": 220837,
"text": "Sinus rhythm\nProlonged QT interval is nonspecific but clinical correlation is suggested\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2148-12-11 00:00:00.000",
"description": "Report",
"row_id": 220838,
"text": "Sinus rhythm. Q-T interval prolongation. Compared to the previous tracing\nof the diffuse ST-T wave changes have improved. The Q-T interval is\nprolonged. The rate has slowed. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2148-12-09 00:00:00.000",
"description": "Report",
"row_id": 220839,
"text": "The rate has slowed to 118. There is moderate artifact but the\nrhythm does appear to be sinus. The non-specific ST segment changes\nreported previously are much less prominent and there are only non-specific\nT wave changes at this time.\nTRACING #2\n\n"
}
] |
1,172 | 199,569 | The baby required intubation about 24 hours of age for increasing oxygen requirement. Started on settings of 24/6 and a rate of 24, received one dose of Surfactant and weaned to 18/5 and a rate of 14. The infant was transitioned to CPAP by day of life six and required CPAP until day of life thirteen where the infant transitioned into nasal cannula oxygen. The infant is receiving nasal cannula oxygen 100% about 25 ccs. The infant was started on caffeine at day of life sixteen when transitioned to CPAP. Current dose of caffeine is 13.5 mg which equals 7.9 mg/kg/dose. The baby has approximately six to eight episodes of apnea and bradycardia per 24 hours, mostly quickly self resolving. Baseline respiratory rate is in the 30s to 60s. Cardiovascular - The baby was treated with Indomethacin one course for presumed patent ductus arteriosus on , day of life two. After the course was completed, the infant had an intermittent murmur and had an echocardiogram done on , which showed a small patent foramen ovale and no patent ductus arteriosus, some right ventricular hypertrophy. The patient has been cardiovascularly stable. Baseline heart rate 150s to 160s, baseline blood pressure 60s to 70s over 30s to 40s with means in the 40s to 50s. Fluid, electrolytes and nutrition - The baby was initially on via peripheral intravenous and was started on PN and Intralipid and had a central PICC placed on day of life five which stayed in place until day of life fourteen. Enteral feedings were introduced on day of life six and advanced to full feedings by day of life fourteen. Calories were increased to current caloric density of breast milk 30 with ProMod. The baby is receiving 150 cc/kg/day and receiving mostly PG feedings. The last set of electrolytes on , were sodium 138, potassium 4.6, chloride 102, bicarbonate 23. On , the infant had a calcium of 10.3, phosphorus 6.4, alkaline phosphatase 507. Last hematocrit on , was 38.8. Gastrointestinal - The baby demonstrated physiologic jaundice and had a peak bilirubin on , of 8.6 over 0.3/8.3 and was started on phototherapy. Phototherapy was discontinued with a rebound bilirubin of 6.2 over 0.3/5.9. Infectious disease - The baby initially had a blood culture and complete blood count sent. The white blood cell count was 12.4 with 28 polys, 0 bands, 72 lymphocytes, platelets 290,000, hematocrit 50.1. Blood culture was sent, and the infant was started on a 48 hour course of Ampicillin and Gentamicin. Cultures remained negative. The baby was clinically well and antibiotics were discontinued. The infant has had no further issues with infection. Neurologic - On day of life six, the baby had a head ultrasound which showed a small choroid plexus cyst. The plan is to follow-up at one month of age. The baby's examination is appropriate for gestational age. Sensory - Audiology screening has not been done to date. Ophthalmology examination has not been done to date. Psychosocial - The parents look forward to moving closer to home. | Dc'd->RA at0900. Her FiO2 has been closeto RA. On reflux prec.#3O: In air isolette with stable temp. MildIC/SC retractions. Now in RA.AFSOF. Cap refill- wnl. Sxn prn. + mild intercostal andsubcostal retractions. Remains onCaffeine. Remains onCaffeine. Check bili.7. and 1 sm. Pulsesare wnl. stim. +BS. The cardiomediastinal contour is within normal limits. Feeding time ^ to1hr20min. Bilito be drawn in am.CV: Murmur heard x 1 ( but soft) and intermittent. A: NPO, stable. Mild retractions. Mild inter/subcostal retractions noted. soft,round, +BS. Nochanges made in vent support today. F/N: O: Infant is NPO for now, on 120cc/k/d of TFconsisting of TPN and lipids infusing via a PIV. Lungsounds cl/=. On 22 cal BM. 9 A/B. Check PICC placement. Infant isstable. The endotracheal tube has been advanced somewhat and is past the thoracic inlet. asp. Pn (d10) + IL continue as ordered. Due for lytes in am.Stable, con't as planned and monitor. secondsmall pulm hemorrage). Soft murmor reappeared thismornign. Weened rate after CBG 7.39/38. Isolettetemp weaned accordingly. IVF of PN(D12.5) infusing through PICC.Gavage time ^'d to 1hr; mod. Remains NPO w/ beginningcourse of Indocin. Recieving caffiene. Caffeine dose ^'d. Mild IC/SC retractions. Follow resp statusclosely. Level to be checked Thurs. Softloops noted x1. Remains NPO.TF=130cc/kg/day. New dose ofCaffeine given. TPN D10 w/ IL. Abd benign, BS active. A: S/p 48hours r/o. Shecalms w/ containment. Pulses full w/ palmar pulses. Lytes were sent and are pnd at thiswriting. A: Stable on the vent whenquiet. Voiding/trace stool x1. come back to hold #2later. Mild retractions. Occ. She is voiding 2.9cc/k/hr. Belly is soft with +BS, noloops, did have a stool after a supp., voids qs.#3O: In isolette on air mode with stable emp. Sxn prn.2. PN top be advanced.Rebound bili to be rechecked in am.Temp stable in air isollette. G/D: Temp stable in servo-isolette. Abd benign, BSactive. Toleratingfeedings well; abd exam benign, AG stable, one sm. Remains NPO for PDA/indomethacin course. Fio2 .25-.30, bs clear, rr 50-60 with mild retractions. LS clear, mildIC/SC retractions, RR 30-50s. 120 PN D11, 30 /k BM20. Temp. Settles well in between cares. soft, noloops, B.S. One mild stim brady as of this writing. Sxn for sm-mod amts cldy sec (slightly bl-tinged x1 @ ). Mild retractions. Tolerating well.In air isolette.d/s 119u/o 4.4, no stoolRebound bili 7.1/0.4Plan:1. to monitor resp. Plan cont CPAP. girth stable, blood sugar 112. Tolerating now full feedsof bm/pe20well. Slight increase O2 with cares, no desats 1spell. Responds well toswaddling and pacifier. IC/SCR noted. Recieving caffiene.FEN: TF 150cc/k/d. Bilirubin acceptable. Min. Rebound bilirubin 6.2/0.3. NeonatologyDoing well. P:Cont. Suctioned with cares for mod amt from ETTand nares. nut.,monitor.G/DO: Temp stable in an off isolette. A: Stable on CPAP. LS clear/=, mild sc/ic retractionsnoted. NP CPAP in place. IC/SC ret. Suctioned with cares for mod amt from tubeand nares. Occ Bradys. Girthstable. BSCE bilat. Last hct 38.8. RR 30-60s, LS clear, IC/SCretractions. Abd soft, bs +. Abd soft, bs +. Periodicbreathing pattern noted, w/ assoc. Occ. Continunes oncaffiene. Stable on CPAP cont to follow. One mild stim brady recorded. DS stable. NPN NOCSInfant had 1 A and B requiring mild stim(see nsg flowsheet for details). Tolerating well. A: AGA. Lytes sent, see flow sheet.3 G&DTemp stable in servo controlled isolette. in am. Currently recieving 130cc/k of TPN D11w/IL via PICC. AFSOF. Sm spit, max aspirate of3.0ccs, Dstx-106. Lungsounds clear/=. Lungsounds clear/=. Bili mask in place.Level tonigh 7.8/0.4/7.4 Plan cont CPAP @ present. Cont tomonitor.G/D: Temp stable in off isolette. Independent withcares and very . Continues oncaffeine. heme neg. Consentobtained. cx ng. Nospits or aspirates noted. A- Tol. A; Alt inDEV P; cont with appropriate dev. +PICC. PICC in place. Occ. NNP informed. Mild retractionsnoted. given as ordered, bld. to lg. One med spit today.Girth stable. Mild ic rtxns. Plan cont CPAP. O2req. BS coarse-> clear. Br. Mild sc rtx. As and Bs. Lytes 141/5.4/108/15. amt. Lungs cl and =. o- Temp stable in off isolette. Mild retractions. P-Follow wts.#3Dev. AFSOF. Oneassociated with apnea / needing mild stim. Last Hct 38. Sucks onpacifier. Cont in low flow O2 per NC. Labile with O2 saturations. BBS equal and clear, well aerated, minimalsecretions, occ desats to 70's requiring increased 02.Pinkand well perfused. Start photherapy, d/c amp and gent. Fio2 .21, rr 50's , bs clear. OTconsult done today. Able to ween rate after ABG 7.40/36. HUS scheduledfor thurs. tosupport resp. Lytes 138/4.6/102/23. Abd benign, BSactive. cont on IVcaffeine. IC/SCRnoted. G/D: Temps stable in servo-isolette. Normalpulses & good cap refill noted. One spell noted thus far this shift - QSR. Dc'd to this AM. to monitor resp. Settles well in between cares. Bilirubin under control. Suckingintermitt. Alk Phos 507 Phos 6.4 Ca 10.3. Tolerating well. Recieving amp and gent per orders for48hours. Sxn x1 for small amts of whitesecretions. P:Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. P: Cont. Abominal exambenign, voiding and well with stable girths andminimal residuals. Settles with containment. SMALLSPIT X1. IC/SCR noted. Currently NPO until resp. Orally intubated at10am and recieved survanta x1. status stabilizes. Will cont. Mild/skinny ic/sc retractionsnoted. AGA. AGA. on pacifier. level sent,andis pending. Mildinter/subcostal retractions noted. Cont to educateand support.A/B's: One spell thus far this shift. CBG on CPAP: 7.20/71/29/29/-2 -> ABG checked: 7.32/54/68/29/0. RR 30-60's with mild ICR/SCR. Likely some element of GE-reflux. Infant continues on Vit E and Fe. BSCE bilat. RR 30-70's.IC/SC ret. to monitor resp. nutrition.,monitor.G/DO: Temp stable in air isolette. BW 1435 Initial ds 73->103->170. Remains NPO with PICC in place, PN-D10W-IL. Abd soft, bs +. tosupport and udpate .4. Monitor for s/s ofintolerance. A: Pt. CBG 7.39/38. Settles well in between cares. Mild IC/SCR noted. WBC 12.4 28N 0B HCT 50.1 PLT290. Remainder of fluids as PN via PICC line. Extubated on NC. Maintain reflux precautions, HOB 45deg.#3. Passed heme negative stool. Stable temperatue on servo-controlled incubator. Dstick wnl. 136/4.8/104/23. Reflux precautions. Labs noted and PN adjusted accordingly. Labs noted and PN adjusted accordingly. P: Cont. | 133 | [
{
"category": "Radiology",
"chartdate": "2104-09-05 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 771170,
"text": " 10:08 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: Check ETT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with respiratory distress - 34 wks, day 0\n REASON FOR THIS EXAMINATION:\n Check ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM, \n\n HISTORY: Infant with respiratory distress, 34 and 5/7 weeks, chesck ET tube\n placement.\n\n Endotracheal tube is just at the level of the thoracic inlet. There are\n diffuse granular opacities, with air bronchograms, consistent with hyaline\n membrane disease. The cardiomediastinal contour is within normal limits.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-09-08 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 771417,
"text": " 2:20 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: Check PICC placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with RDS, prematurity\n REASON FOR THIS EXAMINATION:\n Check PICC placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infant with RDS, prematurity. Check PICC placement.\n\n FINDINGS: A new left-sided PICC catheter tip projects over the expected\n position of the left brachiocephalic vessel. The lung volumes are better\n aerated than on the study of . The hyaline membrane disease has\n improved markedly. The cardiomediastinal contour is normal. A pleural\n effusion is not seen. The bowel gas pattern is non-obstructive. The\n endotracheal tube has been advanced somewhat and is past the thoracic inlet.\n\n"
},
{
"category": "Radiology",
"chartdate": "2104-09-10 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 771571,
"text": " 8:22 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: Rule out IVH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 29 weeks gestation\n REASON FOR THIS EXAMINATION:\n Rule out IVH\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Ex- 29 weeker, now six days of age.\n\n Ultrasound exam of the head demonstrates normally developed posterior fossa\n and midline structures. The ventricles are normal in size including the fourth\n and periventricular white matter is normal echotexture. There is a tiny mm in\n size, cystic structure adjacent to the anterior aspect of the choroid plexus\n within the left lateral ventricle, likely an incidental tiny choroid plexus\n cyst with hemorrhage less likely as this does not appear to be associated with\n the caudothallamic groove. No evidence of subependymal or intraventricular\n hemorrhage otherwise.\n\n IMPRESSION: Findings consistent with a tiny peripheral cyst associated with\n the left choroid plexus as described. Hemorrhage is less likely. Further\n followup would be helpful.\n\n"
},
{
"category": "Echo",
"chartdate": "2104-09-10 00:00:00.000",
"description": "Report",
"row_id": 72802,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease.\nStatus: Inpatient\nDate/Time: at 08:11\nTest: Portable TTE(Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report to be generated at .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-07 00:00:00.000",
"description": "Report",
"row_id": 1696021,
"text": "NPN 0700-1900\n\n\nRESP: remains intubatedon settings of 18/5 x 16. No\nchanges made in vent support today. Found that infant\nbecomes apneic and rides the vent s/p crying and desats to\n50-60's. She can require up to 50% FIO2 to recover. team\nnotified- may consider Caffeine soon.\n Breath sounds are clear and equal. + mild intercostal and\nsubcostal retractions. RR 50-60, occasionally up to 80's.\nA/P: Occasional apnea after crying, otherwise stable on\ncurrent vent support.\n\nF&N: Tf remain at 120cc/kg/d. Remains NPO as she completes\nher course of Indocin this afternoon.\n Pn (d10) + IL continue as ordered. PIV found leaking-\nreplaced in left leg and is infusing well.\n Abd is round, soft with active bowel sounds and no loops.\nAg 20.5cm. No stool passed this shift ( last stool >36hrs\nago). Voiding well-3.3cc/kg/hr x 8hrs so far.\nA/P: ?beginning enteral feeds tomorrow if remains stable s/p\nIndocin. Monitor IV.\n\nG&D: Temp fluctuating d/t phototherapy light. Infant is\nstable. Sh eis alert and active, irritable at times, but\nsettles w/ containment and pacifier. Will transfer to\nisolette tonight. HUS to be done early this week.\n\nPARENTS: Mom called for an update and both parents will be\nin to visit this afternoon for kangaroo care. family mtg\nset for Tuesday at 2pm.\n\nBILI: Remains under single phototherapy with a bili of\n8.6/.3/8.3. Tf unchanged. voiding well. No stool. Bili\nto be drawn in am.\n\nCV: Murmur heard x 1 ( but soft) and intermittent. Pulses\nare wnl. Pulses pressures 21-27. Cap refill- wnl. Will\ncomplete course of Indocin at 1600 this afternoon.\n HR120-170's, can drift in low 100's s/p crying. blood out\nremains at 4.3cc.\nA/P: Follow murmur closely. Continue to monitor vital signs\nclosely.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-07 00:00:00.000",
"description": "Report",
"row_id": 1696022,
"text": "NURSING ADDENDUM\n Infant continued to have drifts in HR and periods of apnea. Loaded with caffeine at 1800 and to begin maintenance dose tomorrow evening. No episodes of bradycardia.\n Infant was also kangarooed by Mom for ~1hr and tolerated it well. She was also transferred to an isolette on servo-control.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-19 00:00:00.000",
"description": "Report",
"row_id": 1696089,
"text": "NPN\n\n\nNPN#2 O=WT unchanged at 1435gms, TF at 150cc/k/d of ^cals of\nBM22 q4hrs over 70min..tol well, x1 small spit only, \nasp,,Abd exam benign, softly ronded , + active BS, -loops,\nvoiding qdiaper change, tr stool only, AG 21.0 A=tol feeds\nP= cont to monitor tol. of feeds and follow daily weights\n\nNPN#3 O= temp stable on servo in heated isolette, nested in\nsheepskin with boundaries in place, sl irritable with cares\nbut settles with containment, hands to face, likes pacifer,\nAF soft & flat, good tone, sleeping well inbetween cares A=\nAGA P= cont to assess & support dev needs\n\nNPN#4 O= no contact thus far from this shift A/P=\ncont to teach/ update & support\n\nNPN#8 & 9 O= remains in NCO2 with 200cc flow in mostly\n25-30% FIO2 maintaining O2 sats>94%, RR 40's-60's..occ 70's,\nLS clear & equal with baseling IC/SCR, infant with x1 brady\nto 64 with desat which was SR this shift thus far..cont on\ncaffeine as ordered A=occ spells/ cont to O2/flow\nrequirement P= cont to monitor # , frequency & severity of\nspells,cont to assess resp status for ^ WOB, cont per plan\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-19 00:00:00.000",
"description": "Report",
"row_id": 1696090,
"text": "Neonatology Attending\n\nDay 15\n\nRemains in RA after coming off cannula this morning. RR 40-70s. Mild retractions. Intermittent murmur. BP mean 49. Weight 1430 gms (uncahanged). TF at 150 cc/kg/d. On 22 cal BM. Gavaged over one hour. Stable temperature in servo-controlled incubator.\n\nImproving respiratory status. Monitoring cardio-respiratory status. Advancing to 24 cal/oz feeds today. in daily.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-19 00:00:00.000",
"description": "Report",
"row_id": 1696091,
"text": "Neonatology Fellow\nComfortable in incubator. Now in RA.\nAFSOF. Lungs - clear and symmetric. Mild retractions.\nCV - s1s2, regular, no murmurs. Warm and well perfused.\nNo rashes. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-19 00:00:00.000",
"description": "Report",
"row_id": 1696092,
"text": "NPN/0700-1900\n\n\n#2 FEN: TF=150cc/k/d; ^'d to BM24 today. Feeding time ^ to\n1hr20min. Infant continuing to have to small to moderate\nspits after feedings (associated with spells). Abd. soft,\nround, +BS. Girths=21-22cm. Voiding/no stools. Started on\nFe and Vit E today.\n\n#3 DEVELOPMENT: Infant nested on sheepskin in servo\nisolette; temps stable. Very irritable with cares, however\nsettling well b/t cares. . Sucking intermitt. on\npacifier.\n\n#4 : Mom called this AM for update. Both \nvisiting early evening. Dad . with cares;\nkangarooing infant. very and involved.\n\n#9 RESP: Received infant in 200cc flow NC, 21%. Dc'd->RA at\n0900. O2 sats have remained >96%. RR 40-60's. LSC. Mild\nIC/SC retractions. Infant has had 4 spells thus far (apneic\nand with spits) requiring mild to mod. stim. Remains on\nCaffeine.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-08 00:00:00.000",
"description": "Report",
"row_id": 1696023,
"text": "1. Resp: O: Infant received on the vent at settings of 18/5\nX 16. RR 30-50s, ls clear, color pink. FiO2 has been 21-23%\nwhen infant is sleeping and up to 40% after she has been\ncrying. She tends to be a bit apneic after crying and her HR\ncan drift to the 90s. She has been started on caffeine. Ls\nare clear, she is being sxned q 4 hours for a mod amt of\nsecretions which are just slightly tan in color. A: Stable\non the vent, now on caffeine. P: Monitor. Sxn prn. Gasses\nprn.\n\n2. F/N: O: Infant is NPO for now, on 120cc/k/d of TF\nconsisting of TPN and lipids infusing via a PIV. Her d/s was\n51 tonight, whereas it was 132 24 hours ago on the same\nfluids. NNP aware. Her PIV flushed well. Her abd is benign,\nshe is not stooling and voided 3.8cc/k/hr so far this shift.\nShe gained 5g. A: NPO, stable. D/s much lower than before.\nP: Monitor d/s. Otherwise monitor per NICU protocol.\n\n3. G/d: O: Infant is in a heated isolette, nestled in a\nsheepskin, under single phototx. She is sleeping peacefully\nand seems much happier tonight in the isolette than she was\non a warmer. She still escalates during cares, but calms\nquickly. A/P: Continue to support infant needs.\n\n4. Parents: No contact from the family so far this shift.\n\n6. Bili: O: Infant is under single phototx w/ her eyes\ncovered. She is not stooling. She is jaundiced. A bili was\nsent and is pending at this writing. A: Hyperbilirubinemia.\nP: Phototx as ordered. Check bili.\n\n7. CV: O: No murmur has been audible tonight. HR 120-130s.\nInfant's secretions have been white. Her FiO2 has been close\nto RA. A: Stable. P: Monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-08 00:00:00.000",
"description": "Report",
"row_id": 1696024,
"text": "RESPIRATORY CARE NOTE\nBaby #1 received intubated on vent settings 18/5 rate 16 FiO2 21-23%. Suctioned ETT for mod amt of white secretions and sm amt of tan secretions. Breath sounds are clear. Baby started on caffeine. Will cont to monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-08 00:00:00.000",
"description": "Report",
"row_id": 1696025,
"text": "Neonatology Attending\nDOL 4\n\n is on SIMV 18/5 x 16 in 21-30% FiO2. Caffeine bolus yesterday.\n\nMurmur not noted today. Indomethacin course completed 18 hours ago.\n\nWt 1300 (+50) on TFI 120 cc/kg/day PN-D10W. D-stick 51->67 overnight. Abdomen benign. Urine output 3.8 cc/kg/hr. No stools.\n\nBilirubin 8.6/0.4 under single phototherapy.\n\nA&P\nPreterm infant with surfactant deficiency, resolved PDA, hyperbilirubinemia.\n\nWe will continue to monitor cardiac status clinically, with plan for echocardiography if symptoms recur.\n\nPICC line will be placed today. TFI will be increased to 130 cc/kg/day. Continue to follow glucose closely. We will start trophic feeds today.\n\nContinue phototherapy and recheck bilirubin in 24 hours.\n\nFamily meeting planned for tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-08 00:00:00.000",
"description": "Report",
"row_id": 1696026,
"text": "Neonatology Fellow\nOn vent in incubator. 18/5 x 16, 35%FiO2. Active. Pink.\nETT/NGT in place. Lungs - good aeration, slightly coarse breath sounds. CV - s1s2, 2/6 systolic murmurs at LSB, radiates to back. Palmar pulses, bounding radial pulses. Abdomen - soft, flat, nontender. No edema. Neuro - nonfocal. Some bruising on arm and erythema in left axilla.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-20 00:00:00.000",
"description": "Report",
"row_id": 1696093,
"text": "NPN 1900-0700\n\n\n2 FEN\nCurrent weight 1.480 kg, up 30 grams. TF remain at\n150cc/kg/day of BM 24. Abd soft, girth stable. asp.\nSmall spit x's 2, feed time increased to 1 hr 20 .\nVoiding with each diaper change. No stool.\n\n3 G&D\nTemp stable in servo controlled isolette. Awake and active\nwith cares. Sleeps well between cares. Sucks\nintermittently on pacifier.\n\n4 \nDad kangarooing this infant at start of shift. Dad helped\nplace infant back in isolette. Will be in for visit\ntomorrow.\n\n8 As and B's\nTwo spells with apnea noted thus far. See flow sheet for\nresults. Continues on caffiene.\n\n9 Resp\nRemains in RA with sats greater than 95%. RR 40-60's. Lung\nsounds cl/=. Mild inter/subcostal retractions noted.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-20 00:00:00.000",
"description": "Report",
"row_id": 1696094,
"text": "Neonatology Attending\nExam AF soft, flat, clear bs, no murmur, soft abd, + bs, no hsm, active and \n\nI met updated them and discussed potential transfer to . They are interested in a tour. They are a little nervous about transfer and will consider it and get back to staff.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-20 00:00:00.000",
"description": "Report",
"row_id": 1696095,
"text": "Neonatology Attending\n\nDOL 16 CGA 32 weeks\n\nStable in RA. 9 A/B. Most associated with feeds and GER. On caffeine.\n\nOn 150 cc/kg/d BM 24 over 90 . On Vit E and iron. Voiding. . Wt 1480 grams (up 50).\n\nHUS normal.\n\n visiting. Initial maternal transfer from .\n\nA: Doing well. Spells secondary to immaturity and GER. Tolerating feeds and advancing calories.\n\nP: Monitor\n Increase to 26 cals\n Discuss transfer to with \n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-20 00:00:00.000",
"description": "Report",
"row_id": 1696096,
"text": "NPN/0700-1900\n\n\n#2 FEN: TF=150cc/k/d; ^'d to BM26 today. Feeding time ^'d\nto 2hrs; infant cont. to have large spits after feedings.\nV/S. Abd. benign. +BS. No loops. Girths-21cm. V/S.\nRemains on Vit E and FE.\n\n#3 DEVELOPMENT: Received infant nested on sheepskin in servo\nisolette. Temps stable. Active with cares; sleeping well\nb/t. Less irritable than yesterday. . Plan to\nswaddled infant in air isolette after kangarooing this\nafternoon.\n\n#4 : Mom and dad visiting this afternoon. Updated at\nbedside by team. Mom . with cares. Kangarooed\ninfant x 2hrs; infant tolerating well.\n\n#8 Apnea: No spells thus far this shift. Remains on\nCaffeine.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-21 00:00:00.000",
"description": "Report",
"row_id": 1696097,
"text": "Nursing Note\n\n\n#2O: Wt.up 30g on 150cc/kg/d BM26, q 4 hr. feeds. Belly\nsoft, full, voids qs, no stool. . asp. and 1 sm. spit.\nFeeds over 2 hrs. On reflux prec.\n#3O: In air isolette with stable temp. Active and \nwith cares, does some sucking on pacifier.\n#4O: No contact.\n#8O: Numerous spells this shift, most with apnea some req.\nstim. NNP, R.Buck notified and infant was bolused with\nCaffeine and maintenance dose has been increased, HOB\nelevated.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-06 00:00:00.000",
"description": "Report",
"row_id": 1696014,
"text": "NPN 0700-1900\n\n\nRESP: Received infant intubated on settings of 18/5 x 18.\nFIO2-30%.\n8AM: cap gas-7.33/40- rate weaned to 16.\n Breath sounds - clear but diminisihed- aeration improved\nthroughout the day. Rr 40-70's with mild to moderate\ni/c-s/c retractions.\n Sxn'd x 3 for small to large amounts of frank red blood\nfrom ETT. Team aware and infant examined. Murmur\nre-appeared in afternoon- Indocin begun at 1530.\nA/P: Will obtain cap gas this evening. Follow resp status\nclosely. Monitor secretions.\n\nF&N:TF-increased to 120cc/kg/d. Remains NPO w/ beginning\ncourse of Indocin. Abd is round and soft with hypoactive\nbowel sounds. Ag 20.5cm. No stool passed. Voiding well.\n PN(D10) ( IL to begin this evening) infusing well via PIV.\n D/s-99.\nA/p: Lytes this evening\n\nG&D: Temp98.4-99.3 on open warmer- warmer temp weaned x 1.\nInfant is alert and irritable at times. Responds well to\ncontainemnt and takes pacifier occasionally. Positioned side\nto side. Labile w/ cares and after crying.\n\nParents: Dad called for an update and then visited infants\nwith family. Both parents will visit this afternoon.\n\nSEPSIS: Blood cx remains negative to date. No clinical\nsigns of sepsis. received last dose of Amipicillin at\n1100and abx were d/c'd.\n\nBILI: 24hr Bili: 6.0/.3/5.7. infant is slightly jaundiced\nwith bruising on back andextreimites. Single phototherapy\nstarted at 1000. Bili to be drawn this evening.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-07 00:00:00.000",
"description": "Report",
"row_id": 1696015,
"text": "1.Resp: O: Infant received on the vent at settings of 18/5 X\n16 w/ FiO2 23-27% when she is quiet. She requires higher\nFiO2 when she is crying. Ls clear, Sxned q 4 hours for a\nsmall to mod amt of cloudy secretions. RR 50-60s. ABG showed\npH = 7.31, pCO2 = 22 but she had been crying vigorously.No\nchanges were made. No bradys. A: Stable on the vent when\nquiet. P: Monitor. Gasses prn. Sxn prn.\n\n2. F/N: O: Infant is on TF = 120cc/k/d of TPN and lipids\ninfusing via a PIV. Lytes were sent and are pnd at this\nwriting. She is currently NPO. Abd is benign w/ good bs, no\nstool. She is voiding 2.9cc/k/hr. D/s was 132. She lost 85g.\nA: NPO, on TPN and lipids. P: Check results of labs.\nContinue to monitor per NICU protocol.\n\n3. G/d: O: Temp stable on servo on a heated warmer. Infant\nis nestled on a sheepskin w/ bounderies. She is able to be\nquiet but rapidly escalates to hysterical w/ cares. She\ncalms w/ containment. A/P: Continue to support infant needs.\n\n4. Parents: O: Parents were up to visit, take pictures and\nread to their infants. They were asking appropriate\nquestions and seem very pleased with their babies. A:\nLoving, involved parents. P: Continue to support.\n\n5. Sepsis: O: Infant is no longer on antibx. VSS. A: S/p 48\nhours r/o. P: D/c problem.\n\n6. Bili: O: Infant is under single phototx w/ her eyes\ncovered. Her bili is now 8.6, up from 6.0 yesterday. She is\nnot yet stooling and is jaundiced. A: Hyperbilirubinemia. P:\nPhototx as ordered. Monitor bili.\n\nCV: O: Infant is on indocin for a presumed PDA. She is\nstable on the vent and no murmur is audible. Her secretions\nhave been clear. Pulses are full, pp are 16-32. A: Infant\nseems to be responding well to indocin. P: Continue w/\ntherapy as ordered. Monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-16 00:00:00.000",
"description": "Report",
"row_id": 1696078,
"text": "Rehab/OT\n\nMet with at the bedside. Discussed the role of OT, premie behavior, and ways to optimize her comfort during the NICU stay. Recommended dark blankets to cover the isolette. OT to follow. Care plan / full observational eval to be completed on thursday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-17 00:00:00.000",
"description": "Report",
"row_id": 1696079,
"text": "nicu npn 1900-0700\n\n\nA's&B'sO: No spells to time this shift,baby remains on\ncaffeine.O2 sats 96-100%.\n\n#2 FEN O: Tf remain at 150cc/k/d.Tolerating advancing feeds\nof bm20 well,at 105/k.IV of pn, infusing through PICC line\nwell. Baby is voiding and stooling, and abdominal exam is\nbenign. NoSpits,minimal ngt aspirates.\n\n#3 DEV O: Temps are stable, nested onsheepskin,in servo\nisolette.Baby is and active with cares,sleeps well in\nbetween cares, takes pacifier for comfort. Fontanells are\nsoft and flat.\n\n#4 Parenting O: Nocontact overnight.\n\n#6 O: Lights shut off this am, colorpink, slightly\njaundiced. Level to be checked Thurs.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-17 00:00:00.000",
"description": "Report",
"row_id": 1696080,
"text": "1 Alt resp status\n8 A's&B's\n\nREVISIONS TO PATHWAY:\n\n 1 Alt resp status; d/c'd\n 8 A's&B's; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-17 00:00:00.000",
"description": "Report",
"row_id": 1696081,
"text": "Neonatology Fellow\nComfortable in incubator. Pink in RA. No distress. AFSOF. Lungs - clear and symmetric. Only mild retractions. CV - s1s2, regular, no murmur. Abdomen - active bowel sounds, soft, flat, nontender. No rashes. No edema. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-17 00:00:00.000",
"description": "Report",
"row_id": 1696082,
"text": "Neonatology Attending\n\nDay 13\n\nBack on nasal cannula oxygen at 300 cc/min with 30% oxygen after cluster of bradycardia this morning. Remains on caffeine. RR 40-50s. wEight 1455 gms (+30). TF at 150 cc/kg/d. Enteral feeds of PE 20 at 120 cc/kg/d. PN via PICC. Phototherapy discontinued this morning. Plan to recheck in morning. Stable temperature in incubator. in daily.\n\nImmaturity of breathing control still evident. Will continue with blended nasal cannula oxygen and optimize caffeine dosing. Tolerating feeding advance well. Will continue to advance to full feeds. up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-17 00:00:00.000",
"description": "Report",
"row_id": 1696083,
"text": "NPN/0700-1900\n\n\n#2 FEN: TF=150cc/k/d. Enteral feeds of PE/BM20 at\n120cc/k/d; to be ^'d to 135cc/k/d this afternoon (^'ing\n15cc/k ). IVF of PN(D12.5) infusing through PICC.\nGavage time ^'d to 1hr; mod. spits x2. Abd soft, full, +BS.\nNo loops. Girth=22cm. V/S.\n\n#3 DEVELOPMENT: Infant nested on sheepskin in servo\nisolette. Temps stable. Active and with cares;\nirritable at times. Sucking occass. on pacifer. .\n\n#4 : Mom called x1 this AM for update. will\nbe in to hold later this afternoon.\n\n#6 : Single phototx dc'd this AM; rebound ordered for\nAM.\n\n#9 RESP: Infant placed back into NC this AM following a\ncluster of spells requiring stim and O2 (see nsg flowsheet).\nRemains in 300cc flow, 21-30% throughout day. RR 40-60's.\nLSC. Mild IC/SC retractions. Caffeine dose ^'d.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-08 00:00:00.000",
"description": "Report",
"row_id": 1696027,
"text": "Neonatology Fellow\nProcedure Note: PICC placement\n2 mcg/kg of fentayl administered for analgesia/sedation. CVR and cont sat monitor. Left arm prepped and draped using sterile technique. 23 Gauge introducer placed in branch of antecubital vein. 1.9 french catheter inserted vua introducer to 11 cm and secured with tegaderm and steri-stripps. Tip of line at left subclavian/inominate vein junction on CXR. Patient tolerated procedure well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-08 00:00:00.000",
"description": "Report",
"row_id": 1696028,
"text": "Respiratory Care\nPt recieved on SIMV, rate of 16, pressures of 18/5, with the fio2 21 to 28%. Pt suctioned for a sm amt of white to cloudy secretions. Pt's respiratory rates 30's to 60s'. Pt's ventilator rate decreased from 16 to 14 based on good blood gas results.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-08 00:00:00.000",
"description": "Report",
"row_id": 1696029,
"text": "NPN 7a-7p\n\n\nResp: IMV 18/7 x14bpm. Weened rate after CBG 7.39/38. FiO2\n21-30%. LS clear, RR 40-70s. Suctioning q 3-4hrs for cloudy\nsecretions and once for mod amount of new blood (? second\nsmall pulm hemorrage). Intermittent tachypnea followed by\napnea. One brady this shift. Recieving caffiene. Stable on\ncurrent resp support, may try on CPAP once PDA issues\nresolve.\n\nFEN: TF increased to 130cc/k/d. TPN D10 w/ IL. PICC placed\ncentrally in Left arm. DS 68. Abd benign, BS active. UO:\n3.5cc/k/hr this shift. No stools. Due for lytes in am.\nStable, con't as planned and monitor. consider starting\nfeeds tomorrow if echo is benign.\n\nG&D: Alert and active w/ cares, irritable and arching at\ntimes. Recieved fentanyl 2mcg/k for pain and sedation during\nPICC placement. Nested in sheepskin in servo isolette, temps\nstable. HUS thursday. Con't to support dev needs.\n\nFamily: Mom and dad in to visit. come back to hold #2\nlater. Will not hold #1 today because she has been out and\nstressed by PICC placment and echo. Asking questions, met w/\nfellow. Appropriate. Family meeting scheduled for 2pm\ntomorrow. Con't to support and update as needed.\n\nBili: Remains under single phototherapy w/ eye covers on.\nCheck level in am.\n\nCV: Pink and well perfused. Soft murmor reappeared this\nmornign. Pulses full w/ palmar pulses. Precordium quiet.\nSuctioned ETT for small new blood. BP means 38-46, pulse\npressures not wide. blood out 5cc. Echo done today to check\nif PDA remains open. Results pending at this time. Stable,\ncon't to monitor closely.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-09 00:00:00.000",
"description": "Report",
"row_id": 1696030,
"text": "RESPIRATORY CARE NOTE\nBaby #1 received intubated on vent settings 18/5 rate 14 FiO2 21%. Suctioned ETT for sm amt of blood tinge secretions. Breath sounds are clear. Stable on current vent settings cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-09 00:00:00.000",
"description": "Report",
"row_id": 1696031,
"text": "NPN\n\n\n#1 Resp- Remains on vent in 21-23% o2,18/5x14. BS clear\nafter sxn q 4-8 hrs for sm-mod amts of old bl tinged.RR=\n50-70's. Mild retractions.A=No change in settings\ntonight.P=Monitor.\n#2 F/N- Abd soft,+bs, no loops. Remains NPO.TF=\n130cc/kg/day. TPN+ IL infusing per patent PIC line.Voiding\nin adeq amts No stool yet tonight.Wt up 45gms.Labs to be\ndrawn in AM.\n#4 Mom+ Dad here to visit x1.Changed diaper.Updated\non pt condition.A= Involved. p= Support.\n#6 Bili- Remains under single phototx w/eye shields on. A=\nHyperbili.p= draw bili in AM.Phototx as ordered.\n#7 CV- +m,HR=130-160.B/P w/m's in the 40's.Neg PDA on\necho.Remains on caffeine.No A's or B's yet tonight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-21 00:00:00.000",
"description": "Report",
"row_id": 1696098,
"text": "Neonatology Attending\n\nDay 17\n\nRemains in RA. Sats high 90s. RR 40s. Mild retractions. Received caffeine bolus earlier this morning for increasing episodes of bradycardia. No murmur. Has had only one quickly self-resolving episode since then. Weight 1510 gms (+30). On BM 26 at 150 cc/kg/d. Fewer spits with extended time for gavage feeds. Benign abdomen. Stable temperature in air-controlled incubator.\n\nExacerbaton of breathing control immaturity responsive to increase in methylxanthine therapy. Will continue to monitor closely. Gaining weight well. Family up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-21 00:00:00.000",
"description": "Report",
"row_id": 1696099,
"text": "NPN/0700-1900\n\n\n#2 FEN: TF=150cc/k/d of BM26, promod added today. Gavage\ntime ^'d to 2hr15min (from 2hrs). Infant had one large spit\ntoday during kangaroo cares. Abd. soft, round +BS. Soft\nloops noted x1. Voiding/trace stool x1. Glycerin supp.\ngiven with last cares.\n\n#3 DEVELOPMENT: Infant swaddled in air isolette. Isolette\ntemp weaned accordingly. Infant active and with\ncares; sleeping well b/t. .\n\n#4 : Mom and dad visiting during afternoon. Dad\n. with infants cares. Held infant x20 only d/t\ninfant having large spit and brady's associated with it.\n will be in again to visit tomorrow.\n\n#8 APNEA: Infant had four documented brady's this shift,\nhowever had additional QSR HR drifts to 80-90's not observed\nby this nurse. Appear to be associated with feedings/spits\nand apnea. Remains on Caffeine.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-22 00:00:00.000",
"description": "Report",
"row_id": 1696100,
"text": "Nursing Note\n\n\n#2O: Wt up 40g on 150cc/kg BM26 with promod. Spitting\ncont. with feeds over 2 1/2 hrs. Placed on 3 hr. feeds and\nafter 1, has had no spits. Belly is soft with +BS, no\nloops, did have a stool after a supp., voids qs.\n#3O: In isolette on air mode with stable emp. Quite mellow\nwith cares tonight. Occ. sucking on pacifier.\n#4O: dad called early in the shift to see about spits and\nspells. Dad was updated and called early this am.\n#8O: Decreased # of spells tonight but does cont. to have\nthem, all with apnea and most requiring stim. New dose of\nCaffeine given.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-22 00:00:00.000",
"description": "Report",
"row_id": 1696101,
"text": "Neonatology Fellow\nComfortable in incubator. Swaddled. Responds to exam. Active. AFSOF. Lungs - clear and symmetric, no distress. CV - s1s2, reg, no murmur. Warm and well perfused. Active bowel sounds. Soft, nontender, nondistended abdomen. Skin - no rashes. Neuro - nonfocal.\nGiven increased spells, but reassuring exam, will put back on NC - flow at 200cc. Caffeine bolused and increased over the weekend. If spell persist will evaluate further.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-22 00:00:00.000",
"description": "Report",
"row_id": 1696102,
"text": "Neonatology Attending\n\nDay 18\n\nPlaced on nasal cannula at 200 cc/ because of 8 bradycardic events since midnight. Caffeine bolused two days ago. HR 150-170s. BP mean 52. Weight 1550 gms (+40). TF at 150 cc/kg/d. On BM 26 with Promod. Now on three hourly feeds because of frequent spitting. Benign abdomen. Minimal aspirates. Passed stool with glycerin suppository. Stable temperature in incubator. in daily.\n\nIncreased apnea. Will continue to monitor closely on nasal cannula. Will proceed to CPAP, as well as evaluate for infection, if persists. Gaining weight well. Will require more calories but in view of spits, will wait another day. Family up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-07 00:00:00.000",
"description": "Report",
"row_id": 1696016,
"text": "Infant pCO2 was really 41, not 22 as reported by me above.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-07 00:00:00.000",
"description": "Report",
"row_id": 1696017,
"text": "Respiratory Care\nBaby cont on 18/5, R 16 with 02 req 22-27%. BS clear. Sxn for sm-mod amts cldy sec (slightly bl-tinged x1 @ ). ABG: 7.31/41/37/22/-5; no changes made. (Infant crying when gas drawn.) Rr mostly 50's-60's with mild- mod(at times) IC/SCR. Rc'd 2nd dose Indocin tonight. Will cont to follow closely, support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-07 00:00:00.000",
"description": "Report",
"row_id": 1696018,
"text": "Neonatology Attending\nDOL 3\n\n is on IMV 18/5 x 16 in 22-27% FiO2. ABG 7.31/41/37/22.\n\nNo murmur after 2 doses of indomethacin (last dose scheduled for 4pm today). BP 52/31 (41).\n\nEBL 4.3 cc total.\n\nWt 1295 (-85) on TFI 120 cc/kg/day PN-D10W. Remains NPO for PDA/indomethacin course. D-stick 132. 136/5.1/105/20. Abdomen benign. Urine output 2.9 cc/kg/hr in the past 8 hours.\n\nUnder single phototherapy with bilirubin 8.6/0.3 last night.\n\nA&P\nPreterm infant with surfactant deficiency, resolving PDA, hyperbilirubinemia.\n\nWe will plan to continue on current ventilatory support in light of some lability with handling.\n\nContinue course of indomethacin and maintain bigilance for signs of recurrence of PDA.\n\nSerum bilirubin will be rechecked tomorrow morning.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-07 00:00:00.000",
"description": "Report",
"row_id": 1696019,
"text": "Neonatology Attending\nAddendum - Physical Examination\n\nHEENT AFSF\nCHEST mild retractions with spont breaths; good excursion with IMV; good bs bilat; no crackles\nCVS well-perfused; RRR: femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; bs active; no organomegaly\nCNS active, responsive to stim; tone decreased but AGA; moving all limbs symm\nINTEG normal\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-07 00:00:00.000",
"description": "Report",
"row_id": 1696020,
"text": "Respiratory Care\n remains on SIMV. Fio2 .25-.30, bs clear, rr 50-60 with mild retractions. No vent changes made today. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-18 00:00:00.000",
"description": "Report",
"row_id": 1696084,
"text": "NICU NPN 1900-0700\n\n\n#2 FEN O: Tf remains at 150cc/k/d. Tolerating now full feeds\nof bm/pe20well. Abdominal exam benign,voiding and ,\n ngt aspirates, no spits. PICC line heplocked.\n\n#3 G&D O: Temps are stable,nested on sheepskin,in servo\nisolette. Babyis and active with cares,sleeps well in\nbetween cares. Fontanells are soft and flat. Takes pacifier\nfor comfort.\n\n#4 Parenting O: No contact overnight.\n\n#6 O: is pending.\n\n#8 A's&B's O: baby on caffeine, nospells totime this\nshift.\n\n#9 RespO: Baby in nco2 200cc;s 21-25% during the\nnight. O2 sats 94-99%, with occasional drifts to the high\n80s.LS cta, baselins mild retradtions, rr 40-60's\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-18 00:00:00.000",
"description": "Report",
"row_id": 1696085,
"text": "Neonatology Fellow\nComforatble in incubator. NC - 300cc, 30%fiO2. Feeding tube in place. Lungs clear and symmetric. CV - s1s2, regular, no murmur. Warm and well perfused. Abdomen - soft, nontender, nondistended. No rashes. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-18 00:00:00.000",
"description": "Report",
"row_id": 1696086,
"text": "Neonatology Attending\n\nDay 14\n\nRemains on nasal cannula at 200 cc/ flow with 25% oxygen. Mild retractions. RR 40-70s. Had three bradycardic episodes overnight. BP mean 47. Weight 1430 gms (-25). TF at 150 cc/kg/d of BM 20. Benign abdomen. No spits. Passing stool. Rebound bilirubin 6.2/0.3. Stable temperature in servo-controlled incubator.\n\nAdequate respiratory status. Monitoring closely for immaturity of breathing control. Will advance calories. Bilirubin acceptable. up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-18 00:00:00.000",
"description": "Report",
"row_id": 1696087,
"text": "NPN 0700-1900\n\n6 Hyperbilirubinemia\n\n1. FEN: TF remain at 150 cc/kg/day of BM20/PE20. Tolerating\nfeedings well; abd exam benign, AG stable, one sm. spit, and\n asp. D/S 72. Voiding qs and no stool thus far. P:\nCont. to support nutritional needs and increase cal to 22\nthis evening.\n\n2. G/D: Temp stable in servo-isolette. Infant is nested in\nsheepskin with boundaries in place. and active with\ncares. Settles well in between cares. Appropriately brings\nhands to face and sucks on pacifier to comfort self. AFSF.\nAGA. P: Cont. to support developmental needs.\n\n3. : Mom called x 1. She was udpated on infant's\ncondition and plan of care. Asking appropriate questions.\nWill be in at 1700 to visit. , involved . P:\nCont. to support and udpate .\n\n4. Resp: Infant remains in NC O2 200 cc flow requiring\nbetween 25-35 % FiO2 to maintain her O2 sats greater than\n90% . Lung sounds clear/=. IC/SCR noted. RR 50-70's. Two\nspells noted thus far this shift - please see flowsheet for\nfurther details. P: Cont. to monitor resp. status and\nintervene as required.\n\n\n\nREVISIONS TO PATHWAY:\n\n 6 Hyperbilirubinemia; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-18 00:00:00.000",
"description": "Report",
"row_id": 1696088,
"text": "Rehab/OT\n\nMet with at bedside. Reviewed infant stress signs and coping skills. have brought in dark blankets to darken isolettes. Loaned heartbeat box for calming auditory sounds. OT to follow for developmental care interventions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-13 00:00:00.000",
"description": "Report",
"row_id": 1696058,
"text": "Neonatology Attending Note\nDay 9\n\nCPAP NP6, RA. RR30-50s. Suction sm secretions. On caffeine. 2 A&Bs past 24h. +int murmur, none heard today. Mean BP 40. Pink and well perfused. HR 140-160s.\n\nWt 1345, up 5. TF 150 cc/k/day. 120 PN D11, 30 /k BM20. Adv enteral feedings 10/k/. Tolerating well.\n\nIn air isolette.\n\nd/s 119\nu/o 4.4, no stool\nRebound bili 7.1/0.4\n\nPlan:\n1. Wean CPAP to 5.\n2. Monitor AOP.\n3. Continue feeding advance.\n4. Check another bili Monday.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-13 00:00:00.000",
"description": "Report",
"row_id": 1696059,
"text": "NPN 7a-7p\n\n\nResp: NP CPAP decreased from , FiO2 21%. LS clear, mild\nIC/SC retractions, RR 30-50s. 2 bradies so far this shift,\nmild stim for HR 55, sats 88%. Recieving caffiene.\n\nFEN: TF 150cc/k/d. Currently 110cc/k of PN D11 w/ IL and\n40cc/k of BM 20; 9.6cc gavaged over 15min. Abd benign, BS\nactive. No spits, min aspirates. Girth stable at 21cm.\nVoiding qs, no stools. Tolerating feeds well, con't as\nplanned and monitor. Plan to increase feeds 10cc/k .\n\nG&D: Alert and active w/ cares, very irritable but settles\nb/w feeds. Sucks on pacifier. Temps stable swaddled in low\nair isolette. AGA, con't to support dev needs.\n\nFamily: Dad called for update. Planning to be in to kangaroo\nat 5pm. Con't to support and update as needed.\n\nBili: Rebound this am 7.1/0.4. Phototherapy remains off,\nrecheck rebound monday morning.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-13 00:00:00.000",
"description": "Report",
"row_id": 1696060,
"text": "Respiratory Therapy\nWeaned CPAP from 6 to 5 today. FiO2 0.21. RR 30-50. On caffeine with occ spells. Continue with CPAP as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-14 00:00:00.000",
"description": "Report",
"row_id": 1696061,
"text": "Respiratory Care\nBaby continues on NPCPAP 5, 21%. BS clear. Sxn for sm amt white sec. RR 30's-50's. One mild stim brady as of this writing. On caffeine. Plan cont CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-04 00:00:00.000",
"description": "Report",
"row_id": 1695997,
"text": "Admission Note\n29-5/7 week GA female admitted with respiratory distress\n\nMaternal Hx - 36 year old G2P0->2 woman with PMHx notable for uterine fibroids and infertility. Prenatal screens were as follows: blood group B positive, antibody negative, HBsAg negative, RPR non-reactive, rubella immune, GBS unknown.\n\nPregnancy Hx - LMP for and EGA 29-5/7 weeks. In utero insemination pregnancy with diamniotic dichorionic twin gestation. Pregnancy complicated by gestational diabetes mellitus, initially controlled with diet but requiring insulin for the week prior to delivery. Cervical shortening with preterm labor at 22 weeks gestation, leading to admission to . Betamethasone course completed at 26 weeks (). Fetal survey normal in both twins. On MgSO4, but noted to have bulging membranes with presenting foot, and progressed to cesarean section for breech/breech presentation, under spinal anesthesia. Membranes ruptures at delivery, yielding clear amniotic fluid. No maternal fever or fetal tachycardia intrapartum.\n\nNeonatal course - Infant emerged with good tone and cry. Orally and nasally bulb suctioned for copious clear secretions, then tactile stim, brief facial CPAP and free flow oxygen. Subsequently pink with mild retractions. Transferred uneventfully to NICU.\n\nPE\ninfant with exam consistent with 29 weeks gestation\nWT 1435g (75th %ile) LN 40cm (50-75th %ile) OFC 28.5cm (50-75th %ile)\nhr 168 rr 74 T 97.6 BP 51/33 (41)\nHEENT AFSF; non-dysmorphic; palate intact; moderate nasal flaring prior to CPAP; neck/mouth normal\nCHEST moderate intercostal retractions; fair bs bialt; few scattered crackles\nCVS well-perfused; RRR; femoral pulses normal; S1S2 normal; no murmur\nABD soft, non-distended; no organomegaly; no masses; bs active; anus patent; 3-vessel umbilical cord\nGU normal female genitalia\nCNS active, responsive to stim; tone AGA; moving all extremities symm; suck/root/gag/grasp/Moro normal\nINTEG normal\nMSK normal spine/limbs/hips/clavicles\n\nINV\nd-stick 73\n\nImpression\n29-5/7 week GA female with\n1. Moderate respiratory distress, likely secondary to surfactant deficiency. Differential also includes retained fetal lung fluid, infection, and other less common pathologies.\n2. Sepsis risk, based on preterm labor with unknown maternal GBS colonization status.\n3. Risk for hypoglycemia, based on maternal gestational diabetes mellitus.\n4. Risk for developmental dysplasia of the hip, based on female gender and breech presentation.\n\nPlan\nInfant has been placed on CPAP. Respiratory status will be monitored closely and further investigations including chest radiograph and blood gas will be obtained if symptoms persist or worsen over the next 3 hours. Consideration will be given in that case to intubation and surfactant administration. In the interim, we will maintain oxygen saturation 88-92%.\n\nCardiac examination is currently unremarkable. We will maintain vigilance for clinical signs of PDA. Mean blood pressure will be maintained > 34 mmHg.\n\nInfant\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-04 00:00:00.000",
"description": "Report",
"row_id": 1695998,
"text": "Admission Note\n(Continued)\nwill remain NPO until cardiorespiratory stability has been established. IV maintenance fluids will be given in the interim, with close attention to glucose levels.\n\nA CBC and blood culture have been drawn, and broad spectrum antibiotic therapy started for anticipated course of 48 hours pending clinical symptoms, WBC and culture results.\n\nInfant will require ophthalmological and cranial ultrasound screening per routine, as well as hip ultrasound screening in light of female breech presentation.\n\nParents have been updated regarding current status, diagnostic considerations and our management plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-14 00:00:00.000",
"description": "Report",
"row_id": 1696065,
"text": "Nursing note\n\n\n#1O: Infant received on NPCPAP5 in room air and has remained\nthere all day. Slight increase O2 with cares, no desats 1\nspell. On Caffeine qd. Br. sounds clear, with mild\nretractions. Sx x 1 for sm. amt. secretions.\n#2O: Total fluids at 150cc/kg/d PN increased to D12.5 and\nlipids at 90cc/kg infusing without issues thru PIC. Feeds\nincreased to 60cc/kg of BM, q 4 hrs. Belly soft, voiding\nand had a very lg. mec. stool. Min. asp. and no spits.\n#3O: In air mode isolette with stable temp. Quite irritable\nwith cares but calms once left alone. with dad\nfor 2 hrs. and did very well.\n#4O: in and updated, both pleased that she is doing\nso well. Dad held daughter today.\n#6O: level done and results pnd. Color slightly\njaundiced.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-14 00:00:00.000",
"description": "Report",
"row_id": 1696062,
"text": "NPN 1900-0700\n\n#1.Respiratory\n\nInfant remains stable on NPCPAP 5cm in RA.LSC=, RR mainly\n30's-50's, mild inter/subcostal retractions noted.\nOn Caffeine, brady x1 as per flowsheet. Suctioned x2 as per\nflowsheet.\n\n#2.Fluid and Nutrition\n\nInfant's wt. 1360 gms (+15). Total fluids 150cc/k/day; IVF's\nat 100cc/k/day: receiving PN of D11 with lytes and IL as per\nflowsheet. Enteral feeds at 50cc/k/day (BM20). Feeding plan\nfollowed; increased by 10cc/k/day at 0500. Abd. soft, no\nloops, B.S.(+), no emesis. Voiding 2.9cc/k/day, no stool.\nAbd. girth stable, blood sugar 112. Minimal aspirates.\n\n#3.Growth and Development\n\nInfant awake, active and irritable with care periods. She\ndoes calm down once cares are complete. Responds well to\nswaddling and pacifier. Temp. stable in the heated isolette\nwith infant swaddled. , .\n\n#4.Parenting\n\nInfant's father called once and was updated on the twins'\nstatus by this nurse. He stated that they (the )\nwould be in early Sunday afternoon.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-14 00:00:00.000",
"description": "Report",
"row_id": 1696063,
"text": "Neonatology\nDoing well. Remains on CPAP RA. Comfortable appearing. Few spelsl on caffeine. Murmur. as before.\n\nWt 1460 up 15. TF at 150 cc/k/d of d11 at 100 cc/k/d. Advancing on feeds without difficulty. PN top be advanced.\n\nRebound bili to be rechecked in am.\n\nTemp stable in air isollette.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-14 00:00:00.000",
"description": "Report",
"row_id": 1696064,
"text": "Respiratory Care\nBaby continues on cpap5, fio2 21%, bs clear, RR 30-50's, on caffeine, had one spell on shift so far. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-15 00:00:00.000",
"description": "Report",
"row_id": 1696066,
"text": "NURISNG PROGRESS NOTE\n\n\n1. Infant remains on NP CPAP of 5cms, on RA. RR-40s-50s. LS\nclear and equal, mild subcoastal and intercoastal rtxns\nnoted upon exam. Infant remians on caffeine as ordered. No\nspells thus far. Cont to monitor infant for any signs of\nincreased WOB.\n\n2. Present wgt: 1.390g, up 30g. TF remain @ 150cc/kg/d. TPN\nD12.5 and IL infusing @ 90cc/kg via central picc line\nwithout incident. Enteral feeds of BM20 @ 60cc/kg are being\ngavaged over 20mins on pump. Sm spit, max aspirate of\n3.0ccs, Dstx-106. Abd soft, flat, pink, no loops. No stool\nthus far, vdg adaquate amts. U/O for 24hrs was 2.8ccs/kg.\nPlan: Cont to wean IVF and increase enteral feeds by\n10cc/kg/ as tolerated.\n\n3. Infant is presently nested with boundaries in a servo\ncontrolled isolette. Temps remain stable. Alert and active\nwith cares, extremely irritable when disturbed. Sucking\noccassionaly on pacifier to soothe. Cont to encourage dev\nneeds.\n\n4. No contact with thus far.\n\n6. Infant restarted on single phototherapy this pm for a\nrebound level of: 9.3/0.4/8.9. Infant appears sl/\njaundice, no stool thus far. Cont to monitor infants skin\ncolor and hyperbilirubin levels.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-15 00:00:00.000",
"description": "Report",
"row_id": 1696067,
"text": "Respiratory Care\nBaby continues on NPCPAP 5, 21%. BS clear. Sxn for sm-mod amts secretions as per flowsheet. RR 40's-60's with IC/SCR. One mild stim brady recorded. On caffeine. Plan cont CPAP @ present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-15 00:00:00.000",
"description": "Report",
"row_id": 1696068,
"text": "Neonatology Fellow\nNot in open crib - in incubator.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-15 00:00:00.000",
"description": "Report",
"row_id": 1696069,
"text": "Neonatology Fellow\nActive, nondistressed in open crib. Under phototherapy. NP CPAP at 5 cm, RA. AFSOF. Feeding tube in place. Lungs - mild retractions, clear and symmetric. CV - s1s2, regular, no murmur. Warm and well perfused. Abdomen - bowel sounds, soft, nondistended, nontender. No edema. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-12 00:00:00.000",
"description": "Report",
"row_id": 1696052,
"text": "Neonatology Attending\n\nDay 8\n\nRemains on CPAP with fio2 0.21. RR 40-60s. No bradycardia on caffeine. Intermittent soft murmur. HR 130-160s. BP mean 43. Last hct 38.8. Weight 1340 gms (-20). Enteral feeds of BM at 10 cc/kg/d. PN and lipids at 140 cc/kg/d. Intermittent small gastric aspirates. Stable girth. Normal bowel sounds. Passing stools. Lytes 140/4.5/107/17. Blood gluocse 148. Urine output 4.6 cc/kg/hr. On single phototherapy. Bilirubin 6.2/0.4. Stable temperature in servo-controlled incubator.\n\nAdequate breathing control on current regimen. Will continue to monitor closely. Will wean CPAP to 5 cm H2O today and follow. Advancing breast milk infusion rate. Will discontinue phototherapy today and check bilirubin rebound.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-12 00:00:00.000",
"description": "Report",
"row_id": 1696053,
"text": "Respiratory Care\nBaby continues on cpap 6, fio2 21%, Bs clear, RR 40-50's, on caffiene, baby had one spell on shift so far. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-12 00:00:00.000",
"description": "Report",
"row_id": 1696054,
"text": "NPN 7a-7p\n\n\nResp: NP CPAP 6. FiO2 21%. RR 30-60s, LS clear, IC/SC\nretractions. Tube changed today, suctioned nares for large\nthick yellow secretions. 1 brady so far this shift, apneic,\nHR 59, mod stim. Stable in current resp support, con't to\nmonitor.\n\nFEN: TF 150cc/k/d. Currently recieving 130cc/k of TPN D11\nw/IL via PICC. 20cc/k of BM20; 4.8cc q 4hrs gavaged.\nIncreasing enteral feeds 10cc/k . Abd benign, BS active.\nNo spits, max asp 1.2cc brown old blood. NG tube remeasured\nand pulled back. Voiding qs, no stool this shift.\n\nG&D: Alert and active w/ cares, sleeping fair. Very\nirritable, often trying to pull out NP and NG. Temps stable\nnested in servo isolette, swaddled after phototherapy d/c'd,\nseems calmer now. Con't to support dev needs.\n\nFamily: Mom called x1. Updated by phone. Appropriate and\nasking questions. Planning to come in at 5pm to kangaroo.\nCon't to support and update as needed.\n\nBili: Phototherapy d/c'd at 10am for bili of 6.2/0.4. Check\nrebound tomorrow morning.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-13 00:00:00.000",
"description": "Report",
"row_id": 1696055,
"text": "NPN NOCS\n\n\n1. O: Remains on NPCPAP of 6 with FiO2 21%. LS clear.\nSuctioned for small secretions via NP tube. RR30-50's. No\nspells. A: Stable on CPAP. P: Continue to monitor.\n\n2. O: Wt up 5gms. TF at 150cc/kg. PN and lipids infusing\nwell via PICC. Feedings increased to 30cc/kg of BM20 gavaged\nover 10min q4hrs. Abd. benign. No spits. Min residuals.\nVoiding, no stools. DS stable. A: Tol feeds. P: Continue\nwith current plan.\n\n3. O: Alert,active and irritable with cares. Sleeps between\ncares. Sucking on pacifier. Temp stable in weaning air\nisolette. Swaddled. AFOF. A: AGA. P: Continue to support\ndev. needs.\n\n4. No contact from thus far this shift.\n\n6. Remains off phototherapy. Rebound bili sent and pending.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-13 00:00:00.000",
"description": "Report",
"row_id": 1696056,
"text": "NPN NOCS\nInfant had 1 A and B requiring mild stim(see nsg flowsheet for details).\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-13 00:00:00.000",
"description": "Report",
"row_id": 1696057,
"text": "Respiratory Care\nBaby remains on NP CPAP 6 21%.RR 30-50,stable night.Sx npt for sm cldy secs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-11 00:00:00.000",
"description": "Report",
"row_id": 1696048,
"text": "Nursing Progress Note\n\n\nRESP O/A: Infant remains on NP CPAP of 6. 21-28% FiO2 today.\nMaintaining sats 95-100%. LS clear/=, mild sc/ic retractions\nnoted. 3 spells noted thus far today; HR 50-60s w/ apnea,\nmild stim or self resolve. Caffeine bolus given this\nmorning. Sxn x1 for sm amts of cloudy secretions. P: Cont to\nmonitor for s/s of increased spells.\n\nF&N O/A: TF increased to 150cc/k/d. Currently TPN D12 @\n120cc/k/d w/ lipids. IVF D12.5 w/ 2NaCl & 1KCl @ 20cc/k/d.\nEnteral feeds restarted today @ 1300 of 10cc/k/d. Infant\nreceives 2.4cc of BM20 q4h pg. No current plans to increase\nfeedings, will re-evaluate tomorrow. Abdomen soft/round, pos\nBS, no loops, girth 22.5-21.5. Voiding/meconium stooling\n(after glycerin suppository). One small brown aspirate noted\nthis morning & discarded, Fellow aware. Repeat lytes to be\ndrawn tonight. P: Cont to monitor feeding tolerance.\n\nG&D O/A: Infant temps high in servo isolette; altering\nenvironment accordingly. is A/A with cares, slightly\nirritable @ times. Settles well with containment. Likes\npacifier. P: Cont to monitor temps & support developmental\nneeds.\n\nPAR O/A: in for evening cares to kangaroo. Called\nthis morning for an update. Aware of current plans for\n. P: Cont to support first time .\n\nBili O/A: Infant remains under single phototherapy. Pink/\nsl. jaund. Repeat bili to be drawn tonight. P: Cont to\nmonitor for s/s of hyperbili.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-12 00:00:00.000",
"description": "Report",
"row_id": 1696049,
"text": "NPN 1900-0700\n\n\n1 Resp\nRemains on NP CPAP 5 with FiO2 21%. RR 40-70's. Lung\nsounds clear/=. Suctioned with cares for mod amt from ETT\nand nares. Mild inter/subcostal retractions noted.\nContinues on caffiene, no spells thus far this shift.\n\n2 FEN\nCurrent well 1.340 kg, up 20 grams. TF remain at\n140cc/kg/day. IVF of PN D 13 and lipids infusing well via\npicc at 130cc/kg/day. Enteral feedings continue at\n10cc/kg/day. Tolerating well. Abd soft, bs +. Girth\nstable. No spits, min asp. Dstick 148. Voiding with each\ndiaper change, no stool. Lytes sent, see flow sheet.\n\n3 G&D\nTemp stable in servo controlled isolette. Awake and\nirritable with cares. Sleeps well between cares. Sucks\nintermittently on pacifier.\n\n4 Parenting\nNo contact\n\n6 Bili\nContinues under single phototherapy. Bili sent, see flow\nsheet. Goggles in place.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-12 00:00:00.000",
"description": "Report",
"row_id": 1696050,
"text": "RESPIRATORY CARE NOTE\nBaby #1 remains on NP CPAP 6 FiO2 21%. Suctioned NP tube for mod amt of white secretions. Breath sounds are clear. RR 40-70's no spells so far tonight, on caffeine. Stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-12 00:00:00.000",
"description": "Report",
"row_id": 1696051,
"text": "Neonatology Fellow\nActive in incubator. Under phototherapy. NP CPAP in place. No distress. AFSOF, some overriding of sutures. Feeding tube in place. Lungs - clear and symmetric, mild retractions. CV - s1s2, regular, no murmur, warm and well perfused. Abdomen - soft, nontender, active bowel sounds. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-26 00:00:00.000",
"description": "Report",
"row_id": 1696121,
"text": "Fellow PE note\nStable on 100cc NC with clear BS, mild retractions\nRRR no murmur\nAbd soft, non-distended\n\nContinues on NC O2.\nTolerating 150 cc/kg 30 cal feeds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-26 00:00:00.000",
"description": "Report",
"row_id": 1696122,
"text": "Nursing Addendum\nBaby Girl was noted to have two more episodes of bradycardia. No apnea noted. (see flow sheet)\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-11 00:00:00.000",
"description": "Report",
"row_id": 1696043,
"text": "NPN 1900-0700\n\n\n1 Resp\nNP CPAP increased to CPAP 6 for spells. 5 brady's with\napnea thus far this shift, see flow sheet. Continunes on\ncaffiene. FiO2 requirements 21-23%. RR 40-50's. Lung\nsounds clear/=. Suctioned with cares for mod amt from tube\nand nares. Mild inter/subcostal retractions noted.\n\n2 FEN\nCurrent weight 1.360 kg, up 25 grams. TF remain at\n140cc/kg/day. IVF of BP D 12 with lipids infusing well via\npicc at 120cc/kg/day. Enteral feedings continue at\n20cc/kg/day of BM 20. Enteral feeds not advanced this shift\nd/t brown asp. Abd soft, bs +. Girth stable. No spits,\nmax asp 0.6cc. Voiding with each diaper change. No stool\nthus far this shift. Dstick 100, lytes sent, see flow\nsheet.\n\n3 G&D\nTemp stable in servo controlled isolette. Awake and\nirritable with cares. Settles well between cares.\n\n4 Parenting\nNo contact thus far this shift.\n\n6 Bili\nContinues under single phototherapy. Bili mask in place.\nLevel tonigh 7.8/0.4/7.4\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-11 00:00:00.000",
"description": "Report",
"row_id": 1696044,
"text": "Respiratory Care\nBaby rec'd on NPCPAP 5. BS clear. Sxn as per flowsheet for lg amts. Occ Bradys. NPT replaced without difficulty. Bradys continue, 5 this shift as of this writing-see flowsheet. RR 40's-50's with mild IC/SCR. On caffeine. Plan cont to follow closely, monitor spells, increase caffeine dose if appropriate, consider reintubation if significant spells persist.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-27 00:00:00.000",
"description": "Report",
"row_id": 1696123,
"text": "NICU nursing progress note\n\n\nPlease refer to flow sheet for specific info.\nResp/ A and B's\nO: remains in NC 150cc flow, fi02 25-30%. RR\n30-60's. Sat's >94%. IC/SC ret. BSCE bilat. Periodic\nbreathing pattern noted, w/ assoc. desat's requiring\ndialing. Caffeine dose increased tonight. 6 brady's since\n7am. A: Stable. Caffeine dose increased w/ decrease in # of\nbrady's since 2100. P: cont to provide opt.oxygenation,\nmonitor.\nF/N\nO: Weight 1690g ^35g. TF of 150cc/kg/day of BM 30w/promod.\nGavaged over 1 hour 30\". One large spit tonight. Abd. soft,\nround, pink, no loops, active bs. Voiding/ heme\n(-). A: Stable. Improved feeding tolerance w/ advance of\nfeeding time over 1 hour 30\". P: cont to provide opt. nut.,\nmonitor.\nG/D\nO: Temp stable in an off isolette. Active and quietly \nw/ cares. Occ. irritable. Calms w/ containment and pacifier.\nBoundaries in place. MAE. Brings hands to midline. Font\nsoft, flat. Kangarooed tonight 120\" then had two\nspells. A: AGA P:cont to support dev. milestones. Possible\nneed to Decrease kangaroo time.\n\nO: Mom and dad in tonight. Updated and verbalizing\nunderstanding. Signed consent for transfer to \nHosp. in am. A: Involved and . P: cont to\nsupport, update, educate. Transfer infant in am when bed\navailable.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-27 00:00:00.000",
"description": "Report",
"row_id": 1696124,
"text": "Newborn Med Attending\n\nDOL#23. Cont in low flow O2 per NC. Multiple spells. AF , clear BS, no murmur, abd soft, MAE. Wt=1690 up 35 on 150 cc/kg/d BM30 with PM.\nA/P: Growing premie with residual CLD. As and Bs. Transfer to \n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-27 00:00:00.000",
"description": "Report",
"row_id": 1696125,
"text": "NPN Days\n\n\nFEN: Wt 1690 up 35 gms. 150/kg BM 30cPM. gavage over 90min\ndue to hx of spits. Voiding. heme neg. Cont to\nmonitor.\n\nG/D: Temp stable in off isolette. Swaddled. Sucks on\npacifier. and active with care.\n\nA/B's. RR 30 -60. 2spells this shift thus far. NC 150cc flow\n30% Fio2. Clear and equal. Mild sc rtx. Cont to monitor and\nintervene as necessary.\n\nTransporting to via isolette in abulance. Consent\nobtained. aware. Ready for transport.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-11 00:00:00.000",
"description": "Report",
"row_id": 1696045,
"text": "Neonatology Attending\n\nDay 7\n\nRemains on CPAP with fio2 0.21-0.23. Clear breath sounds. RR 40s. Has had 7 bradycardic events over last 24 hours. Mild retractions. Received caffeine bolus last night and daily dose increased. No murmur heard. BP mean 42. HR 140-170s. Pale, pink. Last Hct 38. Weight 1360 gms (+25). TF increased to 140 cc/kg/d. PICC in place. On PN and lipids. Made NPO last night for gastric residuals. Benign abdomen. Normal bowel sounds. Girth stable. No stool passed over recent days. Lytes 141/5.4/108/15. Remains on phototherapy with bilirubin 7.8/0.4. Stable temperature.\n\nSomewhat improved breathing control on caffeine and CPAP. Will continue with this regimen for now. Monitoring cardio-respiratory status closely. Immature gut motility evident. Will attempt again to establish enteral feeds. Will recheck lytes, given anion gap acidosis. Plan to check KUB if bilious aspirate seen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-11 00:00:00.000",
"description": "Report",
"row_id": 1696046,
"text": "Neonatolgoy Fellow\nActive in incubator, under phototherapy, on NP CPAP at 6 cm H2O.\nAFSOF. Pink. Lungs - mild retractions, clear and symmetric breath sounds. CV - s1s2, reg, no murmur, warm and well perfused. Bowel sounds present, soft, nontender, nondistended. No edema. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-11 00:00:00.000",
"description": "Report",
"row_id": 1696047,
"text": "Respiratory Care\n remains on CPAP. Fio2 .21, rr 50's , bs clear. sx for sm amt. On caffeine. 3 brady spells noted this shift. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-25 00:00:00.000",
"description": "Report",
"row_id": 1696116,
"text": "Neonatology Fellow\n\nComfortable in incubator. NC and feeding tube in place. Lungs - clear and symmetric. No retractions. CV - s1s2, regular, no murmurs. Warm and well perfused. Abdomen - active bowel sounds, nondistended, nontender. No edema. No rashes. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-25 00:00:00.000",
"description": "Report",
"row_id": 1696117,
"text": "NPN Days\n\n\n\nFEN: 150/kg BM30cPM. 40cc NG over 90min. One med spit today.\nGirth stable. Voiding. Passed one heme neg stool this shift.\nCont to monitor.\n\nG/D: Temp stable in off isolette. Swaddled on sheepskin.\nLikes boundaries and calms easily. Sucks on pacifier. OT\nconsult done today. Cont to support dev needs.\n\nParenting: Mom and Dad in this evening. Independent with\ncares and very . Updates given and Dad held infant.\nCont to support and educate.\n\nA/B's: Four spells this shift. NC 100cc RA. Continues on\ncaffeine. Cont to monitor and intervene as necessary.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-26 00:00:00.000",
"description": "Report",
"row_id": 1696118,
"text": "Nursing Progress Note 1900-0730\n\n\n#2 Gaining weight well on full enteral feeds of BM30w/PM\npo/pg. Weight up 40gms to 1655. Po feeding very poorly\nwith little effort and no coordination. Took 5cc by default.\nAbdomen remains benign, voiding and well with\nstable girths and minimal residuals. Feeding times shortened\nto one hour with no spitting this shift. Will cont with\ncurrent plan of care and re-evaluate readiness to bottle.\n\n#3 Temp stable in off isolette. Waking for feeds, vigorous\nroot/suck. Active and with cares, sleeping quietly in\nbetween. Will cont to support growth and development.\n\n#4 No parental contact thus far this shift.\n\n#8 Cont with regular apnea/brady events. Usually clustered\nand lasting approx 5-10min. No particular correlation to\nfeedings or spits. Four spells thus far this shift. Will\ncont to monitor and document.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-26 00:00:00.000",
"description": "Report",
"row_id": 1696119,
"text": "Neonatology Attending\nDOL 22\n\n remains in NC 100 cc/ of 25% FiO2 with intermittent bradycardia, on caffeine.\n\nWt 1655 (+40) on TFI 150 cc/kg/day BM30PM, tolerating well. All feeds by gavage (poor attempt at bottling). On ferinsol and vitamin E.\n\nA&P\nPreterm infant with respiratory and feeding immaturity.\n\nNo changes in management today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-26 00:00:00.000",
"description": "Report",
"row_id": 1696120,
"text": "NPN\n\n\n#2F/N O-Remains on feeds of BM30calw/promod at 150cc/kg. No\nspits or aspirates noted. Feeds given per gavage over 1 hr.\nVoiding well. No stool passed. A- Tol. feeds. P-Follow wts.\n#3Dev. o- Temp stable in off isolette. Infant swaddled and\ndressed. Inant active and with cares. Infant sucking\non pacifier when offered. A- AGA P- Support dev.\n#4Family Mom called and updated. Family did take tour at\n and they would like twins transfered.\n(bed availability checked today and SCN is unable to take\ntwins this PM) A- Family updated Transfer to \ntommorrow if beds available.\n#8A+B's O- infant had two epiosodes of bradycardia. One\nassociated with apnea / needing mild stim. Remains on\ncaffeine A- A+B's of prematurity P- Continue to follow.\n#9Resp O- Infant remains in NC 25% O2 100cc flow to maintain\nO2 sat above 92. RR 40-70. Lungs clear. Mild retractions\nnoted. Soft murmur audible this AM A- Continues with minimal\nO2 requirement P- Wean O2 as tolerated.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-10 00:00:00.000",
"description": "Report",
"row_id": 1696038,
"text": "Respiratory Care\nBaby continues on NPCPAP 5, 21-25%. BS coarse-> clear. Sxn x1 for mod white from NPT and yellow from naris. RR mostly 30's-50's. On caffeine. No spells noted. Plan cont CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-10 00:00:00.000",
"description": "Report",
"row_id": 1696039,
"text": "Neonatology Attending\nDay 6\n\nNP CPAP 5, 21-25%. RR40-60s. Lungs cl and =. Mild ic rtxns. No A&Bs. 1 past 24 hrs. On caffeine. +int murmur, not heard this am. Mean BP 40s.\n\nHct 38.8.\n\nSlightly jaundiced. Bili 8.7 a couple of days ago. Under photo.\n\nWt 1335, down 10 gms. TF 130 cc/k/day (BM20 at 10 and PN/IL at 120). +PICC. d/s 75. Nl voiding. No stool since day 2.\nHUS today normal.\n\nIn isolette.\n\nPlan:\n1. CVR monitoring. Con't CPAP. Con't caffeine, follow AOP.\n2. Advance feedings cautiously.\n3. Inc TF to 140.\n4. Maximize PN/IL content.\n5. Check lytes and bili in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-05 00:00:00.000",
"description": "Report",
"row_id": 1696008,
"text": "NPN 1500-2300\n\n\n#1 RESp O: Infant remains on SIMV, orally intubated, 02\n25-35%, weaned on vent settings for good gas, tolerating\nwean well. BBS equal and clear, well aerated, minimal\nsecretions, occ desats to 70's requiring increased 02.Pink\nand well perfused. A; Alt in RESP r/t prematurity P: cont to\nassess for changes in resp status, monitor 02 requirment,\nmonitor blood gases as needed.\n#2 FEN O: Infant remains on 80cc/k/day of D10W TPN. Remains\nNPO, abd soft and nondistended, good bowel sounds, uop\nbrisk, d/s stable, 24 hours lytes pending. A; ALt in FEn P;\ncont with strict I&O, wt q day, maintain NPO status.\n#3 dEV O: Infant alert and active, irritable at times, sucks\non pacifier, temp stable after adjusting warmer. A; Alt in\nDEV P; cont with appropriate dev. interventions.\n#4 PARENTING O: DAD in to visit, asking appropriate\nquestions and updated on infant's progress. Grandparents in\nto visit. A: Involved and concerned family P: cont to inform\nand support family as needed.\n#5 Sepsis O: Infant remains on Ampi and GEnt, blood cultures\npending, no overt signs of sepsis. A; R/O Sepsis P: cont to\nassess for signs of sepsis. monitor blood culture results.\nCont with antibiotics as ordered.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-06 00:00:00.000",
"description": "Report",
"row_id": 1696009,
"text": "Nursing Note\n\n\n#1O: Received infant orally intubated 20/5 x 20. After cap\ngas (see flow sheet) infant weaned and is now 18/5 x 18. O2\nreq. hi 20's to 30's. Br. sounds are clear and sx q 3 -4\nhrs. for mod. to lg. amt. bld tinged secretions.\n#2O: Total fluids at 100cc/kg of PND10W, NPO. D-s 144,\nbelly soft, hypoactive BS, no stool. Urine out 5.2cc/kgfor\n.\n#3O: On open warmerr with temps in the 99 range. Quite\nirritable at x's. Occ. sucking with thumbie pacifier.\nPrefers being in supine position.\n#4O: No contact.\n#5O: Antibx. given as ordered, bld. cx ng. to date.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-06 00:00:00.000",
"description": "Report",
"row_id": 1696010,
"text": "Respiratory Care\nBaby rec'd on 24/6, R 20. ABG: 7.36/34/93/20-5. Parameters weaned as per flowsheet. BS clear. Sxn for mod amts blood-tinged secretions. NNP informed. CBG @ 0400, further weaning done. Presently on 18/5, R 18. 02 req 25-30% this shift. Will cont to follow closely, support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-06 00:00:00.000",
"description": "Report",
"row_id": 1696011,
"text": "Start photherapy, d/c amp and gent. Will start indocin if murmur reappears or pulses pick up in intensity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-06 00:00:00.000",
"description": "Report",
"row_id": 1696012,
"text": "Newborn Med Attending\n\nDOL#2. Cont in SIMV 18/5 x 16, 25-30% O2. 7.33/40 last CBG. AF flat, coarse BS, intermittent murmur, abd soft, MAE. Blood cx -. Wt=1380 down 55. Tf=100cc/kg. On PN and IL. Na=142.\nA/P: Infant with RDS now with probable PDA. Increase TF=120 cc/kg/d.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-06 00:00:00.000",
"description": "Report",
"row_id": 1696013,
"text": "Respiratory Therapy\nWeaned on vent settings based on CBG of 7.33/40. Currently on SIMV, 18/5-16, 0.23-0.34. Suctioning large amount of frank blood from ETT. Infant started on indocin today. Labile with O2 saturations. Plan to follow CBG and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-10 00:00:00.000",
"description": "Report",
"row_id": 1696040,
"text": "Neonatology Note\nComfortable in incubator, under phototherapy, NP CPAP in place. No distress. AFSOF. Feeding tube in place. CV - s1s2, regular, no murmur, normal pulses. Warm and well perfused. Lungs - mild retractions, clear and symmetric breath sounds. Abdomen - active bowel sounds, soft, nontender. Ruddy. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-10 00:00:00.000",
"description": "Report",
"row_id": 1696041,
"text": "Respiratory Care\nBaby continues on cpap 5, fio2 21-23%, Bs clear, RR 30-60's, on caffeine, no spells through most of shift. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-10 00:00:00.000",
"description": "Report",
"row_id": 1696042,
"text": "Nursing Progress Note\n\n\nRESP O/A: Infant remains on NP CPAP of 5, 21-24% FiO2. RR\n30-60s. LS clear, mild (skinny) sc/ic retractions noted;\ninfant breathing comfortably. Sxn x1 for small amts of white\nsecretions. Two spells today, HR in the 50s w/ apnea, sats\n80-90s, mild stim required for resolve. cont on IV\ncaffeine. P: Cont to monitor for s/s of distress &\nadditional spells.\n\nFEN O/A: TF increased to 140cc/k/d. Enteral feeds increased\nto 20cc/k/d today @ 1300. Plan to increase enteral feeds by\n10cc/k (@ 1300 & 0100). Infant receives 5cc pg q4h. IVF\nincreased from D11 to D12 tonight plus lipids. Infusing well\nthrough a central PICC line. Abdomen benign, pos BS.\nTolerating feeds, no spits. Aspirate of .2cc, brown mucous;\ndiscarded. Voiding/no stool, urine output 3.3cc/k/h for the\nlast 12h. Lytes to be drawn tonight. P: Cont to monitor\nfeeding tolerance & increase pg as ordered.\n\nG&D O/A: Temps high in servo, weaning isolette accordingly.\nInfant alert/irritable with cares; settles well with\ncontainment. Tolerated kangaroo care for ~90 min today. Head\nUS this morning showed normal findings. P: Cont to monitor\ntemps & support developmental needs.\n\nPAR O/A: called this am for update. In for afternoon\ncares. Mom is very independent with temps, diapers & umbi\ncare. Updated @ bedside regarding infants plan of care. Dad\n. P: Cont to support first time .\n\nBili O/A: Infant is pink/ sl jaund. Remains under single\nphototherapy. Level to be drawn tonight. P: Cont to monitor\nfor s/s of hyperbili.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-24 00:00:00.000",
"description": "Report",
"row_id": 1696110,
"text": "#2 TF 150CC/KG BM28C/PRO. FEEDS TOLERATED OVER 2HR. SMALL\nSPIT X1. ABD SOFT, FLAT, ACTIVE. WEIGHT INCREASE 40GM.\nVOIDING, NO STOOL AT THIS TIME IN SHIFT.\n#3 TEMPS STABLE IN LOW AIR ISO. AND ACTIVE. SLEEPING\nWELL BETWEEN CARES. SUCKING ON PACIFIER.\n#4 NO CONTACT FROM FAMILY THIS SHIFT.\n#8 BRADY WITH DESAT X1 WITH FEEDING.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-24 00:00:00.000",
"description": "Report",
"row_id": 1696111,
"text": "Neonatology Attending\n\nDay 20\n\nRemains on nasal cannula at 200 cc/- 21-30%. Had only two bradycardic events over last 24 hours. On caffeine. Had 1600 gms (+40). On BM 28 with Promod. Now on every four hour feeds. Benign abdomen. Stable temperature in incubator.\n\nImproving breathing control. Will move again to low flow nasal cannula or RA while continuing to monitor for apnea. Gaining weight well. Tolerating feeds well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-24 00:00:00.000",
"description": "Report",
"row_id": 1696112,
"text": "Neonatology Fellow\n\nComfortable in incubator. In RA sats of 95%. Feeding tube in place. AFSOF. Lungs - clear and symmetric. Regular, nondistressed breathing. CV - s1s2, reg, no murmur. Abdomen - active bowel sounds, soft, flat, nontender. No rashes. No edema. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-16 00:00:00.000",
"description": "Report",
"row_id": 1696076,
"text": "Neonatology Attending\n\nDay 12\n\nRemains in RA. Clear breath sounds. RR 50-60s. No drifts. Had four bradycardic events over last 24 hours. HR 140-170s. Pink, well-perfused. Weight 1425 gms (+35). TF at 150 cc/kg/d. PN and lipids at 60 cc/kg/d. On enteral feeds at 90 cc/kg/d. Blood glucose 101. Passing transitional stools. Lytes 138/4.6/102/23. Bilirubin 6.1/0.4 on phototherapy. and active. in daily.\n\nContinued respiratory immaturity on caffeine. Will continue to monitor closely for apnea. Gaining weight well. Will discontinue lipids today and continue feeding advance. Hope to discontinue PN tomorrow. Metabolically fine. Bilirubin under control. up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-16 00:00:00.000",
"description": "Report",
"row_id": 1696077,
"text": "NPN 0700-1900\n\n\n1. Resp: Infant remains in RA, maintaining her O2 sats\ngreater than 95%. Lung sounds clear/=. RR 40-70's. IC/SCR\nnoted. 5 spells noted thus far this shift - see flowsheet\nfor details. Infant continues on caffeine. P: Cont. to\nsupport resp. status.\n\n2. FEN: TF remain at 150 cc/kg/day. IV fluids of PND12.5\nare currently running at 45 cc/kg/day through a patent PICC\nwithout incidence. Ent feedings of BM20/PE20 are currently\nat 105 cc/kg/day, which are being advanced by 10 cc/kg/\nat 17, 05. D/S 86. Tolerating feedings well: Abd exam\nbenign, no spits, AG stable, and min asp. UO for past 12\nhours has been 4.1 cc/kg/hr. No stool noted this shift. P:\nCont. to support nutritional needs.\n\n3. G/D: Temps stable in servo-isolette. Infant is nested in\nsheepskin with bumper in place. and active with\ncares. Settles well in between cares. Appropriately brings\nhands to face to comfort self. OT in to consult - spoke\nwith . AFSF. AGA. P: Cont. to support developmental\nneeds.\n\n4. : Mom and Dad in for 1700 cares. Independent with\nhanding infant; taking temp; and changing diaper. Updated\nat bedside on infant's condition and plan of care. Asking\nappropriate questions. is currently kangarooing with\ndad. , involved . P: Cont. to support and\nudpate .\n\n5. Hyperbili: Infant remains under single phototherapy with\neye shields in place. Level this am was 6.1/0.4 down from\n9.3/0.4. Plan is to turn lights off in am and check a\nrebound thurs am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-24 00:00:00.000",
"description": "Report",
"row_id": 1696113,
"text": "NPN0700-1900\n\n\n#2 FEN: TF=150cc/k/d; ^'d to BM30 w/pm. Tolerating gavage\nfeedings over 2hrs. No spits thus far. Voiding/no stools.\nAbd. benign. Girths=23-24cm. Ordered for nutrition labs in\nAM.\n\n#3 DEVELOPMENT: Received infant swaddled in air isolette;\noff this AM with infant temps 988-98.9 this afternoon.\nActive and with cares; resting well b/t. Sucking\nintermitt. on pacifier. .\n\n#4 : Dad called x1 this AM for update. to be\nin to visit for late afternoon cares.\n\n#8 RESP: Received infant on 200cc flow NC, 21%. Dc'd to \nthis AM. Tolerating well. O2 sats>95%. RR 40-60's. LSC.\nInfant has had 4 spells thus far (see nsg. flowsheet).\nRemains on Caffeine.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-25 00:00:00.000",
"description": "Report",
"row_id": 1696114,
"text": "Nursing Progress Note 1900-0730\n\n\n#2 FEN cont to grow and gain weight on full enteral\nfeedings of BM30w/PM at 150cc/k/d po/pg. Weight up 15gms to\n1615. Offered po feeding last night secondary to vigorous,\nalmost frantic suck on pacifier. Poor suck/swallow coord\nand general disinterest. Would cont to offer breast/bottle\nat least once daily to stimulate interest. Abominal exam\nbenign, voiding and well with stable girths and\nminimal residuals. Cont to demonstrated moderate reflux\nwith spitting long after feeds end, and persistent apnea.\nWill cont to monitor and support, maintain HOB elevation.\n\n#4 No parental contact thus far this shift.\n\n#8 Had two episodes of clustered spells requiring almost\nconstant stim for >10min with last episode. Placed back in\nflow cannula at 100cc/ with improvement seen. Will cont\nto monitor and trial off periodically.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-25 00:00:00.000",
"description": "Report",
"row_id": 1696115,
"text": "Neonatology Attending\n\nDay 21\n\nBack on nasal cannula flow last night for multiple bradycardic events- mild. None since then. Fio2 0.21. RR 40-50s. No murmur. HR 150-160s. Weight 1615 gms (+15). TF at 150 cc/kg/d- BM 30 with Promod. Had one large spit. Stable girth. Alk Phos 507 Phos 6.4 Ca 10.3. Stable temperture in incubator.\n\nContinues to demonstrate immaturity of breathing control. Will continue to monitor closely. Gaining weight well. Intermittent spitting continues.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-05 00:00:00.000",
"description": "Report",
"row_id": 1696003,
"text": "NPN 7a-3p\n\n\nResp; Recieved in NP CPAP 6. FiO2 increasing from 30-50%,\nhaving some increased WOB and RR 60-90s. Orally intubated at\n10am and recieved survanta x1. Currently on IMV 24/6 x\n20bpm. Able to ween rate after ABG 7.40/36. FiO2 34-46%. LS\nclear, RR 30-50s, IC/SC retractions. Suctioning ETT for\nsmall white. Stable on current vent settings, con't to\nmonitor and ween as tol.\n\nFEN: NPO. TF 80cc/k/d of D10W running in PIV. Starting TPN\nD10 this evening. DS 178today, team aware. Abd benign, BS\nactive. Girth stable. UO: 6.5cc/k/hr x8hrs. No stool this\nshift. Stable, con't as planned. Possibly start feeds\ntomorrow. Due for 24hr lytes and bili tonight.\n\nG&D: Alert and active. Irritable at times and had high\npitched cry when on CPAP. Nested in sheepskin on open\nwarmer, servo controlled. Cold this am, servo increased,\ntemps stable at this time. AGA, con't to support dev needs.\n\nFamily: Mom and dad in to visit. Dad kangaroo' for\n~30min. Appropriate and asking questions. both seem a little\noverwhelmed. Reviewed some things they may expect in the\nnext few days such as: bili lights, possibility of murmors,\ndevelopment care. Reviewed clustering cares, and holding\nonce a day, not overstimulating. Parents will be up to visit\nagain later. Con't to support and update as needed.\n\nR/O Sepsis: Infant alert and active. Temps stable. No signs\nof infection noted. Recieving amp and gent per orders for\n48hours. Will con't to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-05 00:00:00.000",
"description": "Report",
"row_id": 1696004,
"text": "NPN 7a-3p\nUO: 4.5cc/k/hr not 6.5.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-05 00:00:00.000",
"description": "Report",
"row_id": 1696005,
"text": "Clinical Nutrition:\nO:\nFormer 29 weeker, BG (twin #1) now on DoL #1\nMaternal history/delivery reviewed.\nBirth wt: 1435g (50-75th%ile)\nBirth LN: 40cm (~75th%ile)\nBirth HC: 28.5cm (50-75th%ile)\nLabs: none yet\nDsticks: 73-178 since birth\nAccess: PIV\nNutrition: NPO/PN (D10 & 1.5g% AA)\nProjected 24hr Nutrition: 32Kcals/kg & 1.0 g/kg of AA\nGI: +BS, trace meconium\n\nA/goals:\nPn initiated today on DoL #1. Currently NPO until resp. status stabilizes. x1 episode of BP instability o/n requiring a NS bolus. Awaiting 24hr lytes, started w/ std. Na/K in PN. Can begin lipids tomorrow @ 1.0 g/kg. Dsticks slightly elevated, suggest advance dextrose infusion slowly until wnl. PN/IL goals: 90-110 Kcals/kg, 3.0-3.5 g/kg of protein & 3.0 g/kg of IL. Growth goals: ~15-20 g/kg/day, ~0.5-1.0 cm/wk for HC & ~1.0 cm/wk for LN. Will cont. to follow progress & participate in nutrition plans.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-05 00:00:00.000",
"description": "Report",
"row_id": 1696006,
"text": "SOCIAL WORK\nParents known to social work from mother's antepartum stay on 6s. They were referred for support during mother's lengthly antepartum admission, and were appropriately focused on the well being of the pregnancy, mom was compliant with bedrest, husband very supportive of her.\n Met with parents this am following delivery of their twins. Parents excited, tired and beginning to adjust to NICU. Will continue to follow. Please call with questions/concerns. thank-you.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-05 00:00:00.000",
"description": "Report",
"row_id": 1696007,
"text": "Respiratory Care\nRecv'd baby on cpap 6, baby intubated for increased fio2 50%, RR40-90's, cxr showed low lung volumes. Intubated and surfed with 6cc at 10am and 4pm. Baby currently on simv 24/6 x 20, fio2 25-38%. ABG drawn 7.40/36/28/23/-2, f decreased from 24bpm. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-09 00:00:00.000",
"description": "Report",
"row_id": 1696036,
"text": "Nursing Progress Note\n\n\nRESP O/A: Infant received on the vent w/ settings of 18/5 R\n14, 21% O2. Maintaining O2 sats 99-100%. At 1200, infant was\ntrialed off the vent and put into NC 400cc flow w/ 30-60%\nFiO2. CBG prior to this=7.29/43. Infant was placed in NP\nCPAP @ 1600 for increased O2 requirement & increased WOB.\nRepeat CBG prior to going on CPAP=7.24/51. RR 30-50s, LS sl.\ncoarse to clear after sxn. Sxn x2 today for sm/mod amounts\nof Blood tinged secretions. Mild/skinny ic/sc retractions\nnoted. One spell today, HR 40s, O2 70s, Mild stim for\nresolve; remains on IV caffeine. P: Cont to monitor\ninfant's resp status & increased As/Bs.\n\nF&N O/A: TF @ 130cc/k/d. Started on enteral feeds @ 10cc/k\ntoday. receives 2.4cc BM q4h pg. Tolerating well, no\nspits, abdomen benign. Voiding/ no stool. Girth 21.\nRemaining fluids of TPN D10 & lipids running through a PICC\nline in the left arm. TPN will be increased to D11 tonight.\nDS 107. Repeat Crit & triglycerides to be drawn tonight.P:\nBegin to monitor feeding tolerance.\n\nG&D O/A: Temps stable in a servo isolette. is\nirritable with cares. Settles with containment. Tolerated\nkangaroo care with mom for 60 minutes today. HUS scheduled\nfor thurs. P: Cont to support developmental needs.\n\nPAR O/A: Parent in for kangaroo care this afternoon. Mom\ndischarged today, teary/emotional about leaving the babies.\nFamily meeting @ 1400 to discuss plan of care for . P:\nCont to support first time parents.\n\nBili O/A: Infant is pink/sl.jaund. Remains under single\nphototherapy. Eye in place. Bili today 8.7/.3. P:\nCont to monitor for s/s of hyperbili.\n\nCV O/A: Murmur audible x1 today. B/P 57/35 (45). Normal\npulses & good cap refill noted. P: Cont to monitor CV\nstatus.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-15 00:00:00.000",
"description": "Report",
"row_id": 1696073,
"text": "NPN 0700-1900\n\n\n1. Resp: Received infant in NP CPAP 5. FiO2 requirement\nremained 21%. Infant was weaned off to NC O2 at 1200 and\nquickly transitioned to RA at 1500 - See flowsheet for\nfurther details. RR 50-60's. IC/SCR noted. Lung sounds\nclear/=. One spell noted thus far this shift - QSR. Infant\ncontinues on caffeine. P: Cont. to monitor resp. status and\nmonitor for s/s of increased WOB.\n\n2. FEN: TF remain at 150 cc/kg/day. IV fluids of PND12.5 and\nIL are currently running at 80 cc/kg/day through a patent\nPICC line without incidence. Ent feedings of BM20 are\ncurrently at 70 cc/kg/day which will be advanced by 10 cc/kg\n() at 1700. D/S 114. Tolerating feedings well; abd exam\nbenign, no spits, AG stable, and min asp. UO for past 8\nhours has been 2.7 cc/kg/hr. Infant has one sm trans.\nstool. P: Cont. to support nutritional needs.\n\n3. G/D: Temps stable in servo-controlled isolette. Infant\nis nested in sheepskin with bumper in place. Alert\nand active with cares. Settles well in between cares.\nAppropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n4. : Mom called x 1. She was updated on infant's\ncondition and plan of care. Asking appropriate questions.\nMom and Dad will be in for 1700 care to kangaroo. Loving,\ninvolved . P: Cont. to support and udpate .\n\n5. Hyperbili: Infant remains under single phototherapy with\neye shields in place. Plan is to check a in am with\nlytes. P: Cont. to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-16 00:00:00.000",
"description": "Report",
"row_id": 1696074,
"text": "NICU NPN 1900-0700\n\n\n#1 RESP O: Baby remains in room air, with o2 sats 97-100%.\nrr 40-60's, LS cta, baseline mild ic retractions. No spells\nto time this shift, no sat drifts.\n\n#2 FEN O: Tf remain at 150cc/k/d, working up on feeds and\ntolerating well. Voiding and stooling, abdominal exam\nbenign, ag stable. No spits, min ngt aspirates. pn,\ninfusing through picc line well. Picc dsg site with old\nbloody drainage.\n\n#3 G&D O: Temps are stable,nested on sheepskin, in servo\nisolette. Baby is and active with cares, sleeps well\ninbetween cares. Takes pacifier for comfort. Fontanells are\nsoft and flat. A: aga P: Continue to support development.\n\n#4 Parenting O: Nocontact overnight.\n\n#6 O: Baby remains under single phototherapy, wearing\neye shields. Color slightly jaundiced. level sent,and\nis pending.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-16 00:00:00.000",
"description": "Report",
"row_id": 1696075,
"text": "Neonatology Fellow\nIn incubator, under phototherapy. In RA, pink. AFSOF. Mild intercostal retractions. Normal work of breathing. Clear and symmetric breath sounds. s1s2, reg, no murmur. Warm and well perfused. Active bowel sounds, soft, nontender. No edema. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-10 00:00:00.000",
"description": "Report",
"row_id": 1696037,
"text": "NPN 1900-0700\n\n7 Alt. CV: presumed PDA.\n\n1 Resp\nRemains on Prong CPAP 5 FiO2 21-25%. RR 50-60's. Mild\ninter/subcostal retractions noted. Lung sounds cl/=.\nSuctioned with cares for small to mod secretions. Continues\non caffiene.\n\n2 FEN\nCurrent weight 1.335 down 10 grams. TF remain at\n130cc/kg/day. IVF of PN D 12 with lipids infusing well via\npicc. Dstick wnl. Triglycerides sent, results pending.\nEnteral feedings continue at 10cc/kg/day of BM 20.\nTolerating feedings well. Abd soft, bs +. Girth stable.\nNo spits, min asp. Voiding, no stool.\n\n3 G&D\nTemp stable in servo controlled isolette. Awake and\nirritable with cares. Sleeping comfortably between cares.\n\n4 \nDad called for update. Asking appropriate questions.\n\n6 Bili\nContinues under single phototherapy. Mask on.\n\n\n\nREVISIONS TO PATHWAY:\n\n 7 Alt. CV: presumed PDA.; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-23 00:00:00.000",
"description": "Report",
"row_id": 1696106,
"text": "Clinical Nutrition\nO:\n~32 wk CGA BG on DOL 19.\nWt: 1560 g (+10)(~25th to 50th %ile); birth wt: 1435 g. Average wt gain over past wk ~12 g/kg/d.\nHC: 28.5 cm (~10th to 25th %ile); last: 28 cm\nLN: 40.5 cm (~10th to 25th %ile); last: 40.5 cm\nMeds include Vit E and Fe.\nLabs due this wk.\nNutrition: 150 cc/kg/d of BM 28 w/ promod, q 3 hr feeds pg over 2 hrs due to hx of spits. Feeds just increased this am; projected intake for next 24 hrs ~140 kcal/kg/d, ~4.1 g pro/kg/d.\nGI: Multiple small spits; max aspirate ~5 cc--refed; BM guaic - yesterday after glycerine, no BM today.\n\nA/Goals:\nTolerating feeds with spits and aspirates as noted above required extended frequent feeds (feeds are only off ~1 hr between feedings); also has HOB elevated. Monitoring tolerance and will advance feedings cautiously. Labs due this wk. Current feeds + supps meeting recommendations for kcals/pro/vits and mins. Growth is not meeting recommendations for wt gain of ~15 to 20 g/kg/d or LN gain of ~1 cm/wk; expect improvement now that feeds have been advanced. HC gain is meeting recommendations. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-23 00:00:00.000",
"description": "Report",
"row_id": 1696107,
"text": "Neonatology Fellow\n\nComfortable in incubator. NC and feeding tube in place. AFSOF. Lungs - clear and symmetric. No distress. CV - s1s2, regular, no murmur. Warm and well perfused. Abdomen - active bowel sounds, soft, nontender, nondistended. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-23 00:00:00.000",
"description": "Report",
"row_id": 1696108,
"text": "NPN Days\n\n\nFEN: Wt 1560grams. TF 150cc/kg. Previously on q3hr feeds.\nWill try q4hrs feeds today. Increased calories to BM 28cPM.\nHx of spits. One small spit this morning. Passed heme neg\nstool twice today. Girth stable. Belly soft. Voiding qs. HOB\nelevated 45degrees. Cont to monitor and assess tolerance of\nq4hr feeds.\n\nG/D: Temp stable in air controlled isolette. Swaddled with\ntshirt on. Sheepskin. and active with cares. Sucks on\npacifier. Cont to support developmental needs.\n\nParenting: Dad called for updates this am. Cont to educate\nand support.\n\nA/B's: One spell thus far this shift. See flow for details.\nCont to monitor and intervene as necessary.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-09 00:00:00.000",
"description": "Report",
"row_id": 1696032,
"text": "Neonatology Attending\nDOL 5\n\n remains on SIMV 18/5 x 14 in 21-25% FiO2. CBG 7.39/38. Small amounts of blood-tinged endrotracheal secretions. On caffeine.\n\nEcho yesterday showed no PDA (s/p indomethacin). Soft murmur intermittently noted. BP normal without pressor support.\n\nWt 1345 (+45) on TFI 130 cc/kg/day. Remains NPO with PICC in place, PN-D10W-IL. D-stick 70. Urine output 3.8 cc/kg/hr. 136/4.8/104/23. TG 222. Abdomen benign.\n\nUnder single phototherapy with bilirubin 8.7/0.3.\n\nA&P\nPreterm infant with resolving surfactant deficiency, resolving pulmonary hemorrhage, s/p PDA.\n\nWe will wean ventilatory support as tolerated.\n\nFeeds will be started today and lipids weaned in light of elevated TG.\n\nCranial ultrasound later this week.\n\nFamily meeting will be held today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-23 00:00:00.000",
"description": "Report",
"row_id": 1696109,
"text": "Nursing NICU Note\n\n\n#2. FEN O: TF 150cc/kg/d of BM28 w/PM= 39cc Q 4hrs,\ngavaged over 2hrs for hx of spitting. Abdomen is soft,\npink, +BS, no loops. No spits noted this shift. Abdominal\ngirth is 21-22.5cm. She is voiding/ guiac -stool\nQS. A: Pt. is tolerating current nutritonal plan. P:\nContinue w/ current feeding plan. Monitor for s/s of\nintolerance. Maintain reflux precautions, HOB 45deg.\n\n#3. Growth/Development O: Pt. remains in an Air isolette\nswaddled w/ stable temps. She is and active w/ cares\nsleeps well in between. Fontanelle soft/flat. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n#4. Parenting O: in to visit this afternoon,\nasking appropriate questions. They were updated at bedside\non pt's current status and daily plan of care. A: \n and involved. P: Continue to update, support and\neducate.\n\n#8. A&B's. O: Pt. has had 1 spell this shift thus far.\nShe is on Caffeine. A: Potential for A&B's. P: Continue\nto monitor for A&B's.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-09 00:00:00.000",
"description": "Report",
"row_id": 1696033,
"text": "Clinical Nutrition\nO:\n~30 wk CGA BG on DOL 5.\nWt: 1345 g (~25th to 50th %ile); birth wt: 1435 g. Wt currently down ~6% from birth wt.\nHC: n/a\nLN: n/a\nLabs noted.\nNutrition: 130 cc/kg/d TF. NPO; plan to start enteral feeds today @ 10 cc/kg BM 20. Remainder of fluids as PN via PICC line; projected intake from PN for next 24 hrs ~70 kcal/kg/d, ~3.4 g pro/kg/d, and ~1.3 g fat/kg/d. From EN: ~7 kcal/kg/d, ~0.1 g pro/kg/d, and ~0.4 g fat/kg/d. Glucose infusion rate from PN ~8.7 mg/kg/min.\nGI: No BM since initial meconium after birth; abdomen benign.\n\nA/Goals:\nTolerating PN with good BS control. Plan to start trophic feeds today. Advancing glucose infusion rate slowly. Labs noted and PN adjusted accordingly. Current PN + EN not yet meeting recommendations for kcals due to slow advancement of GIR and PICC line was just placed yesterday. Meeting recommendations for pro intake; lipids were decreased to ~1.5 g/kg/d due to elevated TG level; plan to recheck level tomorrow and re-advance lipids accordingly. Full vit and min recommendations will not be met until EN feeds reach initial goal of ~150 cc/kg/d PE/BM 24. Growth should improve as enteral feeds advance to initial goal. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-09 00:00:00.000",
"description": "Report",
"row_id": 1696034,
"text": "Neonatology Fellow\nAlert and awake. Extubated on NC. AFSOF. Pink in RA. Mild retractions, good aeration. CV - s1s2, reg, no murmur. Warm and well perfused. Abdomen - active bowel sounds, soft, nondistended, nontenders. No edema. Vigorous. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-09 00:00:00.000",
"description": "Report",
"row_id": 1696035,
"text": "Respiratory Care\nBaby extubated to nasal cannula 30-60% / 400cc flow, Bs clear with good air entry, sx small white secretions, cbg drawn 7.24/51, baby placed on cpap 5, fio2 21%, baby continues on caffiene. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-22 00:00:00.000",
"description": "Report",
"row_id": 1696103,
"text": "NPN 0700-1900\n\n\n1. FEN: TF remain at 150 cc/kg/day of BM26 with promod.\nFeedings are currently q 3 hours sec to spits o/n.\nTolerating NGT feedings well; abd exam benign, no spits, \nasp, and AG stable. Voiding QS and large yellow\nguiac neg x 1. Infant continues on Vit E and Fe. P: Cont.\nto support nutritional needs.\n\n2. G/D: Temps stable swaddled in air-controlled isolette.\n and active with cares. Settles well in between cares.\n Appropriately brings hands to face and sucks on pacifier to\ncomfort self. AFSF. AGA. P: Cont. to support\ndevelopmental needs.\n\n3. : No contact thus far this shift. will be\nin for 1700 cares. , involved . P: Cont. to\nsupport and udpate .\n\n4. Resp: Infant was place in NC O2 at 0815 sec to multiple\nspells o/n. Infant has remained in NC O2 200 cc flow 21%\nFiO2 maintaining her O2 sats 98-100%. Lung sounds clear/=.\nRR 40-60's. Mild IC/SCR noted. Infant continues on\ncaffeine. One spell noted thus far this shift - please see\nflowsheet for details. P: Cont. to monitor resp. status.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-05 00:00:00.000",
"description": "Report",
"row_id": 1695999,
"text": "NICU Admit Note\nBaby Girl #1 was born by c/s d/t footling breech with bulging bag. Beta complete at 26 weeks. Infant emerged crying needing facial CPAP and stim. Apgars 6,8. Infant shown to parents and tranferred to NICU in transport isolette. Infant placed on CPAP for grunting, flaring, retractions. CBC with diff and blood culture sent. Started IVF at 80cc/k/d of D10W via PIV. Infant remains on CPAP of 6cm FiO2 28-37% ABG 68/54/7.32/29/0. RR 30-60's with mild ICR/SCR. Suctioned for small amt from NP tube, but mod-large yellow from nare. Initial BP means in 40's then down to 27. Infant given 15cc NS bolus with BP 53/36 41. Color pink, no murmur. HR 150-170. BW 1435 Initial ds 73->103->170. Abd soft, +BS, AG 20cm. Voiding 1.8cc/k/hr x10hrs. Had trace mec at delivery. CBC with diff sent for maternal GBS unknown and PTL. WBC 12.4 28N 0B HCT 50.1 PLT290. Infant started on ampi and gent. Blood culture pending. Newborn meds given. Parents came by on their way down to postpartum floor and were updated on infants. Mom plans to BF.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-05 00:00:00.000",
"description": "Report",
"row_id": 1696000,
"text": "Respiratory Care\nSee attending and nursing admit notes for hx and further details. Baby placed on NPCPAP 6 after arrival in NICU. Infant grunting, flaring, and retracting. 02 req weaned to ~30%. Sxned for lg clear secretions in DR in NICU prior to being placed on CPAP. BS coarse. CBG on CPAP: 7.20/71/29/29/-2 -> ABG checked: 7.32/54/68/29/0. Plan cont to follow closely, support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-05 00:00:00.000",
"description": "Report",
"row_id": 1696001,
"text": "Neonatology Fellow\nOn warmer, on NP-CPAP 6 cm H20. AFSOF. Lungs - moderate tachypnea, Fi02 45%, fair aeration, scattered crackles. CV - s1s2, regular, no murmurs. Strong femoral pulses. Warm and well perfused. Abdomen - bowel sounds present, soft, flat, no masses or organomegally. Nl premature female genetalia. No edema. Skin - bruised arms and back. Neuro - nonfocal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-05 00:00:00.000",
"description": "Report",
"row_id": 1696002,
"text": "Neonatology Attending\nDOL 1\n\n remained on CPAP 6 cm H2O overnight, but is now on SIMV 24/6 x 24 in 25-40% FIO2.\n\nNo murmur. BP borderline early in her course, but now well-maintained.\n\nRemains NPO on TFI 80 cc/kg/day. Urine output 1.8 cc/kg/hr. Stooling appropriately.\n\nA&P\nPreterm infant with surfactant deficiency. We will continue to monitor blood pressure closely. We will wean ventilatory support as tolerated and repeat surfactant dose if oxygen requirement remains > 30%. PN will be started, and she will remain NPO for now. Continue antibiotic course through 48 hours.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-15 00:00:00.000",
"description": "Report",
"row_id": 1696070,
"text": "Neonatology Attending\n\nDay 11\n\nRemains on CPAP at 5 cm with fio2 0.21. Had two bradycardic events over last 24 hours on caffeine. Mild white secretions. HR 140-160s. BP mean 44. Weight 1390 gms (+30). TF at 150 cc/kg/d. IV PN and lipids at 80 cc/kg/d. Enteral feeds of breast milk at 70 cc/kg/d. Blood glucose 106. Minimal gastric residuals. Urine output 2.8 cc/kg/hr. Bilirubin rebound 9.3/0.4 so restarted on single phototherapy. Stable temperatue on servo-controlled incubator. in daily.\n\nWill trial off CPAP today. Will continue to monitor cardio-respiratory status closely. Will recheck lytes tomorrow. Advancing enteral feeds by 10 cc/kg twice daily. Tolerating advance well. Exaggerated physiologic hyperbilirubinemia. Family up to date.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-23 00:00:00.000",
"description": "Report",
"row_id": 1696104,
"text": "NICU nursing progress note\n\n\nPlease refert to flowsheet for specific info.\nResp/ A and B's\nO: remains in 200cc flow of fi02 21-28%. RR 30-70's.\nIC/SC ret. Sat's >96%. BSCE bilat. Periodic breathing\npattern noted, on caffeine. 3 spells tonight/ 5 in 24 hours.\nMild, mod stim to QSR. A: Stable. P: Cont to provide opt.\noxygenation, monitor.\nF/N\nO: Weight 1560g ^5g. TF of 15cc/kg/day of BM 26 w/ promod.\nGavaged Q 3 hours over 2 hours at present due to the\nincrease in spits, and brady's. Abd. soft, round, pink, no\nloops, active bs. Voiding/ no stool tonight thus far. A:\nStable. Gaining weight. P: cont to provide opt. nutrition.,\nmonitor.\nG/D\nO: Temp stable in air isolette. Active, irritable at times,\nthen quietly post care. Calms w/ containment,\npacifier, and brings hands to face. MAE. Font soft, flat. A:\nAGA P: cont to support dev. milestones.\n\nNo contact w/ thus far tonight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-23 00:00:00.000",
"description": "Report",
"row_id": 1696105,
"text": "Neonatology Attending\n\nDay 19\n\nRemains in nasal cannula at 200 cc/- 21-30% oxygen. Has had five bradycardic events over last 24 hours. On caffeine. Mild retractions. RR 30-40s. Pale, pink. HR 140-160s. No murmur. Weight 1560 gms (+50). TF at 150 cc/kg/d of BM 26 with Promod. Fed over two hours. Having small spits. Stable girth. Passed heme negative stool. Stable temperature in air-controlled incubator.\n\nAdequate breathing control on current nasal cannula and caffeine regimen. Will continue to monitor closely. Likely some element of GE-reflux. Gaining weight well overall. Reflux precautions. Extended gavage feeding time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-15 00:00:00.000",
"description": "Report",
"row_id": 1696071,
"text": "Respiratory Care Note\nReceived pt on NP CPAP +5,.21 - changed to NC ~12:30pm on 300cc/min of.21FiO2. Tolerating well and able to wean flow to 200cc/min .21, w/sats remaining >95% BBS ess clear. Sx'd small loose white secretions from NP tube prior to removing and small clear secretions from nares. Comfortable RR 40-60s. Mild retractions. One brady noted this morning that was QSR. Continues on caffeine. NARD. Plan to wean flow as tolerated and monitor for spells.\n"
},
{
"category": "Nursing/other",
"chartdate": "2104-09-15 00:00:00.000",
"description": "Report",
"row_id": 1696072,
"text": "Clinical Nutrition\nO:\n~31 wk CGA BG on DOL 11.\nWt: 1390 g (+30(~25th to 50th %ile); birth wt: 1435 g. Wt currently down ~3% from birth wt\nHC: 28 cm (25th to 50th %ile);last: 28.5 cm\nLN: 40.5 cm (~50th %ile); last: 40 cm\nLabs noted.\nNutrition: 150 cc/kg/d TF. Feeds currently @ 70 cc/kg/d BM 20, increasing 10 cc/kg/. Remainder of fluids as PN via PICC line. Projected intake for next 24 hrs from PN ~41 kcal/kg/d, ~2.8 g pro/kg/d; lipids d/c'd. From EN: 53 kcal/kg/d, ~0.8 g pro/kg/d, and ~3.0 g fat/kg/d. Glucose infusion rate from PN ~6.1 mg/kg/min.\nGI: Abdomen soft; maximum 3 cc aspirate (refed); some small spits.\n\nA/Goals:\nTolerating feeds without GI problems. Tolerating PN with good BS control. Labs noted and PN adjusted accordingly. Current feeds + PN meeting recommendations for kcals/pro; will not meet full vit/min recommendations until feeds reach initial goal of ~150 cc/kg/d of BM 24. Growth should improve as feeds reach initial goal. Will continue to follow w/ team and participate in nutrition plans.\n"
}
] |
32,754 | 140,826 | A/P: Mr. is a 79yo male with PMH as listed above who presents with odontoid fracture and hypotension. His admission was complicated by MRSA parotitis and MRSA bacteremia. He failed evaluation by speech and swallow secondary to aspiration. The patient made it clear to family and the medical team that he did not want any "tubes" or to be kept alive by a machine. He had an episode on when he desaturated to the low 80's with SBP in the 70s. He declined intubation and transfer to the MICU. His goals of care were advanced to CMO. Below is a brief summary of his hospital course by problem. . 1)Hypotension: The patient was found to be hypotensive with SBPs~80 in ED. He was given 3L of NS and BP now in 90's. Per PCP's office and OSH records, baseline SBP is 80-90's. Of note, he was recently admitted to OSH with hypotension and dizziness. He had multiple imaging tests as described above, none of which were very revealing. Despite this, there was concern for possible underlying infection given his leukocytosis with WBC elevated to 25. He was found to have parotitis with cultures positive for MRSA. He also had positive blood cultures for MRSA. . #) MRSA bacteremia/parotitis: As above. He was started on vancomycin. He received 1mg IV vancomycin x 2 on due to communication errors (dose should have been x1) and his dose was elevated on to 150. Given his depressed renal function and decreased ability to clear the vancomycin, he will likely have the antibiotic in his system at a supra/therapeutic level for several days. His vancomycin level on discharge was 18.3. To receive one dose tonight () and one final dose on . . 2)Odontoid fracture: Patient found to have odontoid fracture as a result of a mechanical fall. He was transferred to for further management. He was seen by Dr. (ortho-spine) who did not feel that the patient is candidate for halo given his age and morbidity associated with this procedure. Therefore, it was decided to treat conservatively with cervical collar. When goals of care were changed to CMO, the patient requested to have the collar removed. He is fully aware of the potential risks associated with this. . 3)Bilateral pleural effusions: Patient has history of bilateral pleural effusions since as per OSH records. He presented on this admission with predominantly R sided effusion, which is likely loculated on his CXR. He admits to productive cough over past few weeks but denies any fevers, chills, or other systemic symptoms. It was thought most likely secondary to CHF and no further work-up was pursued. . 4)Chronic renal insufficiency: Patient is known to have renal insufficiency, thought to be secondary to tubulointerstitial nephritis and longstanding hypertension. Per OSH reports, he is refusing dialysis. He confirmed his decision on admission. . 5)Hyponatremia/Hypernatremia: He presented with Na~131 on admission. Baseline Na per OSH records is in mid-high 130's. Patient appeared volume overloaded on physical exam, and his hyponatremia was thought most likely secondary to underlying CHF. Could also be abnormal in light of CRI. Over the course of admission, the patient became hypernatremic, likely secondary to volume depletion due to decreased PO intake. He was repleted gently with IVF given his low EF and Na was slowly trending back down. . 6)Anion gap metabolic acidosis: He also presented with an elevated anion gap of 17. Uremia is the most likely cause given elevated creatinine. He had a normal lactate. . 7)CHF: Patient known to have dilated cardiomyopathy. Recent echo reveals EF~10-15%. He is on diuretics as outpatient. There is also evidence of volume overload which is suggested by bilateral LE edema. His recent complaint of dizziness and chronic hypotension is likely due to underlying CHF and very poor cardiac output. Home indapanide was held for hypotension. . 8)Atrial fibrillation: Patient in sinus rhythm on admission. Per OSH records he self converts in and out of AF. s/p ICD placement at . He has been anticoagulated in the past but was stopped secondary to severe bleeding. Well rate controlled. Patient on Amiodarone as outpatient. Amiodarone was continued. . 9)COPD: Per recent PFTs has severe restrictive and obstructive disease at baseline. He is on several inhalers as an outpatient. He has excellent oxygen saturations on physical exam. He was treated here with atrovent nebs. . 10)Type 2 DM: Last hemoglobin A1C ~6.2. Diet controlled at home. He was controlled by a humalog insulin sliding scale here. . 11)Hypothyroidism: Patient on Levoxyl as outpatient. Per OSH records he has been found to be subtherapeutic. He was continued on levothyroxine at 50mcg daily. . 12)GERD/hiatal hernia: He was continued on a PPI, as per his outpatient regimen. . 13) Comfort care: Goals of care were advanced to comfort measures only. His medication regimen was adjusted accordingly but all PO meds and antibiotics continued. ICD was deactivated by EP. He is written for PO liquid morphine, though he continues to deny symptoms of pain. He is being transferred to for hospice care. | Incompletely evaluated is the loculated right pleural effusion, emphysematous changes of the lungs, and focal scarring of the left upper lobe which appear similar to yesterday's chest CT where they are better evaluated. Similarly, a small fluid-density locule inferior to the pancreatic head is noted-- uncertain if this is related to the pancreas (IPMN, pancreatic pseudocyst or side branch) or lymph node. Unchanged large right pleural effusion causing compressive atelectasis of right lower lobe and part of right middle lobe. A few scattered benign hemangiomas are noted within the thoracic spine, and there is marked degenerative changes. Moderate centrilobular emphysema with slightly irregular region of left upper lobe scarring and probable 1-2 mm left upper lobe pulmonary nodule. Additionally, there is a questionable mm nodule (3:23) and an irregular area of scarring and traction bronchiectasis noted within the left upper lobe (3:16). The airways are patent to the segmental level, although prominence of the interstitial septae (right greater than left) may suggest a mild amount of interstitial pulmonary edema. Hence, evaluation is limited for accurate assessment of abscess or abnormal enhancmeent in the region of left parotid and elsewhere in the neck. Mild-to-moderate left lower lobe atelectasis persists with slightly diminished visualization of left hemidiaphragm suggesting increased atelectasis or slight differences in technique. The laryngeal phase demonstrate mild delay in initiation of the pharyngeal swallow. The oral phase demonstrate markedly reduced bolus formation, bolus control, and anterior to posterior tongue movement. concern for abscess. CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There is a large lobulated lateral and medial simple right pleural effusion causing compression of the majority of the right lower lobe and partial atelectasis of the right middle lobe. Diffusely hyperattenuated hepatic parenchyma on this non-contrast examination may be related to prior contrast examination (if done at OSH), or suggest underlying hemosiderosis, hemochromatosis or be related to Amiodarone therapy. The lung parenchyma displays moderate diffuse centrilobular emphysema and a small right apical calcified granuloma with multiple punctate calcified density is noted within portions of collapsed right lower lobe, likely suggestive of granulomas as well. concern for absc Admitting Diagnosis: S/P FALL MEDICAL CONDITION: 79 yo M s/p odontoid fx, now with new L parotid area swelling, extremely tender; elev WBC. There are small subcentimeter scattered lymph nodes of the bilateral cervical chains, not pathologic by CT criteria. Moderate right pleural effusion, with loculation. IMPRESSION: Decreased pulmonary edema with slightly increased left lower lobe atelectasis. Pt with hypotension in ED, loculated right pleural effusion of right lung REASON FOR THIS EXAMINATION: Eval of loculated effusion of right lung CONTRAINDICATIONS for IV CONTRAST: ARF FINAL REPORT HISTORY: Severe CHF, hypertensive in ED with loculated right pleural effusion. Amount of vascular engorgement is slightly diminished. Mild prominence of the interstitial septae suggests mild amount of edema. IMPRESSION: No significant internal change in size of right effusion and adjacent atelectasis with persistent mild CHF. FINDINGS: There is moderate right pleural effusion, with loculation along the lateral aspects. Loculated right pleural effusion with lateral and medial components causing compressive atelectasis of the majority of the right lower lobe and partial atelectasis of the right middle lobe. Also cover area on gluteal fold with same duoderm.Psychosocial:No family communication overnoc. A 13 x 19 mm fluid-density locule is seen inferior to the pancreatic body. Epiglottic deflection was absent. IMPRESSION: Unsuccessful nasointestinal tube placement. This causes mild-to-moderate degree of spinal canal narrowing at several levels, most pronounced at C3/C4 due to posterior osteophyte formation and facet arthropathy. A small amount of gallbladder sludge is noted to be layering dependently. There is prominent bilateral simple renal cysts with chronic cortical thinning and atrophy of the renal parenchyma. There is marked cardiomegaly in this patient with a pacemaker present with left ventricular and left atrial enlargement and coronary circulation atherosclerotic disease. See c-spine CT for dens fracure. After the swallow, moderate residue remain in the valleculae and mild residue was seen in the piriform sinuses. IMPRESSION: Heterogeneous enlargement of the left parotid gland with adjacent edema of the soft tissues of the neck. Given differences in technique, the size of large right pleural effusion causing atelectasis of the right lower lobe and part of the right middle lobe is not significantly changed. Pt has significant pitting edema of the lower extremities. NPNNeuro:intactPain: Pt c/o left jaw and neck pain dilaudid increased per Dr see new order. CT OF THE NECK WITHOUT CONTRAST: There is heterogeneous enlargement of the left parotid gland which measures about 4.5 x 3.3 cm on axial view. These findings could represent post- traumatic hematoma and edema. The findings in the left parotid with loss of adjacent fat planes can be due to post-traumatic changes, hematoma, inflammation, edema, or infection. Atherosclerotic disease noted in the abdominal aorta and there is mild fatty replacement of the pancreas. The orientation of the dens is abnormal, consistent with a dens fracture. Thus IV's are saline locked.Huo=30-50ml/hr.Breath sounds remained clear but decreased especially in the bases.Coughing without raising secetions. Rule out bleed. Aspiration Precautions.VS q 1 hr and Prn Cardiomegaly and coronary and aortic atherosclerotic disease. 10:26 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: please assess swelling on L parotid region. (Over) 10:26 PM CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # Reason: please assess swelling on L parotid region. IMPRESSION: Severe oropharyngeal dysphasia with aspiration of all consistencies. | 12 | [
{
"category": "Radiology",
"chartdate": "2114-07-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 976045,
"text": " 11:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cause of acute change in status\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with chronic R pleural effusion, CHF, COPD, acute onset SOB\n and desat\n REASON FOR THIS EXAMINATION:\n eval for cause of acute change in status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute onset of shortness of breath and desaturation. Evaluate for\n interval change.\n\n PORTABLE CHEST\n\n Comparison made to CT and chest radiograph. No\n significant interval change is noted in size and appearance of large right\n pleural effusion causing compressive atelectasis of a part of the right middle\n and right lower lobes. Mild-to-moderate left lower lobe atelectasis persists\n with slightly diminished visualization of left hemidiaphragm suggesting\n increased atelectasis or slight differences in technique. Prominence of the\n perihilar vessels and interstitial markings is not significantly changed.\n No pneumothorax or new infiltrates are identified.\n\n IMPRESSION:\n\n No significant internal change in size of right effusion and adjacent\n atelectasis with persistent mild CHF. No new infiltrates or pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-07-17 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 975937,
"text": " 3:02 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: Please place dopoff under fluoroscopy\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with parotitis, s/p fall with odontoid fx. Fail speech and\n swallow. Needs Doopoff for feeding\n REASON FOR THIS EXAMINATION:\n Please place dopoff under fluoroscopy\n ______________________________________________________________________________\n FINAL REPORT\n NASOINTESTINAL TUBE PLACEMENT\n\n INDICATION: 79-year-old man with odontoid fracture and aspiration.\n\n Under continuous fluoroscopic guidance, numerous attempts were made to advance\n an 8 French - feeding tube. All attempts were unsuccessful due\n to patient's discoordinated swallowing.\n\n There were no immediate procedure-related complications.\n\n IMPRESSION: Unsuccessful nasointestinal tube placement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-07-16 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 975757,
"text": " 1:30 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for aspiration, new consolidation\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with chronic R pleural effusion, CHF, COPD, desat'd overnight\n with crackles on exam\n REASON FOR THIS EXAMINATION:\n eval for aspiration, new consolidation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate for new aspiration or consolidation.\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n Comparison is made to supine radiograph dated and CT\n examination from same day.\n\n Given differences in technique, the size of large right pleural effusion\n causing atelectasis of the right lower lobe and part of the right middle lobe\n is not significantly changed. Amount of vascular engorgement is slightly\n diminished. Slight increase in left lower lobe atelectasis is noted. No\n evidence of pneumothorax or new infiltrates. Single lead AICD device is\n unchanged.\n\n IMPRESSION:\n\n Decreased pulmonary edema with slightly increased left lower lobe\n atelectasis. Unchanged large right pleural effusion causing compressive\n atelectasis of right lower lobe and part of right middle lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-07-14 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 975541,
"text": " 10:26 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: please assess swelling on L parotid region. concern for absc\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 yo M s/p odontoid fx, now with new L parotid area swelling, extremely\n tender; elev WBC.\n REASON FOR THIS EXAMINATION:\n please assess swelling on L parotid region. concern for abscess.\n CONTRAINDICATIONS for IV CONTRAST:\n elevated Cr\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79-year-old male after recent fall with dens fracture, now with left\n parotid area of swelling which is tender. Patient has leukocytosis.\n\n COMPARISON: CT cervical spine, CT head, and CT chest .\n\n TECHNIQUE: Non-contrast CT of the neck with soft tissue algorithm.\n\n CT OF THE NECK WITHOUT CONTRAST: There is heterogeneous enlargement of the\n left parotid gland which measures about 4.5 x 3.3 cm on axial view. There is\n adjacent edema and inflammatory stranding of the subcutaneous fat of the left\n neck. No focal fluid collection or abscess is seen. There is no subcutaneous\n emphysema. There are small subcentimeter scattered lymph nodes of the\n bilateral cervical chains, not pathologic by CT criteria. The dens fracture\n is better visualized on yesterday's CT cervical spine. Incompletely evaluated\n is the loculated right pleural effusion, emphysematous changes of the lungs,\n and focal scarring of the left upper lobe which appear similar to yesterday's\n chest CT where they are better evaluated.\n\n IMPRESSION: Heterogeneous enlargement of the left parotid gland with adjacent\n edema of the soft tissues of the neck. These findings could represent post-\n traumatic hematoma and edema. No focal drainable fluid collection identified.\n No subcutaneous gas to suggest infection but this cannot be definitively\n excluded.\n\n NOTE ON ATTENDING REVIEW:\n\n IV Contrast was not given due to pt.'s elevated serum creatinine of 3.7 on\n .\n Hence, evaluation is limited for accurate assessment of abscess or abnormal\n enhancmeent in the region of left parotid and elsewhere in the neck.\n Study can be repeated with IV contrast, after discussion with clinical team\n and appropriate precautions or treatment for elevated creatinine.\n The findings in the left parotid with loss of adjacent fat planes can be due\n to post-traumatic changes, hematoma, inflammation, edema, or infection.\n\n Accurate assessment of symmetry of structures in the neck is limited due to\n positioning.\n\n Dr. reviewed the study and edited the report.\n (Over)\n\n 10:26 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: please assess swelling on L parotid region. concern for absc\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 975342,
"text": " 7:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with odontoid fx, elevated WBC\n REASON FOR THIS EXAMINATION:\n Evaluate for PNA\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL CHEST RADIOGRAPH\n\n CLINICAL HISTORY: Elevated WBC, odontoid fracture, evaluate for pneumonia.\n\n COMPARISON: None.\n\n TECHNIQUE: Single frontal supine portable chest radiograph.\n\n FINDINGS: There is moderate right pleural effusion, with loculation along the\n lateral aspects. There is increased opacity in the right mid lung which could\n represent atelectasis, however, pneumonia cannot be excluded. Left-sided\n pacemaker is noted, with its single lead projecting over left ventricle. The\n right cardiac border cannot be accurately evaluated, however, there is likely\n cardiomegaly. There is no pneumothorax. The osseous structures are grossly\n unremarkable.\n\n IMPRESSION:\n 1. Moderate right pleural effusion, with loculation. Underlying pneumonia\n can't be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-07-13 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 975324,
"text": " 4:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P FALL, C2 FX FROMOSH, ASSESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with c2 fx after fall\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KMcd FRI 7:30 AM\n No ICH. See c-spine CT for dens fracure.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79-year-old man with C2 fracture after fall. Rule out bleed.\n\n COMPARISONS: None.\n\n TECHNIQUE: CT head without contrast.\n\n FINDINGS: No acute intracranial hemorrhage, mass effect, shift of normally\n midline structures, or major vascular territorial infarct is apparent. The\n visualized paranasal sinuses and mastoid air cells are clear. The\n orientation of the dens is abnormal, consistent with a dens fracture. The\n remainder of the bony structures and surrounding soft tissue structures are\n unremarkable.\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage.\n\n 2. Abnormal orientation of the dens corresponds to dens fracture, visualized\n on the C-spine CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-07-13 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 975325,
"text": " 4:42 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: S/P FALL, C2 FX FROM PSH, ASSESS.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with ?odontoid fx on OSH CT after fall from standing\n REASON FOR THIS EXAMINATION:\n Evaluate for C-spine injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD FRI 6:46 AM\n POSITIVE for acute fracture of the mid-dens (the fx line is just below the\n anterior atlantodental space). There is 30 degree angulation and 3.5mm\n posterior displacement of the cranial portion of the dens relative to the\n base.\n\n MD\n ______________________________________________________________________________\n FINAL REPORT\n 5INDICATION: 79-year-old man with question odontoid fracture on outside\n hospital CT after fall from standing. Evaluate for fracture.\n\n CT C-SPINE WITHOUT CONTRAST: The outside hospital films are not available for\n comparison. There is a fracture through the base of the dens with 4 mm\n posterior displacement of the dens in relation to the base. There also is a\n posterior offset of the ring of C1 in relation to C2. There is no significant\n compromise of the spinal canal and the outline of the thecal sac appears\n unremarkable. There are multilevel degenerative changes throughout the\n cervical spine. This causes mild-to-moderate degree of spinal canal narrowing\n at several levels, most pronounced at C3/C4 due to posterior osteophyte\n formation and facet arthropathy. There is also associated narrowing of the\n neural foramina. There is no prevertebral soft tissue swelling. Surrounding\n soft tissue structures do not demonstrate evidence of trauma. Lung apices are\n clear and there is no pneumothorax.\n\n IMPRESSION: Type II dens fracture. Posterior offset of C1 over C2 could\n indicate possible ligamentous injury. If this is a concern, then an MRI would\n be recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-07-16 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 975760,
"text": " 1:44 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: assess for etiology of difficulty swallowing\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with multiple medical problems, now s/p odontoid fracture and\n failed speech and swallow eval\n REASON FOR THIS EXAMINATION:\n assess for etiology of difficulty swallowing\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Difficulty swallowing.\n\n TECHNIQUE: Oral and pharyngeal swallowing video fluoroscopy was performed in\n collaboration with speech pathology division. Nectar thick liquid, and puree\n consistency barium were administered.\n\n The oral phase demonstrate markedly reduced bolus formation, bolus control,\n and anterior to posterior tongue movement. Premature spillage was\n consistently seen prior to initiation of the swallow. The oral cavity residue\n was observed after swallow. The laryngeal phase demonstrate mild delay in\n initiation of the pharyngeal swallow. Epiglottic deflection was absent. After\n the swallow, moderate residue remain in the valleculae and mild residue was\n seen in the piriform sinuses.\n\n Penetration was seen after the swallow with all consistencies. Aspiration of\n thin liquid, nectar thick liquids, and puree fluids was observed after swallow\n due to spillage. Cough was produced upon aspiration.\n\n IMPRESSION: Severe oropharyngeal dysphasia with aspiration of all\n consistencies.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-07-13 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 975427,
"text": " 5:24 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Eval of loculated effusion of right lung\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with severe CHF, new odontoid fracture now with C-collar. Pt\n with hypotension in ED, loculated right pleural effusion of right lung\n REASON FOR THIS EXAMINATION:\n Eval of loculated effusion of right lung\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Severe CHF, hypertensive in ED with loculated right pleural\n effusion. Further characterize effusion.\n\n Comparison is made to prior radiograph dated .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest without\n intravenous contrast. 5 mm, 1.25 mm, and coronal reformations were evaluated.\n\n CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There is a large lobulated\n lateral and medial simple right pleural effusion causing compression of the\n majority of the right lower lobe and partial atelectasis of the right middle\n lobe. No left effusion is identified and there is no pericardial fluid noted.\n There is marked cardiomegaly in this patient with a pacemaker present with\n left ventricular and left atrial enlargement and coronary circulation\n atherosclerotic disease.\n\n The lung parenchyma displays moderate diffuse centrilobular emphysema and a\n small right apical calcified granuloma with multiple punctate calcified\n density is noted within portions of collapsed right lower lobe, likely\n suggestive of granulomas as well. Additionally, there is a questionable \n mm nodule (3:23) and an irregular area of scarring and traction bronchiectasis\n noted within the left upper lobe (3:16). The airways are patent to the\n segmental level, although prominence of the interstitial septae (right greater\n than left) may suggest a mild amount of interstitial pulmonary edema. A mild\n amount of scarring is noted within the left lower lobe.\n\n Limited examination of the upper abdomen displays mild diffusely increased\n attenuation of the liver on this non-contrast examination, with Hounsfield\n units measuring approximately 86. No focal hepatic masses are identified. A\n small amount of gallbladder sludge is noted to be layering dependently. There\n is prominent bilateral simple renal cysts with chronic cortical thinning and\n atrophy of the renal parenchyma. Atherosclerotic disease noted in the\n abdominal aorta and there is mild fatty replacement of the pancreas. A 13 x 19\n mm fluid-density locule is seen inferior to the pancreatic body.\n\n BONE WINDOWS: No malignant-appearing osseous lesions are identified. A few\n scattered benign hemangiomas are noted within the thoracic spine, and there is\n marked degenerative changes.\n\n (Over)\n\n 5:24 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Eval of loculated effusion of right lung\n Admitting Diagnosis: S/P FALL\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Loculated right pleural effusion with lateral and medial components\n causing compressive atelectasis of the majority of the right lower lobe and\n partial atelectasis of the right middle lobe. Unable to assess pleural\n enhancement on this non-contrast examination.\n\n 2. Moderate centrilobular emphysema with slightly irregular region of left\n upper lobe scarring and probable 1-2 mm left upper lobe pulmonary nodule. In\n absence of prior comparison examinations, this can be further evaluated for\n stability in 12 months.\n\n 3. Cardiomegaly and coronary and aortic atherosclerotic disease. Mild\n prominence of the interstitial septae suggests mild amount of edema.\n\n 4. Diffusely hyperattenuated hepatic parenchyma on this non-contrast\n examination may be related to prior contrast examination (if done at OSH), or\n suggest underlying hemosiderosis, hemochromatosis or be related to Amiodarone\n therapy. Please correlate clinically and consider MRI if needed. Similarly, a\n small fluid-density locule inferior to the pancreatic head is noted--\n uncertain if this is related to the pancreas (IPMN, pancreatic pseudocyst or\n side branch) or lymph node. If MR is performed, this can also be assessed at\n that time.\n\n 5. Bilateral renal cysts with atrophic appearing kidneys.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-07-13 00:00:00.000",
"description": "Report",
"row_id": 1676354,
"text": "Admission Note\nD. Pt admitted to Sicu from ER A&O,moving all extremities with J collar on,3 Np at 2l and Foley catheter\n Pt's Sbp initially dropped from 96 to 83 for which Medical Resident ordered sm fluid bolus of 250ml Normal saline.Hr remained unchanged at 90's AF. Pt's Bp miniml responded to fluid. Pt has significant pitting edema of the lower extremities. Thus IV's are saline locked.Huo=30-50ml/hr.Breath sounds remained clear but decreased especially in the bases.Coughing without raising secetions. O2 sat on 2l= 95-99\n Pt remains A&O,follows commands. Pt has strong gag and cough reflexes. However,pt aspirated water stating that it is hard to swallow with the collar on.\n Afebrile.\n Pt states that he has a pain level of 4 constant .His neck and jaw especially the left side of jaw very sensitive to touch as when collar care was done. He also stated he had rlq abd pain which hurts when he coughs. Medical Team aware\na. Call Ho if Sys bp <80. Pt to have chest CT scan this PM. Aspiration Precautions.VS q 1 hr and Prn\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-07-14 00:00:00.000",
"description": "Report",
"row_id": 1676355,
"text": "NPN\nNeuro:intact\nPain: Pt c/o left jaw and neck pain dilaudid increased per Dr see new order. Pt needs to be medicated before turming.\nCV:Pt has AICD and is in afib rate in the 90's. skin cool and dry, oximeter on foot due to poor trace using fingers.\nResp:O2 sats 98 on 3l NP. breath sound crackles bibasilar. No maintainance fluid per MICU team.\nGI:Pt chocked on water on day shift so is NPO, no pills yet. Swallow study to be done today. Blood sugars 154 (2 units reg insulin given)\nand 101(no insulin given).\nGU:Adequate u/o concentrated yellow urine.\nSkin per carevue, duoderm to coccyx for reddened skin that blanches. Also cover area on gluteal fold with same duoderm.\nPsychosocial:No family communication overnoc. Pt pleasant copimg well under the circumstances. DNR status needs to be addressed with pt and family\nPlan:Comtinue plan of care\nlogroll and maintain J collar\nassess need for special mattress.\nPlan\n"
},
{
"category": "ECG",
"chartdate": "2114-07-18 00:00:00.000",
"description": "Report",
"row_id": 112208,
"text": "Accelerated junctional rhythm. Low limb lead voltage. Intraventricular\nconduction delay. No previous tracing available for comparison. Clinical\ncorrelation is suggested.\n\n"
}
] |
1,488 | 182,355 | A/P: 1.)Respiratory failure - Patient presented with SOB and respiratory failure and was found to have PNA on CXR with bilateral lower lobe opacities, as well as mild CHF, superimposed on severe emphysema. The patient was intubated and ventilated. Empiric antibiotics were started to cover community acquired PNA and sepsis. Once blood, urine, and sputum cultures were obtained antibiotics were tailored appropriately. Attempts at weaning the patient were unsuccessful. The patient also had severe AS and mild CHF contributing to the respiratory picture, and she was gently hydrated in the setting of sepsis. Albuterol, atrovent, and solumedrol were given for treatment of COPD. However, once the patient suffered a CVA (see below), goals of care were reassessed and the patient was extubated, became apneic, and passed away from respiratory distress. . 2.)Sepsis - Patient was hypotensive and tachycardica. Blood cultures grew MRSA in bottles. GPC were found on gram stain of the sputum, but nothing grew, and MRSA grew in the urine. She was treated with broad spectum empiric antibiotics but eventually tapered to vancomycin, as staph aureus was sensitive to this. Hypotension was also treated with gentle fluid boluses in setting of AS. There was a concern for endocarditis with her valve, and a TTE was done that showed worsening AS and EF, but no vegetations. However, the suspicion for endocarditis remained high, especially after her CVA that showed evidence of multiple acute emboli. The patient required pressors throughout her hospital stay to maintain pressures. Once it was determined that recovery from CVA would be minimal, it was decided to withdraw all artificial support and the patient passed within one hour of extubating and removing pressors. . 3.) R-sided paralysis - No evidence of ICH on CT, but MRI showed multiple areas of acute infarct, thought to be d/t endocarditis in the setting of a dilated /t severe AS. Neuro was involved and made recommendations to start ASA, maintain pressures 140-160, and obtain carotid U/S. While these maneuvers were attempted, it was difficult to maintain SBP in setting of sepsis. Ultimately it was decided that the multiple new acute infarcts would be detremental to the patient's quality of life, and that she would not wish to live in such a compromised state, and pressors were withdrawn. . 4.)ARF - Initially was prerenal, but evolution led to muddy brown casts on sediment, suggestive of ATN, likely d/t hypotension in setting of sepsis. UOP markedly improved and Cr normalized. . 5.)CAD - CK and troponins elevated and peaked. Elevated enzymes represented demand ischemia in setting of critical AS, infection, and hypotension. Dr. of cardiology saw the patient and determined that cardiac cath was not indicated at the time. . 6.) Hyperglycemia - Insulin gtt with good control . 7.) Thrombocytopenia- stabalized at 65, normal. HIT Ab was negative. Meds such as vancomycin and protonix were likely contributors. | There is moderateglobal left ventricular hypokinesis (anterior wall appears slightly morehypokinetic). Trace aortic regurgitation is seen. Since the previous tracingof atrial fibrillation is now seen. Normal ascending aorta diameter.AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Sinus tachycardiaRight axis deviationPoor R wave progression with late precordial QRS transition - is nonspecificClinical correlation is suggested for possible chronic pulmonary diseaseSince previous tracing of , precordial ST-T wave changes decreased SINGLE VIEW CHEST, AP: Severe bullous emphysematous changes are again identified. A/p: pt with mrsa sepsis, now attempting to wean from vent. Endocarditis.Height: (in) 60Weight (lb): 100BSA (m2): 1.39 m2BP (mm Hg): 120/60HR (bpm): 122Status: InpatientDate/Time: at 14:17Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.LEFT VENTRICLE: Mild symmetric LVH. Again, there are small areas of periventricular white matter hypoattenuation, which likely relates to chronic microvascular ischemic changes. There is mild symmetric left ventricularhypertrophy. There is a tortuous aorta with calcifications. A small focus of low signal on susceptibility-weighted images in the left corona radiata basal ganglia region indicate a small area of chronic blood products from previous hemorrhage. Received albuterol and atrovent mdi's in-line. The right internal jugular central venous line tip terminates at the cavoatrial junction. ET tube and right internal jugular line are in standard placements and a nasogastric tube passes above the diaphragm and out of view. COMPARISON: Chest x-ray dated . There ismoderate pulmonary artery systolic hypertension. Moderate mitralannular calcification. sedation off. Severe AS.Trace AR.MITRAL VALVE: Moderately thickened mitral valve leaflets. Sinus tachycardia. Sinus tachycardia. Right jugular CV line is in mid SVC. ]TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. [Due toacoustic shadowing, the severity of mitral regurgitation may be significantlyUNDERestimated.] The tracing continues to show right axisdeviation, left ventricular hypertrophy by voltage in the precordial leads,and non-specific ST-T wave abnormalities.TRACING #1 There is a mild, S-shaped scoliosis to the thoracolumbar spine. An ET tube terminates within the trachea. Persistent small bilateral pleural effusions. Moderate global LVhypokinesis.AORTA: Normal aortic root diameter. SINGLE VIEW CHEST, AP: There has been interval placement of a nasogastric tube, which extends off the lower edge of the film within the stomach. ID: remains on vanco for mrsa sepsis. other abx dc'd. Breath sounds are diminished bilat. small amt stool out after dulcolax supp. FINDINGS: The diffusion images demonstrate multiple small foci of slow diffusion involving the left frontal and both parietooccipital lobes. IMPRESSION: Multiple small areas of acute infarcts in both cerebral and cerebellar hemispheres as described above. Mild leftward mediastinal shift suggests component of atelectasis in the left lower lobe opacification. Mild thickening of mitral valve chordae. Could represent asymmetric edema or pneumonia particularly aspiration, accompanied by increasing small left pleural effusion. Moderate (2+) mitralregurgitation is seen. SINGLE PORTABLE AP SEMI UPRIGHT CHEST RADIOGRAPH: There is moderate to severe cardiomegaly. Increased ST-T wave abnormalitiesare noted diffusely throughout the tracing. Pt has brief periods of apnea able to recover. GI: Abd soft, bs+,tympanic in quality this pm. tolerating vasopressor wean. remains on triple abx. REMAINS ON VANCO, CEFTRI, AND AZITHOMYCIN. Intubated for resp. pt with + UTI, and + PNA. AND EVEN THOUGH PT. COntinued to be acidotic via abg. HAS BEEN GIVEN SENOKOT, COLACE, AND REGLAN TO ADD IN EFFECTIVE MOTILITY. Postion change q2-3hr as tolerated. Pt currently in SR with bp 121/58. Note bun/cr, electrolyes, ?etiology of low uo, prerenal vs other. Her CVP is . HAS RECEIVED BOTH COLACE AND REGLAN. REMAINS ON VANCOMYCIN. Receiving MDI's. OTHERWISE PT. ABG'S DRAWN AND PT. REMAINS A FULL CDODE, WITH PLANS TO WEAN VENT WHEN POSSIBLE. cpk/MB 121/14 and 159/25 today. CV: ST with varrying rate. able to tolerate fio2 wean. Pt remains on current vent settings, see carevue for details. NPN/ADM-MICUMrs. GI: ab firm, distended, bs +. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. assess tolerance of tf's. REMAINS TO WEAP, AND HAS REDDENED HEELS BILAT WITH NO NOTED BREAKDOWN AT THIS TIME. TEAM FEELS AFTER ASSESSMENT THAT PT. 12 lead ekg done this am. HAD BEEN EXHIBITING LOW GRADE TEMP WITH TMAX 100.4, PT. CV: HR 90's-1teens, NSR/ST, with rare short of svt to , which are self limiting. She was cx, central line placed, put on Levophed, given IV AB and IVF. IS TRENDING DOWN WITH LAST B.S. Her Hr con tto be in the 120's,still holding her her Dilt dose. Pulm: See data/RT notes for vent changes and abg's. lactate 2.2. REMAINS UNSEDATED FOR >36HRS. Alb/atro MDI x 3. on lansoprazole. ?further diuresis vs fluid repletion. PeRRL. Resp CarePt remains intubated and on Cpap/Psv. abg was 7.29/45/227/23. NPN-MICUMrs. S/P SEPSIS +BLD CX, PNA, UTI, PULM HTN BY ECHO MOD AS, 1+ MR AND 2+ TRICUSPID REGURG, COPD ON HOME O2, R/O MI +CK AND +TROPONIN CR 1.2 HOWEVERP. taking 1-2 breaths over set ventilator rate.Bs: coarse exp. Will continue mech vent and wean as tol. Will continue mech vent and wean as tol. PRESENTLY PT. Monitor BP as pt is still labile Cont resp support until pt in better postion to be eval for extubation, freq nebs, steroids and IVAB cont. HAS BEEN SUCTIONED FOR MOD. Team will allow pH greater than 7.2. Resp CarePt remains on PCV-parameters noted. Free water boluses continue q4hr for na level 151. REMAINS ON PS 18 PEEP 5.WITH SATS 93-96%.CVS; TMAX 99. Some flatus passed and some stool noted at rectum. REMAINS ON VANCOMCIN AT THIS TIME, WITH CULTURES EXHIBITING MRSA IN BLOOD AND SPUTUM.PT. Pt having periods of dysynchrony. Resp Care73 adm. from ED with SOB, tachypnea, tachycardia, hypotension> MUST protocol. Hct is stable and coags WNL. CXR done and per intern ? | 38 | [
{
"category": "Echo",
"chartdate": "2177-08-20 00:00:00.000",
"description": "Report",
"row_id": 61612,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Endocarditis.\nHeight: (in) 60\nWeight (lb): 100\nBSA (m2): 1.39 m2\nBP (mm Hg): 120/60\nHR (bpm): 122\nStatus: Inpatient\nDate/Time: at 14:17\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: Mild symmetric LVH. Normal LV cavity size. Moderate global LV\nhypokinesis.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Severe AS.\nTrace AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. No MS.\nModerate (2+) MR. Eccentric MR jet. [Due to acoustic shadowing, the severity\nof MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. There is moderate\nglobal left ventricular hypokinesis (anterior wall appears slightly more\nhypokinetic). The aortic valve leaflets are severely thickened/deformed. There\nis severe aortic valve stenosis. Trace aortic regurgitation is seen. The\nmitral valve leaflets are moderately thickened. Moderate (2+) mitral\nregurgitation is seen. The mitral regurgitation jet is eccentric. [Due to\nacoustic shadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is\nmoderate pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the findings of the prior study (tape reviewed) of , the\noverall LVEF has significantly decreased and the degree of aortic stenosis\ndetected is now severe.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2177-08-23 00:00:00.000",
"description": "Report",
"row_id": 114140,
"text": "Atrial fibrillation, average ventricular rate 182. Since the previous tracing\nof atrial fibrillation is now seen. Increased ST-T wave abnormalities\nare noted diffusely throughout the tracing.\n\n"
},
{
"category": "ECG",
"chartdate": "2177-08-19 00:00:00.000",
"description": "Report",
"row_id": 114141,
"text": "Sinus tachycardia\nRight axis deviation\nPoor R wave progression with late precordial QRS transition - is nonspecific\nClinical correlation is suggested for possible chronic pulmonary disease\nSince previous tracing of , precordial ST-T wave changes decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2177-08-18 00:00:00.000",
"description": "Report",
"row_id": 114142,
"text": "Sinus tachycardia. No diagnostic change from the previous tracing of .\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2177-08-17 00:00:00.000",
"description": "Report",
"row_id": 114143,
"text": "Sinus tachycardia. Other than a more rapid rate, no diagnostic change from the\nprevious tracing of . The tracing continues to show right axis\ndeviation, left ventricular hypertrophy by voltage in the precordial leads,\nand non-specific ST-T wave abnormalities.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 881784,
"text": " 12:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: post intubation film\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman intubated\n REASON FOR THIS EXAMINATION:\n post intubation film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia, status post intubation.\n\n COMPARISONS: Two hours earlier.\n\n SINGLE VIEW CHEST, AP: There has been interval placement of a nasogastric\n tube, which extends off the lower edge of the film within the stomach. An ET\n tube terminates within the trachea. There are persistent increased asymmetric\n interstitial opacities consistent with pulmonary edema, which appears slightly\n worse when compared to the previous exam.\n\n IMPRESSION:\n 1. Appropriate placement of NG and ET tube.\n 2. Worsening, asymmetric pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 882484,
"text": " 2:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess for infarction, hemorrhage, masses, shift\n Admitting Diagnosis: CHRONIC OBSTRUCTIVE PULMONARY DISEASE FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with new R sided U.E/L.E paresis, facial sparing, limited CN\n exam seems normal.\n REASON FOR THIS EXAMINATION:\n please assess for infarction, hemorrhage, masses, shift\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS:\n\n Today's examination is compared to the prior from . Again, there\n are small areas of periventricular white matter hypoattenuation, which likely\n relates to chronic microvascular ischemic changes. However, there is no\n evidence of an intracranial hemorrhage. The -white matter differentiation\n is otherwise preserved. There is no midline shift, mass effect or\n hydrocephalus.\n\n IMPRESSION: Chronic microvascular ischemic changes without evidence of acute\n intracranial hemorrhage or infarct. No midline shift.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 882020,
"text": " 3:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ****\n Admitting Diagnosis: CHRONIC OBSTRUCTIVE PULMONARY DISEASE FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Increased ventilatory support requirements.\n\n REASON FOR THIS EXAMINATION:\n ****\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Increased ventilatory support requirements.\n\n COMPARISON: Chest x-ray dated .\n\n SINGLE PORTABLE AP SEMI UPRIGHT CHEST RADIOGRAPH: There is moderate to severe\n cardiomegaly. There is a tortuous aorta with calcifications. Note is made of\n emphysema with a large bulla in the right upper lobe. The pulmonary arteries\n are dilated consistent with pulmonary arterial hypertension. The previously\n identified mild congestive heart failure is improving. There are persistent\n small bilateral pleural effusions. There are bilateral opacities in the lower\n lobes, worse on the left, which could represent pneumonia versus atelectasis.\n The endotracheal tube is 4.7 cm above the carina. The right internal jugular\n central venous line tip terminates at the cavoatrial junction. The NG tube\n tip is not visualized but is below the diaphragm.\n\n IMPRESSION:\n 1. Improving mild congestive heart failure. Persistent small bilateral\n pleural effusions.\n 2. Bilateral lower lobe opacities, worse on the left, which could represent\n pneumonia versus atelectasis.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 881775,
"text": " 9:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Hx of copd w/ aortic stenosis and fever\n\n REASON FOR THIS EXAMINATION:\n pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD, aortic stenosis, fever.\n\n COMPARISONS: .\n\n SINGLE VIEW CHEST, AP: Severe bullous emphysematous changes are again\n identified. There is persistent cardiomegaly and unfolding of the aorta.\n There are interval increased interstitial opacities within the left and right\n mid lung zones, which likely represent asymmetric distribution of pulmonary\n edema. There is no evidence of pneumothorax. There is a mild, S-shaped\n scoliosis to the thoracolumbar spine.\n\n IMPRESSION: Asymmetric pulmonary edema superimposed on severe, bullous\n emphysema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 882390,
"text": " 3:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please reassess chest\n Admitting Diagnosis: CHRONIC OBSTRUCTIVE PULMONARY DISEASE FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n mrsa pna\n REASON FOR THIS EXAMINATION:\n please reassess chest\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4 A.M. \n\n HISTORY: Staph pneumonia.\n\n IMPRESSION: AP chest compared to chest films since , most\n recently :\n\n Asymmetric pulmonary edema has improved in the left lung, remains stable on\n the right. Some pneumonia may be present, difficult to distinguish from\n edema. Mild leftward mediastinal shift suggests component of atelectasis in\n the left lower lobe opacification. Right internal jugular line, ET tube, and\n nasogastric tube are in standard placements.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 882490,
"text": " 3:18 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: reassess\n Admitting Diagnosis: CHRONIC OBSTRUCTIVE PULMONARY DISEASE FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n mrsa pna\n REASON FOR THIS EXAMINATION:\n reassess\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: MRSA pneumonia.\n\n Endotracheal tube is 6 cm above carina. Right jugular CV line is in mid SVC.\n NG tube is in stomach with distal end not included on film. No pneumothorax.\n There has been no change in the appearance of the heart or lungs since the\n previous film obtained on the same date. The bilateral pleural effusions and\n ill-defined pulmonary opacities predominantly in the right lower zone and left\n perihilar region are again demonstrated as is the marked bullous emphysema in\n the right upper lobe and to a lesser extent in the left upper lobe. No\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-23 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 882566,
"text": " 11:27 AM\n MR HEAD W/O CONTRAST Clip # \n Reason: Please perform MRI brain c stroke protocol\n Admitting Diagnosis: CHRONIC OBSTRUCTIVE PULMONARY DISEASE FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman with PNA/sepsis, intubated, noticed to have R hemiparesis.\n REASON FOR THIS EXAMINATION:\n Please perform MRI brain c stroke protocol\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Patient with sepsis intubation and right hemiparesis\n for further evaluation.\n\n TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial\n images of the brain were obtained.\n\n FINDINGS: The diffusion images demonstrate multiple small foci of slow\n diffusion involving the left frontal and both parietooccipital lobes. Small\n foci of slow diffusion are also seen in both cerebellar hemispheres. Several\n of these foci are also visualized on T2 and FLAIR images. Findings are\n indicative of multiple acute small cortical and subcortical infarcts. There\n is no mass effect or hydrocephalus. A small focus of low signal on\n susceptibility-weighted images in the left corona radiata basal ganglia region\n indicate a small area of chronic blood products from previous hemorrhage.\n There is no hydrocephalus or midline shift seen.\n\n IMPRESSION: Multiple small areas of acute infarcts in both cerebral and\n cerebellar hemispheres as described above. No mass effect or hydrocephalus.\n Other changes as above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-08-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 881787,
"text": " 1:58 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate line placement\n Admitting Diagnosis: CHRONIC OBSTRUCTIVE PULMONARY DISEASE FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old woman intubated s/p Right IJ. Check line placement.\n\n REASON FOR THIS EXAMINATION:\n evaluate line placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 1:58 A.M. ON \n\n HISTORY: Intubation following internal jugular line placement.\n\n IMPRESSION: AP chest compared to and :\n\n Severe emphysema, apical predominant, dilated pulmonary arteries due to\n pulmonary arterial hypertension and moderate-to-severe cardiomegaly are\n chronic. Over the past 48 hours, interstitial abnormality, predominantly in\n the left lung, has worsened. Could represent asymmetric edema or pneumonia\n particularly aspiration, accompanied by increasing small left pleural\n effusion.\n\n ET tube and right internal jugular line are in standard placements and a\n nasogastric tube passes above the diaphragm and out of view.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-21 00:00:00.000",
"description": "Report",
"row_id": 1281520,
"text": "NPN 7a-7p:\n Nuero: Propofol weaned throughout day. Initially pt minimally responsive to pain, withdrawing only LLE. Later, pt attempting to open eyes to voice. Propfol off at this time, in attempts to obtain true RSBI/SBT. PERRLA.\n CV: maps 70's. HR 80's-90's NSR. CVP 3-6. Received 500cc's ns bolus x 1 for low UO with good effect.\n RESP: peep decreased to 5 from 8 with adequate abg. pt remains on PSV 18/5/.40 at this time. will follow off propofol. Sx q 4 hrs for thick white/yellow secretions. weak cough and gag while sedated.\n FE: cont on insulin gtt 2.5-5units/hr. pt weeping large amt serous fluid from bilateral arms. lytes ok.\n heme: heparin dc'd, as pt with plts dropping to 67K today. HIT ab sent.\n Integ: remains with edematous, red arms. Unit based wound care specialist into evaluate pt's LLE and RLE wounds. pt obtained both wounds prior to hospitalization when her grandson's scooter fell on her leg. sites cleansed with NS, duoderm gel and duoderm applied bilaterally. please cont this regime at this time. Duoderm in place to coccyx. pt placed on kinair mattress d/t high risk for breakdown.\n Gi: tf's off much of the day, as residuals >100cc's. bs present. disempacted for large amt hard brown stool, and started on bowel regime. small amt stool out after dulcolax supp. will most likely need further disempaction. Tf's resumed at 1/2 previous rate as residuals down to 10cc's this afternoon. nutrition consult ordered.\n Gu: urine with sediment, yellow. UO improved after 500cc's fluid bolus today.\n ID: remains on vanco for mrsa sepsis. other abx dc'd. afebrile.\n Social: daughter and son into visit. other dtr called.\n A/p: pt with mrsa sepsis, now attempting to wean from vent. sedation off. plan to trial rsbi/sbt when pt more awake. cont frequent fsbs, titrate up tf's as able. cont bowel regime/skin care regime.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-21 00:00:00.000",
"description": "Report",
"row_id": 1281521,
"text": "Pt remains on current vent settings, see carevue for details. No vent changes made this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-20 00:00:00.000",
"description": "Report",
"row_id": 1281515,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Received albuterol and atrovent mdi's in-line. No morning abg at this time.\n\nRSBI not determine due to level of PEEP required.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-20 00:00:00.000",
"description": "Report",
"row_id": 1281516,
"text": "Resp Care\nPt remains on mech vent-parameters noted. NO wean this shift. Plan is to wean PEEP, but waiting on new a-line. Pt has brief periods of apnea able to recover. Breath sounds are diminished bilat. Alb/atro x 3. Will continue mech vent and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-20 00:00:00.000",
"description": "Report",
"row_id": 1281517,
"text": "NPN 0700-1900;\nCARDIAC ECHO DONE AWAITING RESULTS.\nNEURO; SEDATED WITH PROPOFOL WEANED FROM 40 MCGS/KG/MIN TO 20 AS UNABLE TO ELICIT AND RESPONSE TO NAILBED PRESS. RAISED EYE BROWS ONCE BUT INCREASED AGAIN AT 6PM AS RR 35-45. ANNND SATS 96-93%.\n\nRESP; LUNGS COARSE DIMINISHED AT BASES. SUCTIONED Q2 FOR MOD AMOUNTS THICK TAN SECRETIONS.SATS 96-93%.HAVING PERIODS OF APNEA ESPECIALLY AFTER REPOSITIONING. RR UP AND SATS DECREASED ON 20 MCGS PROPOFOL THEREFORE PROPOFOL RESTURNED TO 35 MCGS/KG/MIN.\n\nCVS; TMAX 100. 130-118. BP 85-113/70. NO ECTOPY NOTED. CVP 3-4\n\nGU; 20-40 MLS/HR YELLOW URINE VIA FOLEY . TEAM AWRE.\n\nGI TOLERAING T/F INCREASING TO GOAL OF 40 MLS/HR RESIDUALS , MOD 20 MLS Q4. CONTINUES TO PASS SOFT FORMED STOOL WITH OCCASS HARD STOOL WITH EACH REPOSITIONING GUAIAC NEG.BELLY SOFT HYPOACTIVE BS REGAL REDUCED TO 5MGS .\n\nENDO REMAINS ON INSULIN GTT. WILL REASSES WHEN T/F AT GOAL.\n\nID; MSRA GROWN IN BLOOD AND URINE.\n\nSKIN WEEPING FROM I.V SITES REQUIRING CHANGING Q2.\nDUODERM INTACT ON COCCYX, ? SMALL TEAR ON POSTERIOR ANUS.\n\nSOC ;DAUGHTERS INTO VISIT SEPARATELY BOTH VERY TEARFUL UPDATED WITH CURRENT CONDITION AND PLAN OF CARE.\n\nA/P CONTINUE TO MONITOR URINE OUTPUT AND RENAL LABS. ? CHANGE SEDATION TO FENTANYL AND VERSED ONE SET OF BLOOD CULTURES DONE UNABLE TO OBTAIN PERIPH CULTURE TEAM STILL PLANNING TO PLACCE ALINE.\n OFFER EMOTIONAL SUPPORT TO PT AMD FAMILY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-21 00:00:00.000",
"description": "Report",
"row_id": 1281518,
"text": "Respiratory Care:\nPatient's PEEP was dropped to 8 cm from 10 cm. Morning abg results determined a mild partially compensated respiratory acidemia with excellent oxygenation on the current settings (see CareVue).\n\nFailed RSBI (253)\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-21 00:00:00.000",
"description": "Report",
"row_id": 1281519,
"text": "PT. REMAINS SEDATED ON PROPOFOL GTT AT 35MCG/KG/MIN. PT. HAS BEEN LIGHTENED, AT 20MCG'S WITH PT. NOTED TO GRIMACE WITH ASSESSMENT AND MOVES HEAD FROM SIDE TO SIDE. PT. DOES NOT FOLLOW ANY COMMANDS, NOR IS THERE MUCH UPPER OR LOWER EXT'S MOVEMENT. PT. DOES NOT OPEN EYE TO VERBAL OR NOXIOUS STIMULI. PT. HAD BEEN EXHIBITING LOW GRADE TEMP WITH TMAX 100.4, PT. PRESENTLY 99.4 BLOOD CULTURES WERE DRAWN LAST NIGHT PT. REMAINS ON VANCO, CEFTRI, AND AZITHOMYCIN. PUPILS ARE EQUAL AND REACTIVE. PT. HAS BEEN NST 116-122 WITH NO NOTED ECTOPR THROUGHOUT THIS SHIFT. B/P HAS WNL'S WITHOUT SUPPORTIVE MEASURES. PT. HAS BEEN OFF LEVOPHED FOR >24HRS. MAP'S >60. PULSES ARE WEAK BUT PALPABLE, WITH GROSS GENERALIZED EDEMA N0TED IN BOTH UPPER AND LOWER EXT'S. PT. CONTINUES TO WEAP AT ALL OLD PUNCTURE SITES. PT. REMAINS INTUBATED WITH ONLY VENT CHANGES OF PEEP FROM MADE WITH PT. MAINTAINING SATS. ABG'S DRAWN AND PT. TOLERATED THIS WELL. PT. UNFORTUNATELY HAS A RSBI >200 THIS AM. Q2HR SUCTIONING REVEALS THICK TENACIOUS TAN COLORED SECRETIONS. PT. RESP RATE HAS BEEN CONTROLLED AND SATS >95%. PT. REMAINS ON TUBE FEEDS AT GOAL, PROMOTE WITH FIBER AT 40CC/HR VIA OGT.. RESIDUALS HAD BEEN HIGN OVER THE PAST 24HRS, BUT OVER THIS PAST 12HRS PT'S LARGEST RESIDUAL HAS BEEN 20CC Q4HRS. BLOOD SUGARS HAVE BEEN RANGING 42-285 WITH INSULIN GTT ON AND OFF. PRESENTLY PT. IS TRENDING DOWN WITH LAST B.S. 185 AND INSULIN GTT AT 2UNITS/HR. PT. CONTINUES TO HAVE CONSTANT SMALL SEMI FORMED BROWN GUAIC NEGATIVE STOOL. SMALL POSTERIOR ANAL TEAR NOTED WHICH IS NO WORST AND APPROX. 0.25CM IN SIZE. PT. REMAINS TO WEAP, AND HAS REDDENED HEELS BILAT WITH NO NOTED BREAKDOWN AT THIS TIME. DUODERM TO COCCYX REGION REMAINS INTACT. ALL LINES REMAIN INTACT, SECURED, AND FUNCTIONING WELL. ALINE CONTINUES TO CORRELATE WITH CUFF PRESSURES. PT. REMAINS A FULL CODE, PLAN TO WEAN VENT SETTINGS WHEN APPROPRIATE, AND MONITOR ABG'S AS WELL BLOOD SUAGRS WITH INSULIN GTT. TEAM IS AWARE OF MARGINAL URINARY OUTPUT WITH CREAT SLIGHTLY DOWN THIS AM AND BUN SLIGHTLY UP. CVP HAS BEEN , BUT NO ADDITIONAL FLUIDS ARE WANTED AT THIS TIME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-19 00:00:00.000",
"description": "Report",
"row_id": 1281511,
"text": "NEURO PROPOFOL AT 36MCG/KG/MIN SEDATION SHUT OFF NEURO EXAM MAE, FC, PUPILS EQUAL AND REACTIVE PROPOFOL RESUMED.\nRESP PCV 40%/ PINSP 34/ TINSP .65/ RESP RATE 25/ PEEP 10 ABG 7.42/35/149/23/0 LUNGS CTA SX SM AMT YELLOW THIN SECRETIONS\nCVS HCT 31.3 LEVOPHED SHUT OFF AT 0500 MAINTAINING BP > 100/ MEAN > 60, HR 100-111 ST WITHOUT ECTOPY. CVP 5-11. SKIN MOIST, ECCHYMOTIC, WEEPY, THIN. HAS AN AREA ON LT CALF SIZE OF HALF DOLLAR YELLOW DRAINAGE SM. CK 159/72 MB 25/14 PP DOPPLER\nID TEMP MAX 99.8 WBC 16.5 ON CEFTRIAXONE/VANCO AND AZITHROMAX ALSO RECEIVING SOLUMEDROL IV\nGU U/O < 59CC X3 HRS GIVEN A 500CC BOLUS LR MN -05 +69CC, BUN 56 CR 1.2 URINE AMBER WITH SEDIMENT SENT FOR UA CR AND NA\nGI TF INCREASED TO 30CC PROMOTE WITH FIBER GOAL 40CC RESIDUALS 20-100 ABD SOFT BS+ NO STOOL\nENDO BS 162 NOT ON SS INSULIN\nACCESS LT RADIAL A LINE, RT IJ, 20G RLA\nA. S/P SEPSIS +BLD CX, PNA, UTI, PULM HTN BY ECHO MOD AS, 1+ MR AND 2+ TRICUSPID REGURG, COPD ON HOME O2, R/O MI +CK AND +TROPONIN CR 1.2 HOWEVER\nP. ANTIBX AS ORDERED AWAIT CX RESULTS, MONITOR WBC, DIFF, TEMP,\nORDER SS INSULIN, INCREASE TF TO GOAL TF 40CC CHECK RESIDUALS Q NEED REGLAN, WEAN AS TOL FROM VENT\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-19 00:00:00.000",
"description": "Report",
"row_id": 1281512,
"text": "Resp Care\nPt remains on mech vent-parameters noted. Pt having periods of dysynchrony. Increased sedation will little alleviation. After multiple episodes of dysynchrony, pt switched to PS/CPAP. ABG pending. Will continue mech vent and wean as tol. Increased aeration following bronchdilator therapy.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-19 00:00:00.000",
"description": "Report",
"row_id": 1281513,
"text": "See data, MD notes/orders. Neuro: , pt responds locally to noxious stimuli. Propofol gtt increased to 50mcg/kg/min for hypertension,dysynchrony with ventilator and tachycardia. CV: ST with varrying rate. Initially 125 decreasing to 106-110 after fluid bolus x2. Currently heart rate is 127- 130. IVF initiated at 200cc/hr with no change in heart rate, cvp 11-20. levophed gtt remains off, sbp 109-130/70's. Pulm: See data/RT notes for vent changes and abg's. Lung sounds have been coarse to clear, decreased on right side. CXR done this pm for drop in 02 sats, reccurring dysynchrony and tachycardia. CXR done and per intern ? worsening pnuemonia on right side vs fluid. GU: Uo has been 5cc/hr since this am and has not responded to fluid boluses. Lasix 10mg given IVP with little improvement. Pm electrolytes to include bun/cr pending. Foley catheter irrigated with normal saline flushing easily. GI: Abd soft, bs+,tympanic in quality this pm. Tube feeds held for several hours for residuals >100cc. Reglan iniated as ordered and tube feed resumed at 10cc/hr one hour later with hob 45 degrees or >. Some flatus passed and some stool noted at rectum. Endo: Blood glucose elevated >180 with insulin gtt resumed to keep glucose 80-110. Skin: Papery, ecchymotic and weeping from upper extremities. Area of demarcation on right arm outlined at request of team. No change noted this shift. Pt oozing serosanguanous fluid from upper extremities, is continually diaphoretic and has pitting edema of lower extremities. Pedal pulses by , crt sec. Duoderm applied to bony prominence at coccyx. Soc: Has three children, lives with daughter \"\". P: Continue propofol gtt titrate prn comfort and to assist with ventilatory synchrony, daily wake up. On going assessment of tachycardia/tachypnea. Vent changes as ordered and appropriate. ?further diuresis vs fluid repletion. Note bun/cr, electrolyes, ?etiology of low uo, prerenal vs other. Titrate tube feed q4hrs to goal 40cc/hr if residuals <100cc. Q1-2hr finger stick glucose, titrate insulin gtt prn for above parameters. Postion change q2-3hr as tolerated. Keep family up to date on poc, offer reassurance, answer questions as appropriate. Pt seen by pcp . who also spoke with pts daughter . status reviewed and remains full status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-20 00:00:00.000",
"description": "Report",
"row_id": 1281514,
"text": "NPN-MICU\nMrs. remains on vent, hemodynamically stable\nResp:pt cont to be vent on PSV of 18/10 with RR 20 and TV of 400. She has intermitenly had some apnea where her RR is down to 8, no obvious cause and pt remains sedated on propofol (even a sl less dose than when met). Her secretions are min but thick and tan. She has a low grade fever.Her O2 sats have been 93-95%\nCV: pt cont to maintain her own BP 88-110/50's MAP>60. Her Hr con tto be in the 120's,still holding her her Dilt dose. Her CVP is . K+ holding at 4.8\nGU: pt has been increasing her u/o now up to 15-20cc/hr.BUN/CR remain up for her. HO looked at urine and confirm her to have ATN at present.\nNeuro:pt remains on propofol, have decreased dose to 40mcg as pt is unrsp to anything. Her PERL, and she has moved her head away during mouth care but she does not MAE. She still takes these ineffective breathes that do not trigger vent they are not interfereing withthe vent.\nSkin:pt stil very edematous and is now weeping from prev puncture sites and oozing from skin tears.left leg dsd is intact. Rt Aline was D/c'd as it leaking and eventually unablke to draw blood from it, Mulptiple sticks done to get new Aline but they were defeated.\nGI:pt cont on TF promote. It has been very slowly increased as pt still has about 60cc asp q4hrs. She had sm amt of hard stool in rectum, and it was removed, OB-. Hct is stable and coags WNL. Insulin drip cont, BS are 116-130's on 1u/hr\nA/P:Will cont to follow her renal function and try diuresis when able, Follow lytes & u/o to determine cont ATN.\n Monitor BP as pt is still labile\n Cont resp support until pt in better postion to be eval for extubation, freq nebs, steroids and IVAB cont. Keep comf on vent with sedatives\n Cont to get TF back to goal of 40cc/hr, assess for increased asp, note stool amt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-23 00:00:00.000",
"description": "Report",
"row_id": 1281530,
"text": "See data. MD notes/orders. Neuro: Opens eyes spontaneously, , doesn't follow commands, track or respond to questions. Left hand and toes move spontaneously, grimaces but does not move right hand/lower extremity away from noxious stimuli. MRI of brain done this am that per team, shows multiple samll hemorrhages. CV: Pt had been in SR with occ pac's until late this morning when she had sustained sinus tachycardia accompanied by tachypnea and hypertension. She responded to vent changes per RT notes as well as 2.5mg haldol IV with HR decreasing to low 100's. At 1615 she went into raf with sustained hr up to 200 bpm which was accompanied by hypotension to a systolic bp of 68-77. She was given 500cc fluid bolus and total of 10mg metoprolol with hr decreasing to 150's and hypotension continued. She was cardioverted back to SR after 1mg midazolam IVP with 50jules of energy. Norepinephrine gtt was initiated for hypotension and amio bolus 150mg was given over ten minutes followed by amio gtt running at 1mg/min. Pt currently in SR with bp 121/58. Pulm: Had done well on cpap , placed on AC durring above event and is now on AC with 60%fi02. O2 sats 100%, lungs coarse bilaterally. GU: Uo >50cc/hr clear amber. GI: Abd soft, tube feeds off temporarily, back on at 45cc/hr with hob elevated 30 degrees. Free water boluses continue q4hr for na level 151. Pt incontinent of small formed stool x2. Endo: Insulin gtt in place and titrated to keep glucose 80-110 currently at 1.5u/hr. Soc: Pt has three children who were notified of critical change in status as well as MRI results. Code status discussed by family, MD and nurse and decision was made to make pt DNR based on her wishes. P: Continue current poc keeping DNR status in mind, provide support to family. R: As above, the catholic priest notified and will come in tonight at request of family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-18 00:00:00.000",
"description": "Report",
"row_id": 1281506,
"text": "NPN/ADM-MICU\nMrs. is a 73yo woman adm to MICU for sepsis and COPD/?PNX\nPMH:HTN, CAD, MI :EF of 45-55%\n COPD, long h/o cig use\n h/o DVT's, Herpes Zoster\nAll:NKDA\nMeds:numerous but inc:Lasix, prednisoe, Dilt, ASA, Neurotin, lipitor\nPt in her USOH till about 3days ago when she developed cough&fever.She denied any N/V no CP. Today, she sudsequently became increasingly SOB, dehydrated, taking decreased po's, fever to 102, and daughter called ambulance. In EW, pt was acutely SOB, trial of Bipap was not tolerated and she was thus intubated. Pt was also becoming more hypotensive and septic:urine very cloudy. She was cx, central line placed, put on Levophed, given IV AB and IVF. Sent to MICU for cont care of her sepsis/PNX.\nMICU Course:\nNeuro: pt placed on propofol, currently at 45mcg/mn, she is well sedated. Her PERL, she has moved her extrem but not to mcuh. She has a good gag and cough, but does not follow commands.\nResp:multiple vent changes made to optimize her oxygenation and improve ventilation. Ultimately, she was placed on PCV 36/10 and able to get Fio2 to 60% and improve her pH and CO2. She has some secretions and is moving a sm amt of air by 6am.Sputum cx sent is EW. She cont on steroids and freq nebs:alblut and atrovent.\nID:she is currently afebrile, cx pnd. Her WBC ct is up to30 this am. She is on 3 IVAB for now\nGU:pt has recieved totol of 7L IVF, CVP is about now. She has min u/o due to cont mild hypotension. Her BUN/CR is 46/1.4(baseline is .5). Her urine cx is pnd but it is reported to be cloudy.\nGI: pt is NPO for now, OGT in place, no stool as yet +BS. Her blood sugars are 140-130, no coverage as yet.\nCV: pt cont on Levophed, able to wean some but by 6am pt was dropping again and so currently is on .3mch/kg/mn, Her BP is now up more at 90/60 with MAP 60.Her Hr has been in ST 112-120, holding Dilt for low BP. Her lactate was 3 on adm but now down to 2.4.Adm EKG With changes ?rate related but on R/O MI\nAccess:rt IJ, x2 \nSocial:pt with 3 children, Daughter: -HCP, lives with and a son. Pt was DNR but consented to these recessitative measures for a short time.\nA/P:Will cont to wean off Levo as able, MAP>60, follow R/o MI- enzymes at 1pm.\n Cont to follow ABG and adjust vent to optimize lung status,Cont IVAB and pulm toilet as able. Follow fever curve and await cx results.\n Monitor u/o and CVP to optimize hydration status\n Keep pt comf on vent with propofol and add fentanyl for pain as needed.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-18 00:00:00.000",
"description": "Report",
"row_id": 1281507,
"text": "Resp Care\n73 adm. from ED with SOB, tachypnea, tachycardia, hypotension> MUST protocol. Intubated for resp. distress. H/O severe COPD,empysema.\nPoor aeration upon arrival, hypoxic with severe resp. acidosis and hypotensive on levo for support. Given 20 puffs of albuterol, which had a good effect, improved aeration and flow-volume loop. initially had 13-15cm auto-peep, which resolved with increasing applied PEEP to 10, bronchodilator and short I time. COntinued to be acidotic via abg. Changed over to PCV, sedation increased. Follow up abgs revealed improving respiratory acidosis/oxygenation.Tidal volumes on a DP of 26 350-420cc, occ. taking 1-2 breaths over set ventilator rate.\nBs: coarse exp. wheezes otherwise diminished. No secreations noted.\nPlan: continue current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-18 00:00:00.000",
"description": "Report",
"row_id": 1281508,
"text": "Resp Care\nPt remains on PCV-parameters noted. Decreased resp rate per team to decrease auto peep. Team will allow pH greater than 7.2. Scattered wheezes bilat. Alb/atro MDI x 3. Will continue mech vent and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-18 00:00:00.000",
"description": "Report",
"row_id": 1281509,
"text": "MICU NURSING 7A-7P:\n REVIEW OF SYSTEMS:\n Neuro: pt remains deeply sedated on Propofol, not overbreathing vent, which is goal, as pt is on PCV. Prop weaned from 45mcg/kg/min proprofol, to 36mcg/kg/min propofol, still without overbreathing. Withdraws extremities to pain. PeRRL.\n RESP: remains vented PCV, DP 26/peep10/fio.60, resp rate decreased to 28 to 30 in hopes of decreasing auto-peep (was 12), and in hopes of permissive hypercapnea, to facilitate later weaning attempts. abg was 7.29/45/227/23. fio2 decreased to .50, sats remain 97%. Will wean further as tolerated. Sx for minimal secretions, yellow and thick. LS remain clear at this time. on solu-medrol atc.\nID: pt with 4/4 blood cx + GPC, no speciation yet. pt with + UTI, and + PNA. low grade temps. remains on triple abx. lactate 2.2.\n CV: HR 90's-1teens, NSR/ST, with rare short of svt to , which are self limiting. team aware. CVP 7-14, attempted several fluid boluses to keep cvp mid teens, as UO dropped to 10cc's/hr this am. Unable to keep cvp higher than 12, but uo has increased to 70-80cc's/hr past 2 hrs. pt is currently 11L +. per team no further fluid boluses, unles UO drops below 30cc's/hr. 12 lead ekg done this am. cpk/MB 121/14 and 159/25 today. pt initially on .3mcg/kg/min levo, weaned to .09mcg/kg/min levo this afternoon after fluid boluses.\n GI: ab firm, distended, bs +. Tf's started and maintained at 10cc's/hr, as residual 70cc's last check. on lansoprazole. + flatus, no stool this shift.\n GU; uo as noted, urine amber with sediment.\n FE: fsbs wnl. repleated with K+ total 60meq iv today, and 4 amps mgso4, and 2 amps calcium gluconate. please f/u with team r/e need for labs this evening.\n Social: pt's daughter in at bedside throughout day, spoke with MD's. pt's son also into visit, to return this pm.\n INteg: pt with LLE laceration/abrasion from bumping into her grandson's skooter this week. laceration had duoderm over it from pt's vna.. duoderm removed, and area cleaned. bacitracin applied with dsd.\n A/P: pt with sepsis, + UTI, + PNA and + blood cx. tolerating vasopressor wean. able to tolerate fio2 wean. Cont to wean pressors/fio2 as tolerated. no further fluid boluses unless uo <30. assess tolerance of tf's. may need swab of LLE. f/u with team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-19 00:00:00.000",
"description": "Report",
"row_id": 1281510,
"text": "Respiratory Care:\nPatient remains on PCV ventilatory support with improved compliance leading to Pinsp = 34; PEEP = 10; and delta P = 24. Morning abg results revealed a normal acid-base balance with excellent oxygenation.\n\nNo RSBI at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-22 00:00:00.000",
"description": "Report",
"row_id": 1281524,
"text": "NPN 0700-1500;\nNEURO; OFF PROPOFOL SINCE 30; OPENS EYES TO VOICE APPEARS TOCLOSE EYES TO COMMAND BUT NOT CONSISTENTLY. NO RESPONSE TO NAIL BED PRESS ON RT , WRIGGLED FINGERS ON LT AND SMILED AND OPENED MOUTH TO COMMAND. RSPONDS VERY SLOWLY.PERLA 3-2 MM. FAMLIY WONDER IF PT HAS RT SIDED FACIAL DROOP. DAUGHTER STATES THAT PT HAD SHINGLES IN WAS ADMITTED TO HOSPITAL AS COULD NOT MOVE RT ARM WITH PT PT HAD ABBOUT 60 % FUNCYION RT ARM WAS MUCH WEAKER THAN LT. MD AWARE.\n\nRESP; LUNGS COARSE WITH EXP WHEEZE SUCTIONED INITAILLY FOR COPIOUS AMOUNTS OF THICK TAN SECRETIONS MUCH LESS TOWARDS END OF SHIFT. PT WITH PERIODS OF TACHYPNEA RR TO 45. ABG SHOWED DROP IN PO2 TO 64 FIO2 INCREASED TO 40% WITH PO2 TO 84. ? REMAINS ON PS 18 PEEP 5.WITH SATS 93-96%.\n\nCVS; TMAX 99. 110 WITH PAC;S. BP 130-155/77 WITH SUCTIONING.\n\nGU; GOOD RESPONSE TO LASIX 20 MGS I.V\n\nGI; T/F CHANGED TO PROBALANCE SF STARTING AT20 ADVANCING TO GOAL OF 40 BY 10 MLS Q4 IF TOLERATED. CONTINUES TO HAVE SMALL AMOUNT OF STOOL WITH EACH TURN. BELLY SOFT HYPO BS RESIDUALS 10-20 MLS Q4.\n\nENDO ;INSULIN GTT CONT BS 94-110.\n\nSKIN MUCH LESS WEEPY CONTINUES TO DRAIN AROUND INSERTION SITE SEROUS DRAINAGE AQUALCELL PLACED.WITH SOME IMPROVEMENT. DUODERM ON COCCYX INTACT.RT ARM REDDENESS UNCHANGED.DUODERMONLEGS INTACT.\n\n SOC; FAMILY INTO VISIT UPDATED WITH PT CURRENT CONDITION ANDPLAN OF CARE SPOKE WITH MD EXPRESSED CONCERN AS THOUGHT PT HAD RT SIDED FACIAL WEAKNESS.\n\nA/P NOT WAKENING UP FROM PROPOFOL GTT APPROPRIATELY FOR HEAD CT. CONTINUE TO MONITOR URINE OUTPUT. MONITOR NEURO STATUS OFFER EMOTIONAL SUPPORT PT AND FAMILY\n\n\n\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-22 00:00:00.000",
"description": "Report",
"row_id": 1281525,
"text": "NURSING MICU NOTE 3P-7P\n\nPLEASE SEE CAREVUE FOR ALL DATA. SEE ABOVE NOTE FOR EVENTS OF THE DAY. PT TAKEN TO HEAD CT FOR EVAL OF WAKING SLOWLY OFF PROPOFOL GTT. EARLY READ SHOWS NO BLEED OR STROKE. NEURO TEAM CALLED TO CONSULT, REREADING CT SCAN. POSSIBLE MRI IN FUTURE. PT WILL OPEN EYES, MOVE LEFT EXTREMITES. PT WILL MOVE TOES ON RIGHT SIDE, BUT NOT MOVING LEG. PT'S DAUGHTER UPDATED ON CT SCAN. SHE WILL CALL LATER IN NIGHT TO GET ANOTHER UPDATE. PT IS A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-22 00:00:00.000",
"description": "Report",
"row_id": 1281526,
"text": "Pt remains on current vent settings, see carevue for details. Head CT today neg for bleed/stroke. Receiving MDI's. No vent changes made today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-23 00:00:00.000",
"description": "Report",
"row_id": 1281527,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Morning abg results determined a respiratory alkalemia with excellent oxygenation on the current settings.\n\nAlthough the patient failed her RSBI, it should be noted that the number indicates that she is progressing. RSBI = 119.7 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-23 00:00:00.000",
"description": "Report",
"row_id": 1281528,
"text": "PT. REMAINS UNSEDATED FOR >36HRS. PT. OPENS EYES SPONTANEOUSLY, BUT DOES NOT TRACK AT THIS TIME. PT. DOES FOLLOW SIMPLY COMMANDS BUT THIS REMAINS INCONSISTANT AT THIS TIME. PT. DOES MOVE LEFT ARM AND AND LEG BUT MINIMAL RIGHT HAND MOVEMENT NOTED AND NO RIGHT LEG MOVEMENT NOTED DURING THIS SHIFT. NEURO WAS IN TO ASSESS PT. AND EVEN THOUGH PT. HAS HEAD CT YESTERDAY, WHICH WAS NEGATIVE. TEAM FEELS AFTER ASSESSMENT THAT PT. HAS EXPERIENCED A SIGNIFICANT EVENT. PT. HAS BEEN ORDERED FOR BILAT CAROTID DUPLEX AND MRI FOR FURTHER ASSESSMENT. PT. HAS BEEN AFEBRILE DURNG THIS SHIFT. PT. HAS BEEN NSR 80-90'S WITH NO NOTED ECTOPY. B/P HAS BEEN WITHOUT SUPPORT FOR >72HRS. PT. HAS GENERALIZED EDEMA WHICH CONTINUES TO IMPROVE. PT. IS WEAPING AT OLD PUNCTURE SITES BUT THIS HAS BEEN LESSENING QSHIFT. PULSES ARE VERY WEAK BUT PALPABLE, AND EASILY DOPPLED. PT. REMAINS INTUBATED WITH SETTINGS UNCHANGED, AND RSBI'S IMPROVING, EVEN THOUGH PT'S AM RSBI IS 119. PT. HAS BEEN SUCTIONED FOR MODERATE AMT'S OF THICK BLOOD TINGED/TAN SECRETIONS. RESP RATE HAS BEEN CONTROLLED AND O2 SATS ARE >95%. PT. HAS BEEN RECEIVNG TUBE FEEDS AT 20CC/HR. GOAL IS PROMOTE WITH FIBER AT 40CC/HR.RESIDUALS HAVE REMAINED ELEVATED Q4HRS 20-50-70. PT. REMAINS ON INSULIN GTT RANGING 1-3 UNITS/HR AND BLOOD SUGARS HAVE BEE 72-186. BOWEL SOUNDS ARE EASILY AUDIBLE AND PT. HAS NOT REQUIRED DISIMPACTION DURING THIS SHIFT. PT. HAS BEEN GIVEN SENOKOT, COLACE, AND REGLAN TO ADD IN EFFECTIVE MOTILITY. PT. HAS HAD TWO SEMI FORMED BROWN GUAIC NEGATIVE STOOL. PT. ABD. IS OTHERWISE BENIGN IN ASSESSMENT. FOLEY CATHETER REMAINS INTACT AND FUNCTIONING WELL WITH >50CC/HR NOTED, WHICH IS MUCH IMPROVED FROM PREVIOUS SHIFTS. PT. SKINS EXHIBITS DOUDERM TO COCCYX AND WOUND GEL TO LOWER EXTREMITIES WOUNDS WHICH OCCURRED PRIOR TO ADMISSION. OTHERWISE PT. CONTINUES TO WEAP FROM OLD PUNCTURE SITES. ALL LINES ARE INTACT AND PATENT, WHILE SECURED. PT. REMAINS ON SPECIALTY BED. PT. HAS EXPERIENCED ELEVATED WBC COUNT 19.8-30-36.6 AM LAS ARE PENDING. PT. REMAINS ON VANCOMCIN AT THIS TIME, WITH CULTURES EXHIBITING MRSA IN BLOOD AND SPUTUM.\nPT. REMAINS A FULL CDODE, WITH PLANS TO WEAN VENT WHEN POSSIBLE. PT. IS SCHEDULED A CAROTID U/S ,AND MRI RE: NEURO ASSESSMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-23 00:00:00.000",
"description": "Report",
"row_id": 1281529,
"text": "Resp Care\n\nPt remains intubated and on Cpap/Psv. Pt had SBT this am and lasted 15 minutes before hr increased to 120's and rr increased to high 30's. After having an MRI pressure support was decreased to 15 with a follwupabg of 7.41/47/91/34. BS remain diminished and suctioning thick tan sputum.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-22 00:00:00.000",
"description": "Report",
"row_id": 1281522,
"text": "PT. REMAINS OFF PROPOFOL SINCE 1730 YESTERDAY. PT. IS INCREASINGLY BECOMING MORE AWAKE. PT. OPENS EYES TO VERBAL STIMULI, BUT IS ONLY ABLE TO WIGGLE FINGERS UPON COMMAND. PT. PUPILS REMAIN BILAT BRISK EQUAL. PT. HAS BEEN AFEBRILE EVEN THOUGH WBC'S CONTINUE TO CLIMB DRAMATICALLY, 19.8-30-36.8 PT. REMAINS ON VANCOMYCIN. PT. HAS BEEN NSR 80-90'S WITH NO NOTED ECTOPY. B/P REMAINS WNL'S WITHOUT ANY SUPPORT REQUIRED. ALINE CONTINUES TO WORK WELL AND CORRELETES WITH CUFF PRESSURE. PT. CONTINUES TO EXHIBIT GENERALIZED EDEMA, WHICH IS SLOWLY IMPROVING OVER THE PAST FEW DAYS. PT. HAS BEEN ON PRESSURE SUPPORT SINCE YESTERDAY AND HAS BEEN TOLERATING THIS WELL WITH RESP RATE CONTROLLED AND O2 SATS >95%. PT. HAS BEEN SUCTIONED FOR MOD. AMT'S OF THICK TAN SECRETIONS. PT. REMAINS ON TUBE FEEDS AT 20CC/HR GOAL IS 40CC/HR BUT RESIDUALS HAVE BEEN ELEVATED. DURING THIS SHIFT RESIDUALS HAVE REMAINED <50CC Q4HR. ABD. IS SOFT SLIGHTYL DISTENDED AND PT. HAS BEEN DISIMPACTED FOR SMALL AMT'S OF FORMED STOOL. PT. HAS RECEIVED BOTH COLACE AND REGLAN. MINIMAL EFFECTS WITH SUPPOSITORY IN HTE PAST. BLOOD SUAGRS HAVE RANGED 100-189 INSULIN GTT WAS OFF AND NOW IS ON AT 1UNIT/HR. FOLEY CATHETER IS IN PLACE AND URINARY OUTPUT HAS BEEN >30CC/HR IF YELLOW SEDIMENT URINE. ALL LINES REMAIN INTACT, SECURED AND FUNCTIONING WELL. DRESSINGS REMAIN INTACT TO LOWER LEGS, AND DUODERM REMAINS INTACT TO COCCYX. PT. PRESENTLY HAS BILAT WRIST RESTRAINTS ON DUE TO NO SEDATION.\nPT. REMAINS A FULL CODE, WITH POSITIVE MRSA IN HER BLOOD AND URINE. PT. HAS BEEN SUCCESSFULLY WEANED TO WITH SATS MAINTAINING >95% BUT MORNING RSBI REMAINS HIGH AT 179.\n"
},
{
"category": "Nursing/other",
"chartdate": "2177-08-22 00:00:00.000",
"description": "Report",
"row_id": 1281523,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes thorughout the night. Morning abg results are compatible with mild compensated respiratory acidemia with adequate oxygenation on the current settings.\n\nFailed RSBI.\n"
}
] |
44,527 | 125,479 | This is a 50M w/ esophageal cancer, with a purulent pericardial effusion and pericardial tamponade, sepsis, and acute renal failure, who transfered from an OSH hospital for additional management. The patient was admitted to the SICU for aggressive resuscitation with IV fluids, blood products and pressors. He was additionally treated with broad spectrum antibiotics (vanco/zosyn/micafungin). He had an arterial line and monitoring initiaited to monitor his hemodynamics and a CVL placed to provide additional access reuscitation. Repeat TTE after admission showed small circumferential pericardial effusion without evidence for tamponade. ID was consulted to provide antibiotic recommedations. Blood and urine cultures were sent. Thoracics was consulted to help evaluate whether there was a communication between the esophagus and pericardium and to perform either pigtail placement or a pericardial window for drainage of the pericardium--a pericardial window was ultimatedly placed. Imaging studies failed to reveal any abnormal connection between the esophagus and the pericardium, so the source of the pericardial infection remained unclear (possibly hematogenous spread from a pneumonia). Despite aggressive resuscitation as described above and successful weaning of IV pressor support, the patient's renal failure failed to improve and urine output dropped of preciptitously. Renal was consulted to initiate hemodialysis; however, the patient's family and HCP ultimately decided that this was not in-keeping with the patient's wishes; he was made CMO and placed on minimal vent settings and a fentanyl drip. The final cause of death was from respiratory failure at 1715pm on . The family did request a complete autopsy to shed additional light on his death. Medications on Admission: : ASA 325', diltiazem 240', magic mouth wash, nystatin swish & swallow, percocet . MEDS @OSH: atrovent INH, levalbuterol, admiodarone 900', diltiazem, hydromorphone, imipenem 250q8hrs, lorazepam, morphine, sodium bicarb, zofran, pantoprazole 40', zosyn 3.375q8hrs, vancomycin 1', neosynephrine, ASA 325', benadryl, lidocaine viscous, percocet, miralax, nitroglycerin 0.4q5min prn, colace | --EF nl->hyperdynamic --PAC removed (elevated PAP & RV diastolic pressures prior to d/c) -- placed. Amiodarone 0.25 mg/min IV INFUSION afib Order date: @ 0032 12. --EF nl->hyperdynamic --PAC removed -- placed --EKG w/ elevated Jpoint in lateral leads, CE neg @ osh Pulmonary: --hypoxic on admission, now on cmv 450x16/1.0/14 after abg worse --abg 7.29/53/109/27/-1->7.27/59/79/28/0 --Aa gradient continues, ards protocol->careful of BP as PEEP incr. Hematology: --Hct 26.1 -> 25.1 -> 24.5 ->22.5, transfusing 1 unit --coagulopathic, INR decreased from 3.1 -> 2.1-> 1.7, s/p Vit K x 2 days --FFP on call to OR if needed Endocrine: RISS Infectious Disease: --vanco/zosyn/micafungin () --WBC 30.3->30.1->23.1-> 20.9 --ID consulted --f/u cx osh --GS: WBC, rare GPC in clusters, Aerobic: no growth, Anaerobic pending -- Blood/urine cx: pending --Vanco level 20.4 Lines / Tubes / Drains: R SC port, LIJ TLC, L axillary Aline, foley, ETT, Jtube Wounds: N/A Imaging: CXR today Fluids: KVO Consults: General surgery, CT surgery, ID dept, Nephrology Billing Diagnosis: Sepsis ICU Care Nutrition: Glycemic Control: Regular insulin sliding scale Lines: Indwelling Port (PortaCath) - 08:22 PM Arterial Line - 09:00 PM Multi Lumen - 10:41 PM Prophylaxis: DVT: Boots, SQ UF Heparin Stress ulcer: VAP bundle: Comments: Communication: ICU consent signed Comments: Code status: DNR (do not resuscitate) Disposition: ICU Total time spent: 35 Patient is critically ill Amiodarone 0.25 mg/min IV INFUSION afib Order date: @ 0032 12. Midazolam 1-2 mg IV Q2H:PRN agitation Order date: @ 0032 4. Piperacillin-Tazobactam 2.25 g IV ONCE Duration: 1 Doses Start: Order date: @ 2243 8. Piperacillin-Tazobactam 2.25 g IV Q8H until after dialysis has started. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: @ 2119 24 Hour Events: CORDIS/INTRODUCER - STOP 01:51 PM ULTRASOUND - At 06:34 PM abdominal EKG - At 01:10 AM - minimal UOP with increasing Bun/Cr - entered AFiv with RVR. Norepinephrine 0.3-0.5 mcg/kg/min IV DRIP TITRATE TO map>60 start vasopressin first, add norepi as needed, titrate norepi off first and have vasopressin off last. Albuterol Inhaler PUFF IH Q4H:PRN wheezing Order date: @ 0032 11. Diltiazem 5 mg IV ONCE MR1 Duration: 1 Doses Order date: @ 0028 18. Decompensated overnight & intubated 4am found to have pericardial effusion & tamponade. Decompensated overnight & intubated 4am found to have pericardial effusion & tamponade. Decompensated overnight & intubated 4am found to have pericardial effusion & tamponade. Decompensated overnight & intubated 4am found to have pericardial effusion & tamponade. ABG sent while hypoxic. ABG sent while hypoxic. Underwent pericardocentesis and sent to . Underwent pericardocentesis and sent to . Decompensated overnight & intubated 4am found to have pericardial effusion & tamponade. Decompensated overnight & intubated 4am found to have pericardial effusion & tamponade. Midazolam 1-2 mg IV Q2H:PRN agitation Order date: @ 2119 3. Chlorhexidine Gluconate 0.12% Oral Rinse 7. Albuterol Inhaler PUFF IH Q4H:PRN wheezing Order date: @ 0358 11. Update: 1 unit of PRBCs transfusing d/t drop in HCT prior to OR today. Post operative day: POD#0 - vats, pericardial window. Micafungin 100 mg IV Q24H Order date: @ 2249 4. Monitor closely Hematology: --Hct 26.1 -> 25.1 -> 24.5 ->22.5, transfusing 1 unit PRBC --coagulopathic, INR decreased from 3.1 -> 2.1-> 1.7->1.5 s/p Vit K x 2 days Endocrine: RISS Infectious Disease: --vanco/zosyn () --WBC 30.3->30.1->23.1-> 20.9->20.7 --ID consulted --f/u cx osh --GS: WBC, rare GPC in clusters, Aerobic: no growth, Anaerobic pending -- Blood/urine cx: pending --Vanco level pending --F/up OR Cx Lines / Tubes / Drains: R SC port, LIJ TLC, L axillary Aline, foley, ETT, Jtube, CT, Wounds: Left thoracotomy Imaging: CXR today Fluids: Consults: gen , thoracic, nephrology, ID Billing Diagnosis: (Respiratory distress), Sepsis, Liver failure, Acute renal failure ICU Care Nutrition: Replete with Fiber () - 03:10 AM 10 mL/hour Glycemic Control: Regular insulin sliding scale Lines: Indwelling Port (PortaCath) - 08:22 PM Arterial Line - 09:00 PM Multi Lumen - 10:41 PM Prophylaxis: DVT: Boots Stress ulcer: H2 blocker VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI Comments: Communication: ICU consent signed Comments: Code status: Full code Disposition: ICU Total time spent: 35 minutes Patient is critically ill Opacification of the minimally-distended esophagus up to the level of T8. --thoracics consult - Gangadahran --EF nl->hyperdynamic --PAC removed (elevated PAP & RV diastolic pressures prior to d/c) -- placed. Borderline size of the cardiac silhouette, unchanged retrocardiac atelectasis. CT CHEST WITHOUT CONTRAST: The minimally distended esophagus was opacified up to the level of T8. Compared to the previous tracing of thepatient has gone from atrial fibrillation to normal sinus rhythm. --CXR w/ diffuse haziness Gastrointestinal / Abdomen: --npo/J-tube --no ogt/ngt w/ poss esophageal perf --elevated transaminases. t/x 2u sent --coagulopathic, inr 3.1, stable. A right subclavian central venous catheter terminates at the cavoatrial junction. Minimal improvement of the pre-existing retrocardiac atelectasis. Unchanged marked paraseptal emphysema predominantly involves the apices. Neurologic: --intubated, sedated on fent gtt. Unchanged size of the cardiac silhouette, unchanged extent and severity of the pre-existing parenchymal opacities. --thoracics consulted. --EKG w/ elevated Jpoint in lateral leads, CE neg @ osh --Lactate 1.5<-3.6 Pulmonary: --hypoxic on admission, now on cmv 400x20/0.8/14 --abg 7.30/54/121/28/0 --Aa gradient continues, ards protocol->careful of BP as PEEP incr. Decompensated overnight & intubated 4am found to have pericardial effusion & tamponade. Decompensated overnight & intubated 4am found to have pericardial effusion & tamponade. Decompensated overnight & intubated 4am found to have pericardial effusion & tamponade. | 64 | [
{
"category": "Echo",
"chartdate": "2132-02-19 00:00:00.000",
"description": "Report",
"row_id": 88124,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Previous history of pericardiocentesis.\nHeight: (in) 66\nWeight (lb): 117\nBSA (m2): 1.59 m2\nBP (mm Hg): 99/65\nHR (bpm): 73\nStatus: Inpatient\nDate/Time: at 12:36\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%). False LV tendon (normal variant).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic\nfunction.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3).\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP.\n\nTRICUSPID VALVE: Moderate [2+] TR. Borderline PA systolic hypertension.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential.\nNo echocardiographic signs of tamponade.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). The right\nventricular cavity is mildly dilated with borderline normal free wall\nfunction. The aortic valve leaflets (3) are mildly thickened. The mitral valve\nleaflets are structurally normal. There is no mitral valve prolapse. Moderate\n[2+] tricuspid regurgitation is seen. There is borderline pulmonary artery\nsystolic hypertension. There is a small to moderate sized pericardial effusion\n(1.2 cm). The effusion appears circumferential. There is no evidence of\ntamponade physiology.\n\nCompared with the prior study (images reviewed) of , the effusion is\nlarger. The severity of tricuspid regurgitation has increased.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Report",
"row_id": 88697,
"text": "PATIENT/TEST INFORMATION:\nIndication: s/p pericardiocentesis. ?residual effusion/tamponade.\nHeight: (in) 66\nWeight (lb): 117\nBSA (m2): 1.59 m2\nBP (mm Hg): 103/82\nHR (bpm): 92\nStatus: Inpatient\nDate/Time: at 00:16\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and no color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction.\n\nAORTA: Normal descending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPERICARDIUM: Small pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - ventilator. The rhythm appears to\nbe atrial fibrillation. Emergency study performed by the cardiology fellow on\ncall. Echocardiographic results were reviewed with the houseofficer caring for\nthe patient.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and global\nsystolic function (LVEF>55%). Due to suboptimal technical quality, a focal\nwall motion abnormality cannot be fully excluded. Right ventricular chamber\nsize is normal. with borderline normal free wall function. The aortic valve\nleaflets (?#) appear structurally normal with good leaflet excursion. No\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. There is no mitral valve prolapse. There is\na small, circumferential pericardial effusion, most prominent anterior to the\ndistal right ventricular free wall (0.8cm) with no echocardiographic signs of\ntamponade.\n\nIMPRESSION: Small circumferential pericardial effusion without evidence for\ntamponade physiology. Mild symmetric left ventricular hypertrophy with normal\ncavity size and 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": "Nursing",
"chartdate": "2132-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725502,
"text": "Pericardial effusion with tamponade\n Assessment:\n HR ranging in the 80\ns and 90\ns without ectopy. Heart sounds are\n regular without gallops, murmurs or rubs. CO 4.98 and SBP 114/75.\n Pericardial and anterior chest tube draining small to moderate amounts\n of serosangaunous fluid and are attached to 20mm suction. No leaks or\n crepitus noted and breath sounds are equal bilaterally and 02 sat was\n 99%. Fentanyl running at 50mcg/hr and versed at 3mg/hr. He is not\n responsive to verbal or noxious stimuli and PERRlL.\n Action:\n Maintained Chest tube integrity, noted electrolytes and lightened\n sedation. He was trialed on pressure support ventilation.\n Response:\n He remained hemodynamically stable with electrolytes wnl. He became\n hypertensive with a systolic blood pressure >160 when sedation was\n turned off and with ventilator changes. Sedation was then resumed for\n and he was returned to CMV ventilation.\n Plan:\n Maintain current vent settings, titrate sedation for patient comfort\n and follow hemodynamics. Time wiil be arranged with pts sister/HCP to\n meet with Dr. tomorrow to discuss further poc.\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-22 00:00:00.000",
"description": "Intensivist Note",
"row_id": 725558,
"text": "SICU\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to .\n Chief complaint:\n sepsis, pericardial effusion\n PMHx:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with\n CHADS score of 0 treated with ASA only\n .\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0032 9. Fentanyl\n Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: @ 0032\n 2. IV access: None Order date: @ 0032 10. Heparin 5000 UNIT SC\n TID Order date: @ 0032\n 3. Albuterol Inhaler PUFF IH Q4H:PRN wheezing Order date: @\n 0032 11. Midazolam 1-2 mg IV Q2H:PRN agitation Order date: @\n 0032\n 4. Amiodarone 0.25 mg/min IV INFUSION afib Order date: @ 0032\n 12. Micafungin 100 mg IV Q24H Order date: @ 0032\n 5. Calcium Gluconate IV Sliding Scale Order date: @ 0032 13.\n Midazolam 0.5-5 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0032\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 0032 14. Piperacillin-Tazobactam 2.25 g IV Q8H\n until after dialysis has started. Order date: @ 0032\n 7. Famotidine 20 mg PO/NG Q24H Order date: @ 0841 15. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0032\n 8. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ 0032 16. Vancomycin 1000\n mg IV Q 24H\n Hold for level >15 Order date: @ 0032\n 24 Hour Events:\n Post operative day:\n POD#1 - vats, pericardial window.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:36 PM\n Infusions:\n Amiodarone - 0.25 mg/min\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:23 AM\n Heparin Sodium (Prophylaxis) - 12:24 AM\n Other medications:\n : ASA 325', diltiazem 240', magic mouth wash, nystatin swish &\n swallow, percocet\n .\n Flowsheet Data as of 06:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36.4\nC (97.5\n HR: 70 (69 - 93) bpm\n BP: 112/75(91) {103/68(84) - 183/100(131)} mmHg\n RR: 24 (3 - 27) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.4 kg (admission): 50 kg\n Height: 66 Inch\n CVP: 16 (8 - 335) mmHg\n CO/CI (Thermodilution): (3.97 L/min) / (2.6 L/min/m2)\n SVR: 1,975 dynes*sec/cm5\n SV: 45 mL\n SVI: 29 mL/m2\n Total In:\n 2,284 mL\n 635 mL\n PO:\n Tube feeding:\n 766 mL\n 364 mL\n IV Fluid:\n 1,308 mL\n 271 mL\n Blood products:\n Total out:\n 657 mL\n 110 mL\n Urine:\n 187 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,627 mL\n 525 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n Compliance: 36.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.26/47/99./21/-5\n Ve: 9.8 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 209 K/uL\n 10.1 g/dL\n 116 mg/dL\n 5.5 mg/dL\n 21 mEq/L\n 4.8 mEq/L\n 110 mg/dL\n 98 mEq/L\n 133 mEq/L\n 31.6 %\n 17.9 K/uL\n [image002.jpg]\n 01:00 AM\n 01:12 AM\n 12:58 PM\n 01:57 AM\n 02:11 AM\n 02:36 AM\n 01:44 AM\n 01:59 AM\n 03:07 AM\n 03:19 AM\n WBC\n 23.1\n 20.9\n 20.7\n 17.9\n Hct\n 24.5\n 22.3\n 28.8\n 31.6\n Plt\n 398\n 290\n 197\n 209\n Creatinine\n 3.3\n 4.2\n 4.7\n 5.5\n Troponin T\n <0.01\n TCO2\n 25\n 20\n 23\n 21\n 21\n 22\n Glucose\n 94\n 97\n 83\n 116\n Other labs: PT / PTT / INR:15.3/33.3/1.3, CK / CK-MB / Troponin\n T:319/5/<0.01, ALT / AST:566/134, Alk-Phos / T bili:184/1.4, Amylase /\n Lipase:152/9, Differential-Neuts:94.0 %, Band:1.0 %, Lymph:1.0 %,\n Mono:0.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:2.3 g/dL, Ca:8.3 mg/dL, Mg:2.5 mg/dL, PO4:7.5 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PERICARDIAL EFFUSION WITH\n TAMPONADE, ATRIAL FIBRILLATION (AFIB), SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n Assessment and Plan: 50 yo m w/ T3N1 esophageal ca, septic w/ purulent\n pericardial effusion s/p L thoracotomy and pericardial window \n Neurologic: -- intubated and sedated with midazolam gtt & prn\n -- follows commands, Moves all extremities\n -- pain control: fentanyl gtt & IV prn\n Cardiovascular: Aspirin, -- pAF, amio gtt decreased to 0.25mg/min gtt,\n dilt gtt off. SR.\n -- s/p pericardiocentesis @ osh. >600cc green, viscous, purulent\n fluid aspirated. Cell count: 1800RBC, 22K WBC (98% pmns)\n -- s/p L thoracotomy and pericardial window , fluid sent\n --CT, drain\n -- PCCO, continue\n -- Lactate 1.1 <-2.5 <- 1.7 <- 1.5 <- 3.6\n Pulmonary: -- intubated, weaning PEEP down\n -- ARDS protocol\n -- CXR w/ diffuse haziness\n -- CT scan showed Multifocal PNA, bilateral pleural effusions\n -- IP consulted for pleural effusions but did not drain\n -- Albuterol Nebs\n Gastrointestinal / Abdomen: -- J tube - TF goal 60cc/hr\n -- no evidence of esophageo-pericardial fistula\n -- elevated transaminases. ?shock liver. trending down.\n -- s/p 5FU & cisplatin completed .\n -- GI prophy: famotidine\n Nutrition: -- TF (3/4 strength replete with fiber) - goal 60cc/hr\n Renal: -- oliguric, no improvement despite IVF hydration.\n -- baseline cr 0.5, now increased to Cr 4.7\n -- renal consulted - plan to begin CVVH if no improvement in next few\n days pending family discussion. Vanc held till levels < 15, and zosyn\n dosed renally.\n -- Na 132. fluid restricting. f/u.\n Hematology: -- s/p 1 unit PRBC \n -- Hct 28.8->31.6\n -- coagulopathic, s/p Vit K x 2days: INR 1.5\n Endocrine: RISS\n Infectious Disease: -- vanco/zosyn ()\n -- Vanco level 18.1\n -- WBC downtrending 20.7->17.9\n -- ID consulted\n -- CX @ osh: (prelim) diphtheroids, 1 single colony, very rare, will\n not do sensitivities\n -- Blood cx: pending\n -- F/up OR Cx\n Lines / Tubes / Drains: R SC port, LIJ TLC, L axillary Aline, foley,\n ETT, Jtube, CT, \n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery, Cardiology, Pulmonology, ID dept,\n Nephrology, thoracic\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis, Other:\n pericarditis, multiorgan failure.\n ICU Care\n Nutrition:\n Comments: TF\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 08:22 PM\n Arterial Line - 09:00 PM\n Multi Lumen - 10:41 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: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724998,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds slightly coarse, aerating throughout\n Vent settings- fio2 80%, rate 20 and peep 14\n Sats 96-98%\n Action:\n Peep increased to 17\n Abg\ns checked q6hrs\n Response:\n Repeat abg- 7.37/41/174/25\n Plan:\n Wean fio2 to 70%\n Continue to monitor abg\ns and sats\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n WBC 30 this am\n Vasopressin gtt at 1.2\n CO 4.3-3.06\n Minimal urine output, CR 2.4\n Action:\n Urine cultures sent\n Chest CT done with contrast via ngt\n Seen by ID- micafungin and zosyn started\n Vasopressin weaned to off\n 500cc LR bolus this am, IVF at 75cc/hr\n Response:\n Repeat WBC now 27\n Remains off vasopressin\n Minimal urine output, CR 3.0\n Plan:\n Await CT results\n Await culture reports\n Continue to check WBC\n Atrial fibrillation (Afib)\n Assessment:\n Normal sinus rhythym with rate in 80\n On Amiodarone gtt at 0.5\n Action:\n Hemodynamics monitored\n Response:\n Remains in SR\n Plan:\n Continue Amiodarone as ordered\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724901,
"text": "50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated Ph post\n intubation 6.7 4am found to have pericardial effusion & tamponade.\n Underwent pericardocentesis and sent to .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Arrived from OSH intubated given Bolus ativan and morphine\n prior to leaving hospital\n On arrival to SICU pt HTN and Tachycardic and dysychronous\n with both transport vent as well as our vent when switched over\n Difficult to pick up accurate sat. Once we did Sats in the\n High 60\ns to low 70\ns. Venous blood gas sent and venous Pa02 38\n Lactate 3.6\n Pt continuously difficult to ventilate\n Sats remaining Mid 70\ns with adequate pleth\n Lung sounds clear to very diminished at the bases\n ? possible atelectasis during transport\n 2mg versed given for sedation\n Sxn for brown thick secretions\n Action:\n Pt cont to require increased peep without change in 02sat\n Removed from vent and ambu\n CXR ordered\n Pt seemed to be more compliant after bolus versed\n Lungs remain diminished at the bases\n Pt ambu\nd until Sats >90%\n Pt placed back on vent\n Axillary aline placed and ABG obtained and pt with\n compensated acidosis with improved Pa02 with Fi02 of 100% and Peep 12\n Response:\n Cont to tolerate CMV w/12 peep\n Pt very low reserve when repositioned or lying flat sats in\n mid 80\n Abg later showing decreased pa02 to 79 with Ph 7.27 Pt auto\n peeping at times\n Mult vent changes made nebs given\n Peep up to 14\n ABg improved current vent setting CMV TV 400X20 80% Fi02 14\n peep\n Lungs still remain clear but right lung base very diminished\n Plan:\n Frequent ABG\n Monitor for worsening acidosis\n AM CXR evaluate RLL\n Pericardial effusion with tamponade\n Assessment:\n Pt with documented pericardial effusion at OSH\n Effusion drained for approx 600cc per OSH of bilious/pus\n drainage per report\n Specimen sent prelim Gram ++cocci\n Prior to noted effusion\n Pt in RAF and hypotensive but no noted EKG changes\n When pt arrived here Cards c/s\n PAD\ns/CVP/Wedge all +/- 2 point difference and hovering\n around 30\n Action:\n Echo done by cards\n Response:\n Effusion not very big per Cards\n No need to drain at this time\n During exam pt was off pressors\n ? if esophageal tumor eroding into pericardiam\n PA line removed post echo\n WBC\ns up to 30\n Plan:\n Cont to monitor pt hemodynamics closely\n ? possible repeat echo today to see if effusion\n reaccumulates\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt arriving to SICU hypertensive to 150\ns with neo infusing\n HR afib with amnio gtt infusing at .5\n ? hypertension R/T respiratory situation as indicated above\n Pt hypothermic\n Auxiliary aline placed\n Central line placed and monitoring initiated\n WBC\ns up to 30 HCT 26 baseline creatinine .5 2.2 on arrival\n and anuric\n Potassium at osh up to 6.2 treated with D50 and insulin WNL\n on admission\n Hemodynamics mimicking tamponade physiology\n Pt reported to be unresponsive but on arrival pt MAE not\n following commands and dysychronous with vent.\n Lactate 3.6\n Action:\n Pt given 1liter fluid bolus on arrival\n Neo weaned to off withing 3.5hrs of admission\n INR noted to be elevated to 3.0 LFT\ns sent\n CO thermodilution 4.4 with index >2 off pressors SVR 1100\n Response:\n Pt after MN with dropping SBP <90\n Pt appearing more tachy with self limiting burst of afib to\n 140\ns at times\n CO dropping to <4.0\n Levo on to support SBP\n Pt with worsening tachycardia despite improving CO/CI and\n normalized SVR\n Levo switched to vasopressin\n Tachycardia unresolved and SVV up to >20 ? if pt is dry\n Given additional fluid bolus and IVF increased to 75cc/hr\n No improvement in HR to start dilt per HO\n Notabley LFT ^^ >3000/>8000 with normal Tbili glucose in mid\n 60\n ? etiology of elevated LFT\n This am slightly decreased with bump in T bili Glucose\n remaining mid 60\n amp D50 given\n Pt\nwaking this am post CXR. Neuro exam pt following\n command and moving all extremities. + purposeful movements\n Plan:\n Pt very ill\n Cont to monitor hemodynamics closely\n ? possible CRRT tomorrow\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 724909,
"text": "SICU\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to .\n Chief complaint:\n sepsis, pericardial effusion\n PMHx:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with CHADS\n score of 0 treated with ASA only\n Current medications:\n 1. IV access: Peripheral line Order date: @ 11. Micafungin\n 100 mg IV Q24H *Awaiting ID Approval* Order date: @ 2249\n 2. 1000 mL LR Bolus 500 ml Over 30 mins\n MRx1 Order date: @ 2130 12. Micafungin 100 mg IV ONCE Duration: 1\n Doses Start: Order date: @ 2256\n 3. 1000 mL LR\n Continuous at 5 ml/hr Order date: @ 2353 13. Norepinephrine\n 0.3-0.5 mcg/kg/min IV DRIP TITRATE TO map>60\n start vasopressin first, add norepi as needed, titrate norepi off first\n and have vasopressin off last. Order date: @ 2119\n 4. Albuterol Inhaler PUFF IH Q4H:PRN wheezing Order date: @\n 0358 14. Piperacillin-Tazobactam 2.25 g IV ONCE Duration: 1 Doses\n Start: Order date: @ 2218\n 5. Amiodarone 0.5 mg/min IV INFUSION afib Order date: @ 1740 15.\n Piperacillin-Tazobactam 2.25 g IV Q6H *Awaiting ID Approval* Order\n date: @ 2233\n 6. Famotidine 20 mg IV Q24H Order date: @ 2233 16.\n Piperacillin-Tazobactam 2.25 g IV ONCE Duration: 1 Doses Start:\n Order date: @ 2243\n 7. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ 17. Sodium Chloride\n 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 8. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: @\n 2119 18. Vasopressin 1.2 UNIT/HR IV DRIP INFUSION\n start prior to levophed, d/c after levophed off. Order date: @\n 2119\n 9. Heparin 5000 UNIT SC TID Order date: @ 19. Vancomycin\n 1000 mg IV Q 24H\n ID Approval will be required for this order in 63 hours. Order date:\n @ 2233\n 10. Midazolam 1-2 mg IV Q2H:PRN agitation Order date: @ 2119\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:20 PM\n PA CATHETER - START 08:21 PM\n INDWELLING PORT (PORTACATH) - START 08:22 PM\n ARTERIAL LINE - START 09:00 PM\n CORDIS/INTRODUCER - START 09:00 PM\n MULTI LUMEN - START 10:41 PM\n ULTRASOUND - At 11:30 PM\n ECHO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:20 PM\n Micafungin - 01:29 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Vasopressin - 1.2 units/hour\n Other ICU medications:\n Midazolam (Versed) - 10:30 PM\n Other medications:\n : ASA 325', diltiazem 240', magic mouth wash, nystatin swish &\n swallow, percocet\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.9\nC (98.4\n HR: 115 (77 - 125) bpm\n BP: 106/79(91) {90/69(36) - 145/101(109)} mmHg\n RR: 18 (8 - 27) insp/min\n SPO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 66 Inch\n CVP: 18 (-2 - 33) mmHg\n PAP: (49 mmHg) / (34 mmHg)\n PCWP: 30 (30 - 30) mmHg\n CO/CI (Thermodilution): (4.37 L/min) / (2.8 L/min/m2)\n SVR: 1,043 dynes*sec/cm5\n PVR: 165 dynes*sec/cm5\n SV: 42 mL\n SVI: 27 mL/m2\n Total In:\n 1,598 mL\n 933 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,598 mL\n 933 mL\n Blood products:\n Total out:\n 10 mL\n 0 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,588 mL\n 933 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 450) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 80%\n PIP: 31 cmH2O\n Plateau: 26 cmH2O\n Compliance: 35.4 cmH2O/mL\n SPO2: 97%\n ABG: 7.30/54/121/25/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 151\n Physical Examination\n General Appearance: No acute distress, Cachectic, follows commands on\n minimal sedation\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular, Irregular), (Distant heart sounds:\n Present), Irreg rhythm from admission to 6a. SR since 6a.\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 492 K/uL\n 8.3 g/dL\n 68 mg/dL\n 2.4 mg/dL\n 25 mEq/L\n 5.2 mEq/L\n 57 mg/dL\n 101 mEq/L\n 136 mEq/L\n 25.1 %\n 30.1 K/uL\n [image002.jpg]\n 07:50 PM\n 08:48 PM\n 08:59 PM\n 12:06 AM\n 02:21 AM\n 02:27 AM\n WBC\n 30.3\n 30.1\n Hct\n 26.1\n 25.1\n Plt\n 556\n 492\n Creatinine\n 2.2\n 2.4\n TCO2\n 27\n 28\n 28\n Glucose\n 79\n 61\n 63\n 64\n 68\n Other labs: PT / PTT / INR:30.4/40.1/3.0, ALT / AST:3101/7197, Alk-Phos\n / T bili:112/0.9, Differential-Neuts:91.0 %, Band:4.0 %, Lymph:3.0 %,\n Mono:2.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL, Lactic Acid:1.5 mmol/L,\n Albumin:2.3 g/dL, Ca:7.2 mg/dL, Mg:2.4 mg/dL, PO4:7.3 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PERICARDIAL EFFUSION WITH\n TAMPONADE, ATRIAL FIBRILLATION (AFIB), SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n Assessment and Plan: 50 yo m w/ T3N1 esophageal ca, septic w/ purulent\n pericardial effusion.\n Neurologic: --intubated, sedated on fent gtt. intermittent midaz.\n --follows commands, MAE\n Cardiovascular: --PAF, in fib from admission to 6am. good rate control\n on admission, increased O/N. amio gtt @ 0.5. transition to PO or off\n once stable\n --dilt gtt if RVR again, now SR\n --neo on admission, now off. vasopressin for map >60. add levophed\n next.\n --s/p pericardiocentesis @ osh. >600cc green, viscous, purulent\n fluid aspirated. Cell count: 1800RBC, 22K WBC (98% pmns)\n --cardiology consulted, formal echo result pending. prelim not\n tamponade.\n --thoracics consult if echo worsens.\n --EF nl->hyperdynamic\n --PAC removed (elevated PAP & RV diastolic pressures prior to d/c)\n -- placed.\n --EKG w/ elevated Jpoint in lateral leads, CE neg @ osh\n --Lactate 1.5<-3.6\n Pulmonary: --hypoxic on admission, now on cmv 400x20/0.8/14\n --abg 7.30/54/121/28/0\n --Aa gradient continues, ards protocol->careful of BP as PEEP incr.\n --CXR w/ diffuse haziness\n Gastrointestinal / Abdomen: --npo/J-tube\n --no ogt/ngt w/ poss esophageal perf\n --elevated transaminases. ?shock liver. will trend.\n --s/p 5FU & cisplatin completed \n Nutrition: --npo, cachectic ?start TPN\n Renal: --oliguric\n --baseline cr 0.5 (0.6 @ osh). now 2.2->2.4. decreasing ivf\n administration in light of no further tamponade physiology by echo and\n oliguric.\n --K @ osh 6.2. tx w/ bicarb, D50 & insulin. w/ good result.\n --lytes otherwise wnl on admission, K trending up again. chck pm lytes.\n --likely CVVH in future.\n Hematology: --Hct 26.1->25.1, will trend. t/x 2u sent\n --coagulopathic, inr 3.1, stable.\n --no FFP unless actively bleeding or needs colloid\n Endocrine: RISS\n Infectious Disease: --vanco/zosyn/micafungin ()\n --WBC 24.9 w/ 32 bands @ osh. ->wbc 30.3->30.1\n --f/u formal ID recs\n --f/u cx osh\n --Blood/urine cx sent\n Lines / Tubes / Drains: R SC port, LIJ TLC, L axillary Aline, Rt fem\n cordis (PAC d/c'd), foley, ETT, Jtube\n Wounds:\n Imaging: CXR today\n Fluids: LR 100->5cc/h\n Consults: General surgery, Cardiology, ID dept\n Billing Diagnosis: Sepsis, (Shock: Septic), Liver failure, Acute renal\n failure, Other: Pericardial effusion\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PA Catheter - 08:21 PM\n Indwelling Port (PortaCath) - 08:22 PM\n Arterial Line - 09:00 PM\n Cordis/Introducer - 09:00 PM\n Multi Lumen - 10:41 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: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 724910,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 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 / Plug\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: 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: Underlying illness\n not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 725398,
"text": "SICU\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to \n Chief complaint:\n sepsis, pericardial effusion\n PMHx:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with CHADS\n score of 0 treated with ASA only\n Current medications:\n 1. 2. 3. Albuterol Inhaler 4. Amiodarone 5. Calcium Gluconate 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Famotidine 8. Fentanyl Citrate 9. Fentanyl Citrate 10. Heparin 11.\n Midazolam 12. Micafungin\n 13. Midazolam 14. Piperacillin-Tazobactam 15. Sodium Chloride 0.9%\n Flush 16. Vancomycin\n 24 Hour Events:\n OR SENT - At 10:37 PM\n OR RECEIVED - At 12:25 AM\n EKG - At 02:29 AM\n post-op\n - to OR for pericardial window. Received FFP and 1 U prbcs preop.\n Post operative day:\n POD#0 - vats, pericardial window.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:14 PM\n Infusions:\n Amiodarone - 0.25 mg/min\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:13 PM\n Other medications:\n Flowsheet Data as of 05:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.9\nC (96.6\n T current: 35.8\nC (96.4\n HR: 79 (55 - 87) bpm\n BP: 109/73(89) {96/61(0) - 166/97(123)} mmHg\n RR: 20 (18 - 24) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61 kg (admission): 50 kg\n Height: 66 Inch\n CVP: 18 (13 - 25) mmHg\n CO/CI (Thermodilution): (3.19 L/min) / (2.1 L/min/m2)\n SVR: 1,906 dynes*sec/cm5\n SV: 56 mL\n SVI: 36 mL/m2\n Total In:\n 2,627 mL\n 645 mL\n PO:\n Tube feeding:\n 23 mL\n IV Fluid:\n 2,015 mL\n 502 mL\n Blood products:\n 612 mL\n Total out:\n 113 mL\n 60 mL\n Urine:\n 113 mL\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,514 mL\n 585 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 29 cmH2O\n Compliance: 33.3 cmH2O/mL\n SPO2: 94%\n ABG: 7.32/39/166/19/-5\n Ve: 8.7 L/min\n PaO2 / FiO2: 415\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities\n Labs / Radiology\n 197 K/uL\n 9.7 g/dL\n 83 mg/dL\n 4.7 mg/dL\n 19 mEq/L\n 4.6 mEq/L\n 90 mg/dL\n 99 mEq/L\n 132 mEq/L\n 28.8 %\n 20.7 K/uL\n [image002.jpg]\n 03:23 PM\n 03:34 PM\n 01:00 AM\n 01:12 AM\n 12:58 PM\n 01:57 AM\n 02:11 AM\n 02:36 AM\n 01:44 AM\n 01:59 AM\n WBC\n 27.3\n 23.1\n 20.9\n 20.7\n Hct\n 25.0\n 24.5\n 22.3\n 28.8\n Plt\n 97\n Creatinine\n 3.0\n 3.3\n 4.2\n 4.7\n Troponin T\n <0.01\n TCO2\n 25\n 25\n 20\n 23\n 21\n 21\n Glucose\n 83\n 94\n 97\n 83\n Other labs: PT / PTT / INR:16.8/32.3/1.5, CK / CK-MB / Troponin\n T:319/5/<0.01, ALT / AST:833/250, Alk-Phos / T bili:119/1.8, Amylase /\n Lipase:152/9, Differential-Neuts:94.0 %, Band:1.0 %, Lymph:1.0 %,\n Mono:0.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:2.3 g/dL, Ca:7.9 mg/dL, Mg:2.3 mg/dL, PO4:6.3 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PERICARDIAL EFFUSION WITH\n TAMPONADE, ATRIAL FIBRILLATION (AFIB), SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n Assessment and Plan: 50 yo m w/ T3N1 esophageal ca, septic w/ purulent\n pericardial effusion.s/p L thoracotomy and pericardial window \n Neurologic: --intubated and sedated with midazolam gtt & prn\n --follows commands, Moves all extremities\n --pain control: fentanyl gtt & IV prn\n Cardiovascular: --pAF, amio gtt decreased to 0.25mg/min gtt\n --dilt gtt off\n --s/p pericardiocentesis @ osh, though no drain currently in\n place. >600cc green, viscous, purulent fluid aspirated. Cell count:\n 1800RBC, 22K WBC (98% pmns)\n --echo (): small effusion noted, no tamponade. EF>60%. Mild\n symmetric LVH.\n --echo (): small to moderate sized pericardial effusion (1.2 cm).\n The effusion appears circumferential. There is no evidence of tamponade\n physiology. The severity of tricuspid regurgitation has increased.\n --s/p L thoracotomy and pericardial window , w/ in\n pericardium\n --PCCO\n --Lactate -<1.1<-2.5 <- 1.7 <- 1.5 <- 3.6\n Pulmonary: --intubated, weaning PEEP down\n --ARDS protocol\n --CXR w/ diffuse haziness\n --CT scan showed Multifocal PNA, bilateral pleural effusions\n -- Albuterol Nebs\n --IP consulted for pleural effusions but did not drain\n -CT tube to suction no leak\n Gastrointestinal / Abdomen: --J tube - TF started at 30 (now held for\n OR)\n --no evidence of esophageo-pericardial fistula\n --elevated transaminases. ?shock liver. trend down.\n --s/p 5FU & cisplatin completed .\n --GI prophy: famotidine\n Nutrition: --Resume TF\n Renal: --oliguric, no improvement despite IVF hydration.\n --baseline cr 0.5, now increased to Cr 4.7.\n --renal consulted - plan to begin dialysis if no improvement in next\n few days. Vanc held till levels < 15, and zosyn dosed renally.\n --Na 132. Monitor closely\n Hematology: --Hct 26.1 -> 25.1 -> 24.5 ->22.5, transfusing 1 unit PRBC\n \n --coagulopathic, INR decreased from 3.1 -> 2.1-> 1.7->1.5 s/p Vit K x 2\n days\n Endocrine: RISS\n Infectious Disease: --vanco/zosyn ()\n --WBC 30.3->30.1->23.1-> 20.9->20.7\n --ID consulted\n --f/u cx osh --GS: WBC, rare GPC in clusters, Aerobic: no growth,\n Anaerobic pending\n -- Blood/urine cx: pending\n --Vanco level pending\n --F/up OR Cx\n Lines / Tubes / Drains: R SC port, LIJ TLC, L axillary Aline, foley,\n ETT, Jtube, CT, \n Wounds: Left thoracotomy\n Imaging: CXR today\n Fluids:\n Consults: gen , thoracic, nephrology, ID\n Billing Diagnosis: (Respiratory distress), Sepsis, Liver failure, Acute\n renal failure\n ICU Care\n Nutrition:\n Replete with Fiber () - 03:10 AM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 08:22 PM\n Arterial Line - 09:00 PM\n Multi Lumen - 10:41 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: 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": "2132-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724894,
"text": "50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated Ph post\n intubation 6.7 4am found to have pericardial effusion & tamponade.\n Underwent pericardocentesis and sent to .\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Arrived from OSH intubated given Bolus ativan and morphine\n prior to leaving hospital\n On arrival to SICU pt HTN and Tachycardic and dysychronous\n with both transport vent as well as our vent when switched over\n Difficult to pick up accurate sat. Once we did Sats in the\n High 60\ns to low 70\ns. Venous blood gas sent and venous Pa02 38\n Lactate 3.6\n Pt continuously difficult to ventilate\n Sats remaining Mid 70\ns with adequate pleth\n Lung sounds clear to very diminished at the bases\n 2mg versed given for sedation\n Sxn for brown thick secretions\n Action:\n Pt cont to require increased peep without change in 02sat\n Removed from vent and ambu\n CXR ordered\n Pt seemed to be more compliant after bolus versed\n Lungs remain diminished at the bases\n Pt ambu\nd until Sats >90%\n Pt placed back on vent\n Axillary aline placed and ABG obtained with improved\n oxygenation\n Response:\n Cont to tolerate settings of\n Plan:\n Pericardial effusion with tamponade\n Assessment:\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 724999,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 27 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 Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Pt received on AC as noted.\n PEEP increased MD from 14 to 17cm. ABG was within normal limits\n with excellent oxygenation with a PaO2 of 174. FiO2 weaned slowly to\n 70%.\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: Plan is to continue on current settings at this\n time.\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 CT\n 14:30\n Transport was without incident.\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 725278,
"text": "SICU\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to .\n Chief complaint:\n Pericardial effusion, sepsis in the setting of esophageal cancer\n PMHx:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with CHADS\n score of 0 treated with ASA only\n Current medications:\n 1. IV access: Peripheral line Order date: @ 10. Heparin 5000\n UNIT SC TID Order date: @ \n 2. Albuterol Inhaler PUFF IH Q4H:PRN wheezing Order date: @\n 0358 11. Midazolam 1-2 mg IV Q2H:PRN agitation Order date: @\n 2119\n 3. Amiodarone 0.5 mg/min IV INFUSION afib Order date: @ 1740 12.\n Micafungin 100 mg IV Q24H Order date: @ 2249\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 0216 13.\n Midazolam 0.5-5 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0534\n 5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1359 14. Phytonadione 10 mg IV ONCE coagulopathy Duration: 1 Doses\n Infuse over 15 to 30 minutes Order date: @ 0824\n 6. Diltiazem 5-15 mg/hr IV INFUSION Order date: @ 0044 15.\n Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 2233\n 7. Famotidine 20 mg IV Q24H Order date: @ 2233 16. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 8. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ 17. Vancomycin 1000\n mg IV Q 24H Order date: @ 2233\n 9. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: @\n 2119\n 24 Hour Events:\n BLOOD CULTURED - At 11:01 AM\n cvl\n BLOOD CULTURED - At 11:01 AM\n peripheral\n SPUTUM CULTURE - At 11:02 AM\n Post operative day:\n N/A\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:20 PM\n Micafungin - 01:29 AM\n Piperacillin/Tazobactam (Zosyn) - 12:55 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Amiodarone - 0.5 mg/min\n Diltiazem - 5 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 05:57 AM\n Famotidine (Pepcid) - 07:45 PM\n Fentanyl - 01:00 AM\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.2\nC (97.1\n T current: 35.8\nC (96.5\n HR: 60 (53 - 112) bpm\n BP: 92/63(76) {87/59(72) - 139/83(103)} mmHg\n RR: 19 (13 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 57 kg (admission): 50 kg\n Height: 66 Inch\n CVP: 16 (12 - 32) mmHg\n CO/CI (Thermodilution): (3.92 L/min) / (2.5 L/min/m2)\n SVR: 1,429 dynes*sec/cm5\n SV: 56 mL\n SVI: 36 mL/m2\n Total In:\n 2,829 mL\n 366 mL\n PO:\n Tube feeding:\n 278 mL\n IV Fluid:\n 2,551 mL\n 366 mL\n Blood products:\n Total out:\n 84 mL\n 28 mL\n Urine:\n 84 mL\n 28 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,745 mL\n 338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 403 (403 - 403) mL\n RR (Set): 20\n RR (Spontaneous): 2\n PEEP: 17 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 26 cmH2O\n Compliance: 44.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.34/38/71/21/-4\n Ve: 10.2 L/min\n PaO2 / FiO2: 142\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Wheezes : , Crackles : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: No(t) Absent)\n Right Extremities: (Edema: No(t) Absent)\n Skin: No(t) Rash:\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 290 K/uL\n 7.5 g/dL\n 97 mg/dL\n 4.2 mg/dL\n 21 mEq/L\n 4.8 mEq/L\n 87 mg/dL\n 99 mEq/L\n 132 mEq/L\n 22.3 %\n 20.9 K/uL\n [image002.jpg]\n 06:32 AM\n 10:01 AM\n 03:23 PM\n 03:34 PM\n 01:00 AM\n 01:12 AM\n 12:58 PM\n 01:57 AM\n 02:11 AM\n 02:36 AM\n WBC\n 27.3\n 23.1\n 20.9\n Hct\n 25.0\n 24.5\n 22.3\n Plt\n \n Creatinine\n 3.0\n 3.3\n 4.2\n TCO2\n 26\n 23\n 25\n 25\n 20\n 23\n 21\n Glucose\n 80\n 83\n 94\n 97\n Other labs: PT / PTT / INR:19.0/35.0/1.7, ALT / AST:1280/546, Alk-Phos\n / T bili:122/1.2, Amylase / Lipase:152/9, Differential-Neuts:94.0 %,\n Band:1.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL,\n Lactic Acid:2.5 mmol/L, Albumin:2.3 g/dL, Ca:8.0 mg/dL, Mg:2.3 mg/dL,\n PO4:6.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PERICARDIAL EFFUSION WITH\n TAMPONADE, ATRIAL FIBRILLATION (AFIB), SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n Assessment and Plan: 50 yo m w/ T3N1 esophageal ca, septic w/ purulent\n pericardial effusion.\n Neurologic: --intubated and sedated with midazolam gtt & prn\n --follows commands, Moves all extremities\n --pain control: fentanyl gtt & IV prn\n Cardiovascular: --PAF, amio gtt @ 0.5. transition to PO or off once\n stable\n --dilt gtt weaning, decrease amio due to relative bradycardia.\n --s/p pericardiocentesis @ osh, though no drain currently in\n place. >600cc green, viscous, purulent fluid aspirated. Cell count:\n 1800RBC, 22K WBC (98% pmns). Window today.\n --echo (): small effusion noted, no tamponade. EF>60%. Mild\n symmetric LVH.\n --PCCO\n --Lactate 2.5 <- 1.7 <- 1.5 <- 3.6\n Pulmonary: --intubated, weaning PEEP down\n --ARDS protocol\n --CXR w/ diffuse haziness\n --CT scan showed Multifocal PNA, bilateral pleural effusions\n -- Albuterol Nebs\n --IP consulted for pleural effusions but did not drain\n Gastrointestinal / Abdomen: --J tube - TF started at 30 (now held for\n OR)\n --no evidence of esophageo-pericardial fistula\n --elevated transaminases. ?shock liver. trend down.\n --s/p 5FU & cisplatin completed .\n --GI prophy: famotidine\n Nutrition: --Resume TF after OR\n Renal: --oliguric, no improvement despite IVF hydration.\n --baseline cr 0.5, now increased to Cr 3.3.\n --renal consulted - f/u recs, possibly begin dialysis. Will wait for a\n day or so to have family chance to decide r.e dialysis.\n Hematology: --Hct 26.1 -> 25.1 -> 24.5 ->22.5, transfusing 1 unit\n --coagulopathic, INR decreased from 3.1 -> 2.1-> 1.7, s/p Vit K x 2\n days\n --FFP on call to OR if needed\n Endocrine: RISS\n Infectious Disease: --vanco/zosyn/micafungin ()\n --WBC 30.3->30.1->23.1-> 20.9\n --ID consulted\n --f/u cx osh --GS: WBC, rare GPC in clusters, Aerobic: no growth,\n Anaerobic pending\n -- Blood/urine cx: pending\n --Vanco level 20.4\n Lines / Tubes / Drains: R SC port, LIJ TLC, L axillary Aline, foley,\n ETT, Jtube\n Wounds: N/A\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery, CT surgery, ID dept, Nephrology\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 08:22 PM\n Arterial Line - 09:00 PM\n Multi Lumen - 10:41 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent: 35\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725395,
"text": "Pt is a 50 y/o male with esophageal adenoca (T3, N1) admitted to OSH\n Friday () from clinic with c/o weakness, worsening\n dysphagia, \"scratchy throat\", dehydration & decreased PO intake. Was\n started on vanc/zosyn & imipenem for suspected sepsis\n (leukocytosis w/o source initially) in setting of ARF. Decompensated\n overnight & intubated at 4am found to have pericardial\n effusion & tamponade. Underwent pericardocentesis and sent to .\n POST-OP NOTE:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Post-op Pericardial window via Subxiphoid approach for\n purulent pericarditis. Returned from OR with tube at\n pericardium and left anterior chest tube. Set at -10cc H2O. Lungs\n clear.\n Continues with clinical picture being that of a multisystem\n organ failure. Renal function continues to worsen with BUN/Cr slowly\n elevating. Foley patent with minimal urine output at approx 20cc clear\n yellow urine every 4 hours.\n Fentanyl for pain. Initially no versed restarted as pt has\n not been reversed from OR procedure and appeared comfortable in bed. No\n spontaneous movements. Prior to procedure MAE lift/holding BUE and\n moving BLE on bed grimacing to pain.\n continues. NSR/SB HR 55-65. No ectopy. SBP 100-110.\n CVP 16-19.\n Hypothermic. Unable to accurately obtain PO or axillary\n temperature immediately post-op.\n TF reinitiated at 10cc/hr with goal of 30cc/hr via J-tube.\n Action:\n Monitoring CT output.\n Bair hugger applied and warm blankets to head, still unable\n to obtain temp >> rectal probe placed revealing pt cold at 33.4 >> warm\n lavages done. Unable to warm fluid as pt receiving total of 20cc/hr\n between three fluids. Fungal culture obtained. Thoracics and SICU team\n notified.\n Response:\n Chest tubes remain without fluctuation or leak. Left\n anterior with greater sang drainage .\n Became hypertensive to 180s at which time localizing\n grimacing to nail bed pressure and over-breathing ventilator>> Versed\n restarted.\n Slowly re-warming. Current temp 36.2 (97 F).\n Plan:\n Continue to monitor CT drainage.\n Monitor labs. Consider starting HD as pt currently 10L\n positive for LOS and remains oliguric with rising BUN/Cr.\n Maintain pt comfort. Titrate sedation to comfort.\n Monitor temperature and hemodynamics.\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725641,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Family meeting with patient sister, father, and brothers,\n decision made to make patient comfortable,\n Action:\n Fi02 decreased to 21% rate decreased to 14,peep at 0\n Amidorane d/cd\n Fentanyl increased up to 150mcg/hr\n Versed increased to 8mg/hr\n Response:\n Pt continue to thrash arms and head on bed\n Fentanyl increased to 250mcg/hr\n Versed increased to 10mg/hr, pt comfortable\n Plan:\n Continue to monitor\n Titriate sedation for comfort\n Provide emotional support to family\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724983,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds slightly coarse, aerating throughout\n Vent settings- fio2 80%, rate 20 and peep 14\n Sats 96-98%\n Action:\n Peep increased to 17\n Abg\ns checked q6hrs\n Response:\n Repeat abg- 7.37/41/174/25\n Plan:\n Wean fio2 as tolerated\n Continue to monitor abg\ns and sats\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n WBC 30 this am\n Vasopressin gtt at 1.2\n CO\n Action:\n Urine cultures sent\n Chest CT done with contrast via ngt\n Seen by ID- micafungin and zosyn started\n Response:\n Repeat WBC now 27\n Plan:\n Await CT results\n Await culture reports\n Continue to check WBC\n Atrial fibrillation (Afib)\n Assessment:\n Normal sinus rhythym with rate in 80\n On Amiodarone gtt at 0.5\n Action:\n Hemodynamics monitored\n Response:\n Remains in SR\n Plan:\n Continue Amiodarone as ordered\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Physician Surgical Admission Note",
"row_id": 724887,
"text": "Chief Complaint: sepsis, tamponade\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to .\n Post operative day:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:20 PM\n Micafungin - 01:29 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Norepinephrine - 0.05 mcg/Kg/min\n Other ICU medications:\n Midazolam (Versed) - 10:30 PM\n Other medications:\n : ASA 325', diltiazem 240', magic mouth wash, nystatin swish &\n swallow, percocet\n .\n MEDS @OSH: atrovent INH, levalbuterol, admiodarone 900', diltiazem,\n hydromorphone, imipenem 250q8hrs, lorazepam, morphine, sodium bicarb,\n zofran, pantoprazole 40', zosyn 3.375q8hrs, vancomycin 1',\n neosynephrine, ASA 325', benadryl, lidocaine viscous, percocet,\n miralax, nitroglycerin 0.4q5min prn, colace\n Past medical history:\n Family / Social history:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with CHADS\n score of 0 treated with ASA only\n Flowsheet Data as of 03:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 35.9\nC (96.6\n Tcurrent: 35.9\nC (96.6\n HR: 115 (77 - 115) bpm\n BP: 99/74(86) {90/69(36) - 145/101(109)} mmHg\n RR: 18 (8 - 27) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 66 Inch\n CVP: 19 (-2 - 33)mmHg\n PAP: (49 mmHg) / (34 mmHg)\n PCWP: 30 (30 - 30) mmHg\n CO/CI (Thermodilution): (4.37 L/min) / (2.8 L/min/m2)\n SVR: -3,918 dynes*sec/cm5\n PVR: 201 dynes*sec/cm5\n SV: 41 mL\n SVI: 26 mL/m2\n Total In:\n 1,598 mL\n 234 mL\n PO:\n TF:\n IVF:\n 1,598 mL\n 234 mL\n Blood products:\n Total out:\n 10 mL\n 0 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,588 mL\n 234 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 450) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 100%\n RSBI Deferred: PEEP > 10, FiO2 > 60%\n PIP: 35 cmH2O\n Plateau: 28 cmH2O\n Compliance: 30.8 cmH2O/mL\n SpO2: 97%\n ABG: 7.30/54/121/25/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 121\n Physical Examination\n General Appearance: Thin, cachectic\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal), Rub\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 : )\n Abdominal: Soft, J tube present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Responds to: Noxious stimuli, Movement: Not assessed,\n Sedated, Tone: Not assessed\n Labs / Radiology\n 492 K/uL\n 8.3 g/dL\n 68 mg/dL\n 2.4 mg/dL\n 25 mEq/L\n 5.2 mEq/L\n 57 mg/dL\n 101 mEq/L\n 136 mEq/L\n 25.1 %\n 30.1 K/uL\n [image002.jpg]\n 07:50 PM\n 08:48 PM\n 08:59 PM\n 12:06 AM\n 02:21 AM\n 02:27 AM\n WBC\n 30.3\n 30.1\n Hct\n 26.1\n 25.1\n Plt\n 556\n 492\n Cr\n 2.2\n 2.4\n TCO2\n 27\n 28\n 28\n Glucose\n 79\n 61\n 63\n 64\n 68\n Other labs: PT / PTT / INR:30.4/40.1/3.0, ALT / AST:3101/7197, Alk Phos\n / T Bili:112/0.9, Differential-Neuts:91.0 %, Band:4.0 %, Lymph:3.0 %,\n Mono:2.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL, Lactic Acid:1.5 mmol/L,\n Albumin:2.3 g/dL, Ca++:7.2 mg/dL, Mg++:2.4 mg/dL, PO4:7.3 mg/dL\n Assessment and Plan\n Assessment And Plan: 50 yo m w/ T3N1 esophageal ca, septic w/ purulent\n pericardial effusion.\n Neurologic: --intubated, sedated on fent gtt. intermittent midaz.\n --occ non purposeful movement.\n --not following commands\n Cardiovascular: --PAF, currently in fib, good rate control. amio gtt @\n 0.5. transition to PO or off once stable\n --neo on admission, now off. levophed & vasopressin if decompensates.\n --s/p pericardiocentesis @ osh. >600cc green, viscous, purulent\n fluid aspirated.\n --cardiology consulted, formal echo result pending. prelim not\n tamponade.\n --thoracics consult if echo worsens.\n --EF nl->hyperdynamic\n --PAC removed\n -- placed\n --EKG w/ elevated Jpoint in lateral leads, CE neg @ osh\n Pulmonary: --hypoxic on admission, now on cmv 450x16/1.0/14 after abg\n worse\n --abg 7.29/53/109/27/-1->7.27/59/79/28/0\n --Aa gradient continues, ards protocol->careful of BP as PEEP incr.\n --CXR w/ diffuse haziness\n Gastrointestinal: --npo/J-tube\n --no ogt/ngt w/ poss esophageal perf\n --elevated transaminases. ?shock liver. will trend.\n --s/p 5FU & cisplatin completed .\n Renal: --oliguric\n --baseline cr 0.5 (0.6 @ osh). now 2.2. decreasing ivf\n administration in light of no further tamponade physiology by echo and\n oliguric.\n --K @ osh this am 6.2. tx w/ bicarb, D50 & insulin. w/ good result.\n --lytes otherwise wnl\n --likely CVVH in future.\n --CVVH if becoming overloaded\n Hematology: --Hct 26.1, will trend. t/x 2u sent\n --coagulopathic, inr 3.1, will trend. septic vs. elevated LFTs\n --no FFP unless actively bleeding or needs colloid\n Infectious Disease: --vanco/zosyn/micafungin ()\n --WBC 24.9 w/ 32 bands @ osh. ->wbc 30.3 on admission\n --f/u formal ID recs\n --f/u cx osh\n --Blood/urine cx sent\n Endocrine: RISS\n Fluids: LR 100->5cc/h\n Electrolytes: --oliguric\n --baseline cr 0.5 (0.6 @ osh). now 2.2. decreasing ivf\n administration in light of no further tamponade physiology by echo and\n oliguric.\n --K @ osh this am 6.2. tx w/ bicarb, D50 & insulin. w/ good result.\n --lytes otherwise wnl\n --likely CVVH in future.\n Nutrition: --npo, cachectic ?start TPN\n General:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PA Catheter - 08:21 PM\n Indwelling Port (PortaCath) - 08:22 PM\n Arterial Line - 09:00 PM\n Cordis/Introducer - 09:00 PM\n Multi Lumen - 10:41 PM\n Comments: R SC port, LIJ TLC, L axillary Aline, Rt fem cordis (PAC\n d/c'd), foley, ETT, Jtube\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Need for restraints reviewed\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725064,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725071,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Assist control 400x20, peep 17, fio2 70%\n Lung sounds mostly clear\n Occasionally waking and attempting to grab tube,\n inconsistently follows commands\n Action:\n Frequently medicated with Fent & Versed\n AM ABG sent and pa02 (180\ns), otherwise unremarkable-\n Fi02 dropped to 50%\n Response:\n Patient still occas getting agitated and appearing\n uncomfortable, Dr. aware\n Plan:\n Start Versed gtt\n Repeat ABG\n Atrial fibrillation (Afib)\n Assessment:\n Patient on amio gtt @ 0.5mg/min\n @ beginning of the shift, patient in nsr -> converted to\n afib with HR 130-140\n Maintained sbp 90-110 (cardiac output/index unchanged)\n Patient makes minimal urine, creat 3.3 this am\n Action:\n EKG done, Dilt bolus given x 2 and Dilt gtt started\n Labs sent and unchanged\n Response:\n Patient remains in afib, HR < 120, patient tolerating\n Awaiting renal input\n Plan:\n ? dialysis\n ? echo for recurring pericardial effusion\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-23 00:00:00.000",
"description": "Intensivist Note",
"row_id": 725714,
"text": "SICU\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to \n Chief complaint:\n sepsis, pericardial effusion, esophageal cancer\n PMHx:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with CHADS\n score of 0 treated with ASA only\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0032 4. Fentanyl\n Citrate 100-500 mcg/hr IV DRIP INFUSION Order date: @ 1529\n 2. IV access: None Order date: @ 0032 5. Midazolam 5-10 mg/hr IV\n DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 1529\n 3. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ 0032\n 24 Hour Events:\n FEVER - 204.8\nC - 08:00 PM\n I met with family for about 1 hr yesterday r.e. plan of care.\n Decision for comfort measures with continued ventilation, but at low\n level.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:18 AM\n Infusions:\n Midazolam (Versed) - 10 mg/hour\n Fentanyl - 275 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 AM\n Other medications:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 96\nC (204.8\n T current: 35.6\nC (96\n HR: 116 (65 - 122) bpm\n BP: 93/65(77) {92/65(77) - 135/86(107)} mmHg\n RR: 14 (11 - 24) insp/min\n SPO2: 58%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 62.4 kg (admission): 50 kg\n Height: 66 Inch\n CVP: 18 (12 - 19) mmHg\n CO/CI (Thermodilution): (4.32 L/min) / (2.8 L/min/m2)\n SVR: 1,444 dynes*sec/cm5\n SV: 64 mL\n SVI: 41 mL/m2\n Total In:\n 1,814 mL\n 164 mL\n PO:\n Tube feeding:\n 940 mL\n IV Fluid:\n 874 mL\n 164 mL\n Blood products:\n Total out:\n 840 mL\n 330 mL\n Urine:\n 335 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 974 mL\n -166 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (300 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 21%\n RSBI Deferred: CMO\n PIP: 13 cmH2O\n Plateau: 17 cmH2O\n Compliance: #Division by zero# cmH2O/mL\n SPO2: 58%\n ABG: ////\n Ve: 5.4 L/min\n Physical Examination\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Responds to: Unresponsive), Sedated\n Labs / Radiology\n 209 K/uL\n 10.1 g/dL\n 116 mg/dL\n 5.5 mg/dL\n 21 mEq/L\n 4.8 mEq/L\n 110 mg/dL\n 98 mEq/L\n 133 mEq/L\n 31.6 %\n 17.9 K/uL\n [image002.jpg]\n 01:00 AM\n 01:12 AM\n 12:58 PM\n 01:57 AM\n 02:11 AM\n 02:36 AM\n 01:44 AM\n 01:59 AM\n 03:07 AM\n 03:19 AM\n WBC\n 23.1\n 20.9\n 20.7\n 17.9\n Hct\n 24.5\n 22.3\n 28.8\n 31.6\n Plt\n 398\n 290\n 197\n 209\n Creatinine\n 3.3\n 4.2\n 4.7\n 5.5\n Troponin T\n <0.01\n TCO2\n 25\n 20\n 23\n 21\n 21\n 22\n Glucose\n 94\n 97\n 83\n 116\n Other labs: PT / PTT / INR:15.3/33.3/1.3, CK / CK-MB / Troponin\n T:319/5/<0.01, ALT / AST:566/134, Alk-Phos / T bili:184/1.4, Amylase /\n Lipase:152/9, Differential-Neuts:94.0 %, Band:1.0 %, Lymph:1.0 %,\n Mono:0.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:2.3 g/dL, Ca:8.3 mg/dL, Mg:2.5 mg/dL, PO4:7.5 mg/dL\n Assessment and Plan\n COMFORT CARE (CMO, COMFORT MEASURES), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), PERICARDIAL EFFUSION WITH TAMPONADE, ATRIAL FIBRILLATION\n (AFIB), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 50 yo m w/ T3N1 esophageal ca, septic w/ purulent\n pericardial effusion s/p L thoracotomy and pericardial window \n Pt made CMO\n Neurologic: -- intubated and sedated with midazolam gtt and fentanyl\n gtt. Titrate to comfort.\n Cardiovascular: -- s/p pericardiocentesis @ osh. >600cc green,\n viscous, purulent fluid aspirated. Cell count: 1800RBC, 22K WBC (98%\n pmns)\n -- s/p L thoracotomy and pericardial window , fluid sent\n --CT, drain\n Pulmonary: remains intubated while CMO\n Gastrointestinal / Abdomen: No further nutrition\n Nutrition: TF stopped\n Renal:\n Hematology: No further labs\n Endocrine: No further blood glucose checks\n Infectious Disease: Antibiotics stoppted\n Lines / Tubes / Drains: R SC port, LIJ TLC, L axillary Aline, foley,\n ETT, Jtube, CT, \n Wounds:\n Imaging: None\n Fluids:\n Consults: General surgery, CT surgery, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 08:22 PM\n Arterial Line - 09:00 PM\n Multi Lumen - 10:41 PM\n Prophylaxis:\n DVT: N/A\n Stress ulcer: N/A\n VAP bundle: N/A\n Comments:\n Communication: Family meeting held Comments:\n Code status: Comfort measures only\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724976,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds slightly coarse, aerating throughout\n Vent settings- fio2 80%, rate 20 and peep 14\n Sats 96-98%\n Action:\n Peep increased to 17\n Abg\ns checked q6hrs\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724984,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds slightly coarse, aerating throughout\n Vent settings- fio2 80%, rate 20 and peep 14\n Sats 96-98%\n Action:\n Peep increased to 17\n Abg\ns checked q6hrs\n Response:\n Repeat abg- 7.37/41/174/25\n Plan:\n Wean fio2 as tolerated\n Continue to monitor abg\ns and sats\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n WBC 30 this am\n Vasopressin gtt at 1.2\n CO 4.3-3.06\n Minimal urine output, CR 2.4\n Action:\n Urine cultures sent\n Chest CT done with contrast via ngt\n Seen by ID- micafungin and zosyn started\n Vasopressin weaned to off\n 500cc LR bolus this am, IVF at 75cc/hr\n Response:\n Repeat WBC now 27\n Remains off vasopressin\n Minimal urine output\n Plan:\n Await CT results\n Await culture reports\n Continue to check WBC\n Atrial fibrillation (Afib)\n Assessment:\n Normal sinus rhythym with rate in 80\n On Amiodarone gtt at 0.5\n Action:\n Hemodynamics monitored\n Response:\n Remains in SR\n Plan:\n Continue Amiodarone as ordered\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724985,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds slightly coarse, aerating throughout\n Vent settings- fio2 80%, rate 20 and peep 14\n Sats 96-98%\n Action:\n Peep increased to 17\n Abg\ns checked q6hrs\n Response:\n Repeat abg- 7.37/41/174/25\n Plan:\n Wean fio2 to 70%\n Continue to monitor abg\ns and sats\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n WBC 30 this am\n Vasopressin gtt at 1.2\n CO 4.3-3.06\n Minimal urine output, CR 2.4\n Action:\n Urine cultures sent\n Chest CT done with contrast via ngt\n Seen by ID- micafungin and zosyn started\n Vasopressin weaned to off\n 500cc LR bolus this am, IVF at 75cc/hr\n Response:\n Repeat WBC now 27\n Remains off vasopressin\n Minimal urine output\n Plan:\n Await CT results\n Await culture reports\n Continue to check WBC\n Atrial fibrillation (Afib)\n Assessment:\n Normal sinus rhythym with rate in 80\n On Amiodarone gtt at 0.5\n Action:\n Hemodynamics monitored\n Response:\n Remains in SR\n Plan:\n Continue Amiodarone as ordered\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-02-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 725059,
"text": "Day of mechanical ventilation: 3\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Cuff Management:\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: 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: pt remains orally intubated on\n full mechanical support; FiO2 weaned this shift, all other parameters\n unchanged.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Comments: pt continues to have periods of dysynchrony on vent w/\n occasional erratic Vts.\n Plan\n Next 24-48 hours: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725183,
"text": "50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to .\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Patient with resolving sepsis, no longer pressor dependent\n On versed for sedation\n On amio and dilt for afib\n Cardiac echo done that still shows pericardial effusion\n Still with little to no urine output and rising Bun and Cr\n Vented, unable to tolerated PEEP wean from 17 to 14 (pO2 dropped to 54)\n IP into evaluate pleural effusions and benefit to tap\n Action:\n Family in, talked with Dr. about overall condition and poor\n prognosis\n Sister (HCP) very supportive and knowledgeable about patient\n wishes\n Small pleural effusion on right, larger on left.\n No plans to tap at this point due to elevated PEEP\n Response:\n Continue with supportive care\n PEEP back to 17\n Renal continues to follow\n Will assess patient over next few days and have another meeting with\n sister\n :\n Continue to support\n Address aggressive care ie/ dialysis, prolonged intubation with sister\n later in week.\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-02-19 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 725184,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Tube Type\n ETT:\n Position: 23 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: White / Thin\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n 18:28\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-23 00:00:00.000",
"description": "Intensivist Note",
"row_id": 725694,
"text": "SICU\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to \n Chief complaint:\n sepsis, pericardial effusion, esophageal cancer\n PMHx:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with CHADS\n score of 0 treated with ASA only\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0032 4. Fentanyl\n Citrate 100-500 mcg/hr IV DRIP INFUSION Order date: @ 1529\n 2. IV access: None Order date: @ 0032 5. Midazolam 5-10 mg/hr IV\n DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 1529\n 3. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ 0032\n 24 Hour Events:\n FEVER - 204.8\nC - 08:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 06:18 AM\n Infusions:\n Midazolam (Versed) - 10 mg/hour\n Fentanyl - 275 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 10:00 AM\n Heparin Sodium (Prophylaxis) - 10:00 AM\n Other medications:\n Flowsheet Data as of 06:48 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 96\nC (204.8\n T current: 35.6\nC (96\n HR: 116 (65 - 122) bpm\n BP: 93/65(77) {92/65(77) - 135/86(107)} mmHg\n RR: 14 (11 - 24) insp/min\n SPO2: 58%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 62.4 kg (admission): 50 kg\n Height: 66 Inch\n CVP: 18 (12 - 19) mmHg\n CO/CI (Thermodilution): (4.32 L/min) / (2.8 L/min/m2)\n SVR: 1,444 dynes*sec/cm5\n SV: 64 mL\n SVI: 41 mL/m2\n Total In:\n 1,814 mL\n 164 mL\n PO:\n Tube feeding:\n 940 mL\n IV Fluid:\n 874 mL\n 164 mL\n Blood products:\n Total out:\n 840 mL\n 330 mL\n Urine:\n 335 mL\n 60 mL\n NG:\n Stool:\n Drains:\n Balance:\n 974 mL\n -166 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 300 (300 - 400) mL\n Vt (Spontaneous): 0 (0 - 0) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 21%\n RSBI Deferred: CMO\n PIP: 13 cmH2O\n Plateau: 17 cmH2O\n Compliance: #Division by zero# cmH2O/mL\n SPO2: 58%\n ABG: ////\n Ve: 5.4 L/min\n Physical Examination\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Responds to: Unresponsive), Sedated\n Labs / Radiology\n 209 K/uL\n 10.1 g/dL\n 116 mg/dL\n 5.5 mg/dL\n 21 mEq/L\n 4.8 mEq/L\n 110 mg/dL\n 98 mEq/L\n 133 mEq/L\n 31.6 %\n 17.9 K/uL\n [image002.jpg]\n 01:00 AM\n 01:12 AM\n 12:58 PM\n 01:57 AM\n 02:11 AM\n 02:36 AM\n 01:44 AM\n 01:59 AM\n 03:07 AM\n 03:19 AM\n WBC\n 23.1\n 20.9\n 20.7\n 17.9\n Hct\n 24.5\n 22.3\n 28.8\n 31.6\n Plt\n 398\n 290\n 197\n 209\n Creatinine\n 3.3\n 4.2\n 4.7\n 5.5\n Troponin T\n <0.01\n TCO2\n 25\n 20\n 23\n 21\n 21\n 22\n Glucose\n 94\n 97\n 83\n 116\n Other labs: PT / PTT / INR:15.3/33.3/1.3, CK / CK-MB / Troponin\n T:319/5/<0.01, ALT / AST:566/134, Alk-Phos / T bili:184/1.4, Amylase /\n Lipase:152/9, Differential-Neuts:94.0 %, Band:1.0 %, Lymph:1.0 %,\n Mono:0.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:2.3 g/dL, Ca:8.3 mg/dL, Mg:2.5 mg/dL, PO4:7.5 mg/dL\n Assessment and Plan\n COMFORT CARE (CMO, COMFORT MEASURES), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), PERICARDIAL EFFUSION WITH TAMPONADE, ATRIAL FIBRILLATION\n (AFIB), SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n Assessment and Plan: 50 yo m w/ T3N1 esophageal ca, septic w/ purulent\n pericardial effusion s/p L thoracotomy and pericardial window \n Pt made CMO\n Neurologic: -- intubated and sedated with midazolam gtt and fentanyl\n gtt. Titrate to comfort.\n Cardiovascular: -- s/p pericardiocentesis @ osh. >600cc green,\n viscous, purulent fluid aspirated. Cell count: 1800RBC, 22K WBC (98%\n pmns)\n -- s/p L thoracotomy and pericardial window , fluid sent\n --CT, drain\n Pulmonary: remains intubated while CMO\n Gastrointestinal / Abdomen: No further nutrition\n Nutrition: TF stopped\n Renal:\n Hematology: No further labs\n Endocrine: No further blood glucose checks\n Infectious Disease: Antibiotics stoppted\n Lines / Tubes / Drains: R SC port, LIJ TLC, L axillary Aline, foley,\n ETT, Jtube, CT, \n Wounds:\n Imaging: None\n Fluids:\n Consults: General surgery, CT surgery, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 08:22 PM\n Arterial Line - 09:00 PM\n Multi Lumen - 10:41 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Family meeting held Comments:\n Code status: Comfort measures only\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 724981,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Breath sounds slightly coarse, aerating throughout\n Vent settings- fio2 80%, rate 20 and peep 14\n Sats 96-98%\n Action:\n Peep increased to 17\n Abg\ns checked q6hrs\n Response:\n Repeat abg- 7.37/41/174/25\n Plan:\n Wean fio2 as tolerated\n Continue to monitor abg\ns and sats\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n WBC 30 this am\n Action:\n Urine cultures sent\n Chest CT done with contrast via ngt\n Seen by ID- micafungin and zosyn started\n Response:\n Repeat WBC now 27\n Plan:\n Await CT results\n Await culture reports\n Continue to check WBC\n Atrial fibrillation (Afib)\n Assessment:\n Normal sinus rhythym with rate in 80\n On Amiodarone gtt at 0.5\n Action:\n Hemodynamics monitored\n Response:\n Remains in SR\n Plan:\n Continue Amiodarone as ordered\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 725054,
"text": "TITLE:\n SICU\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to .\n Chief complaint:\n sepsis, pericardial effusion\n PMHx:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with CHADS\n score of 0 treated with ASA only\n Current medications:\n 1. IV access: Peripheral line Order date: @ \n 12. Heparin 5000 UNIT SC TID Order date: @ \n 2. 1000 mL LR\n Continuous at 75 ml/hr Order date: @ 0703\n 13. Midazolam 1-2 mg IV Q2H:PRN agitation Order date: @ 2119\n 3. Albuterol Inhaler PUFF IH Q4H:PRN wheezing Order date: @\n 0358\n 14. Micafungin 100 mg IV Q24H Order date: @ 2249\n 4. Amiodarone 0.5 mg/min IV INFUSION afib Order date: @ 1740\n 15. Norepinephrine 0.3-0.5 mcg/kg/min IV DRIP TITRATE TO map>60\n start vasopressin first, add norepi as needed, titrate norepi off first\n and have vasopressin off last. Order date: @ 2119\n 5. Calcium Gluconate IV Sliding Scale Order date: @ 0216\n 16. Phytonadione 10 mg IV ONCE Duration: 1 Doses\n Infuse over 15 to 30 minutes Order date: @ 1226\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1359\n 17. Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 2233\n 7. Diltiazem 5 mg IV ONCE MR1 Duration: 1 Doses Order date: @\n 0028\n 18. Piperacillin-Tazobactam 2.25 g IV ONCE Duration: 1 Doses Start:\n Order date: @ 2243\n 8. Diltiazem 5-15 mg/hr IV INFUSION Order date: @ 0044\n 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 9. Famotidine 20 mg IV Q24H Order date: @ 2233\n 20. Vasopressin 1.2 UNIT/HR IV DRIP INFUSION\n start prior to levophed, d/c after levophed off. Order date: @\n 2119\n 10. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ \n 21. Vancomycin 1000 mg IV Q 24H Order date: @ 2233\n 11. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 2119\n 24 Hour Events:\n CORDIS/INTRODUCER - STOP 01:51 PM\n ULTRASOUND - At 06:34 PM\n abdominal\n EKG - At 01:10 AM\n - minimal UOP with increasing Bun/Cr\n - entered AFiv with RVR. Dilt 5mg IV x 2 without effect. Placed on\n dilt gtt with conversion to sinus tach.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:20 PM\n Micafungin - 01:29 AM\n Piperacillin/Tazobactam (Zosyn) - 11:23 PM\n Infusions:\n Amiodarone - 0.5 mg/min\n Diltiazem - 10 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:46 PM\n Heparin Sodium (Prophylaxis) - 11:22 PM\n Midazolam (Versed) - 12:00 AM\n Fentanyl - 12:31 AM\n Diltiazem - 12:41 AM\n Other medications:\n Flowsheet Data as of 04:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.4\nC (97.5\n HR: 121 (79 - 139) bpm\n BP: 103/77(88) {99/67(83) - 149/93(115)} mmHg\n RR: 17 (0 - 26) insp/min\n SPO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 57 kg (admission): 50 kg\n Height: 66 Inch\n CVP: 19 (13 - 25) mmHg\n Total In:\n 3,600 mL\n 513 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,600 mL\n 513 mL\n Blood products:\n Total out:\n 97 mL\n 15 mL\n Urine:\n 97 mL\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,503 mL\n 498 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10\n PIP: 38 cmH2O\n Plateau: 32 cmH2O\n SPO2: 100%\n ABG: 7.37/42/181/23/0\n Ve: 10 L/min\n PaO2 / FiO2: 259\n Physical Examination\n General Appearance: No acute distress, intubated, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Tactile stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 398 K/uL\n 8.1 g/dL\n 94 mg/dL\n 3.3 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 76 mg/dL\n 99 mEq/L\n 134 mEq/L\n 24.5 %\n 23.1 K/uL\n [image002.jpg]\n 08:59 PM\n 12:06 AM\n 02:21 AM\n 02:27 AM\n 06:32 AM\n 10:01 AM\n 03:23 PM\n 03:34 PM\n 01:00 AM\n 01:12 AM\n WBC\n 30.1\n 27.3\n 23.1\n Hct\n 25.1\n 25.0\n 24.5\n Plt\n 492\n 441\n 398\n Creatinine\n 2.4\n 3.0\n 3.3\n TCO2\n 27\n 28\n 28\n 26\n 23\n 25\n 25\n Glucose\n 63\n 64\n 68\n 80\n 83\n 94\n Other labs: PT / PTT / INR:22.1/34.6/2.1, ALT / AST:2172/, Alk-Phos\n / T bili:123/1.1, Amylase / Lipase:152/9, Differential-Neuts:94.0 %,\n Band:1.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL,\n Lactic Acid:1.7 mmol/L, Albumin:2.3 g/dL, Ca:7.7 mg/dL, Mg:2.3 mg/dL,\n PO4:7.0 mg/dL\n Imaging: TTE: EF 60%, Small circumferential pericardial effusion\n without evidence for tamponade, mild LVH\n ABD U/S: No hydronephrosis. Diffusely echogenic kidneys\n bilaterally, suggestive of medical renal disease. Small to moderate\n ascites, largest pocket in the RLQ. Bilateral pleural effusions and a\n pericardial effusion. Rounded echogenic foci in the porta , \n reflect normal fat within the porta . However, as these appear\n fairly discrete and rounded, lymphadenopathy cannot be excluded.\n CT Chest: Sufficient opacification of the esophagus. No evidence\n of esophageo-pericardial fistula. Multifocal PNA. Large bilateral\n pleural effusions. Large ascites. Small pericardial effusion.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PERICARDIAL EFFUSION WITH\n TAMPONADE, ATRIAL FIBRILLATION (AFIB), SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n ASSESSMENT:\n 50 yo m w/ T3N1 esophageal ca, septic w/ purulent pericardial effusion.\n Neurologic:\n --intubated and sedated with midazolam prn\n --follows commands, Moves all extremities\n --pain control: fentanyl gtt & IV prn\n Cardiovascular:\n --PAF, amio gtt @ 0.5. transition to PO or off once stable\n --dilt gtt started AM for AFib with RVR again, now Sinus tachy\n --vasopressin/levophed prn map < 60.\n --s/p pericardiocentesis @ osh, though no drain currently in\n place. >600cc green, viscous, purulent fluid aspirated. Cell count:\n 1800RBC, 22K WBC (98% pmns)\n --echo (): small effusion noted, no tamponade. EF>60%. Mild\n symmetric LVH.\n --thoracics consulted\n --PCCO\n --Lactate 1.7 <- 1.5 <- 3.6\n Pulmonary:\n --intubated on cmv 400x20/0.8/14\n --abg 7.37/42/181/25/0\n --ARDS protocol\n --CXR w/ diffuse haziness\n --CT scan showed Multifocal PNA, Large bilateral pleural effusions\n Gastrointestinal / Abdomen:\n --npo/J-tube\n --NGT placed to level of proximal esophagus for CT scan.\n --no evidence of esophageo-pericardial fistula\n --elevated transaminases. ?shock liver. trend down.\n --s/p 5FU & cisplatin completed .\n --GI prophy: famotidine\n Nutrition:\n --npo, cachectic ?start TPN \n Renal:\n --oliguric, no improvement despite IVF hydration.\n --baseline cr 0.5, now increased to Cr 3.3.\n --K @ osh 6.2. tx w/ bicarb, D50 & insulin. w/ good result. K 5.0\n currently\n --renal consulted - f/u recs, ?CVVHD\n -- Abd u/s - no evidence of hydronephrosis. Diffusely echogenic kidneys\n bilaterally, suggestive of medical renal disease\n Hematology:\n --Hct 26.1 -> 25.1 -> 24.5\n --coagulopathic, INR decreased from 3.1 -> 2.1, s/p Vit K \n --no FFP unless actively bleeding\n Endocrine:\n --RISS\n ID:\n --vanco/zosyn/micafungin ()\n --WBC 30.3->30.1->23.1\n --ID consulted\n --f/u cx osh --GS: WBC, rare GPC in clusters, Aerobic: no growth,\n Anaerobic pending\n -- Blood/urine c: pending\n T/L/D: R SC port, LIJ TLC, L axillary Aline, foley, ETT, Jtube\n Wounds: Jtube\n Imaging:\n Fluids: LR @ 75cc/hr\n Consults: gen , cardiology\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: boots, sqh\n Stress ulcer: H2B\n VAP bundle: +\n Comments: consent signed by sister\n Communication: , pt's sister is HCP\n status:DNR\n Disposition:SICU\n Time spent: 35\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725537,
"text": "Pericardial effusion with tamponade\n Assessment:\n Hemodynamically stable. HR 70-80. No ectopy. CO ranging .\n SBP 105-115 however becomes hypertensive to 170s during wake-ups.\n Pericardial and Left anterior CT draining small to moderate\n amounts of serosang fluid. Attached to 10mm suction. No\n leaks/fluctuations. No crepitus noted. Lungs clear. Remains on CMV.\n Fentanyl and Versed continues. Opens eyes to painful stimuli\n lift/holding BUE when sedation lightened. Pupils brisk equal and\n reactive.\n Remains oliguric. Foley patent. BUN/Cr continue to elevate.\n Action:\n Monitoring drain outputs.\n pH revealing slight acidosis. Rate changed to 24.\n Response:\n Continues on Fentanyl/Versed and monitoring drain outputs.\n Sats >96%\n Plan:\n Maintain pt comfort. Titrate sedation accordingly.\n Monitor hemodynamics.\n Monitor Pericardial and anterior chest tubes.\n Family meeting scheduled at 2pm today with Dr to\n discuss further POC.\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725153,
"text": "50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to .\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Patient with resolving sepsis, no longer pressor dependent\n On versed for sedation\n On amio and dilt for afib\n Cardiac echo done that still shows pericardial effusion\n Still with little to no urine output and rising Bun and Cr\n Vented, unable to tolerated PEEP wean from 17 to 14 (pO2 dropped to 54)\n Action:\n Family in, talked with Dr. about overall condition and poor\n prognosis\n Sister (HCP) very supportive and knowledgeable about patient\n wishes\n Response:\n Continue with supportive care\n PEEP back to 17\n Renal continues to follow\n Will assess patient over next few days and have another meeting with\n sister\n :\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725326,
"text": "50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to .\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Clinical picture continues to be one of multisystem organ failure in\n the presence of sepsis\n Renal function worsening with creatnine continuing to rise\n Minimal urine output\n More awake and agitated /competing w/ vent\n Action:\n Thoracic service by this am\n Plan to take patient to OR for pericardial drainage\n No weaning from vent\n Midaz @ 3 and fentanyl gtt added\n Response:\n Comfortably sedated\n Plan:\n On callto OR\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-22 00:00:00.000",
"description": "Intensivist Note",
"row_id": 725574,
"text": "SICU\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to .\n Chief complaint:\n sepsis, pericardial effusion\n PMHx:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with\n CHADS score of 0 treated with ASA only\n .\n Current medications:\n 1. IV access: Peripheral line Order date: @ 0032 9. Fentanyl\n Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: @ 0032\n 2. IV access: None Order date: @ 0032 10. Heparin 5000 UNIT SC\n TID Order date: @ 0032\n 3. Albuterol Inhaler PUFF IH Q4H:PRN wheezing Order date: @\n 0032 11. Midazolam 1-2 mg IV Q2H:PRN agitation Order date: @\n 0032\n 4. Amiodarone 0.25 mg/min IV INFUSION afib Order date: @ 0032\n 12. Micafungin 100 mg IV Q24H Order date: @ 0032\n 5. Calcium Gluconate IV Sliding Scale Order date: @ 0032 13.\n Midazolam 0.5-5 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0032\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 0032 14. Piperacillin-Tazobactam 2.25 g IV Q8H\n until after dialysis has started. Order date: @ 0032\n 7. Famotidine 20 mg PO/NG Q24H Order date: @ 0841 15. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 0032\n 8. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ 0032 16. Vancomycin 1000\n mg IV Q 24H\n Hold for level >15 Order date: @ 0032\n 24 Hour Events:\n Post operative day:\n POD#1 - vats, pericardial window.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:36 PM\n Infusions:\n Amiodarone - 0.25 mg/min\n Fentanyl - 75 mcg/hour\n Midazolam (Versed) - 5 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:23 AM\n Heparin Sodium (Prophylaxis) - 12:24 AM\n Other medications:\n : ASA 325', diltiazem 240', magic mouth wash, nystatin swish &\n swallow, percocet\n .\n Flowsheet Data as of 06:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.8\nC (98.2\n T current: 36.4\nC (97.5\n HR: 70 (69 - 93) bpm\n BP: 112/75(91) {103/68(84) - 183/100(131)} mmHg\n RR: 24 (3 - 27) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 62.4 kg (admission): 50 kg\n Height: 66 Inch\n CVP: 16 (8 - 335) mmHg\n CO/CI (Thermodilution): (3.97 L/min) / (2.6 L/min/m2)\n SVR: 1,975 dynes*sec/cm5\n SV: 45 mL\n SVI: 29 mL/m2\n Total In:\n 2,284 mL\n 635 mL\n PO:\n Tube feeding:\n 766 mL\n 364 mL\n IV Fluid:\n 1,308 mL\n 271 mL\n Blood products:\n Total out:\n 657 mL\n 110 mL\n Urine:\n 187 mL\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,627 mL\n 525 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 33 cmH2O\n Plateau: 28 cmH2O\n Compliance: 36.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.26/47/99./21/-5\n Ve: 9.8 L/min\n PaO2 / FiO2: 250\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Moves all extremities, Sedated. Not following commands\n when lightened.\n Labs / Radiology\n 209 K/uL\n 10.1 g/dL\n 116 mg/dL\n 5.5 mg/dL\n 21 mEq/L\n 4.8 mEq/L\n 110 mg/dL\n 98 mEq/L\n 133 mEq/L\n 31.6 %\n 17.9 K/uL\n [image002.jpg]\n 01:00 AM\n 01:12 AM\n 12:58 PM\n 01:57 AM\n 02:11 AM\n 02:36 AM\n 01:44 AM\n 01:59 AM\n 03:07 AM\n 03:19 AM\n WBC\n 23.1\n 20.9\n 20.7\n 17.9\n Hct\n 24.5\n 22.3\n 28.8\n 31.6\n Plt\n 398\n 290\n 197\n 209\n Creatinine\n 3.3\n 4.2\n 4.7\n 5.5\n Troponin T\n <0.01\n TCO2\n 25\n 20\n 23\n 21\n 21\n 22\n Glucose\n 94\n 97\n 83\n 116\n Other labs: PT / PTT / INR:15.3/33.3/1.3, CK / CK-MB / Troponin\n T:319/5/<0.01, ALT / AST:566/134, Alk-Phos / T bili:184/1.4, Amylase /\n Lipase:152/9, Differential-Neuts:94.0 %, Band:1.0 %, Lymph:1.0 %,\n Mono:0.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:2.3 g/dL, Ca:8.3 mg/dL, Mg:2.5 mg/dL, PO4:7.5 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PERICARDIAL EFFUSION WITH\n TAMPONADE, ATRIAL FIBRILLATION (AFIB), SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n Assessment and Plan: 50 yo m w/ T3N1 esophageal ca, septic w/ purulent\n pericardial effusion s/p L thoracotomy and pericardial window \n Neurologic: -- intubated and sedated with midazolam gtt & prn\n -- follows commands, Moves all extremities\n -- pain control: fentanyl gtt & IV prn\n Cardiovascular: Aspirin, -- pAF, amio gtt decreased to 0.25mg/min gtt,\n dilt gtt off. SR.\n -- s/p pericardiocentesis @ osh. >600cc green, viscous, purulent\n fluid aspirated. Cell count: 1800RBC, 22K WBC (98% pmns)\n -- s/p L thoracotomy and pericardial window , fluid sent\n --CT, drain\n -- PCCO, continue\n -- Lactate 1.1 <-2.5 <- 1.7 <- 1.5 <- 3.6\n Pulmonary: -- intubated, weaning PEEP down\n -- ARDS protocol\n -- CXR w/ diffuse haziness\n -- CT scan showed Multifocal PNA, bilateral pleural effusions\n -- IP consulted for pleural effusions but did not drain\n -- Albuterol Nebs\n Gastrointestinal / Abdomen: -- J tube - TF goal 60cc/hr\n -- no evidence of esophageo-pericardial fistula\n -- elevated transaminases. ?shock liver. trending down.\n -- s/p 5FU & cisplatin completed .\n -- GI prophy: famotidine\n Nutrition: -- TF (3/4 strength replete with fiber) - goal 60cc/hr\n Renal: -- oliguric, no improvement despite IVF hydration.\n -- baseline cr 0.5, now increased to Cr 4.7 now 5.5 BUN 110\n -- renal consulted - plan to begin CVVH if no improvement in next few\n days pending family discussion. Vanc held till levels < 15, and zosyn\n dosed renally.\n -- Na 132. fluid restricting. f/u.\n Hematology: -- s/p 1 unit PRBC \n -- Hct 28.8->31.6\n -- coagulopathic, s/p Vit K x 2days: INR 1.5\n Endocrine: RISS\n Infectious Disease: -- vanco/zosyn ()\n -- Vanco level 18.1\n -- WBC downtrending 20.7->17.9\n -- ID consulted\n -- CX @ osh: (prelim) diphtheroids, 1 single colony, very rare, will\n not do sensitivities\n -- Blood cx: pending\n -- F/up OR Cx\n Lines / Tubes / Drains: R SC port, LIJ TLC, L axillary Aline, foley,\n ETT, Jtube, CT, \n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery, Cardiology, Pulmonology, ID dept,\n Nephrology, thoracic\n Billing Diagnosis: (Respiratory distress: Failure), Sepsis, Other:\n pericarditis, multiorgan failure.\n ICU Care\n Nutrition:\n Comments: TF\n Glycemic Control:\n Lines:\n Indwelling Port (PortaCath) - 08:22 PM\n Arterial Line - 09:00 PM\n Multi Lumen - 10:41 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments: Family meeting today r.e. goals of care.\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725251,
"text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n monitoring continues: CO 3.6-4.2. Continued little to no urine\n output.\n SBP 90s. HR 50-70s NSR- brady to 40s x 1 during period of agitation and\n desaturation.\n Periods of restlessness and agitation/ fighting vent on midaz gtt. OR\n planned for today for pericardial window.\n Action:\n AM labs sent- renal function include. Vanco level.\n Pt awoken for neuro check but bolused with midaz as well as fent x 1\n for increasing agitation and fighting vent-hypoxemia. ABG sent while\n hypoxic. Midaz gtt increased x 2 to 3 mg/hr.\n Turning and reposititoning.\n Emotional support.\n VAP care.\n Tube feeds held at midnight for procedure today. Vit K given iv.\n Response:\n Increasing Bun/Creat. Pt following inconsitent simple commands but\n mostly just agitated and fighting the vent when lightened on sedation.\n Unable to wean sedation and actually increased versed gtt. ABG with pa\n 02 70s with episode of desat to 80s. Fio2 increased to 100% and pt\n suctioned. Sats improved as pt calmed with midaz bolus. Fio2 back to\n previous and sats remain 100%.\n Plan:\n OR today for pericardial window- pt is an add on procedure and pt\n sister has been notified of the procedure and risks that it involves.\n FFP on call to OR.\n Update: 1 unit of PRBCs transfusing d/t drop in HCT prior to OR today.\n Pt is to receive 1 unit of FFP at 7am for INR 1.7 prior to OR per\n order. Confirmed with sicu resident.\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-02-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 725343,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 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: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / 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: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Pending procedure / OR\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-02-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 725384,
"text": "Demographics\n Day of mechanical ventilation: 5\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 23 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: Rhonchi\n RUL Lung Sounds: Rhonchi\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 / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n 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 manage secretions, Underlying illness not resolved\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-20 00:00:00.000",
"description": "Intensivist Note",
"row_id": 725247,
"text": "SICU\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to .\n Chief complaint:\n Pericardial effusion, sepsis in the setting of esophageal cancer\n PMHx:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with CHADS\n score of 0 treated with ASA only\n Current medications:\n 1. IV access: Peripheral line Order date: @ 10. Heparin 5000\n UNIT SC TID Order date: @ \n 2. Albuterol Inhaler PUFF IH Q4H:PRN wheezing Order date: @\n 0358 11. Midazolam 1-2 mg IV Q2H:PRN agitation Order date: @\n 2119\n 3. Amiodarone 0.5 mg/min IV INFUSION afib Order date: @ 1740 12.\n Micafungin 100 mg IV Q24H Order date: @ 2249\n 4. Calcium Gluconate IV Sliding Scale Order date: @ 0216 13.\n Midazolam 0.5-5 mg/hr IV DRIP TITRATE TO sedation\n Patient must have adequate airway support prior to administration of\n dose. Order date: @ 0534\n 5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1359 14. Phytonadione 10 mg IV ONCE coagulopathy Duration: 1 Doses\n Infuse over 15 to 30 minutes Order date: @ 0824\n 6. Diltiazem 5-15 mg/hr IV INFUSION Order date: @ 0044 15.\n Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 2233\n 7. Famotidine 20 mg IV Q24H Order date: @ 2233 16. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 8. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ 17. Vancomycin 1000\n mg IV Q 24H Order date: @ 2233\n 9. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: @\n 2119\n 24 Hour Events:\n BLOOD CULTURED - At 11:01 AM\n cvl\n BLOOD CULTURED - At 11:01 AM\n peripheral\n SPUTUM CULTURE - At 11:02 AM\n Post operative day:\n N/A\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:20 PM\n Micafungin - 01:29 AM\n Piperacillin/Tazobactam (Zosyn) - 12:55 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Amiodarone - 0.5 mg/min\n Diltiazem - 5 mg/hour\n Other ICU medications:\n Midazolam (Versed) - 05:57 AM\n Famotidine (Pepcid) - 07:45 PM\n Fentanyl - 01:00 AM\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.2\nC (97.1\n T current: 35.8\nC (96.5\n HR: 60 (53 - 112) bpm\n BP: 92/63(76) {87/59(72) - 139/83(103)} mmHg\n RR: 19 (13 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 57 kg (admission): 50 kg\n Height: 66 Inch\n CVP: 16 (12 - 32) mmHg\n CO/CI (Thermodilution): (3.92 L/min) / (2.5 L/min/m2)\n SVR: 1,429 dynes*sec/cm5\n SV: 56 mL\n SVI: 36 mL/m2\n Total In:\n 2,829 mL\n 366 mL\n PO:\n Tube feeding:\n 278 mL\n IV Fluid:\n 2,551 mL\n 366 mL\n Blood products:\n Total out:\n 84 mL\n 28 mL\n Urine:\n 84 mL\n 28 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,745 mL\n 338 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n Vt (Spontaneous): 403 (403 - 403) mL\n RR (Set): 20\n RR (Spontaneous): 2\n PEEP: 17 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 34 cmH2O\n Plateau: 26 cmH2O\n Compliance: 44.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.34/38/71/21/-4\n Ve: 10.2 L/min\n PaO2 / FiO2: 142\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Wheezes : , Crackles : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: No(t) Absent)\n Right Extremities: (Edema: No(t) Absent)\n Skin: No(t) Rash:\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 290 K/uL\n 7.5 g/dL\n 97 mg/dL\n 4.2 mg/dL\n 21 mEq/L\n 4.8 mEq/L\n 87 mg/dL\n 99 mEq/L\n 132 mEq/L\n 22.3 %\n 20.9 K/uL\n [image002.jpg]\n 06:32 AM\n 10:01 AM\n 03:23 PM\n 03:34 PM\n 01:00 AM\n 01:12 AM\n 12:58 PM\n 01:57 AM\n 02:11 AM\n 02:36 AM\n WBC\n 27.3\n 23.1\n 20.9\n Hct\n 25.0\n 24.5\n 22.3\n Plt\n \n Creatinine\n 3.0\n 3.3\n 4.2\n TCO2\n 26\n 23\n 25\n 25\n 20\n 23\n 21\n Glucose\n 80\n 83\n 94\n 97\n Other labs: PT / PTT / INR:19.0/35.0/1.7, ALT / AST:1280/546, Alk-Phos\n / T bili:122/1.2, Amylase / Lipase:152/9, Differential-Neuts:94.0 %,\n Band:1.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL,\n Lactic Acid:2.5 mmol/L, Albumin:2.3 g/dL, Ca:8.0 mg/dL, Mg:2.3 mg/dL,\n PO4:6.2 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PERICARDIAL EFFUSION WITH\n TAMPONADE, ATRIAL FIBRILLATION (AFIB), SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n Assessment and Plan: 50 yo m w/ T3N1 esophageal ca, septic w/ purulent\n pericardial effusion.\n Neurologic: --intubated and sedated with midazolam gtt & prn\n --follows commands, Moves all extremities\n --pain control: fentanyl gtt & IV prn\n Cardiovascular: --PAF, amio gtt @ 0.5. transition to PO or off once\n stable\n --dilt gtt weaning, currently at 5\n --s/p pericardiocentesis @ osh, though no drain currently in\n place. >600cc green, viscous, purulent fluid aspirated. Cell count:\n 1800RBC, 22K WBC (98% pmns)\n --echo (): small effusion noted, no tamponade. EF>60%. Mild\n symmetric LVH.\n --PCCO\n --Lactate 2.5 <- 1.7 <- 1.5 <- 3.6\n Pulmonary: --intubated, weaning PEEP down\n --ARDS protocol\n --CXR w/ diffuse haziness\n --CT scan showed Multifocal PNA, bilateral pleural effusions\n -- Albuterol Nebs\n --IP consulted for pleural effusions but did not drain\n Gastrointestinal / Abdomen: --J tube - TF started at 30 (now held for\n OR)\n --no evidence of esophageo-pericardial fistula\n --elevated transaminases. ?shock liver. trend down.\n --s/p 5FU & cisplatin completed .\n --GI prophy: famotidine\n Nutrition: --Resume TF after OR\n Renal: --oliguric, no improvement despite IVF hydration.\n --baseline cr 0.5, now increased to Cr 3.3.\n --renal consulted - f/u recs, possibly begin dialysis\n Hematology: --Hct 26.1 -> 25.1 -> 24.5 ->22.5, transfusing 1 unit\n --coagulopathic, INR decreased from 3.1 -> 2.1-> 1.7, s/p Vit K x 2\n days\n --FFP on call to OR if needed\n Endocrine: RISS\n Infectious Disease: --vanco/zosyn/micafungin ()\n --WBC 30.3->30.1->23.1-> 20.9\n --ID consulted\n --f/u cx osh --GS: WBC, rare GPC in clusters, Aerobic: no growth,\n Anaerobic pending\n -- Blood/urine cx: pending\n --Vanco level 20.4\n Lines / Tubes / Drains: R SC port, LIJ TLC, L axillary Aline, foley,\n ETT, Jtube\n Wounds: N/A\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery, CT surgery, ID dept, Nephrology\n Billing Diagnosis: Sepsis\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 08:22 PM\n Arterial Line - 09:00 PM\n Multi Lumen - 10:41 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR (do not resuscitate)\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725380,
"text": "Pt is a 50 y/o male with esophageal adenoca (T3, N1) admitted to OSH\n Friday () from clinic with c/o weakness, worsening\n dysphagia, \"scratchy throat\", dehydration & decreased PO intake. Was\n started on vanc/zosyn & imipenem for suspected sepsis\n (leukocytosis w/o source initially) in setting of ARF. Decompensated\n overnight & intubated at 4am found to have pericardial\n effusion & tamponade. Underwent pericardocentesis and sent to .\n POST-OP NOTE:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Post-op Pericardial window via Subxiphoid approach for\n purulent pericarditis. Returned from OR with tube at\n pericardium and left anterior chest tube. Set at -10cc H2O.\n Continues with clinical picture being that of a multisystem\n organ failure. Renal function continues to worsen with BUN/Cr slowly\n elevating. Foley patent with minimal urine output at approx 20cc clear\n yellow urine every 4 hours.\n Sedated on Fentanyl. No versed restarted as of yet as pt has\n not been reversed from OR procedure and appears comfortable in bed. No\n spontaneous movements. Prior to procedure MAE lift/holding BUE and\n moving BLE on bed grimacing to pain.\n continues. NSR/SB HR 55-65. No ectopy. SBP 100-110.\n CVP 16-19.\n Hypothermic. Unable to accurately obtain PO or axillary\n temperature immediately post-op.\n Action:\n Monitoring CT output.\n Bair hugger applied and warm blankets to head, still unable\n to obtain temp >> rectal probe placed revealing pt cold at 33.4 >> warm\n lavages done. Unable to warm fluid as pt receiving total of 20cc/hr\n between three fluids. Fungal culture obtained. Thoracics and SICU team\n notified.\n Response:\n Chest tubes remain without fluctuation or leak. Left\n anterior with greater sang drainage .\n Pt remains------------------ to nailbed pressure.\n Slowly re-warming. Current temp\n Plan:\n Continue to monitor CT drainage.\n Monitor labs. Consider starting HD as pt currently 10L\n positive for LOS and remains with oliguric with rising BUN/Cr.\n Maintain pt comfort. Titrate sedation to comfort.\n Monitor temperature and continue re-warming.\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-02-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 725532,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 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: White / Thin\n Sputum source/amount: Suctioned / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: 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: Reduce PEEP as tolerated, Adjust Min. ventilation to\n control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions, Underlying illness not\n resolved; Comments: Pt remains on AC settings on vent, no issues this\n shift. Pt RR was increased due to acidotic pH. Pt has good airway\n pressures with minimal to none secretions suctioned. PaO2 at 100 with\n 17 of PEEP called for no PEEP wean. PT has very weak gag. ETT is\n clear and patent. Pt will be assessed by MD team for further plan of\n care.\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725229,
"text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n monitoring continues: CO 3.6-4.2. Continued little to no urine\n output.\n SBP 90s. HR 50-70s NSR- brady to 40s x 1 during period of agitation and\n desaturation.\n Periods of restlessness and agitation/ fighting vent on midaz gtt. OR\n planned for today for pericardial window.\n Action:\n AM labs sent- renal function include. Vanco level.\n Pt awoken for neuro check but bolused with midaz as well as fent x 1\n for increasing agitation and fighting vent-hypoxemia. ABG sent while\n hypoxic. Midaz gtt increased x 2 to 3 mg/hr.\n Turning and reposititoning.\n Emotional support.\n VAP care.\n Tube feeds held at midnight for procedure today. Vit K given iv.\n Response:\n Increasing Bun/Creat. Pt following inconsitent simple commands but\n mostly just agitated and fighting the vent when lightened on sedation.\n Unable to wean sedation and actually increased versed gtt. ABG with pa\n 02 70s with episode of desat to 80s. Fio2 increased to 100% and pt\n suctioned. Sats improved as pt calmed with midaz bolus. Fio2 back to\n previous and sats remain 100%.\n Plan:\n OR today for pericardial window- pt is an add on procedure and pt\n sister has been notified of the procedure and risks that it involves.\n FFP on call to OR.\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-02-20 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 725241,
"text": "Demographics\n Day of mechanical ventilation: 4\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 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: 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 / 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: Triggering synchronously\n Plan\n Next 24-48 hours: Pt remains on high peep d/t desat\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-02-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 725623,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n 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: 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: 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: Comfort measures only\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725524,
"text": "Pericardial effusion with tamponade\n Assessment:\n Hemodynamically stable. HR 70-80. No ectopy. CO ranging .\n SBP 105-115 however becomes hypertensive to 170s during wake-ups.\n Pericardial and Left anterior CT draining small to moderate\n amounts of serosang fluid. Attached to 10mm suction. No\n leaks/fluctuations. No crepitus noted. Lungs clear.\n Fentanyl and Versed continues. Opens eyes to painful stimuli\n lift/holding BUE when sedation lightened. Pupils brisk equal and\n reactive.\n Remains oliguric. Foley patent. BUN/Cr continue to elevate.\n Action:\n Monitoring drain outputs.\n Following trends.\n Response:\n No changes overnight.\n Plan:\n Maintain pt comfort. Titrate sedation accordingly.\n Monitor hemodynamics.\n Monitor Pericardial and anterior chest tubes.\n Re-attempt wean in AM.\n Family meeting scheduled at 2pm today with Dr to\n discuss further POC.\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725612,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Family meeting with patient sister, father, and brothers,\n decision made to make patient comfortable,\n Action:\n Fi02 decreased to 21% rate decreased to 14,peep at 0\n Amidorane d/cd\n Fentanyl increased up to 150mcg/hr\n Versed increased to 8mg/hr\n Response:\n Pt continue to thrash arms and head on bed\n Fentanyl increased to 250mcg/hr\n Versed increased to 10mg/hr, pt comfortable\n Plan:\n Continue to monitor\n Titriate sedation for comfort\n Provide emotional support to family\n"
},
{
"category": "Nursing",
"chartdate": "2132-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725774,
"text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Fentanyl gtt and versed gtt pt comfortable\n Pt family at bedside with patient\n HR and sbp in 20-30\n Pt became a systolic at 1741\n Action:\n Response:\n Plan:\n Provided emotional support to family\n"
},
{
"category": "Nutrition",
"chartdate": "2132-02-21 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 725465,
"text": "Subjective: Patient remains intubated and sedated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 50 kg\n 61 kg ( 01:00 AM)\n 17.8\n Pertinent medications: Fentanyl, Versed, Amiodarone, ABx, Pepcid,\n others noted\n Labs:\n Value\n Date\n Glucose\n 83 mg/dL\n 01:44 AM\n Glucose Finger Stick\n 108\n 10:00 AM\n BUN\n 90 mg/dL\n 01:44 AM\n Creatinine\n 4.7 mg/dL\n 01:44 AM\n Sodium\n 132 mEq/L\n 01:44 AM\n Potassium\n 4.6 mEq/L\n 01:44 AM\n Chloride\n 99 mEq/L\n 01:44 AM\n TCO2\n 19 mEq/L\n 01:44 AM\n PO2 (arterial)\n 166 mm Hg\n 01:59 AM\n PCO2 (arterial)\n 39 mm Hg\n 01:59 AM\n pH (arterial)\n 7.32 units\n 01:59 AM\n pH (urine)\n 5.0 units\n 09:50 AM\n CO2 (Calc) arterial\n 21 mEq/L\n 01:59 AM\n Albumin\n 2.3 g/dL\n 02:21 AM\n Calcium non-ionized\n 7.9 mg/dL\n 01:44 AM\n Phosphorus\n 6.3 mg/dL\n 01:44 AM\n Ionized Calcium\n 1.12 mmol/L\n 02:36 AM\n Magnesium\n 2.3 mg/dL\n 01:44 AM\n ALT\n 833 IU/L\n 01:44 AM\n Alkaline Phosphate\n 119 IU/L\n 01:44 AM\n AST\n 250 IU/L\n 01:44 AM\n Amylase\n 152 IU/L\n 03:23 PM\n Total Bilirubin\n 1.8 mg/dL\n 01:44 AM\n WBC\n 20.7 K/uL\n 01:44 AM\n Hgb\n 9.7 g/dL\n 01:44 AM\n Hematocrit\n 28.8 %\n 01:44 AM\n Current diet order / nutrition support: Tube Feeds: 3/4 strength\n Replete with Fiber @ 60mL/hr (1080kcals, 67g protein)\n GI: abd firm, hypoactive bowel sounds\n Assessment of Nutritional Status\n 50 y.o. Male w/ T3N1 esophageal ca, septic w/ purulent pericardial\n effusion, s/p L thoracotomy and pericardial window . Patient\n remains untubated and sedated. Tube feeds restarted via J-tube with\n strength Replete with Fiber, which is not appropriate for patient at\n this time due to ARF. Given worsening renal function, recommend\n changing to our renal formula\n Novasource Renal\n will leave\n strength and full strength goal recommendations.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend changing tube feeds to\n strength Novasource Renal\n @ 54mL/hr (1296kcals, 48g protein).\n Full strength goal: 27mL/hr.\n Following - #\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-02-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 725679,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: 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:\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: Pt is currently CMO,\n still intubated on vent. Pt had moderate to copious secretions, with\n normal airway pressures. Pt to remain on current vent settings and be\n monitored by RN and RT\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-21 00:00:00.000",
"description": "Intensivist Note",
"row_id": 725438,
"text": "SICU\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to \n Chief complaint:\n sepsis, pericardial effusion\n PMHx:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with CHADS\n score of 0 treated with ASA only\n Current medications:\n 1. 2. 3. Albuterol Inhaler 4. Amiodarone 5. Calcium Gluconate 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Famotidine 8. Fentanyl Citrate 9. Fentanyl Citrate 10. Heparin 11.\n Midazolam 12. Micafungin\n 13. Midazolam 14. Piperacillin-Tazobactam 15. Sodium Chloride 0.9%\n Flush 16. Vancomycin\n 24 Hour Events:\n OR SENT - At 10:37 PM\n OR RECEIVED - At 12:25 AM\n EKG - At 02:29 AM\n post-op\n - to OR for pericardial window. Received FFP and 1 U prbcs preop.\n Post operative day:\n POD#0 - vats, pericardial window.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:14 PM\n Infusions:\n Amiodarone - 0.25 mg/min\n Fentanyl - 50 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:13 PM\n Other medications:\n Flowsheet Data as of 05:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 35.9\nC (96.6\n T current: 35.8\nC (96.4\n HR: 79 (55 - 87) bpm\n BP: 109/73(89) {96/61(0) - 166/97(123)} mmHg\n RR: 20 (18 - 24) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 61 kg (admission): 50 kg\n Height: 66 Inch\n CVP: 18 (13 - 25) mmHg\n CO/CI (Thermodilution): (3.19 L/min) / (2.1 L/min/m2)\n SVR: 1,906 dynes*sec/cm5\n SV: 56 mL\n SVI: 36 mL/m2\n Total In:\n 2,627 mL\n 645 mL\n PO:\n Tube feeding:\n 23 mL\n IV Fluid:\n 2,015 mL\n 502 mL\n Blood products:\n 612 mL\n Total out:\n 113 mL\n 60 mL\n Urine:\n 113 mL\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,514 mL\n 585 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 36 cmH2O\n Plateau: 29 cmH2O\n Compliance: 33.3 cmH2O/mL\n SPO2: 94%\n ABG: 7.32/39/166/19/-5\n Ve: 8.7 L/min\n PaO2 / FiO2: 415\n Physical Examination\n General Appearance: intubated and sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: 1+), (Temperature: Warm)\n Right Extremities: (Edema: 1+), (Temperature: Warm)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities\n Labs / Radiology\n 197 K/uL\n 9.7 g/dL\n 83 mg/dL\n 4.7 mg/dL\n 19 mEq/L\n 4.6 mEq/L\n 90 mg/dL\n 99 mEq/L\n 132 mEq/L\n 28.8 %\n 20.7 K/uL\n [image002.jpg]\n 03:23 PM\n 03:34 PM\n 01:00 AM\n 01:12 AM\n 12:58 PM\n 01:57 AM\n 02:11 AM\n 02:36 AM\n 01:44 AM\n 01:59 AM\n WBC\n 27.3\n 23.1\n 20.9\n 20.7\n Hct\n 25.0\n 24.5\n 22.3\n 28.8\n Plt\n 97\n Creatinine\n 3.0\n 3.3\n 4.2\n 4.7\n Troponin T\n <0.01\n TCO2\n 25\n 25\n 20\n 23\n 21\n 21\n Glucose\n 83\n 94\n 97\n 83\n Other labs: PT / PTT / INR:16.8/32.3/1.5, CK / CK-MB / Troponin\n T:319/5/<0.01, ALT / AST:833/250, Alk-Phos / T bili:119/1.8, Amylase /\n Lipase:152/9, Differential-Neuts:94.0 %, Band:1.0 %, Lymph:1.0 %,\n Mono:0.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL, Lactic Acid:1.1 mmol/L,\n Albumin:2.3 g/dL, Ca:7.9 mg/dL, Mg:2.3 mg/dL, PO4:6.3 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PERICARDIAL EFFUSION WITH\n TAMPONADE, ATRIAL FIBRILLATION (AFIB), SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n Assessment and Plan: 50 yo m w/ T3N1 esophageal ca, septic w/ purulent\n pericardial effusion.s/p L thoracotomy and pericardial window \n Neurologic: --intubated and sedated with midazolam gtt & prn\n --follows commands, Moves all extremities\n --pain control: fentanyl gtt & IV prn\n Cardiovascular: --pAF, amio gtt decreased to 0.25mg/min gtt\n --dilt gtt off\n --s/p pericardiocentesis @ osh, though no drain currently in\n place. >600cc green, viscous, purulent fluid aspirated. Cell count:\n 1800RBC, 22K WBC (98% pmns)\n --echo (): small effusion noted, no tamponade. EF>60%. Mild\n symmetric LVH.\n --echo (): small to moderate sized pericardial effusion (1.2 cm).\n The effusion appears circumferential. There is no evidence of tamponade\n physiology. The severity of tricuspid regurgitation has increased.\n --s/p L thoracotomy and pericardial window , w/ in\n pericardium\n --PCCO\n --Lactate -<1.1<-2.5 <- 1.7 <- 1.5 <- 3.6\n Pulmonary: --intubated, weaning PEEP down\n --ARDS protocol\n --CXR w/ diffuse haziness\n --CT scan showed Multifocal PNA, bilateral pleural effusions\n -- Albuterol Nebs\n --IP consulted for pleural effusions but did not drain\n -CT tube to suction no leak\n Gastrointestinal / Abdomen: --J tube - TF started at 30\n --no evidence of esophageo-pericardial fistula\n --elevated transaminases. ?shock liver. trend down.\n --s/p 5FU & cisplatin completed .\n --GI prophy: famotidine\n Nutrition: --Resume TF\n Renal: --oliguric, no improvement despite IVF hydration.\n --baseline cr 0.5, now increased to Cr 4.7.\n --renal consulted - plan to begin dialysis if no improvement in next\n few days. Vanc held till levels < 15, and zosyn dosed renally.\n --Na 132. Monitor closely\n Hematology: --Hct 26.1 -> 25.1 -> 24.5 ->22.5, transfusing 1 unit PRBC\n \n --coagulopathic, INR decreased from 3.1 -> 2.1-> 1.7->1.5 s/p Vit K x 2\n days\n Endocrine: RISS\n Infectious Disease: --vanco/zosyn ()\n --WBC 30.3->30.1->23.1-> 20.9->20.7\n --ID consulted\n --f/u cx osh --GS: WBC, rare GPC in clusters, Aerobic: no growth,\n Anaerobic pending\n -- Blood/urine cx: pending\n --Vanco level pending\n --F/up OR Cx\n Lines / Tubes / Drains: R SC port, LIJ TLC, L axillary Aline, foley,\n ETT, Jtube, CT, \n Wounds: Left thoracotomy\n Imaging: CXR today\n Fluids:\n Consults: gen , thoracic, nephrology, ID\n Billing Diagnosis: (Respiratory distress), Sepsis, Liver failure, Acute\n renal failure\n ICU Care\n Nutrition:\n Replete with Fiber () - 03:10 AM 10 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Indwelling Port (PortaCath) - 08:22 PM\n Arterial Line - 09:00 PM\n Multi Lumen - 10:41 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: 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": "Respiratory ",
"chartdate": "2132-02-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 725769,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Invasive ventilation assessment:\n Trigger work assessment:\n Plan\n Next 24-48 hours: Comfort measures only\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Respiratory ",
"chartdate": "2132-02-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 725516,
"text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 23 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: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / 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: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: plan to revaluate in AM rounds\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": "2132-02-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 725669,
"text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Family in this pm, went home for the night. Pt sedated on\n Versed/Fentanyl gtts. Pt remains intubated on 21% Fio2, A/C rate 14,\n PEEP 0. Pt suctioned for thick tan secretions. Chest tube and\n mediastinal tube to dry suction 10cm.\n Action:\n Support to family. Versed remains at 10mg/hr and Fentanyl gtt at\n 276mcg/hr.\n Response:\n Pt calm/unresponsive on present gtts.\n Plan:\n Continue with comfort care. Family will be back in am\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-18 00:00:00.000",
"description": "Intensivist Note",
"row_id": 724933,
"text": "SICU\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to .\n Chief complaint:\n sepsis, pericardial effusion\n PMHx:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with CHADS\n score of 0 treated with ASA only\n Current medications:\n 1. IV access: Peripheral line Order date: @ 11. Micafungin\n 100 mg IV Q24H *Awaiting ID Approval* Order date: @ 2249\n 2. 1000 mL LR Bolus 500 ml Over 30 mins\n MRx1 Order date: @ 2130 12. Micafungin 100 mg IV ONCE Duration: 1\n Doses Start: Order date: @ 2256\n 3. 1000 mL LR\n Continuous at 5 ml/hr Order date: @ 2353 13. Norepinephrine\n 0.3-0.5 mcg/kg/min IV DRIP TITRATE TO map>60\n start vasopressin first, add norepi as needed, titrate norepi off first\n and have vasopressin off last. Order date: @ 2119\n 4. Albuterol Inhaler PUFF IH Q4H:PRN wheezing Order date: @\n 0358 14. Piperacillin-Tazobactam 2.25 g IV ONCE Duration: 1 Doses\n Start: Order date: @ 2218\n 5. Amiodarone 0.5 mg/min IV INFUSION afib Order date: @ 1740 15.\n Piperacillin-Tazobactam 2.25 g IV Q6H *Awaiting ID Approval* Order\n date: @ 2233\n 6. Famotidine 20 mg IV Q24H Order date: @ 2233 16.\n Piperacillin-Tazobactam 2.25 g IV ONCE Duration: 1 Doses Start:\n Order date: @ 2243\n 7. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ 17. Sodium Chloride\n 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 8. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: @\n 2119 18. Vasopressin 1.2 UNIT/HR IV DRIP INFUSION\n start prior to levophed, d/c after levophed off. Order date: @\n 2119\n 9. Heparin 5000 UNIT SC TID Order date: @ 19. Vancomycin\n 1000 mg IV Q 24H\n ID Approval will be required for this order in 63 hours. Order date:\n @ 2233\n 10. Midazolam 1-2 mg IV Q2H:PRN agitation Order date: @ 2119\n 24 Hour Events:\n INVASIVE VENTILATION - START 08:20 PM\n PA CATHETER - START 08:21 PM\n INDWELLING PORT (PORTACATH) - START 08:22 PM\n ARTERIAL LINE - START 09:00 PM\n CORDIS/INTRODUCER - START 09:00 PM\n MULTI LUMEN - START 10:41 PM\n ULTRASOUND - At 11:30 PM\n ECHO\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:20 PM\n Micafungin - 01:29 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Vasopressin - 1.2 units/hour\n Other ICU medications:\n Midazolam (Versed) - 10:30 PM\n Other medications:\n : ASA 325', diltiazem 240', magic mouth wash, nystatin swish &\n swallow, percocet\n Flowsheet Data as of 06:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.9\nC (98.4\n HR: 115 (77 - 125) bpm\n BP: 106/79(91) {90/69(36) - 145/101(109)} mmHg\n RR: 18 (8 - 27) insp/min\n SPO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Height: 66 Inch\n CVP: 18 (-2 - 33) mmHg\n PAP: (49 mmHg) / (34 mmHg)\n PCWP: 30 (30 - 30) mmHg\n CO/CI (Thermodilution): (4.37 L/min) / (2.8 L/min/m2)\n SVR: 1,043 dynes*sec/cm5\n PVR: 165 dynes*sec/cm5\n SV: 42 mL\n SVI: 27 mL/m2\n Total In:\n 1,598 mL\n 933 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,598 mL\n 933 mL\n Blood products:\n Total out:\n 10 mL\n 0 mL\n Urine:\n 10 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,588 mL\n 933 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 450) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 80%\n PIP: 31 cmH2O\n Plateau: 26 cmH2O\n Compliance: 35.4 cmH2O/mL\n SPO2: 97%\n ABG: 7.30/54/121/25/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 151\n Physical Examination\n General Appearance: No acute distress, Cachectic, follows commands on\n minimal sedation\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular, Irregular), (Distant heart sounds:\n Present), Irreg rhythm from admission to 6a. SR since 6a.\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 492 K/uL\n 8.3 g/dL\n 68 mg/dL\n 2.4 mg/dL\n 25 mEq/L\n 5.2 mEq/L\n 57 mg/dL\n 101 mEq/L\n 136 mEq/L\n 25.1 %\n 30.1 K/uL\n [image002.jpg]\n 07:50 PM\n 08:48 PM\n 08:59 PM\n 12:06 AM\n 02:21 AM\n 02:27 AM\n WBC\n 30.3\n 30.1\n Hct\n 26.1\n 25.1\n Plt\n 556\n 492\n Creatinine\n 2.2\n 2.4\n TCO2\n 27\n 28\n 28\n Glucose\n 79\n 61\n 63\n 64\n 68\n Other labs: PT / PTT / INR:30.4/40.1/3.0, ALT / AST:3101/7197, Alk-Phos\n / T bili:112/0.9, Differential-Neuts:91.0 %, Band:4.0 %, Lymph:3.0 %,\n Mono:2.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL, Lactic Acid:1.5 mmol/L,\n Albumin:2.3 g/dL, Ca:7.2 mg/dL, Mg:2.4 mg/dL, PO4:7.3 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PERICARDIAL EFFUSION WITH\n TAMPONADE, ATRIAL FIBRILLATION (AFIB), SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n Assessment and Plan: 50 yo m w/ T3N1 esophageal ca, septic w/ purulent\n pericardial effusion.\n Neurologic: --intubated, sedated on fent gtt. intermittent midaz.\n --follows commands, MAE\n Cardiovascular: --PAF, in fib from admission to 6am. good rate control\n on admission, increased O/N. amio gtt @ 0.5. transition to PO or off\n once stable\n --dilt gtt if RVR again, now SR\n --neo on admission, now off. vasopressin for map >60. add levophed\n next.\n --s/p pericardiocentesis @ osh. >600cc green, viscous, purulent\n fluid aspirated. Cell count: 1800RBC, 22K WBC (98% pmns)\n --cardiology consulted, formal echo result pending. prelim not\n tamponade.\n --thoracics consult - Gangadahran\n --EF nl->hyperdynamic\n --PAC removed (elevated PAP & RV diastolic pressures prior to d/c)\n -- placed.\n --EKG w/ elevated Jpoint in lateral leads, CE neg @ osh\n --Lactate 1.5<-3.6\n Pulmonary: --hypoxic on admission, now on cmv 400x20/0.8/14\n --abg 7.30/54/121/28/0\n --Aa gradient continues, ards protocol->careful of BP as PEEP incr.\n --CXR w/ diffuse haziness\n Gastrointestinal / Abdomen: --npo/J-tube\n --no ogt/ngt w/ poss esophageal perf\n --elevated transaminases. ?shock liver. will trend.\n --s/p 5FU & cisplatin completed \n Nutrition: --npo, cachectic ?start TF tomorrow\n Renal: --oliguric\n --baseline cr 0.5 (0.6 @ osh). now 2.2->2.4. ivf administration in\n light of no further tamponade physiology by echo and oliguric.\n --K @ osh 6.2. tx w/ bicarb, D50 & insulin. w/ good result.\n --lytes otherwise wnl on admission, K trending up again. chck pm lytes.\n --likely CVVH in future.\n Hematology: --Hct 26.1->25.1, will trend. t/x 2u sent\n --coagulopathic, inr 3.1, stable.\n --Vit K now. FFP after scan prior to intervention.\n Endocrine: RISS\n Infectious Disease: --vanco/zosyn/micafungin ()\n --WBC 24.9 w/ 32 bands @ osh. ->wbc 30.3->30.1\n --f/u formal ID recs\n --f/u cx osh\n --Blood/urine cx sent\n Lines / Tubes / Drains: R SC port, LIJ TLC, L axillary Aline, D/C Rt\n fem cordis (PAC d/c'd), foley, ETT, Jtube\n Wounds:\n Imaging: CXR today\n Fluids: LR 100->5cc/h\n Consults: General surgery, Cardiology, ID dept, Thoracics\n Billing Diagnosis: Sepsis, (Shock: Septic), Liver failure, Acute renal\n failure, Other: Pericardial effusion\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PA Catheter - 08:21 PM\n Indwelling Port (PortaCath) - 08:22 PM\n Arterial Line - 09:00 PM\n Cordis/Introducer - 09:00 PM\n Multi Lumen - 10:41 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: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2132-02-19 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 725122,
"text": "Subjective: patient intubated and sedated, no family available.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 50 kg\n 57 kg ( 12:00 AM)\n 17.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 64.4 kg\n 78%\n unknown\n Diagnosis: R/O Sepsis, Renal Failure\n PMHx: esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with\n CHADS\n Food allergies and intolerances: none noted\n Pertinent medications: HISS, Heparin, Protonix, Versed, Amiodarone,\n Diltiazem, lactated ringers @ 75mL/hr, others noted\n Labs:\n Value\n Date\n Glucose\n 94 mg/dL\n 01:00 AM\n Glucose Finger Stick\n 123\n 10:00 AM\n BUN\n 76 mg/dL\n 01:00 AM\n Creatinine\n 3.3 mg/dL\n 01:00 AM\n Sodium\n 134 mEq/L\n 01:00 AM\n Potassium\n 5.0 mEq/L\n 01:00 AM\n Chloride\n 99 mEq/L\n 01:00 AM\n TCO2\n 23 mEq/L\n 01:00 AM\n PO2 (arterial)\n 181 mm Hg\n 01:12 AM\n PCO2 (arterial)\n 42 mm Hg\n 01:12 AM\n pH (arterial)\n 7.37 units\n 01:12 AM\n pH (urine)\n 5.0 units\n 09:50 AM\n CO2 (Calc) arterial\n 25 mEq/L\n 01:12 AM\n Albumin\n 2.3 g/dL\n 02:21 AM\n Calcium non-ionized\n 7.7 mg/dL\n 01:00 AM\n Phosphorus\n 7.0 mg/dL\n 01:00 AM\n Ionized Calcium\n 1.05 mmol/L\n 01:12 AM\n Magnesium\n 2.3 mg/dL\n 01:00 AM\n ALT\n 2172 IU/L\n 01:00 AM\n Alkaline Phosphate\n 123 IU/L\n 01:00 AM\n AST\n IU/L\n 01:00 AM\n Amylase\n 152 IU/L\n 03:23 PM\n Total Bilirubin\n 1.1 mg/dL\n 01:00 AM\n WBC\n 23.1 K/uL\n 01:00 AM\n Hgb\n 8.1 g/dL\n 01:00 AM\n Hematocrit\n 24.5 %\n 01:00 AM\n Current diet order / nutrition support: Tube Feeds: 1/2 strength\n Replete with Fiber @ 30mL/hr (360kcals, 22g protein)\n GI: abd firm, bowel sounds absent, J-tube clamped\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: low body wt, likely with significant wt loss\n Estimated Nutritional Needs\n Calories: 1250-1750 (25-35 cal/kg)\n Protein: 45-60 (0.9-1.2 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Estimation of previous intake: Inadequate\n Estimation of current intake: Inadequate\n Specifics:\n 50M w/ esophageal adenocarcinoma (T3, N1), admitted to OSH Friday from\n clinic 2.19 w/ weakness, worsening dysphagia, dehydration &\n decreased po intake. Patient was started on ABx for suspected sepsis\n (leukocytosis w/o source initially) in setting of ARF. Decompensated\n overnight & intubated 4am found to have pericardial effusion\n & tamponade. Underwent pericardocentesis and sent to . Patient\n now remains intubated and sedated. Team would like to start\n strength\n tube feeds via J-tube. Although there is no reason to use diluted tube\n feeds, even with a J-tube, abd exam is very poor and patient may not\n tolerated tube feeds at this time. Will provide tube feeding and TPN\n recommendations below.\n Medical Nutrition Therapy Plan - Recommend the Following\n For tube feeds: recommend eventual goal of Novasource Renal\n @ 27mL/hr (1296kcals, 48g protein).\n If patient unable to tolerate tube feeds, recommend starting\n Day 1 standard with goal of 1100mL (225g dextrose/ 50g amino acid/ 30g\n fat) = 1265kcals.\n Will follow plan/progress\n #\n"
},
{
"category": "Physician ",
"chartdate": "2132-02-19 00:00:00.000",
"description": "Intensivist Note",
"row_id": 725104,
"text": "TITLE:\n SICU\n HPI:\n 50M w/ esophageal adenoca (T3, N1), admitted to OSH Friday from\n clinic Friday w/ c/o weakness, worsening dysphagia, \"scratchy\n throat\", dehydration & decr po intake. Was started on vanc/zosyn &\n imipenem for suspected sepsis (leukocytosis w/o source initially)\n in setting of ARF. Decompensated overnight & intubated 4am\n found to have pericardial effusion & tamponade. Underwent\n pericardocentesis and sent to .\n Chief complaint:\n sepsis, pericardial effusion\n PMHx:\n esophageal cancer s/p chemo (cisplatin/5FU), paroxysmal AFib with CHADS\n score of 0 treated with ASA only\n Current medications:\n 1. IV access: Peripheral line Order date: @ \n 12. Heparin 5000 UNIT SC TID Order date: @ \n 2. 1000 mL LR\n Continuous at 75 ml/hr Order date: @ 0703\n 13. Midazolam 1-2 mg IV Q2H:PRN agitation Order date: @ 2119\n 3. Albuterol Inhaler PUFF IH Q4H:PRN wheezing Order date: @\n 0358\n 14. Micafungin 100 mg IV Q24H Order date: @ 2249\n 4. Amiodarone 0.5 mg/min IV INFUSION afib Order date: @ 1740\n 15. Norepinephrine 0.3-0.5 mcg/kg/min IV DRIP TITRATE TO map>60\n start vasopressin first, add norepi as needed, titrate norepi off first\n and have vasopressin off last. Order date: @ 2119\n 5. Calcium Gluconate IV Sliding Scale Order date: @ 0216\n 16. Phytonadione 10 mg IV ONCE Duration: 1 Doses\n Infuse over 15 to 30 minutes Order date: @ 1226\n 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1359\n 17. Piperacillin-Tazobactam 2.25 g IV Q6H Order date: @ 2233\n 7. Diltiazem 5 mg IV ONCE MR1 Duration: 1 Doses Order date: @\n 0028\n 18. Piperacillin-Tazobactam 2.25 g IV ONCE Duration: 1 Doses Start:\n Order date: @ 2243\n 8. Diltiazem 5-15 mg/hr IV INFUSION Order date: @ 0044\n 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ \n 9. Famotidine 20 mg IV Q24H Order date: @ 2233\n 20. Vasopressin 1.2 UNIT/HR IV DRIP INFUSION\n start prior to levophed, d/c after levophed off. Order date: @\n 2119\n 10. Fentanyl Citrate 25-100 mcg IV Q6H:PRN Sedation\n Give doses every 5 min until sedated. Maintenance target: 3 and\n overbreathing ventilator Order date: @ \n 21. Vancomycin 1000 mg IV Q 24H Order date: @ 2233\n 11. Fentanyl Citrate 25-100 mcg/hr IV DRIP INFUSION Order date: \n @ 2119\n 24 Hour Events:\n CORDIS/INTRODUCER - STOP 01:51 PM\n ULTRASOUND - At 06:34 PM\n abdominal\n EKG - At 01:10 AM\n - minimal UOP with increasing Bun/Cr\n - entered AFiv with RVR. Dilt 5mg IV x 2 without effect. Placed on\n dilt gtt with conversion to sinus tach.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:20 PM\n Micafungin - 01:29 AM\n Piperacillin/Tazobactam (Zosyn) - 11:23 PM\n Infusions:\n Amiodarone - 0.5 mg/min\n Diltiazem - 10 mg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 08:46 PM\n Heparin Sodium (Prophylaxis) - 11:22 PM\n Midazolam (Versed) - 12:00 AM\n Fentanyl - 12:31 AM\n Diltiazem - 12:41 AM\n Other medications:\n Flowsheet Data as of 04:12 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.9\nC (98.4\n T current: 36.4\nC (97.5\n HR: 121 (79 - 139) bpm\n BP: 103/77(88) {99/67(83) - 149/93(115)} mmHg\n RR: 17 (0 - 26) insp/min\n SPO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 57 kg (admission): 50 kg\n Height: 66 Inch\n CVP: 19 (13 - 25) mmHg\n Total In:\n 3,600 mL\n 513 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,600 mL\n 513 mL\n Blood products:\n Total out:\n 97 mL\n 15 mL\n Urine:\n 97 mL\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,503 mL\n 498 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 400 (400 - 400) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 17 cmH2O\n FiO2: 70%\n RSBI Deferred: PEEP > 10\n PIP: 38 cmH2O\n Plateau: 32 cmH2O\n SPO2: 100%\n ABG: 7.37/42/181/23/0\n Ve: 10 L/min\n PaO2 / FiO2: 259\n Physical Examination\n General Appearance: No acute distress, intubated, sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Rhonchorous : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, (Responds to: Tactile stimuli),\n Moves all extremities, Sedated\n Labs / Radiology\n 398 K/uL\n 8.1 g/dL\n 94 mg/dL\n 3.3 mg/dL\n 23 mEq/L\n 5.0 mEq/L\n 76 mg/dL\n 99 mEq/L\n 134 mEq/L\n 24.5 %\n 23.1 K/uL\n [image002.jpg]\n 08:59 PM\n 12:06 AM\n 02:21 AM\n 02:27 AM\n 06:32 AM\n 10:01 AM\n 03:23 PM\n 03:34 PM\n 01:00 AM\n 01:12 AM\n WBC\n 30.1\n 27.3\n 23.1\n Hct\n 25.1\n 25.0\n 24.5\n Plt\n 492\n 441\n 398\n Creatinine\n 2.4\n 3.0\n 3.3\n TCO2\n 27\n 28\n 28\n 26\n 23\n 25\n 25\n Glucose\n 63\n 64\n 68\n 80\n 83\n 94\n Other labs: PT / PTT / INR:22.1/34.6/2.1, ALT / AST:2172/, Alk-Phos\n / T bili:123/1.1, Amylase / Lipase:152/9, Differential-Neuts:94.0 %,\n Band:1.0 %, Lymph:1.0 %, Mono:0.0 %, Eos:0.0 %, Fibrinogen:438 mg/dL,\n Lactic Acid:1.7 mmol/L, Albumin:2.3 g/dL, Ca:7.7 mg/dL, Mg:2.3 mg/dL,\n PO4:7.0 mg/dL\n Imaging: TTE: EF 60%, Small circumferential pericardial effusion\n without evidence for tamponade, mild LVH\n ABD U/S: No hydronephrosis. Diffusely echogenic kidneys\n bilaterally, suggestive of medical renal disease. Small to moderate\n ascites, largest pocket in the RLQ. Bilateral pleural effusions and a\n pericardial effusion. Rounded echogenic foci in the porta , \n reflect normal fat within the porta . However, as these appear\n fairly discrete and rounded, lymphadenopathy cannot be excluded.\n CT Chest: Sufficient opacification of the esophagus. No evidence\n of esophageo-pericardial fistula. Multifocal PNA. Large bilateral\n pleural effusions. Large ascites. Small pericardial effusion.\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), PERICARDIAL EFFUSION WITH\n TAMPONADE, ATRIAL FIBRILLATION (AFIB), SEPSIS, SEVERE (WITH ORGAN\n DYSFUNCTION)\n ASSESSMENT:\n 50 yo m w/ T3N1 esophageal ca, septic w/ purulent pericardial effusion.\n Neurologic:\n --intubated and sedated with midazolam prn\n --follows commands, Moves all extremities\n --pain control: fentanyl gtt & IV prn\n Cardiovascular:\n --PAF, amio gtt @ 0.5. transition to PO or off once stable\n --dilt gtt started AM for AFib with RVR again, now Sinus tachy\n --vasopressin/levophed prn map < 60. Now off.\n --s/p pericardiocentesis @ osh, though no drain currently in\n place. >600cc green, viscous, purulent fluid aspirated. Cell count:\n 1800RBC, 22K WBC (98% pmns)\n --echo (): small effusion noted, no tamponade. EF>60%. Mild\n symmetric LVH.\n --thoracics consulted. Would do repeat pericardiocentesis.\n --PCCO\n --Lactate 1.7 <- 1.5 <- 3.6\n Pulmonary:\n --intubated on cmv 400x20/0.8/14\n --abg 7.37/42/181/25/0\n --ARDS protocol\n --CXR w/ diffuse haziness Pleural effusions. IP to tap.\n --CT scan showed Multifocal PNA, Large bilateral pleural effusions\n Gastrointestinal / Abdomen:\n --npo/J-tube\n --NGT placed to level of proximal esophagus for CT scan.\n --no evidence of esophageo-pericardial fistula on CT\n --elevated transaminases. ?shock liver. trend down.\n --s/p 5FU & cisplatin completed .\n --GI prophy: famotidine\n Nutrition:\n --npo, cachectic ?start TPN \n Renal:\n --oliguric, no improvement despite IVF hydration.\n --baseline cr 0.5, now increased to Cr 3.3.\n --K @ osh 6.2. tx w/ bicarb, D50 & insulin. w/ good result. K 5.0\n currently\n --renal consulted - f/u recs, ?CVVHD\n -- Abd u/s - no evidence of hydronephrosis. Diffusely echogenic kidneys\n bilaterally, suggestive of medical renal disease\n Hematology:\n --Hct 26.1 -> 25.1 -> 24.5\n --coagulopathic, INR decreased from 3.1 -> 2.1, s/p Vit K \n --no FFP unless actively bleeding\n Endocrine:\n --RISS\n ID:\n --vanco/zosyn/micafungin ()\n --WBC 30.3->30.1->23.1\n --ID consulted\n --f/u cx osh --GS: WBC, rare GPC in clusters, Aerobic: no growth,\n Anaerobic pending\n -- Blood/urine c: pending\n T/L/D: R SC port, LIJ TLC, L axillary Aline, foley, ETT, Jtube\n Wounds: Jtube\n Imaging:\n Fluids: LR @ 75cc/hr\n Consults: gen , cardiology\n Billing Diagnosis: sepsis\n Prophylaxis:\n DVT: boots, sqh\n Stress ulcer: H2B\n VAP bundle: +\n Comments: consent signed by sister\n Communication: , pt's sister is HCP\n status:DNR\n Disposition:SICU\n Time spent: 35\n"
},
{
"category": "ECG",
"chartdate": "2132-02-21 00:00:00.000",
"description": "Report",
"row_id": 235959,
"text": "Normal sinus rhythm. Low voltage in the standard leads. Poor R wave progression\nacross the precordial leads. Compared to the previous tracing of the\npatient has gone from atrial fibrillation to normal sinus rhythm. There is no\nother diagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2132-02-19 00:00:00.000",
"description": "Report",
"row_id": 235960,
"text": "Probable \"fine\" atrial fibrillation with rapid ventricular response.\nLow limb lead and lateral precordial lead QRS voltage. Delayed R wave\nprogression. Findings are non-specific. Since the previous tracing\nof atrial fibrillation has replaced sinus rhythm and QRS and T wave\nvoltages are lower.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-02-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1122793,
"text": " 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: lung volumes, ett plcmt\n Admitting Diagnosis: R/O SEPSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ett, ards\n REASON FOR THIS EXAMINATION:\n lung volumes, ett plcmt\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation of interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Unchanged size of the cardiac silhouette, unchanged extent and\n severity of the pre-existing parenchymal opacities. The endotracheal tube and\n the left central venous access lines are in unchanged position. No interval\n recurrence of focal parenchymal opacities. Borderline size of the cardiac\n silhouette, unchanged retrocardiac atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-02-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1122441,
"text": " 8:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: desats to 60s; eval for acute intrathoracic process\n Admitting Diagnosis: R/O SEPSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with esophageal cancer, pleural effusion\n REASON FOR THIS EXAMINATION:\n desats to 60s; eval for acute intrathoracic process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Esophageal cancer, evaluation for interval change.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: An endotracheal tube projects approximately 8 cm above the carina\n with its tip. A Swan-Ganz catheter has been inserted over the inferior\n extremities, the tip of the catheter projects over the right pulmonary artery.\n A Port-A-Cath on the right side is in place.\n\n The size of the cardiac silhouette is at the upper range of normal. There are\n bilateral moderate pleural effusions. Also seen is a near total atelectasis\n of the left lower lobe. Bilateral nodular opacities, combined with a\n centralized reticular pattern strongly suggest metastasis, potentially\n combined to lymphangitis carcinomatosa.\n\n A small tubular device projecting over the left axilla is likely to be part of\n a monitoring and support device.\n\n No evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1123134,
"text": " 4:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: R/O SEPSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man s/p pericardial window\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post pericardial window, to evaluate for change.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Hyperexpansion of the lungs persists. The mild\n prominence of interstitial markings is no longer appreciated. Opacification\n at the left base is again seen, and the pericardial catheter remains in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-02-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1122630,
"text": " 3:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: R/O SEPSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ?ARDS\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for interval change, history of ARDS.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the lung volumes have\n increased, potentially as a consequence of increased ventilatory pressures.\n The overall density of the pre-existing mainly perihilar parenchymal opacities\n are minimally decreased. However, a large retrocardiac left lower lobe\n atelectasis is unchanged in extent.\n\n No evidence of newly appeared focal parenchymal opacities.\n\n No pneumothorax. Unchanged aspect of the hilar and the mediastinal\n structures.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-02-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1122974,
"text": " 12:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for pneumothorax s/p pericardial window\n Admitting Diagnosis: R/O SEPSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with pericardial effusion\n REASON FOR THIS EXAMINATION:\n Eval for pneumothorax s/p pericardial window\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of the patient with pericardial effusion\n after pericardial window.\n\n Portable AP chest radiograph was compared to .\n\n The current study demonstrates slight interval decrease in the cardiac\n contours consistent with the placement of pericardial drainage and at least\n partial removal of pericardial effusion. Small amount of air might be present\n within the pericardium. The bilateral pleural effusions are demonstrated.\n Patient is currently demonstrating unchanged but slightly improved widespread\n parenchymal opacities that are definitely improved since .\n There is no pneumothorax. The ET tube, left internal jugular line, right\n subclavian line and the left midline are in unchanged position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-02-17 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1122447,
"text": " 10:29 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: IJ placement, r/o ptx & chk line placement\n Admitting Diagnosis: R/O SEPSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with new LIJ TLC\n REASON FOR THIS EXAMINATION:\n IJ placement, r/o ptx & chk line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: _____ placement, rule out pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, a new central venous access\n line has been placed over the left internal jugular vein. The course of the\n line is unremarkable, the tip of the line projects over the superior vena\n cava.\n\n No evidence of complications, notably no pneumothorax. Otherwise, the\n radiograph is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-02-18 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1122550,
"text": " 2:26 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: please eval for esophagopericardial fistula\n Admitting Diagnosis: R/O SEPSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with localally advanced esophageal cancer and purulent\n pericardial effusion\n REASON FOR THIS EXAMINATION:\n please eval for esophagopericardial fistula\n CONTRAINDICATIONS for IV CONTRAST:\n Elevated creatinine/oliguria\n ______________________________________________________________________________\n WET READ: ENYa MON 4:25 PM\n 1. Sufficient opacification of the esophagus. No evidence of esophageo-\n pericardial fistula.\n 2. Multifocal PNA.\n 3. Large bilateral pleural effusions.\n 4. Large ascites.\n 5. Small pericardial effusion.\n 6. Limited assessment without IV contrast to assess abscess.\n WET READ VERSION #1 ENYa MON 3:11 PM\n Sufficient opacification of the esophagus. No evidence of esophageo-\n pericardial fistula.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old man, with locally advanced esophageal cancer and\n purulent pericardial effusions. Assess for esophago-pericardial fistula.\n\n COMPARISON: Limited comparison from outside hospital PET CT on .\n\n TECHNIQUE: The patient has a current creatinine of 2.2, and IV contrast was\n not administered. The patient remained intubated during the study, and 50 cc\n of Conray was instilled via the OG-tube to opacify the mid-to-distal\n esophagus. MDCT images were acquired from the thoracic inlet to the lung\n bases. Multiplanar reformatted images were obtained in standard and thin\n slices for evaluation.\n\n CT CHEST WITHOUT CONTRAST: The minimally distended esophagus was opacified up\n to the level of T8. The most distal esophagus was not opacified. There is no\n evidence of esophago-pericardial fistula or any extraluminal contrast. Small\n amount of intraluminal air is noted in the anti-dependent position. There is\n evidence of intraluminal filling defect, but this study is suboptimal to\n evaluate the reported locally advanced esophageal neoplasm.\n\n The cardiac size is within normal limits. There is a small-to-moderate amount\n of pericardial effusion. Assessment for loculation or abscess is limited\n without IV contrast. There is no pneumopericardium or pneumomediastinum.\n Vascular calcification is noted in the aortic arch. Assessment for\n mediastinal lymphadenopathy is limited. A left IJ central venous catheter\n terminates at the confluence of the brachiocephalic veins. A right subclavian\n central venous catheter terminates at the cavoatrial junction. The relative\n (Over)\n\n 2:26 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: please eval for esophagopericardial fistula\n Admitting Diagnosis: R/O SEPSIS;RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n hyperdensity of myocardium compared to the adjacent blood represents baseline\n anemia.\n\n There are large bilateral pleural effusions, new since .\n Subtotal collapse of the left lower lobe is noted with air bronchogram.\n Bilateral, patchy, predominantly central, mixed ground-glass and consolidation\n air-space opacities are also new. In the clinical context of sepsis, these\n findings are compatible with multifocal pneumonia. Unchanged marked\n paraseptal emphysema predominantly involves the apices. There is no\n pneumothorax. The endotracheal tube terminates at 7.7 cm above the carina.\n Mucus secretion is noted in the tracheobronchial tree.\n\n Assessment of abdominal organs is very limited in this study. There is a\n large amount of ascites.\n\n BONE WINDOW: No suspicious lytic or sclerotic lesion is noted.\n\n IMPRESSION:\n 1. Opacification of the minimally-distended esophagus up to the level of T8.\n No evidence of esophago-pericardial fistula or extraluminal contrast.\n 2. Small-to-moderate pericardial effusion. Cannot evaluate potential\n loculation or abscess.\n 3. Large bilateral pleural effusions with subtotal collapse of the left lower\n lobe and air-bronchogram. Patchy opacities, mixed ground-glass and\n consolidation opacities represent multifocal pneumonia.\n 4. Large intra-abdominal ascites.\n 5. Unchanged marked apical paraseptal emphysema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-02-18 00:00:00.000",
"description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT",
"row_id": 1122593,
"text": " 5:58 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: ELEVATED LFTS EVAL FOR ABD PATH R/O HYDRO\n Admitting Diagnosis: R/O SEPSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with increased LFTs, and renal failure\n REASON FOR THIS EXAMINATION:\n eval for abd pathology and please r/o hydronephrosis\n ______________________________________________________________________________\n WET READ: JXKc MON 10:49 PM\n 1. No hydronephrosis. Diffusely echogenic kidneys bilaterally, suggestive of\n medical renal disease.\n 2. Small to moderate ascites, largest pocket in the RLQ.\n 3. Bilateral pleural effusions and a pericardial effusion.\n 4. Rounded echogenic foci in the porta , reflect normal fat within\n the porta . However, as these appear fairly discrete and rounded,\n lymphadenopathy cannot be excluded. If clinically indicated, this can be\n evaulated by cross-sectional imaging.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old male with increased LFTs with renal failure, evaluate\n for abdominal pathology, rule out hydronephrosis.\n\n COMPARISON: CT chest .\n\n PET-CT .\n\n FINDINGS: The liver is normal in echotexture. No definite focal hepatic\n lesion is identified. However, within the region of the porta are\n several well-defined echogenic foci, which measure up to approximately 1.5 cm\n maximally. No demonstrable color-flow is identified. This may reflect foci\n of fat within the porta or lymph nodes. The main portal vein is\n patent with hepatopetal flow. The gallbladder is without gallstones. No\n son sign was evident. There is no intra- or extra-hepatic\n biliary ductal dilatation with the CBD measuring 4 mm. The right kidney\n appears malrotated, and measures 10.1 cm. The left kidney measures 13.4 cm.\n Both kidneys are diffusely echogenic, without evidence of hydronephrosis. The\n spleen is normal in size, measuring 7.8 cm. Visualized pancreas is\n unremarkable, with the pancreatic duct measuring 2 mm.\n\n A small to moderate amount of ascites is seen, with fluid also surrounding the\n gallbladder, with the largest pocket of fluid within the right lower quadrant\n of the abdomen. There are moderate bilateral pleural effusions. In addition,\n a pericardial effusion is also noted.\n\n IMPRESSION:\n 1. Diffusely echogenic kidneys, suggestive of medical renal disease. No\n evidence of hydronephrosis.\n 2. Small to moderate ascites, largest pocket within the right lower quadrant\n of the abdomen.\n 3. Bilateral pleural effusions and a pericardial effusion.\n 4. Small echogenic rounded structures within the porta , which appear\n (Over)\n\n 5:58 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: ELEVATED LFTS EVAL FOR ABD PATH R/O HYDRO\n Admitting Diagnosis: R/O SEPSIS;RENAL FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n external to the liver. These may reflect normal fat within the porta ,\n although enlarged lymph nodes are a possibility. Findings can be further\n evaluated with cross-sectional imaging such as MRI, as clinically warranted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-02-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1122455,
"text": " 4:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tube placement & lung windows\n Admitting Diagnosis: R/O SEPSIS;RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with ETT, resp failure, ?ards\n REASON FOR THIS EXAMINATION:\n eval tube placement & lung windows\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for tube placement.\n\n COMPARISON: , 10:44 p.m.\n\n FINDINGS: As compared to the previous radiograph, the Swan-Ganz catheter has\n been removed in the interval. The other monitoring and support devices are\n unchanged. A tubular structure projecting over the left axilla is in\n unchanged position. Minimal improvement of the pre-existing retrocardiac\n atelectasis. Otherwise appearance of the lung parenchyma and the cardiac\n silhouette is unchanged.\n\n\n"
}
] |
12,666 | 192,675 | The patient on the day of admission was admitted to the Cardiothoracic Service. The patient underwent a cardiac catheterization. This was significant for an ejection fraction of 50% with normal wall motion. Mitral valve showed 1+ regurgitation. There was 3+ aortic regurgitation. Right coronary artery showed 60% stenosis. Left anterior descending coronary artery showed 80% stenosis. Proximal circumflex showed 50% stenosis. Obtuse marginal one was 60% stenotic. On hospital day number two the patient was taken to the Operating Room with Dr. and the Cardiothoracic team where he underwent a coronary artery bypass graft times three and AVR. The patient received a #23 CarboMedics mechanical valve and the grafts were left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to diagonal and saphenous vein graft to posterior descending coronary artery. The patient tolerated this procedure well. He underwent an EVJ on the right thigh with hyper skip. The patient also underwent a Dermabond study. Postoperatively, the patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition. The patient was extubated without incident with good O2 saturation. The patient was weaned off of all drips. The patient received 4 units of packed red blood cells for a hematocrit of 22. The chest tubes had a total drainage of 600 cc over 24 hours. The patient's intravascular was augmented with 500 cc of Hespan. The patient remained hemodynamically stable and in no acute distress. On postoperative day number one the patient remained stable and was transferred to the floor. On the night of postoperative day number one the patient developed atrial fibrillation with rapid ventricular response. The patient was managed with intravenous Lopressor. Rate and blood pressure remained stable in the 130s. The patient was started on po Amiodarone and rate became controlled. The patient spontaneously converted to sinus rhythm on the morning of postoperative day number two. The patient's chest tubes and lines were discontinued on postoperative number two without incident. The patient's hematocrit remained stable at 26. The patient has occasionally reverted back to atrial fibrillation. He has been anticoagulated for his valve and his atrial fibrillation for a goal of 2.5 to 3.5 on Coumadin. The patient is continued on Amiodarone and will be on 400 mg po t.i.d. times one week and then will switched to 400 b.i.d. times one week and then 400 q.d. for several months. The patient's creatinine had been elevated on postoperative day number two to a high of 2.0. The patient's Lasix and potassium had been stopped and the patient's creatinine has now drifted down to a baseline of 1.3. The patient's urine output has remained adequate. The patient's diet has been advanced to a diabetic 1800 diet. The patient is ambulating and is now stable for discharge to home. | OK per PA. Ct's cont w/ serousang dng. rr 13-18. bs diminished bibasilar. UPRIGHT FRONTAL CHEST: A Swan-Ganz catheter and left-sided chest tube have been removed in the interval. Monitor Hct-recheck . CHEST TUBE DRAINAGE 270CC SINCE MIDNOC AND >1L SINCE OR, MORE DEROUS/SANG TOWARD AM. Sxn'd sm. Abg's acceptable prior to extubation, leak test +, pt. There is slight cardiomegaly with LV predominance and tortuosity of the thoracic aorta. Pulm hygiene. Resp status stable.P: Monitor HR/BP. Monitor CT o/p. Palpable DP's bilat, dopplerable PT's bilat. Resp CarePt. On further evaluation and echo showed mild AS/mod AI, Mod MR, mild TR. R LEG WITH DERMABOND AND 1 STERI STRIP~REWRAPPED WITH ACE.ID~VANCO Q 12 X3 MORE DOSES. s/p stent . Glucose 193-212 on SSRI.ID: Afebrile. Left atrial abnormality. REASON FOR THIS EXAMINATION: Preop for CABG/AVR in AM. SSRI per protocol. FINAL REPORT CHEST 2 VIEWS PA & LATERAL: HISTORY: CABG and AVR. Faint rales at bases bilat. Went to OR for CABG x 3 LIMA to LAD, SVG to diag and PDA and Carbomedics AVR. calcium 2 gm x1. LS WITH BIBASE CRACKLES BY AM. Slight peripheral edema. Vanco cont's.Skin: Sternal and CT dsgs dry and intact. Min c/o pain. A tiny rounded density in the right upper zone is likely an end on view of a vessel and not a tiny calcified granuloma. Sinus rhythm. Hct has stablized and pt ready for transfer.NKDAPMH: CAD, Oral diabetic, htn, Cr 1.5.Meds: Asa, mavik, glucovance, lipitor, lasix, toprol.Neuro: Lethargic but easily arousable to voice. Mediastinal drain and left-sided chest tubes are present. The mediastinum is again noted to be wide superiorly, though stable in the postoperative period. Preop for AVR/CABG in AM. Left lower lobe atelectasis and small left pleural effusion. occasional pac's noted. CI >3.0. PLT COUNT FROM 145 TO 96, COAG WITH SLIGHT BUMP IN PTT, INR UNCHANGED. check for pneumothorax. Amb w/ PT.Social: Family in visiting-questions answered.A: Hemodynamically stable. Bleeding intra op and initiallly post op treated w/ extra protamine and blood products (FFP, PRBC's, Plt). PAD 20-24 WITH CVP IF . amts. T wave inversions in I, II, aVL, V3-V6suggestive of diffuse myocardial ischemia. A Swan-Ganz catheter is present, terminating in the main pulmonary artery. Sternal wires and skin staples are noted. There is left lower lobe atelectasis and a small left pleural effusion. perl. CXR shows fluid collection in left chest.Resp: BS diminished at lower lobes left more than right. CSRU NPNMr. CT~2 MEDS AND L PLEURAL WITHOUT LEAK. BP 110-120/60's. REASON FOR THIS EXAMINATION: r/o pneumothorax FINAL REPORT INDICATION: Chest tube removal. COUGHING AND DEEP BREATHING WITH ENCOURAGEMENT.GI~ABD SOFT, NONDISTENDED, NO BS.GU~ADEQUATE U/O. CREAT WITH BUMP TO 1.7~PREOP 1.4-1.5~TORDOL D/C'D, HAD RECIEVED TWO DOSE OF 15MG.SKIN~STERNAL INCISION WITH CLIPS WITH NO DRAINAGE~REDRESSED. There is left-sided pleural effusion and persistent left lower lobe atelectasis. There has been interval median sternotomy and coronary bypass surgery. Eyes closed most of day unless asked to open them.CV: HR 90's NSR, rare APC in am. Swan, cordis, and a line removed without difficulty. SPEAKS AND UNDERSTANDS ENGLISH WELL.CV~APACED~OVERRIDE PACED RATE IN 80~RUNS OF PAC'S SELD LIMITING, RARE PVC. INDICATION: Congestive heart failure. NEURO~PT EXTUBATED WITHOUT INCIDENT~NEUROLOGICALLY INTACT~MAE TO COMMAND~ALERT AND ORIENTATED X3. CT dump of 105cc x 1 w/ oob to chair activity. s/p cabg x 3, and avro: cardiac: sr 60's upon arrival, presently a paced @ 80-v wires do sense and capture appropriately. ct 100ml upon arrival, act 115, plt 145 had recieved 1 pk plt in or, 2uffp in or, pt 15 recieved 2 uffp, and 1 upc for hct 22. repeat hct 24. dr. aware.protamine 50 mg x 1. ct total drainage @ 2130 600ml dsgs d+i. 20 meq kcl x 1. hespan 500 ml x 1.2200 to recieve iupc.bleeding from rij site stiched with slight decrease in bleeding resp: cpap 5/5 @ present. IMPRESSION: Interval widening of mediastinal contour, which may in part be due to portable supine technique, but a mediastinal hematoma should be considered in this recently postoperative patient. dopp pp, feet warmer than initially. Again w/ nausea in afternoon-zofran given with no further nausea. thick yellow prior to extubation. Oriented x 3. Had received reglan earlier in day. MAE w/ equal strength. changes in VS p/ extubation, tolerating well at this time SPO2 98% on current settings. skin: intact: endo: glucose 140-100 pain: recieved 15 mg toradol @ 2130 and mso4 4 mg earlier in shift. HCT POST LATE EVENING UNIT FROM 24 TO 21~TREATED WITH 1UNIT WHICH BUMPED TO 22.3~ADDITIONAL UNIT HUNG. Small amts pain med given d/t sm amts pain and lethargy. Hct 24, 25.5, 23 during day. neuro status, i+O, labs, as per orders. gu: good uo. Cough strong. The remainder of the lungs is grossly clear. gi: ogt to lcs, draining green bilious , + placement, absent bowel sounds. Sinus rhythmInferior/lateral T changes may be due to myocardial ischemiaLow QRS voltages in limb leadsIntraventricular conduction delaySince previous tracing, intraventricular conduction delay COMPARISON: . Cath showed multi vessel CAD and mod to severe AI. Clinical correlation is suggested. sbp requires neo presently @ .25 mcq. WBC WNL.ENDO~PATIENT WITH H/O NIDDM, USES ORAL AGENTS~BS RUNNING >200, TREATED WITH IV REG THRU NOC.PLAN~MONITOR HCT AND CHEST TUBE OUTPUT~DELINE IF STABLE, CARDIAC REHAB~MONITOR SUGARS. More recently pt w/ c/o feeling very fatigued, no chest pressure though. IMPRESSION: No pneumothorax post chest tube removal. Cr up to 1.7 this am (Cr 1.5 pre op)-no toradol.Endo: Insulin gtt d/c'd at 10 am after SC reg insulin started. The right lung is clear. Repeat upright chest radiograph may provide more accurate assessment of the mediastinum. | 9 | [
{
"category": "Radiology",
"chartdate": "2200-04-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 757791,
"text": " 8:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with\n REASON FOR THIS EXAMINATION:\n eval CHF\n ______________________________________________________________________________\n FINAL REPORT\n Portable chest of compared to previous study of two days earlier.\n\n INDICATION: Congestive heart failure.\n\n There has been interval median sternotomy and coronary bypass surgery. There\n is marked widening of the mediastinum and interval increase in cardiac contour\n in the interval.\n\n A Swan-Ganz catheter is present, terminating in the main pulmonary artery.\n Mediastinal drain and left-sided chest tubes are present.\n\n The pulmonary vascularity is normal. There is left lower lobe atelectasis and\n a small left pleural effusion. The right lung is clear.\n\n IMPRESSION: Interval widening of mediastinal contour, which may in part be\n due to portable supine technique, but a mediastinal hematoma should be\n considered in this recently postoperative patient. Repeat upright chest\n radiograph may provide more accurate assessment of the mediastinum.\n\n Left lower lobe atelectasis and small left pleural effusion.\n\n These findings were communicated with the clinical service caring for the\n patient.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-04-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 757909,
"text": " 4:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p CABG/AVR, chest tubes taken out today. check for\n pneumothorax.\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest tube removal.\n\n COMPARISON: .\n\n UPRIGHT FRONTAL CHEST: A Swan-Ganz catheter and left-sided chest tube have\n been removed in the interval. There is no pneumothorax. The mediastinum is\n again noted to be wide superiorly, though stable in the postoperative period.\n The cardiac silhouette is also stable in size in the postoperative period, but\n enlarged when compared with the preoperative study, raising the possibility of\n pericardial effusion. There is left-sided pleural effusion and persistent\n left lower lobe atelectasis. The remainder of the lungs is grossly clear.\n Sternal wires and skin staples are noted.\n\n IMPRESSION: No pneumothorax post chest tube removal.\n\n"
},
{
"category": "ECG",
"chartdate": "2200-04-16 00:00:00.000",
"description": "Report",
"row_id": 160050,
"text": "Sinus rhythm\nInferior/lateral T changes may be due to myocardial ischemia\nLow QRS voltages in limb leads\nIntraventricular conduction delay\nSince previous tracing, intraventricular conduction delay\n\n"
},
{
"category": "ECG",
"chartdate": "2200-04-15 00:00:00.000",
"description": "Report",
"row_id": 160051,
"text": "Sinus rhythm. Left atrial abnormality. T wave inversions in I, II, aVL, V3-V6\nsuggestive of diffuse myocardial ischemia. No previous tracing available for\ncomparison. Clinical correlation is suggested.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-04-16 00:00:00.000",
"description": "Report",
"row_id": 1428413,
"text": "s/p cabg x 3, and avr\no: cardiac: sr 60's upon arrival, presently a paced @ 80-v wires do sense and capture appropriately. occasional pac's noted. sbp requires neo presently @ .25 mcq. ct 100ml upon arrival, act 115, plt 145 had recieved 1 pk plt in or, 2uffp in or, pt 15 recieved 2 uffp, and 1 upc for hct 22. repeat hct 24. dr. aware.protamine 50 mg x 1. ct total drainage @ 2130 600ml dsgs d+i. dopp pp, feet warmer than initially. calcium 2 gm x1. 20 meq kcl x 1. hespan 500 ml x 1.2200 to recieve iupc.bleeding from rij site stiched with slight decrease in bleeding\n resp: cpap 5/5 @ present. o2 sats >96% tv >500. rr 13-18. bs diminished bibasilar. to check abg in 30 minutes . no chest tube leak noted. can raise head off bed.\n neuro: sedate,easily arousable,following commands,mae,grasps strong and equal,gets slightly agitated due to wants ett removed. perl.\n gi: ogt to lcs, draining green bilious , + placement, absent bowel sounds.\n gu: good uo.\n skin: intact:\n endo: glucose 140-100\n pain: recieved 15 mg toradol @ 2130 and mso4 4 mg earlier in shift.\n social: daughter into visit and updated.\na: labile sbp, requiring neo ,fluids and blood, agitated at times upon awakening, awaiting extubation,a paced\nP: monitor comfort, hr and rythym, sbp-wean neo as tolerated, ct drainage, dsgs, pp, resp status if abg good and 2nd upc infused extubate per dr. . neuro status, i+O, labs, as per orders.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-04-16 00:00:00.000",
"description": "Report",
"row_id": 1428414,
"text": "Resp Care\nPt. extubated onto 50% cool aerosol. Abg's acceptable prior to extubation, leak test +, pt. able to lift head from pillow. Sxn'd sm. amts. thick yellow prior to extubation. No sig. changes in VS p/ extubation, tolerating well at this time SPO2 98% on current settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-04-17 00:00:00.000",
"description": "Report",
"row_id": 1428415,
"text": "NEURO~PT EXTUBATED WITHOUT INCIDENT~NEUROLOGICALLY INTACT~MAE TO COMMAND~ALERT AND ORIENTATED X3. SPEAKS AND UNDERSTANDS ENGLISH WELL.\n\nCV~APACED~OVERRIDE PACED RATE IN 80~RUNS OF PAC'S SELD LIMITING, RARE PVC. NO DRIPS OVERNOC. HCT POST LATE EVENING UNIT FROM 24 TO 21~TREATED WITH 1UNIT WHICH BUMPED TO 22.3~ADDITIONAL UNIT HUNG. PAD 20-24 WITH CVP IF . CI >3.0. PLT COUNT FROM 145 TO 96, COAG WITH SLIGHT BUMP IN PTT, INR UNCHANGED. PACING WIRES TO BOX WHICH IS OFF. PULSES VIA DOPPLER.\n\nRESP~PLACED ON 50% OFM CHANGED TO 5L NP WITH ADEQUATE SATS. LS WITH BIBASE CRACKLES BY AM. CT~2 MEDS AND L PLEURAL WITHOUT LEAK. CHEST TUBE DRAINAGE 270CC SINCE MIDNOC AND >1L SINCE OR, MORE DEROUS/SANG TOWARD AM. COUGHING AND DEEP BREATHING WITH ENCOURAGEMENT.\n\nGI~ABD SOFT, NONDISTENDED, NO BS.\n\nGU~ADEQUATE U/O. CREAT WITH BUMP TO 1.7~PREOP 1.4-1.5~TORDOL D/C'D, HAD RECIEVED TWO DOSE OF 15MG.\n\nSKIN~STERNAL INCISION WITH CLIPS WITH NO DRAINAGE~REDRESSED. R LEG WITH DERMABOND AND 1 STERI STRIP~REWRAPPED WITH ACE.\n\nID~VANCO Q 12 X3 MORE DOSES. WBC WNL.\n\nENDO~PATIENT WITH H/O NIDDM, USES ORAL AGENTS~BS RUNNING >200, TREATED WITH IV REG THRU NOC.\n\nPLAN~MONITOR HCT AND CHEST TUBE OUTPUT~DELINE IF STABLE, CARDIAC REHAB~MONITOR SUGARS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-04-17 00:00:00.000",
"description": "Report",
"row_id": 1428416,
"text": "CSRU NPN\n\nMr. is a 56 year old man w/ hx of CAD and CHF. s/p stent . More recently pt w/ c/o feeling very fatigued, no chest pressure though. On further evaluation and echo showed mild AS/mod AI, Mod MR, mild TR. Cath showed multi vessel CAD and mod to severe AI. Went to OR for CABG x 3 LIMA to LAD, SVG to diag and PDA and Carbomedics AVR. Bleeding intra op and initiallly post op treated w/ extra protamine and blood products (FFP, PRBC's, Plt). Hct has stablized and pt ready for transfer.\n\nNKDA\n\nPMH: CAD, Oral diabetic, htn, Cr 1.5.\n\nMeds: Asa, mavik, glucovance, lipitor, lasix, toprol.\n\nNeuro: Lethargic but easily arousable to voice. Oriented x 3. MAE w/ equal strength. Eyes closed most of day unless asked to open them.\n\nCV: HR 90's NSR, rare APC in am. BP 110-120/60's. Palpable DP's bilat, dopplerable PT's bilat. Skin warm, dry. Slight peripheral edema. Swan, cordis, and a line removed without difficulty. Hct 24, 25.5, 23 during day. OK per PA. Ct's cont w/ serousang dng. CT dump of 105cc x 1 w/ oob to chair activity. CXR shows fluid collection in left chest.\n\nResp: BS diminished at lower lobes left more than right. Faint rales at bases bilat. O2 sats 95% or greater on 4l NP. Poor coordination w/ IS-only up to 450cc. Cough strong. No airleak in CT.\n\nGI: Vomited small amt bile w/ sitting this am-which resolved spontaneously. Had received reglan earlier in day. Again w/ nausea in afternoon-zofran given with no further nausea. Tol small amt po's for lunch.\n\nGU: u/o adequate. Cr up to 1.7 this am (Cr 1.5 pre op)-no toradol.\n\nEndo: Insulin gtt d/c'd at 10 am after SC reg insulin started. Glucose 193-212 on SSRI.\n\nID: Afebrile. Vanco cont's.\n\nSkin: Sternal and CT dsgs dry and intact. Leg incision w/ dermabond, no dng, dsg changed.\n\nActivity/Comfort: IN chair all day. Min c/o pain. Small amts pain med given d/t sm amts pain and lethargy. Amb w/ PT.\n\nSocial: Family in visiting-questions answered.\n\nA: Hemodynamically stable. Resp status stable.\n\nP: Monitor HR/BP. Monitor Hct-recheck . Monitor CT o/p. Pulm hygiene. Monitor renal function. SSRI per protocol. Transfer to 6 per team orders.\n\n"
},
{
"category": "Radiology",
"chartdate": "2200-04-15 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 757687,
"text": " 8:15 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: AORTIC VALVE DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with AS/CAD. Preop for AVR/CABG in AM. Cathed today, can get\n out of bed for xray after 8PM.\n REASON FOR THIS EXAMINATION:\n Preop for CABG/AVR in AM.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST 2 VIEWS PA & LATERAL:\n\n HISTORY: CABG and AVR.\n\n There is slight cardiomegaly with LV predominance and tortuosity of the\n thoracic aorta. No evidence for CHF. No pulmonary consolidation or pleural\n effusion. A tiny rounded density in the right upper zone is likely an end on\n view of a vessel and not a tiny calcified granuloma. No previous films for\n comparison.\n\n IMPRESSION: No evidence for CHF.\n\n"
}
] |
30,609 | 193,964 | 44-year-old woman with history of asthma who p/w acute respiratory failure likely anaphylaxis. . #) Respiratory failure - Based off of reported history, suspicion highest for anaphylaxis, but possible severe asthma exacerbation also contributing. Per RT report, edematous airway was visualized during intubation in ED; however, not documented on intubation note. She received epinephrine. She was in the MICU for one day. She was treated for anaphylaxis with IV solumedrol, benadryl, pepcid. She was extubated and satting well on room air, transferred to the medical floor and did well. She will be discharged on advair and prn albuterol as well as with epi pens. . #) Acidosis: On admission she has had both respiratory and metabolic. Metabolic acidosis has an anion gap likely from lactate acidosis secondary to transient hypoxic organ injuries. Respiratory acidosis likely from asthma. No longer acidotic. . #) Elevated CK-199 on admission and increased to a peak of 1108, MB stable at 12, TN slightly elevated likely demand, renal function was never compromised. Her CK was monitored and trended down. . #) Tachycardia - HR was in the 150's, in the setting of receiving 2 doses of epinephrine for anaphylactic shock and agitation on arrival. Rpt EKG on arrival to floor confirms sinus tachycardia. Does have minimal ST depressions on EKG, likely in setting of demand ischemia. Tachycardia was thought to have represented hypovolemia although her UO is ok, and she is hypertensive. Anxiety was also a component, and with ativan she did well. HR on discharge was 100. . #) HTN-pt reports two week history fo HTN, PCP was to start medication soon, no family history of early HTN. No antihypertensives started in the setting of recent anaphylaxis. She will follow up with her PCP. . #) Low grade fever-pt with fever to 100.2 at time of transfer from MICU to medical floor, cough-may have aspirated and caused a chemical pneumonitis. Repeat CXR showed no consolidation. She remained afebrile. . Medications on Admission: albuterol prn Discharge Medications: 1. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: Two (2) Intramuscular prn: please carry with you and use when suspecting severe allergic reaction/anaphylaxis. Disp:*2 pens* Refills:*2* 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation (2 times a day). Disp:*60 disks* Refills:*2* 3. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: anaphylaxis asthma Discharge Condition: stable, afebrile, 98%on room air Discharge Instructions: You were admitted and found to have anaphylaxis. You were briefly intubated and did well after extubation. You had a low grade fever, and your chest x ray and other tests did not show any signs of infection. Please continue to take your medications as prescribed. You will take advair twice daily. In addition you will have an epi pen that you should carry with you. You should follow up as outlined below. Go to the ER or call your doctor if you have any fevers, chills, difficulty breathing, coughing or any other concerning symptoms. Followup Instructions: call your PCP and schedule follow up appointment within the next few days Completed by:[**2114-7-15** | Compared to the previoustracing left atrial abnormality has resolved.TRACING #3 REASON FOR THIS EXAMINATION: please check placement of OGT PROVISIONAL FINDINGS IMPRESSION (PFI): AZB FRI 10:33 AM Correct placement of nasogastric tube. Nursing note (1900-0700) 05:20.EVENTS.Pt weaned to extubation.Neuro.Pt recieved sedated on 50mcg/kg/min of propofol, able to stop at 2100, awake rapidly, following commands, had no complaints of pain, able to move all four limbs well.Currently pt A+Ox3.Resp.Extubated at 2100, on face tent initially, now on NC at 3l, SPO2 good, slight insp wheeze noted, given nebs by RT, otherwise LS clear.CVS.HR 80-90's NSR with no ectopy seen, BP 120-150. There is an RSR' pattern in lead V1 which is probablynormal. PER DR. , REMAIN INTUBATED OVERNOC, WEAN TO ?EXTUBATE THIS AM. PERSISTENTLY TACHYCARDIC 120S-140S, ?R/T EPI&NEBS GIVEN IN ED, DR. Cardiac enzymes elevated, but Cariology feel it is from her sustained periods of Tachycardia previously.LAbs stable this am, no repletion needed.GI/GU.Pt remains NPO at present, needs to be advanced to regular diet in am. FINDINGS: Endotracheal tube and nasogastric tube have been removed. SBP 100S-130S, HCT STABLE. AWARE, 10MG DILT GIVEN W/NO EFFECT. OBTUNDED/INTUBATED IN ED. PT STARTED ON VERSED/FENTANYL DRIPS FOR ETT TOL/COMFORT, PROPOFOL ADDED. Pt was given fentenyl and versed drip and propofol once transfered to unit. RESP SUPPORT, WEAN TO EXTUBATE THIS AM. 1L FLUID BOLUS GIVEN W/NO EFFECT ON HR. She had one episode of wheezing about 0500 which quickly cleared after she was rx with single dose albuterol. This morning she is weaned to PSV 8/+5 and is expected to wean to extubation if there is no indication of residual laryngeal-tracheal edema when cuff is deflated. LUNGS COARSE THROUGHOUT, BS LESS WHEEZY/TIGHT THIS AM. She is now on NC at 3 LPM and continues to have SpO2 of 100% and and VS WNL. OGT TO SXN W/MOD AMT UNDIGESTED FOOD NOTED. Left atrial abnormality. FSBS ELEVATED 214-284, DR. CONT TO MONITOR. ETT was pulled and pt placed on 40% fact ten with cool mist. The hemidiaphragms are in normal position. REASON FOR THIS EXAMINATION: please check placement of OGT PFI REPORT Correct placement of nasogastric tube. Cardiomediastinal contours remain within normal limits. She was on AC during part of the night once resp efforts ceased but Ve was maintained at same level as in spont breathing. She was sx and cuff deflated for successful leak check. She was ventilated on AC mode RR 28 with low tidal volume ~ 350. Compared tothe previous tracing left atrial abnormality and RSR' pattern are new.TRACING #2 PLAN: CONT HEMODYNAMIC MONITORING/TREATMENT FOR CONT TACHYCARDIA. Pt was extubated last evening after good afternoon ABG, RSBI of 30, rr 14,clear BS, 100% saturation, HR 80, BP 130/80. FINAL REPORT INDICATION: Position of devices. NURSING NOTEPLEASE SEE CAREVUE FOR DETAILS PT ADMITTED THROUGH ED AFTER RESP DISTRESS/ANAPHYLAXIS R/T FOOD ALLERGY. Resp CarePt was emergently intubated in the field after acutely developed respiratory distress. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. Non-specific ST-T wave changes. Non-specific ST-T wave changes. The nasogastric tube is in correct position. The size of the cardiac silhouette is within normal ranges, the hilar and mediastinal contours are also normal. CURRENTLY ON PSV 5/8, ABG PENDING. The P-R interval is 120 milliseconds. she continued spontaneous breathing for a while and was exceeding her set MMV. 9:12 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please check placement of OGT Admitting Diagnosis: ANAPHYLAXIS MEDICAL CONDITION: 44 year old woman with anaphylaxis. Non-specific ST-T wave changes.No previous tracing available for comparison.TRACING #1 BS are clear. 10:16 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please eval for interval change post-extubation Admitting Diagnosis: ANAPHYLAXIS MEDICAL CONDITION: 44 year old woman with asthma and possible anaphylactic reaction, s/p extubation REASON FOR THIS EXAMINATION: please eval for interval change post-extubation FINAL REPORT PORTABLE CHEST, , 22:25 COMPARISON: , 05:35. , D. MED SICU-A 9:12 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: please check placement of OGT Admitting Diagnosis: ANAPHYLAXIS MEDICAL CONDITION: 44 year old woman with anaphylaxis. The lungs are clear, and no pleural effusions or pneumothoraces are identified. The tip of the endotracheal tube is 3.5 cm above the carina. +BS with no BM passed this shift.Foley patent for adequate amounts of clear yellow urine.Skin.All pressure areas intact, pt able to turn self in bed for comfort.Social.Husband stayed with pt overnight, all family updated as to condition.Plan.monitor resp status.C/O to floor.Allergy consult. The QRS durationis 100 milliseconds. See flow sheet for RSBI. Po2 was high showing excellent oxygenation. Later she had some vigorous coughing and cleared mod volume of thick yellow - bronish sputum. SITS UPRIGHT IN BED/FOLLOWS COMMANDS WHEN LIGHTENED, DENIES PAIN NON-VERBALLY. COMPARISON: No comparison available at the time of dictation. MULTI FAM MEMBERS TO VISIT, HUSBAND SPENT . Two ABG were drawn in EU both showing severe acidosis and very high pco2, see ABG reports in lab module. | 10 | [
{
"category": "Radiology",
"chartdate": "2114-07-13 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1018576,
"text": " 10:16 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval for interval change post-extubation\n Admitting Diagnosis: ANAPHYLAXIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with asthma and possible anaphylactic reaction, s/p\n extubation\n REASON FOR THIS EXAMINATION:\n please eval for interval change post-extubation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , 22:25\n\n COMPARISON: , 05:35.\n\n FINDINGS: Endotracheal tube and nasogastric tube have been removed.\n Cardiomediastinal contours remain within normal limits. The lungs are clear,\n and no pleural effusions or pneumothoraces are identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-07-12 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1018388,
"text": " 9:12 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please check placement of OGT\n Admitting Diagnosis: ANAPHYLAXIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with anaphylaxis.\n REASON FOR THIS EXAMINATION:\n please check placement of OGT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AZB FRI 10:33 AM\n Correct placement of nasogastric tube.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Position of devices.\n\n COMPARISON: No comparison available at the time of dictation.\n\n The nasogastric tube is in correct position. The tip of the endotracheal tube\n is 3.5 cm above the carina. No central venous catheter is seen. The\n hemidiaphragms are in normal position. There is no evidence of pleural\n effusion. The size of the cardiac silhouette is within normal ranges, the\n hilar and mediastinal contours are also normal. In the lung parenchyma, no\n focal parenchymal opacity suggestive of pneumonia is identified, there is no\n evidence of overhydration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-07-12 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1018389,
"text": ", D. MED SICU-A 9:12 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please check placement of OGT\n Admitting Diagnosis: ANAPHYLAXIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with anaphylaxis.\n REASON FOR THIS EXAMINATION:\n please check placement of OGT\n ______________________________________________________________________________\n PFI REPORT\n Correct placement of nasogastric tube.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-07-13 00:00:00.000",
"description": "Report",
"row_id": 1655675,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n PT ADMITTED THROUGH ED AFTER RESP DISTRESS/ANAPHYLAXIS R/T FOOD ALLERGY. OBTUNDED/INTUBATED IN ED.\n\n PT STARTED ON VERSED/FENTANYL DRIPS FOR ETT TOL/COMFORT, PROPOFOL ADDED. PER DR. , REMAIN INTUBATED OVERNOC, WEAN TO ?EXTUBATE THIS AM. CURRENTLY ON PSV 5/8, ABG PENDING. SITS UPRIGHT IN BED/FOLLOWS COMMANDS WHEN LIGHTENED, DENIES PAIN NON-VERBALLY. PERSISTENTLY TACHYCARDIC 120S-140S, ?R/T EPI&NEBS GIVEN IN ED, DR. AWARE, 10MG DILT GIVEN W/NO EFFECT. 1L FLUID BOLUS GIVEN W/NO EFFECT ON HR. SBP 100S-130S, HCT STABLE. LUNGS COARSE THROUGHOUT, BS LESS WHEEZY/TIGHT THIS AM. OGT TO SXN W/MOD AMT UNDIGESTED FOOD NOTED. MULTI FAM MEMBERS TO VISIT, HUSBAND SPENT . FSBS ELEVATED 214-284, DR. CONT TO MONITOR.\n\n PLAN: CONT HEMODYNAMIC MONITORING/TREATMENT FOR CONT TACHYCARDIA. RESP SUPPORT, WEAN TO EXTUBATE THIS AM. MAINTAIN COMFORT, FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-07-14 00:00:00.000",
"description": "Report",
"row_id": 1655676,
"text": "Nursing note (1900-0700) 05:20.\n\nEVENTS.\nPt weaned to extubation.\n\nNeuro.\nPt recieved sedated on 50mcg/kg/min of propofol, able to stop at 2100, awake rapidly, following commands, had no complaints of pain, able to move all four limbs well.\nCurrently pt A+Ox3.\n\nResp.\nExtubated at 2100, on face tent initially, now on NC at 3l, SPO2 good, slight insp wheeze noted, given nebs by RT, otherwise LS clear.\n\nCVS.\nHR 80-90's NSR with no ectopy seen, BP 120-150. Cardiac enzymes elevated, but Cariology feel it is from her sustained periods of Tachycardia previously.\nLAbs stable this am, no repletion needed.\n\nGI/GU.\nPt remains NPO at present, needs to be advanced to regular diet in am. +BS with no BM passed this shift.\nFoley patent for adequate amounts of clear yellow urine.\n\nSkin.\nAll pressure areas intact, pt able to turn self in bed for comfort.\n\nSocial.\nHusband stayed with pt overnight, all family updated as to condition.\n\nPlan.\nmonitor resp status.\nC/O to floor.\nAllergy consult.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-07-14 00:00:00.000",
"description": "Report",
"row_id": 1655677,
"text": "Pt was extubated last evening after good afternoon ABG, RSBI of 30, rr 14,clear BS, 100% saturation, HR 80, BP 130/80. She was sx and cuff deflated for successful leak check. ETT was pulled and pt placed on 40% fact ten with cool mist. She had one episode of wheezing about 0500 which quickly cleared after she was rx with single dose albuterol. Later she had some vigorous coughing and cleared mod volume of thick yellow - bronish sputum. She is now on NC at 3 LPM and continues to have SpO2 of 100% and and VS WNL. BS are clear.\n"
},
{
"category": "Nursing/other",
"chartdate": "2114-07-13 00:00:00.000",
"description": "Report",
"row_id": 1655674,
"text": "Resp Care\n\nPt was emergently intubated in the field after acutely developed respiratory distress. Family states she has a peanut allergy and was eatnig almonds before she had trouble breathing. Pt was very wheezy in EU and very anxious and agitated. She was ventilated on AC mode RR 28 with low tidal volume ~ 350. Two ABG were drawn in EU both showing severe acidosis and very high pco2, see ABG reports in lab module. Po2 was high showing excellent oxygenation. Pt was given fentenyl and versed drip and propofol once transfered to unit. she continued spontaneous breathing for a while and was exceeding her set MMV. That ABG was 7.29,41,and 105 @ 50%. She was on AC during part of the night once resp efforts ceased but Ve was maintained at same level as in spont breathing. This morning she is weaned to PSV 8/+5 and is expected to wean to extubation if there is no indication of residual laryngeal-tracheal edema when cuff is deflated. See flow sheet for RSBI.\n"
},
{
"category": "ECG",
"chartdate": "2114-07-13 00:00:00.000",
"description": "Report",
"row_id": 177199,
"text": "Sinus tachycardia. Non-specific ST-T wave changes. Compared to the previous\ntracing left atrial abnormality has resolved.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2114-07-12 00:00:00.000",
"description": "Report",
"row_id": 177441,
"text": "Sinus tachycardia. The P-R interval is 120 milliseconds. The QRS duration\nis 100 milliseconds. There is an RSR' pattern in lead V1 which is probably\nnormal. Left atrial abnormality. Non-specific ST-T wave changes. Compared to\nthe previous tracing left atrial abnormality and RSR' pattern are new.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2114-07-12 00:00:00.000",
"description": "Report",
"row_id": 177442,
"text": "Artifact is present. Sinus tachycardia. Non-specific ST-T wave changes.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
51,418 | 192,754 | 75 yo man with fever, mental status change, recent pneumonia p/w delirium, persistent leukocytosis, acute on chronic systolic heart failure. Delirium is likely multifactorial- change in environment at nursing home, benzodiazepines at nursing home, and infection (suspected C. Diff). Mental status, fluid balance, and clinical features of infection all improved during this hospitalization. The patient was transferred to Cardiology service per patient request. # Altered Mental Status/Delirium-Multifactorial: Suspect changes in environment, medications, and infection. Markedly improved from admission, likely superimposed on dementia (though daughter denies). - Infectious w/up as below - Zyprexa 6qpm initiated. Monitor for sedation. - Avoid other sedating meds (e.g., benzos) - Frequent assessment of orientation - Maintain sleep wake cycle - Foley removed; PT out-of-bed - fall precuations. - continue to hold cymbalta for now | Doubt CNS source as status is clearing and FROM in neck, more likely delirium. Doubt CNS source as status is clearing and FROM in neck, more likely delirium. Apnea noted. - diuresis if resp status worsens. - diuresis if resp status worsens. HYPOPHOSPHATEMIA -- replete. HYPOPHOSPHATEMIA -- replete. HYPOPHOSPHATEMIA -- replete. Doubt CNS source as mental status is clearing and FROM in neck, more likely delirium. If respiratory function decreases, consider diuresis - holding BB, will add back if needed # Atrial fibrillation: Currently in sinus rhythm. bacteremia). bacteremia). bacteremia). Continue Amioderone, Digoxin, Toprolol. Continue Amioderone, Digoxin, Toprolol. Continue Amioderone, Digoxin, Toprolol. He is now afebrile after receiving meropenem and tylenol. - haldol 1 mg q1-2hr: prn agitation. FLUIDS -- hypovolemia. FLUIDS -- hypovolemia. FLUIDS -- hypovolemia. Reverse (FFP and Vit K) if bleeding develops. Reverse (FFP and Vit K) if bleeding develops. Reverse (FFP and Vit K) if bleeding develops. - cont vanco (vanco trough 15) and meropenem for now - Fluid bolus today for decreased UOP - f/u blood cx, urine cx, sputum cx. F/U head CT results. F/U head CT results. F/U head CT results. Also compounded by receiving ativan at the rehab. Also compounded by receiving ativan at the rehab. Also compounded by receiving ativan at the rehab. Monitor to therapeutic level, then resume Coumadin. Monitor to therapeutic level, then resume Coumadin. Monitor to therapeutic level, then resume Coumadin. (If obtainable) - monitor fever curve, tylenol prn - monitor WBC trend - if does not defervesce consider US guided thoracentesis of L sided effusion . (If obtainable) - monitor fever curve, tylenol prn - monitor WBC trend - if does not defervesce consider US guided thoracentesis of L sided effusion . (If obtainable) - monitor fever curve, tylenol prn - monitor WBC trend - if does not defervesce consider US guided thoracentesis of L sided effusion . In the ED his CXR showed resolving RLL PNA, he was given vanco/ and transferred to the M/SICU for further management. In the ED his CXR showed resolving RLL PNA, he was given vanco/ and transferred to the M/SICU for further management. In the ED his CXR showed resolving RLL PNA, he was given vanco/ and transferred to the M/SICU for further management. In the ED his CXR showed resolving RLL PNA, he was given vanco/ and transferred to the M/SICU for further management. In the ED his CXR showed resolving RLL PNA, he was given vanco/ and transferred to the M/SICU for further management. Doubt CNS source as mental status is clearing and FROM in neck, more likely delirium. Doubt CNS source as mental status is clearing and FROM in neck, more likely delirium. Doubt CNS source as mental status is clearing and FROM in neck, more likely delirium. Doubt CNS source as mental status is clearing and FROM in neck, more likely delirium. REASON FOR THIS EXAMINATION: Please eval interval change--pt now with significantly decreased BS on L side. # Hypertension: Currently normotensive off of medications. # Hypertension: Currently normotensive off of medications. # Hypertension: Currently normotensive off of medications. # Hypertension: Currently normotensive off of medications. - Fluid bolus today for decreased UOP - f/u blood cx, urine cx, sputum cx. He is now afebrile after receiving meropenem and tylenol. HYPOPHOSPHATEMIA -- replete. Reverse (FFP and Vit K) if bleeding develops. Assessment and Plan ALTERED MENTAL STATUS -- gradual improvement during course of present hospitalization suggests drug-induced or toxic-metabolic process. FLUIDS -- hypovolemia. FLUIDS -- hypovolemia. Also compounded by receiving ativan at the rehab. Also compounded by receiving ativan at the rehab. Also compounded by receiving ativan at the rehab. Also compounded by receiving ativan at the rehab. LACTIC ACIDOSIS -- reflects hypoperfusion. LACTIC ACIDOSIS -- reflects hypoperfusion. bacteremia). bacteremia). bacteremia). bacteremia). # Atrial fibrillation: Currently in sinus rhythm. # Atrial fibrillation: Currently in sinus rhythm. # Atrial fibrillation: Currently in sinus rhythm. # Atrial fibrillation: Currently in sinus rhythm. She is now afebrile after receiving meropenem in the ED and tylenol. She is now afebrile after receiving meropenem in the ED and tylenol. Monitor to therapeutic level, then resume Coumadin. In the ED his CXR showed resolving RLL PNA, he was given vanco/ and transferred to the M/SICU for further management. In the ED his CXR showed resolving RLL PNA, he was given vanco/ and transferred to the M/SICU for further management. Required fluid bolus yesterday and clinically exhibiting symptoms of fluid overload despite low intravascular volume. NT suctioning attempted resulting in slight epistaxsis and increased agitation. Continue Amioderone, Digoxin, Toprolol. Continue Amioderone, Digoxin, Toprolol. Also, the previously identified parenchymal infiltrates, most marked on admission examination of , have regressed markedly. - cont vanco and meropenem for now - vanco level pending, adjust dose as indicated - Fluid bolus today for decreased UOP - f/u blood cx, urine cx - monitor fever curve, tylenol prn - monitor WBC trend . (If obtainable) - monitor fever curve, tylenol prn - monitor WBC trend - if does not defervesce consider US guided thoracentesis of L sided effusion - urine legionella ab . | 32 | [
{
"category": "Nursing",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684734,
"text": "75 yo M w/ a PMH significant for CHF w/ an EF 15%, afib S/P A pacer,\n CAD s/p MI, DM II, HTN, who presented from rehab w/ MS changes. Mr.\n was recently admitted to - for RLL PNA and had\n been discharged back to rehab on . Over the last two days his\n daughter reports he has had a significant decline in mental status (A/O\n x 3 @ baseline) while @ rehab. In the ED his CXR showed resolving RLL\n PNA, he was given vanco/ and transferred to the M/SICU for further\n management.\n Acute Confusion\n Assessment:\n This AM pt very somnolent, very difficult to rouse with stimulation.\n Becoming more awake. Oriented to name. Knows he is in the hospital.\n F/C. This afternoon pt becoming extremely agitated, hallucinating.\n Refusing care. Threatening to be physical with staff.ICU team aware.\n Action:\n Haldol1mg IV . Does not respond to reasoning\n Response:\n Plan:\n Cont to assess MS. . Wrist restraints for safety\n Pneumonia, other\n Assessment:\n Maintaining sats on 2L NP. Congested upper airway cough which usually\n clear with cough. Continues to have apneaic periods. Afeb. Lips,\n fingertips become ashen, purplish after being flat for few minutes.\n Cont on vanco\n Action:\n Ongoing assessment. d/c\nd. Started on azithro, zosyn\n Response:\n Maintaining sats. Denies resp distress\n Plan:\n Follow exam, RR, sats\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n On Insulin 70/30 Q AM with humalog SS. Beginning to take water,\n otherwise no sig PO\ns. BS 160\n Action:\n FS QID\n Response:\n Good glycemic control\n Plan:\n Cont 70/30 with SS humalog QID. need to increased 70/30 to usual\n once taking PO\n Pt\ns wife in to visit.\n"
},
{
"category": "Physician ",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 684705,
"text": "Chief Complaint: Altered mental status, delerium\n I saw and examined the patient, and was physically present with the ICU\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 Somewhat improved this AM. Able to orient, attend. States \"\" and\n \"hospital\"\n No specific complaints. Remains lethargic.\n History obtained from Medical records\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors\n Unknown;\n Metformin\n Unknown;\n Dofetilide\n Unknown;\n Quinidine\n Unknown;\n Fentanyl\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:30 AM\n Vancomycin - 09:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, No(t) Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, 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, Delirious, No(t)\n Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.4\n HR: 70 (62 - 81) bpm\n BP: 107/56(68) {100/13(46) - 132/70(80)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: A Paced\n Total In:\n 1,150 mL\n 907 mL\n PO:\n TF:\n IVF:\n 1,150 mL\n 907 mL\n Blood products:\n Total out:\n 155 mL\n 300 mL\n Urine:\n 155 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 995 mL\n 607 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: 1+, Left: 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: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): year and place, Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 12.5 g/dL\n 150 K/uL\n 153 mg/dL\n 1.7 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 36 mg/dL\n 106 mEq/L\n 145 mEq/L\n 39.9 %\n 12.6 K/uL\n [image002.jpg]\n 05:11 AM\n WBC\n 12.6\n Hct\n 39.9\n Plt\n 150\n Cr\n 1.7\n Glucose\n 153\n Other labs: PT / PTT / INR:43.2/48.0/4.6, ALT / AST:18/30, Alk Phos / T\n Bili:75/1.2, Lactic Acid:2.3 mmol/L, LDH:212 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS -- Continued improvement during course of present\n hospitalization suggests drug-induced or toxic-metabolic process.\n Meningitis or encephalitis much less likely. Avoid psychotropic\n drugs. Consider head CT in context of elevated INR. have\n underlying OSA or sleep disturbance in context of chronic heart\n failure. Check ABG if possible to obtain safely.\n PNEUMONIA -- RLL. represent persistent infection (poorly\n responsive to current antimicrobials) or evolution of resistant\n organism. Adjust antimicrobials, now on Vanco, Meropenem and add\n Azithro. Monitor exam and radiographs.\n SEPSIS -- may represent partial treatment of pneumonia, or new\n infection (such as C. diff, hepatobiliary infection, skin-infection).\n Plan check cultures. Continue supportive care, empirical\n antimicrobials.\n LACTIC ACIDOSIS -- reflects hypoperfusion. Resussitate with fluids,\n monitor lactic acid. Maintain BP MAP > 60 mmHg.\n COAGULOPATHY -- attributed to coumadin, and elevation likely poor\n nutrition and antimicrobial effect. Monitor to therapeutic level, then\n resume Coumadin. Reverse (FFP and Vit K) if bleeding develops.\n CHF\n severly depressed EF, but no evidence for active heart failure.\n Monitor I/O, exam.\n ACUTE RENAL FAILURE -- acute on chronic. Likely prerenal due to\n hypovolemia and sepsis. Replete iv fluids. Monitor BUN, creatinine.\n CAD -- No evidence for active disease.\n HYPOPHOSPHATEMIA -- replete.\n POTASSIUM -- replete to >4.0 while on Digoxin.\n NIDDM -- maintain glucose <150.\n FLUIDS -- hypovolemia. Replete with fluids, monitor I/O.\n A-FIB -- adequate rate control. Continue Amioderone, Digoxin,\n Toprolol. Monitor HR.\n VEA -- pacer in place.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:00 PM\n 16 Gauge - 04:21 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer:\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": "2112-06-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684985,
"text": "75 yo M w/ a PMH significant for CHF w/ an EF 15%, afib S/P A pacer,\n CAD s/p MI, DM II, HTN, who presented from rehab w/ MS changes. Mr.\n was recently admitted to - for RLL PNA and had\n been discharged back to rehab on . Over the last two days his\n daughter reports he has had a significant decline in mental status (A/O\n x 3 @ baseline) while @ rehab. In the ED his CXR showed resolving RLL\n PNA, he was given vanco/ and transferred to the M/SICU for further\n management.\n Acute Confusion\n Assessment:\n Pt. very agitated last night. Received total of 5 mg of IV Haldol\n overnight without effect. Medicated with 5 mg with good effect.\n This morning Pt. somulent but arouseable to voice. Oriented to person\n and time.\n Action:\n Reoriented frequently. Head CT done.\n Response:\n Pt now resting comforatably, arouseable if necessary,\n Plan:\n Cont to assess MS. . F/U head CT results.\n Pneumonia, other\n Assessment:\n Maintaining sats on 2L NP. Congested upper airway cough which usually\n clear with cough. Afeb. Lips, fingertips become ashen, purplish after\n being flat for few minutes.\n Action:\n Ongoing assessment. d/c\nd. Started on azithro, zosyn\n Response:\n Maintaining sats @ 98-100 on 2 L nc . Denies resp distress.\n Plan:\n Monitor hempdynamics , resp status\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n On Insulin 70/30 Q AM with humalog SS. Beginning to take water,\n otherwise no sig PO\ns. Asking for food but falls asleep.\n Action:\n FS QID. Hold PO intake until Pt. is able to stay awake for longer\n periods.\n Response:\n Good glycemic control.\n Plan:\n Cont 70/30 with SS humalog QID. need to increased 70/30 to usual\n once taking PO\n"
},
{
"category": "Nursing",
"chartdate": "2112-06-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 684993,
"text": " - for RLL PNA and had been discharged back to rehab on\n . Over the last two days his daughter reports he has had a\n significant decline in mental status (A/O x 3 @ baseline) while @\n rehab. In the ED his CXR showed resolving RLL PNA, he was given\n vanco/ and transferred to the M/SICU for further management.\n Acute Confusion\n Assessment:\n Pt. very agitated last night. Received total of 5 mg of IV Haldol\n overnight without effect. Medicated with 5 mg with good effect.\n This morning Pt. somulent but arouseable to voice. Oriented to person\n and time.\n Action:\n Reoriented frequently. Head CT done.\n Response:\n Pt now resting comforatably, arouseable if necessary,\n Plan:\n Cont to assess MS. . F/U head CT results.\n Pneumonia, other\n Assessment:\n Maintaining sats on 2L NP. Congested upper airway cough which usually\n clear with cough. Afeb. Lips, fingertips become ashen, purplish after\n being flat for few minutes.\n Action:\n Ongoing assessment. d/c\nd. Started on zosyn.\n Response:\n Maintaining sats @ 98-100 on 2 L nc . Denies resp distress.\n Plan:\n Monitor hempdynamics , resp status\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n On Insulin 70/30 Q AM with humalog SS. Beginning to take water,\n otherwise no sig PO\ns. Asking for food but falls asleep.\n Action:\n FS QID. Hold PO intake until Pt. is able to stay awake for longer\n periods.\n Response:\n Good glycemic control.\n Plan:\n Cont 70/30 with SS humalog QID. need to increased 70/30 to usual\n once taking PO\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 140 kg\n Daily weight:\n Allergies/Reactions:\n Sulfa (Sulfonamides)\n Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors\n Unknown;\n Metformin\n Unknown;\n Dofetilide\n Unknown;\n Quinidine\n Unknown;\n Fentanyl\n Unknown;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Arrhythmias, CHF, Hypertension, MI, Pacemaker\n Additional history: DM with assoc neuropathy, EF 15%,\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:111\n D:59\n Temperature:\n 96.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n A Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 847 mL\n 24h total out:\n 1,084 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 04:41 AM\n Potassium:\n 3.5 mEq/L\n 04:41 AM\n Chloride:\n 103 mEq/L\n 04:41 AM\n CO2:\n 25 mEq/L\n 04:41 AM\n BUN:\n 35 mg/dL\n 04:41 AM\n Creatinine:\n 1.5 mg/dL\n 04:41 AM\n Glucose:\n 129 mg/dL\n 04:41 AM\n Hematocrit:\n 37.0 %\n 04:41 AM\n Finger Stick Glucose:\n 166\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 1 PIV, Foley cath\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: ICU 407\n Transferred to: 1165\n Date & time of Transfer: 15:40 pm\n"
},
{
"category": "Nursing",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684741,
"text": "75 yo M w/ a PMH significant for CHF w/ an EF 15%, afib S/P A pacer,\n CAD s/p MI, DM II, HTN, who presented from rehab w/ MS changes. Mr.\n was recently admitted to - for RLL PNA and had\n been discharged back to rehab on . Over the last two days his\n daughter reports he has had a significant decline in mental status (A/O\n x 3 @ baseline) while @ rehab. In the ED his CXR showed resolving RLL\n PNA, he was given vanco/ and transferred to the M/SICU for further\n management.\n Acute Confusion\n Assessment:\n This AM pt very somnolent, very difficult to rouse with stimulation.\n Becoming more awake. Oriented to name. Knows he is in the hospital.\n F/C. This afternoon pt becoming extremely agitated, hallucinating.\n Refusing care. Threatening to be physical with staff.ICU team aware.\n Action:\n Haldol1mg IV . Does not respond to reasoning\n Response:\n Plan:\n Cont to assess MS. . Wrist restraints for safety\n Pneumonia, other\n Assessment:\n Maintaining sats on 2L NP. Congested upper airway cough which usually\n clear with cough. Continues to have apneaic periods. Afeb. Lips,\n fingertips become ashen, purplish after being flat for few minutes.\n Cont on vanco\n Action:\n Ongoing assessment. d/c\nd. Started on azithro, zosyn\n Response:\n Maintaining sats. Denies resp distress\n Plan:\n Follow exam, RR, sats\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n On Insulin 70/30 Q AM with humalog SS. Beginning to take water,\n otherwise no sig PO\ns. BS 160\n Action:\n FS QID\n Response:\n Good glycemic control\n Plan:\n Cont 70/30 with SS humalog QID. need to increased 70/30 to usual\n once taking PO\n Pt\ns wife in to visit.\n"
},
{
"category": "Nursing",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684742,
"text": "75 yo M w/ a PMH significant for CHF w/ an EF 15%, afib S/P A pacer,\n CAD s/p MI, DM II, HTN, who presented from rehab w/ MS changes. Mr.\n was recently admitted to - for RLL PNA and had\n been discharged back to rehab on . Over the last two days his\n daughter reports he has had a significant decline in mental status (A/O\n x 3 @ baseline) while @ rehab. In the ED his CXR showed resolving RLL\n PNA, he was given vanco/ and transferred to the M/SICU for further\n management.\n Acute Confusion\n Assessment:\n This AM pt very somnolent, very difficult to rouse with stimulation.\n Becoming more awake. Oriented to name. Knows he is in the hospital.\n F/C. This afternoon pt becoming extremely agitated, hallucinating.\n Attempting to get OOB several X\ns. Refusing care. Threatening to be\n physical with staff.ICU team aware.\n Action:\n Haldol1mg IV . Does not respond to reasoning\n Response:\n Calmed down after haldol, Accepting FS, insulin SC\n Plan:\n Cont to assess MS. . Wrist restraints for safety. Haldol\n \n Pneumonia, other\n Assessment:\n Maintaining sats on 2L NP. Congested upper airway cough which usually\n clear with cough. Continues to have apneaic periods. Afeb. Lips,\n fingertips become ashen, purplish after being flat for few minutes.\n Cont on vanco\n Action:\n Ongoing assessment. d/c\nd. Started on azithro, zosyn\n Response:\n Maintaining sats. Denies resp distress\n Plan:\n Follow exam, RR, sats\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n On Insulin 70/30 Q AM with humalog SS. Beginning to take water,\n otherwise no sig PO\ns. BS 160\n Action:\n FS QID\n Response:\n Good glycemic control\n Plan:\n Cont 70/30 with SS humalog QID. need to increased 70/30 to usual\n once taking PO\n Pt\ns wife in to visit. Dtrs phoned several times throughout the shift &\n updated on pt\ns condition.\n"
},
{
"category": "Physician ",
"chartdate": "2112-06-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 685027,
"text": "Chief Complaint: Altered mental status\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Remained disoriented and aggitated last PM, despite Haldol. Eventually\n received zyprexa with good effect.\n Less aggitated this AM.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors\n Unknown;\n Metformin\n Unknown;\n Dofetilide\n Unknown;\n Quinidine\n Unknown;\n Fentanyl\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:30 AM\n Azithromycin - 01:30 PM\n Vancomycin - 07:37 AM\n Piperacillin/Tazobactam (Zosyn) - 10:16 AM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 04:08 AM\n Famotidine (Pepcid) - 07:37 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: Agitated, No(t) Suicidal, No(t) Delirious, No(t)\n Daytime somnolence, Confusion, intermittent\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 71 (70 - 74) bpm\n BP: 127/63(79) {102/44(60) - 133/103(118)} mmHg\n RR: 17 (15 - 23) insp/min\n SpO2: 99%\n Heart rhythm: A Paced\n Total In:\n 2,920 mL\n 570 mL\n PO:\n 930 mL\n 60 mL\n TF:\n IVF:\n 1,990 mL\n 510 mL\n Blood products:\n Total out:\n 770 mL\n 962 mL\n Urine:\n 770 mL\n 962 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,150 mL\n -393 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.33/53/91./25/0\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, Absent),\n (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split , No(t)\n Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 11.9 g/dL\n 168 K/uL\n 129 mg/dL\n 1.5 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 35 mg/dL\n 103 mEq/L\n 143 mEq/L\n 37.0 %\n 16.8 K/uL\n [image002.jpg]\n 05:11 AM\n 04:41 AM\n 06:27 AM\n WBC\n 12.6\n 16.8\n Hct\n 39.9\n 37.0\n Plt\n 150\n 168\n Cr\n 1.7\n 1.5\n TCO2\n 29\n Glucose\n 153\n 129\n Other labs: PT / PTT / INR:43.2/48.0/4.6, ALT / AST:17/26, Alk Phos / T\n Bili:79/1.1, Lactic Acid:2.3 mmol/L, LDH:240 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS -- Continued improvement during course of present\n hospitalization suggests drug-induced or toxic-metabolic process.\n Meningitis or encephalitis much less likely. Avoid psychotropic\n drugs. Head CT in context of elevated INR. have underlying OSA or\n sleep disturbance in context of chronic heart failure. ABG\n reassuring. Improved control with Zyprexa.\n PNEUMONIA -- RLL. represent persistent infection (poorly\n responsive to current antimicrobials) or evolution of resistant\n organism. Adjust antimicrobials, now on Vanco, Meropenem and Azithro.\n Monitor exam and radiographs.\n SEPSIS -- may represent partial treatment of pneumonia, or new\n infection (such as C. diff, hepatobiliary infection, skin-infection).\n Plan check cultures. Continue supportive care, empirical\n antimicrobials.\n LACTIC ACIDOSIS -- reflects hypoperfusion. Resussitate with fluids,\n monitor lactic acid. Maintain BP MAP > 60 mmHg. Slow clearance may be\n related to cardiac dysfuntion.\n COAGULOPATHY -- attributed to coumadin, and elevation likely poor\n nutrition and antimicrobial effect. Monitor to therapeutic level, then\n resume Coumadin. Reverse (FFP and Vit K) if bleeding develops.\n CHF\n severly depressed EF, but no evidence for active heart failure.\n Monitor I/O, exam.\n ACUTE RENAL FAILURE -- acute on chronic. Likely prerenal due to\n hypovolemia and sepsis. Replete iv fluids. Monitor BUN, creatinine.\n CAD -- No evidence for active disease. Monitor.\n HYPOPHOSPHATEMIA -- replete.\n POTASSIUM -- replete to >4.0 while on Digoxin.\n NIDDM -- maintain glucose <150.\n FLUIDS -- hypovolemia. Replete with fluids, monitor I/O.\n A-FIB -- adequate rate control. Continue Amioderone, Digoxin,\n Toprolol. Monitor HR.\n VEA -- pacer in place.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:21 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684735,
"text": "75 yo M w/ a PMH significant for CHF w/ an EF 15%, afib S/P A pacer,\n CAD s/p MI, DM II, HTN, who presented from rehab w/ MS changes. Mr.\n was recently admitted to - for RLL PNA and had\n been discharged back to rehab on . Over the last two days his\n daughter reports he has had a significant decline in mental status (A/O\n x 3 @ baseline) while @ rehab. In the ED his CXR showed resolving RLL\n PNA, he was given vanco/ and transferred to the M/SICU for further\n management.\n Acute Confusion\n Assessment:\n Initially pt very somnolent, very difficult to rouse with stimulation.\n Becoming more awake. Oriented to name. Knew he is in the hospital. F/C.\n Episodes where he becames very angry, agitated esp with wife when she\n was\n Action:\n Pt did settle down. Does not respond to reasoning\n Response:\n More awake for periods of time. Sig wax & wane in MS\n :\n Cont to assess MS. . Wrist restraints for safety\n Pneumonia, other\n Assessment:\n Maintaining sats on 2L NP. Congested upper airway cough which usually\n clear with cough. Continues to have apneaic periods. Afeb. Lips,\n fingertips become ashen, purplish after being flat for few minutes.\n Cont on vanco\n Action:\n Ongoing assessment. d/c\nd. Started on azithro, zosyn\n Response:\n Maintaining sats. Denies resp distress. Will desat to 80\ns on RA with\n apneaic periods\n Plan:\n Follow exam, RR, sats\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n On Insulin 70/30 Q AM with humalog SS. Beginning to take water,\n otherwise no sig PO\ns. BS 160\n Action:\n FS QID\n Response:\n Good glycemic control\n Plan:\n Cont 70/30 with SS humalog QID. need to increased 70/30 to usual\n once taking PO\n Pt\ns wife in to visit. Several call from dtrs for updates throughout\n the sgift\n"
},
{
"category": "Physician ",
"chartdate": "2112-06-01 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 684939,
"text": "Chief Complaint: Altered mental status\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Remained disoriented and aggitated last PM, despite Haldol. Eventually\n received zyprexa with good effect.\n Less aggitated this AM.\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors\n Unknown;\n Metformin\n Unknown;\n Dofetilide\n Unknown;\n Quinidine\n Unknown;\n Fentanyl\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:30 AM\n Azithromycin - 01:30 PM\n Vancomycin - 07:37 AM\n Piperacillin/Tazobactam (Zosyn) - 10:16 AM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 04:08 AM\n Famotidine (Pepcid) - 07:37 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: Agitated, No(t) Suicidal, No(t) Delirious, No(t)\n Daytime somnolence, Confusion, intermittent\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:08 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.1\nC (96.9\n Tcurrent: 36.1\nC (96.9\n HR: 71 (70 - 74) bpm\n BP: 127/63(79) {102/44(60) - 133/103(118)} mmHg\n RR: 17 (15 - 23) insp/min\n SpO2: 99%\n Heart rhythm: A Paced\n Total In:\n 2,920 mL\n 570 mL\n PO:\n 930 mL\n 60 mL\n TF:\n IVF:\n 1,990 mL\n 510 mL\n Blood products:\n Total out:\n 770 mL\n 962 mL\n Urine:\n 770 mL\n 962 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,150 mL\n -393 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: 7.33/53/91./25/0\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, Absent),\n (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split , No(t)\n Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 11.9 g/dL\n 168 K/uL\n 129 mg/dL\n 1.5 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 35 mg/dL\n 103 mEq/L\n 143 mEq/L\n 37.0 %\n 16.8 K/uL\n [image002.jpg]\n 05:11 AM\n 04:41 AM\n 06:27 AM\n WBC\n 12.6\n 16.8\n Hct\n 39.9\n 37.0\n Plt\n 150\n 168\n Cr\n 1.7\n 1.5\n TCO2\n 29\n Glucose\n 153\n 129\n Other labs: PT / PTT / INR:43.2/48.0/4.6, ALT / AST:17/26, Alk Phos / T\n Bili:79/1.1, Lactic Acid:2.3 mmol/L, LDH:240 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS -- Continued improvement during course of present\n hospitalization suggests drug-induced or toxic-metabolic process.\n Meningitis or encephalitis much less likely. Avoid psychotropic\n drugs. Head CT in context of elevated INR. have underlying OSA or\n sleep disturbance in context of chronic heart failure. ABG\n reassuring. Improved control with Zyprexa.\n PNEUMONIA -- RLL. represent persistent infection (poorly\n responsive to current antimicrobials) or evolution of resistant\n organism. Adjust antimicrobials, now on Vanco, Meropenem and add\n Azithro. Monitor exam and radiographs.\n SEPSIS -- may represent partial treatment of pneumonia, or new\n infection (such as C. diff, hepatobiliary infection, skin-infection).\n Plan check cultures. Continue supportive care, empirical\n antimicrobials.\n LACTIC ACIDOSIS -- reflects hypoperfusion. Resussitate with fluids,\n monitor lactic acid. Maintain BP MAP > 60 mmHg. Slow clearance may be\n related to cardiac dysfuntion.\n COAGULOPATHY -- attributed to coumadin, and elevation likely poor\n nutrition and antimicrobial effect. Monitor to therapeutic level, then\n resume Coumadin. Reverse (FFP and Vit K) if bleeding develops.\n CHF\n severly depressed EF, but no evidence for active heart failure.\n Monitor I/O, exam.\n ACUTE RENAL FAILURE -- acute on chronic. Likely prerenal due to\n hypovolemia and sepsis. Replete iv fluids. Monitor BUN, creatinine.\n CAD -- No evidence for active disease. Monitor.\n HYPOPHOSPHATEMIA -- replete.\n POTASSIUM -- replete to >4.0 while on Digoxin.\n NIDDM -- maintain glucose <150.\n FLUIDS -- hypovolemia. Replete with fluids, monitor I/O.\n A-FIB -- adequate rate control. Continue Amioderone, Digoxin,\n Toprolol. Monitor HR.\n VEA -- pacer in place.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:21 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2112-06-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 684941,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Pt agitated, did not respond very well to Haldol, gave Zyprexa\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors\n Unknown;\n Metformin\n Unknown;\n Dofetilide\n Unknown;\n Quinidine\n Unknown;\n Fentanyl\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:30 AM\n Vancomycin - 09:30 AM\n Azithromycin - 01:30 PM\n Piperacillin/Tazobactam (Zosyn) - 04:09 AM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 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 06:40 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: 70 (70 - 74) bpm\n BP: 107/58(71) {100/47(63) - 133/103(118)} mmHg\n RR: 15 (15 - 23) insp/min\n SpO2: 100%\n Heart rhythm: A Paced\n Total In:\n 2,920 mL\n 166 mL\n PO:\n 930 mL\n TF:\n IVF:\n 1,990 mL\n 166 mL\n Blood products:\n Total out:\n 770 mL\n 700 mL\n Urine:\n 770 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,150 mL\n -534 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.33/53/91./25/0\n Physical Examination\n PHYSICAL EXAM\n GENERAL: lying in bed, asleep, awakens to loud voice or physical touch\n HEENT: dry mucous membranes, oropharynx clear, anicteric sclera, no\n lymphadenopathy\n CARDIAC: RRR, no murmurs or gallops hears\n LUNGS: Decreased BS on anterior left with coarse, rhonchorous breath\n sounds. Right side with coarse breath sounds. No wheezing hears.\n ABDOMEN: soft, non-tender, non-distended, +BS\n EXTREMITIES: no edema or cyanosis. Mildly weak DP pulses bilaterally.\n SKIN: sores/ulcers over shins bilaterally with skin erythematous\n around, no hair on lower extremities below the knee.\n NEURO: son\n / Radiology\n 168 K/uL\n 11.9 g/dL\n 129 mg/dL\n 1.5 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 35 mg/dL\n 103 mEq/L\n 143 mEq/L\n 37.0 %\n 16.8 K/uL\n [image002.jpg]\n 05:11 AM\n 04:41 AM\n 06:27 AM\n WBC\n 12.6\n 16.8\n Hct\n 39.9\n 37.0\n Plt\n 150\n 168\n Cr\n 1.7\n 1.5\n TCO2\n 29\n Glucose\n 153\n 129\n Other : PT / PTT / INR:43.2/48.0/4.6, ALT / AST:17/26, Alk Phos / T\n Bili:79/1.1, Lactic Acid:2.3 mmol/L, LDH:240 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Micro:\n UCx negative, legionella urine antigen negative, BCx\ns neg to date\n Assessment and Plan\n ACUTE CONFUSION\n PNEUMONIA, OTHER\n .H/O ATRIAL FLUTTER (AFLUTTER)\n .H/O DIABETES MELLITUS (DM), TYPE II\n This is a 75 year-old man with CHF, afib on coumadin, diabetes, CAD s/p\n MI, recent admission for PNA, who presents from rehab with altered\n status, found to have new fever and leukocytosis.\n # Fever/Leukocytosis: He is now afebrile after receiving meropenem x 1\n day and tylenol. Potentially superimposed PNA resistant to\n vanco/zosyn, possible new infectious source (e.g. bacteremia). UA\n negative for infection. Doubt CNS source as status is clearing\n and FROM in neck, more likely delirium. Lactate trending down, WBC\n trending down. Urine Legionella negative. ABG with some CO2 retention,\n will monitor, but O2 sats good.\n - pt s/p 1 week Vanc treatment and Meropenem x 1day. White count\n elevated from yesterday, clinical exam unimproved, will contact ID re:\n recs for abx coverage. Continue azithromycin\n - f/u blood cx, urine cx, sputum cx. (If obtainable)\n - monitor fever curve, tylenol prn\n - monitor WBC trend\n - if does not defervesce consider US guided thoracentesis of L sided\n effusion\n .\n # Altered status: Likely toxic metabolic in the setting of\n infection. Also compounded by receiving ativan at the rehab. Doubt\n meningitis or encephalitis as patient has FROM in neck and pt is more\n responsive today. Not uremic. No evidence of liver failure. Per PCP,\n status has been changing for 2 months. Responded well to zyprexa\n overnight.\n - CT Head without contrast to rule out intracranial cause of AMS\n - Zyprexa 5 mg SL prn agitation\n - once pt less sedate, advance diet\n # Hypoxia: Oxygenating well on ABG this am with pa02=92.. Large\n component likely secondary to undiagnosed OSA as pt had witnessed\n apneic events during initial physical exam. Could also be related to\n pneumonia. Appears to be volume overloaded today by xray\n - continue O2 by NC, wean as tolerated.\n - diuresis if resp status worsens.\n # Acute on chronic renal failure: Resolving. Cr 1.8 from baseline of\n 1.4. Likely prerenal.\n - UOP approx 50cc/h or more, bolus prn for <30cc/h as above\n - repleat potassium\n - trend Cr\n # Chronic systolic CHF: EF 15%. Required fluid bolus yesterday and\n clinically exhibiting symptoms of fluid overload despite low\n intravascular volume. Continue current management.\n - lasix held for decreased UOP. If respiratory function decreases,\n consider diuresis\n - holding BB, will add back if needed\n # Atrial fibrillation: Currently in sinus rhythm. Dig level 1.2, within\n range.\n - Re-dose digoxin to keep dig level on lower side of range\n - holding amiodarone until able to take PO\n # Diabetes: Complicated by peripheral neuropathy. CBGs WNL.\n - cont insulin 70/30 at decreased dose of 15u while NPO, adjust dose as\n needed\n - humalog sliding scale\n # Hypertension: Currently normotensive off of medications.\n - Monitor, holding lasix, metoprolol in setting of possible infection\n ICU Care\n Nutrition: advance diet once less sedated\n Glycemic Control: Insulin SS\n Lines:\n 16 Gauge - 04:21 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SCD\n Stress ulcer: Famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: call out to floor after CT Head\n"
},
{
"category": "Nursing",
"chartdate": "2112-06-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684797,
"text": "75 yo M w/ a PMH significant for CHF w/ an EF 15%, afib S/P A pacer,\n CAD s/p MI, DM II, HTN, who presented from rehab w/ MS changes. Mr.\n was recently admitted to - for RLL PNA and had\n been discharged back to rehab on . Over the last two days his\n daughter reports he has had a significant decline in mental status (A/O\n x 3 @ baseline) while @ rehab. In the ED his CXR showed resolving RLL\n PNA, he was given vanco/ and transferred to the M/SICU for further\n management.\n Acute Confusion\n Assessment:\n Pt was found agitated trying to lift legs over side rails , pt had\n many of these episodes over noc\n Action:\n Unable to reorient adequately for safety. MD aware , 1 mg IV\n ordered q 1 hr, 1 x dose of zyprexa 5 mg after multiple unsuccessful\n halodol doses\n Response:\n Pt now resting comforatably, arouseable if necessary,\n Plan:\n Cont to assess MS. ? additional zyprexa. Wrist restraints\n for safety\n Pneumonia, other\n Assessment:\n Maintaining sats on 2L NP. Congested upper airway cough which usually\n clear with cough. Continues to have apneaic periods. Afeb. Lips,\n fingertips become ashen, purplish after being flat for few minutes.\n Action:\n Ongoing assessment. d/c\nd. Started on azithro, zosyn\n Response:\n Maintaining sats @ 98-1005 on 2 L nc . Denies resp distress. Will desat\n to 80\ns on RA with apneaic periods\n Plan:\n Monitor hempdynamics , resp status\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n On Insulin 70/30 Q AM with humalog SS. Beginning to take water,\n otherwise no sig PO\n Action:\n FS QID\n Response:\n Good glycemic control\n Plan:\n Cont 70/30 with SS humalog QID. need to increased 70/30 to usual\n once taking PO\n"
},
{
"category": "Nursing",
"chartdate": "2112-05-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684437,
"text": "Discharged from after being treated for PNA. Readmitted with\n PNA . PMH sig for CAD, EF 15%, MI, AF on coumadin, S/P pacer, DM,\n neuropathy, LE ulcers. Today at pt noted to be agitated, combative.\n Given vanco, zosyn at NE .\n In EW BP 122/72, temp 101.8. HR 69, RR 20\ns. Sats 100% on 3L NP Pt\n arousable, sleepy .CXR confirming PNA . Given I gram tylenol.\n Meropenem started. Trans to for further care, monitoring.\n ALLERGIES: Fentanyl, sulfa, metforman, quinadine, Ace inhibitors,\n dofetillide, lyrica\n"
},
{
"category": "Physician ",
"chartdate": "2112-06-01 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 684886,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Pt agitated, did not respond very well to Haldol, gave Zyprexa\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors\n Unknown;\n Metformin\n Unknown;\n Dofetilide\n Unknown;\n Quinidine\n Unknown;\n Fentanyl\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:30 AM\n Vancomycin - 09:30 AM\n Azithromycin - 01:30 PM\n Piperacillin/Tazobactam (Zosyn) - 04:09 AM\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 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 06:40 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: 70 (70 - 74) bpm\n BP: 107/58(71) {100/47(63) - 133/103(118)} mmHg\n RR: 15 (15 - 23) insp/min\n SpO2: 100%\n Heart rhythm: A Paced\n Total In:\n 2,920 mL\n 166 mL\n PO:\n 930 mL\n TF:\n IVF:\n 1,990 mL\n 166 mL\n Blood products:\n Total out:\n 770 mL\n 700 mL\n Urine:\n 770 mL\n 700 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,150 mL\n -534 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.33/53/91./25/0\n Physical Examination\n PHYSICAL EXAM\n GENERAL: lying in bed, asleep, awakens to loud voice or physical touch\n HEENT: dry mucous membranes, oropharynx clear, anicteric sclera, no\n lymphadenopathy\n CARDIAC: RRR, no murmurs or gallops hears\n LUNGS: Decreased BS on anterior left with coarse, rhonchorous breath\n sounds. Right side with coarse breath sounds. No wheezing hears.\n ABDOMEN: soft, non-tender, non-distended, +BS\n EXTREMITIES: no edema or cyanosis. Mildly weak DP pulses bilaterally.\n SKIN: sores/ulcers over shins bilaterally with skin erythematous\n around, no hair on lower extremities below the knee.\n NEURO: son\n / Radiology\n 168 K/uL\n 11.9 g/dL\n 129 mg/dL\n 1.5 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 35 mg/dL\n 103 mEq/L\n 143 mEq/L\n 37.0 %\n 16.8 K/uL\n [image002.jpg]\n 05:11 AM\n 04:41 AM\n 06:27 AM\n WBC\n 12.6\n 16.8\n Hct\n 39.9\n 37.0\n Plt\n 150\n 168\n Cr\n 1.7\n 1.5\n TCO2\n 29\n Glucose\n 153\n 129\n Other : PT / PTT / INR:43.2/48.0/4.6, ALT / AST:17/26, Alk Phos / T\n Bili:79/1.1, Lactic Acid:2.3 mmol/L, LDH:240 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.8 mg/dL\n Micro:\n UCx negative, legionella urine antigen negative, BCx\ns neg to date\n Assessment and Plan\n ACUTE CONFUSION\n PNEUMONIA, OTHER\n .H/O ATRIAL FLUTTER (AFLUTTER)\n .H/O DIABETES MELLITUS (DM), TYPE II\n This is a 75 year-old man with CHF, afib on coumadin, diabetes, CAD s/p\n MI, recent admission for PNA, who presents from rehab with altered\n status, found to have new fever and leukocytosis.\n # Fever/Leukocytosis: He is now afebrile after receiving meropenem x 1\n day and tylenol. Potentially superimposed PNA resistant to\n vanco/zosyn, possible new infectious source (e.g. bacteremia). UA\n negative for infection. Doubt CNS source as status is clearing\n and FROM in neck, more likely delirium. Lactate trending down, WBC\n trending down. Urine Legionella negative. ABG with some CO2 retention,\n will monitor, but O2 sats good.\n - pt s/p 1 week Vanc treatment and Meropenem x 1day. White count\n elevated from yesterday, clinical exam unimproved, will contact ID re:\n recs for abx coverage.\n - f/u blood cx, urine cx, sputum cx. (If obtainable)\n - monitor fever curve, tylenol prn\n - monitor WBC trend\n - if does not defervesce consider US guided thoracentesis of L sided\n effusion\n .\n # Altered status: Likely toxic metabolic in the setting of\n infection. Also compounded by receiving ativan at the rehab. Doubt\n meningitis or encephalitis as patient has FROM in neck and pt is more\n responsive today. Not uremic. No evidence of liver failure. Per PCP,\n status has been changing for 2 months. Responded well to zyprexa\n overnight.\n - haldol 1 mg q1-2hr: prn agitation. Consider another dose of Zyprexa\n 5 mg SL if haldo not effective.\n - continue holding psychotropic meds\n - keep NPO for now\n - Threshold for low for CT head if status worsens\n # Hypoxia: Oxygenating well on ABG this am with pa02=92.. Large\n component likely secondary to undiagnosed OSA as pt had witnessed\n apneic events during initial physical exam. Could also be related to\n pneumonia. Appears to be volume overloaded today by xray\n - continue O2 by NC, wean as tolerated.\n - diuresis if resp status worsens.\n # Acute on chronic renal failure: Cr 1.8 from baseline of 1.4. Likely\n prerenal.\n - UOP approx 50cc/h or more, bolus prn for <30cc/h as above\n - trend Cr\n - send urine lytes if renal function does not improve with IVF\n # Chronic systolic CHF: EF 15%. Required fluid bolus yesterday and\n clinically exhibiting symptoms of fluid overload despite low\n intravascular volume. Continue current management.\n - holding lasix for now unless pulmonary function worsens\n - holding BB, will add back if needed\n # Atrial fibrillation: Currently in sinus rhythm. Dig level 1.2, within\n range.\n - holding amiodarone until able to take PO\n - will continue digoxin IV, continue to follow level daily due to\n improving renal function.\n # Diabetes: Complicated by peripheral neuropathy. CBGs WNL.\n - cont insulin 70/30 at decreased dose of 15u while NPO, adjust dose as\n needed\n - humalog sliding scale\n # Hypertension: Currently normotensive off of medications.\n - holding lasix, metoprolol in setting of possible infection\n ICU Care\n Nutrition: NPO except meds\n Glycemic Control: Insulin SS\n Lines:\n 16 Gauge - 04:21 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SCD\n Stress ulcer: Famotidine\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2112-06-01 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 685059,
"text": " - for RLL PNA and had been discharged back to rehab on\n . Over the last two days his daughter reports he has had a\n significant decline in mental status (A/O x 3 @ baseline) while @\n rehab. In the ED his CXR showed resolving RLL PNA, he was given\n vanco/ and transferred to the M/SICU for further management.\n Acute Confusion\n Assessment:\n Pt. very agitated last night. Received total of 5 mg of IV Haldol\n overnight without effect. Medicated with 5 mg with good effect.\n This morning Pt. somulent but arouseable to voice. Oriented to person\n and time.\n Action:\n Reoriented frequently. Head CT done.\n Response:\n Pt now resting comforatably, arouseable if necessary,\n Plan:\n Cont to assess MS. . F/U head CT results.\n Pneumonia, other\n Assessment:\n Maintaining sats on 2L NP. Congested upper airway cough which usually\n clear with cough. Afeb. Lips, fingertips become ashen, purplish after\n being flat for few minutes.\n Action:\n Ongoing assessment. d/c\nd. Started on zosyn.\n Response:\n Maintaining sats @ 98-100 on 2 L nc . Denies resp distress.\n Plan:\n Monitor hempdynamics , resp status\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n On Insulin 70/30 Q AM with humalog SS. Beginning to take water,\n otherwise no sig PO\ns. Asking for food but falls asleep.\n Action:\n FS QID. Hold PO intake until Pt. is able to stay awake for longer\n periods.\n Response:\n Good glycemic control.\n Plan:\n Cont 70/30 with SS humalog QID. need to increased 70/30 to usual\n once taking PO\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PNEUMONIA\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 140 kg\n Daily weight:\n Allergies/Reactions:\n Sulfa (Sulfonamides)\n Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors\n Unknown;\n Metformin\n Unknown;\n Dofetilide\n Unknown;\n Quinidine\n Unknown;\n Fentanyl\n Unknown;\n Precautions:\n PMH: Diabetes - Insulin\n CV-PMH: Arrhythmias, CHF, Hypertension, MI, Pacemaker\n Additional history: DM with assoc neuropathy, EF 15%,\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:111\n D:59\n Temperature:\n 96.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n A Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 847 mL\n 24h total out:\n 1,084 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 04:41 AM\n Potassium:\n 3.5 mEq/L\n 04:41 AM\n Chloride:\n 103 mEq/L\n 04:41 AM\n CO2:\n 25 mEq/L\n 04:41 AM\n BUN:\n 35 mg/dL\n 04:41 AM\n Creatinine:\n 1.5 mg/dL\n 04:41 AM\n Glucose:\n 129 mg/dL\n 04:41 AM\n Hematocrit:\n 37.0 %\n 04:41 AM\n Finger Stick Glucose:\n 166\n 12:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 1 PIV, Foley cath\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: ICU 407\n Transferred to: 1165\n Date & time of Transfer: 15:40 pm\n ------ Protected Section ------\n Pt family wanted him to transfer him to ,, but\n at present there is no open bed available for this pt. \n transfer team aware about this .contact and tomorrow reg .the transfer.\n ------ Protected Section Addendum Entered By: , RN\n on: 21:18 ------\n"
},
{
"category": "Nursing",
"chartdate": "2112-05-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684490,
"text": "Discharged from after being treated for PNA. Readmitted with\n PNA, MS changes.\n PMH sig for CAD, EF 15%, MI, AF on coumadin, S/P pacer, DM,\n neuropathy, LE ulcers. Today at pt noted to be agitated, combative.\n Given vanco, zosyn at NE & transferred to \n In EW BP 122/72, temp 101.8. HR 69, RR 20\ns. Sats 100% on 3L NP Pt\n arousable, sleepy .CXR confirming PNA . Given I gram tylenol.\n Meropenem started. BC, UC obtained Trans to for further care,\n monitoring.\n ALLERGIES: Fentanyl, sulfa, metforman, quinadine, Ace inhibitors,\n dofetillide, lyrica\n DNR/DNI\n Acute Confusion\n Assessment:\n On arrival to ICU pt ocas moaning. Minimal response to stimuli. Pt\n becoming more arousable to pain. Starting to moan & shout out randomly.\n Does not follow commands or open eyes to name, stimuli, command\n Dtr reports his baseline as A&O prior to becoming ill. Attempted to get\n OOb X1\n Action:\n Oriented by this RN, Dtr at bedside. Three side rails up. Soft\n wrist restraints applied\n Response:\n Pt moving about more & moaning more, otherwise no improvement in MS\n :\n Cont to assess MS. . Wrist restraints.\n Pneumonia, other\n Assessment:\n Afeb on admission. Apnea noted. Sats down to 65% on RA with these\n episodes. BS clear, ronchi. Congested cough.\n Action:\n NTS X1 for mod amt white to plale yellow secretions with frank blood\n / trauma. NP 2l added\n Response:\n Congestion improved\n Plan:\n NPO. Maintaining sats on NP. CPAP as tol.\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n BS 319\n Action:\n To be started on SS insulin coverage\n Response:\n Ongoing assessment\n Plan:\n Follow FS QID with SS\n Dtr (HCP) in to visit. She was updated on pt\ns condition & POC\n by this RN as well as ICU resident\n"
},
{
"category": "Physician ",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 684632,
"text": "TITLE:\n Chief Complaint: AMS, fever leukocytosis\n 24 Hour Events:\n -NS bolus 500cc x 2 for ARF, low UOP\n Allergies:\n Sulfa (Sulfonamides): Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors: Unknown;\n Metformin: Unknown;\n Dofetilide: Unknown;\n Quinidine: Unknown;\n Fentanyl: Unknown;\n Last dose of Antibiotics:\n Meropenem - 10:48 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 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (97\n HR: 69 (62 - 81) bpm\n BP: 106/61(72) {101/13(46) - 132/70(80)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: A Paced\n Total In:\n 1,150 mL\n 567 mL\n PO:\n TF:\n IVF:\n 1,150 mL\n 567 mL\n Blood products:\n Total out:\n 155 mL\n 130 mL\n Urine:\n 155 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 995 mL\n 438 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n PHYSICAL EXAM\n GENERAL: Somnolent, opens eyes to voice\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA. MM dry. OP clear.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP unable to be assessed\n LUNGS: CTA on R side, significantly decreased BS on L\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: son\n / Radiology\n 150 K/uL\n 12.5 g/dL\n 153 mg/dL\n 1.7 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 36 mg/dL\n 106 mEq/L\n 145 mEq/L\n 39.9 %\n 12.6 K/uL\n [image002.jpg] 2x BCxs pending, Urine cx pending\n 05:11 AM\n WBC\n 12.6\n Hct\n 39.9\n Plt\n 150\n Cr\n 1.7\n Glucose\n 153\n Other : PT / PTT / INR:43.2/48.0/4.6, ALT / AST:18/30, Alk Phos / T\n Bili:75/1.2, Lactic Acid:2.3 mmol/L, LDH:212 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ACUTE CONFUSION\n PNEUMONIA, OTHER\n .H/O ATRIAL FLUTTER (AFLUTTER)\n .H/O DIABETES MELLITUS (DM), TYPE II\n This is a 75 year-old man with CHF, afib on coumadin, diabetes, CAD s/p\n MI, recent admission for PNA, who presents from rehab with altered\n mental status, found to have new fever and leukocytosis.\n .\n # Fever/Leukocytosis: Unclear source at this point. He is now\n afebrile after receiving meropenem and tylenol. Potentially\n superimposed PNA resistant to vanco/zosyn, possible new infectious\n source (e.g. bacteremia). UA negative for infection. Doubt CNS source\n as mental status is clearing and FROM in neck, more likely delirium.\n Lactate trending down, WBC trending down.\n - cont vanco (vanco trough 15) and meropenem for now\n - Fluid bolus today for decreased UOP\n - f/u blood cx, urine cx, sputum cx. (If obtainable)\n - monitor fever curve, tylenol prn\n - monitor WBC trend\n - if does not defervesce consider US guided thoracentesis of L sided\n effusion\n .\n # Altered mental status: Likely toxic metabolic in the setting of\n infection. Also compounded by receiving ativan at the rehab. Doubt\n meningitis or encephalitis as patient has FROM in neck and pt is more\n responsive today. Not uremic. No evidence of liver failure.\n - hold all psychotropic medications\n - keep NPO for now\n - will try haldol if becomes agitated\n - CT head if mental status worsens\n -Call PCP today for more info about baseline MS\n .\n # Hypoxia: Improving. Large component likely secondary to undiagnosed\n OSA as pt had witnessed apneic events during initial physical exam.\n Could also be related to pneumonia. Does not appear to be volume\n overloaded.\n - wean O2 as tolerated, using face mask as pt is mouth breather\n - ABG\n .\n # Acute on chronic renal failure: Cr 1.8 from baseline of 1.4. Likely\n prerenal.\n - monitor UOP and bolus prn for <30cc/h as above\n - trend Cr\n - send urine lytes if renal function does not improve with IVF\n .\n # Chronic systolic CHF: EF 15%. Required fluid bolus yesterday and\n clinically exhibiting symptoms of fluid overload despite low\n intravascular volume\n - holding lasix for now unless pulmonary function worsens\n - holding BB, will add back if needed\n .\n # Atrial fibrillation: Currently in sinus rhythm.\n - holding amiodarone until able to take PO\n - will continue digoxin IV, need to follow level daily worsening\n renal function\n .\n # Diabetes: Complicated by peripheral neuropathy. CBGs WNL.\n - cont insulin 70/30 at decreased dose of 15u while NPO, adjust dose as\n needed\n - humalog sliding scale\n .\n # Hypertension: Currently normotensive off of medications.\n - holding lasix, metoprolol in setting of possible infection\n ICU Care\n Nutrition: will advance diet as tolerated\n Glycemic Control: HSSI\n Lines:\n 16 Gauge - 04:21 PM\n 20 Gauge - 05:48 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: start famotidine\n VAP:\n Comments:\n Communication: Comments: - (daughter/HCP) ,\n \n Code status: DNR/DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 684633,
"text": "Chief Complaint: Altered mental status, delerium\n I saw and examined the patient, and was physically present with the ICU\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 Somewhat improved this AM. Able to orient, attend. States \"\" and\n \"hospital\"\n No specific complaints. Remains lethargic.\n History obtained from Medical records\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors\n Unknown;\n Metformin\n Unknown;\n Dofetilide\n Unknown;\n Quinidine\n Unknown;\n Fentanyl\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 08:30 AM\n Vancomycin - 09:30 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: Cough, No(t) Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, 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, Delirious, No(t)\n Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 35.8\nC (96.4\n HR: 70 (62 - 81) bpm\n BP: 107/56(68) {100/13(46) - 132/70(80)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 97%\n Heart rhythm: A Paced\n Total In:\n 1,150 mL\n 907 mL\n PO:\n TF:\n IVF:\n 1,150 mL\n 907 mL\n Blood products:\n Total out:\n 155 mL\n 300 mL\n Urine:\n 155 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 995 mL\n 607 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///27/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , Obese\n Extremities: Right: 1+, Left: 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: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): year and place, Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n / Radiology\n 12.5 g/dL\n 150 K/uL\n 153 mg/dL\n 1.7 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 36 mg/dL\n 106 mEq/L\n 145 mEq/L\n 39.9 %\n 12.6 K/uL\n [image002.jpg]\n 05:11 AM\n WBC\n 12.6\n Hct\n 39.9\n Plt\n 150\n Cr\n 1.7\n Glucose\n 153\n Other : PT / PTT / INR:43.2/48.0/4.6, ALT / AST:18/30, Alk Phos / T\n Bili:75/1.2, Lactic Acid:2.3 mmol/L, LDH:212 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ALTERED MENTAL STATUS -- Continued improvement during course of present\n hospitalization suggests drug-induced or toxic-metabolic process.\n Meningitis or encephalitis much less likely. Avoid psychotropic\n drugs. Consider head CT in context of elevated INR. have\n underlying OSA or sleep disturbance in context of chronic heart\n failure. Check ABG if possible to obtain safely.\n PNEUMONIA -- RLL. represent persistent infection (poorly\n responsive to current antimicrobials) or evolution of resistant\n organism. Adjust antimicrobials, now on Vanco, Meropenem and add\n Azithro. Monitor exam and radiographs.\n SEPSIS -- may represent partial treatment of pneumonia, or new\n infection (such as C. diff, hepatobiliary infection, skin-infection).\n Plan check cultures. Continue supportive care, empirical\n antimicrobials.\n LACTIC ACIDOSIS -- reflects hypoperfusion. Resussitate with fluids,\n monitor lactic acid. Maintain BP MAP > 60 mmHg.\n COAGULOPATHY -- attributed to coumadin, and elevation likely poor\n nutrition and antimicrobial effect. Monitor to therapeutic level, then\n resume Coumadin. Reverse (FFP and Vit K) if bleeding develops.\n CHF\n severly depressed EF, but no evidence for active heart failure.\n Monitor I/O, exam.\n ACUTE RENAL FAILURE -- acute on chronic. Likely prerenal due to\n hypovolemia and sepsis. Replete iv fluids. Monitor BUN, creatinine.\n CAD -- No evidence for active disease.\n HYPOPHOSPHATEMIA -- replete.\n POTASSIUM -- replete to >4.0 while on Digoxin.\n NIDDM -- maintain glucose <150.\n FLUIDS -- hypovolemia. Replete with fluids, monitor I/O.\n A-FIB -- adequate rate control. Continue Amioderone, Digoxin,\n Toprolol. Monitor HR.\n VEA -- pacer in place.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 04:00 PM\n 16 Gauge - 04:21 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Coumadin)\n Stress ulcer:\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": "Physician ",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 684638,
"text": "TITLE:\n Chief Complaint: AMS, fever leukocytosis\n 24 Hour Events:\n -NS bolus 500cc x 2 for ARF, low UOP\n Allergies:\n Sulfa (Sulfonamides): Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors: Unknown;\n Metformin: Unknown;\n Dofetilide: Unknown;\n Quinidine: Unknown;\n Fentanyl: Unknown;\n Last dose of Antibiotics:\n Meropenem - 10:48 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 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (97\n HR: 69 (62 - 81) bpm\n BP: 106/61(72) {101/13(46) - 132/70(80)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: A Paced\n Total In:\n 1,150 mL\n 567 mL\n PO:\n TF:\n IVF:\n 1,150 mL\n 567 mL\n Blood products:\n Total out:\n 155 mL\n 130 mL\n Urine:\n 155 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 995 mL\n 438 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n PHYSICAL EXAM\n GENERAL: Somnolent, opens eyes to voice\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA. MM dry. OP clear.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP unable to be assessed\n LUNGS: CTA on R side, significantly decreased BS on L\n ABDOMEN: NABS. Soft, NT, ND. No HSM\n EXTREMITIES: No edema or calf pain, radial pulses not palpable, WWP\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: son\n / Radiology\n 150 K/uL\n 12.5 g/dL\n 153 mg/dL\n 1.7 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 36 mg/dL\n 106 mEq/L\n 145 mEq/L\n 39.9 %\n 12.6 K/uL\n [image002.jpg] 2x BCxs pending, Urine cx pending\n 05:11 AM\n WBC\n 12.6\n Hct\n 39.9\n Plt\n 150\n Cr\n 1.7\n Glucose\n 153\n Other : PT / PTT / INR:43.2/48.0/4.6, ALT / AST:18/30, Alk Phos / T\n Bili:75/1.2, Lactic Acid:2.3 mmol/L, LDH:212 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ACUTE CONFUSION\n PNEUMONIA, OTHER\n .H/O ATRIAL FLUTTER (AFLUTTER)\n .H/O DIABETES MELLITUS (DM), TYPE II\n This is a 75 year-old man with CHF, afib on coumadin, diabetes, CAD s/p\n MI, recent admission for PNA, who presents from rehab with altered\n mental status, found to have new fever and leukocytosis.\n .\n # Fever/Leukocytosis: He is now afebrile after receiving meropenem and\n tylenol. Potentially superimposed PNA resistant to vanco/zosyn,\n possible new infectious source (e.g. bacteremia). UA negative for\n infection. Doubt CNS source as mental status is clearing and FROM in\n neck, more likely delirium. Lactate trending down, WBC trending down.\n - cont vanco (vanco trough 15) and meropenem for now (will need to\n contact ID for authorization of meropenem use).\n - Fluid bolus today for decreased UOP\n - f/u blood cx, urine cx, sputum cx. (If obtainable)\n - monitor fever curve, tylenol prn\n - monitor WBC trend\n - if does not defervesce consider US guided thoracentesis of L sided\n effusion\n - urine legionella ab\n .\n # Altered mental status: Likely toxic metabolic in the setting of\n infection. Also compounded by receiving ativan at the rehab. Doubt\n meningitis or encephalitis as patient has FROM in neck and pt is more\n responsive today. Not uremic. No evidence of liver failure.\n - hold all psychotropic medications\n - keep NPO for now\n - will try haldol if becomes agitated\n - CT head if mental status worsens\n -Call PCP today for more info about baseline MS\n .\n # Hypoxia: Improving. Large component likely secondary to undiagnosed\n OSA as pt had witnessed apneic events during initial physical exam.\n Could also be related to pneumonia. Appears to be volume overloaded\n today by xray\n - continue O2 by NC\n - diuresis if resp status worsens.\n - ABG\n .\n # Acute on chronic renal failure: Cr 1.8 from baseline of 1.4. Likely\n prerenal.\n - monitor UOP and bolus prn for <30cc/h as above\n - trend Cr\n - send urine lytes if renal function does not improve with IVF\n .\n # Chronic systolic CHF: EF 15%. Required fluid bolus yesterday and\n clinically exhibiting symptoms of fluid overload despite low\n intravascular volume.\n - holding lasix for now unless pulmonary function worsens\n - holding BB, will add back if needed\n .\n # Atrial fibrillation: Currently in sinus rhythm.\n - holding amiodarone until able to take PO\n - will continue digoxin IV, need to follow level daily worsening\n renal function\n .\n # Diabetes: Complicated by peripheral neuropathy. CBGs WNL.\n - cont insulin 70/30 at decreased dose of 15u while NPO, adjust dose as\n needed\n - humalog sliding scale\n .\n # Hypertension: Currently normotensive off of medications.\n - holding lasix, metoprolol in setting of possible infection\n ICU Care\n Nutrition: will advance diet as tolerated\n Glycemic Control: HSSI\n Lines:\n 16 Gauge - 04:21 PM\n 20 Gauge - 05:48 PM\n Prophylaxis:\n DVT: pneumoboots, supratherapeutic on heparin\n Stress ulcer: start famotidine\n VAP:\n Comments:\n Communication: Comments: - (daughter/HCP) ,\n \n Code status: DNR/DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684521,
"text": "75 yo M w/ a PMH significant for CHF w/ an EF 15%, afib on coumadin,\n CAD s/p MI, DM II, HTN, who presented from rehab w/ MS changes. Mr.\n was recently admitted to - for RLL PNA and had\n been discharged back to rehab on . Over the last two days his\n daughter reports he has had a significant decline in mental status (A/O\n x 3 @ baseline) while @ rehab. In the ED his CXR showed\n Pneumonia, other\n Assessment:\n Action:\n Response:\n Plan:\n Acute Confusion\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684524,
"text": "75 yo M w/ a PMH significant for CHF w/ an EF 15%, afib on coumadin,\n CAD s/p MI, DM II, HTN, who presented from rehab w/ MS changes. Mr.\n was recently admitted to - for RLL PNA and had\n been discharged back to rehab on . Over the last two days his\n daughter reports he has had a significant decline in mental status (A/O\n x 3 @ baseline) while @ rehab. In the ED his CXR showed resolving RLL\n PNA, he was given vanco/ and transferred to the M/SICU for further\n management.\n Since admission Mr. has remained profoundly confused, uttering\n incomprehensible sounds and becoming restless @ times. Overnight he\n received 500cc NS bolus x 2 secondary to low urine output, he remains\n afebrile, normotensive, and satting 100% on 2 liters nasal. NT\n suctioning attempted resulting in slight epistaxsis and increased\n agitation. Started on /vanco.\n Pneumonia, other\n Assessment:\n CXR from ED showed improvement in RLL PNA since last film on \n Action:\n Started on broad spectrum abx coverage\n Response:\n All vitals remains WNL\n Plan:\n Cont to monitor hemodynamic/resp status, cont IV abx update\n daughter/HCP on plan of care as it develops. Follow up on renal\n function as U/O remains low.\n Acute Confusion\n Assessment:\n 75 y/o M reportedly A/O x 3 @ baseline, remains profoundly confused\n uttering incomprehensible sounds, PEARL.\n Action:\n Bed low/locked position, bed alarm on, bilateral soft wrist restraints\n on.\n Response:\n No change in clinical presentation\n Plan:\n Possible Head CT today to evaluate for acute process. Cont abx coverage\n @ this time.\n"
},
{
"category": "Physician ",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 684579,
"text": "TITLE:\n Chief Complaint: AMS, fever leukocytosis\n 24 Hour Events:\n -NS bolus 500cc x 2 for ARF, low UOP\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors\n Unknown;\n Metformin\n Unknown;\n Dofetilide\n Unknown;\n Quinidine\n Unknown;\n Fentanyl\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 10:48 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 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (97\n HR: 69 (62 - 81) bpm\n BP: 106/61(72) {101/13(46) - 132/70(80)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: A Paced\n Total In:\n 1,150 mL\n 567 mL\n PO:\n TF:\n IVF:\n 1,150 mL\n 567 mL\n Blood products:\n Total out:\n 155 mL\n 130 mL\n Urine:\n 155 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 995 mL\n 438 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n PHYSICAL EXAM\n GENERAL: Pleasant, well appearing ..... in NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No\n thyromegaly.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP=\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 150 K/uL\n 12.5 g/dL\n 153 mg/dL\n 1.7 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 36 mg/dL\n 106 mEq/L\n 145 mEq/L\n 39.9 %\n 12.6 K/uL\n [image002.jpg]\n 05:11 AM\n WBC\n 12.6\n Hct\n 39.9\n Plt\n 150\n Cr\n 1.7\n Glucose\n 153\n Other labs: PT / PTT / INR:43.2/48.0/4.6, ALT / AST:18/30, Alk Phos / T\n Bili:75/1.2, Lactic Acid:2.3 mmol/L, LDH:212 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ACUTE CONFUSION\n PNEUMONIA, OTHER\n .H/O ATRIAL FLUTTER (AFLUTTER)\n .H/O DIABETES MELLITUS (DM), TYPE II\n This is a 75 year-old man with CHF, afib on coumadin, diabetes, CAD s/p\n MI, recent admission for PNA, who presents from rehab with altered\n mental status, found to have new fever and leukocytosis.\n .\n # Fever/Leukocytosis: Unclear source at this point. She is now\n afebrile after receiving meropenem in the ED and tylenol. Potentially\n superimposed pna resistant to vanco/zosyn, possible new infectious\n source (e.g. bacteremia). UA negative for infection. Doubt CNS source\n as mental status is clearing and FROM in neck, more likely delirium.\n - cont vanco and meropenem for now\n - check vanco level in AM\n - IVF boluses as needed to maintain MAP > 65 and UOP > 30cc/h\n - f/u blood cx, urine cx\n - repeat lactate\n - monitor fever curve, tylenol prn\n - monitor WBC trend\n .\n # Altered mental status: Likely toxic metabolic in the setting of\n infection. Also compounded by receiving ativan at the rehab. Doubt\n meningitis or encephalitis. Not uremic. No evidence of liver failure.\n - hold all psychotropic medications\n - keep NPO for now\n - will try haldol if becomes agitated\n - CT head if mental status worsens\n .\n # Hypoxia: Improving. Large component likely secondary to undiagnosed\n OSA as pt had witnessed apneic events during initial physical exam.\n Could also be related to pneumonia. Does not appear to be volume\n overloaded.\n - wean O2 as tolerated, using face mask as pt is mouth breather\n .\n # Acute on chronic renal failure: Cr 1.8 from baseline of 1.4. Likely\n prerenal.\n - IVF bolus\n - monitor UOP and bolus prn for <30cc/h as above\n - trend Cr\n - send urine lytes if renal function does not improve with IVF\n .\n # Chronic systolic CHF: EF 15%. Currently appears dry.\n - holding lasix\n - holding BB, will add back if needed\n .\n # Atrial fibrillation: Currently in sinus rhythm.\n - holding amiodarone until able to take PO\n - will continue digoxin IV\n .\n # Diabetes: Complicated by peripheral neuropathy.\n - cont insulin 70/30 at decreased dose of 15u while NPO, adjust dose as\n needed\n - humalog sliding scale\n .\n # Hypertension: Currently normotensive off of medications.\n - holding lasix, metoprolol in setting of possible infection\n .\n # FEN: IVF as above, replete electrolytes, NPO for now\n .\n # Prophylaxis: Subcutaneous heparin, bowel regimen\n .\n # Access: PIV x 3\n .\n # Code: DNR/DNI, documentation in chart from previous hospitalization\n .\n # Communication:\n - (daughter/HCP) , \n - will call PCP in AM for more information about clinical history\n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 04:21 PM\n 20 Gauge - 05:48 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Generic Note",
"row_id": 684575,
"text": "TITLE:\n"
},
{
"category": "Physician ",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 684593,
"text": "TITLE:\n Chief Complaint: AMS, fever leukocytosis\n 24 Hour Events:\n -NS bolus 500cc x 2 for ARF, low UOP\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors\n Unknown;\n Metformin\n Unknown;\n Dofetilide\n Unknown;\n Quinidine\n Unknown;\n Fentanyl\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 10:48 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 06:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.7\nC (98\n Tcurrent: 36.1\nC (97\n HR: 69 (62 - 81) bpm\n BP: 106/61(72) {101/13(46) - 132/70(80)} mmHg\n RR: 19 (17 - 26) insp/min\n SpO2: 95%\n Heart rhythm: A Paced\n Total In:\n 1,150 mL\n 567 mL\n PO:\n TF:\n IVF:\n 1,150 mL\n 567 mL\n Blood products:\n Total out:\n 155 mL\n 130 mL\n Urine:\n 155 mL\n 130 mL\n NG:\n Stool:\n Drains:\n Balance:\n 995 mL\n 438 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///27/\n Physical Examination\n PHYSICAL EXAM\n GENERAL: Somnolent, opens eyes to voice\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. PERRLA. MM dry. OP clear.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP unable to be assessed\n LUNGS: CTA on R side, significantly decreased BS on L\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: son\n / Radiology\n 150 K/uL\n 12.5 g/dL\n 153 mg/dL\n 1.7 mg/dL\n 27 mEq/L\n 3.9 mEq/L\n 36 mg/dL\n 106 mEq/L\n 145 mEq/L\n 39.9 %\n 12.6 K/uL\n [image002.jpg] 2x BCxs pending, Urine cx pending\n 05:11 AM\n WBC\n 12.6\n Hct\n 39.9\n Plt\n 150\n Cr\n 1.7\n Glucose\n 153\n Other : PT / PTT / INR:43.2/48.0/4.6, ALT / AST:18/30, Alk Phos / T\n Bili:75/1.2, Lactic Acid:2.3 mmol/L, LDH:212 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ACUTE CONFUSION\n PNEUMONIA, OTHER\n .H/O ATRIAL FLUTTER (AFLUTTER)\n .H/O DIABETES MELLITUS (DM), TYPE II\n This is a 75 year-old man with CHF, afib on coumadin, diabetes, CAD s/p\n MI, recent admission for PNA, who presents from rehab with altered\n mental status, found to have new fever and leukocytosis.\n .\n # Fever/Leukocytosis: Unclear source at this point. He is now\n afebrile after receiving meropenem and tylenol. Potentially\n superimposed PNA resistant to vanco/zosyn, possible new infectious\n source (e.g. bacteremia). UA negative for infection. Doubt CNS source\n as mental status is clearing and FROM in neck, more likely delirium.\n Lactate trending down, WBC trending down.\n - cont vanco and meropenem for now\n - vanco level pending, adjust dose as indicated\n - Fluid bolus today for decreased UOP\n - f/u blood cx, urine cx\n - monitor fever curve, tylenol prn\n - monitor WBC trend\n .\n # Altered mental status: Likely toxic metabolic in the setting of\n infection. Also compounded by receiving ativan at the rehab. Doubt\n meningitis or encephalitis as patient has FROM in neck and pt is more\n responsive today. Not uremic. No evidence of liver failure.\n - hold all psychotropic medications\n - keep NPO for now\n - will try haldol if becomes agitated\n - CT head if mental status worsens\n -Call PCP today for more info about baseline MS\n .\n # Hypoxia: Improving. Large component likely secondary to undiagnosed\n OSA as pt had witnessed apneic events during initial physical exam.\n Could also be related to pneumonia. Does not appear to be volume\n overloaded.\n - wean O2 as tolerated, using face mask as pt is mouth breather\n .\n # Acute on chronic renal failure: Cr 1.8 from baseline of 1.4. Likely\n prerenal.\n - IVF bolus 250 L NS now\n - monitor UOP and bolus prn for <30cc/h as above\n - trend Cr\n - send urine lytes if renal function does not improve with IVF\n .\n # Chronic systolic CHF: EF 15%. Currently appears dry.\n - holding lasix\n - holding BB, will add back if needed\n .\n # Atrial fibrillation: Currently in sinus rhythm.\n - holding amiodarone until able to take PO\n - will continue digoxin IV\n .\n # Diabetes: Complicated by peripheral neuropathy. CBGs WNL.\n - cont insulin 70/30 at decreased dose of 15u while NPO, adjust dose as\n needed\n - humalog sliding scale\n .\n # Hypertension: Currently normotensive off of medications.\n - holding lasix, metoprolol in setting of possible infection\n ICU Care\n Nutrition: will advance diet as\n Glycemic Control:\n Lines:\n 16 Gauge - 04:21 PM\n 20 Gauge - 05:48 PM\n Prophylaxis:\n DVT: not on heparin, start\n Stress ulcer: start lansoprazole\n VAP:\n Comments:\n Communication: Comments: - (daughter/HCP) ,\n \n Code status: DNR/DNI\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684686,
"text": "75 yo M w/ a PMH significant for CHF w/ an EF 15%, afib S/P A pacer,\n CAD s/p MI, DM II, HTN, who presented from rehab w/ MS changes. Mr.\n was recently admitted to - for RLL PNA and had\n been discharged back to rehab on . Over the last two days his\n daughter reports he has had a significant decline in mental status (A/O\n x 3 @ baseline) while @ rehab. In the ED his CXR showed resolving RLL\n PNA, he was given vanco/ and transferred to the M/SICU for further\n management.\n Acute Confusion\n Assessment:\n This AM pt very somnolent, very difficult to rouse with stimulation.\n Becoming more awake. Oriented to name. Knows he is in the hospital.\n F/C. Episodes where he becames very angry, agitated esp with wife when\n was leaving. He was demanding she not leave. Pt did eventually calm\n down\n Action:\n Pt did settle down. Does not respond to reasoning\n Response:\n More awake for periods of time. Sig wax & wane in MS\n :\n Cont to assess MS. . Wrist restraints for safety\n Pneumonia, other\n Assessment:\n Maintaining sats on 2L NP. Congested upper airway cough which usually\n clear with cough. Continues to have apneaic periods. Afeb. Lips,\n fingertips become ashen, purplish after being flat for few minutes.\n Cont on vanco\n Action:\n Ongoing assessment. d/c\nd. Started on azithro, zosyn\n Response:\n Maintaining sats. Denies resp distress\n Plan:\n Follow exam, RR, sats\n .H/O diabetes Mellitus (DM), Type II\n Assessment:\n On Insulin 70/30 Q AM with humalog SS. Beginning to take water,\n otherwise no sig PO\ns. BS 160\n Action:\n FS QID\n Response:\n Good glycemic control\n Plan:\n Cont 70/30 with SS humalog QID. need to increased 70/30 to usual\n once taking PO\n Pt\ns wife in to visit.\n"
},
{
"category": "Physician ",
"chartdate": "2112-05-30 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 684501,
"text": "Chief Complaint: Altered mental status, poorly responsive\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 75 yom discharged to rehab 3 days PTA following hospitalization\n for pneumonia (Vanco/Zosyn). Evolution of confusion, lethargic and\n aggitated on day PTA, yelling and belligerant, alternating with\n lethargy. Received iv Ativan. Transferred to ER.\n ER evaluation revealed T= 101.8 rectal Tachypnea, SaO2 > 90%,\n groaning, openned eyes to command inconsistently. WBC= 14.8, lactic\n acid=4.3 CXR revealed . Transferred to MICU service for further\n evaluation and management.\n Upon arrival in MICU, spontaneously moving all extremities, lethargic,\n making groaning noises, ronchorous breath sounds. Overall mental status\n gradully improving during course of hospitalization today.\n Patient admitted from: ER\n History obtained from Medical records\n Patient unable to provide history: Encephalopathy\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors\n Unknown;\n Metformin\n Unknown;\n Dofetilide\n Unknown;\n Quinidine\n Unknown;\n Fentanyl\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n CHF--> EF= 15%\n CAD distant MI\n A-FIB --> coumadin\n VEA --> pacer\n NIDDM\n Venous Stasis LE ulcers\n Occupation:\n Drugs: reportedly no\n Tobacco: remote cigar smoker (quit 30 yrs ago)\n Alcohol: remote heavy use (quit 20 yrs ago)\n Other:\n Review of systems:\n Constitutional: No(t) Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, 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: 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: Agitated, No(t) Suicidal, Delirious, No(t) Daytime\n somnolence, Lethargic (transient)\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 08:14 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: 70 (62 - 81) bpm\n BP: 108/70(77) {108/13(46) - 132/70(80)} mmHg\n RR: 26 (17 - 26) insp/min\n SpO2: 99%\n Total In:\n 500 mL\n PO:\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 0 mL\n 40 mL\n Urine:\n 40 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 460 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ////\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: No(t) PERRL, No(t) Pupils dilated, No(t)\n Conjunctiva pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n No(t) Wheezes : , No(t) Diminished: , No(t) Absent : , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, No(t) Follows simple commands, Responds to:\n Verbal stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 224\n 40.9\n 314\n 1.8\n 33\n 29\n 100\n 4.4\n 141\n 14.8\n [image002.jpg]\n Other labs: PT / PTT / INR://2.9, ALT / AST:, Alk Phos / T\n Bili:87/2.2, Amylase / Lipase:41/, Differential-Neuts:85, Lymph:9.5,\n Lactic Acid:4.3, Ca++:9.2, Mg++:2.0, PO4:3.0\n Imaging: CXR () RLL infiltrate, dense retrocardiac infiltrate\n and obscuring of left hemidiaphragm.\n Assessment and Plan\n ALTERED MENTAL STATUS -- gradual improvement during course of present\n hospitalization suggests drug-induced or toxic-metabolic process.\n Meningitis or encephalitis much less likely. Avoid psychotropic drugs.\n PNEUMONIA -- RLL. represent persistent infection (poorly\n responsive to current antimicrobials) or evolution of resistant\n organism. Adjust antimicrobials. Monitor exam and radiographs.\n SEPSIS -- may represent partial treatment of pneumonia, or new\n infection (such as C. diff, hepatobiliary infection, skin-infection).\n Plan check cultures. Continue supportive care, empirical\n antimicrobials.\n LACTIC ACIDOSIS -- reflects hypoperfusion. Resussitate with fluids,\n monitor lactic acid. Maintain BP MAP > 60 mmHg.\n CHF\n severly depressed EF, but no evidence for active heart failure.\n Monitor I/O, exam.\n ACUTE RENAL FAILURE -- acute on chronic. Likely prerenal due to\n hypovolemia and sepsis. Replete iv fluids. Monitor BUN, creatinine.\n CAD -- No evidence for active disease.\n NIDDM -- maintain glucose <150.\n FLUIDS -- hypovolemia. Replete with fluids, monitor I/O.\n A-FIB -- adequate rate control. Continue Amioderone, Digoxin,\n Toprolol. Monitor HR.\n VEA -- pacer\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 16 Gauge - 04:21 PM\n 20 Gauge - 05:48 PM\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: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2112-05-31 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 684511,
"text": "Chief Complaint: Altered mental status\n HPI:\n 75 yo man with history of CHF (EF 15%), afib on coumadin, CAD s/p MI,\n diabetes, HTN, presents from rehab with altered mental status. The\n patient was recently admitted to the MICU from for RLL\n pna and was discharged to rehab on ( Signai in\n ). He was to complete a 7-day course of vanco/zosyn. Per\n report, he was alert and oriented x 3 on arrival to rehab. According\n to his baseline, he has a normal mental status at baseline. Over the\n past 2 days, his mental status has deteriorated at rehab. He became\n increasingly combative and confused. He was quite lethargic this\n morning but then became agitated, making threats at the staff, and\n attempting to be physically violent. He was given ativan IV at the\n rehab. Transferred to for section 12.\n .\n Of note, he has been having visual hallucinations for the past few\n weeks and was recently started on risperdal, per the patient's\n daughter.\n .\n In the ED, initial vs were: T 101.8 (rectal), P 73, BP 134/60, R 22, O2\n sat 98% on 3L nasal cannula. On exam he was agitated, groaning,\n gurgling, would open his eyes and make contact in response to his name\n being called. He was moving all extremities. As he had already received\n vanco and zosyn this morning at rehab, he was given meropenem. Also\n received tylenol for fever. Admitted to the ICU for close monitoring.\n Patient admitted from: ER\n History obtained from Family / Friend and medical records.\n Patient unable to provide history: Encephalopathy\n Allergies:\n Sulfa (Sulfonamides)\n Unknown;\n Lyrica (Oral) (Pregabalin)\n Anaphylaxis;\n Ace Inhibitors\n Unknown;\n Metformin\n Unknown;\n Dofetilide\n Unknown;\n Quinidine\n Unknown;\n Fentanyl\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 10:48 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Piperacillin-Tazobactam 4.5 g IV Q8H (day )\n Vancomycin 750 mg IV Q 12H (day )\n Amiodarone 200 mg PO DAILY\n Digoxin 125 mcg PO QOD\n Metoprolol XL 100 mg PO daily\n Aspirin 81mg PO daily\n Furosemide 40 mg PO DAILY\n Insulin 70/30 24 units daily\n Regular sliding scale\n Allopurinol 300 mg PO daily.\n Risperdal 0.5 mg Tablet PO qHS\n Albuterol neb Q4H prn\n Atrovent neb Q6H\n Duloxetine 20 mg, Delayed Release(E.C.) PO DAILY\n Ranitidine 150 mg PO BID\n Colace 100 mg PO BID\n Senna 8.6 mg PO daily\n Miralax 17 gram (100 %) Powder 1 packet daily prn\n Lorazepam 1mg IV q8 prn\n Past medical history:\n Family history:\n Social History:\n Congestive heart failure with cardiomyopathy, EF 15%\n CAD s/p MI\n Atrial fibrillation and ventricular ectopy with a pacemaker\n Diabetes with associated neuropathy\n Hypertension\n History of lower extremity ulcers\n Left vestibular schwannoma\n Non-contributory.\n Occupation:\n Drugs: None\n Tobacco: Formerly smoked cigars, quit about 30 years ago.\n Alcohol: Former heavy EtOH use, quit about 20 years ago, now only\n drinks an occasional beer.\n Other: Has been living in rehab recently given failure to thrive at\n home over past few months.\n Review of systems: Unable to obtain mental status.\n Flowsheet Data as of 01:12 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: 71 (62 - 81) bpm\n BP: 104/55(67) {101/13(46) - 132/70(80)} mmHg\n RR: 22 (17 - 26) insp/min\n SpO2: 98%\n Heart rhythm: A Paced\n Total In:\n 1,150 mL\n 11 mL\n PO:\n TF:\n IVF:\n 1,150 mL\n 11 mL\n Blood products:\n Total out:\n 155 mL\n 15 mL\n Urine:\n 155 mL\n 15 mL\n NG:\n Stool:\n Drains:\n Balance:\n 995 mL\n -4 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n Vitals: T: 95.6 (axillary), BP: 119/67, P: 73, R: 17, O2: 100% 5L NC\n General: Obese elderly male, spontaneously moving all extremities,\n opens eyes to voice occasionally, making groaning noises, withdraws to\n painful stimuli\n HEENT: Sclera anicteric, extremely dry mucous membranes, oropharynx\n clear\n Neck: supple, difficult to assess JVP given body habitus, no LAD\n Lungs: Gurgling upper airway sounds, lower lungs are CTAB anteriorly\n without wheeze or rales\n CV: Distant heart sounds, regular rate and rhythm, normal S1 + S2, no\n murmurs, rubs, gallops\n Abdomen: obese, soft, non-tender, non-distended, bowel sounds present,\n no rebound tenderness or guarding\n Ext: Cool but well perfused, erythematous skin changes and decreased\n hair growth on the bilateral lower legs consistent with venous stasis,\n multiple skin tears/excorations over the bilateral shins, no clubbing,\n cyanosis or edema\n Labs / Radiology\n 224\n 12.3\n 314\n 1.8\n 33\n 29\n 100\n 4.4\n 141\n 40.9\n 14.8\n [image002.jpg]\n Other labs: ALT / AST:, Alk Phos / T Bili:87/2.2, Amylase /\n Lipase:/41, Differential-Neuts:85.1, Band:0, Lymph:9.5, Mono:4.6,\n Eos:0.5, Lactic Acid:4.3, Ca++:9.2, Mg++:2.0, PO4:3.0\n Fluid analysis / Other labs: Dig 0.8\n UA: yellow, hazy, 1.026, sm leuk, lg blood, neg nitr, tr prot, neg\n gluc, tr ket, 21-50 RBC, 0-2 WBC, few bact, no yeast, 0 epi\n Imaging: CXR : Diminished lung volumes; RLL consolidatioin is\n minimally changed; increased LLL opacity may represent aspiration, pna,\n or atelectasis; cardiac silhoutte is stable; no pneumothorax.\n Microbiology: Blood cultures: pending\n Urine cultures: pending\n ECG: V-paced at 72 bpm.\n Assessment and Plan\n ACUTE CONFUSION\n PNEUMONIA, OTHER\n .H/O ATRIAL FLUTTER (AFLUTTER)\n .H/O DIABETES MELLITUS (DM), TYPE II\n This is a 75 year-old man with CHF, afib on coumadin, diabetes, CAD s/p\n MI, recent admission for PNA, who presents from rehab with altered\n mental status, found to have new fever and leukocytosis.\n .\n # Fever/Leukocytosis: Unclear source at this point. She is now\n afebrile after receiving meropenem in the ED and tylenol. Potentially\n superimposed pna resistant to vanco/zosyn, possible new infectious\n source (e.g. bacteremia). UA negative for infection. Doubt CNS source\n as mental status is clearing and FROM in neck, more likely delirium.\n - cont vanco and meropenem for now\n - check vanco level in AM\n - IVF boluses as needed to maintain MAP > 65 and UOP > 30cc/h\n - f/u blood cx, urine cx\n - repeat lactate\n - monitor fever curve, tylenol prn\n - monitor WBC trend\n .\n # Altered mental status: Likely toxic metabolic in the setting of\n infection. Also compounded by receiving ativan at the rehab. Doubt\n meningitis or encephalitis. Not uremic. No evidence of liver failure.\n - hold all psychotropic medications\n - keep NPO for now\n - will try haldol if becomes agitated\n - CT head if mental status worsens\n .\n # Hypoxia: Improving. Large component likely secondary to undiagnosed\n OSA as pt had witnessed apneic events during initial physical exam.\n Could also be related to pneumonia. Does not appear to be volume\n overloaded.\n - wean O2 as tolerated, using face mask as pt is mouth breather\n .\n # Acute on chronic renal failure: Cr 1.8 from baseline of 1.4. Likely\n prerenal.\n - IVF bolus\n - monitor UOP and bolus prn for <30cc/h as above\n - trend Cr\n - send urine lytes if renal function does not improve with IVF\n .\n # Chronic systolic CHF: EF 15%. Currently appears dry.\n - holding lasix\n - holding BB, will add back if needed\n .\n # Atrial fibrillation: Currently in sinus rhythm.\n - holding amiodarone until able to take PO\n - will continue digoxin IV\n .\n # Diabetes: Complicated by peripheral neuropathy.\n - cont insulin 70/30 at decreased dose of 15u while NPO, adjust dose as\n needed\n - humalog sliding scale\n .\n # Hypertension: Currently normotensive off of medications.\n - holding lasix, metoprolol in setting of possible infection\n .\n # FEN: IVF as above, replete electrolytes, NPO for now\n .\n # Prophylaxis: Subcutaneous heparin, bowel regimen\n .\n # Access: PIV x 3\n .\n # Code: DNR/DNI, documentation in chart from previous hospitalization\n .\n # Communication:\n - (daughter/HCP) , \n - will call PCP in AM for more information about clinical history\n .\n # Disposition: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 16 Gauge - 04:21 PM\n 20 Gauge - 05:48 PM\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: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "ECG",
"chartdate": "2112-05-30 00:00:00.000",
"description": "Report",
"row_id": 126433,
"text": "Regular ventricularly paced rhythm. Underying rhythm appears to be atrial\nfibrillation but uncertain. Compared to the previous tracing of \nthere is no significant diagnostic change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-06-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1086640,
"text": " 1:12 PM\n CHEST (PA & LAT) Clip # \n Reason: Please eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with prev PNA\n REASON FOR THIS EXAMINATION:\n Please eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 3:02 PM\n Improvement of previously existing marked pulmonary congestion. Also, basal\n infiltrates have improved, but not completely resolved. Further followup\n recommended.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: Followup for previous pneumonia.\n\n FINDINGS: The patient's condition did not permit routine PA and lateral\n examination in upright position. The patient is examined in AP view and\n lateral view obtained with the patient sitting semi-upright. Available for\n comparison is the next preceding AP single view of . Again,\n marked cardiac enlargement is noted. Permanent pacemaker unchanged in left\n anterior axillary position with single electrode terminating in distal portion\n of right ventricle. No pneumothorax is present. There is a marked\n improvement of the significant perivascular haze in the pulmonary circulation\n noted on the preceding study of . Also, the previously identified\n parenchymal infiltrates, most marked on admission examination of , have regressed markedly. Although the cardiac enlargement obscures the\n left lung base, improved visualization of the left-sided diaphragmatic contour\n and that of the descending aorta suggests at least partial clearance of\n atelectasis and infiltrates. No new parenchymal abnormalities are identified\n and the lateral pleural sinuses are now free. On the lateral view, remaining\n density and blunting of the posterior pleural sinuses is otherwise still\n noted. No pneumothorax is identified.\n\n IMPRESSION: General improvement of chest findings, marked improvement of\n previously identified pulmonary congestion and central edema pattern. Some\n bilateral basal infiltrates persist and further followup is recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-06-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1086641,
"text": ", M. MED 11R 1:12 PM\n CHEST (PA & LAT) Clip # \n Reason: Please eval for interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with prev PNA\n REASON FOR THIS EXAMINATION:\n Please eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n Improvement of previously existing marked pulmonary congestion. Also, basal\n infiltrates have improved, but not completely resolved. Further followup\n recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-05-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1086130,
"text": " 12:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with altered mental status\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old male with altered mental status. Evaluate for\n pneumonia.\n\n Single AP chest radiograph compared to shows diminished lung\n volumes. Right lower lobe consolidation continues to improved. Left basilar\n opacity is unchanged and probably due to atelectasis. The heart remains\n moderately enlarged. Pulmonary vascular congestion is unchanged. Single lead\n of the left chest wall pacemaker is in stable position. There is no\n pneumothorax.\n\n IMPRESSION: Continued improvement of right lower lobe pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-05-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1086234,
"text": " 7:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval interval change--pt now with significantly decre\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year-old man with CHF, afib on coumadin, diabetes, CAD s/p MI, recent\n admission for PNA, who presents from rehab with altered mental status, found to\n have new fever and leukocytosis.\n REASON FOR THIS EXAMINATION:\n Please eval interval change--pt now with significantly decreased BS on L side.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old man with chronic heart failure, evaluation of\n interval change because of decreased breath sounds.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, there is increasing\n retrocardiac atelectasis as well as increasing blunting of the costophrenic\n sinuses. In conjunction with the increased perihilar haziness and a slight\n increase in diameter of the pulmonary vessels, moderate pulmonary edema must\n strongly be considered.\n\n The responsible resident was paged at the time of dictation.\n\n Unchanged position of the left pectoral pacemaker. Unchanged cardiomegaly.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-06-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1086451,
"text": " 12:14 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for cause of AMS\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with admited for AMS, PNA\n REASON FOR THIS EXAMINATION:\n eval for cause of AMS\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status and pneumonia.\n\n COMPARISON: No previous studies.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Due to motion artifact, images of the inferior portion of the brain\n were repeated. There is no evidence of acute intracranial hemorrhage, edema,\n mass effect, or other CT signs of an acute major vascular territorial\n infarction. There is mild-to-moderate periventricular and subcortical white\n matter hypodensity in the cerebral hemispheres, likely related to chronic\n small vessel ischemic disease in a patient of this age. There is moderate-to-\n severe cerebral atrophy with associated prominence of the sulci and\n ventricles. The imaged bones are unremarkable. The imaged portions of the\n paranasal sinuses are well aerated.\n\n IMPRESSION: No evidence of acute intracranial abnormalities. Mild-to-moderate\n chronic small vessel ischemic disease. If there is a clinical suspicion for\n an acute infarction, then MRI would be a more sensitive study.\n\n DFDkq\n\n"
}
] |
4,312 | 136,851 | The patient was felt to possibly be septic at the time of admission; possibly secondary to spontaneous bacterial peritonitis. He was started on ceftriaxone initially. His hypotension was felt to be multifactorial secondary to both hypovolemia secondary to blood loss as well as sepsis. His encephalopathy was felt most likely to be secondary to his underlying liver disease as well as multiple sedating medications. His coagulopathy was felt to be secondary to fulminant liver failure. Initial management was aimed at treating possible spontaneous bacterial peritonitis as well as supportive care for the other problems described. On hospital day two, the patient's pressors were discontinued, and he was ultimately transfused 6 units of packed red blood cells. He also received vitamin K and 4 units of fresh frozen plasma. He developed thrombocytopenia of unknown cause. He then became alcoholic secondary to the bicarbonate as well as ventilator settings; and ventilator adjustments were made as well as bicarbonate drip discontinued. His INR improved to 1.7 from 2.7, but an additional 2 units of fresh frozen plasma were given. His creatinine improved to 1.8 with intravenous fluids. An abdominal ultrasound was obtained given his elevated amylase and lipase and elevated liver function tests. This ultrasound showed liver cysts, normal portal flow, and gallstones but no evidence of obstruction. The pancreas was not visualized. There was evidence of cirrhosis and splenomegaly. He received platelets for his thrombocytopenia. On hospital day three, the ascites cultures came back with 4/4 bottles positive for gram-negative rods. The patient was started on ciprofloxacin and continued on previously prescribed ceftriaxone. His creatinine continued to improve. His fractional secretion of sodium was greater than 25%; consistent with acute tubular necrosis from his hypotension. On hospital day four, nadolol was started for the patient's portal hypertension. His antibodies were sent given his decreasing platelets. These eventually came back negative. Free water boluses were started for rising sodium. On hospital day five, total parenteral nutrition was started, and the patient received his last dose of octreotide. Ciprofloxacin was discontinued as the gram-negative rods were found to be sensitive to ceftriaxone. On hospital day six, the patient's urine culture came back positive for enterococcus. Vancomycin was started. The patient was extubated. Tube feeds were started. On hospital day seven, a paracentesis was done with 6.8 liters of fluid removed. On hospital day eight, the patient was transferred out to the general medical floor. At the time of transfer, the patient was without complaints. He was still very encephalopathic but stable. After arriving to the floor the patient was noted to have extremely poor output with less than 50 cc over four hours. A 500-cc bolus was given without effect. Foley irrigation was done, and approximately 50 cc of gross blood and clots were removed. The patient was hemodynamically stable, and oxygen saturations were within normal limits. He received 12.5 g of albumin as well as normal saline, and a three way Foley catheter was inserted with continuous irrigation. Overnight, his urine output improved. On hospital day nine, the patient had an esophagogastroduodenoscopy and banding of his esophageal varices by Dr. . This procedure was without complaints, and the patient appeared stable that evening following the procedure. On the tenth hospital stay, the patient's diet was slowly be advanced. His hematocrit was noted to be slowly trending down, but there was initially no evidence of rebleeding. However, later that morning the patient developed hematemesis around 2 p.m. He had eaten lunch and was up in the chair doing well and then developed 200 cc to 300 cc of hematemesis. He had no shortness of breath, chest pain, or abdominal pain at that time. He did have some slight dizziness, however. A STAT hematocrit was sent. Then the patient developed a bloody bowel movement, maroon stool, which was approximately 300 cc. He then had approximately 200 cc of bright red blood per rectum following. His blood pressure was 94/70 at this time. The patient was still mentating and feeling "fine." Given the evidence of what appeared to be massive rebleeding of his esophageal varices, the patient was transferred back to the Medical Intensive Care Unit for further management. Upon transfer back to the Medical Intensive Care Unit, the patient developed massive upper gastrointestinal hemorrhage; and despite pressors, fluid resuscitation, blood resuscitation, and octreotide, the patient was not able to be resuscitated. The patient passed away later that evening. | cipro was dc'dgi: abdomin distended but soft with palpation, also + bowel sounds---also hernia noted on abdminal surface. expired at per monitor and MDs to pronounce. S/p 2u FFP and 1 Plts with last HCT 28.8 and INR 1.5. gnr in peritoneal fluid. Became hypotensive, IVF boluses, domamine started, transfused with PRBCs, platlets and FFP. A right IJ central venous catheter terminates with its tip in the region of the cavo-atrial junction. Respiratory Care:Pt. Peritonitis. Anesthesia intubated pt. The gallbladder is distended. IMPRESSION: Tip of IJ line lies in the right subclavian vein. COMPARISON: AP UPRIGHT PORTABLE CHEST: An NG tube is appropriately positioned in the distal stomach. Right IJ line remains pointed toward the axilla and the subclavian vein. Sepsis. COMPARISON: AP PORTABLE SEMI-UPRIGHT CHEST: Endotracheal and NG tubes are well positioned. lethargic o/n, mumbling, oriented to person. anuric. REASON FOR THIS EXAMINATION: SP replacement of rigth IJ line. Linear atelectasis left lower zone. lactolose continues qhrs. The liver demonstrates a coarsened echotexture. MICU-NPNNEURO: pt. Inserted this am w/fair amt of trauma/bleeding. Receiving lactulose q4hrs via OGT. The tip of the right IJ line is in the right subclavian vein. rr upper teens, nonlabored.post extub abg stable. Left hemidiaphragm is obscured by what appears to be a hazy, small-to-moderate layering effusion. HISTORY:variceal-bleed and tube placement. Afebrile. Cirrhotic liver. HR 90s-100s SR/ST with occasional PVC. AP CHEST: Again there are low lung volumes. tube extends into proximal stomach. COMPARISON: AP UPRIGHT PORTABLE CHEST CENTERED AT THORACO-LUMBAR JUNCTION: An NG tube is appropriately positioned. Foley intact and pt. To start on TFs when NGT palcement confirmed by CXR. IMPRESSION: Left-sided pleual effusion. Normal portal venous flow. Lungs coarse throughout with minimal secretions.GI/GU: Abd grossly distended with ascites. SBP 90s-120s- off pressors. Status post placement of right IJ line. bp stable. Appropriately positioned NG tube. Bibasilar atelectasis is present. Cholelithiasis with a normal, nondilated common bile duct. There is linear atelectasis at the left base laterally and patchy atelectasis at both bases. initially required nts post extubation. rectal tube intact draining sm amt stool. Right IJ central line travels retrograde down the right subclavian vein toward the axilla. u/a sent. Check position. MDs aware. Post-extubation and placement of new NG tube. Sx'd for tan odiferous secretions moderate amounts. Check placement. Check placement. Follows commands, squeezes hands, moves lower extremities, shakes head to verbal commands.CV: Tmax: 99.2po, HR 54-75 NSR, 96-127/48-77, a-line dampened but does obtain , some difficulty drawing labs, sluggish.GI: abdomen soft and distended, hypo BS, liquid stool draining via rectal tube, lactulose Q8hrs. Pt. Pt. Pt. octreotide was dc'd today. Color and doppler wave forms demonstrate normal, hepatopedal flow within the main portal vein. The NGT remains well positioned and the right IJ line is again seen extending retrograde into the right subclavian vein. IMPRESSION: 1. IMPRESSION: 1. REASON FOR THIS EXAMINATION: assess for ET tube placement FINAL REPORT ABDOMEN, SINGLE FILM. was initially on SIMV and changed to CPAP&PS, tolerating well.GI: abdomen firm and distended, lg. Bloody drainage.ID: ceftraixone started QDAtivan gtt staarted @ 1mg/hr, currently @3mg/hr with good effect, con't to monitor sedation. Resp Care,Pt. Encephalopathic with NH3 50 at OSH.CV: Afebrile. OGT d/c'd with ETT. Bld CX x1 sent, INR 1.7 (3.1)RESP: pt. generalized pitting edema. BP 80s-90s systolic and receiving NS bolus 250ccx1. Na continues to be elevated, started on free H2O boluses pNGT.GU: U/O qs via foley catheter.ID: Afebrile today. otherwise pt noresonsvie. continues on Sandostatin gtt, lactulose Q4/hr's.GU: foley drng adequate amt's of urine.ID: ceftriaxone, ciprofloxacin Lactulose Q6hrs, fecal bag in place. MICU-NPNNeuro: Pt. Nursing Progress Note 7a-7pNeuro: Pt very lethargic, arousable to voice. , 3mm, sluggish.CV: VSS, a-line dsg changed, oozing bldy drng from site. Sinus rhythmLong QT intervalNonspecific ST-T abnormalitiesSince previous tracing, voltage lower ABG in AM 7.53/24/97/21/0/ repeat ABG pending. RR in the 20's, appears more comfortable.GI: abdomen distended with ascites, umbilical hernia noted, +BS, liquid stool drng per rectal tube. REASON FOR THIS EXAMINATION: s/p extubation FINAL REPORT CHEST SINGLE AP FILM: HISTORY: Cirrhosis with hematemesis and extubation. unsuceesful in obtaining urine cx.id: temp max 99.9 orally pt skin warm. Resp. ls coarse.gi: sandostatin at 100mcg, ngt clampled coffee ground residuals noted. NGT placed, verified by x-ray and auscultation, putting out bilious material when to LCS. NG tube extends below diaphragm. +BS's. Right jugular CV line is in region of cavoatrial junction. soft and distended with ascites. unresponsive to painful stimuli.CV: SBP 60's-100's, started on Levophed and then switched to Dopamine titrating to SBP>90. SBP 90's-140's, afebrile, HCT Q4/hr's.RESP: No vent changes made, LS coarse t/o, suctioned for large amt's of thick, tan secretions. afebrile. Turned and repositioned. was intubated, LS clear, suctioned for thick, tan secretions. rn progress note 8amneruo: pt seems be moving more, turns head to voice and name calling looks like he is moving eyelid in an attemtp to open eyescad: vss aline postional see flwsheetresp:no vent changes sats 97-99% ls cleargu; wnl amber with clotsgI cont on lactulose 400-600 stolol with each doselast amnonia 37plan: cont monitoring vss, labs blood cx need. LS coarse, diminished @ bases,bilat. NURSING NOTEPT REMAINS SEDATED AND INTUBATED, CURRENT VENT SETTINGS CPAP PS5P5 35% O2, POX 94-97%, SUCTIONED COPIOUS AMTS YELLOW SECRETIONS, VSS HR 90-115, BP 118/67-150/90, IVF @ 150CC/HR X1L, SANDOSTATIN GTT CONTINUED, R IJ IN PLACE, LACTULOSE GIVEN Q4H, RECTAL TUBE IN PLACE LARGE AMTS LOOSE STOOL @ 1000CC OVER 12HR, PT RESPONDING SLIGHTLY TO PAIN, MOVES EXTREMITIES SPONTAN, FOLEY CATH IN PLACE DRAINING DARK AMBER URINE WITH SM AMTS CLOTS, PT TURNED AND REPOSIT FREG SEE CAREVUE FOR FULL ASSEESMENTS Continues on TPN. of tannish secretions. umbilical hernia noted, abdomen was tapped for >30cc and cx were sent. | 33 | [
{
"category": "Radiology",
"chartdate": "2193-04-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758205,
"text": " 5:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for chf, copd, pna, line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hep b,c cirrhosis, admitted for esophageal variceal bleed.\n REASON FOR THIS EXAMINATION:\n eval for chf, copd, pna, line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for heart failure.\n\n COMPARISON: .\n\n AP CHEST: Again there are low lung volumes. The heart size is stable. There\n is interval increase in pulmonary vascular congestion and bilateral alveolar\n opacifications consistent with heart failure. In addition, there appear to be\n small bilateral pleural effusions. The NGT remains well positioned and the\n right IJ line is again seen extending retrograde into the right subclavian\n vein.\n\n IMPRESSION: Interval worsening of heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-04-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758253,
"text": " 12:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for ngt placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hcv, hbv cirrhosis, sp variceal bleed and now ngt\n placement\n REASON FOR THIS EXAMINATION:\n assess for ngt placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n NG tube placement.\n\n COMPARISON:\n \n\n AP UPRIGHT PORTABLE CHEST:\n An NG tube is appropriately positioned in the distal stomach. Right IJ central\n line travels retrograde down the right subclavian vein toward the axilla.\n There is no pneumothorax. There is linear atelectasis at the left base\n laterally and patchy atelectasis at both bases. The lungs are otherwise clear.\n There are no pleural effusions and there has been marked improvement in the\n overall appearance of the vascular haziness and widening of the vascular\n pedicle.\n\n IMPRESSION:\n 1. Improved appearance of CHF.\n 2. Appropriately positioned NG tube.\n 3. Right IJ line remains pointed toward the axilla and the subclavian vein.\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-04-26 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 758417,
"text": " 5:40 PM\n PORTABLE ABDOMEN Clip # \n Reason: TUBE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with Hep C cirrhosis now with acute variceal bleed.\n REASON FOR THIS EXAMINATION:\n assess for ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n\n ABDOMEN, SINGLE FILM.\n\n HISTORY:variceal-bleed and tube placement.\n\n tube extends into proximal stomach. Distal end of tube is not\n included on the film. The balloon is not inflated. There is moderate gaseous\n distension of the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-04-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758089,
"text": " 1:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: MICU pt., s/p extubation with placement of new NGtube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with cirrhosis, s/p GIBleed, HBV, HCV, sepsis; \n REASON FOR THIS EXAMINATION:\n MICU pt., s/p extubation with placement of new NGtube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cirrhosis and GI bleed. Sepsis. Post-extubation and placement\n of new NG tube.\n\n COMPARISON: \n\n AP UPRIGHT PORTABLE CHEST CENTERED AT THORACO-LUMBAR JUNCTION: An NG tube is\n appropriately positioned. Endotracheal tube is no longer seen. A right IJ\n central venous catheter is again noted coursing retrograde into the subclavian\n vein on the right. Bibasilar atelectasis is present. The lungs appear\n otherwise clear. There is diffuse haziness and relative paucity of bowel gas\n over the abdomen compatible with ascites.\n\n IMPRESSION: Satisfactory NG tube placement.\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-04-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 757765,
"text": " 7:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna, chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with cirrhosis, s/p variceal bleed and egd now with elevated\n wbc count. r/o aspiration pna\n REASON FOR THIS EXAMINATION:\n r/o pna, chf\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM:\n\n History of variceal bleed with elevated white count and possible aspiration.\n To evaluate for pneumonia.\n\n There are low lung volumes. No pulmonary consolidation. Linear atelectasis\n is present in the left lower zone.\n\n IMPRESSION: No evidence for pneumonia. Linear atelectasis left lower zone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-04-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758029,
"text": " 4:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: SP replacement of rigth IJ line. Check placement.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with liver disease, peritonitis, intubated.\n REASON FOR THIS EXAMINATION:\n SP replacement of rigth IJ line. Check placement.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 57 y/o man with liver disease. Peritonitis. Status post\n placement of right IJ line. Check position.\n\n The tip of the right IJ line is in the right subclavian vein. No pneumothorax\n is seen. The chest is otherwise unchanged since .\n\n IMPRESSION: Tip of IJ line lies in the right subclavian vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-04-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 757883,
"text": " 11:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with alcholic cirrhosis; in MICU with GI bleed; \n REASON FOR THIS EXAMINATION:\n Evaluate for PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n Alcoholic cirrhosis in the MICA with a GI bleed. Evaluate for pneumonia.\n\n COMPARISON:\n \n\n AP PORTABLE SEMI-UPRIGHT CHEST:\n Endotracheal and NG tubes are well positioned. A right IJ central venous\n catheter terminates with its tip in the region of the cavo-atrial junction.\n There is no pneumothorax. Lung volumes are low. Left hemidiaphragm is obscured\n by what appears to be a hazy, small-to-moderate layering effusion. The lungs\n are grossly clear.\n\n IMPRESSION:\n Left-sided pleual effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-04-18 00:00:00.000",
"description": "ABDOMEN U.S. (PORTABLE)",
"row_id": 757826,
"text": " 2:53 PM\n ABDOMEN U.S. (PORTABLE); DUPLEX DOPP ABD/PEL Clip # \n Reason: INCREASED LIVER ENZYMES AND HEP BAND C\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with hep b/c cirrhosis, s/p recent esophageal rupture with\n acute re-bleed, ascities, and elevated amylase and lipase.\n REASON FOR THIS EXAMINATION:\n evaluate portal venous flow, evaluate for evidence of cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Cirrhosis, esophageal rupture and acute bleed. Evaluate\n portal venous flow and biliary tree.\n\n There is a 2.3 cm gallstone within the gallbladder. There is no evidence of\n gallbladder wall thickening. The gallbladder is distended. The common bile\n duct is not dilated. There is no evidence of intrahepatic ductal dilatation.\n The liver demonstrates a coarsened echotexture. There is a 1.1 cm hypoechoic\n mildly marginated rounded lesion within the right lobe of the liver. There is\n a 5 mm hypoechoic foci within the right lobe of the liver. Color and doppler\n wave forms demonstrate normal, hepatopedal flow within the main portal vein.\n The hepatic veins and arteries are patent with normal doppler flow. There is\n ascites surrounding the liver. Both right and left kidneys are normal without\n evidence of hydronephrosis or stones. The right kidney measures 11.9 cm. The\n left kidney measures 10.4 cm. The pancres is not well visualized. The spleen\n is enlarged measuring 18.3 cm.\n\n IMPRESSION:\n\n 1. Two small hypoechoic foci within the right lobe of the liver which appears\n sharply marginated and mostly could represent liver cysts. If further\n evaluation is indicated an MRI can be performed.\n\n 2. Normal portal venous flow.\n\n 3. Cholelithiasis with a normal, nondilated common bile duct. There is no\n son evidence for acute cholecytitis.\n\n 4. Cirrhotic liver.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-23 00:00:00.000",
"description": "Report",
"row_id": 1318038,
"text": "NURSING NOTE\n\nPT MORE ALERT TODAY, FOLLOWS SIMPLE COMMANDS, VSS HR 60-70'S, SBP 105/70-140/70'S, POX 100% ON 3LNC, LUNGS COARSE SUCTIONED LARGE AMTS THICK YELLOW SECRETIONS, PT UNABLE TO EXPECTORATE SECRETIONS, PT CONTINUES ON LACTULOSE, CONTINUES WITH LARGE AMTS LOOSE STOOL, INCONTIN BAG REPLACED SEVERAL TIMES, RECTAL TUBE PLACED, PT TURNED AND REPOSIT FREQ, TF ON HOLD THIS AM FOR LARGE AMTS RESIDUALS, RESTARTED THIS AFTERNOON @ 20CC/HR, L ALINE D/C'D, R TLIF IN PLACE, FAMILY MEETING THIS AFTERNOON WITH MDS, SEE CAREVUE FOR FULL ASSESSMENTS\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-24 00:00:00.000",
"description": "Report",
"row_id": 1318039,
"text": "micu/sicu npn 1900-0700\npatient remains stable. lethargic o/n, mumbling, oriented to person. ?place and time. difficult to understand. slept well o/n. lactolose continues qhrs. rectal tube intact draining sm amt stool. vss. hr 50-60's, nsr. bp stable. see carevue for details. tube feeds off for most of night for high residuals, free h20 bolus' continue q6hrs. pt remains on 2l nasal cannula, sats 98-100%. rr 12-16. weak cough noted, needs assistance to claer secretions.. no contact from family this shift. cont to support, follow ammonia levels, monitor resp status..awaiting am labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-24 00:00:00.000",
"description": "Report",
"row_id": 1318040,
"text": "MICU/SICU NPN 0700-1500\n\nLethargic and disoriented. Sl restless at times. NGT noted to be out at 0700. Inserted this am w/fair amt of trauma/bleeding. Wrist restraints on but pt scoots down bed and is often able to reach lines. No gag noted. Weak cough. Unable to sip through straw. Afebrile. Passing liq yellow stool. To start on TFs when NGT palcement confirmed by CXR. Trans to 5S this afternoon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-26 00:00:00.000",
"description": "Report",
"row_id": 1318041,
"text": "MICU NSG ACCEPT NOTE:\nSee intern note for details and pmhx. Pt. transferred from 5 south after hematemesis and BRBPR. Transferred to ICU for ?tips procedure and closer monitoring. Upon arrival to ICU pt. with BRBPR and Hematemesis in large amts. Became hypotensive, IVF boluses, domamine started, transfused with PRBCs, platlets and FFP. Anesthesia intubated pt. and tube attempted to be inserted without success. Decision made by PCP and sister (proxy) to stop treatment and make pt. comfort care only due to poor prognosis. All supportive measures withdrawn at 1845 and MSO4 gtt started at 2mg/hr and advanced to 6mg/hr per sister's request. Sister and husband at bedside. Pt. expired at per monitor and MDs to pronounce.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-21 00:00:00.000",
"description": "Report",
"row_id": 1318032,
"text": "pmicu nursing progress note\nresp: no vent changes today--presently on 35% 5 peep and 5 pressure support with sptvs of 700-790 and a resp rate of , and o2 sats of 94-95%. pt suctioned several times for a copious amt of thick tannish foul smelling sputum---sample sent for culture. lung sounds were deminished at the bases, otherwise clear.\nnew triple lumen placed today at a new site in the right ij--placement verified by cxr.\n\ncardiac: nbp 93-126/54-74 with a pulse of 70-78sr, and no ectopy noted. rec'd a total of 80 meq of kcl for a k+ of 3.4. na level was 152--- d5w infusing at 75cc/hr. arterial line in place, and able to obtain an arterial bp, but very dampened----also able to draw bloods from line\n\nid: temp 98.4 po, 98 po and 99 po. blood culture sent from the arterial line and a sputum was sent. urine has enterococcus. gnr in peritoneal fluid. cipro was dc'd\n\ngi: abdomin distended but soft with palpation, also + bowel sounds---also hernia noted on abdminal surface. lactulose change'd to q8 hrs---out approx 700cc of liquidy golden brown stool passed through a rectal tube. octreotide was dc'd today. t. bilib elevated.\n\ngu: urine output approx 25-20cc/hr---urine culture sent.\n\nneuro: pt \"lighter\" today-----following simple commands with moving extremities and moving head from side to side. attempts to open eyes, but unable to, when asked. hands are restrained, because pt made attempt to go for ettube.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-22 00:00:00.000",
"description": "Report",
"row_id": 1318033,
"text": "MICU-NPN\n\nNEURO: pt. tries to open eyes to verbal stimuli, L eye opens further than R eye. Follows commands, squeezes hands, moves lower extremities, shakes head to verbal commands.\nCV: Tmax: 99.2po, HR 54-75 NSR, 96-127/48-77, a-line dampened but does obtain , some difficulty drawing labs, sluggish.\nGI: abdomen soft and distended, hypo BS, liquid stool draining via rectal tube, lactulose Q8hrs. OGT clamped. NA 154(152) D5W increased to 100cc/hr, am labs pending.\nRESP: no changes made in vent settings, see carevue. Suctioned for copious amt's of thick, tan, foul smelling sputum, cx sent yesterday.\nGU: foley draining adeq amt's of clear, amber urine. u/a sent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-22 00:00:00.000",
"description": "Report",
"row_id": 1318034,
"text": "Respiratory Care:\nPt. had a quiet noc. Sx'd for tan odiferous secretions moderate amounts. See Carevue for more details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-22 00:00:00.000",
"description": "Report",
"row_id": 1318035,
"text": "Resp care\nweaned and extubated after prolonged time on . initially required nts post extubation. now less congested. rr upper teens, nonlabored.\npost extub abg stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-18 00:00:00.000",
"description": "Report",
"row_id": 1318023,
"text": "MICU NPN:\nNEURO: Pupils3mm, round and reactive to light. No response to pain noted. No movement of extremities noted.\n\nCV: Afebrile. HR 90s-100s SR/ST with occasional PVC. SBP 90s-120s- off pressors. CVP 8-14. S/p 2u FFP and 1 Plts with last HCT 28.8 and INR 1.5. Skin cool to touch with dopplerable pulses distally. IVF NS at 100cc/hr via patent TLC in R IJ.\n\nRESP: Vent with PS 5 Peep 5 FiO2 40% with last ABG 7.54/22/126. RR 16-19. Lungs coarse throughout with minimal secretions.\n\nGI/GU: Abd grossly distended with ascites. Umbilical hernia protruding. No bleeding from OGT noted. Octreotide continues. Receiving lactulose q4hrs via OGT. Stooling liquid-loose melena, no BRBPR noted. GI following. EGD possible later today. Foley intact and pt. anuric. Foley flushed with sterile saline with equal amt of return noted, no clots. MDs aware. Unable to obtain urine cs due to insufficent urine output.\n\nSKIN: Intact. Peri-care given.\n\nID: Cipro IV added today.\n\nSOCIAL: Social service involved for complicated family dynamics. Proxy to be pt's sister who is due to arrive this afternoon from FL. Pt. also with x-wife and daughter , ex-girlfriend with daughter , nephew and other sister . Family mtg to be planned to discuss family's wishes for pt's plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-19 00:00:00.000",
"description": "Report",
"row_id": 1318024,
"text": "rn progess note\n 430am\nneruo: pt noted to withdraw arm when staff attempted to move it noted on both arms also witdraw toes slightly with foot stim. otherwise pt noresonsvie. pt overbreting vent on e episode into 40's while daughter to him.\ncad hr 100's wit pvc's b/p teens to 120's/70's\nresp; on ps5/5 at 40% suctioned for scant amt. of tannish secretions. ls coarse.\ngi: sandostatin at 100mcg, ngt clampled coffee ground residuals noted. lactulose given q4 effective 250cc melena output.\ngu: pt making approx 30cc/hr of amberish blood tinged urine output. unsuceesful in obtaining urine cx.\nid: temp max 99.9 orally pt skin warm. pt currently on antb tx.\nfamily: patients healthcare proxy arrived at 12am last night. pt was made at dnr at that time will discuss further tx plans in a.m. with family doctor.\nplan: see above, moniotr hct q4 last 32.1 at 12am, monitor vs and labs as neded. provide care and support to pt. and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-17 00:00:00.000",
"description": "Report",
"row_id": 1318020,
"text": "MICU NSG ADMIT NOTE:\nSee Adm/history page for details. Pt. admitted to ICU at 1830.\nNEURO: Pupils 3mm PERL. Unresponsive to pain. No movement noted. Encephalopathic with NH3 50 at OSH.\nCV: Afebrile. Skin cool to touch with weak but palpable pulses distally. BP 80s-90s systolic and receiving NS bolus 250ccx1. Has 18G and 20G to L arm. HR 80s-100s SR/ST with occ. PVC. Labs drawn and pending.\nRESP: RA with O2 Sat 100% Lungs CTA.\nGI: Abd. soft and distended with ascites. Umbilical hernia. Smear of dark tary black stool upon arrival.\nGU: Foley with frank hematuria. Poor u/o.\nSKIN: Intact. No breakdown noted.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-18 00:00:00.000",
"description": "Report",
"row_id": 1318021,
"text": "57 m admitted from outside hospital with esoph. varices,etoh and drug abuse, reanl insuf, htn, cirrhosis, intubated with 7.5 et for resp.insuf. and placed on simv ventilation. pt.was being medicated but still overriding the ventilator so he was placed on 5 cpap-5 ips-60%+fb which he has tol.well.vt.800 on own, rr.17-18, abg on simv.7.40,27,170,17,-5,97%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-18 00:00:00.000",
"description": "Report",
"row_id": 1318022,
"text": "NEURO: pt. unresponsive to painful stimuli.\nCV: SBP 60's-100's, started on Levophed and then switched to Dopamine titrating to SBP>90. Weaned from Dopamine @0600 with BP stable in the low 100's. Pt. becomes hypotensive with turning. Bld CX x1 sent, INR 1.7 (3.1)\nRESP: pt. was intubated, LS clear, suctioned for thick, tan secretions. Pt. was initially on SIMV and changed to CPAP&PS, tolerating well.\nGI: abdomen firm and distended, lg. umbilical hernia noted, abdomen was tapped for >30cc and cx were sent. OGT introduced and lavaged for coffee ground aspirates. 2L of dark bldy drainage obtained. Pt was transfused with 6units of PRBC's and 4 units FFP over. HCt on admit was 2, am labs 30.2, potassium 4.4\nGU: Foley in place, no u/o over noc. Bloody drainage.\nID: ceftraixone started QD\nAtivan gtt staarted @ 1mg/hr, currently @3mg/hr with good effect, con't to monitor sedation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-19 00:00:00.000",
"description": "Report",
"row_id": 1318025,
"text": "Resp Care,\nPt. remains intubated on CPAP IPS5/.4/5peep. VT 600, RR20. Suctioned thick tan sputum. Maintain current vent settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-19 00:00:00.000",
"description": "Report",
"row_id": 1318026,
"text": "NURSING NOTE\n\nPT REMAINS INTUBATED, NO SEDATION GIVEN, REMAINS DIFFICULT TO AROUSE, PUPILS REACTIVE, MINIMAL SPONTAN MOVEMENT NOTED BY FAMILY, AND PT NOTED TO W/D L ARM TO PAINFUL STIMULI, SLIGHT SPONTAN MOVEMENT NOTED OF LE, VSS BP 101/69-127/67, HR 90'S, AFEBRILE, PT CONTINUES ON LACTULOSE Q4H, RECTAL TUBE IN PLACE DRAINING LARGE AMTS LOOSE STOOL, HEME +, OGT IN PLACE, MEDS GIVEN, LUNGS COARSE, PS 5 P5, TV 700, 35% O2, POX 97%, SUCTIONED THICK TAN SECRETIONS SM AMTS, L TLIJ IN PLACE, L PERIP IV REMOVED ARM REDDENED, R RAD ALINE IN PLACE, ABD REMAINS DISTENDED + ASCITES, + BS, UMBILICAL HERNIA UNCHANGED, HCT REMAINS STABLE, PT TURNED AND REPOSIT FREQ, MOUTHCARE DONE PRN, SEE CAREVUE FOR FULL ASSESSMENTS\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-20 00:00:00.000",
"description": "Report",
"row_id": 1318027,
"text": "MICU-NPN\nNeuro: Pt. unresponsive, non-purposeful movement right arm @ times. , 3mm, sluggish.\nCV: VSS, a-line dsg changed, oozing bldy drng from site. SBP 90's-140's, afebrile, HCT Q4/hr's.\nRESP: No vent changes made, LS coarse t/o, suctioned for large amt's of thick, tan secretions. RR in the 40's x1, dropped TV's suctioned for copious secretions. RR in the 20's, appears more comfortable.\nGI: abdomen distended with ascites, umbilical hernia noted, +BS, liquid stool drng per rectal tube. continues on Sandostatin gtt, lactulose Q4/hr's.\nGU: foley drng adequate amt's of urine.\nID: ceftriaxone, ciprofloxacin\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-20 00:00:00.000",
"description": "Report",
"row_id": 1318028,
"text": "Respiratory Care:\nPt's condition notable for lack of any responses over noc. He is on mechanical ventilation with very junky breath sounds and has needed lots of suctioning for moderate amounts of sec. often. No vent changes. Carevue has further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-20 00:00:00.000",
"description": "Report",
"row_id": 1318029,
"text": "Resp. Care Note\nPt remains intubated and vented on settings CPA 5 PSV 5 35% with TV variable from 400-700cc and RR 8-20. Pt with periods of apnea throughout the day today, team aware. ABG in AM 7.53/24/97/21/0/ repeat ABG pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-20 00:00:00.000",
"description": "Report",
"row_id": 1318030,
"text": "NURSING NOTE\n\nPT REMAINS SEDATED AND INTUBATED, CURRENT VENT SETTINGS CPAP PS5P5 35% O2, POX 94-97%, SUCTIONED COPIOUS AMTS YELLOW SECRETIONS, VSS HR 90-115, BP 118/67-150/90, IVF @ 150CC/HR X1L, SANDOSTATIN GTT CONTINUED, R IJ IN PLACE, LACTULOSE GIVEN Q4H, RECTAL TUBE IN PLACE LARGE AMTS LOOSE STOOL @ 1000CC OVER 12HR, PT RESPONDING SLIGHTLY TO PAIN, MOVES EXTREMITIES SPONTAN, FOLEY CATH IN PLACE DRAINING DARK AMBER URINE WITH SM AMTS CLOTS, PT TURNED AND REPOSIT FREG SEE CAREVUE FOR FULL ASSEESMENTS\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-21 00:00:00.000",
"description": "Report",
"row_id": 1318031,
"text": "rn progress note\n 8am\nneruo: pt seems be moving more, turns head to voice and name calling looks like he is moving eyelid in an attemtp to open eyes\ncad: vss aline postional see flwsheet\nresp:no vent changes sats 97-99% ls clear\ngu; wnl amber with clots\ngI cont on lactulose 400-600 stolol with each dose\nlast amnonia 37\nplan: cont monitoring vss, labs blood cx need.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-22 00:00:00.000",
"description": "Report",
"row_id": 1318036,
"text": "Nursing Progress Note 7a-7p\nNeuro: Pt very lethargic, arousable to voice. Follows all commands. MAE's. Lactulose increased to q6hrs secondary to minimal stool output today.\n\nCV: HR 50's-60's. ABP 110's-130's/80's. Aline positional. afebrile. generalized pitting edema. Rt IJ TLCL, dsg intact.\n\nResp: Pt extubated at 12:30pm without difficulty. Required NT Sxn X1 post extubation secondary to very poor cough effort. RR 13-16, O2 sat 98-100% on 3L nc, respirations nonlabored. Post extubation ABG wnl.\n\nGI: Abdomen with ascites and large umbilical hernia. +BS's. Minimal stool output from rectal tube. Lactulose increased. OGT d/c'd with ETT. NGT placed, verified by x-ray and auscultation, putting out bilious material when to LCS. Continues on TPN. Started on TF's via NGT, Deliver 2.0 at 10cc/hr, to be increased by 10cc q8hrs to goal of 55cc/hr. Na continues to be elevated, started on free H2O boluses pNGT.\n\nGU: U/O qs via foley catheter.\n\nID: Afebrile today. Started on vancomycin for +urine culture. Also continues on ceftriaxone.\n\nSkin: Pt continues on bedrest. Turned and repositioned. No breakdown noted to backside.\n\nSoc: Ex-girlfriend, , and daughter, in visiting throughout day. is inpatient after having c-section delivery of baby girl. Spoke with other daughter on the phone re: family meeting to take place tomorrow afternoon at 15:30. Made resident aware of time. Attempted to contact social work, but was unable. form social work will need to be notified in the morning. inquired if she could bring newborn to visit if she wrapped her up and put a mask on her. I advised her that it would not be a good idea, but she will most likely bring her in within the next few days.\n"
},
{
"category": "Nursing/other",
"chartdate": "2193-04-23 00:00:00.000",
"description": "Report",
"row_id": 1318037,
"text": "MICU-NPN\n\nNEURO: Lethargic, follows commands, MAE, mumbles words, difficult to understand.\nCV: afebrile, VSS, see carevue. A-line very positional, able to draw labs, NBP cuff in place. Generalized pitting edema, HCT stable @ 36.\nRESP: extubated yeterday, POX 96-100% 3LNC, congested,productive cough @ times - needs encouragement for coughing. LS coarse, diminished @ bases,bilat. Did not require suctioning during noc.\nGI: abdomen firm and very distended, ascites, minimal stool output over noc - 150cc. Lactulose Q6hrs, fecal bag in place. Free water boluses for high NA level, am labs pending. Umbilical hernia unchanged.\nGU: Foley draining adequate amt's of amber urine.\nSOC: daughter in to visit. Inquired about bringing her newborn daughter in to visit, advised against it offering her rationale.\n\n"
},
{
"category": "ECG",
"chartdate": "2193-04-18 00:00:00.000",
"description": "Report",
"row_id": 254289,
"text": "Sinus rhythm\nLong QT interval\nNonspecific ST-T abnormalities\nSince previous tracing, voltage lower\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-04-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 757774,
"text": " 9:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p central line plcmt, intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with\n gepatitis, cirrhosis\n REASON FOR THIS EXAMINATION:\n s/p central line plcmt, intubation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: Cirrhosis and CV line placement with intubation.\n\n Endotracheal tube is at the carina and too low for optimal location. Right\n jugular CV line is in region of cavoatrial junction. Distal end of feeding\n tube is in distal esophagus. No pneumothorax. No evidence for pulmonary\n edema. There are atelectasis at both lung bases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2193-04-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 758122,
"text": " 6:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p extubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with cirrhosis and s/p esophageal bleed now extubated.\n REASON FOR THIS EXAMINATION:\n s/p extubation\n ______________________________________________________________________________\n FINAL REPORT\n\n CHEST SINGLE AP FILM:\n\n HISTORY: Cirrhosis with hematemesis and extubation.\n\n NG tube extends below diaphragm. Poor detail on this poorly centered film.\n\n"
}
] |
26,038 | 111,329 | The patient is a 53 year-old female admitted to Dr. surgery service at the on for surgical management of chest wall reconstruction. She underwent a bronchoscopy with aspiration of secretions, right thoracoplasty with closure of bronchopleural fistula, and combined pectoralis major musculocutaneous flap containing entire right breast, transferred into the fistula area and split-thickness skin graft, 200 cm2 on by Dr. and Dr. . For details operation, please refer to the operative reports. Following the surgery, she was transferred to the CSRU. . On POD 1, she was continued on levofloxacin and ancef. Her pain was well-controlled with a dilaudid PCA, she was afebrile, had good oxygenation, and adequate urine output. Her VAC was functioning, CT was continued to wall suction, and her arm sling was continued. . On POD 2, her pain was well-controlled, however, she was over sedated from the narcotics and her PCA was discontinued. She continued to remain afebrile with O2 saturation at 97% on 2L NC. Her antibiotics were continued. Her VAC remained intact and her CT was continued on wall suction. . On POD 3, she continued to remain afebrile and pain was controlled with PO dilaudid. The drain was placed to bulb suction. A CXR demonstrated almost complete opacification of the right lung and a bronch was performed with removal of thick brown/bloody secretions and mucus plugs from the right mainstem bronchus, resulting in improved aeration of right lung. . On POD 4, her antibiotics was switched to cefepime to pseudomonas cultured from BAL. She remained afebrile and pain well-controlled with PO dilaudid. Again the patient required another bronch following a chest x-ray with progressive opacification of the right lung. Clear thick secretions were removed from the right mainstem bronchus. The VAC continued to be and continued on suction and her drain was continued to bulb suction. . On POD 5, she was continued on the cefepime and remained afebrile. The VAC was continued as well as her drain. Her pain continued to be well controlled with PO dilaudid. No bronch was required on this day. . From POD , the patient continued to remain afebrile in the ICU, requiring a bronch on POD 7 and POD 9 for removal of thick secretions. Her VAC was continued on suction and her was continued on bulb suction. Pain continued to be well-controlled with input from acute pain service. . On POD 10, she had a fever of 101.9 with increased WBC to 45.6 and a CT chest demonstrated severe PNA of the right lung. Her antibiotics were broaden to include vancomycin, tobramycin, flagyl, and the cefepime was continued. The decision was made at this point to have daily bronchs for removal of purulent secretions from the right mainstem bronchus. She also complained of diarrhea and C.Diff cultures were sent. Her VAC was continued on suction and her was continued on bulb suction. . On POD 11, she continued to have low grade temperatures and her antibiotics were continued. A CT chest/abdomen/pelvis was performed showing thickening and pericolonic inflammatory change of the cecum and ascending colon, consistent with colitis. Bronch today demonstrated moderate thick prurlent secretions in the right mainstem bronchus. Her VAC was continued on suction and her was continued on bulb suction. . On POD 12, she was found to be C.Diff positive and was continued on the flagyl, vancomycin, and cefepime. The tobramycin was discontinued. Her VAC was continued on suction and her was continued on bulb suction. She remained afebrile and continued to oxygenate well, not requiring a bronch today. . On POD 13, she continued to remain afebrile and her diarrhea was resolving. Her drain was discontinued. Bronch demonstrated moderate secretions in right mainstem bronchus and she was deemed stable to be tranferred to the floor. She continued to oxygenate well on 2 liters nasal cannula. The vancomycinwas discontinued and the flagyl and cefepime were continued. . On POD 14, she was started on a clear liquid diet, which she tolerated well, and TF were started at 30 cc/hr. She was continued on the flagyl and cefepime. Her diarrhea continued to resolve and she remained afebrile. She was advanced to a regular diet, which she tolerated well. . On POD 15, she remained afebrile but continued to have copious secretions requiring a bronch. Her wound continued to heal wellwith the d/c'd and the VAC d/c'd. She continued to tolerate her regular diet. . On POD 16, she was continued on the flagyl and cefepime without fevers. Her pain was well-controlled, she was tolerating a regular diet with increasing PO intake, and starting to ambulate well. Her wound continued to be clean, dry, intact, and well. . On POD 17-19, her TFs were cycled overnight, she remained afebrile and continued to increase her PO intake. Her chest x-ray continued to show improvement without a need for further bronchs. Her antibiotics were continued as well as aggressive pulmonary toilet and ambulation. . On POD 20-21, she continued to improve clinical and remain afebrile. Her chest x-rays remain unchanged with no indication for a bronch. She was deemed stable for discharge home. She will be discharged home with VNA and will continue her cefepime for 3 weeks and flagyl for 4 weeks. She has been been instructed to follow-up with Dr. next week and to follow-up with Dr. in 1 week. | cont pulm hygiene. hypo bsp. pt mucomyst was DC'ed. prn albuterol w/ effect. DILAUDID DC'D. reglan w/ effect. TOL DOSAGE WELL. po dilaudid prn w/ toradol q6h. DP/PT palp. +bowel sounds. SKIN W-D. oozing serosang at CT site. Pt receiving Nebs. perococet prn atc. BP/CVP WNL. Respiratory CarePt. PT ON PRECAUTIONS FOR C-DIFF. +Cdiff. e/s providedCV: sinus rhythm/sinus tachy. REPOSTIONED PRN.CV- NSR-85->ST 105. I.S./CDB. PO INTAKE. Cdiff precautions and NPO for bowel rest for now. pt was then see MD note. resp careadmininstered albuterol neb x2 with subjective relief. Nebs by RT. PERRLA. PT PLACED ON PRECAUTIONS.ENDO~TX W SSRI. PT GIVEN CONTRAST THIS AM. Able to ambulate to commode with one assist.Resp: On 2L NC. +PP. not able to do IS r/t pain issue.gi: abd softly distended. seen for routine nebulized bronchodilators. GABAPENTIN AND TRAMADOL CONTINUED. Afebrile. AFEBRILE. AFTERNOON CXR REPORTED TO SHOW DIMINISHING AERATION RLL. g tube dressing . TO TRANSFUSE W/ 1 UNIT PRBC'S. pulm toilet. Pulm toilet. OOB x1 to commode w/1 assist. LUNGS SOUNDS DIMINISHED BILAT. TO START ACETYLCYSTINE PER IP. to change scapula dsg this am. PT. PT. TAKING PO LOPRESSOR FOR RATE CONTROL.AFEBRILE. Respiratory to continue and follw as condition requires. DIM LEFT BASE.EXTREMELY DIFFICULT OT HEAR RT BASE.CHEST/ARM HOLDER INTACT.VAC DSG INTACT.BACK DSG WITH SMALL STAIN.CT TO BULB SX WITH SMALL AMT S/S DRG.GU- AUTODIURESING > 150CC/HR.GI- ABD.SOFT. ENC. ENC. PL CT~MINIMAL DRAINAGE. +BS. NPC, both times. R CT to water seal w/min serosang output.C/V: NSR-st, hr 80-110. Hct 26.4 (29.4)Resp: Bronch as above. nebs done by resp. Ambulate TID. Cont PO intake. extrs w/d. Afebrile, wbc 7.2 (13.2)GI/GU: Abd softly distended. vac drsg . seen for nebulized alb. afebrile.resp: ls clr, bases are dim. lytes repleted- mag.RESP: slight wheeze bilat. pan cx results. gait steady.CV: sinus tachy. CT draining minimal serosanguinous drainage.CV: Pt in ST entire shift. afebrile.resp: ls clr upper, bases are dim. sc heparin & compression sleeves on for dvt prophylaxis. sc heparin & compression sleeves on for dvt prophylaxis. LS diminshed throughout. pulm toilet, cont q4h nebs. DP/PT palp. +palp pp. pulses palp. Replete lytes as necessary. declining i/s use d/t nauseaGI/GU: abd soft, +bowel sounds. Respiratory CarePt. pulm toilet- encourage pt. sc heparin, compression sleeves on for dvt prophylaxis. c/o pain early in shift~ treated w/tylenol, ultram, motrin. Pulmonary toilet a priority. VAC dsg to R chest wall. Remains tachy. Had pain score of this morning which was acceptable. See carevue for latest gases. PERRL. pain is tolerable "not so bad".LINES/ACCESS: RIJ 3 lumen. TF's and po intake good.GU: Voiding qs.Skin: Skin to buttocks/heels/back intact. mag repleted. Last bm . independently uses I.S. cultures and c diff pending. IVSKIN: R chest and thoracotomy dressings changed axillary intact. Right arm still w/ restricted motion which has been .A: Respiratory status stable. follow cxr. binder in place around chest.GI/GU: abd soft, +bowel sounds. Lopressor dose ^ yesterday with some effect. Hct stable.Resp: BS diminished at bases, otherwise clear. Again is seen the evidence of the right-sided thoracoplasty with small foci of air. Post-operative changes status post thoracoplasty, with decreased size of right pleural effusion and improved aeration of the right lower lobe. Post-operative right upper chest, unchanged in appearance, although there may be less bulk to the soft tissues extending into the right axilla and subcutaneous emphysema in that region has nearly cleared. The right-sided chest tube has now been removed and the right lower lobe lung field appears better aerated. The right internal jugular central venous catheter has been removed. Several fluid collections (containing fluid and gas) are noted in the right lung apex, unchanged compared to the previous examination. The right-sided IJ catheter tip overlies the proximal SVC. IMPRESSION: Improved aeration of the right lung base with persistent right basilar atelectasis, status post right-sided thoracoplasty. Small right-sided pleural effusion persists. A right-sided chest drain remains in position. INDICATION: Status post bronchoscopy. The right lower lobe remains aerated with extensive reticulonodular interstitial opacities and a relatively prominent linear opacity extending along the course of the inferior pulmonary ligament. IMPRESSION: Stable postoperative changes with continued aeration of the right lower lobe. IMPRESSION: AP chest compared to and : Subcutaneous emphysema in the right axillary region adjacent to recently resected upper ribs has decreased, although this may have been replaced by a new fluid collection continuous with the uniform opacity now filling the region of resection in the right upper chest, presumably a flap. Position of right-sided IJ approach central venous line and right-sided apical chest tube, and the apical of the thoracoplasty appear unchanged. Lower part of the right lung remains reexpanded, with linear opacities, extending to the level of the diaphragm, unchanged, likely representing atelectasis versus scarring. Pleural tube in the right upper midline, unchanged in position since . Subcutaneous emphysema in the right axilla is unchanged. There is unchanged level of aeration in the right middle and lower lung region with residual poorly defined opacities in perihilar region, as well as prominent linear opacity extending to the diaphragm level, not significantly changed from the previous examination. There is unchanged appearance of right middle lobe density, as well as streaky peribronchial changes in the right lower lobe. IMPRESSION: Right lower lobe remains re-expanded, unchanged appearance since previous study. The patient is again noted to be status post right-sided thoracoplasty. IMPRESSION: Continued progressive clearing of the right lower lung. IMPRESSION: Improved aeration of the right lower lung field in this post-thoracoplasty patient; some persistent density is appreciated in the previously -out region. Areas of subcutaneous emphysema are noted and unchanged. Right chest tube or chest wall drain remains in place. IMPRESSION: Unchanged radiographic appearance of the chest since previous examination. Dextroscoliosis of the thoracic spine is unchanged. IMPRESSION: Continued improving aeration in the right mid and lower lung regions status post right thoracoplasty. Right-sided chest tube remains unchanged. Postoperative changes at the thoracoplasty site are stable in appearance except for slight decrease in the amount of soft tissue gas in the operative site. | 71 | [
{
"category": "Nursing/other",
"chartdate": "2191-09-18 00:00:00.000",
"description": "Report",
"row_id": 1601180,
"text": "NEURO~INTACT. FC MAE. OOB TO CHAIR W/ ASSIST. INCISIONAL DISCOMFORT. PAIN MANAGEMENT PROTOCOL, SEE FLOW SHEET. PT COMFORTABLE. MED W/ 2.5 MG IV VERSED PRIOR TO AM BRONCH. TOL DOSAGE WELL. FAMILY IN VISITING.\n\nRESP~AM CXR. IMPROVED FROM YESTERDAY. AM BRONCH~MOD AMTS OF THICK SECRETIONS. LUNGS SOUNDS DIMINISHED BILAT. PL CT~MINIMAL DRAINAGE. PT GIVEN CONTRAST THIS AM. ON CALL FOR CT SCAN OF THE TORSO. ON 2 L NP MAINTAINING SAT @ 100%.\n\nCARDIAC~EPISODE OF ST ^130'S DURING BRONCH. NOT RESOLVING ON OWN POST BRONCH. GIVEN 5 MG IVP LOPRESSOR. EFFECTIVE. HR~90'S W/ SBP~114. HCT~23 THIS AM TO BE TRANSFUSED W/ 1 UNIT PRBC'S. ELECTROLYTES REPLETED. IV .45 NS W/ 20 KCL INFUSING @ 75 CC'S HR. POS PAL PEDAL PULSES BILAT. VENODYNE BOOTS ON.\n\n\nGI/GI~NPO FOR BRONCH THIS AM. CONT NPO FOR CT SCAN THIS AFTERNOON. VOIDS VIA BEDPAN OR COMMODE. SM AMT OF BROWN LOOSE STOOL THIS AM. UNABLE TO OBTAIN STOOL SPECIMEN. ** 1400 LAB RESULTS CALLED RESULTS OF THE STOOL SPECIMEN, + FOR C-DIFF. PT PLACED ON PRECAUTIONS.\n\nENDO~TX W SSRI. PER CSRU PROTOCOL.\n\nA/P~ PLAN FOR CT OF TORSO THIS AFTERNOON. TO TRANSFUSE W/ 1 UNIT PRBC'S. TO START ACETYLCYSTINE PER IP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-18 00:00:00.000",
"description": "Report",
"row_id": 1601181,
"text": "1630 TO CT SCAN W CONTRASR. RESULTS PENDING. IV 1/2 NS W 20 MEQ KCL.^ TO 100CC'S HR. RE STRTED TF ~ NUTREN PULMONARY @ 30 CC/HR. PRBC'S STILL INFUSING AS OF . POST HCT TO BE COLLECTED. PT ON PRECAUTIONS FOR C-DIFF. SM/MOD AMTS OF LIQUID STOOL. CURRENTLY RESTING COMFORTABLY\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-19 00:00:00.000",
"description": "Report",
"row_id": 1601184,
"text": "NEURO: A&Ox3, PERRL, gait steady. amb in unit with PT, up in chair all afternoon. COPING: pt expressing frustration r/t hospitalization and NPO status. e/s provided\nCV: sinus rhythm/sinus tachy. no VEA noted. NIBP sbp 120's-140's skin warm and dry. DP/PT palp. no edema.\nRESP: lungs diminished bilat bases. sats 97-100% on 2L desats to 88% off O2. R post chest tube changed to JP bulb suction. not able to maintain suction. team aware. pt using flutter valve. non-productive cough.\nGI/GU: abd soft, distended. +bowel sounds. +Cdiff. no diarrhea this shift. pt NPO and no tube feeds for bowel rest. voiding clear yellow urine in commode/bedpan.\nENDO: blood gluc covered with RISS\nID: afebrile today. vanco d/c'd.\nSKIN: thoracotomy R post. intact reddened at incision. R ax and ant dressings . g tube dressing . pressure points intact but coccyx reddened encouraged turning, OOB. hair washed today.\nLINES/ACCESS: L AC PIV.\nPAIN/COMFORT: mult scheduled PO analgesics with good effect repositioned frequently.\nSOCIAL:husband called today will visit this eve.\nA/P: continue to monitor cv, resp status, pain control. Cdiff precautions and NPO for bowel rest for now. hold tube feeds. no bronch today. CXR in the AM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Report",
"row_id": 1601151,
"text": "Neuro: Dozing & oriented x3 in AM, more alert throughout the day; calm & cooperative; MAE's follows commmand.\n\nCV: Afeb; NSR/ST 90's-110's; SBP 80's-110's; lopressor 12.5mg given @ ~1400 for ^HR\n\nResp: Lung sound clear, dim @bases; productive cough with thick white sputum; IS to ~600; R CT to sxn, minimal amount of serrousang drainage\n\nGI: Abd soft, BS x4; tolerating soft food; TF promote with fiber @ 40 ml/hr, no residual\n\nGU: Foley to gravity, clear yellow urine\n\nInteg: Intact; R thoroplasty site with wound vac; L thigh skin graft with drsg\n\nPain: c/o R shoulder pain; pain managed with dilaudid PCA 0.05/6/0.5 with better control in AM; started on PO Ultram & Percocet to wean PCA\n\nActivity: OOB to chair with 2 assist, tolerated well; sling on R arm, stayed on for 1 week after surgery\n\nPlan: pulm toilet; pain management; inc activity as tolerated; encourage PO intake\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Report",
"row_id": 1601152,
"text": "shift cover 1500-1900\n\ngen: pleasant. reinforce on use of PCA for pain management w effect. perococet prn atc. pulm toilet. no distress. remain sr -st. map>60. con't monitor - pain managment, pulm toilet. keep chest binder & immobilezer on r arm. vac at 75mmhg con't sxn- tolerating per pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Report",
"row_id": 1601153,
"text": "Respiratory Care Note\nPt received nebs as ordered. BS decreased at bases I/E, but clear after treatment. Pt on room air.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Report",
"row_id": 1601154,
"text": "Respiratory Care\nPt. seen for routine nebulized bronchodilators. BS decreased T/O, pt. splinting and very stiff in bed. Has difficult time lifting head C/O pain with any movement. Poor cough. Respiratory to continue and follw as condition requires.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-12 00:00:00.000",
"description": "Report",
"row_id": 1601164,
"text": "Neuro: A&O x3, calm & cooperative, MAE's follows command\n\nCV: Afeb; palpable pulses x4; NSR 90's, SBP 120's-130's in AM; ^HR 110'2, ^SBP 140's-160's in PM after OOB to chair; team awared, inc lopressor regimen to 37.5 mg TID; K repleted; c/o lightheadiness when getting, resolved with resting\n\nResp: 2L NC, sat high 90's to 100; lung sound dim on R side & L base; tube to bulb suction with minimal serrousang drainage, leakage of drainage @ CT site noted, drsg ; IS to ~600; non-productive cough, no chest PT per plastic team\n\nGI: bowel sound x4; +flatus; LBM ; poor PO intake, encouraged with poor outcome; TF Novasource Pulmonary FS @ 40 ml/hr, no residual; c/o nausea in PM, resolved with IV reglan 10 mg\n\nGU: Foley draining clear yellow urine\n\nEndo: Follow protocol\n\nID: Cefepime for +pseudomonas in resp culture\n\nPain: c/o pain on R side chest incision, pain comfortable throughout shift, worsenwith movement; currently on IV Ketamime 3.7mg/hr, tylenol/motrin/ultram/methadone/neurotin with good effect\n\nPlan: Monitor hemodynamics; monitor lytes; ketamime dose and titrate methdone dosage; pain management; inc activity as tolerated; pulm toilet; encourage PO intake\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-13 00:00:00.000",
"description": "Report",
"row_id": 1601165,
"text": "NEURO- ALERT/ORIENTED X3. MAE. FOLLOWS ALL COMMANDS. VOICES NEEDS/CONCERNS FOR PAIN CONTROL. CONTINUES ON KETAMINE GTT,TYLENOL,MOTRIN,TRAMADOL,NEUROTIN ATC WITH ADEQUATE RELIEF. REPOSTIONED PRN.\n\nCV- NSR-85->ST 105. BP/CVP WNL. TAKING PO LOPRESSOR FOR RATE CONTROL.\nAFEBRILE. SKIN W-D. PALE. HCT=25.- NO INTERVENTION AT THIS TIME.+ PP. NO EDEMA.\n\nRESP-2L N95%.CLEAR UPPER RT/LT LUNG. DIM LEFT BASE.EXTREMELY DIFFICULT OT HEAR RT BASE.CHEST/ARM HOLDER INTACT.VAC DSG INTACT.BACK DSG WITH SMALL STAIN.CT TO BULB SX WITH SMALL AMT S/S DRG.\n\nGU- AUTODIURESING > 150CC/HR.\n\nGI- ABD.SOFT. +BS. TUBE FEED AT GOAL. G- TUBA FLUSHED AND PATENT.\n\nPLAN- PAIN SERVICE CONSULT TO ASSESS KETAMINE GTT (WEAN) AND DRUG REGIME. ENC. I.S./CDB. ENC. PO INTAKE. OOB TO CHAIR.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-13 00:00:00.000",
"description": "Report",
"row_id": 1601166,
"text": "PROB: S/P THOROPLASTY\n\nCV: ST-SR, HR 80-110, NO ECTOPY NOTED, LOPRESSOR GIVEN WITH GOOD EFFECT.\n\nRESP: O2 SATS ADEQUATE. NEBS Q 4HR PER RESP. DRESSINGS CLEAN AND DRY. VAC DRESSING DRAINING MINIMAL S/S DRAINAGE.\n\nGU/GI: CLEAR YELLOW URINE. APPETITE IMPROVING. CONT ON TFEEDS, TOLERATING WITHOUT RESIDUALS. PT SPOKE TO DIETICIAN ABOUT FOOD CHOICES.\n\nPAIN: SEEN BY PAIN TEAM, KETAMINE DECREASED TO 2MG/HR, METHADONE INCREASED TO 5MG. PT RESTING INTERMITTENTLY. C/O PAIN MOSTLY WITH POSITION CHANGES. OOB TO CHAIR, TOLERATED WELL. R ARM IMMOBILIZED.\n\nENDO: BS TREATED PER S/S.\n\nNEURO: NO S/S HALLUCINATIONS FROM KETAMINE, DID REPORT HAVING STRANGE DREAMS LAST NIGHT TO PAIN SERVICE MD. THEM TO PAIN MEDS. OOB TO CHAIR, MAE.\n\nASSESSMENT: PT REPORTS IT'S EASIER TO MOVE AROUND TODAY.\n\nPLAN: CONT.\nVAC DRESSING TO BE CHANGED TOMORROW BY PLASTICS TEAM.\nMONITOR BS\nCONT PAIN MEDS.\nTRANSFER TO FLOOR TOMORROW.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-19 00:00:00.000",
"description": "Report",
"row_id": 1601182,
"text": "Nursing 7p-7a\nNeuro: A&Ox3. PERRLA. MAE- surgical restriction to L shoulder (pt not allowed to adduct/abduct or extend arm, can move from elbow down). OOB x1 to commode w/1 assist. Steady gait.\n\nResp: Sats >98% on 2L NC. Lungs w/bilat basilar crackles, clear LUL, absent RUL. Nebs by RT. Using flutter device w/encouragement. Non-productive congest cough. R CT to water seal w/min serosang output.\n\nC/V: NSR-st, hr 80-110. No ectopy. SBP 105-140, tol tid po lopressor. +PP. Hct 27.3.\n\nGi: TF @ goal, 30cc/hr. +BS, no c/o n/v. Cont w/liquid-loose green stool. Incont x1, all other times able to use bedpan/commode. Tol thin liquids w/meds.\nGu: Voiding adequate amts in bedpan/commode.\nEndo: RISS.\n\nSkin: See carevue for incisions.\nSocial: No call/visit from family/friends.\nID: Afebrile. On iv antibiotics & po flagyl. cultures pnd. Contact precautions for +cdiff.\nPain: Pt states well controlled, on muliple po analgesics & po ultram around the clock.\n\nPlan: ?Bedside bronch. F/U w/cultures. Increase diet/act as tol. Pulm toilet. Provide support/encouragement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-19 00:00:00.000",
"description": "Report",
"row_id": 1601183,
"text": "Respiratory Care:\nPatient received albuterol/mucomyst nebulizer treatments, tolerated well. NPC, both times. Last RX as noted in Carevue was given at 0400. Using Acapella PEP device independently. Appears to be moving a larger volume per each breath.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-20 00:00:00.000",
"description": "Report",
"row_id": 1601185,
"text": "Neuro: Pt A&O X3. MAE and obeys commands. Some complaints of pain in back and sternal area treated with scheduled analgesics and repositioning. Able to ambulate to commode with one assist.\n\nResp: On 2L NC. Nonproductive cough. Pt receiving Nebs. RUL sounds absent, dim at bases, clear at LUL. Uses flutter valve and IS independently.\n\nCV: NSR entire shift with no ectopy. Afebrile. Taking Lopressor 25 mg PO TID. Mg repleted.\n\nGI/GU: Pt has 1 JP drain to bulb suction (MD aware there is a lack of suction in the bulb). PEG tube clamped. Pt is off her tube feeds and is on bowel rest for the next couple of days. Pt is NPO except for water to take with meds. Voids clear, yellow urine via commode or bed pan.\n\nEndo: RISS per CSRU protocol. No coverage needed this shft.\n\nID: Pt is on Cefepime 2 mg IV q12 h and Flagyl 500 mg PO TID.\n\nA/P: Pulmomary toilet, treat pain. Pt seems depressed about her current situation, especially NPO status. Encourage pt to have positive outlook.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-20 00:00:00.000",
"description": "Report",
"row_id": 1601186,
"text": "Respiratory care\npt was seen and rx'ed with 2.5mg of albuterol and 2cc of 10% mucomyst tol well. pt was then see MD note. pt mucomyst was DC'ed. see respiratory page of carevue for more information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-07 00:00:00.000",
"description": "Report",
"row_id": 1601148,
"text": "PT. RECEIVED FROM OR AT 1730 - S/P #1THORACOPLASTY, #2 CLOSURE BRONCHIAL PLEURAL CUTANEOUS FISTULA WITH MYOCUTANEOUS FLAP, #3 REMOVAL RIGHT TISSUE EXPANDER #4 STSG #5 EXPLORATION RIB RESECTION-BP FISTULA-PEC FLAP.\n\nNEURO: PT. ALERT, ORIENT X2-3 (NOT TO TIME AT TIMES), MAE (EXCEPT FOR RIGHT ARM WHICH IS PLACED IN SLING), PUPILS 2MM, SLUGGISH, PT. GIVEN 40MCG NARCAN ONE HOUR AFTER ARRIVAL FOR INCREASED CO2 AND DECREASED PUPILLARY RESPONSE.\n\nCV: PT. NSR, SINUS TACHYCARDIA AT TIMES, GOAL TO KEEP MAP >60, CVP 2 (TEAM IS AWARE), UPON ARRIVAL SYSTOLIC BLOOD PRESSURE DECREASED INTO MID 80'S- 2 LITERS FLUID GIVEN AND GOOD EFFECT WITH INCREASED SYSTOLIC BLOOD PRESSURE.\n\nRESP: PT. EXP WHEEZE THROUGHOUT, HX OF SMOKING- CURRENTLY ON 3LNC. PT. HYPOXIC IN FIRST HOUR, ACIDOTIC AND RETAINING CO2. NARCAN GIVEN (QUESTION OVERSEDATION- ORDER PER TEAM)- CO2 IMPROVED- CONTINUES TO BE ACIDOTIC. CT TO SUCTION- SANGUINOUS DRAINAGE, NO AIR LEAK NOTED. WOUND VAC R UPPER BACK- TO 75.\n\nGI/GU/ENDO: PT. ABD CONCAVED, ABSENT BOWEL SOUNDS, FOLEY DRAINING CLEAR, YELLOW URINE- GOOD H/U/O.\n\nPAIN: PCA- DILAUDID FOR PAIN CONTROL. PCA NOT STARTED DUE TO ?OVERSEDATION AND HIGH CO2 LEVELS.\n\nPLAN: MONITOR SBP, HR AND RHYTHM, RECHECK ABG'S, REPLETE MAG, MONITOR RESP STATUS VIA ABG'S, SLING TO BE IN PLACE X1 WEEK, PAIN MGT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-11 00:00:00.000",
"description": "Report",
"row_id": 1601160,
"text": "csru update\nevents: pain control issues and cont nausea.\n\nneuro/pain: oriented x3. did state \" \" for the year early in shift. pt w/ pain control issues. po dilaudid prn w/ toradol q6h. didn't take 2400 ultram r/t nausea. by 0400 cont moaning w/ pain 9 out of 10. additional iv dilaudid given w/ effect. maew in bed. cooperative to care.\n\ncv: vs as per flowsheet. tachy and hypertensive. additional 5mg iv lopressor given w/ min effect. cvp 4-10. hct 29 this am. na+ up to 129.\n\nresp: rt chest tube to h20 seal, no dng. oozing serosang at CT site. no crepitus. lungs clear, dim. c/o diff breathing at times. prn albuterol w/ effect. purse lip breathing noted. o2 sats good on 2l n/c. congested non-pro cough. not able to do IS r/t pain issue.\n\ngi: abd softly distended. hypo bsp. nausea w/ dry heaves. reglan w/ effect. npo since mn. ns at 60/hr. only sips clears taken.\n\ngu: large amt clear light yellow urine autodiuresing.\n\nid: afeb. wbc 13. abx change to cefapime.\n\nskin: splint to rt arm throughout shift. to change scapula dsg this am. vac intact. lt skin graft site c&D.\n\nassess: issues w/ pain control and nausea.\n\nplan: address analgesics. to be bronched. cont pulm hygiene. reglan prn, advance diet as tol s/p bronch\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-11 00:00:00.000",
"description": "Report",
"row_id": 1601161,
"text": "resp care\nadmininstered albuterol neb x2 with subjective relief. difficult to assess bs due to dressings/binder. no audible wheezing. per serial cxr pt will need to be bronched this evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-11 00:00:00.000",
"description": "Report",
"row_id": 1601162,
"text": "POD #4 S/P RIB RESECTION/MYOCUTANEOUS FLAP\nCONTINUES W/ST & HTN EPISODES. METOPROLOL ^37.5MG . NEED ADDITIONAL FOR BETTER CONTROL. PT WARM, GOOD COLOR. MULTIPLE EPISODES W/ C/O FEELING COLD AND HOT. PT ROOM APPEARS COOL TO ALL STAFF. AFEBRILE. PT STATES THAT SHE IS POSTMENOPAUSAL. INTERMITTENT USE OF ROOM FAN REQUESTED.\n\nBREATHSOUNDS - ABSENT RUL, OCCASIONAL EXP WHEEZE. RARE PRODUCTIVE COUGH (SWALLOWED). PT C/O SEVERE PAIN THIS AM AND REPORTED TO HAVE UNDER 2HRS SLEEP DURING THE LAST 12HR SHIFT D/T PAIN AND NAUSEA. DILAUDID PO AND IV GIVEN DURING PREVIOUS SHIFT. PAIN SERVICE CONSULTED. DILAUDID DC'D. GOAL TO PROVIDE NSAID SUPPORT, CONTINUE KETAMINE IV (WEAN OFF IN 1-2DAYS) GTT WHILE METHADONE TITRATED. GABAPENTIN AND TRAMADOL CONTINUED. PT C/O #8PAIN IN HER R ANTERIOR CHEST AREA THIS AM. MULTIPLE EPISODES OF PURSED LIP BREATHING DW/PAIN AND EXERTION. SINCE NEW MEDICATIONS STARTED, APPEARS MUCH MORE COMFORTABLE AND STATES THAT HER PAIN IS #. CXR X 2 TODAY. AFTERNOON CXR REPORTED TO SHOW DIMINISHING AERATION RLL. PLAN BRONCHOSCOPY BUT G-TUBE FEEDING RESUMED ~11AM. TUBE FEEDING OFF ~1600. NO GASTRIC RESIDUAL WHEN TUBE FEEDING STOPPED. IP TO PERFORM BRONCH W/LIMITED SEDATION @ 20/HR TONIGHT. NC @ 2L/MIN W/APO2 95%. R CHEST TUBE MOVED FROM WATER SEAL TO BULB SUCTION PER REQUEST OF DR. (PLASTIC SURGICAL ATTENDING).\n\nVAC CONTINUES @ 75 MMHG TO RCHEST WALL (MINIMAL DRAINAGE). R THORACOTOMY INCISION INTACT. SEROSANGUINOUS DRAINAGE SOAKED THROUGH LOWER PORTION OF WOUND AROUND CT SITE. DSG CHANGED. R ARM SLING REMOVED BY PLASTIC SURGICAL RESIDENTS. CHEST BINDER KEEPING R ARM AGAINST R FLANK - INTACT. PT NOW MOVE HER R ARM BELOW THE ELBOW BUT NOT ABDUCT OR RAISE HER R ARM.\n\nNOVASOURCE TUBE FEEDINGS RESUMED THIS AM ~11AM AND STOPPED ~16. NO GASTIC RESIDUAL. SOME REDNESS AROUND G TUBE INSERT SITE. C/O SOME EPIGASTRIC DISCOMFORT EARLIER W/TUBE FEEDING OFF (OFF 24HR->11), NONE WHILE TUBE FEEDING ON. ONLY 2 SMALL NIBBLES OF FRESH FRUIT FOR SOLID FOOD INTACT.\n\nGLUCOSE ^. SSRI PER CSRU GLUCOSE PROTOCOL.\n\nOOB TO CHAIR W/2 STEPS EARLIER. VERY SOB FOLLOWING ACTIVITY. LIFTED BACK TO BED W/BEDSHEET WITHOUT SOB FOLLOWING MOVEMENT. C/O DIZZINESS W/SITTING UP AND GETTING TO CHAIR. SBP 160S. NO LOSS OF BP. OOB W/ONLY LIFTING TO AND FROM CHAIR THIS AFTERNOON. BETTER TOLERATED.\n\nORIENTED X 3.\n\nNO CALLS FROM OR VISITS FROM FAMILY.\n\nPLAN BRONCHOSCOPY THIS EVENING W/VERY CAREFUL, LIMITED SEDATION/ANALGESIA. CONTINUE PAIN ASSESSMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-12 00:00:00.000",
"description": "Report",
"row_id": 1601163,
"text": "7p-7a\n\nEvents: bronchoscopy at 8pm for mod-lge amts thick, tan secretions, sm amt blood tinged. Versed 0.5mg given iv for procedure. Pt was slow to wake. VSS. Ketamine infusion stopped until pt awake (Methadone dose also held per Dr . By 10:30pm pt's alertness back to pre-procedure level. CXR done.\n\nNeuro: alert and oriented x3. Extremities equal/strong. PERL. Admits to minimal discomfort to chest area. APS following. Pt on Ketamine infusion @ 3.7 mg/hr, as well as Ultram, Tylenol, Motrin, Methadone, Neurontin po atc with effect.\n\nCV: VS as per flowsheet. Remains tachy. Lopressor dose ^ yesterday with some effect. +palp pp. Hct 26.4 (29.4)\n\nResp: Bronch as above. Lungs clear left, absent rul, diminished base. Using I/S with encouragement, <250cc. Sats 97% on 2L/nc. CT changed over to bulb sxn yesterday with minimal drainage. VAC dsg to rt chest (until Wed) cartridge changed 11pm. Afebrile, wbc 7.2 (13.2)\n\nGI/GU: Abd softly distended. +bs, denies flatus tonight. Last bm . Novasource tube feeds restarted at goal (40cc) after bronch.\nUrine yellow, good output. RISS\n\nSkin: see careview.\n\nSocial: Husband here til after bronch yesterday eve. Coming back today.\n\nPlan: Cont to monitor hemodynamics. Monitor resp status closely. Encourage I/S. Pain control. Wean Ketamine while Methadone titrated. Cont Cefipime iv for pseudomonas. Cont tube feeds, as well as po's. Recheck hct later.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-17 00:00:00.000",
"description": "Report",
"row_id": 1601177,
"text": "nursing note 7a-7p):\n\nneuro: a&ox3, follows commands and answering questions appropriately, oob to chair x 2 w/one asst patient tolerated well, receiving neurotin, tramadol, ibuprofin, and tylenol w/good effect, afebrile today & wbc 45 w/a.m. labs from 18.6, awaiting I.D. consult\n\nresp: on 2l/nc w/sat >95%, rr 18-25 desats rapidly w/out O2, bronch done & samples sent (BAL of lobes), on vancomycin & tobramycin for pseudomonas & gram neg cocci in sputum, tobramycin trough sent before 4th dose today, vanco trough due @ 0730, chest pt attempt & o.k. per plastics teams patient did not tolerate well, non-productive weak cough, possible ct scan & ?? bronch in a.m.\n\ncv: hr 115+ st w/no ectopy, sbp 90-115, chest tubes w/minimal drainage, palpable pules, blood cultures pending for , lft's sent wnl, otherwise cardiac uneventful\n\ngu/gi: @ times incontinent for urine & stool, mult loose bm c-diff x 1 sent and fecal bag placed, placed on flagyl, t-feeds to goal for add'l nutrition, house diet poor appetite today\n\nendo: ssri\n\nplan/goal: check pending lab results, send on vancomycin trough @ 0730, attempt & con't w/pulmonary toilet\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-18 00:00:00.000",
"description": "Report",
"row_id": 1601178,
"text": "NEURO: A&Ox3. PERRL. gait steady.\nCV: sinus tachy. no ectopy. NIBP sbp 100-140's L arm higher(170's) in L thigh. skin warm, dry. DP/PT palp. tolerating 25 mg lopressor PO.\nRESP:Lungs dim at bases. sats 94-98% on 2L nasal cannula. using flutter valve. non-productive cough. chest tube with very scant serous drainage. water seal. binder in place around chest.\nGI/GU: abd soft, +bowel sounds. g tube feeding at goal. mult. episodes of watery stool over noc. voiding clear yellow urine sufficient amts. tolerating sips clears, some jello.\nENDO: blood gluc covered with RISS.\nID: afebrile. cultures and c diff pending. mult. piperacillin/tobra/vanco. IV\nSKIN: R chest and thoracotomy dressings changed axillary intact. pressure points intact. reddened area over coccyx. encouraged pt to turn freq. skin care done with BM.\nPAIN/COMFORT: pain control regimen effective. pain pt states is \"not too bad\".\nLINES/ACCESS: PIVx2 L arm.\nSOCIAL: husband in to visit in eve.\nA/P: continue to monitor CV, resp. pulm toilet. pan cx results. and IV abx. advance activity and diet.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-18 00:00:00.000",
"description": "Report",
"row_id": 1601179,
"text": "Respiratory Care:\nPatient received albuterol nebulizer treatments Q4 throughout the night, using a mouthpiece. Used Acapella flutter-device with each Rx. C+R X 1 all night. Appears to be very cooperative.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-15 00:00:00.000",
"description": "Report",
"row_id": 1601172,
"text": "CSRU NPN 1200-1900\nS. \"SOMEONE IS TRYING TO HURT US!\"\n \"I THINK I WAS HALLUCINATING.\"\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nNEURO/PAIN: ALERT, ORIENTED X , AT TIMES SLOW TO ANSWER QUESTIONS, SLIGHTLY \"OFF\", 12 PM AFTER AMBULATING WITH PHYSICAL THERAPY, PT BACK TO CHAIR AND C/O R BREAST PAIN, ALLOWED PT TO REST X 30 MIN W/O CHANGE IN PAIN SCALE, 1225 - GIVEN DILAUDID 1MG PO, PT BACK TO BED, WAKING PT Q 30 MIN, AT FIRST EASILY AWAKENED, LATER DIFFICULT TO AROUSE W/RR 7-8 - ABG DRAWN BY - 7.27/77/116/ - RR INCREASED TO 16-18 WHEN WAKENED, O2 DECREASED TO 2L NC, PT CONT TO SLEEP ON/OFF - 1600 AWAKENED PT EASILY, HOWEVER VERY CONFUSED, ORIENTED X1, STATING SOMEONE IS TRYING TO HARM HER; INITIALLY REFUSING TO TAKE PO MEDS, EVENTUALLY MS CLEARER, RECOGNIZING SHE WAS NOT THINKING CLEARLY; RECEIVED TYLENOL, ULTRAM, MOTIN, NEURONTIN BUT METADONE HELD AS PT INITIALLY REFUSING TO TAKE, NOW DOZING COMFORTABLY IN CHAIR BUT INTERMITTENTLY CONTINUES TO C/O R BREAST OR LOWER BACK PAIN \nPAIN SERVICE AWARE, , ALL AWARE, DILAUDID D/C'D, RECOMMENDED TO GIVE METHADONE 2.5MG WITH NEXT C/O PAIN, HOWEVER MOST RECENT ORDER FOR METHADONE REMAINS 5MG TID\n\nCV: HR 80-90'S SR, NO ECTOPY, BP 89/44-110/69 RECEIVED LOPRESSOR 37.5MG PO AT 1700\n\nRESP: NO COMPLAINTS OF SOB, BREATHING UNLABORED, CONGESTED COUGH UPON COMMAND BUT NO SPONTANEOUS COUGHING, CXR DONE IN AFTERNOON, RESULTS WORSE PER THORACIC TEAM - TO HAVE BRONCH IN AM, R POST CT REMAINS TO 20CM SUX, NO LEAK/CREPITUS\n\nGI: TF'S CONT AT 30CC/HR VIA GTUBE, COLACE STARTED, AWAITING FAMILY VISIT TO TAKE PO MOM TABLETS, NO STOOL SINCE \n\nENDO: FS 148-141 - RECEIVED 4-6U SS PER PROTOCOL\n\nGU: VOIDING LIGHT YELLOW URINE ON COMMODE, INCONTINENT LG AMT X1 WHILE SLEEPING\n\nSKIN: R BREAST DRESSING D+I, CHEST BINDER LOOSELY IN PLACE, R ARM RESTRICTED MOVEMENT CONTINUES\n\nACTIVITY: OOB TO CHAIR AND COMMODE X2, AMBULATED X1 WITH PT AY 12 PM, LATER SOMNULENT/CONFUSED\n\nA: CONTINUED DIFFICULTY MANAGING PAIN REGIMEN W/O AFFECTING MENTAL STATUS, DILAUDID W/ACUTE SOMNULENCE/PARANOIA UPON WAKENING, MUCH IMPROVED PRESENTLY; BRONCH SCHEDULED FOR \n\nP: MONITOR CARDIO/RESP STATUS, CONT PAIN MED REGIME AS ORDERED AND ASSESS CHANGES IN MS, REORIENT PRN, NPO AFTER MN FOR BRONCH IN AM, ENCOURAGE C+DB, INCENTIVE SPIROMETRY, NEBS GIVEN BY RESP; EMOTIONAL SUPPORT, KEEP PT/FAMILY INFORMED OF PT CONDITION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-16 00:00:00.000",
"description": "Report",
"row_id": 1601173,
"text": "neuro: pt a&ox1, to name only; forgetful, required frequent reorientation throughout shift. difficulty remembering surgery & being hospitalized, or any instructions immediately after being told. in chair @ shift change, attempted to get up x1 despite being asked to use call light for assistance. pt also had difficulty identifying daughter & son & law when they visited & became slightly irritated, yelling \"these people can't visit me now, it's too late, I don't know who they are\". pt slept often overnight, does arouse easily. c/o pain early in shift~ treated w/tylenol, ultram, motrin. CPS update on pt mental status, okay to hold PM methodone dose per Dr. from CPS, pt to receive of AM dose IF mental status improves; in chair at shift change, attempted to get up x1 without assistance.\n\ncv: sr 80s-90s, no ectopy. bp 90s, 80s while asleep. palpable pulses. sc heparin & compression sleeves on for dvt prophylaxis. afebrile.\n\nresp: ls clr upper, bases are dim. o2sats >95% on 2L nc, resp rate 10s, no distress. on q4h nebs. congested cough, no secretions raised. rt pleural ct to lwc drained scant s/s fluid overnight. cxr due in AM, bronch to be done today.\n\ngi/gu: pt tolerates sm amts po intake; no c/o nausea; tf novasource pulm running @ goal 30cc/hr, no resids, +bs, +flatus, no bm. tf off @ 2400. maint fluid started->D5.45NS @ 75cc/hr. pt voids adequate amts clr yellow urine.\n\nendo: bs monitored per ss protocol-rssi coverage required overnight.\n\nskin: see carevue.\n\nplan: continue monitoring neuro status & reorient as necessary. monitor pain, update CPS. pulm toilet, cont q4h nebs. cont. emotional support & prepare for bronch. increase activity & po intake as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-15 00:00:00.000",
"description": "Report",
"row_id": 1601170,
"text": "neuro: pt a&ox3, dozed intermittently overnight; maes to command, but rt arm cautiously due to immobilizer. cooperative with care, able to reposition self without difficulty. oob to commode x1 and stood at bedside. no c/o pain overnight. +perrl.\n\ncv: sr 80s-90s, no ectopy. mag repleted. nbp 90s-100s, 80s while asleep. palpable pulses. sc heparin & compression sleeves on for dvt prophylaxis. afebrile.\n\nresp: ls clr, bases are dim. o2sats >98% on 2L nc. resp rate 10s-20s; independently uses I.S. to 750. good cough, sounds congested however nonproductive. jp @ rt thoracot site drained scant s/s fluid overnight. CXR to be done this AM to determine whether pt to be bronched today per -thoracic team.\n\ngi/gu: tf novasource pulm @ 30cc/hr. no resids. no c/o nausea, +bs, abd soft, nt, nd. pt voiding adequate amts clr yellow urine.\n\nendo: bs monitored per ss protocol-rssi coverage required overnight.\n\nplan: continue monitoring cardioresp status. enc. I.S. coughing & raising. increase activity & po intake as tolerated. follow cxr. transfer to floor if appropriate.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-15 00:00:00.000",
"description": "Report",
"row_id": 1601171,
"text": "CSRU NPN\n\nNeuro/Pain: Alert and oriented this morning. However, noted to be repeating statements during conversation. Also seemed slightly off when relaying activities of the morning (i.e. dietary tech asking her the day of the week when it was the RN who did so). Spoke w/ CPS regarding above which they said they have seen in patient in past. Later in morning, NP changed collection unit and she felt pt was lethargic at that time. Methadone decreased to 2.5mg tid. Pt also verbalizing to PT that she felt like she had been \"partying\" this morning. Had pain score of this morning which was acceptable. Able to perform activities comfortably. Wakens easily to voice.\n\nCV: HR and BP stable. No peripheral edema. Hct stable.\n\nResp: BS diminished at bases, otherwise clear. Cough congested, unproductive. Good effort w/ cough but ? effectiveness. pleural tube changed to pleurovac collection unit as bulb not holding self suction. O2 sats stable. No c/o sob. Flutter valve reviewed by PT w/ patient for proper technique.\n\nGi: Abd soft. Plans to call husband for MOM tabs this evening. TF's and po intake good.\n\nGU: Voiding qs.\n\nSkin: Skin to buttocks/heels/back intact. Thoracotomy incision mildly reddened at superior portion. Team aware.\n\nActivity: Ambulated w/ PT. Right arm still w/ restricted motion which has been .\n\nA: Respiratory status stable. Pain control seems adequate however pt slightly lethargic late morning.\n\nP: Cont to assess LOC and effectiveness of pain control regimine. Flutter valve QID. Ambulate TID. ? 2 .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-16 00:00:00.000",
"description": "Report",
"row_id": 1601174,
"text": "nursing note (7a-7p):\n\nneuro: alert to place and time, however unable to explain why she is in the hospital, inappropriate words, questioning if this is d/t pain med or if something is brewing metabolically wbc upto 18.6 w/am\nlabs, afternoon labs pnding, methadone dc'd\n\nresp: lung cta except in rll diminished, sats > 95% on 2l/nc & rr wnl, cxr done & bronched for thick mucus plugs/secretions, ct scan done, non-productive weak cough, not using flutter valve or IS, sputum culture sent, no chest PT or + ventilation pressure to be used per plastics\n\ncv: hr 90-117 nsr/st w/no ectopy, sbp < 110 for most of shift, lopressor dose decreased, blood cultures sent, cvl removed & 2 peripheral iv access placed, on maintenance K+ fluids\n\ngi/gu: NPO via mouth, t-feeds restarted this afternoon novasource full strength, using bedpain & incontinent x 1 ?? d/t lethargy of pain, meds, lg bm x 1, abdomen soft and non-tender to touch\n\nendo: ssri\n\nskin: right scapula incision red d/t pressure placed on left side\n\nplan/goal: con't w/pain med control, con't w/pulmonary toileting, awaiting pending labs and culture results\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-10 00:00:00.000",
"description": "Report",
"row_id": 1601157,
"text": "Respiratory Care\nPt. seen for nebulized alb. Tol well. Pt. has only fair to poor cough and abilty to Deep Breath. Pt does not like to be awoken and may benefit from having nebulizers between the hours of 06:00 and 00:00 only.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-10 00:00:00.000",
"description": "Report",
"row_id": 1601158,
"text": "NEURO: A&Ox3 PERRL. strength wnl. anxious/tense at times.\nCV: sinus rhythm. SBP 110's-140's BP elevated with pain/anxiety. no edema. pulses palp. lytes repleted- mag.\nRESP: slight wheeze bilat. nebs done by resp. dim. bases. resps shallow with pain but otherwise no resp distress. i/s coached. poor effort. declining i/s use d/t nausea\nGI/GU: abd soft, +bowel sounds. tube feeding at goal with <5cc residual. c/o nausea +retching but no emesis. treated with reglan with good effect. foley with clear yellow urine in good amts.\nENDO: blood gluc treated with RISS\nSKIN: R thoracotomy and vac dressing intact. pt has brace and sling on. not to be removed. L thigh skin graft harvest site with xeroform gauze intact.\nPAIN/COMFORT: c/o pain in chest medicated with dilaudid PO, toradol IV, ultram PO, neurontin PO acetamin PO. also c/o headache. states pain decreased to following meds. pain is tolerable \"not so bad\".\nLINES/ACCESS: RIJ 3 lumen. L rad A-Line\nSOCIAL: husband is spokesperson\nA/P: advance diet and activity. encourage PO intake- poor nutr. status. pulm toilet- encourage pt. pain control. vac dressing and arm sling R arm per team don't remove. tubefeeds at goal. ?transfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-10 00:00:00.000",
"description": "Report",
"row_id": 1601159,
"text": "nursing note (7a-7p):\n\nneuro: a&ox3, follows commands & answers questions appropriately, right arm in sling do \"NOT\" move arm or remove sling, oob to chair x 1 tolerated fairly well, on toradol, ultram for pain discomfort and hydromorphone prn\n\nresp: now on FM 10L & 50%, sats >94% quickly desats in mid 80's w/out oxygen supplement, cxr w/consolidation on right side, bronched today for large amounts of thick mucus plugs given versed & fentanyl for discomfort low rr & poor abg narcan given for reversal, non-productive wet cough, attempted niv pipap for approx 1 hour patient did not tolerate mask, plan to bronch again in the a.m. per IP d/t large amounts of secretions, unable to do chest pt d/t incision on right side\n\ncv: hr 90 to 105 nsr/st w/occasional pac's, sbp> 120 via nbp, a-line to be attempted, palpable pedal pulses, hct sent @ 1530 results pending, IV fluids to be started @ midnight, chest tubes w/minimal drainage & on water seal, free water restricted d/t low sodium\n\ngu/gi: given t-feeds for additional nutrient supplement currently @ goal 50cc/hr promote w/fiber, poor appetite & drinking fair amounts of fluids, c/o +n/-v reglan & anzamet given\n\nskin: right breast w/VAC drainage, right scapula incision dressing changed \"DO NOT LIFT ARM OR REMOVE SLING!!!\", left thigh skin graft, left wrist d/t abg & a-line attempts\n\nplan/goal: NPO after midnight for bronch, start IV fluid after midnight (order in ), continue encouraging CDB & IS use, increase diet & activity as tolerated\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-16 00:00:00.000",
"description": "Report",
"row_id": 1601175,
"text": "addendum:\n\nurine cultures sent via straight cath, patient remains incontinent diaper placed, vancomycin & tobramycin ordered d/t + sputum cultures, attempted to ambulate to chair when sitting on side of bed c/o +n/-v sbp dropped from 118 lying to 88/31 sitting, unable to stand patients knees buckled, ct tubes to h2o seal, patient remians confused and lethargic\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-17 00:00:00.000",
"description": "Report",
"row_id": 1601176,
"text": "Neuro: pt very lethargic and confused earlier in shift. Difficult time answering questions, repeating words spoken. Around 0200 pt woke talking appropriately oriented to time and person but thought she was at the . Assisting with turning and asking for the bedpan.\nResp: Breath sounds clear but diminished in left base. Once awake pt has junky cough but not raising anything. Attempted Acapella treatment but pt needs more instruction. Chest tube to water seal no fluctuation or drainage.\nC/V: Heart rate 110-130's all night pt receiving lopressor 25mg ppo which did bring HR down to 110 for a while. Blood pressure stable.\nGI: Pt tolerating tube feeds at 30cc/hr well. pt passed 4 loose stoools quaiac neg.\nEndo: blood sugars treated with sliding scale.\nGU: pt passing large amount of urine. Incontinent most of night when lethargic but using bedpan this am.\nSkin: pt has reddened areas over bony areas coccyx and right scapular Pt turned frequenly to relieve pressure. Right thorocotomy incision pink with small areas of yellow exudate along incision line\nPain: pt states that her pain is well controlled Hurts with certain movements but otherwise it is ok.\nID: WBC's up to 45.0 Temp spike up to 101.3 last evening but has since come down overnight. Cultures pending,\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-13 00:00:00.000",
"description": "Report",
"row_id": 1601167,
"text": "1500-1900\nA/Ox3. Continues with Ketamine GTT for pain control @ 2mg/hr with good effect. NSR-ST no ectopy. LS diminshed throughout. Congested unproductive cough. R arm sling in place. VAC dsg to R chest wall. CT with minimal S/S drainage. Tolerating tubefeeding @ goal 40cc/hr. Foley D/C'd due to void by 0200 .\nAgree with above plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Report",
"row_id": 1601168,
"text": "neuro: pt a&ox3, approp. follows commands, moves left arm & bilateral le's equally without difficulty; rt arm has immobilizer, unable to move. cooperative w/care, respositions self cautiously. APS following pt~c/o constant rt side pain, ketamine gtt infusing constantly via PCA pump, pt also receiving po meds~>tramadol, methadone, ibuprofen & tylenol. pt verbalized pain is well controlled, able to rest intermittently overnight. +perrl.\n\ncv: sr 90s, no ectopy. bp 120s-130s, palpable pulses. extrs w/d. cvp >2. sc heparin, compression sleeves on for dvt prophylaxis. hct 25. afebrile.\n\nresp: ls dim throughout o2sats >96% on 2l nc. rr 10s-20. pt has congested sounding nonproductive cough. independently uses I.S. to 750. Jp to bulb sxn at rt thoracot site drained min s/s fluid overnight. vac drsg . plastics to change drsgs on days.\n\ngi/gu: tf resparlor @ goal 40cc/hr. no resids. tolerated po intake on previous shift, no c/o nausea. +bs, no bm , abd, soft, nt, nd. foley dc'd on previous shift, pt voided 100cc clr yellow urine within 4hrs, adequate uo overnight. bun 14, creatinine 0.2\n\nendo: bs monitored per ss protocol; covered rssi overnight.\n\nsocial: pt's husband visited @ shift change; no phone calls from family overnight.\n\nplan: continue monitoring cardiorespiratory status. monitor pain. plastics to change pt drsgs today. increase activity & po intake as tolerated. transfer to floor if appropriate.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-14 00:00:00.000",
"description": "Report",
"row_id": 1601169,
"text": "nursing note (7a-7p):\n\nneuro: a&ox3, mae's, oob to chair for 6 hours, follows commands and answers questions appropriately, on multiple meds for pain control/mgmt, also receiving dilaudid prn, ketamine pca to be dc'd\n\nresp: on 2l/nc w/sats >93%, rr wnl, bronched this afternoon after cxr results from this morning, non-productive cough, chest pt not to be done per plastics\n\ncv: hr 90's nsr w/no ectopy, sbp >100, jp w/minimal drainage, vac dressing removed this morning, right arm remains in sling do not manipulate, palpable pulses\n\ngu/gi: voiding in bed pan, +bs w/no bm, ate breakfast & NPO for luch d/t bronch, t-feeds off since 0900, new t-feed orders written, abdomen soft & non-tender to touch\n\nendo: ssri\n\nplan/goal: con't w/pulm toilet, increase activity and diet as tolerated, resume t-feeds, possible transfer to floor in a.m.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Report",
"row_id": 1601155,
"text": "Neuro: Pt A&O X3. MAE and obeys commands. Pain treated by Hydromorphone IVPCA; PCA now dc'd. Pain also treated with Percocets q4 until 0000 (not given additional doses d/t resp status-increased CO2). Pt also receiving Gabapentin and Tramadol.\n\nResp: Pt on 2L NC. See carevue for latest gases. Encouraged use of IS and CDB-pt needs prompting. Pt has moderately strong cough, nonproductive. CT draining minimal serosanguinous drainage.\n\nCV: Pt in ST entire shift. Pt receiving Lopressor 12.5 mg . Pt received Mg. Palpable pedal pulses.\n\nID: Pt receiving Cefazolin.\n\nGI/GU: Pt receiving Promote with Fiber @ 40cc/hr. Taking PO meds and regular diet without difficulty. Voiding light yellow urine via Foley in large quantities. +BS, no BM.\n\nEndo: RISS per CSRU protocol.\n\nInteg: No issues at this time.\n\nA/P: Address pain issues. Pulmonary toilet a priority. Replete lytes as necessary. Cont PO intake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-09 00:00:00.000",
"description": "Report",
"row_id": 1601156,
"text": "neuro/pain: pt irritable in am -yelling and c/o \"many things..pain, uncomfortable...frequent calling & loudly asked for nasal spray when repeatly told pt that med already been ordered and just waiting from pharm\" temp applied ofm w effect. teach pt use PCA as needed, gave scheduled ultram, keterolac for pain and tynelol for headache --wash up ->improvement. pt spirit better in pm. ^in chair.\n\nid: afebrile. con't atb\n\ncv: sr-st. sbp 100s-140s. asked team to ^lopressor po?. no ectopies.\n\nresp: ls very diminish in bases, very congest cough, non-productive. pt denies dyspnea/sob. sat>95 on 2lnc. desat to low 90 on ra. use nasal spray prn for nares congesttion. R ct to sxn-no leak/crepitus, min drg. recieved nebs atc. need reminder to use IS/dbc. cxr. pt wears chest binder and r arm sling x1week?\nLabs: phosphate x3 doses for low phosphate level\ngi: changed tf to nomasource pulmo fs at goal rate. tol. c/o nausea x1->gave reglan w effect. poor intake. need much encourage.\ngu: autodiuresis adequate huo\nendo: treat bs per riss\nwound: see careview\nact: oob to chair w 2 assist, tol well.\nsocial: no family call. support pt prn\n\na/p: ^lopressor po. Need po narcotic to slow weaning off pca as tol. aggressive pulm toilet. ^act and diet.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Report",
"row_id": 1601149,
"text": "nursing progress note 7p-7a\nneuro: a/ox3, dozing off and on most of night. PCA dilaudid for pain control initially poor control but now . c/o r arm pain r/t immobilizer - thoracic team aware.\n\ncv: afebrile. nsr, no ectopy. rate control w/ iv lopressor. bp stable, MAP >60. Hct 32. sleeves and sc heparin for dvt prophylaxis. +3 distal pulses, no edema.\n\nresp: lungs clear except dim r base. occasional insp wheezes in bases, clears w/ albuterol neb prn. abgs acidotic, low po2 and co2 retaining. o2 @ 2l via prongs. sats 95-97%. pulm hygine hourly, strong cough, unable to bring up secretions. using IS to 500+.\n\ngi: +bos. PEG - promote w/ fiber full strength @ goal of 40cc/hr, no resid. on protonix for pud prophylaxis. also tolerating cl liqs may advance as tol.\n\ngu: foley to gravity, clear yellow. adequate huo.\n\nplan: monitor resp status, pulmonary hygiene, nebs prn. pca for pain control. oob to chair. plastics to change vac dsg on pod #3. advance diet and activity. continue current poc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-09-08 00:00:00.000",
"description": "Report",
"row_id": 1601150,
"text": "Resp Care\nPt currently on 2L NC. BS diminshed R>L. Wheezing noted and improved by Albuterol nebs. ABG shows partially compensated respiratory acidosis. Incentive spirometer=600.\nPlan: continue nebs as ordered, moniter ABGs.\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 931530,
"text": " 8:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p bronch\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch\n\n REASON FOR THIS EXAMINATION:\n s/p bronch\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post bronchoscopy.\n\n Single portable radiograph of the chest again demonstrates the patient to be\n status post right-sided thoracoplasty, similar in appearance when compared to\n . The right internal jugular central venous catheter has been\n removed. Right-sided chest tube remains in position. There is improved\n expansion of the right lower lung. The left lung remains clear without\n evidence of a left-sided pleural effusion. Right basilar atelectasis\n persists.\n\n IMPRESSION:\n\n Improved aeration of the right lung base with persistent right basilar\n atelectasis, status post right-sided thoracoplasty.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 931966,
"text": " 4:00 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for interval change s/p bronch; Please due between 1330\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p bronch\n REASON FOR THIS EXAMINATION:\n eval for interval change s/p bronch; Please due between 1330-1430.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, PA and lateral.\n\n INDICATION: Status post bronchoscopy. Evaluate for interval changes.\n\n FINDINGS: PA and lateral views obtained with patient in upright position are\n analyzed in direct comparison with a similar preceding study obtained 10 hours\n earlier during the same date. Status post right upper thoracoplasty appears\n unchanged. The right-sided chest tube has now been removed and the right\n lower lobe lung field appears better aerated. Findings in the left hemithorax\n remain unchanged and do not show any new parenchymal infiltrates or increased\n vascular congestion. Heart size remains unchanged and also within normal\n limits. Left gastroscopy drainage unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 932171,
"text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for right lower lobe collapse\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s//p thoracoplasty\n\n REASON FOR THIS EXAMINATION:\n eval for right lower lobe collapse\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old woman status post thoracoplasty.\n\n Bedside AP chest radiograph dated compared to CT chest\n radiograph dated . There is complete opacification of right\n lower lung with air bronchograms, likely representing atelectasis due to mucus\n plugging. The rest of the examination is unchanged. There is extensive\n thoracoplasty changes in right upper hemithorax. There is no pneumothorax\n appreciated on this study. Left lung is clear.\n\n IMPRESSION: Right lower lobe atelectasis likely due to mucus plugging.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 930928,
"text": " 7:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: want to see if there is any interval change.\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch on \n\n REASON FOR THIS EXAMINATION:\n want to see if there is any interval change.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess for interval changes in a 53-year-old woman who is status\n post bronchoscopy two days ago and has a past history of thoracoplasty.\n\n COMPARISON: Prior chest x-ray from .\n\n TECHNIQUE AND FINDINGS: A single view frontal chest x-ray obtained in\n semi-erect position showed no significant change as compared to the prior film\n from the day before. Unchanged position of the lines and tubes.\n\n CONCLUSION: No significant change since yesterday.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 931692,
"text": " 7:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia, interval change\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch\n\n REASON FOR THIS EXAMINATION:\n eval for pneumonia, interval change\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Status post thoracoplasty.\n\n A single AP view of the chest is obtained at 07:50 hours and is\n compared with the prior radiograph of approximately 24 hours previously. Again\n is seen the evidence of the right-sided thoracoplasty with small foci of air.\n There has been further improvement in the opacities in the right lower lobe.\n No infiltrate is seen in the left side. A right-sided chest drain remains in\n position.\n\n IMPRESSION:\n\n Further improvement in the opacities in the right base since the prior\n examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-18 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 931653,
"text": " 4:42 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: interval CT scan s/p bronch\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with thoracoplasty w/ bronchopleural cutaneous fistula w/\n myocutaneous flap, rib resection\n REASON FOR THIS EXAMINATION:\n interval CT scan s/p bronch\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old woman with thoracoplasty, check for interval change.\n\n TECHNIQUE: CT scan of the chest, abdomen, and pelvis was performed\n with intravenous and oral contrast. Prior study is from .\n\n FINDINGS:\n\n CT CHEST: Extensive postoperative changes of the right thorax are noted. The\n patient is status post right upper lobectomy and subsequent thoracoplasty for\n bronchopleural fistula. There has been resection of numerous right upper ribs\n and packing of the thoracotomy site with a chest wall flap. Several fluid\n collections (containing fluid and gas) are noted in the right lung apex,\n unchanged compared to the previous examination. There is a right sided\n pleural effusion and small amount of pleural gas, decreased compared to the\n previous exam. A pleural catheter appears to be pulled back slightly, with\n tip located anterior to the scapula.\n\n There is severe emphysema of the lungs. Aeration at the right lung base is\n improved compared to the previous exam, with mild residual reticular opacity\n of the right lower lobe. There is shift of the mediastinum to the right.\n\n An elongated filling defect outlined by contrast in the right internal jugular\n vein, representing either flow artifact or less likely an intra- luminal\n filling defect.\n\n CT ABDOMEN AND PELVIS: There is free fluid in the abdomen, seen within the\n pelvis and adjacent to the liver and spleen. No definite loculated fluid\n collections are seen. There is thickening of the cecum and ascending colon,\n consistent with colitis. There are vascular calcifications. Bilateral hip\n degenerative disease is noted. There is a bowel containing right inguinal\n hernia on the right side. Images of the kidneys, pancreas, spleen, and liver\n are unremarkable.\n\n IMPRESSION:\n\n 1. Thickening and pericolonic inflammatory change of the cecum and ascending\n colon, consistent with colitis. Differential possibilities include an\n infectious or inflammatory etiology.\n (Over)\n\n 4:42 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: interval CT scan s/p bronch\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Post-operative changes status post thoracoplasty, with decreased size of\n right pleural effusion and improved aeration of the right lower lobe. No\n change in fluid collections at the surgical site.\n\n 3. Apparent filling defect within the right internal jugular vein may be\n artifactual or less likely represent intralumenal thrombus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 931390,
"text": " 7:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: need an interval change\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch w/ drain now\n not holding sxn\n REASON FOR THIS EXAMINATION:\n need an interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:59 A.M. .\n\n HISTORY: Thoracoplasty. Status post bronchoscopy. drain in place.\n\n IMPRESSION: AP chest compared to through 12:\n\n Right lung is entirely airless. I suspect that there is more than atelectasis\n responsible for radio-opacification in the right lower chest which previously\n contained somewhat aerated right lower lung. There may well be new pleural\n effusion. Uniform opacification of the right upper thoracoplasty is stable\n and there is no gas present. Left lung shows mild edema. Mediastinal\n position, slightly to the right of midline is unchanged. The right upper\n chest drain and right internal jugular line are in standard placements\n respectively. paged to report these findings.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 932065,
"text": " 9:56 AM\n CHEST (PA & LAT) Clip # \n Reason: eval right lower lobe collaspe\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s//p thoracoplasty\n REASON FOR THIS EXAMINATION:\n eval right lower lobe collaspe\n ______________________________________________________________________________\n FINAL REPORT\n PA/LATERAL CHEST :\n\n INDICATION: Status post thoracoplasty. Evaluate right lower lobe collapse.\n\n Compared with the studies of , the re-aeration of the right lower lung\n has been maintained. Extensive thoracoplasty changes in the right upper\n hemithorax also unchanged. Left lung remains clear. No pneumothorax\n appreciated.\n\n IMPRESSION: No significant interval changes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 932257,
"text": " 3:03 PM\n CHEST (PA & LAT) Clip # \n Reason: Assess for progerssion of atelectasis/disease\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s//p thoracoplasty, now s/p bronch\n\n REASON FOR THIS EXAMINATION:\n Assess for progerssion of atelectasis/disease\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post thoracoplasty and now bronchoscopy.\n\n CHEST:\n Left lung remains clear. There has been clearing of the consolidation\n collapse in the right lower lobe since the prior chest x-ray of six hours ago.\n\n IMPRESSION: Reexpansion and clearing of right lower lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-16 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 931427,
"text": " 12:08 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: bronchopleural fistula and empyema?RIGHT ARM MUST BE KEPT AT\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with thoracoplasty w/ bronchopleural cutaneous fistula w/\n myocutaneous flap, rib resection\n REASON FOR THIS EXAMINATION:\n bronchopleural fistula and empyema?RIGHT ARM MUST BE KEPT AT SIDE -page w/\n questions #\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of thoracoplasty with bronchopleural cutaneous fistula\n with myocutaneous flap rib resection.\n\n CT CHEST WITH CONTRAST.\n\n TECHNIQUE: MDCT of the chest was performed from the thoracic inlet through\n the adrenals with injection of intravenous contrast.\n\n COMPARISON: Chest radiograph of .\n\n Patient is status post history of right upper lobectomy and radiation therapy\n for right breast cancer with recent right thoracoplasty for bronchopleural\n fistula. As per surgical nodes a tissue expander have been placed in the\n right lateral chest wall with a new percutaneous flap.\n\n The right chest wall is deformed with the mucocutaneous flap covering the apex\n and a tissue expander occupying the right upper chest.\n\n There are secretions in the right bronchus intermedius narrowing it to 4 mm\n and also narrowing the right lower lobe bronchus. The right lower lobe is\n atelectatic. There is a small amount of fluid within the right pleural space\n with a few air locules (4:116) . Air locules also noted within the right-sided\n posterior chest wall. An external drain is seen on the right side, along the\n scapula with its tip in the soft tissue of the chest wall (1:56). This tube\n does not drain the pleural space.\n An emphysematous bulla is in the left lower lobe measuring 4.4 x 2.4 cm\n (4:182). Moderate emphysema is noted in the left lung. The left-sided airway\n and the subsegmental bronchi are patent. There are no pulmonary nodules in\n the left lung. There is no left pleural effusion or pericardial effusion.\n Coronary artery calcifications are noted.\n\n In the imaged upper abdomen, the liver, spleen, adrenals and imaged kidneys\n are unremarkable. The gastrostomy tube is in standard position. There are no\n suspicious osteolytic or osteoblastic lesions in the bones. Suspicious for\n malignancy.\n\n Post-thoracoplasty changes in the right chest wall. As described.\n\n IMPRESSION:\n (Over)\n\n 12:08 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: bronchopleural fistula and empyema?RIGHT ARM MUST BE KEPT AT\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 1. Narrowing of the bronchus intermedius and the right lower lobe bronchus\n with secretions, causing atelectasis of the right lower lobe. Small effusion\n with air locules in the right pleural space. Thoracoplasty changes at the\n right upper lobe with a tissue expander in place.\n\n 2. Right-sided drain external and terminating within the soft tissue of the\n chest wall.\n\n Findings as described.\n\n These findings were discussed at length with Dr. .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 931101,
"text": " 7:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change, Right lung\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch on \n\n REASON FOR THIS EXAMINATION:\n eval interval change, Right lung\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:46 A.M. \n\n HISTORY: Thoracoplasty. Status post bronchoscopy.\n\n IMPRESSION: AP chest compared to through 10:\n\n The previously aerated right lower lung is now collapsed. Post-operative\n right upper chest, unchanged in appearance, although there may be less bulk to\n the soft tissues extending into the right axilla and subcutaneous emphysema in\n that region has nearly cleared.\n\n Heart size is normal. Left lung is mildly hyperemic, but unchanged. Right\n apical pleural tube and internal jugular line are in standard placements\n respectively.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 932474,
"text": " 8:43 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for progression of atelectasis\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p R thoracoplasty w/ closure of bronchial pleural cutaneous\n fistula w/ myocutaneous flap, rib resection, removal R breast tissue expander\n REASON FOR THIS EXAMINATION:\n eval for progression of atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, AT 8:40 A.M.\n\n HISTORY: Post-right thoracoplasty with closure of bronchopleural cutaneous\n fistula and myocutaneous flap. Atelectasis followup.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: The significant post-surgical changes in the right upper chest are\n again evident, consistent with the given history. The right lower lobe\n remains aerated with extensive reticulonodular interstitial opacities and a\n relatively prominent linear opacity extending along the course of the inferior\n pulmonary ligament. The left lung remains hyperexpanded and clear. The\n mediastinum is stable in morphology. No definite effusion or pneumothorax is\n seen.\n\n IMPRESSION: Stable postoperative changes with continued aeration of the right\n lower lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 931245,
"text": " 7:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o RLL colapse\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch on \n\n REASON FOR THIS EXAMINATION:\n r/o RLL colapse\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post thoracoplasty, to evaluate for right lower lobe\n collapse.\n\n PORTABLE AP CHEST.\n\n COMPARISON: .\n\n Patient is status post thoracoplasty with deformity of the right upper chest\n wall. The left lung field is clear.The right lower lobe is better aerated.\n Small right-sided pleural effusion persists. The right-sided IJ catheter tip\n overlies the proximal SVC. Heart size is normal.\n\n IMPRESSION: No interval change since prior radiograph of .\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 930520,
"text": " 7:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess Right lung\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty\n\n REASON FOR THIS EXAMINATION:\n assess Right lung\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:50 a.m. on \n\n HISTORY: Right thoracoplasty.\n\n IMPRESSION: AP chest compared to and :\n\n Subcutaneous emphysema in the right axillary region adjacent to recently\n resected upper ribs has decreased, although this may have been replaced by a\n new fluid collection continuous with the uniform opacity now filling the\n region of resection in the right upper chest, presumably a flap. Following\n resection of the upper portion of the right lung, the residual in the lower\n lung is unchanged in appearance since the preoperative radiographs. Left lung\n is clear. The heart is normal in size. Right internal jugular catheter tip\n projects over the upper SVC. A drain projects over the right upper hemithorax\n and axilla.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 931196,
"text": " 5:08 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Need to see CXR s/p bronch\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch on \n\n REASON FOR THIS EXAMINATION:\n Need to see CXR s/p bronch\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old woman, status post thoracoplasty and bronchoscopy.\n\n Portable AP view of the chest dated is compared to the prior from 10\n hours earlier. The patient is status post thoracoplasty, and there is\n deformity of the right upper chest wall with an overlying soft tissue density\n likely representing the tissue expander employed during the surgery. There is\n a right internal jugular central venous catheter terminating in the mid SVC.\n Right chest drainage tubes are in unchanged position. The heart remains\n normal in size. There has been interval improved aeration of the previously\n collapsed right lower lung lobe. There is no visible pulmonary vascular\n congestion. There is a small right pleural effusion. The surrounding osseous\n and soft tissue structures are stable. A gastrostomy tube is seen in the left\n upper quadrant.\n\n IMPRESSION: Interval improved aeration of the right lower lung lobe.\n Otherwise, stable appearance of the chest and surrounding osseous and soft\n tissues.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 930645,
"text": " 7:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax, evalutate interval change\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty\n\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax, evalutate interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 07:32.\n\n INDICATION: Thoracoplasty; check for interval change.\n\n PRIOR: at 07:50.\n\n FINDINGS:\n\n Compared to the prior study, there has been increased opacification of the\n right lower lung such that there is almost no aerated lung. All lines and\n tubes remain in place, and the left lung remains clear. Subcutaneous\n emphysema in the right axilla is unchanged.\n\n IMPRESSION: Almost complete opacification of the right lung. I spoke with\n Dr. regarding these findings, which he had been aware of at\n the time of our conversation - 9:36 a.m. on .\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 932367,
"text": " 10:04 AM\n CHEST (PA & LAT) Clip # \n Reason: Assess for atelectasis, new pathology\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s//p thoracoplasty, now s/p bronch\n\n REASON FOR THIS EXAMINATION:\n Assess for atelectasis, new pathology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post thoracoplasty.\n\n PA and lateral chest radiographs dated , compared to PA and\n lateral chest radiographs dated . In the interval, there has\n been no significant change in the radiographic appearance of the chest. Left\n lung remains clear. Right lower lobe remains re-expanded since the prior\n study. There are extensive thoracoplasty changes in the right upper chest.\n\n IMPRESSION: Right lower lobe remains re-expanded, unchanged appearance since\n previous study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 930666,
"text": " 12:20 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o pneumo, assess atelectasis\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty s/p bronch\n\n REASON FOR THIS EXAMINATION:\n r/o pneumo, assess atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST at 12:22\n\n INDICATION: Opacity at right lung; recent bronchoscopy.\n\n FINDINGS: Compared to at 07:32, there is markedly improved aeration of\n the right lower lung field, however greater opacity and linear markings are\n appreciated compared to a more remote prior film from at 07:50. No\n change in the appearance of the postoperative right upper lung and the left\n lung remains clear. Areas of subcutaneous emphysema are noted and unchanged.\n A right CVL remains in place. There is a radiopaque catheter projecting over\n the left neck and I am uncertain if this is inside or outside the patient. The\n tip of this is seen adjacent to the portion of the left first rib.\n\n IMPRESSION:\n\n Improved aeration of the right lower lung field in this post-thoracoplasty\n patient; some persistent density is appreciated in the previously -out\n region.\n\n Catheter overlying left neck - see above.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 930744,
"text": " 7:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumo\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty\n\n REASON FOR THIS EXAMINATION:\n r/o pneumo\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 08:03.\n\n INDICATION: Reevaluation of right lower lobe after prior collapse.\n\n COMPARISON: at 12:22.\n\n FINDINGS:\n\n In the area of interest in the right lower lung field there is some volume\n loss and triangular increased region of density consistent with partial\n atelectasis. There is no change in the remainder of the study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 932985,
"text": " 9:31 AM\n CHEST (PA & LAT) Clip # \n Reason: please assess and compare with prior\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p R thoracoplasty w/ closure of bronchial pleural\n cutaneous fistula w/ myocutaneous flap, rib resection, removal R breast\n tissue expander\n REASON FOR THIS EXAMINATION:\n please assess and compare with prior\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST RADIOGRAPHS\n\n INDICATION: Status post right thoracoplasty.\n\n COMPARISON: Serial radiographs, latest dated .\n\n FINDINGS: Again noted, extensive thoracoplasty changes. Lower part of the\n right lung remains reexpanded, with linear opacities, extending to the level\n of the diaphragm, unchanged, likely representing atelectasis versus scarring.\n Left lung is clear. There are no pleural effusions.\n\n IMPRESSION: Unchanged radiographic appearance of the chest since previous\n examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 931318,
"text": " 2:38 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: pls eval for ptx. now to pleuravac-pls obatin be tween\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch w/ drain now\n not holding sxn\n REASON FOR THIS EXAMINATION:\n pls eval for ptx. now to pleuravac-pls obatin be tween 2-3pm\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable, single view.\n\n INDICATION: Status post thoracoplasty, status post bronchoscopy with \n drain now.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting upright position and comparison is made directly with a similar\n preceding study obtained seven hours earlier during the same date. Position\n of right-sided IJ approach central venous line and right-sided apical chest\n tube, and the apical of the thoracoplasty appear unchanged. The remaining\n right-sided lower lung is less aerated than on the previous examination, most\n likely related to lesser inspirational effort. Appearance of left lung is\n completely unchanged without evidence of significant parenchymal densities,\n pulmonary congestion, or evidence of pleural effusion. No pneumothorax on\n left side.\n\n IMPRESSION: No significant interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 930775,
"text": " 2:21 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval interval change\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty\n\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 14:22.\n\n INDICATION: Thoracoplasty, check for interval change.\n\n COMPARISON: at 08:03.\n\n FINDINGS:\n\n Progressive opacification of the limited right lower lobe airspace is\n identified with further volume loss. Findings are consistent with progressive\n atelectasis, perhaps due to mucous plugging. No other significant interval\n changes are noted with the left lung remaining clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 931606,
"text": " 7:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval CXR\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch\n\n REASON FOR THIS EXAMINATION:\n interval CXR\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST, .\n\n COMPARISON: \n\n INDICATION: Status post thoracoplasty and bronchoscopy.\n\n Postoperative changes related to recent thoracoplasty are again demonstrated\n with partial resection of multiple right-sided ribs with adjacent homogeneous\n opacity reflecting muscle flap and fluid as well as a few small adjacent\n collections of gas. Right chest tube or chest wall drain remains in place.\n Right lower lobe opacities are improving and may relate to resolving\n asymmetrical edema and/or atelectasis. Left lung is grossly clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-26 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 932674,
"text": " 10:28 AM\n CHEST (PA & LAT) Clip # \n Reason: eval need for bronch; Please do STAT\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p R thoracoplasty w/ closure of bronchial pleural cutaneous\n fistula w/ myocutaneous flap, rib resection, removal R breast tissue expander\n REASON FOR THIS EXAMINATION:\n eval need for bronch; Please do STAT\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST RADIOGRAPH\n\n INDICATION: Status post right thoracoplasty.\n\n PA and lateral chest radiograph dated compared to PA and\n lateral chest radiograph dated . In the interval, there has\n been no significant change in radiographic appearance of the chest. Right\n lower lobe remains aerated. There is unchanged appearance of right middle\n lobe density, as well as streaky peribronchial changes in the right lower\n lobe. Left lung remains clear. There are extensive post-thoracoplasty\n changes in the right chest wall.\n\n IMPRESSION: No interval change from the previous study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 931849,
"text": " 6:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for right lower lobe collapse\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch\n\n REASON FOR THIS EXAMINATION:\n eval for right lower lobe collapse\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:32 a.m., \n\n HISTORY: Thoracoplasty following bronchoscopy. Assess right lung collapse.\n\n IMPRESSION: AP chest compared to through 16:\n\n Aeration at the base of the right lung is worse than it was on , now\n almost entirely atelectatic, having improved between and 14.\n Extent of rightward upper mediastinal shift is stable. Left lung is clear.\n Heart is normal size. Tiny left pleural effusion is unchanged. No left\n pneumothorax. Small gas bubbles remain in the postoperative right upper\n chest. Pleural tube in the right upper midline, unchanged in position since\n .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 932553,
"text": " 8:15 AM\n CHEST (PA & LAT) Clip # \n Reason: please assess R chest, question of need to bronch\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p R thoracoplasty w/ closure of bronchial pleural\n cutaneous fistula w/ myocutaneous flap, rib resection, removal R breast tissue\n expander\n REASON FOR THIS EXAMINATION:\n please assess R chest, question of need to bronch\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, at 08:14.\n\n HISTORY: Status post right thoracoplasty.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Extensive postsurgical changes consistent with right thoracoplasty\n again identified. There has been progressive expansion and clearing of the\n right lower lung. No new focal consolidation is identified. The left lung\n remains relatively clear.\n\n IMPRESSION: Continued progressive clearing of the right lower lung.\n Extensive postsurgical changes as previously described.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 930804,
"text": " 10:46 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o pTX\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch on \n\n REASON FOR THIS EXAMINATION:\n r/o pTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 22:48\n\n INDICATION: Bronchoscopy on .\n\n COMPARISON: at 14:22.\n\n FINDINGS:\n\n There is improved aeration and expansion of right lower lung. Some persistent\n atelectasis is present. There is no pneumothorax. The right chest tube and\n right CVL remain in place and the left lung remains clear.\n\n IMPRESSION: Improved expansion of the lung with some residual atelectasis.\n No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 930325,
"text": " 4:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ptx, effusion\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty\n REASON FOR THIS EXAMINATION:\n eval ptx, effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 4:51 P.M. ON \n\n INDICATION: Status post thoracoplasty. Evaluate for pneumothorax/effusion.\n\n FINDINGS: A right chest tube has its tip near the right apex. The right IJ\n central line has its tip at the level of the mid SVC. The right lower lobe\n and left lung remain clear. There may be small pleural effusions at the right\n base medially and at the right apex.\n\n Compared with , there has been an extensive thoracoplasty of the right\n upper thorax. No obvious pneumothorax is identified, however, there is a\n small collection of air at the apex, which could represent small pneumothorax\n or the upper tip of otherwise collapsed right upper lobe. There is an ovoid\n soft tissue \"mass\" at the operative site, measuring 9 x 5 cm, raising the\n possibility of a hematoma. However, further discussion with thoracic surgery\n indicates that this represents a large soft tissue flap filling the chest wall\n defect at this level. There is also postoperative soft tissue air in the right\n axillary region.\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 932805,
"text": " 8:05 AM\n CHEST (PA & LAT) Clip # \n Reason: eval need for bronch\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p R thoracoplasty w/ closure of bronchial pleural cutaneous\n fistula w/ myocutaneous flap, rib resection, removal R breast tissue expander\n REASON FOR THIS EXAMINATION:\n eval need for bronch; Please do by 8AM.\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST, .\n\n COMPARISON: .\n\n INDICATION: Status post right thoracoplasty.\n\n The patient is status post right thoracoplasty procedure. There has been\n continued improved aeration in the right middle and lower lung regions with\n residual poorly defined opacities in the perihilar region as well as a\n prominent linear opacity extending to the diaphragm level. The left lung is\n grossly clear, and there is no evidence of pleural effusion. Postoperative\n changes at the thoracoplasty site are stable in appearance except for slight\n decrease in the amount of soft tissue gas in the operative site.\n\n IMPRESSION: Continued improving aeration in the right mid and lower lung\n regions status post right thoracoplasty.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 930833,
"text": " 7:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch on \n\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, AT 07:54\n\n INDICATION: Thoracoplasty and recent bronch.\n\n COMPARISON: at 22:48.\n\n FINDINGS:\n\n The reexpanded right lower lung field continues to demonstrate better\n aeration, slight improvement versus prior. There are no other interval\n changes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 931546,
"text": " 11:18 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: re-expansion of RLL and RML\n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman sp thoracoplasty, s/p bronch\n\n REASON FOR THIS EXAMINATION:\n re-expansion of RLL and RML\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Thoracoplasty.\n\n Single portable chest radiograph is submitted. Comparison is made to the\n portable chest radiograph obtained earlier the same day.\n\n There is interval improvement in expansion of the right lower lung.\n Right-sided chest tube remains unchanged. The patient is again noted to be\n status post right-sided thoracoplasty. Left lung is clear. Dextroscoliosis\n of the thoracic spine is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-09-27 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 932882,
"text": " 3:25 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please check placement l bas picc for abx call beeper \n Admitting Diagnosis: BRONCHO PLEURAL FISTULA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s//p thoracoplasty\n\n REASON FOR THIS EXAMINATION:\n please check placement l bas picc for abx call beeper with wet read asap\n thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post thoracoplasty. Left PICC placement.\n\n AP portable chest radiograph dated at 15:32, compared to PA\n and lateral chest radiographs dated at 7:44 a.m. Since\n previous radiograph, left PICC has been placed, with tip terminating over the\n expected location of the mid SVC. There is no pneumothorax. There are\n extensive thoracoplasty changes. There is unchanged level of aeration in the\n right middle and lower lung region with residual poorly defined opacities in\n perihilar region, as well as prominent linear opacity extending to the\n diaphragm level, not significantly changed from the previous examination.\n Left lung is grossly clear. No pleural effusions.\n\n IMPRESSION: Satisfactory PICC placement. Otherwise unchanged appearance of\n the chest since the previous study.\n\n\n"
}
] |
7,572 | 110,345 | The patient was transferred from the MICU to the floor where he remained normotensive and afebrile. He tolerated regular diet well. He was discharged to home on on a regular diet. | The aorta and major abdominal branches are partialy calcified. Again seen are a few peripancreatic lymph nodes, which are unchanged. There he was hypotensive into the 70's systolic, responded to fluid boluses and had a temp of 104.6. Lungs are CTA, no cough or secretions noted.GI/ Npo. Skin W&D, weak palpable DP bilaterally. Abd CT shows no perforation.GU - u/o has been good 60-360cc/hr. MICU NURSING NOTE 14:30CV - Pt has remained HD stable, BP 78-106/28-53, MAPs in low 60's down to 45 x 1. No edema noted.P/ 2L NC, spo2 >95%. Transferred back to and ERCP redone with no significant findings noted. HR 70's-80's NSR, no ectopy. Vit K 1mg IV given. Breath sounds crackles bilaterally 1/2 up, otherwise clear. + BS hypoactive. K, Mg, Kphos repleted - AM labs->Hct 30, K 3.5, Na 137, Mg 2.0, Phos 2.8. The aorta is partially calcified. Sats high 90's.GI - Abd soft, nontender. Afebrile, all extremir=tes are warm with weak palpable pulses. Good output.Skin/ Dry and intact.Had chest, ab, and pelvic CT tonight, results pending. There is a small amount of fluid in the superior pericardial recess. Abdomen is soft, non tender, pos BS. Denies any pain or discomfort.CV/ NSR with rare PVC noted. There is a small amount of fluid and stranding surrounding the gallbladder and pancreatic head. IVF D51/2NS at 150 for 1L. sespis may be due to first ERCP?Pt has had stable night with no signifiacnt events. The gallbladder is present, and contains a small amount of air. Hypoactive BS, no BM.Gu/ #16 french foley cath placed using sterile technique. Baseline BP 130's per pt. BO has been stable, drops to the 90's when asleep. Kphos to be given when KCL finished. T max 97.1.Neuro - A&O x 3, MAE. There is a new stent in the duodenum and common duct. HOH, wearing hearing aid in left ear.Resp - Lungs cta, dim at bases. The appendix is normal. The distal ureters are normal. BP stable, can go into the high 80's systolic when asleep , comes up with waking. (Over) 1:26 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST CT RECONSTRUCTION Reason: recent ERCP c/b hypotension 1 day post procedure, ? 1:26 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST CT RECONSTRUCTION Reason: recent ERCP c/b hypotension 1 day post procedure, ? Transferred to for repeat ERCP? CT ABDOMEN WITH IV CONTRAST: There are no focal liver lesions. restart IVF if MAP falls <60. There is a compressive atelectases adjacent to the gastric pull-up. Sinus rhythm. Denies abd pain. There is a tiny amount of fluid in the pleural spaces. There are a few prominent mediastinal lymph nodes, the largest one in the right paratracheal region measures 9 mm in greatest diameter. micu addendum 18:30Pt returned from ERCP, stent placed is patent. Abdomen is soft, non tender. Sedated but arrouseable, VSS. Received one 500ccNS bolus on arrival. Otherwise, no diagnostic interim change. IVF heplocked for now and monitor BP, Sats for ? REASON FOR THIS EXAMINATION: recent ERCP c/b hypotension 1 day post procedure, ? Good output.Skin/ Dry and intact. Loops of small bowel are not dilated. Diverticulosis, no evidence of inflammatory changes. The heart is normal in size. Had had ERCP on fri with stenting and sent home. perforation of esophagectomy site, evidence of any other viscus perforation No contraindications for IV contrast FINAL REPORT INDICATION: S/P esophageal resection, pancreatic cancer with stent placement, recent ERCP, hypotension one day post procedure. Ct of the Chest with IV contrast: There is a gastric pull- up. Had CT of pelvis, abdomen and chest tonight, results pending.HX: esphogagstrectomy' for esophageal adenocarcinoma, Periampillary adeno CA present, hx bilat DVTs with PE in ', GERD, BPH, colon polyps.N/ AA&Ox3, but can be a little cinfused on waking. Rn Shift summaryPt was admitted from in at 2230 . There is a small lymph node in the precarinal region that measures 8 mm. Lung windows demonstrate bullous changes in bilateral lung apices. Pupils are equal and brisk.CV/ NSR, no ectopy. no edema noted. The adrenals and both kidneys are normal. perforat Field of view: 36 Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) PT 16.3, INR 1.8. pt is ~ 5liters + so far today.ID - On flagyl, ampicillin, levoflox. The main pulmonary artery is unremarkable. HAd received fluid boluses and aggressive rehydration in last couple days, none tonight. HAd bed bath and linens changed after foley came apart at connection.Plan/ Monitor VS, mental status. Pt has been aggressively hydrated to maintain MAP>60. Back to OSH with fever of 104.6 and unresponsive per family. Denies SOB, dyspnea.GI/ Advanced to House diet, tolerating fluids and crackers well. Immediate return of clear amber urine. There are degenerative changes in the thoracolumbar spine. The rectum is distended with a large amount of stool. Tmax 100.4, all extremiites are warm with palpable pulses. There are biapical pleural scars. There are bibasilar dependent atelectases. TECHNIQUE: Axial images of the chest, abdomen and pelvis were obtained after the administration of Optiray per patient's request. The pancreatic tail and body are unremarkable. CT PELVIS WITH IV CONTRAST: There is a Foley catheter in the bladder. | 6 | [
{
"category": "Radiology",
"chartdate": "2184-12-05 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 775911,
"text": " 1:26 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n CT RECONSTRUCTION\n Reason: recent ERCP c/b hypotension 1 day post procedure, ? perforat\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p esophageal resection and new ampullary pancreatic ca\n s/p multiple stent placements.\n REASON FOR THIS EXAMINATION:\n recent ERCP c/b hypotension 1 day post procedure, ? perforation of\n esophagectomy site, evidence of any other viscus perforation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P esophageal resection, pancreatic cancer with stent placement,\n recent ERCP, hypotension one day post procedure. Evaluate for perforation.\n\n TECHNIQUE: Axial images of the chest, abdomen and pelvis were obtained after\n the administration of Optiray per patient's request.\n\n Ct of the Chest with IV contrast: There is a gastric pull- up. There are a few\n prominent mediastinal lymph nodes, the largest one in the right paratracheal\n region measures 9 mm in greatest diameter. There is a small amount of fluid\n in the superior pericardial recess. There is a small lymph node in the\n precarinal region that measures 8 mm. The main pulmonary artery is\n unremarkable. The aorta is partially calcified. The heart is normal in size.\n There is a tiny amount of fluid in the pleural spaces.\n\n Lung windows demonstrate bullous changes in bilateral lung apices. There are\n biapical pleural scars. There is a compressive atelectases adjacent to the\n gastric pull-up. There are bibasilar dependent atelectases.\n\n CT ABDOMEN WITH IV CONTRAST: There are no focal liver lesions. The gallbladder\n is present, and contains a small amount of air. There is a small amount of\n fluid and stranding surrounding the gallbladder and pancreatic head. The\n pancreatic tail and body are unremarkable. There is a new stent in the\n duodenum and common duct. There are clips in the left upper quadrant. The\n adrenals and both kidneys are normal. Again seen are a few peripancreatic\n lymph nodes, which are unchanged. Loops of small bowel are not dilated. There\n are multiple diverticula within the colon. The appendix is normal. The aorta\n and major abdominal branches are partialy calcified. There is no free air in\n the abdomen.\n\n CT PELVIS WITH IV CONTRAST: There is a Foley catheter in the bladder. The\n distal ureters are normal. The rectum is distended with a large amount of\n stool. There are degenerative changes in the thoracolumbar spine.\n\n IMPRESSION: No evidence of bowel perforation.\n Diverticulosis, no evidence of inflammatory changes.\n Mesenteric stranding surrounding the pancreatic head and free fluid in the\n abdomen suggesting focal pancreatitis.\n (Over)\n\n 1:26 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n CT RECONSTRUCTION\n Reason: recent ERCP c/b hypotension 1 day post procedure, ? perforat\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-12-05 00:00:00.000",
"description": "Report",
"row_id": 1363862,
"text": " Rn Shift summary\n\nPt was admitted from in at 2230 . Had had ERCP on fri with stenting and sent home. Family found him unresponsive sat afternoon and was taken to ED at . There he was hypotensive into the 70's systolic, responded to fluid boluses and had a temp of 104.6. Transferred to for repeat ERCP? Had CT of pelvis, abdomen and chest tonight, results pending.\nHX: esphogagstrectomy' for esophageal adenocarcinoma, Periampillary adeno CA present, hx bilat DVTs with PE in ', GERD, BPH, colon polyps.\n\nN/ AA&Ox3, but can be a little cinfused on waking. Very hard of hearing, bilat hearing aids. MAE, follows commands. Denies any pain or discomfort. Pupils are equal and brisk.\n\nCV/ NSR, no ectopy. BP stable, can go into the high 80's systolic when asleep , comes up with waking. Received one 500ccNS bolus on arrival. IVF D51/2NS at 150 for 1L. Tmax 100.4, all extremiites are warm with palpable pulses. 3 PIVs, currently being repleated with 40 meq KCL and 4GM MAgso4. Kphos to be given when KCL finished. No edema noted.\n\nP/ 2L NC, spo2 >95%. Lungs are CTA, no cough or secretions noted.\n\nGI/ Npo. Abdomen is soft, non tender. Hypoactive BS, no BM.\n\nGu/ #16 french foley cath placed using sterile technique. Immediate return of clear amber urine. Good output.\n\nSkin/ Dry and intact.\n\nHad chest, ab, and pelvic CT tonight, results pending.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-12-05 00:00:00.000",
"description": "Report",
"row_id": 1363863,
"text": "MICU NURSING NOTE 14:30\nCV - Pt has remained HD stable, BP 78-106/28-53, MAPs in low 60's down to 45 x 1. HR 70's-80's NSR, no ectopy. Skin W&D, weak palpable DP bilaterally. K, Mg, Kphos repleted - AM labs->Hct 30, K 3.5, Na 137, Mg 2.0, Phos 2.8. Pt has been aggressively hydrated to maintain MAP>60. Baseline BP 130's per pt. PT 16.3, INR 1.8. Vit K 1mg IV given. T max 97.1.\n\nNeuro - A&O x 3, MAE. HOH, wearing hearing aid in left ear.\n\nResp - Lungs cta, dim at bases. Sats high 90's.\n\nGI - Abd soft, nontender. + BS hypoactive. Denies abd pain. No stool. see careview for recent labs. Abd CT shows no perforation.\n\nGU - u/o has been good 60-360cc/hr. pt is ~ 5liters + so far today.\n\nID - On flagyl, ampicillin, levoflox. WBC 29.5.\n\nPlan - pt to go to for ERCP this afternoon then return to MICU for monitoring. Labs to be drawn when pt returns.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-12-05 00:00:00.000",
"description": "Report",
"row_id": 1363864,
"text": "micu addendum 18:30\nPt returned from ERCP, stent placed is patent. Pt also had sigmoidoscopy. Sedated but arrouseable, VSS. Sats high 90's on 3l NC. Breath sounds crackles bilaterally 1/2 up, otherwise clear. IVF heplocked for now and monitor BP, Sats for ? restart IVF if MAP falls <60.\n"
},
{
"category": "Nursing/other",
"chartdate": "2184-12-06 00:00:00.000",
"description": "Report",
"row_id": 1363865,
"text": "NightRN shift summary\nPt S/P ERCP on with stent placed in bile duct, discharged home. Back to OSH with fever of 104.6 and unresponsive per family. Transferred back to and ERCP redone with no significant findings noted. sespis may be due to first ERCP?\n\nPt has had stable night with no signifiacnt events. Pt slept until about midnight, then has been awake since. Diet advanced and is tolerating fluids well, will try house diet for breakfast.\n\nN/AA&ox3, MAE, follows commnads. Pupils are equal and brisk. Denies any pain or discomfort.\n\nCV/ NSR with rare PVC noted. BO has been stable, drops to the 90's when asleep. HAd received fluid boluses and aggressive rehydration in last couple days, none tonight. Afebrile, all extremir=tes are warm with weak palpable pulses. no edema noted. Has 2 PIVs, NS at KVO. Am labs K+3.5, will give 40 meqPO per orders, phos 2.3 will give neutraphos per orders.\n\nP/ 3L NC, spo2>95%. Luns are clear at apexes with fine crackles noted to bases, seem better than last night. Denies SOB, dyspnea.\n\nGI/ Advanced to House diet, tolerating fluids and crackers well. Abdomen is soft, non tender, pos BS. no Bm.\n\nGU/ Foley draining clear yellow urine with sediment. Good output.\n\nSkin/ Dry and intact. HAd bed bath and linens changed after foley came apart at connection.\nPlan/ Monitor VS, mental status. Transfer to floor?\n\n"
},
{
"category": "ECG",
"chartdate": "2184-12-05 00:00:00.000",
"description": "Report",
"row_id": 124343,
"text": "Sinus rhythm. Q-T interval prolongation, increased compared to the previous\ntracing of . Otherwise, no diagnostic interim change.\n\n"
}
] |
26,727 | 181,663 | Aspiration pneumonia. Based on his initial chest x-ray, it appeared that his fevers were secondary to a pneumonia, questionable aspiration pneumonia. Further history is obtained from the nursing home. It was found that he is on a mechanical soft diet with the nursing staff not aware of any gross aspiration. Blood and sputum cultures were obtained, of which the sputum culture grew out moderate growth of coagulase positive staph aureus which was Oxacillin sensitive. He was initiated on Levofloxacin 500 mg q. 24 hours as well as Flagyl 500 mg q. 24 hours with suspected aspiration pneumonia. A bedside swallowing evaluation was obtained on hospital day number two which revealed severe oral motor weakness and difficulty initiating swallows, probable aspiration of apple sauce and water and was, therefore, placed n.p.o. as a diet. The neurology service was consulted for further evaluation of the etiology of his oropharyngeal dysphagia. They recommended performing an egrophonium test during a repeated speech and swallow to evaluate for possible myasthenia . A repeat speech and swallow evaluation with this tensilon was performed with similar results to his initial evaluation -- namely considerable aspiration with inability to propel pureed foods as well as inability to protect his airway. Oxacillin was added to his antibiotic regimen for further coverage of his aspiration pneumonia and his persistence of a leukocytosis. With this antibiotic regimen, he continued to remain afebrile and completed a two week course in total of these antibiotics. However, his leukocytosis did not resolve despite clinical improvement and it was felt that this was a leukomoid reaction, unrelated to current infection. On hospital day number ten, consent was obtained from his legal guardian, , phone # and a percutaneous gastric jejunostomy tube was placed without complications. Tube feeds were initiated through this gastrojejunostomy tube and the patient tolerated goal feeds of Ultra-Cal at 75 cc an hour. Repeat chest x-ray on hospital day number 14 revealed improving bibasilar densities, consistent with improving pneumonias. However, he continued to sound somewhat congested and may be chronically aspirating despite the placement of the gastrojejunostomy tube. He continues to remain a chronic aspiration risk and was started on Bactrim DS p.o. one tablet q. day for prophylaxis. IN regards to further work-up of his oral and motor weakness, an otorhinolaryngology consult was obtained to rule out further involvement of his gingival cancer. A biopsy was taken one day prior to discharge with pathology results pending at this time. Alcohol induced psychosis. It was difficult to determine the baseline mental status of this patient and given the possibility of neuroleptics causing dystonia, interfering with his oral motor weakness, his psychiatric medications were held, though upon further review of his history, he had speech and swallowing difficulties prior to admission. Despite the continuation of his neuroleptic, again his oral and motor function did not improve. The psychiatry service was consulted in regards to further evaluation of his dementia as well as recommended medications that would not interfere with his oral and motor function. Multiple laboratory studies were sent including liver function tests, B-12, folate and TSH and RPR all of which were normal and was started on Trilafon 8 mg by gastrojejunostomy tube twice a day. The psychiatrist at Hospital was informed of his hospital course and will continue further neuropsychiatric evaluation at this facility. Dyspnea. On hospital day number four, the nursing staff noticed that the patient was acutely dyspneic. An arterial blood gases was drawn during this event which revealed a pH of 7.17, Pc02 of 87 and P02 of 104, indicative of a respiratory acidosis. He was transferred to the Medical Intensive Care Unit for a trial of mask ventilation. He was also started on stress dose steroids, Solu-Medrol 80 mg intravenous three times a day as well as nebulizer treatments. It was thought that the etiology of his dyspnea was secondary to a possible aspiration event, super imposed on his chronic obstructive pulmonary disease. Code status was clarified with his legal guardian, stating that he is a DNR/DNI patient. After approximately 24 hours of mask ventilation, the patient clinically improved with good oxygen saturations and was significantly less labored in terms of his respiratory status. He was discharged from the Medical Intensive Care Unit after a three day stay and sent back to the floor, with continuation of treatment for aspiration pneumonia as primary treatment of his dyspnea. His oxygen requirements gradually tapered throughout the rest of his hospital course, to a requirement of two liters nasal cannula. His nebs were switched to an as needed basis and he was quickly tapered off of steroids over a three day course in total. Hypernatremia. The patient was noted to be hypernatremic upon admission with a sodium level of 150. His calculated free water deficit was approximately three liters and, throughout his hospital course, his sodium gradually corrected with the supplementation of free water bolus. However, upon discontinuation of his free water boluses, his hyponatremia worsened. Therefore, he will be discharged on a standing order of 250 cc of free water every six hours through his gastrojejunostomy tube to replenish his free water. | Baseline artifactSinus rhythmSupraventricular extrasystolesPoor R wave progression - probable normal variantSince previous tracing of : precordial T wave less prominent Diaphoretic @ times.Psychosocial: DNR/DNI order signed & in chart. MICU NPN:NEURO: A&O x3 c intermittent confusion. hypoactive BS. ***DNR/DNI As of now R/O.RESP: Received pt on BIPAP (settings on carevue sheet). back care given & pt turned side to side. BP 130-180 systolic. #20 Coude cath inserted. LS are coarse/rhoncherous to auscultation c fair clearing once NTS'ing has been performed effectively. HR 90-130- ST c PVC. Bi-pap replaced after CPT, pt resting again. Sinus tachycardiaInferior and lateral ST-T wave changes are nonspecificNo previous tracing for comparison + Pill Rolling. Questioning to intubate pt due to Resp status. no intervention.CV: Tmax 101.8 Last Tylenol given @ 1730. (Tachypneic to mid 20s c agitation). New IV inserted in R antecub. PMH: COPD, ETOH induced psychosis, Osteoarthritis, s/p Partial gastrectomy, Gum CA.NEURO: Arousable to voice/stimuli. 6:00 PM CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # Reason: as per rec on head ct; thank you. 8:01 AM PERC G/G-J TUBE PLMT Clip # Reason: place post-pyloric FT Contrast: CONRAY Amt: 10 ********************************* CPT Codes ******************************** * PERC PLCMT GASTROMY TUBE PLCT GJ TUBE * * -59 DISTINCT PROCEDURAL SERVICE PERC PLCMT ENTROCLYSIS TUBE * * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF * * C1892 INT/SHTH,EP,FXD CURVE/ AWY C1894 INT.SHTH NOT/GUID,EP,NONLASER * **************************************************************************** MEDICAL CONDITION: 74 year old man with aspiration pneumonia, etoh-induced psychosis REASON FOR THIS EXAMINATION: place post-pyloric FT FINAL REPORT INDICATION: Aspiration pneumonia, requires percutaneous postpyloric tube for long-term nutrition. Pt presently is not dyspneic and is respirating comfortably on NC.CV: Pt is in a NSR c freq PAC's. #22 Coude cath ordered. Chest PT in AM. Normotensive c a normal body temp of 98.4. Pt remains on triple antibiotics which include; Vanco, Flagyl and Levofloxacin.GI: NGT placement confirmed by HO, FWB hydration provided as ordered. HR 90-120 SR/ST c PVC & PAC. Repeat Na value c 19:00 labs = 143, HO notified, FWB therapy subsequently d/c'ed. The stomach was insufflated via the existing NG tube. On arrival to MICU pt found to have tremors to tactile and very rigid. D5W started @ 150 cc/hr.GI: Abd soft. Of note, Albumin = 3.0. Dobhoff tube inserted by HO. MEDICATIONS: Local anesthesia (1% Lidocaine). +BS, NT, ND abdomen.MS: Pt re-oriented to person, time and place to improve LOC. The pt was repeatedly removing his mask, therefore 5LNCO2 was provided c stable resp fxn noted. Pt uncooperative. Repeat lytes better. The parotid and submandibular glands are within normal limits. BS: Coarse R lobe, Diminished L lobe c scattered Rhonchi. Poor R wave progression may be normalvariant. But DNR/DNI obtained by health care proxy. Pt cont to exhibit a weak/ineffective cough. + BS. ABG c resp acidosis. These areas or incompletely evaluated. Lab results back with K+ 2.4, Na 152, Cl 122. Pulses palpable x 4. Will send repeat AM labs shortly. The anterior abdominal wall was prepped and draped in sterile fashion. The pt is presently positive one liter input @ this time per I&O's. Sinus tachycardia. Nursing Progress Note.RESP: Pt c weak/ineffective cough O/N requiring NTS Q3 hours to mobilize/evacuate moderate/large amounts of thick, tan/blood-tinged secretions. Dr. on MICU team notified. Pt remains in MICU for Pulm Toilet.CV: Tmax. Will draw/send AM labs shortly. Very rigid extremities, tremulous most of time. The pt is a DNR/DNI but can receive pressors/BiPap if necessary.OTHER: Please see CareVue for additional pt care data/comments. Small lymph node in the thoracic inlet to the right of the esophagus. There is mild calcification within the right carotid bulb. Baseline artifact. The tube was then afixed to the skin with an 0 Prolene suture and FlexiTract. Prominent precordial T waves - may be within normal limits butconsider also possible hyperkalemia and/or possible ischemia. neroleptic malignant syndrome due to haldol? Receives Free H20 Boluses 300cc q3h.GI: Abd softly distended. Foley placed. Tremors occur c agitation. IMPRESSION: 1. In the thoracic inlet to the left of the esophagus, is a lymph node which measures 7.5 mm in short axis. New IV inserted in L arm #18. Pt denies SOB or dyspnea when questioned. REASON FOR THIS EXAMINATION: as per rec on head ct; thank you. Rigidity x 4 limbs persists yet less than yest. CT OF THE NECK WITH CONTRAST: There is a symmetric appearance to the soft tissues of the pharynx. Plan to give free H2O bolus via feeding tube for hypovolemia.GU: Foley replaced x2. Confused c impaired short term memory evident. Phone # in chart. Since theprevious tracing of precordial T waves are more prominent. Alveolar opacities within the lungs dependently which are incompletely imaged. Placed on bi-pap of 12cm PSV above 5cm PEEP. | 10 | [
{
"category": "Radiology",
"chartdate": "2148-03-13 00:00:00.000",
"description": "PLCT GJ TUBE",
"row_id": 783139,
"text": " 8:01 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: place post-pyloric FT\n Contrast: CONRAY Amt: 10\n ********************************* CPT Codes ********************************\n * PERC PLCMT GASTROMY TUBE PLCT GJ TUBE *\n * -59 DISTINCT PROCEDURAL SERVICE PERC PLCMT ENTROCLYSIS TUBE *\n * CATHETER, DRAINAGE C1769 GUID WIRES INCL INF *\n * C1892 INT/SHTH,EP,FXD CURVE/ AWY C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with aspiration pneumonia, etoh-induced psychosis\n REASON FOR THIS EXAMINATION:\n place post-pyloric FT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aspiration pneumonia, requires percutaneous postpyloric tube for\n long-term nutrition.\n\n RADIOLOGISTS: Drs. and . Dr. , the attending\n radiologist, performed the procedure.\n\n TECHNIQUE: After discussing the risks, benefits and alternatives of the\n procedure, consent was obtained via telephone conversation with the patient's\n attorney (patient not consentable due to mental status). The anterior\n abdominal wall was prepped and draped in sterile fashion. The stomach was\n insufflated via the existing NG tube. Using fluoroscopic guidance, two T-\n fasteners were deployed within the stomach. Under fluoroscopic monitoring, a\n needle was advanced into the stomach and the guidewire advanced into a\n postpyloric position. A catheter was advanced over the wire into the proximal\n jejunum. Next, an Amplatz wire was advanced through the catheter and the\n catheter removed. Serial dilation was performed over the wire up to 14 Fr. A\n 14.5 Fr gastrojejunostomy tube was then advanced over the wire under\n fluoroscopic guidance into the proximal jejunum. Approximately 10 cc of Conray\n contrast was administered through the tube and a postplacement radiograph was\n performed demonstrating the tip of the catheter to be in the proximal jejunum.\n The tube was then afixed to the skin with an 0 Prolene suture and FlexiTract.\n\n MEDICATIONS: Local anesthesia (1% Lidocaine).\n\n COMPLICATIONS: No immediate complications.\n\n IMPRESSION: Successful placement of a 14 Fr gastrojejunostomy tube with\n the tip in the proximal jejunum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2148-03-06 00:00:00.000",
"description": "CT 100CC NON IONIC CONTRAST",
"row_id": 782590,
"text": " 6:00 PM\n CT NECK W/CONTRAST (EG:PAROTIDS); CT 100CC NON IONIC CONTRAST Clip # \n Reason: as per rec on head ct; thank you.\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with copd, etoh induced psychosis, admitted with aspiration\n pneumonia, undergoing w/u for dysphagia.\n REASON FOR THIS EXAMINATION:\n as per rec on head ct; thank you.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COPD with alcohol-induced psychosis, admitted with aspiration\n pneumonia, patient has dysphagia.\n\n TECHNIQUE: Axial images were performed from the skull base through the\n thoracic inlet after the administration of 100 cc of intravenous Optiray due\n to the patient's cardiac status.\n\n CT OF THE NECK WITH CONTRAST: There is a symmetric appearance to the soft\n tissues of the pharynx. No definite masses are seen. The neck vasculature is\n symmetric. The parotid and submandibular glands are within normal limits.\n There is mild calcification within the right carotid bulb. The soft tissues of\n the neck appear symmetric.\n\n No masses are identified at the skull base.\n\n In the thoracic inlet to the left of the esophagus, is a lymph node which\n measures 7.5 mm in short axis. In the imaged portions of the lungs, there are\n apical bullous changes, as well as alveolar opacities seen dependently in the\n right upper lobe and a focal area in the left upper lobe. These areas or\n incompletely evaluated.\n\n IMPRESSION:\n 1. No evidence of mass is seen in the oro- or - pharynx. Direct\n inspection should be performed to exclude an underlying malignancy. CT is not\n an adequate evaluation for mucosal abnormalities.\n 2. Small lymph node in the thoracic inlet to the right of the esophagus.\n 3. Alveolar opacities within the lungs dependently which are incompletely\n imaged. Correlation with other chest imaging is necessary.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-08 00:00:00.000",
"description": "Report",
"row_id": 1612412,
"text": "Nursing Progress Note.\n\nRESP: Pt c weak/ineffective cough O/N requiring NTS Q3 hours to mobilize/evacuate moderate/large amounts of thick, tan/blood-tinged secretions. Pt finds this procedure quite uncomforable. Sats have been in the mid-90's c a RR in the mid-twenty range. Pt denies SOB or dyspnea when questioned. LS are coarse/rhoncherous to auscultation c fair clearing once NTS'ing has been performed effectively. Pt exhibits occ apneic phases (RR < 10) while asleep which is then followed by a tachypneic c a RR in the 40's. No ABG drawn O/N thus far.\n\nCV: TMax of 101.9 tonight, pt provided c 650mg Acetaminophen per NGT Q 4 hours c only a small reduction in measured oral temp(101.5). Lytes re-checked @ 23:00 c Na = 150 (D5W infusion increase to 200ml/hr and 250ml FWB provided Q 3 hours) and K = 3.5(repleted c a total of 40 MEQ KCL per NGT). Of note, Albumin = 3.0. Will send repeat AM labs shortly. Pt remains on triple antibiotics which include; Vanco, Flagyl and Levofloxacin.\n\nGI: NGT placement confirmed by HO, FWB hydration provided as ordered. FS Promote c Fiber TF started @ 10ml/hr per team request pending a Nutrition consult. +BS, NT, ND abdomen.\n\nMS: Pt re-oriented to person, time and place to improve LOC. Pt follows commands and is generally cooperative. Pt appears confused and does not initiate verbal communication on his own. Pt difficult to turn in bed 2nd gen body rigidity and shaking tremulousness. Pt insisted that he was going to get OOB to have some soup -- pt informed that he would not be able to do this in a hospital setting. Verbal/non-verbal support given.\n\nDERM: Skin intact.\n\nFAMILY: No visitors or phone calls received O/N for this pt. Per HO, after speaking c the pt's Lawyer the pt was made a DNR/DNI. However, the pt can go back on BiPap if necessary.\n\nOTHER: Please see CareVue for additional pt care data/comments.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-08 00:00:00.000",
"description": "Report",
"row_id": 1612413,
"text": "MICU NPN:\nNEURO: A&O x3 c intermittent confusion. Follows all commands. @ times pt is belligerent, refusing care. c insistance/time pt usually cooperates. Tremors much less than yest. Tremors occur c agitation. + Pill Rolling. Rigidity x 4 limbs persists yet less than yest. c/o vague pain in abd intermittently.\n\nRESP: Face mask changed to CSM 50%. O2 Sats 90-100% RR 10-20. (Tachypneic to mid 20s c agitation). BS: Coarse R lobe, Diminished L lobe c scattered Rhonchi. Chest PT in AM. Pt uncooperative. NTS x 3 for large amt thick tan blood tinge secretions. + nonproductive cough.\nNo ABG today. Pt remains in MICU for Pulm Toilet.\n\nCV: Tmax. 100.1. HR 90-120 SR/ST c PVC & PAC. 10 beat run SVT 160s.\nBP 125-157/60-80. Pulses palpable x 4. Na+ 150. IVF changed to D5 1/2 NS @200 cc/hr. Receives Free H20 Boluses 300cc q3h.\n\nGI: Abd softly distended. + BS. no BM. TF changed to Ultracal @ 20 cc/hr via Dobhoff. Goal 75 cc/hr. FS Glucose 230. On Insulin Sliding Scale.\n\nGU: Foley draining 30-40 cc/hr golden urine. No leakage around 22 Coude Cath.\n\nSkin: Intact. Diaphoretic @ times.\n\nPsychosocial: DNR/DNI order signed & in chart. health care proxy, called today for an update. Phone # in chart.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-07 00:00:00.000",
"description": "Report",
"row_id": 1612410,
"text": "T-SICU Nsg Note\n Mr. was transferred into T-SICU about 6:45am from floor. Initially pt lethargic, answered \"no\" to all questions. Placed on bi-pap of 12cm PSV above 5cm PEEP. Pt resting unless disturbed, tolerating bi-pap mask. At 8am, pt oriented to self and \"hospital\", but not which hospital nor day, date. Followed commands with all 4 limbs, answered questions appropriately. Very rigid extremities, tremulous most of time. Resists movement and nursing care.\n New IV inserted in R antecub. Foley placed. back care given & pt turned side to side. IV of .45 NS started at 100cc/hr. CPT of percussion, shaking & postural drainage done both sides, then pt suctioned for copious, extremely tenacious tan blood-tinged sputum. Pt does have cough when stimulated. Bi-pap replaced after CPT, pt resting again.\n Lab results back with K+ 2.4, Na 152, Cl 122. Dr. on MICU team notified. IV fluid changed to D5W with 40mEqKCL per liter at rate of 150cc/hr.\n Report called to RN () in MICU A. Pt transfered in bed to MICU A, and ventilator also brought to MICU A.\nA: Metabolic derangements, Copious thick sputum, Rigid limbs and tremulous.\nP: hydrate, replete lytes and water, humidify inspired gases, re-orient to environment, pulmonary toilet. Institute orders per MICU team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-07 00:00:00.000",
"description": "Report",
"row_id": 1612411,
"text": "MICU NSG ADMIT NOTE:\nPt is 74 yo male transferred to MICU today @1130 from Trauma ICU. Admitted to on from ArborPsych Facility for aspiration pneumonia after swallowing pills. On floor having labored breathing c poor ABG sent to ICU to start BiPap mask ventilation. PMH: COPD, ETOH induced psychosis, Osteoarthritis, s/p Partial gastrectomy, Gum CA.\n\nNEURO: Arousable to voice/stimuli. Intermittently answers questions. confused to place and time. alert to person (self). otherwise somulent. On arrival to MICU pt found to have tremors to tactile\n and very rigid. HO ? neroleptic malignant syndrome due to haldol? As of now R/O.\n\nRESP: Received pt on BIPAP (settings on carevue sheet). ABG c resp acidosis. Questioning to intubate pt due to Resp status.\n But DNR/DNI obtained by health care proxy. Pt taken off Bipap and remains on 50% face mask. RR20-30. O2 Sat 88-94%.\n Last ABG PO2 approx 65 % HO aware. no intervention.\n\nCV: Tmax 101.8 Last Tylenol given @ 1730. HR 90-130- ST c PVC.\n BP 130-180 systolic. New IV inserted in L arm #18. AM labs\n Lytes out of range. Repeat lytes better. NA 149. Hct 41.\n D5W started @ 150 cc/hr.\n\nGI: Abd soft. hypoactive BS. Dobhoff tube inserted by HO. awaiting placement confirmation from HO. Plan to give free H2O bolus\n via feeding tube for hypovolemia.\n\nGU: Foley replaced x2. #20 Coude cath inserted. Pt still leaking amber urine. #22 Coude cath ordered. HO aware pt is making urine but unable to measure.\n\n***DNR/DNI\n"
},
{
"category": "Nursing/other",
"chartdate": "2148-03-09 00:00:00.000",
"description": "Report",
"row_id": 1612414,
"text": "Nursing Progress Note.\n\nRESP: Pt received on 40% FiO2 high flow venti-mask c sats in the mid/high 90's and a RR generally in the teens. The pt was repeatedly removing his mask, therefore 5LNCO2 was provided c stable resp fxn noted. NTS provided Q3-4 hours O/N c moderate amounts of thick yellow/blood tinged/mucoid sec evacuated successfully. Pt cont to exhibit a weak/ineffective cough. LS are clear in upper lobes, diminished @ bases c fairly poor air movement noted in all lung fields. Pt denies SOB/dyspnea, though the pt is a very poor historian. Pt presently is not dyspneic and is respirating comfortably on NC.\n\nCV: Pt is in a NSR c freq PAC's. Normotensive c a normal body temp of 98.4. Will draw/send AM labs shortly. Repeat Na value c 19:00 labs = 143, HO notified, FWB therapy subsequently d/c'ed. Other labs values WNL. Pt denies CP, again he is a poor historian. The pt is presently positive one liter input @ this time per I&O's. Prednisone steroid therapy to be tapered off over the course of one week per HO note. Elevated FS cov c ISS.\n\nGI: Pt now receiving FS Ultracal @ 20ml/hr via NGT c target of 65ml/hr per nutrition note. No stool output tonight. Abd is soft, +BS, NT.\n\nMS: Pt is alert, mildly confused, more cooperative tonight and follows simple commands. Confused c impaired short term memory evident. Pt oriented to person only, thought he was @ home earlier. The pt is not restrained. No psychomimetic agents provided to this pt tonight. Pt cont to exhibit muscle rigidity/tremulousness.\n\nFAMILY: No calls or visitors received overnight. The pt is a DNR/DNI but can receive pressors/BiPap if necessary.\n\nOTHER: Please see CareVue for additional pt care data/comments.\n"
},
{
"category": "ECG",
"chartdate": "2148-03-07 00:00:00.000",
"description": "Report",
"row_id": 313525,
"text": "Baseline artifact. Sinus tachycardia. Poor R wave progression may be normal\nvariant. Prominent precordial T waves - may be within normal limits but\nconsider also possible hyperkalemia and/or possible ischemia. Since the\nprevious tracing of precordial T waves are more prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2148-03-17 00:00:00.000",
"description": "Report",
"row_id": 313524,
"text": "Baseline artifact\nSinus rhythm\nSupraventricular extrasystoles\nPoor R wave progression - probable normal variant\nSince previous tracing of : precordial T wave less prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2148-03-04 00:00:00.000",
"description": "Report",
"row_id": 313749,
"text": "Sinus tachycardia\nInferior and lateral ST-T wave changes are nonspecific\nNo previous tracing for comparison\n\n"
}
] |
28,160 | 184,274 | He was admitted to cardiac surgery for IV heparin after stopping his coumadin in preparation for surgery. He was taken to the operating room on where he underwent a CABG x 2 and AVR. He was transferred to the ICU in stable condition. He was extubated on POD #1. He was transfused. He returned to rate controlled atrial fibrillation. He was started on coumadin for his mechanical valve and afib. He developed complete heart block and was seen by electrophysiology. His complete heart block resolved and he again had atrial fibrillation. He was started on IV heparin while his INR was subtherapeutic. He was transferred to the floor on POD #6. He was noted to cough while drinking thin liquids and was seen by speech and swallow and did not aspirate upon bedside examination. He continued to require aggresive pulmonary toilet. He was started on vanoc, cipro and flagyl for ? of aspiration pna. His INR became supratherapeutic and his coumadin was held for several days. Video swallow performed on showed no aspiration but he continued to be high risk for aspiration. He was re-started on thin liquids and soft solids, and aspiration precautions. He improved, his CXR improved, white count decreased, and INR decreased and was ready for discharge to rehab on POD #14. | Cardiomediastinal silhouette has a normal postoperative appearance. IMPRESSION: Stable postoperative changes with small left-sided pleural effusion and left-sided atelectatic change. CHEST AP SEMI-UPRIGHT PORTABLE: The cardiomediastinal contours show stable postoperative widening. The cardiomediastinal silhouette is within normal limits. FINDINGS: In comparison with the study of , there has been a CABG procedure with intact sternal sutures. IMPRESSION: PA and lateral chest compared to through 13: Small bilateral pleural effusions, unchanged since . MEDIASTINAL DRAINX2, LEFT CHEST TUBE, RIGHT IJ SWAN GANZ ARE UNCHANGED. Minimal remaining bilateral pleural effusions. Rule out pneumothorax. FINDINGS: In comparison to the previous radiograph, the central venous access line has been removed. There was mildly reduced laryngeal elevation in the pharyngeal phase and incomplete epiglottic deflection. Again seen is the small left pleural effusion and left-sided atelectasis. Generalized edema. THE CARDIOMEDIASTINAL CONTOUR SHOWS STABLE POSTOPERATIVE WIDENING. TIP OF NG TERMINATES INTEH STOMACH. No resp distress noted, = rise and fall of chest. IMPRESSION: Standard appearance following cardiac surgery. Tip of the right jugular line projects over the low SVC. IMPRESSION: Moderate oropharyngeal dysphagia with evidence of penetration and increased pharyngeal residue. SMALL BILATERAL PLEURAL EFFUSIONS AND LEFT BASILAR ATELECTASIS IS PRESENT. Severe right lower lobe atelectasis persists. Mild cardiomegaly without signs of cardiac decompensation. 11p-7aneuro: arouses to voice, follows commands, very drowsy on receipt of pt, appears more wakeful as shift continued, mae, perrlaacv: a paced 88 (underlying rhythm sr 60s w/ occasional pvcs) for bp support, sbp 90-130 (goal this am sbp >110 for renal perfusion), neo gtt titrated to keep sbp>110, pad 23-3-, cvp 14-20, ci 2.4-3, max temp 38, ct draining small/moderate amounts s/s drainageresp: lungs cta, dim to left base, attempts at cpap overnoc unsuccesful r/t metabolic acidosis, improved abg once returned to simv, 02 sats >97% on vent settings overnoc, minimal secretions overnocgi: abdomen soft/nondistended, og to lcs draining clear/bilious drainage, insulin gtt restarted overnoc, 40 units lantus sc given this amgu: foley to gravity draining clear yellow urine in small amounts, no improvement in uop w/ fluid boluses, 20 mg iv lasix given w/ small improvement in uop for short timelabs: k 5.7 overnoc txed w/ 10 units iv regular insulin and 12.5g d50, ca repletedplan: wean neo to keep sbp>110, wean insulin gtt to off, wean vent as able, once extubated, deline and transfer to 6 Cardiomediastinal contours appear unchanged. FINDINGS: In the oral phase, mild swallow delay was noted. The chest tube has been removed. COMPARISON: Chest portable AP from . MEDIAN STERNOTOMY WIRES AND PROSTHETIC VALVE ARE DEMONSTRATED. Small left pleural effusion has increased and left basal atelectasis is new and mild. VSS stable w/HTN, metoprolol 12.5 mg this AM. The right internal jugular line tip is at cavoatrial junction. The appearance of the post-sternotomy wires is intact. cardiac index remains >2.remains a paced for bp support,underlying rhythm sinus 60's.awoke,weakly mae x 4 but failed 1st wean attempt with resp. NP indeed calling it CHB with slow ventricular escape. PP palpable.RESP: LS clear, dim in bases with audible wheeze; upper airway. Required 1L crysttaloid and 25% albumin X2 for low uo.Pedal pulses weakly palpable. Pt c/o pain this am, given 1 PO percocet with good relief. Pt c/o Nausea x1-given zofran. Moderate (2+) aortic regurgitation is seen. Creat 1 this am.GI: Abdomen softly distended with no bowel sounds. sbp 140-160, drops lower after lopressor. Pt transfused with 1 unit PRBCs for drop in Hct, post Hct 29.4. CT D/C'd this am->x-ray done.GI/GU: Pt nauseous this am, given zofran with good relief. Weaned off neo. med for mild incisional discomfort x 2 with 1 percocet. Mild to moderate(+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Bilateral legs with ace wraps intact.A: Slow return GI function. ABG's remain acidotic with pO2>90's. Albuterol neb given. ABGs improving throughout shift; Attempted CPAP trial overnoc unsuccessful; will attempt this AM. NP in to adjust pacer, set at V demand, pacer did not 100% capture. k repleted x 1. breath sounds usually clear, occ rhonchi and faint exp wheeze, receiving inhalers. + belching and nausea X2-treated with reglan and then zofran with effect. Pt given albuterol NEB prn. There is a moderateaortic regurgitation with moderate aortic stenosis. skin on back and buttocks intact, is generally edematous. AEG done with atrial wires which showed a questionable 2 to 1 AV Block vs CHB. Swan dc'd.Ca repleted X1. abd soft, distended, bowel sounds present, some flatus, but no stool overnight. LVEF 55%.Ascending aortic contour is well preserved.Mild to Moderate regurgitation is seen.There is a mechanical valve in the native aortic position, stable and movingwell with residual gradients of a peak of 12 and a mean of 5mm of Hg. 7p-7aneuro: oriented to self only, reoriented to place and time, at beginning of shift pt slow to answer questions and would repeat answer to previous question when asked a new question, pt seems better able to answer questions correctly this am, but still unable to state where he is and what year it is, mae, follows commandscv: sr/st 79-101 w/ occasional pvcs, sbp 95-135, afeb, ct draining small amts s/s drainage, pacer set to aai backup 58resp: upper lobes clear bilat, crackles to bilat lower lobes, moderate strength cough productive of thick yellow sputum, able to wean 02 to 2L nc this am for sats >95%, pt unable to follow directions at this time to use incentive spirometergi: abdomen soft/nondistended, bowel sounds present, tolerated clear liquids overnoc, elevated blood sugars overnocgu: foley to gravity draining small amts yellow urine, small improvement in uop w/ lasix 20mg ivlabs: hct dropped from 27 to 24 this amassess: stableplan: reorientation prn, increase activity, pulmonary toilet, increase lantus dose?, transfer to 6 sternal wound and ct sites dry, dressing changed. | 24 | [
{
"category": "Radiology",
"chartdate": "2179-02-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1003293,
"text": " 1:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: AORTIC STENOSIS\\CORONARY ARTERY BYPASS GRAFT WITH AVR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p AVR qand CT removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man status post AVR and chest tube removal. Rule out\n pneumothorax.\n\n COMPARISON: Chest portable AP from .\n\n CHEST AP SEMI-UPRIGHT PORTABLE: The cardiomediastinal contours show stable\n postoperative widening. Again seen is the small left pleural effusion and\n left-sided atelectasis. There is opacification of the retrocardial space\n again consistent with postsurgical change. The Swan-Ganz catheter has been\n removed but the sheath still remains. There is no pneumothorax. The chest\n tube has been removed.\n\n IMPRESSION: Stable postoperative changes with small left-sided pleural\n effusion and left-sided atelectatic change. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-07 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1002607,
"text": " 4:59 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: AORTIC STENOSIS\\CORONARY ARTERY BYPASS GRAFT WITH AVR\n Admitting Diagnosis: AORTIC STENOSIS\\CORONARY ARTERY BYPASS GRAFT WITH AVR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with\n REASON FOR THIS EXAMINATION:\n pre-op AVR/CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: This is a preop examination for a patient with aortic stenosis.\n\n FINDINGS: Two views of the chest were obtained that demonstrate no focal\n airspace opacities. No effusions are seen. The cardiomediastinal silhouette\n is within normal limits. The bony thorax is grossly intact.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-22 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 1004977,
"text": " 9:11 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval for aspiration\n Admitting Diagnosis: AORTIC STENOSIS\\CORONARY ARTERY BYPASS GRAFT WITH AVR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p CABG/AVR\n REASON FOR THIS EXAMINATION:\n eval for aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man status post CABG/TVR. Evaluate for aspiration.\n\n OROPHARYNGEAL VIDEO FLUOROSCOPIC SWALLOWING EVALUATION:\n Oral and pharyngeal swallowing video fluoroscopy was performed in\n collaboration with the speech and swallow team. Barium in multiple\n consistencies and one half barium pill were administered.\n\n FINDINGS: In the oral phase, mild swallow delay was noted. There was\n premature spillage into the pharynx and retention in the valleculae.\n\n There was mildly reduced laryngeal elevation in the pharyngeal phase and\n incomplete epiglottic deflection. A prominent cricopharyngeus muscle was\n noted. No aspiration was seen.\n\n IMPRESSION: Moderate oropharyngeal dysphagia with evidence of penetration and\n increased pharyngeal residue. No evidence of aspiration. Despite the\n visualization of aspiration, the patient is at continued risk of aspiration\n given the significant pharyngeal residue.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1003792,
"text": " 10:02 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: assess line placement-r/o ptx\n Admitting Diagnosis: AORTIC STENOSIS\\CORONARY ARTERY BYPASS GRAFT WITH AVR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p AVR and central line change\n REASON FOR THIS EXAMINATION:\n assess line placement-r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF :\n\n COMPARISON: .\n\n INDICATION: Line change.\n\n Right internal jugular vascular catheter has been placed, with tip terminating\n in the lower superior vena cava near the junction with the right atrium.\n There is no pneumothorax. Cardiomediastinal contours appear unchanged. Left\n basilar atelectasis and adjacent pleural effusion have improved, and a small\n right pleural effusion is also slightly smaller.\n\n IMPRESSION: Vascular catheter terminates in lower superior vena cava with no\n evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1002959,
"text": " 4:52 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate\n Admitting Diagnosis: AORTIC STENOSIS\\CORONARY ARTERY BYPASS GRAFT WITH AVR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with s/p avr\n REASON FOR THIS EXAMINATION:\n evaluate\n ______________________________________________________________________________\n WET READ: KYg TUE 8:27 PM\n ETT TERMINATES 5.9CM ABOVE THE CARINA. MEDIASTINAL DRAINX2, LEFT CHEST TUBE,\n RIGHT IJ SWAN GANZ ARE UNCHANGED. TIP OF NG TERMINATES INTEH STOMACH. MEDIAN\n STERNOTOMY WIRES AND PROSTHETIC VALVE ARE DEMONSTRATED. THE CARDIOMEDIASTINAL\n CONTOUR SHOWS STABLE POSTOPERATIVE WIDENING. NO PTX. SMALL BILATERAL PLEURAL\n EFFUSIONS AND LEFT BASILAR ATELECTASIS IS PRESENT. \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:27 P.M., \n\n HISTORY: Status post AVR.\n\n IMPRESSION: AP chest compared to at 12:46 p.m.:\n\n Mild pulmonary edema has improved. Small left pleural effusion has increased\n and left basal atelectasis is new and mild. Heart size normal. Lines and\n tubes in standard placements. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1004372,
"text": " 9:47 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: AORTIC STENOSIS\\CORONARY ARTERY BYPASS GRAFT WITH AVR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of a patient after CABG.\n\n Portable AP chest radiograph compared to .\n\n The appearance of the post-sternotomy wires is intact. The cardiomegaly is\n stable. The right pleural effusion has slightly increased in the interim with\n new right lower lobe opacity which may represent a developing pneumonia or\n aspiration. The rest of the lungs is unremarkable with no evidence of edema.\n The right internal jugular line tip is at cavoatrial junction.\n\n Findings discussed over phone with Dr. by Dr. at the time\n of dictation.\n\n\n DL\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2179-02-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1004976,
"text": " 9:09 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: AORTIC STENOSIS\\CORONARY ARTERY BYPASS GRAFT WITH AVR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Follow up.\n\n COMPARISON: .\n\n FINDINGS: In comparison to the previous radiograph, the central venous access\n line has been removed. No pneumothorax. Minimal remaining bilateral pleural\n effusions. Mild cardiomegaly without signs of cardiac decompensation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1002911,
"text": " 12:06 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pleural effusion, pulmonary edema, tamponade, pneumothorax.\n Admitting Diagnosis: AORTIC STENOSIS\\CORONARY ARTERY BYPASS GRAFT WITH AVR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with CABG/AVR\n REASON FOR THIS EXAMINATION:\n Pleural effusion, pulmonary edema, tamponade, pneumothorax. \n will issues . Pt in OR 2 and will be in CSRU in 30 mins.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: In comparison with the study of , there has been a CABG\n procedure with intact sternal sutures. The tip of the endotracheal tube lies\n approximately 4.5 cm above the carina. Right Swan-Ganz catheter extends well\n into the right pulmonary artery. Nasogastric tube extends into the stomach.\n Left chest tube is in place and there is no pneumothorax. Some atelectatic\n changes at the left base.\n\n IMPRESSION: Standard appearance following cardiac surgery.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1004567,
"text": " 10:36 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: AORTIC STENOSIS\\CORONARY ARTERY BYPASS GRAFT WITH AVR\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p CABG/AVR\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: CABG and AVR, evaluate pleural effusions.\n\n IMPRESSION: PA and lateral chest compared to through 13:\n\n Small bilateral pleural effusions, unchanged since . Severe right\n lower lobe atelectasis persists. Upper lungs clear. Cardiomediastinal\n silhouette has a normal postoperative appearance. No pneumothorax. Tip of\n the right jugular line projects over the low SVC.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-09 00:00:00.000",
"description": "Report",
"row_id": 1630153,
"text": "volume given for low filling pressures,brisk huo,ongoing metabolic acidosis with rising hct & labile bp. cardiac index remains >2.remains a paced for bp support,underlying rhythm sinus 60's.awoke,weakly mae x 4 but failed 1st wean attempt with resp. acidosis. lethargic unless stimulated,unable to lift & hold head or extremities off the bed @ this time.glucoses managed with insulin gtt,see flow sheet. family in,questions answered,see flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-10 00:00:00.000",
"description": "Report",
"row_id": 1630154,
"text": " 11p-7a\nneuro: arouses to voice, follows commands, very drowsy on receipt of pt, appears more wakeful as shift continued, mae, perrlaa\n\ncv: a paced 88 (underlying rhythm sr 60s w/ occasional pvcs) for bp support, sbp 90-130 (goal this am sbp >110 for renal perfusion), neo gtt titrated to keep sbp>110, pad 23-3-, cvp 14-20, ci 2.4-3, max temp 38, ct draining small/moderate amounts s/s drainage\n\nresp: lungs cta, dim to left base, attempts at cpap overnoc unsuccesful r/t metabolic acidosis, improved abg once returned to simv, 02 sats >97% on vent settings overnoc, minimal secretions overnoc\n\ngi: abdomen soft/nondistended, og to lcs draining clear/bilious drainage, insulin gtt restarted overnoc, 40 units lantus sc given this am\n\ngu: foley to gravity draining clear yellow urine in small amounts, no improvement in uop w/ fluid boluses, 20 mg iv lasix given w/ small improvement in uop for short time\n\nlabs: k 5.7 overnoc txed w/ 10 units iv regular insulin and 12.5g d50, ca repleted\n\nplan: wean neo to keep sbp>110, wean insulin gtt to off, wean vent as able, once extubated, deline and transfer to 6\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Report",
"row_id": 1630162,
"text": "ROS:\n\nNeuro: A+O x's 3. Sleepy but arouses w/ease. Denies pain. Transfers w/2 assists. Steady gait, amb x's 2 today.PERRLA.\n\nCV:Afib rate 80-90's. This afternoon Aflutter. VSS stable w/HTN, metoprolol 12.5 mg this AM. This afternoon HTN ^, metoprolol dose ^ to 25 po and dose given at 1800 per Dr. . ABP line cath w/crack, unable to be rewired per Dr. , line dc'd. Has RIJ cordis. Heparin gtt at 900 units/hr PTT remains subtheraputic. Generalized edema. Has 1 A wire and 2 V wires. V wires sense and capture. Pacer set for VVI rate 40.\n\nResp: Breath shounds diminished w/rhonci in bases. Productive cough of thick yellow sputum. O2 2L/ NP, sats 95% or >. No resp distress noted, = rise and fall of chest. Good cough. IS w^ to 250cc.\n\nGI: Taking general diet this AM and at noon w/o c/o n/v. Some coughing noted w/fluids. c/o upset stomach at evening meal time, refuses meal after several bites. H2 blocker for gi prophylaxis.\n\nGU: Foley patent drainin clear yellow urine in QS. Auto diuresing this AM w/tappering amt throughout day and notable ^ in rhonci in breath sounds. Bun/Crt down. Laxis 40 give IVP w/good response.\n\nENdo: FSG not requiring coverage.\n\nLytes: K and IC repleted this afternoon.\n\nSocial: Wife and daughter phoned w/update.\n\nPlan: Check PTT at 2230. F/U lytes w/next lab draw. Pulmonary toilet. Mobilize . Pacing SWAN in room on standby for emergency need. Monitor, tx, support, and comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Report",
"row_id": 1630163,
"text": "ekg aflutter, rate 78-90, occ very briefly up to 100s. no ectopy. sbp 150s, lopressor at 25 mg . afebrile. responded briskly to iv lasix earlier. k and mag repleted, glucose followed per protocol, no insulin req overnight. breath sounds clear, decreased at bases, deep breathes well, uses incentive spirometer, achieves 500cc. excellent cough, produces mod amt thick yellow to white secretions. maintains spo2 > 95% on 2l nc. sternal wound and ct sites dry, some skin tears on r torso, covered with tegaderm. abd soft, distended, bowel sounds present, some flatus, but no stool overnight. drank a lot of fluid, refused offers of food. feet warm, dp and pt palp bilat. skin on back and buttocks intact, is generally edematous. pupils equal, alert and oriented, although loses track of day sometimes. denied pain, but accepted tylenol x 1 for general discomfort. plan today is to advance diet and activity as tolerated, start coumadin if pacer is not needed, transfer to f6 when ready.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-10 00:00:00.000",
"description": "Report",
"row_id": 1630155,
"text": "Resp care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear suct sm th off white sput. ABGs improving throughout shift; Attempted CPAP trial overnoc unsuccessful; will attempt this AM. RSBI low but Vt and RR low. Cont wean to extub.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-10 00:00:00.000",
"description": "Report",
"row_id": 1630156,
"text": "NPN: S/P CABG X2, AVR\n\nNeuro: Awakened, moving all extremities. Oriented X2. Moves all extremities but very stiff/volume overloaded. After extubation-pt slightly lethargic and uncooperative at times. In afternoon slightly improved with wife visiting. Pupils R>L 3-2mm-reactive. +strong cough and gag.\nID: Tmax 98.1 orally. WBC-15.6\nCV: 70-80's SR with rare PAC seen. Weaned off neo. CI> 2.5. Swan dc'd.\nCa repleted X1. Required 1L crysttaloid and 25% albumin X2 for low uo.\nPedal pulses weakly palpable. To recieve Coumadin this pm.\nResp: Extubated to 50% OFT neb and weaned to 4l nc O2. Sats >97%. ABG's remain acidotic with pO2>90's. RR 15-24 Lungs diminished in L base. CT/MT to sxn. No airleak. dumped 320cc serosang drainage when OOB to chair. Cough fair. Productive X1 thick yellow green sputum.\nGU: Foley with low uo all am despite 1L volume. Given albumin and then lasix 20mg IV with ^ to 70cc/hr X 2 hrs. Creat 1 this am.\nGI: Abdomen softly distended with no bowel sounds. OGT dc'd with extubation. + belching and nausea X2-treated with reglan and then zofran with effect. Only tolerating small amount water.\nEndocrine: Given 40 units glargine 6am-insulin gtt stopped at 9am. Glucoses 151-171-covered with regular insulin 6 units sc X2. Ordered for usual home insulin in am.\nComfort: Percocet given X1 then N/V in pm. Morphine 2mg IV given with better effect.\nActivity: OOB to chair X 4 hrs-tolerated well. Moved fairly.\nIncisions: Sternum and CT with DSD-D/I. Bilateral legs with ace wraps intact.\nA: Slow return GI function. Acidotic ABG's.\nP: Pulmonary toilet, Recheck hct, follow BUN and creat, Lopressor and lasix as ordered. Coumadin\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Report",
"row_id": 1630164,
"text": "SEE CHART FOR HARD COPY OF NOTE FOR THIS SHIFT\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Report",
"row_id": 1630165,
"text": "ekg aflutter, no ectopy, rate 80-90. lopressor at 25 mg , pacing wires out. sbp 140-160, drops lower after lopressor. afebrile, wbc down to 12.6 this am from 14 yesterday. adequate uo, lasix decreased to once daily yesterday. continues on heparin, subtherapeutic after being off for wire removal, and increased to 1050 units. glucose rx per sliding scale, was 60 from am labs, rechecked and up to 80, was asymptomatic. k repleted x 1. breath sounds usually clear, occ rhonchi and faint exp wheeze, receiving inhalers. excellent cough, produces mod to large amts thick yellow sputum, maintaining spo2 >95% on 2l nc, drops to 90 on room air, especially when asleep. sternal wound and ct sites dry, dressing changed. skin warm and dry, still edematous. leg incisions slightly pink, dry. feet warm, dp and pt palp bilat. abd soft, distended, bowel sounds present. tolerating fluids, did not want solids during night. no problems with swallowing noted. very small soft stool this am on commode, patient was offered laxatives this am, but refused, is afraid of having diarrhea. alert and oriented, anxious to go to floor, is a little discouraged. med for mild incisional discomfort x 2 with 1 percocet. plan to have swallowing consult, start coumadin today, increase activity and encourage nutritional intake, transfer to .\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Report",
"row_id": 1630157,
"text": " 7p-7a\nneuro: oriented to self only, reoriented to place and time, at beginning of shift pt slow to answer questions and would repeat answer to previous question when asked a new question, pt seems better able to answer questions correctly this am, but still unable to state where he is and what year it is, mae, follows commands\n\ncv: sr/st 79-101 w/ occasional pvcs, sbp 95-135, afeb, ct draining small amts s/s drainage, pacer set to aai backup 58\n\nresp: upper lobes clear bilat, crackles to bilat lower lobes, moderate strength cough productive of thick yellow sputum, able to wean 02 to 2L nc this am for sats >95%, pt unable to follow directions at this time to use incentive spirometer\n\ngi: abdomen soft/nondistended, bowel sounds present, tolerated clear liquids overnoc, elevated blood sugars overnoc\n\ngu: foley to gravity draining small amts yellow urine, small improvement in uop w/ lasix 20mg iv\n\nlabs: hct dropped from 27 to 24 this am\n\nassess: stable\n\nplan: reorientation prn, increase activity, pulmonary toilet, increase lantus dose?, transfer to 6\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Report",
"row_id": 1630158,
"text": "NEURO: Pt very lethargic and confused. At times pt able to state his name, birthday, president and that he is in a hospital. Most recently pt was unable to state his name, location or year. Pt c/o pain this am, given 1 PO percocet with good relief. Pt did not receive any more pain medication d/t lethargy and pt has since denied pain.\n\nCV: Pt in NSR this am\u0013; given 12.5mg PO lopressor. Pt began to havee pauses and eventually went into slow AF 30s-50s. AEG done with atrial wires which showed a questionable 2 to 1 AV Block vs CHB. NP indeed calling it CHB with slow ventricular escape. Tried A pacing pt, and pacer would not capture. NP in to adjust pacer, set at V demand, pacer did not 100% capture. Eventually AV paced pt and noticed longer pauses-->team notified at which time a cadiology consult was placed.- MD in to evaluate pt and adjust pacer settings. Settings as documented in carevue. Pacer does not always capture 100%, currently V pacing in A-flutter. Cardiology feels that this is all d/t post-op edema in the AV node and will resolve with time-->all strips in pt chart(maroon). External pacer placed on pt @ 1800. Coumadin held NP . Pt maintained SBP>90 throughout shift, even when rate in 30s. Pt likes higher BP, currently SBP 130s-150s. Pt transfused with 1 unit PRBCs for drop in Hct, post Hct 29.4. Pt likes higher SBP. PP palpable.\n\nRESP: Pt on 2L NC, sats>95%. Pt coughing and deep breathing off and on, pt is occ non-compliant, refusing to CDB & use IS. Pt used IS uneffectively, not completely understanding and not listening to instructions. LS crackles/exp wheezing and dim in bases. Albuterol neb given. Asked NP for albuterol prn order. CT D/C'd this am->x-ray done.\n\nGI/GU: Pt nauseous this am, given zofran with good relief. Pt refused food and drinks. Refused pills this afternoon/pt too lethargic to swallow @ times. 20mg IV lasix given for standing order-->pt did not respond, given additional 40mg IV after unit PRBCs with + diuresis (pt also had ^ BP @ this time). BUN/creat^.\n\nENDO: Pt BS remained >200 for over 12 hrs with no relief from humalog & lantus this am-->cahnged to RISS-->BS remained elevated-->started on insulin gtt.\n\nSOCIAL: wife in to visit with pt, stated she will call to check on husband.\n\nPLAN: Continue to pace pt at current settings, monitor VS, neuro status, resp status. Cont to encourage pulmonary toileting.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Report",
"row_id": 1630159,
"text": "\n NEURO PT A/O RELAXED IN FAIR SPIRITS MAE AROUND BED TOL WELL MILD SOB ON MOTION PLEASE SEE CAREVIEW FOR DETAILS NO PAIN OR DISCOMFORT\n RESP RHONCHI THRU OUT CLEARS AFTER PRODUCTIVE COUG DONE NOTE GREEN IN COLOR 2/NP SAO2 98\n HEART V/PACED UNDERLINING SLOW A/F MD POS 3 THRU OUT VSS NO TEMP DISTANT HEART TONES\n GI POS B/S NOTED U/O QS SOFT NON DISTENDED NO PAINFUL SOME FLATUS\n WOUNDS STERNUM CLEAN NO DRAINAGE\n PLAN SUPPORTIVE T/P OOB PT CONSULT FAMILY HELP WITH UNDERSTANDING OF SITUATION\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Report",
"row_id": 1630160,
"text": "NEURO: Pt lethargic most of day; arousable by voice. Follows commands and MAE. Pt Ox3 earlier this shift, however does not consistently respond to questions; falls asleep before answering despite being asked numerous times. Reoriented prn throughout the shift. Denied pain all shift; ? hold percocet or change pain medicine d/t lethargy from 2 percocets given @ 0300. Pt OOB to chair for few hours. Pt was able to stand and turn with some assisstance. PT will work with pt .\n\nCV: Pt V paced 60 @ beginning of shift, checked underlying rhythm and found pt to be in AF 30s, cont V Pacing @ 60 with occ pauses (not a new finding). Shortly after MD from EP @ bedside to evaluate pt. Checked wires and underlying, which he found to be 40s A fib/flutter. 12 lead EKG done at bedside and pacer turned rate set @ 40. Pt slowly ^ A-fib 50-60s. MD noticed pt had rate in 80s overnight, which abruptly slowed back to 30s which was same time pt received 2gm Mag for level 1.9->he suggested that we do not replete Mg unless hypomagnesemic; check with team before repleting Mg! Shortly after pacer was turned down, pt rate ^ 130s; pt tol, no change in BP. NP 2.5mg Lopressor IV MR1. Would like HR<100. Coumadin held NP ; plans to start pt on heparin gtt tonight. Pt has since remained in AF 44-50s. SBP 110s-150s, MAP 60-80. Hct 28. PP palpable.\n\nRESP: LS clear, dim in bases with audible wheeze; upper airway. Pt given albuterol NEB prn. Pt not breathing well and not using IS effectively. Has been continuously instructed on how to use IS, however <200 and refusing throughtout shift. CPT done x1. Expectorated small amt yellow thick sputum.\n\nGI/GU: More active BS, however Pt refusing to eat. Ate small amt of jello and drank little bit of broth and ginger ale. Pt c/o Nausea x1-given zofran. min HUO- given 40mg IV lasix, ordered , with little diuresis.\n\nENDO: 60 units lantus given this am; BS tx per RISS.\n\nSOCIAL: Wife and daughter in to visit with pt; Wife spoke with NP and was updated on status of pt.\n\nPLAN: Monitor HR & rhythm; VS. Encourage pt to eat/drink, ^ acivity->PT plans to see pt . Cont with pulmonary toileting. Start Heparin gtt. ? Access--NP aware of diff stick!\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Report",
"row_id": 1630161,
"text": "\n NEURO PT A/O RELAXED NO C/O PAIN OR DISCOMFORT NOTED MAE ONLY LIMITATION EDEMA AT HANDS AND FEET PT TIRED SLEEPS LONG PERIODS WAKES LETHARGIC SOMETIMES WITHDRAWN IN APPEARANCE\n RESP RHONCHI CLEARS AFTER PRODUCTIVE COUGH 2 L NP SAO2 100 CPT TOL WELL YELLOW/GREEN SPUTUM\n HEART UNDERLINE HEART BEAT AFF RATES 40 PAUSES SEC PACER ON VENT 90 PERSENT CAPTURE RATE 40 TO 60 MD POS 3 THRU OUT 3 PLUS EDEMA VSS NO TEMP DISTANT HEART TONES\n GI POS B/S PO LIMITED LACK OF WANT NO STOOL U/O FAIR POST ALBUMIN 5\n WOUND D/I DRESSING CHANGE DONE\n PLAN WEAN PACER AS HEART HEALS SUPORTIVE PO FOOD AND FLUIDS EMOTIONAL HELP WITH HEALING PROCESS\n"
},
{
"category": "Echo",
"chartdate": "2179-02-08 00:00:00.000",
"description": "Report",
"row_id": 85831,
"text": "PATIENT/TEST INFORMATION:\nIndication: CABG, AVR\nStatus: Inpatient\nDate/Time: at 16:49\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPlease this TEE was done on during the surgery\nLEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\nascending aorta. Complex (>4mm) atheroma in the aortic arch. Complex (>4mm)\natheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Moderate AS (AoVA 1.0-1.2cm2) Moderate (2+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild to moderate\n(+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. Results were personally reviewed with\nthe MD caring for the patient.\n\nsions:\nPRE-BYPASS:\nThe left atrium is dilated. No spontaneous echo contrast or thrombus is seen\nin the body of the left atrium/left atrial appendage or the body of the right\natrium/right atrial appendage. No atrial septal defect is seen by 2D or color\nDoppler. There is mild symmetric left ventricular hypertrophy with normal\ncavity size and regional/global systolic function (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. There are complex\n(>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the\ndescending thoracic aorta. Moderate (2+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nMild to moderate (+) mitral regurgitation is seen. There is a moderate\naortic regurgitation with moderate aortic stenosis. There is no pericardial\neffusion. Dr. was notified of the findings in the operating room.\n\nPost_Bypass:\nPreserved biventricular normal systolic function. LVEF 55%.\nAscending aortic contour is well preserved.\nMild to Moderate regurgitation is seen.\nThere is a mechanical valve in the native aortic position, stable and moving\nwell with residual gradients of a peak of 12 and a mean of 5mm of Hg.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2179-02-09 00:00:00.000",
"description": "Report",
"row_id": 213556,
"text": "Sinus rhythm. First degree A-V delay. Left atrial abnormality. Left anterior\nfascicular block. ST-T wave abnormalities with probable prolonged\nQTc interval (although it is difficult to measure) are non-specific. Clinical\ncorrelation is suggested for possible drug/electrolyte/metabolic effect and/or\npossible myocardial ischemia. No previous tracing available for comparison.\n\n"
}
] |
13,856 | 163,708 | A/P: 76 yo female with hx of CAD s/p CABG and AVR, HTN, hypothyroidism who was initially admitted to an OSH for TKR with multiple complications including abdominal abscess with sepsis, CHF, and DVT now being transferred for further management. . On arrival she was assessed and noted to have cardiogenic shock with 4+ MR 25%. Additionally she had severe volume overload from resuscitation and required pressor support with neosynephrine to maintain her blood pressure. She had respiratory failure due to her cardiogenic shock but was unable ot be diuresed due to hypotension. She had multiple abdominal abscesses on her CT scan from hospital. She had no positive blood cultures from but had abdominal catheter growing E.coli and Klebsiella. Additionally on arrival she was noted to have a cold, pulseless left lower extremity. Given her over-riding cardiogenic shock and inability to be off pressor medication, she was not a candidate for surgical intevention, and her additional problems it was determined that she would not make a meaningful recovery. Her family decided to withdraw ventilatory and blood pressure support and pursue comfort with morphine and ativan. She expired 10 hours later. | 2 L IJ lumen treated w/ TPA. She is DNR @ this time per Dr. . intubated due to MI. Cuff BP:80's-90's/systolic with MAP 55-73 on IV neosynephrine 2.0-2.4mcg/kg/min. Check re repleting K 3.9. Marked diminution in voltage compared tothe previous tracing of and evidence of recent or ongoinganterolateral myocardial infarction, with continued upward coved ST segmentelevation in leads V2-V4 and prominent Q waves in leads I, aVL and V5-V6.QS deflections in leads V2-V3. L popliteal present by doppler, as well as L posterior tibial. R DP & PT present by doppler. Able to obtain CVP & withdraw blood from catheter after TPA.A/P: Patient still hemodynamically unstable requiring IV neo to maintain BP & having runs of V-tach. The patient is after median sternotomy and aortic valve replacement. septic.was on ps 10/5 but sedated for hospital transfer. The right PICC line tip terminates in superior SVC. B pleural effusions.GI: hypoactive + bowel sounds. Squeezes hand,and attempts to stick out tongue on command.CV: HR: 109-129 ST w/frequent APC's & PVC's & short, 3-10 beat runs V-tach. Ett 7.0, retaped,rotated and secured @ 20 lip. NGTube pulled out when patient was extubated.gu: urine output trending down with BP dropping. Pulses on R > than L. Anasarca, w/serum albumin low (<2.0).Resp: O2 sats remained @ 100% ON A/C (CMV). Frequent atrial ectopy. Patient did fine but changed back to A/C to decrease workload on heart. EKG shows low-voltage cardiogram due to amt cardiac damage.At risk for inadequate arterial perfusion to L foot & lower leg. NGT- recieved tube feedings through it @ Hospital. All meds/treatments are to be continued (not CMO).Access: L double lumen PICC w/ 1 lumen clotted, despite TPA.L triple lumen IJ. s/p l knee repl. Watch for increased ectopy, increased HR, decreased BP. Did not tolerate Dobutamine as it raised HR to 129 @ low dose (2.5mcg/kg/min) almost immediately. ABG'S7.49/PCO2 31/PO2 106/base xs 1/calc CO2 24. **Note found ett tube has been cut back** Bs are clear and suctioned for scant amount of thin white secretions. Brief trial on CPAP w/PS10/PEEP 5/ tV500/FiO2 30%. Vent changes to decrease VT to 450, R 10 with additional abg pending. Placement confirmed by CXR done @ Hospital.GU: Foley draining amber urine @ 40+ cc/hrSkin: Small (.5X.5cm) decub @ coccyx w/scant blood when drsg . NPO overnight except for meds. Abg 7.49/31/106/24. care76 yo from osh. Resp: pt on a/c 12/500/5+/30%. Patient expired @ 2130 . Events:Patient made CMO after family meetingSacrament of sick given by Catholic priestMorphine drip started @ 1345Neosynephrine and Heparin drip dc'dExtubated @ 1430Neuro: Comfortable with morphine drip @ 20mg/hr, no signs of grimacing with turning/reposition. Gravity of patient's condition explained by doctors this . Followup and clinical correlation are suggested.Question pericardial effusion and/or ischemic cardiomyopathy. Gurgling sounds intermittently.gi: tube feeds not started, hypoactive bowel sounds. Returned to IV neo. The NG tube tip terminates in the stomach. Ativan 2mg given x 2 prior to and soon after extubation.CV: SVT 150's with 10 runs of v-tach intermittently. now on a/c.sx'd for no sputum. Await family's decision re: patient's care Continue to monitor pulses & maintain in arterial position if possible. Family remained w/ patint until she expired. C&S sent. plan to wean back to ps as when awake. Portable AP chest radiograph compared to . Patient turned side to side to keep off decub. Ordered for IV flagyl, po vanco & ipenum-cilastin IV.Coping: Patient's daughter (proxy) & son visited patient this evening. NPN 1900-2300Patient on comfort measures only. Sinus rhythm. resp. Arrived w/ 1 lumen completely clotted &the other 2 lumen unable to be drawn from. The left internal jugular line tip is at the junction of the brachiocephalic vein with SVC. Off of pressor since 1345. pedal pulses dopplerable, LLE mottled, great and 2nd toe purplish in color, cold to touch. Watch for color changes/S&S necrosis/ lack of pain from no perfusion. 10:57 PM CHEST (PORTABLE AP) Clip # Reason: assess for worsening effusions Admitting Diagnosis: SEPSIS MEDICAL CONDITION: 76 year old woman with hx of CAD s/p CABG admitted with cardiogenic shock REASON FOR THIS EXAMINATION: assess for worsening effusions FINAL REPORT REASON FOR EXAMINATION: Evaluation for pulmonary effusions in a patient after CABG admitted for cardiogenic shock. Bed placed in arterial position & monophasic pulse returned by midnight. On IV morphine @ 20mg/hr. Bilateral pleural effusions are demonstrated at least moderate in size. Feet suspended off pillow(s) to prevent pressure ulcers.Pain: Patient looked uncomfortable by grimace scale w/ palpation of abdomen or w/ movement L foot. L lower leg & foot cool & mottled. Patient appears comfortable when not moving or being examined & slept during night.Infection: Hx grm - rods growing from abdominal abcess drainage (viscous green-yellow fluid). Family at bedside, emotional support provided. Tidal volume decreased to 450(from 500)/RR decreased to 10(from 12)/PEEP5/fiO2 30%. respi: extubated @ 1430, satting 82-87% at room air, morphine increased in the setting of agonal breathing; levsin given SL for increased secretions. Tmax 99po. HCP and family was made aware of the options they have as well as the diagnosis at present, decided to make patient CMO. Mild perihilar haziness is present which might be attributed to pulmonary edema although the precise degree of the congestive heart failure is difficult to appreciate in the presence of layering bilateral pleural effusions. Family then remained w/the body for awhile afterwards. | 9 | [
{
"category": "Radiology",
"chartdate": "2131-04-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 964395,
"text": " 10:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for worsening effusions\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with hx of CAD s/p CABG admitted with cardiogenic shock\n REASON FOR THIS EXAMINATION:\n assess for worsening effusions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation for pulmonary effusions in a patient after\n CABG admitted for _____cardiogenic shock.\n\n Portable AP chest radiograph compared to .\n\n The patient is after median sternotomy and aortic valve replacement. The\n heart size is normal. The ET tube tip is 4.3 cm above the carina. The NG\n tube tip terminates in the stomach. The left internal jugular line tip is at\n the junction of the brachiocephalic vein with SVC.\n\n The right PICC line tip terminates in superior SVC.\n\n Bilateral pleural effusions are demonstrated at least moderate in size. Mild\n perihilar haziness is present which might be attributed to pulmonary edema\n although the precise degree of the congestive heart failure is difficult to\n appreciate in the presence of layering bilateral pleural effusions.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2131-04-27 00:00:00.000",
"description": "Report",
"row_id": 190123,
"text": "Sinus rhythm. Frequent atrial ectopy. Marked diminution in voltage compared to\nthe previous tracing of and evidence of recent or ongoing\nanterolateral myocardial infarction, with continued upward coved ST segment\nelevation in leads V2-V4 and prominent Q waves in leads I, aVL and V5-V6.\nQS deflections in leads V2-V3. Followup and clinical correlation are suggested.\nQuestion pericardial effusion and/or ischemic cardiomyopathy.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-04-26 00:00:00.000",
"description": "Report",
"row_id": 1443270,
"text": "resp. care\n76 yo from osh. s/p l knee repl. intubated due to MI. ? septic.\nwas on ps 10/5 but sedated for hospital transfer. now on a/c.\nsx'd for no sputum. plan to wean back to ps as when awake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-04-27 00:00:00.000",
"description": "Report",
"row_id": 1443271,
"text": "Resp: pt on a/c 12/500/5+/30%. Ett 7.0, retaped,rotated and secured @ 20 lip. **Note found ett tube has been cut back** Bs are clear and suctioned for scant amount of thin white secretions. Abg 7.49/31/106/24. Vent changes to decrease VT to 450, R 10 with additional abg pending. Plan to maintain present settings on a/c.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-04-27 00:00:00.000",
"description": "Report",
"row_id": 1443272,
"text": "NPN 1900-0700\nNeuro: Opens eyes to voice. Squeezes hand,and attempts to stick out tongue on command.\n\nCV: HR: 109-129 ST w/frequent APC's & PVC's & short, 3-10 beat runs V-tach. Cuff BP:80's-90's/systolic with MAP 55-73 on IV neosynephrine 2.0-2.4mcg/kg/min. Did not tolerate Dobutamine as it raised HR to 129 @ low dose (2.5mcg/kg/min) almost immediately. Returned to IV neo. No L DP or L anterior tibial even by doppler @ . L popliteal present by doppler, as well as L posterior tibial. Bed placed in arterial position & monophasic pulse returned by midnight. R DP & PT present by doppler. L lower leg & foot cool & mottled. Pulses on R > than L. Anasarca, w/serum albumin low (<2.0).\n\nResp: O2 sats remained @ 100% ON A/C (CMV). ABG'S7.49/PCO2 31/PO2 106/base xs 1/calc CO2 24. Tidal volume decreased to 450(from 500)/RR decreased to 10(from 12)/PEEP5/fiO2 30%. Brief trial on CPAP w/PS10/PEEP 5/ tV500/FiO2 30%. Patient did fine but changed back to A/C to decrease workload on heart. B pleural effusions.\n\nGI: hypoactive + bowel sounds. NPO overnight except for meds. NGT- recieved tube feedings through it @ Hospital. Placement confirmed by CXR done @ Hospital.\n\nGU: Foley draining amber urine @ 40+ cc/hr\n\nSkin: Small (.5X.5cm) decub @ coccyx w/scant blood when drsg . Duoderm applied @ midnight. Patient turned side to side to keep off decub. Feet & heels intact. Feet suspended off pillow(s) to prevent pressure ulcers.\n\nPain: Patient looked uncomfortable by grimace scale w/ palpation of abdomen or w/ movement L foot. No pain med yet for CV instablity. Patient appears comfortable when not moving or being examined & slept during night.\n\nInfection: Hx grm - rods growing from abdominal abcess drainage (viscous green-yellow fluid). C&S sent. Tmax 99po. Ordered for IV flagyl, po vanco & ipenum-cilastin IV.\n\nCoping: Patient's daughter (proxy) & son visited patient this evening. Gravity of patient's condition explained by doctors this . will discuss this info w/her 2 brothers this morning to determine the plan for this patient. She is DNR @ this time per Dr. . All meds/treatments are to be continued (not CMO).\n\nAccess: L double lumen PICC w/ 1 lumen clotted, despite TPA.\nL triple lumen IJ. Arrived w/ 1 lumen completely clotted &the other 2 lumen unable to be drawn from. 2 L IJ lumen treated w/ TPA. Able to obtain CVP & withdraw blood from catheter after TPA.\n\nA/P: Patient still hemodynamically unstable requiring IV neo to maintain BP & having runs of V-tach. EKG shows low-voltage cardiogram due to amt cardiac damage.At risk for inadequate arterial perfusion to L foot & lower leg.\n Check re repleting K 3.9.\n Await family's decision re: patient's care\n Continue to monitor pulses & maintain in arterial position if possible. Watch for color changes/S&S necrosis/ lack of pain from no perfusion.\n Watch for increased ectopy, increased HR, decreased BP.\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-04-27 00:00:00.000",
"description": "Report",
"row_id": 1443273,
"text": "Events:\n\nPatient made CMO after family meeting\nSacrament of sick given by Catholic priest\nMorphine drip started @ 1345\nNeosynephrine and Heparin drip dc'd\nExtubated @ 1430\n\n\nNeuro: Comfortable with morphine drip @ 20mg/hr, no signs of grimacing with turning/reposition. Ativan 2mg given x 2 prior to and soon after extubation.\n\nCV: SVT 150's with 10 runs of v-tach intermittently. Off of pressor since 1345. pedal pulses dopplerable, LLE mottled, great and 2nd toe purplish in color, cold to touch.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-04-27 00:00:00.000",
"description": "Report",
"row_id": 1443274,
"text": "respi: extubated @ 1430, satting 82-87% at room air, morphine increased in the setting of agonal breathing; levsin given SL for increased secretions. Gurgling sounds intermittently.\n\ngi: tube feeds not started, hypoactive bowel sounds. NGTube pulled out when patient was extubated.\n\ngu: urine output trending down with BP dropping.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-04-27 00:00:00.000",
"description": "Report",
"row_id": 1443275,
"text": "social: family and HCP met with team and discussion were made unto how the patient's condition is, the plan of care for her. Family verbalized that they dont want their mother to be in pain, they wanted her comfortable and doesn't want any aggressive treatment be done in the setting of multi-organ involvement and cardiogenic shock couldn't sustain the quality of life she would want to have even with procedures to be done and an open heart surgery will not be tolerated by patient considering her weak heart. HCP and family was made aware of the options they have as well as the diagnosis at present, decided to make patient CMO. Family requested for sacrament of sick, given by Catholic priest. Family at bedside, emotional support provided.\n"
},
{
"category": "Nursing/other",
"chartdate": "2131-04-27 00:00:00.000",
"description": "Report",
"row_id": 1443276,
"text": "NPN 1900-2300\nPatient on comfort measures only. On IV morphine @ 20mg/hr. No S&S pain or discomfort. Family remained w/ patint until she expired. Patient expired @ 2130 . Family then remained w/the body for awhile afterwards. Family took belongings (a cross).\n"
}
] |
40,474 | 130,539 | She was admitted after evaluation in The Emergency Department for shortness of breath. She was treated with steroids and nebulizers in the Emergency Room, however, due to elevated BNP was felt to be in acute diastolic heart failure. She was treated with diuretics. She underwent cardiac catheterization for evaluation of possible intervention but was found to have restenosis of the stents placed previously that was not amenable to PCI. cardiac surgery was consulted for surgical evaluation. She underwent preoperative workup that include hepatology consult due to Hepatitis B and was noted as Childs A. The hepatologists recommended discontinuing the Tenofovir after the surgery until her creatinine was noted to be stable for a couple days. Urine culture revealed klebsiella in the urine and she was treated with ciprofloxacin with a repeat urine culture pending at the time of surgery. She continued to be diuresed, however, her creatinine increased and renal was consulted due to history of chronic kidney disease with evidence of acute injury with diuresis. Diuretics were then dosed as needed and creatinine monitored daily. Surgery was delayed until improvement of renal function. There also was concern for aspiration and a swallow study was evaluated and she was placed on restriction with 1:1 observation with meals. She also underwent a barium swallow which ruled out esophagitis but did reveal tertiary dysmotility. Additionally, was consulted preoperatively for diabetes management as she was on U500 at home to assist with blood glucose management. On she was brought to the Operating Room and underwent off pump coronary artery bypass graft surgery (see operative report for further details). She received vancomycin and cefazolin for perioperative antibiotics and transferred to the intensive care unit for post operative management. She was weaned from sedation, however, was resedated due to dyssynchrony with the ventilator. She remained intubated and sedated overnight. She continued to fail weaning of sedation and remained on Propofol and pressure support ventilation. A Lasix drip was started for gentle diuresis and she progressively improved. On post operative day two she was weaned off Propofol and was extubated with anesthesia at the bedside. She required BiPAP post extubation for ventilation. Her respiratory status improved and chest tubes and pacing wires were removed per cardiac surgery protocol. She was transferred to the floor in stable condition. She continued to require frequent nebulizer treatments, diuresis and chest PT for a tenuous respiratory status. Her renal function was improving while she was on a low dose of Lasix for gentle diuresis. Lopressor and Lantus were both titrated for better blood pressure and blood sugar control. She was tolerating a full diet, ambulating with assistance and her incisions were healing well by POD#6. Physical Therapy worked with her for mobility and strength. She was able to progress to self feeding. A stay at rehabilitation was recommennded prior to her returning home with family with continued diuresis with intravenous lasix for a few more days. It was felt that she was safe for discharge to Rehab MACU on . | Unchanged position of the nasogastric tube, the endotracheal tube and the right central venous access line. Unchanged mild left basal atelectasis, potentially combined with a minimal pleural effusion. FINDINGS: The right IJ catheter ends in the low SVC. FINDINGS: The right IJ catheter ends in the low SVC. Unchanged moderate cardiomegaly with signs of minimal pulmonary edema. The left ventricularcavity size is normal.3.Doppler parameters are most consistent with Grade I (mild) left ventriculardiastolic dysfunction.4. Low lung volumes with unchanged minimal bibasilar atelectasis. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. The cardiac and mediastinal contours are unchanged and have an expected post-operative appearance. No thrombus in the LAA.LEFT VENTRICLE: Mild symmetric LVH. Decreased small bilateral pleural effusions. FINDINGS: Right internal jugular vascular catheter terminates in the mid superior vena cava. Caliber of the postoperative cardiomediastinal silhouette is comparable to the preoperative and so is mild distention of upper lobe pulmonary vasculature, physiologic in the supine positioning. Cardiac silhouette remains enlarged and is associated with mild upper zone vascular re-distribution. There is mild symmetric left ventricular hypertrophy. FINDINGS: Moderate cardiomegaly is unchanged since . Shortness of breath.Status: InpatientDate/Time: at 12:57Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA and RA cavity sizes. Doppler parametersare most consistent with Grade I (mild) LV diastolic dysfunction.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.Normal ascending aorta diameter. Mild bibasilar atelectasis is unchanged. PORTABLE AP CHEST RADIOGRAPH: Moderate cardiomegaly is stable since . Linear atelectasis in the lower lobe is unchanged since .A well-circumscribed density projected over the right lower zone is consistent with a nipple. Swan-Ganz catheter ends in the main pulmonary artery, midline and bilateral pleural drains are in standard positions. Small bilateral pleural effusions are decreased. Trace AR.MITRAL VALVE: Moderate mitral annular calcification. Right IJ ends in the low SVC. Right ventricular chamber size and free wall motion are normal.5.The diameters of aorta at the sinus, ascending and arch levels are normal.There are simple atheroma in the descending thoracic aorta.6. Mild (1+) mitral regurgitation is seen.8. Trace aorticregurgitation is seen.7. A tiny hyperdense focus is seen along the superior sternum, likely external to the patient. Stable moderate cardiomegaly. There is pulmonary vascular congestion without evidence of pulmonary edema. Sternotomy wires are midline and intact. Mild atelectatic changes at the bases. Mildly thickened aortic valveleaflets (3). Pulmonary vascular congestion without evidence of pulmonary edema, unchanged. FINDINGS: As compared to the previous radiograph, the chest tubes and mediastinal drains have been removed. Indeterminate PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. The aortic valve leaflets (3) are mildly thickened butaortic stenosis is not present. There is no pericardialeffusion.Compared with the prior study (images reviewed) of , the degree ofMR seen appears less. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Esophageal dysmotility with ineffective primary and tertiary contractions. IMPRESSION: No findings typical of eosinophilic esophagitis. There is dysmotility noted with ineffective primary peristalsis and tertiary peristaltic contractions. Compared to theprevious tracing of no diagnostic interim change. ]TRICUSPID VALVE: Tricuspid valve not well visualized. Non-specific ST-T wave changes. Lateral ST-T wave changes are non-specific. Diffuse ST-T wave changes are non-specific. Mild(1+) mitral regurgitation is seen. Modest ST-T wave changes with borderline prolonged/upper limitsof normal QTc interval, non-specific, but cannot excludedrug/electrolyte/metabolic effect or possible myocardial ischemia. Modest ST-T wave changes with borderline prolonged/upper limitsof normal QTc interval, non-specific, but cannot exclude possibledrug/electrolyte/metabolic effect or possible myocardial ischemia. The pulmonaryartery systolic pressure could not be determined. Suboptimalimage quality - poor parasternal views. IMPRESSION: Cardiomegaly, mild congestion. No large pleural effusion is seen. Anterolateral lead ST-T wave abnormalities are non-specific.Since the previous tracing of same date there is probably no significantchange. Despite these limitations, several double contrast images taken of the esophagus show no classic findings suggestive of eosinophilic esophagitis. Mild(1+) MR. [Due to acoustic shadowing, the severity of MR may be significantlyUNDERestimated. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. Moderate mitralannular calcification. No resting LVOT gradient. No MVP. No evidence for DVT. No evidence for DVT. Left ventricular function. COMPARISON: No prior imaging for comparison. There is no mitral valve prolapse. Normal interatrial septum.No ASD by 2D or color Doppler.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolicfunction (LVEF>55%). No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No MS. No aortic regurgitation is seen. Due to suboptimaltechnical quality, a focal wall motion abnormality cannot be fully excluded.There is no ventricular septal defect. Right ventricular function.Height: (in) 62Weight (lb): 175BSA (m2): 1.81 m2BP (mm Hg): 137/67HR (bpm): 104Status: InpatientDate/Time: at 11:37Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Suboptimal image quality - poorsubcostal views. No evidence of any mucosal irregularities. There is no pneumothorax. Bony structures appear grossly stable. IMPRESSION: Normal Doppler ultrasound of right lower extremity. Soft tissues overlying the lower chest somewhat limit evaluation. [Due to acoustic shadowing, the severity ofmitral regurgitation may be significantly UNDERestimated.] Since the previous tracing of sinus tachycardia is now present. Since the previous tracing of the rate isslower but, otherwise, there may be no significant change.TRACING #1 Left mid lung plate-like atelectasis is present. Since the previous tracing of same date there is nosignificant change.TRACING #2 | 22 | [
{
"category": "Radiology",
"chartdate": "2118-05-15 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1188556,
"text": " 1:44 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval for ileus\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with acute LUQ pain\n REASON FOR THIS EXAMINATION:\n eval for ileus\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL RADIOGRAPH DATED \n\n No prior abdominal radiographs for comparison.\n\n Exam is somewhat limited by suboptimal technique, but there is no evidence of\n intestinal obstruction or free intraperitoneal air on these radiographs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1187905,
"text": " 11:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p rt ij line change over wire\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p off pump cabg\n REASON FOR THIS EXAMINATION:\n s/p rt ij line change over wire\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post off-pump CABG, status post right IJ line change over\n wire.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The right IJ catheter ends in the low SVC. The ET tube ends 4.4 cm\n above the carina. An NG tube passes below the level of the diaphragm and out\n of the field of view inferiorly. Two mediastinal drains are seen overlying\n the mid thorax. There are bilateral pleural tubes ending at the right lung\n base and left mid lung, respectively. There is no pneumothorax. Lung volumes\n are low, causing crowding of the pulmonary vasculature and accentuation of the\n heart size. There is pulmonary vascular congestion without evidence of\n pulmonary edema. Mild bibasilar atelectasis is unchanged. The heart and\n mediastinum have an expected postoperative appearance. No definite pleural\n effusions are seen. The patient is status post midline sternotomy and CABG.\n\n IMPRESSION:\n\n 1. Right IJ ends in the low SVC.\n\n 2. No evidence of pneumothorax.\n\n 3. Low lung volumes with unchanged minimal bibasilar atelectasis.\n\n 4. Pulmonary vascular congestion without evidence of pulmonary edema,\n unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-09 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1187777,
"text": " 1:34 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: FAST TRACK EXTUBATION CARDIAC SURGERY, eval for ptx and effu\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p Off Pump CABG\n REASON FOR THIS EXAMINATION:\n FAST TRACK EXTUBATION CARDIAC SURGERY, eval for ptx and effusions. icu provider\n is , please page her if there is concern\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:41 P.M. ON \n\n HISTORY: Recent heart surgery.\n\n IMPRESSION: AP chest compared to preoperative chest radiograph :\n\n Tip of the ET tube is at the level of the sternal notch between 5 and 6 cm\n above the carina, in standard placement. Swan-Ganz catheter ends in the main\n pulmonary artery, midline and bilateral pleural drains are in standard\n positions. There is no pneumothorax or appreciable pleural effusion. Caliber\n of the postoperative cardiomediastinal silhouette is comparable to the\n preoperative and so is mild distention of upper lobe pulmonary vasculature,\n physiologic in the supine positioning. No pulmonary edema. Nasogastric tube\n ends in the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1187815,
"text": " 7:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: post bronchoscopy\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with respiratory failure\n REASON FOR THIS EXAMINATION:\n post bronchoscopy\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure after bronchoscopy.\n\n FINDINGS: In comparison with the earlier study of this date, there is no\n change in the appearance of the monitoring and support devices except for the\n Swan-Ganz catheter being clearly in the proximal left pulmonary artery. No\n evidence of pneumothorax or pneumomediastinum following the procedure. Mild\n atelectatic changes at the bases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1188555,
"text": " 1:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with SOB\n REASON FOR THIS EXAMINATION:\n effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY OF \n\n COMPARISON: .\n\n FINDINGS: Right internal jugular vascular catheter terminates in the mid\n superior vena cava. Cardiac silhouette remains enlarged and is associated\n with mild upper zone vascular re-distribution. Mild pulmonary edema which was\n present on and has recurred and is accompanied by bilateral small\n pleural effusions which have increased since the recent radiograph of \n and is accompanied by bibasilar atelectasis. Linear perihilar atelectasis on\n the left is not substantially changed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1188009,
"text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct removal\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p cabg\n REASON FOR THIS EXAMINATION:\n s/p ct removal\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post chest tube removal.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the chest tubes and\n mediastinal drains have been removed. There is no evidence of pneumothorax.\n Unchanged mild left basal atelectasis, potentially combined with a minimal\n pleural effusion. Unchanged moderate cardiomegaly with signs of minimal\n pulmonary edema. Unchanged position of the nasogastric tube, the endotracheal\n tube and the right central venous access line.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-17 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1188772,
"text": " 10:10 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p cabg\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, evaluate for effusion.\n\n COMPARISON: Chest radiograph from .\n\n FINDINGS: The right IJ catheter ends in the low SVC. Low lung volumes cause\n crowding of the pulmonary vasculature and accentuation of the heart size. The\n cardiac and mediastinal contours are unchanged and have an expected\n post-operative appearance. Small bilateral pleural effusions are decreased.\n There is no pneumothorax. The patient is status post midline sternotomy and\n CABG. A tiny hyperdense focus is seen along the superior sternum, likely\n external to the patient.\n\n IMPRESSION:\n\n 1. Decreased small bilateral pleural effusions.\n\n 2. Low lung volumes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1188182,
"text": " 10:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old woman status post CABG, evaluate for effusion.\n\n COMPARISON: .\n\n PORTABLE AP CHEST RADIOGRAPH: Moderate cardiomegaly is stable since . Bilateral pleural effusions are minimally improved since the most\n recent prior examination.\n\n There is no evidence of pneumothorax. There has been interval removal of the\n ET tube and the nasogastric tube since most recent prior examination.\n Sternotomy wires are midline and intact. The right IJ line tip projects over\n the distal SVC.\n\n IMPRESSION:\n 1. Stable moderate cardiomegaly.\n 2. Bilateral pleural effusions stable to minimally improved since the most\n recent prior examination.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-05-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1188484,
"text": " 2:49 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: PA and lateral chest, .\n\n CLINICAL HISTORY: 64-year-old woman, status post CABG. Evaluate for\n effusion.\n\n FINDINGS: Comparison is made to the previous study from .\n\n There is stable cardiomegaly. There is again seen a right IJ central venous\n catheter with distal lead tip at the cavoatrial junction. Median sternotomy\n wires are seen. There is improvement in the pulmonary interstitial markings\n since the prior study. There is also improved aeration at both lung bases\n with reduction of the pleural effusions. There remains some atelectasis\n within the left upper lobe.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-04-29 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1186564,
"text": " 9:51 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CONGESTIVE HEART FAILURE\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with CHF and 3VD pre-op prior to CABG\n REASON FOR THIS EXAMINATION:\n preop\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Congestive cardiac failure, three-vessel coronary artery disease,\n preoperative radiographs.\n\n COMPARISON: Radiographs dating back to and most recently .\n\n FINDINGS: Moderate cardiomegaly is unchanged since . Prominence of\n the upper lobe vasculature is somewhat more prominent suggesting pulmonary\n venous congestion. Linear atelectasis in the lower lobe is unchanged since\n .A well-circumscribed density projected over the right lower zone is\n consistent with a nipple.\n\n IMPRESSION:\n New pulmonary venous congestion.\n\n"
},
{
"category": "Echo",
"chartdate": "2118-05-09 00:00:00.000",
"description": "Report",
"row_id": 67541,
"text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Congestive heart failure. Coronary artery disease. Hypertension. Shortness of breath.\nStatus: Inpatient\nDate/Time: at 12:57\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes. Good (>20 cm/s) LAA ejection\nvelocity. No thrombus in the LAA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Doppler parameters\nare most consistent with Grade I (mild) LV diastolic dysfunction.\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 diameter of aorta at the sinus, ascending and arch levels.\nNormal ascending aorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Moderate mitral annular calcification. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The patient received antibiotic\nprophylaxis. No TEE related complications. Results were personally reviewed\nwith the MD caring for the patient.\n\nConclusions:\n1. The left atrium and right atrium are normal in cavity size. No thrombus is\nseen in the left atrial appendage.\n2. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal.\n3.Doppler parameters are most consistent with Grade I (mild) left ventricular\ndiastolic dysfunction.\n4. Right ventricular chamber size and free wall motion are normal.\n5.The diameters of aorta at the sinus, ascending and arch levels are normal.\nThere are simple atheroma in the descending thoracic aorta.\n6. There are three aortic valve leaflets. The aortic valve leaflets (3) are\nmildly thickened. There is no aortic valve stenosis. Trace aortic\nregurgitation is seen.\n7. Mild (1+) mitral regurgitation is seen.\n8. There is no pericardial effusion.\n9. After off pump cabg was performed, there were no permanent focal wall\nmotion abnormalities.\n\nDr. was notified in person of the results.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2118-04-29 00:00:00.000",
"description": "Report",
"row_id": 67542,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function. Right ventricular function.\nHeight: (in) 62\nWeight (lb): 175\nBSA (m2): 1.81 m2\nBP (mm Hg): 137/67\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 11:37\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. No MS. Mild\n(1+) MR. [Due to acoustic shadowing, the severity of MR may be significantly\nUNDERestimated.]\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - poor parasternal views. Suboptimal image quality - poor\nsubcostal views. Suboptimal image quality - body habitus.\n\nConclusions:\nThe left atrium is elongated. No atrial septal defect is seen by 2D or color\nDoppler. There is mild symmetric left ventricular hypertrophy with normal\ncavity size and global systolic function (LVEF>55%). Due to suboptimal\ntechnical quality, a focal wall motion abnormality cannot be fully excluded.\nThere is no ventricular septal defect. Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. No aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse. Mild\n(1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of\nmitral regurgitation may be significantly UNDERestimated.] The pulmonary\nartery systolic pressure could not be determined. There is no pericardial\neffusion.\n\nCompared with the prior study (images reviewed) of , the degree of\nMR seen appears less.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-04-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1186147,
"text": " 12:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with wheezing\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON \n\n COMPARISON: \n\n CLINICAL HISTORY: Wheezing, assess for pneumonia.\n\n FINDINGS: Portable AP upright view of the chest is obtained. Soft tissues\n overlying the lower chest somewhat limit evaluation. Cardiomegaly is again\n noted with mild pulmonary vascular congestion. No large pleural effusion is\n seen. Left mid lung plate-like atelectasis is present. Atherosclerotic\n calcification at the aortic knob is noted. There is no pneumothorax. Bony\n structures appear grossly stable.\n\n IMPRESSION: Cardiomegaly, mild congestion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-04-27 00:00:00.000",
"description": "R UNILAT LOWER EXT VEINS RIGHT",
"row_id": 1186296,
"text": " 11:17 AM\n UNILAT LOWER EXT VEINS RIGHT Clip # \n Reason: R/O DVT/RT LEG SWELLING\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with tachypnea and r>L lower extremity edema\n REASON FOR THIS EXAMINATION:\n ro DVT\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND DOPPLER RIGHT LOWER EXTREMITY\n\n INDICATION: Query DVT.\n\n COMPARISON: No prior imaging for comparison.\n\n FINDINGS:\n Normal flow, compression and augmentation demonstrated within the deep venous\n system of the right lower extremity. No evidence for DVT.\n\n IMPRESSION:\n Normal Doppler ultrasound of right lower extremity. No evidence for DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-04-29 00:00:00.000",
"description": "ESOPHAGUS",
"row_id": 1186628,
"text": " 4:05 PM\n ESOPHAGUS Clip # \n Reason: dysphagia\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with eosinophilia and chronic abdominal pain with ? of\n eosinophilic esophagitis since also has dysphagia\n REASON FOR THIS EXAMINATION:\n dysphagia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old female with eosinophilia and chronic abdominal pain,\n question eosinophilic gastritis.\n\n COMPARISON: CT abdomen with contrast from .\n\n FINDINGS: The study was significantly limited by the patient's limited\n mobility and inability to stand or follow commands. Despite these\n limitations, several double contrast images taken of the esophagus show no\n classic findings suggestive of eosinophilic esophagitis. There is dysmotility\n noted with ineffective primary peristalsis and tertiary peristaltic\n contractions. There are no strictures or webs.\n\n IMPRESSION:\n\n No findings typical of eosinophilic esophagitis. No evidence of any mucosal\n irregularities. Esophageal dysmotility with ineffective primary and tertiary\n contractions.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-04-26 00:00:00.000",
"description": "Report",
"row_id": 141211,
"text": "Sinus rhythm. Modest ST-T wave changes with borderline prolonged/upper limits\nof normal QTc interval, non-specific, but cannot exclude\ndrug/electrolyte/metabolic effect or possible myocardial ischemia. Clinical\ncorrelation is suggested. Since the previous tracing of same date there is no\nsignificant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2118-04-26 00:00:00.000",
"description": "Report",
"row_id": 141212,
"text": "Sinus rhythm. Modest ST-T wave changes with borderline prolonged/upper limits\nof normal QTc interval, non-specific, but cannot exclude possible\ndrug/electrolyte/metabolic effect or possible myocardial ischemia. Clinical\ncorrelation is suggested. Since the previous tracing of the rate is\nslower but, otherwise, there may be no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2118-04-26 00:00:00.000",
"description": "Report",
"row_id": 141213,
"text": "ECG interpreted by ordering physician.\n see corresponding office note for interpretation.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-05-15 00:00:00.000",
"description": "Report",
"row_id": 141207,
"text": "Sinus rhythm. Anterolateral lead ST-T wave abnormalities are non-specific.\nSince the previous tracing of same date there is probably no significant\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-05-15 00:00:00.000",
"description": "Report",
"row_id": 141208,
"text": "Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing\nof ST-T wave changes are more prominent.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-05-09 00:00:00.000",
"description": "Report",
"row_id": 141209,
"text": "Sinus tachycardia. Diffuse ST-T wave changes are non-specific. Unstable\nbaseline makes assessment difficult. Since the previous tracing of \nsinus tachycardia is now present.\n\n"
},
{
"category": "ECG",
"chartdate": "2118-04-28 00:00:00.000",
"description": "Report",
"row_id": 141210,
"text": "Sinus rhythm. Lateral ST-T wave changes are non-specific. Compared to the\nprevious tracing of no diagnostic interim change.\n\n"
}
] |
7,605 | 107,327 | 1. Cardiac: The patient was felt to be in congestive heart failure by exam and by history. He was initially diuresed with IV Lasix. The other cardiac issue for him was his bradycardia which may have been due to increased Digoxin level. Consequently his Digoxin was initially held. Since he was hypotensive, his Nitro paste was also held. Given his history of coronary artery disease, he was also ruled out for a myocardial infarction. His Aspirin and Statin were continued. Cardiology was consulted regarding his symptomatic bradycardia. Cardiology initially recommended to continue with the diuresis. They recommended holding the angiotensin receptor blocker and to continue holding the Digoxin. Because of his elevated INR, they also recommended holding his Coumadin until it drifted back down to 2-3. Cardiology was consulted on the first day of admission. Cardiology also recommended starting him on Hydralazine 25 mg po tid to improve his afterload reduction. He ruled out for myocardial infarction with peak CK of 135. However, his troponin was elevated at 2.1 but drifted down to .6. The elevated troponin may have been in the setting of congestive heart failure. On the second day of admission, the patient felt better, having had diuresis. He was practically negative 300 ml after the first day. He was also continued back on his Nitro paste to improve preload reduction. Telemetry showed that his heart rate was generally in the 50's but would decrease down to 30's occasionally. His elevated troponin was thought to be secondary to his CHF, particularly in the setting of acute renal failure. Because of his bradycardia, the electrophysiology service was consulted. It was felt that he would benefit from electrophysiology study. Based on that, he may have needed a pacemaker. His history of having a syncopal episode was concerning. The syncopal episode occurred in approximately 4 months prior to admission. The goal is to do these studies when his INR was less than 1.8. As of the second day of admission, the patient's INR was 2.7. Because of the patient's blood pressure, it was difficult for him to receive his Hydralazine and his Furosemide. Secondary to admission, the patient received echocardiogram which showed moderate left atrial enlargement, mild symmetric left ventricular hypertrophy, mild left ventricular dilatation and severely depressed left ventricular systolic function. It also showed moderate global right ventricular free wall hypokinesis, trace aortic regurgitation, 1+ mitral regurgitation and an ejection fraction of 20%. Compared to echocardiogram done in , showed significant decrease in left ventricular function. For his bradycardia, electrophysiology also felt that functional status of his heart would also be important prior to the electrophysiology study. Consequently he was to go for stress thallium test. By the third day of admission, the patient's heart rate had gradually improved to 60's to 70's. This is more suggestive of a possible Digoxin as the cause. His stress thallium was done on the third day of admission. During the exercise portion, the patient had no angina, no ischemic electrocardiographic changes. The patient was on Heparin since his Coumadin was being held for his aortic valve replacement anticoagulation. His stress thallium test showed no angina, no ischemic EKG changes. Showed moderate partly reversible perfusion defects in the inferior and inferior septal wall. Had mild reversible perfusion defects in the apex, apical septum and distal anterior wall with liable myocardium. Showed dilated left ventricle. Had global hypokinesis of left ventricle and akinesis at the apex. Ejection fraction was listed at 29%. Because of these partly reversible defects, he was considered a cardiac catheterization candidate. However, his creatinine was still elevated at 2.1. In the hopes of improving his renal function, the patient was considered for no known therapy. The goal was to improve his cardiac but to improve his renal function such that he would better tolerate a cardiac catheterization without reducing his chances of complications. Consequently, for the Milrinone to be administered, the patient was transferred to the CCU on the 5th day of his admission. After the cardiac catheterization, the patient would then be a candidate for the EP study. He was continued on his Lasix, first 120 mg IV bid. He was also continued on his Heparin drip for the aortic valve replacement while his Coumadin was held. He was monitored closely with the Milrinone for possible arrhythmias. In the CCU he had a Swan Ganz catheter placed to monitor his hemodynamics. His initial pressures were such that his pulmonary artery pressure was 51/22, pulmonary capillary wedge pressure was 22. CVP was 17. Cardiac output was 4.5, based on the situation. Cardiac index was 2.36 and his systemic vascular resistance was 800. The following day, , the patient's pulmonary artery pressure was 58/22, pulmonary capillary wedge pressure was 20, CVP was 12, cardiac index was 2.62 and systemic vascular resistance was 720. He did show some improvement with Milrinone; at that point 33 mcg/kg/minute. His urine output had decreased by the 6th day of admission. Subsequently he was started on Furosemide IV drip. Initially started at 10 mg/hour and then increased to 20 mg per hour. With the increase to 20 mg per hour, he responded with increased urination. On the 6th day of admission, his pulmonary artery pressure was 63/29 and CUP was 17. He had a diuresis of only 200 ml during that day. He had a cardiac catheterization done on the 7th day of admission. With the Milrinone, he had episodes of non sustained ventricular tachycardia. However, he was asymptomatic during these episodes. Because he was having sustained V tach, his Milrinone was decreased. His Milrinone was decreased by half to .16 mcg/kg/minute. His cardiac catheterization showed diffuse disease. Proximal RCA was 100% occluded. Left main with 80% osteal lesion. Proximal LAD showed 100% occlusion, mid left circumflex showed 80%. Saphenous vein grafts, two were 100% occluded. The saphenous vein grafts to the first diagonal, showed 99% occlusion. Two stents were placed in the saphenous vein graft to the diagonal artery first branch. He had resulting good flow. During the procedure, he had intra-aortic balloon pump placed. However, prior to coming to the CCU, it was removed. During this period he also had two units of packed red blood cells transfused. He had evidence of fluid overload during the second unit of packed red blood cells. Consequently he was given 100 mg IV times one. He was finally started on IV drip 15 mg per hour. He responded with a 250 ml urine output. He did have bleeding from the catheterization site. There was some discussion of whether to intervene later on his left main and left circumflex. However, at this time the SVG to first diagonal was intervened upon. Because of the intervention, he was started on Plavix for a total course of 30 days. He was subsequently started on Integrilin for a total course of 18 hours. He had evidence of continued fluid overload. Because of low blood pressure, his Hydralazine was discontinued. It was thought that it might also help with increasing the renal perfusion. To more accurately assess his blood pressure, he had an arterial line placed on the 8th day of his admission. Since there was some evidence that he was extremely hypotensive, his Furosemide drip was discontinued. He was started on a Nitroglycerin drip to decrease the load and to possibly improve cardiac output. On the 9th day of admission, the patient continued to have anuria. However, it seemed to be mostly due to a Foley situation. He, during the night of his 8th day of admission, became hypotensive. His hematocrit decreased to 27. His pulmonary artery pressure was 69/27, with mean arterial pressure of 50 and CVP of 14. Pulmonary capillary wedge pressure had been done earlier and decreased to 26. It was thought that he was becoming hypovolemic from the over diuresis and from the epistaxis. He was given a unit of packed red blood cells. His blood pressure improved after that. The Heparin and Nitroglycerin were discontinued in the setting of bleeding. On the next day of admission, the patient had an episode of vomiting after which he went into pulseless ventricular tachcardia. He was shocked once and continued to be in ventricular fibrillation. He was then given a mg of Epinephrine and was shocked two more times and converted to sinus rhythm. During the code, CPR was performed. He was started on Amiodarone drip and was also intubated at that time. After the code, it was decided that to improve his hemodynamics, he would benefit from dialysis to improve his volume overload. He was started on ultrafiltration. He was also started on pressors, initially Vasopressin. Because it was ineffective, he was then started on Dopamine which improved his blood pressure. He initially had Dopamine rate of 4 mcg/kg/minute. His Aspirin was continued. His bleeding had to be balanced against the risk of clotting his stent. The Heparin was discontinued. After the 9th day of admission, his CHF was managed by dialysis. He was also started on Dopamine to improve his contractility and to improve flow. Because of his ventricular fibrillation arrest, he was started on Amiodarone. The Amiodarone was 1 mg/kg drip per 24 hours. During that first day he had nearly three liters removed. He was becoming more hypotensive and his Dopamine was increased to 11 mcg/kg. His Heparin was restarted as his bleeding was under better control. However, after the Heparin was started, he had increased bleeding, he was transfused two units additionally, and his hematocrit increased from 29 to 31. Because of his bleeding, the Heparin was again stopped. The goal was to keep his hematocrit above 30. He had been on Milrinone but that was stopped after the code situation. The ventricular tachycardia may have been related to his Milrinone but the exact etiology is unclear. On the 10th day of admission, he was in atrial fibrillation, despite being on Amiodarone. He was considered for cardioversion. Heparin was again restarted on the 10th day of admission, particularly because of the stent placement and his aortic valve replacement. He was dialyzed with a goal of removing fluid. Predialysis his CVP was between 19 and 22. Post dialysis his CVP had been between 15 and 24. His pulmonary artery diastolic pressures went from 72 to 34 predialysis. After dialysis was 28 to 33. During then night of his 9th night of his admission, he had two episodes of ventricular tachycardia. He was shocked one time each and was converted to a non tachycardic rhythm. He was considered for atrial fibrillation, cardioversion, but it was deferred after his episodes of ventricular tachycardia. On the 10th day, his dialysis was stopped early because of blood pressure decrease. MAP decreased to 50's. After dialysis decreased to 70's. He was still on Vasopressin drip and Dopamine drip at this time. On the 11th day of admission, patient had decreased distal pulses. His Vasopressin was stopped. The decreased distal pulses were thought to be due to peripheral vasoconstriction due to the Vasopressin and also the Dopamine. Since the patient was thought to be in cardiogenic failure, the goal was to try to wean him off the Dopamine and to place him on Dobutamine. Because his low blood pressure would not be able to tolerate intermittent dialysis, he was then started on CVVH for more gentle diuresis through dialysis. Because of the episodes of ventricular tachycardia that required cardioversion or shock, Amiodarone was discontinued as possibly increasing his QT interval. He had reverted back to sinus rhythm. On the 11th day, after discussion with the family he was made no defibrillation. When Dobutamine was added his cardiac output and systemic vascular resistance improved. However, his mean arterial pressures were still less than 60. Consequently it was difficult to wean off the Dopamine and had to be continued. Because the patient was hypothermic and possibly having septic etiology, with a very low SVR down to 472, he was started on Vasopressin. The goal was to try to wean off the pressors. During the 13th day of admission, the patient had another episode of ventricular tachycardia that was pulseless. Since family did not want him to have defibrillation, he was not shocked. He spontaneously converted to sinus bradycardia and then to sinus tachy/arrhythmia with increased systolic blood pressure. However, then his mean arterial blood pressure decreased to 45 and then the patient remained in sinus rhythm after restarting pressors. Lidocaine drip was initiated. Discussion was had with the family concerning the patient's code status. Since the patient had a very poor prognosis, the family decided they did not want him to continue to suffer. They wanted to wean pressor support. They also felt that he should withdraw the dialysis. This was on the 13th day of admission. 2. Renal: The patient had an elevated creatinine during this admission. It was thought to be initially due to setting of congestive heart failure exacerbated by having angiotensin receptor blockers and also ACE inhibitors. He had hyperkalemia which was thought to be due to the acute renal failure. His increased Digoxin and Coumadin were also thought to be due to acute renal failure. Consequently the angiotensin receptor blocker was held. For his hyperkalemia, he was on telemetry and had the ER course as stated above. On the second day of admission his creatinine was essentially stable at 2.4. On the third day, his creatinine increased to 2.6. The management remained the same, most likely due to his congestive heart failure. On the 4th day of admission, decreased to 2.3. On the 5th day, the patient's creatinine was 2.1, close to his baseline. He was sent to the CCU for Milrinone therapy to improve his cardiac output and subsequently improved his renal function. His creatinine on the first day in CCU was 2.2, essentially stable. He did receive anecetalcistine prior to and day after catheterization. His creatinine remained stable at 2.2 prior to catheterization. After catheterization, his creatinine increased to 2.3. This was on the 8th day of admission. He had evidence of decreased urine output. Consequently he was started on Furosemide IV drip. He was essentially anuric on the 9th day of admission, however, he had multiple clots in his Foley. It was then forcefully flushed and he was placed on continuous irrigation. His urine output improved after that. His creatinine increased to 3.6 in the setting of having probably an obstructed Foley. On the 9th day of admission, he had an episode of ventricular fibrillation and was shocked. He was then started on hemodialysis for fluid overload management. His increased creatinine was thought to be mostly due to the obstructed Foley. His creatinine remained stable at 3.8. Goal was to try to improve his fluid outflow to improve his renal perfusion. He had a renal ultrasound which showed no evidence of hydronephrosis or obstruction. The ultrasound was done approximately on the day of admission. Because of difficulty maintaining his blood pressure, he was converted to CVVH for more gentle diuresis and dialysis. His creatinine continued to increase to 4.6. However, on the 12th day of admission the patient's creatinine improved to 3.3. The CVVH was thought to be helping. On day of his death, the patient's creatinine improved to 2.6 in the setting of continued diuresis with dialysis and continued dialysis. His potassium was under control. However, his family felt that because of his poor prognosis, he would not want to suffer further. Consequently, CVVH was withdrawn on the 13th day of admission. 3. Heme: The patient had episodes of epistaxis during this admission. He had had a previous history of epistaxis for the past week. However, it intensified while he had been on anticoagulation. However, because of the importance of his anticoagulation, it was difficult to completely wean him off the therapy. He had episodes of epistaxis which were controlled with pressure. However, he continued to have bleeding from the epistaxis and from his right groin site from the catheterization. He also had evidence of guaiac positive stool. Consequently because the bleeding was coming to a point where he was requiring blood transfusions, the ear, nose and throat department was consulted. His hematocrit decreased to 27 from 30. The otolaryngology service recommended packing the nose. They suggested avoiding nasal cannula. They also felt that he should continue to have packing. He also had bleeding from the Foley. He had evidence of hematuria. He was not cardiopathic, his INR remained between 1.4 and 1.5. His PTT though, was elevated in the setting of using Heparin. When his bleeding worsened, his Heparin was stopped, however, as the bleeding improves, the Heparin would be restarted. During the course of admission he required multiple transfusions. When he became hypovolemic in the setting of bleeding, he received one unit of packed red blood cells and improved. It was thought that from his viremia he would have dysfunctional platelets. On the 11th day of admission, his INR was slowly increasing to 1.7. Consequently he was given Vitamin K 1 mg IV. The increase in the INR was thought to be secondary to possibly from his Heparin use. The following day his INR decreased to 1.6. The bleeding improved when the Heparin was decreased. 4. ID: The patient had evidence of urinary tract infection. Initially when he presented, he was treated with Levofloxacin. On the day of admission he had evidence of possible pneumonia. He had a temperature max of 100.8. He has had increased white blood cells to 15.3. He was treated for possible pseudomonas pneumonia given that he was on a ventilator. He was started on Ceftazidime and Vancomycin for possible line infection. He also had decreased SVR on the 12th day of admission. Consequently he was developing a septic physiology. He had increased cardiac output, decreased SVR and was hypothermic. He had multiple sources of infection. He was covered broadly with Vancomycin and Ceftazidime. 5. Pulmonary: The patient had episodes of congestive heart failure discussed in the cardiac section. He also had evidence of possible pneumonia towards the end of his admission treated with Ceftazidime. However, because of the code situation, the patient was intubated. He was initially placed on assist control with respiratory rate set at 16. His total volume was 650 ml, rate was 12, FIO2 was decreased down to 50% and PEEP was 5. He did not really have any respiratory issues besides the CHF and was satting well at 98-100%. However, in the setting of continued diuresis with dialysis, he continued on the ventilator. He did not really have any ventilator issues except for possible pneumonia which was treated with Ceftazidime. He was able to maintain decent oxygenation and ventilation with ventilator support. FIO2 was decreased down to 40%. He was mainly kept on a ventilator because of diuresis. His last ABG was 7.42 PH, CO2 43, PO2 67. On the 13th day of admission, the patient's family felt that they did not want the patient to suffer any longer considering his poor prognosis. Consequently they wanted to withdraw pressor support and CVVH. Shortly thereafter, the patient passed away on . He was found to have no spontaneous respiration, and no evidence of heart sounds. His pupils were fixed and dilated. He was not responsive to pain. Patient's family was made aware of the situation and was there when the patient passed away. Patient's family declined any autopsy. , M.D. Dictated By: MEDQUIST36 D: 15:20 T: 17:03 JOB#: | PT RETURNED FROM CATH LAB 7P- SEE CATH LAB REPORT.REMAINS WITH MARGINAL BP- 88/30- 90/50, HR- 90-100'S ST/AFIB.MUCH VT- RUNS, NONSUSTAINED. Still continues Milrone at 0.16mcg, Heparin at 800u/hr(PTT therapeutic; 69.7). npn ccun-sedated on propofol infusion, prn mso4 for , arouse to significant stimulationr-ventilation/respiration remain constantcv-nsr 80's freq mf pvc's, repleted k and ca++map's>60 with dopa/dobut/vasopressin- #'s more septic with dobut at 10 and pit at .02-changed to dobut at 5 and pit at .04 and numbers are mixed cardiogenic/sirs picturepad's 28-pa sats 74,gi-tf at goalgu-making approx 15cc uo/hr, cvvh changed bath from 5k/l to 4k/l, have needed to replete k throughout day,normal temp today-cultures all negativefamily in and updateda/p-conditon remains guarded-continue all current supports Lasix gtt and Integrilin dc'c today. SM BLD OOZ NOTED FROM L NARES. - 5.3, SVR 664. continues on amiodorone.Heme: Heparin restarted at 800u/hr. HEPARIN CONTS AT 800U/HR WITH THERAPEUTIC PTT.RESP: LUNGS WITH BASILAR CRACKLES, R BASE DIMISHED AERATION. CCU NPN 3-11PMCV: remains on milrinine at 0.16 mcg/kg and hep at 800u with therapeutic PTT, IV nitro at 15ug. Elevated bun/cr.NEURO: No limitations, sharp as a tack.SKIN: intact.ENDO: glu to mid 300's. His last C/O was 3.7/1.9 with SVR 1059. Continues on Milrinone at 0.33mcg during procedure and bolused and started on Intergrillin.PLAN: Reapplied pressure dsg and advancing pt slowly currently at30 degrees.RESP: LS clear with crackles throughout bases. Remains in lesser degree of chf, started lasix gtt to goal of 80-100cc/hr. 6.1/ 3.19 -> conts on milrinone gtt at 0.16mcg.GI: Abd soft NT. R groin is dry though quentin catheter has had some oozing.RESP: Pt remians intubated on AC 40% 12 X 650 5 PEEP with last gas was 7.34/ 38/ 86.Breath sound remain course. Rec'g 1u PRBCS at this time. CBI continues.Resp: LS coarse on L and bronchial at R base. suctioned for moderate amt. voiding through day w/ neg 300cc prior to lasix gtt up. During dialysis vasopressin at .04u/min or 2.4 units/hr was added and maps are now in the 70s. There ismoderate mitral annular calcification. Ventricular ectopy ispresent. Trace aortic regurgitation is seen. There ismoderate global right ventricular free wall hypokinesis. PULM=INTUBATED & VENTED. Normal sinus rhythm*** if rhythm correct, report below may be invalid ***Intraventricular conduction defectInferior infarct - age undeterminedPossible old anterior infarctLateral ST-T changes offer additional evidence of ischemiaSince last ECG, , rhythm change CV=NSR W RARE ECTOPY. Compared to tracing #1 the rate has slowed and atrial fibrillationis present. Occasional ventricular ectopy. CO/CI/SVR-ON DOPA @ 9MCG & VASOPRESSIN @ 0.04- 5.6/2.93/571. ProlongedP-R interval as previously described. Overall left ventricular systolicfunction is severely depressed.RIGHT VENTRICLE: There is moderate global right ventricular free wallhypokinesis.AORTIC VALVE: A bileaflet aortic valve prosthesis is present. Regular supraventricular rhythm with discrete atrial activity preceding eachQRS complex (e.g.in lead V1). Regular supraventricular rhythm most likely sinus tachycardia. REINFORCED LEFT DRESSING SITE.ALSO SOME BRACHIAL IV SITE OOZING.LESS SO THAN YESTERDAY. There is mild symmetric leftventricular hypertrophy. The rate isslower. Ventricular ectopy. Prior anteroseptal myocardial infarction. ID=T 97.5 TO 96.4--WARMER ADDED--DCED WHEN T 98.6. Since the previous tracing of the rate is more rapid.ST segment depressions are now noted in leads V2-V6. Compared to the previous tracing of the atrialrhythm appears to have changed to atrial fibrillation and the ST-T waveabnormalities in the anterior precordial leads have again worsened. The rhythm is likely sinustachycardia or atrial tachycardia. CCU NSG PROGRESS NOTE 11P-7A/ S/P VT ARREST; BLEEDS- INUTBATEDO- SEE FLOWSHEET FOR OBJECTIVE DATA. CCU NSG PROGRESS NOTE 7P-7A/ S/P STENT; VT ARRESTS- INTUBATED. CCU NSG PROGRESS NOTE.O:NEURO=SEDATED W PROPOFOL GTT @ 30MCG W GD EFFECT. CK AM LABS-REPLACE AS INDICATED. TOLERATED DOBUTA WEAN & DC. Anterolateral ST-T wave abnormalities persist. Prior inferiorinfarction. Atrial fibrillation. Mitral valve disease.Height: (in) 67Weight (lb): 163BSA (m2): 1.86 m2BP (mm Hg): 135/115HR (bpm): 53Status: InpatientDate/Time: at 10:59Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. Ventricular ectopy is present. Sinus rhythm. PORTABLE AP SUPINE CHEST: The right internal jugular approach Swan-Ganz catheter has been withdrawn slightly. The patient is s/p median sternotomy and CABG. There are sternal wires and clips overlying the cardiac silhouette consistent with a prior CABG. There is cardiomegaly with evidence of interstitial and alveolar pulmonary edema and a small right pleural effusion. 3) Dilated left ventricular cavity with an estimated end diastolic volume of 229 ml. The left ventricular cavity is seen to be dilated with an end diastolic volume of 229 ml. Resting perfusion images were obtained with thallium. REASON FOR THIS EXAMINATION: New right IJ cordis with Swan-Ganz catheter. Prior inferior myocardial infarction. Tip of Swan-Ganz catheter is probably entering orifice of left pulmonary artery. 8:29 AM CHEST (PORTABLE AP) Clip # Reason: Assess PA catheter position, pulmonary edema. 9:03 AM CHEST (PORTABLE AP) Clip # Reason: assess for pulmonary edema. 8:03 AM CHEST (PORTABLE AP) Clip # Reason: Assess pulmonary edema. FINAL REPORT INDICATION: Respiratory distress. The bladder is decompressed and the ballon from the Foley catheter is seen. There is interstitial and alveolar pulmonary edema and a small right pleural effusion which are unchanged. | 49 | [
{
"category": "Nursing/other",
"chartdate": "2147-01-17 00:00:00.000",
"description": "Report",
"row_id": 1364010,
"text": "CCU NPN 3-11PM\nCV: remains on milrinine at 0.16 mcg/kg and hep at 800u with therapeutic PTT, IV nitro at 15ug. BP 110-120/50, HR low 100's ST, cont to have freq PVC's, occ runs 4-5bts. No CP and states breathing is comfortable. No change in CO. PCWP 26, PAD remains 30. Given 120mg lasix at 9PM, 150cc urine out in 1 hr. Oozing from L groin site, held pressure for prob 1hr with cont ooz, applied gelfoam and reapplied pressure dressing, cont to ooz, not through dressing. Oozing from A-line site also, dressing changed x2, also using gelfoam.\n\nGU: Cont to have no UO, irrigated foley, obtained sm amt of bloody urine back with clot, foley changed to 3 way and bladder irrigation started, finally after vigorous manual irrigation, many clots removed and pts urin became pink. CBI continues.\n\nResp: LS coarse on L and bronchial at R base. RR 18-20. O2 sats high 90's on 5L, placed CN on for humidity. ABG: 63/43/7.38 with sat of 95%. Productive cough.\n\nEndo: BS in 300's, covered with 15U reg and given PM Lente dose at 6PM. Taking in good po's.\n\nPsych/soc: pt pleasant, discouraged, Verbalizing, c/o being tired, does not want to suffer. Allowed to vent, provide support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-18 00:00:00.000",
"description": "Report",
"row_id": 1364011,
"text": "CCU NURSING PROGRESS NOTE 11P-7A\n\nNEURO: Pt very pleasant. Alert and oriented x3. Cooperative with care.\n\nRESP: LS coarse. Wearing 100% cool neb with sats mid 90's; however does desaturate to 80's when O2 is removed. Pt denies SOB, CP, palps.\nLeft nare bleeding resulting in expectoration of large clots. Pt does state that he does not feel like blood is coming for his stomach, but does feel it is from post nasal gtt. Left nare has been packed x2-> awaiting ENT consult this am.\n\nCARDIAC: BP 110-120's most of the night, however with episode of increased bleeding and in setting of lasix, pt is hypotensive this am to mid 80's. Rec'd 250cc NS bolus x1 and is in process of rec'g 1U PRBCs. Of note wedge is down to 17 from mid 20's. Denies CP or cardiac complaints. NTG has been stopped in setting of hypotension.\nSWAN numbers improved with better c.o. 6.1/ 3.19 -> conts on milrinone gtt at 0.16mcg.\n\n\nGI: Abd soft NT. Straining for small hard blood tinged bm. To start on colace this am. NGT was dropped and pt was lavaged with 500cc NS. Team feels blood is post nasal rather than a GIB at this point.\nHCT 29 at 2am-> down to 27 at 4 am with increased nasal bleeding. Rec'g 1u PRBCS at this time. left nare re-packed by team. Repeat HCT to be checked once blood has infused. Pt had been on heparin gtt at 800 cc/hr with am PTT of 90. Heparin was stopped at 5am x2 hrs and will restart at 700u/hr at 7am. Conts to ooze small amt from left groin (pressure dressing changed) and from open areas (left side from elastoplast; old sticks; pink tinged urine, etc).\n\nGU: 3 way foley draining pink clear urine. Pt conts on CBI, however at beginning of shift, unable to assess true urine output accurately. Pt has since been rec'g 3000 bladder irrigant over ~2 1/2 hrs and has cleared ~300cc urine for the shift. Did receive 120mg IVP lasix at 2am. Pt is presently even for the night. Foley will intermittently leak around insertion site-> manual flush and aspiration will eventually release any clots. Of note creat up to 3.6 this morning.\n? etiology of bladder irritation/bleeding.\n\nID: afebrile.\n\nA: pt most likely hypovolemic from bleeding and diuresis.\n Hypotensive req'g volume resuscitation with fluids and blood.\n CREAT worsening-> ?etiology.\n\nP: follow HD status closely. Follow repeat HCT. Assess for s/s further bleeding and HD compromise. Await ENT consult for nosebleed.\nAssess for s/s worsening CHF in setting of volume resuscitation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-18 00:00:00.000",
"description": "Report",
"row_id": 1364012,
"text": "CCU NSG PROG NOTE\nMr had an eventful day. He was noted to be continuing to bleed from multiple sources, especially his nose. ENT saw him, packed his nose w/ only scant sensation from pt that the blood was still trickling down his throat. Team said he could eat. Approx 11 am pt was eating when c/p nausea. Vomited BRB w/ food particles and immediately went into pulseless VT. CPR initiated, code called. Intubated. REquired several shocks, epi to restore rhythm.\n\nROS:\nCARDIAC: hr was 106-112 st w/ occ- pvc. b/p stable prior to arrest.\n\nRESP: was sob w/ mask off and noted to drop sats to 77% during ent procedure, requiring NRB and immediate restoration of oxygenation. Continuing to cough productive.\n\nRENAL: increasing bun/cr. on irrigant to keep urine pink\n\nSOCIAL; wife aware of arrest.\n\nASSESS: decompensation w/ subsequent cardiac arrest\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-18 00:00:00.000",
"description": "Report",
"row_id": 1364013,
"text": "CCU NPN 1pm - 11pm\nS/O: Resp: Pt. remains intubated presently on 50%, vT 700, rate - 14, IMV with ABG 129/33/7.45/24. Pt. suctioned for moderate amt. of bloody sputum Q 2 - 3 hours. Lots of bloody secretions from the back of mouth.\nCVS: BP has been labile. Pitressin has been weaned off and the dopamine has been increased to 7 mcg/kg/min. BP presently in the 90/50 range. HR - 90 - 100 ST intially, now in afib. Continues to have lots of PVC's and some short runs of VT. C.O. - 5.3, SVR 664. continues on amiodorone.\nHeme: Heparin restarted at 800u/hr. Pt. continues to bleed from back of mouth, bladder and nose.. ENT in again to pack right nare. HCT stable at 31. PT/PTT pending.\nNeuro: Pt. is sedated on propofol drip.\nG.I.: OGT placed and pt. is receiving meds through it. No blood noted from stomach.\nG.U: Continues on bladder irrigant. U/O this shift is 500cc's. Urine pink with a little increase in bleeding noted around 10pm.\nI.D.: Pt. is afebrile. WBC - 13, Pt. given cefazolin 1.5 gm IV.\nA: s/p VT arrest\nP: monitor rhythm, continue amiodorone, monitor bleeding, continues pressors, check labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-16 00:00:00.000",
"description": "Report",
"row_id": 1364006,
"text": "CCU Nursing Note 0700-1900: CHF\nID: Afebrile, Tmax 98.7 PO, WBC 8.4\n\nCV: NSR with frequent PVC's and today a three beat run of VT, HR 80-90's. No c/o chest pain today or during run of VT. SBP intially 90-100's throughout day became increasingly hypotensive with SBP decreasing to 70-mid 80's. Pt alert and awake with no c/o dizziness say he \"feels fine.\" PO Hydralazine held. Came done on the Lasix gtt to 15mg(20mg),due to shut off, on call to CL. Still continue on Heparin at 800cc/hr and Milrinoe at 0.33mcg/kg/min. PA readings improving from initial start on Milrinone. PAD's 22-26, PCWP=22, CVP in the mid to high teens. CO/CI/SVR numbers from 1300, questionable 5.1/2.67/298 in comparison to earlier numbers done at 0200. Numbers almost identical except for SVR which was 819 at 0200.\n\nRESP: LSCTA with crackles at bases, O2Sats 98-100% on Cool Neb/FM at 70%. O2Sat on RA 88%. At rest occasionally Sats will drop to low 90's but will increase by arousing pt. RR stable.\n\nRENAL: Foley draining brown to pinky-red color urine (traumatic inserion) at about 100cc/hr, BUN 105(baseline 60-80), Creat 2.2(baseline 1.8).\n\nGI: NPO on call to CL, Abd soft with normoactive BS.\n\nHEME: Hct down from HCT on admission 30(36). Last night pt had perfuse bleeding from his nose. Not a problem with pt. Outpatient had been seeing ENT doc. If continues will consult ENT. Pt ordered for NS drops to help relieve.\n\nENDO: FS QID,ranging in the 150's treated per sliding scale. FS 153 at noon not treated. Pt felt that he did not need it and refused. Follows BS's very closely at home.\n\nSOCIAL: Wife aware pt in cath lab and will continue to call. Would like to come and visit with pt tonight.\n\nPLAN:\n-Awaiting return from Cath Lab\n-Continue to diuresis with goal of weaning gtt to standing dose\n-Continue afterload reducer if BP's tolerate\n-Team may consider dc'g Milrinone if SVR continues to be low, ideal\n PCWP 17-18\n-Plan to c/s Renal in re: CRI\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-16 00:00:00.000",
"description": "Report",
"row_id": 1364007,
"text": "ADDEDUM: POST CATH REPORT 1840\nPt started at 1430 and tolerated fair, intially thought pt was going to need a IABP so inserted a 6FR A-sheath in left groin but ended up not needing. 8FR in right groin for procedure. Pt stented x 2 to old vein graft sites. Veing graft at circ and diag totally occluded, try to pass wire and dilate, unsucceful so stented old osteo graft and distal portion to that. Pt recieved Fentanyl and Versed for sedation, given 300mg of plavix. Continues on Milrinone at 0.33mcg during procedure and bolused and started on Intergrillin.\n\nPLAN:\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-17 00:00:00.000",
"description": "Report",
"row_id": 1364008,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P CATH/STENT; CHF\n\nS- \" CAN I EAT, CAN I MOVE...?\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT RETURNED FROM CATH LAB 7P- SEE CATH LAB REPORT.\nREMAINS WITH MARGINAL BP- 88/30- 90/50, HR- 90-100'S ST/AFIB.\nMUCH VT- RUNS, NONSUSTAINED. INTEGRILLEN 1 MG, MILRINONE 0.33 MCG, DECREASED TO 0.16 MCG FOR VEA- WITH SLIGHTLY LESS VT ON LOWER DOSE.\nNO CHANGE IN CO/CI PRE/POST CHANGE IN DRUG.\nBILATERAL GROIN SHEATH D/C 8:30 PM- RESTART HEPARIN 12:30 AT 800U, NO BOLUS.\nSMALL SLOW OOZE LEFT GROIN- DRESSED WITH PRESSURE DSG. PULSES ALL (+).\nHOLDING HYDRALAZINE D/T BP<100- 90/\nCURRENTLY THIS EARLY AM AFTER 2 U PRBC, BP TRENDING UP > 100/\nCONTINUES ON POST CATH FLUIDS S/P 2U PRBC FOR HCT- 27 PRE CATH.\n\n PT CONTINUES TO HAVE GOOD O2 SATS ON 4 L ALT WITH 40% NEB.\nCRACKLES PERSISTS BASE- 1/4 UP WITH PAD- 28-32, PCW- 26-28.\nNO CHANGES IN FILLING PRESSURES THIS SHIFT.\nI/O (-) 1200CC AS OF 12 AM,DEFERED LASIX D/T LOW BP.\nBY 3 AM, I/O MORE EVEN, BP SLIGHTLY HIGHER..\nATTEMPTED LASIX 100 MG X 1- NO RESULT.\nRESTARTED 15 MG LASIX/HOUR 4 AM.\nAWAIT RESPONSE.\n\nGU- SEE ABOVE- UO- 20-40/HOUR.\nHEMATURIA.\n\n PT WANTING TO EAT ON ARRIVAL FROM LAB.\nGIVEN LIX/TOAST.\nABD SOFT, (+) BOWEL SOUNDS.\nNO ISSUES CURRENTLY.\n\n PT ANXIOUS AND WANTING TO MOVE, EAT ETC.\nWIFE IN TO VISIT.\nAFTER EXPLAINING COURSE OF EVENING, PLAN OF CARE, CATH RESULTS ETC AND SPEAKING TO CCU TEAM, PT LESS ANXIOUS AND ABLE TO REST AFTER AMBIEN.\nWIFE WENT HOME.\nPT APPEARS TO UNDERSTAND COURSE OF EVENTS.\nTURNING SIDE TO SIDE ON BEDREST S/P SHEATHS OUT FOR COMFORT, FREQUENTLY.\n\nID- AFEBRILE.\n\nA/ PT WITH LOW BP AND UO S/P CARDIAC CATH/STENT.\nNO EVIDENCE OF ISCHEMIA/PERFUSION ISSUES.\nREMAINS DIFFICULT TO DIURESE/KEEP MAPS>60 ON CURRENT MEDICAL REGIMEN.\n\nCONTINUE TO CLOSELY WATCH HEMODYNAMICS AND RESP STATUS.\nWATCH RESULTS OF LASIX GTT.\n? DISCUSS PLAN WITH MILRINONE.\nCHECK AM LABS/PTT AT 6:30 AM. KEEP HEPARIN AT THERAPEUTIC LEVELS.\nBEDREST/WATCH GROINS.\nCHECK AM HCT AND TRANSFUSE AS NEEDED.\nMUCH SUPPORT AND REINFORCEMENT.\nKEEP PT AND WIFE INFORMED RE: PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-17 00:00:00.000",
"description": "Report",
"row_id": 1364009,
"text": "CCU Nursing Note 0700-1500: CHF, S/P Stent\nID: Afebrile, 96.7 PO\n\nCV: ST with frequent PVC's and runs of VT, HR 90-100's, SBP 80-90's post hydralazine with no increase, ? if NIBP cuff was accurate so inserted an A-Line into his right radial. BP's improved 100-110's. Lasix gtt and Integrilin dc'c today. Still continues Milrone at 0.16mcg, Heparin at 800u/hr(PTT therapeutic; 69.7). Started on Nitro to decrease preload. Started at 5mcg and recently increased to 10mcg. BP's tolerated but no real change in filling pressures PAD's in the high 20-mid 30's, last CO/CI/SVR 4.8?/2.57/819 essentially the same upon starting Milrinone with PCWP of 26. Right groin site clean and dry with transparent dsg and left groin with very small amount of ooze. Reapplied pressure dsg and advancing pt slowly currently at\n30 degrees.\n\nRESP: LS clear with crackles throughout bases. Strong and productive cough. Producing brown and red colored sputum, thick. O2Sats decreases upon removal of mask to low 80's. Will increase to high 90's once mask back on. Alternated between NP and FM for pt comfort, with same effect.\n\nRENAL: No U/O for the past three hours. Just informed to start Lasix gtt back at 20mg/hr. BUN and Creat still elevated at 104/2.3. ? if pt is going into ATN vs Failure\n\nMS: Anxious at times is alert and oriented. Feels very against any more intervention being done. Was planned for ?EPS. EPS MD did come around and talk to pt but refused and would like to talk it over with his CARD. Wants to move arouud and get up but told him we need to takes things slow. Is ordered for Ambien at night\n\nGI: Diet advance to cardiac/renal diet. Tolerated well at 30 degrees.\nTaking sips of juice and ginger ale. Abd soft with normoactive BS. No BM's this shift.\n\nHEME: HCT stable after 2uPRBC's last night at 30.9\n\nENDO: This morning Lente dose in anticipation of EPS. Did not recieve the other half today. BS two hours after eating was 297 at 1300 and was treated with 9u of Reg. Does receive PM Lente dose.\n\nSOCIAL: Wife and daughter in at bedside currently visiting. Updated on pt's status by CARD's fellow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-15 00:00:00.000",
"description": "Report",
"row_id": 1364004,
"text": "CCU NSG PROG NOTE: AM'S\n****REFER TO CAREVIEW FOR DATA*****\n\nRemains stable on Millranone, lasix gtt, heparin gtt, swan ganz catheter, awaiting cardiac cath probably tomorrow.\n\nROS:\n\nCARDIAC: pain free. Improved c.o. on Millrinone. Remains in lesser degree of chf, started lasix gtt to goal of 80-100cc/hr. Occass. pvc.\nLungs w/ crackles L base. He tolerates lying flat w/ 100% CN and 6Lnc.\nAmb to chair to bed to chair to bed to commode to bed w/ very little sob or v.s. change. Oh heparin gtt 700u/hr. Ptt pnd. Had difficulty wedging swan...Dr advanced it to 55cm w/ good wedging. All tracing good. Posted strips.b/p 113-41.\n\nRESP: alt 50% cn w/ 4-6L humidified nc. SOB only noted w/ prolonged lying supine. Few L basilar crackles. He has this productive cough (dk tan secretions) which he states he's had for a year.\n\nGI: Diet changed to REnal, , CARDIAC, LOW NA, 1L fluid restriction.\nHad large formed guiac + BM.\n\nRENAL: receiving mucomyst pre-cath. voiding through day w/ neg 300cc prior to lasix gtt up. (gtt began at 6pm). Elevated bun/cr.\n\nNEURO: No limitations, sharp as a tack.\n\nSKIN: intact.\n\nENDO: glu to mid 300's. now down to 150. He is very good at managing own insulin doses.\n\nASSESS; stable, with improved cardiac output on Millranone. Potential for electrolyte or acid/base imbalance w/ lasix gtt and diuresis.\n\nPLAN: for cath probably tomorrow. follow u.o. titrate gtt for u.o. 80-100cc/hr. follow filling pressures and c.o. follow lytes w/ diruesis. follow FS.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-16 00:00:00.000",
"description": "Report",
"row_id": 1364005,
"text": "CCU NPN\nS:\"THESE NOSE BLEEDS ARE IMPOSSIBLE.\" \"AM I HAVING THE CATH FOR SURE TODAY?\"\nO: SEE VS/OBJECTIVE DATA PER CARE VUE. AFEBRILE. CV: HR INCREASING TONIGHT, RANGING 90-100'S SR/ST, ALSO INCREASE IN VEA TONIGHT. BP 90'S ON MILRINONE .33MCG/KG/MIN. PAD'S IN THE HIGH 20'S WITH CVP HIGH TEENS TO LOW 20'S. CO/CI BASICALLY UNCHANGED. LASIX GTT INCREASED TO 20MG/HR FOR DECREASE IN UO WITH NO SIGN CHANGE IN PAD/CVP. HEPARIN CONTS AT 800U/HR WITH THERAPEUTIC PTT.\nRESP: LUNGS WITH BASILAR CRACKLES, R BASE DIMISHED AERATION. O2 AT 4LNP BUT DECREASE IN SATS WITH SLEEPING THEREFORE CHANGED TO COOL NEB MASK AT 70% WITH IMPROVED O2 SAT. HAS PRODUCTIVE COUGH OF TAN/BROWN SPUTUM. 3:30AM WOKE UP WITH MOD-LG NOSE BLEED.\nGI/GU: NPO AFTER MIDNIGHT FOR CATH, FOLEY DRNG PINK/RED URINE WITH UO APPROX 60-100CC/HR. DECREASE IN UO AT ONE POINT BUT INCREASED THE LASIX GTT WITH AN INCREASE IN UO.\nMS: REMAINS ALERT AND ORIENTED X 3, HE IS MOD HARD OF HEARING. UP SITTING AT EDGE OF BED A FEW TIMES TO \"REST\" HIS BACK. WIFE CALLED TO CHECK.\nA: INCREASE IN HR/VEA\n LASIX GTT WITH ADEQUATE UO\n PRODUCTIVE COUGH\n NOSE BLEED\nP: PREPARE FOR CATH\n ? IF HE WILL NEED ENT CONSULTFOR NOSE BLEED\n FOLLOW HR, ? ADDITION OF DIG BACK TO REGIMEN\n CONT TO FOLLOW UO AND INCREASE LASIX GTT AS NEEDED\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-14 00:00:00.000",
"description": "Report",
"row_id": 1364002,
"text": "CCU NSG ACCEPTANCE NOTE:\n73 Y.O. man admitted to CCU from 3 w/ CHF for swan placement and millrinone gtt.\n\nNKDA\n\nPHX: CAD, CABG X 2VD, MI, CHF, DM, CRI (BASEINE CR 1.8-2), LCEA , PVD, ^CHOL.\n\nHPI: ADMITTED W/ CHF EXACERBATION .Managed on 3. Stable.\n\nCARDIAC: b/p 125/78. hr 79 nsr. No c/p. 25% ef(),\n\nRESP: bibasilar crackles. Room air sats 93%. SOB w/ lying flat. Has nose bleeds w/out humidification in o2.\n\nGI: BM today. Takes po well.\n\nACTIVITY: was walking in hallway on floor today.\n\nENDO: glu 207 today...covered w/ 4u insulin.\n\nNEURO: intact. A&O x3. Able to make own decisions.\n\nSOCIAL: lives in , wife aware of transfer to unit and hsb \"sent her home\".\n\nASSESS:stable chf\n\nPLAN;for Millranone and swan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-15 00:00:00.000",
"description": "Report",
"row_id": 1364003,
"text": "CCU NPN\nS:\"DID YOU START THAT MEDICINE YET?\"\nO: SEE VS/OBJECTIVE DATA PER CARE VUE. CV: HR 70-80'S NSR WITH RARE-OCC PVC. BP 90-110'S. SWAN PLACED VIA RIJ WITHOUT COMP. PAD'S 22-28, CVP 21-26. STARTED MILRINONE AFTER 2000MCG BOLUS AT .33MCG/KG/MIN WITH INCREASE IN CO FROM 4.5 TO 5.6 INDEX FROM 2.36 TO 2.93 AND A DECREASE IN SVR FROM 800-443. AT 4AM SWAN NOTED TO BE IN WEDGE POSITION, RESIDENT AND INTERN AWARE AND SWAN PULLED BACK. ABG CONFIRMED PLACEMENT IN PA. INCREASING CVP AND PAD THEREFORE REC'D LASIX 120MG IV. HEPARIN RESTARTED AFTER SWAN PLACED AT 750U/HR\nRESP: LUNGS INITIALLY CLEAR, O2 INCREASED FOR SWAN PLACEMENT PLACED BACK TO NC AFTER BUT DECREASE IN O2 SAT WHILE SLEEPING SO PLACED BACK ON NEB AT 60% WITH SATS 95-96%. AT 4AM CRACKLES AT BASES BILAT, REC'D LASIX.\nGI/GU: VOIDS WHILE SITTING AT EDGE OF BED.\nMS: ASKING APPROPRIATE QUESTIONS. REC'D AMBIEN 5MG WITH EXCELLENT EFFECT. ALERT/ORIENTED MAE WITH EQUAL STRENGTH.\nA: MILRINONE STARTED WITH INCREASE IN CO/CI\n INCREASE IN PAD/CVP REC'D LASIX\nP: DIURESE FOLLOW BUN/CREAT\n CONT TO FOLLOW SWAN NUMBERS\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-21 00:00:00.000",
"description": "Report",
"row_id": 1364020,
"text": "NSG NOTE\n\nCV: REMAINS IN NSR,BUT CON'T TO HAVE FREQ MULTIFOCAL PVC'S. ABLE TO WEAN OFF PITRESSIN GTT,KEEPING MAP'S > 60. DOBUTAMINE REMAINS ON @ 10MCG AS WELL AS DOPAMINE @ 18.5 MCG. PAD'S 24-29,CVP 13-14,PCWP 20. CO 8.3,CI 4.35,SVR 472. NO RUNS OF VT NOTED AT THIS TIME.\n\nRESP: AC,40%,650X12,PEEP 5. SUCTIONED FOR THICK BLD TINGE/TAN SECRETIONS. BS COURSE BILAT. O2 SATS HAVE REMAINED 97-98%. SM BLD OOZ NOTED FROM L NARES. PACKING REMAIN IN PLACE.\n\nID: CON'T ON CEFAZOLIN. RECEIVED 1 TIME DOSE VANCO ON . SLOWLY BECOMING HYPOTHERMIC. PACKED PT IN BLANKETS FROM WARMER WITH LITTLE EFFECT. BAIR HUGGER APPLIED.\n\nGU: CVVHD ONGOING. NOTED THAT FILTER PRESSURES INCREASING TO 199-205. FILTER APPEARS TO HAVE DARKENED AREAS OF NOTE. RENAL FELLOW NOTIFIED. NO CHANGES ORDERED AT THIS TIME. SEE FLOW.\n\nGI: NEPRO INFUSING @ 30CC/HR. TOL WELL BY PT WITH LOW RESIDUALS. HYPOACTIVE BS. NO STOOL THIS SHIFT.\n\nSKIN: L GROIN DSG INTACT.. R GROIN C&D.\n\nNEURO: RESPONDS TO STIMULATION. UNABLE TO FOLLOW COMMANDS. CALM\n\nHEME: TRANSFUSED 1 UNIT PRBC. AWAITING HCT.\n\nLABS: PTT 44.4 CARDIAC FELLOW NOTIFIED. RATE OF HEPARIN INCREASED TO 300U/HR WITHOUT BOLUS\n K+ 3.4 RECEIVED 10MEQ KCL IV.\n BS PER FLOW. INSULIN GTT TITRATED UP TO 17U/HR\n\nSOCIAL: NO CALLS FROM FAMILY.\n\nA: CRITICAL/DNR\n\nP: CON;T WITH PRESSORS,CVVHD AND COMFORT CONTROL\n PER NSG JUDGEMENT.\n RENAL WILL SEE TODAY\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-21 00:00:00.000",
"description": "Report",
"row_id": 1364021,
"text": "Respiratory Care:\n\nPatient remains intubated on mechanical support. Vent settings Vt 650, A/C 12, Fio2 40%, Peep 5. PAP/Plateau 28/25. Bs coarse bilaterally. Sx'd/lavaged for moderate amounts of thick tan sputum. No further changes made. Continue with mechanical support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-21 00:00:00.000",
"description": "Report",
"row_id": 1364022,
"text": "npn ccu\nn-sedated on propofol infusion, prn mso4 for , arouse to significant stimulation\nr-ventilation/respiration remain constant\ncv-nsr 80's freq mf pvc's, repleted k and ca++\nmap's>60 with dopa/dobut/vasopressin- #'s more septic with dobut at 10 and pit at .02-changed to dobut at 5 and pit at .04 and numbers are mixed cardiogenic/sirs picture\npad's 28-pa sats 74,\ngi-tf at goal\ngu-making approx 15cc uo/hr, cvvh changed bath from 5k/l to 4k/l, have needed to replete k throughout day,\nnormal temp today-cultures all negative\nfamily in and updated\na/p-conditon remains guarded-continue all current supports\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-19 00:00:00.000",
"description": "Report",
"row_id": 1364016,
"text": "CCU NSG NOTE: CV\nO: For complete VS see CCU flow sheet.\nID: Pt afebrile.\nCV: Pt has not made progress today. HR has bee in 80-90 probably a-fib, though difficult to interpret. Pt now has only rate ectopy and no runs seen. He remains on amiodarone at 1mg, which should problably be decreased to .5. At 8am map remained in 50 and dopamine was increased to 11mic/kilo, where it remains. During dialysis vasopressin at .04u/min or 2.4 units/hr was added and maps are now in the 70s. There has been no significant change in PAPs ranging 55-63/32-35 with wedge 22-25 and RA 15-19. His last C/O was 3.7/1.9 with SVR 1059. Due to oral bleeding heparin was shut off at 8:30 but restarted at 1pm at 2500u/hr with no bolus. PTT pending. The pulses in his R foot are dopplerable, but have been able to doppler pulses in left foot only intermittently. HO notified. Both feet are cool, but pt can move them and they are both pale. R groin is dry though quentin catheter has had some oozing.\nRESP: Pt remians intubated on AC 40% 12 X 650 5 PEEP with last gas was 7.34/ 38/ 86.Breath sound remain course. Sats had been 97% most of the day with minimal secretions, however at 6:30pm sats dropped to 94% --gas sent and pt then suctioned with lavage for a few old bloody clot that probably came from -pharynx.\nHEME: Pt Had copious bloody secretion in am with oozing from IV sites. Heparin was shut off at 8:30 and PTT at 11am was 47. With heparin off and now at low dose all bleeding has decreased, though frank blood can still be suction from oral cavity, though at far slower rate.\nGI: Bowel sounds decreased. Pt to start nepro when pump available. Pt has had minimal gastric asp ~ 8-12 cc of coffee ground matl which appears to have come from above.\nRENAL: Pt continues on cbi with urine far clearer than in am. He is\nProbably putting out between 50-100cc/hr. He was dialyzed today and had only 900cc taken off due to dropping of maps even on vasopressin.\nENDO: FS have been in high 100s to low 200s and ss reg insulin given at 11a and 4pm. Glucose pending.\nMS/SEDATION/FAMILY: Pt continues on propofol at 23mic/9kilo/min. He is rouseable and at one point would open his eyes, squeeze my hands and wiggle toes on command. Family in to visit and is understandably distraught at pt condition. The spoke with fellow and will speak with attending tomorrow.\nA: C/O decreasing/now on vasopressin\nP: Start TF when pump arrives. Check results of labs sent at 6:30. Monitor for change. Support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-20 00:00:00.000",
"description": "Report",
"row_id": 1364017,
"text": "WITH A RUN OF \nPT. MAINTAINED ON A/C VENTILATION WITH GOOD OXYGENATION. PT IS UNRESPONSIVE AT THIS TIME. PT BECAME UNSTABLE WITH A RUN OF V-FIB NEEDING DIFIB. WITH A RETURN TO NORMAL SINUS. PLAN IS TO CONT. WITH CURRENT MANAGEMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-20 00:00:00.000",
"description": "Report",
"row_id": 1364018,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P STENT; VT ARREST\n\n\nS- INTUBATED.\n\n PT WITH SUSTAINED VT ON AMIODORONE 0.5 MG- DECREASED FROM 1 MG AT 8PM. REQUIRING SHOCK 360 J X 1 WITH EACH EVENT- CONVERTING TO SLOW AF- 50-60.\nHR- 60-80'S AFIB OTHERWISE WITH BP - 104/51- 126/51.\nHEPARIN GTT INCREASED FROM 250-300-400U FOR PTT<60.\nDUE FOR PTT 8:30 AM.\nK- 5.4, 5.7- RECEIVED KEXILATED 15 GM , THEN 30 GM.\nDOPA GTT AT 11 MCG AND VASOPRESSIN AT 0.04 U\n\nRESP- REMAINS VENTILATED ON SAME SETTINGS WITH ADEQUATE ABG'S. SUCTIONED FOR THICK TANNISH SPUTUM.\nNO ISSUES.\n\nID - AFEBRILE.\n\nGU- REMAINS ON GU IRRIGANT- LESS CLOTS/BLOODY.\nPOOR UO- CREATINE INCREASED- S/P DIALYSIS AFTERNOON.\n\nGI- STARTED NEPRO 10CC/HOUR\nHYPO BOWEL SOUNDS, NO STOOL.\n\nHEME- HCT STABLE- NO FURTHER TRANSFUSIONS THIS SHIFT.\n\nGROIN SITES- LEFT SITE OOZING- RT SIDE DRY. REINFORCED LEFT DRESSING SITE.\nALSO SOME BRACHIAL IV SITE OOZING.\nLESS SO THAN YESTERDAY.\n\n PT AWAKENED, BUT SEDATED WITH 20MCG PROPOFOL AND KEPT COMFORTABLE.\nNO CALLS FROM FAMILY THIS SHIFT.\n\nDM- BS- 270-330- REG INSULIN SS- U.\nINCREASED BS ON TUBE FEEDS.\n\nA/ PT S/P VT ARREST/STENT/RENAL FAILURE- CURRENTLY EXPERIENCING SUSTAINED VT X 2 THIS SHIFT.\n\nCONTINUE TO MONITOR CLOSELY CV STATUS- DISCUSS ? EP STUDY OR ADDITION OF ANOTHER ANTIARRYTHMIC .\nDIALYSIS/MONITOR OF ELECTROLYTES.\nSS INSULIN/NUTRITION.\nGU IRRIGATION AS NEEDED.\nCLOSELY MONITOR FOR FURTHER BLEEDING.\nSEDATE/COMFORT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-20 00:00:00.000",
"description": "Report",
"row_id": 1364019,
"text": "npn ccu\nn-sedated with propofol, arouses to tactile/noxious stimuli-med with prn mso4 for comfort\n\nr-remains on ac 650 x 12 40% +5 peep, thick purulent sx's, maintaining stable oxygenation/ventilation\n\ncv-acc junct rhythem changed to nsr in 70's now, no further vt today\nmap's less than 50 with max dopa/resumed vasopressin, dobut at 10 for low output state ci 1.7, now ci>3 with svr 600 but bp marginal\npa sat 51>>68- now warm and dilated, had been cold and clamped\n\ngi-nepro at goal 30cc/hr, stooling liquid black melena type stool\n\ngu-bladder irrigant at 400cc/hr-no urine output, cvvh per renal specs-goal removal 80cc/hr-running basically net even-no fluid removal\nquinton site oozing-\n\nhct dropped to 27-to be tx with 1 u prbc goal to keep hct >30\noozing from all invasive sites/mouth/nose-ptt 90 on heparin at 400u/hr-dropped to 200u/hr-need to keep heparin infusing to run cvvh-remains on asa and plavix also\n\nafebrile-on cephazolin for ent coverage, added ceftaz/vanco additonal coverage lines/lungs\n\nfamily meeting-dnr now for defib/pacing-will continue with all other aggressive tx\nblood sugars>400-insulin drip being titrated to get bl sugars<200\n\na/p-requiring max vasopressor/inatropic support/ventilation/cvvh with no improvement-condition is guarded-keep family informed\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-22 00:00:00.000",
"description": "Report",
"row_id": 1364023,
"text": "CCU NSG PROGRESS NOTE.\nO:NEURO=SEDATED W PROPOFOL GTT @ 30MCG W GD EFFECT. RESPONDS TO NOXIOUS STIM W W DRAWAL. DOES NOT FOLLOW COMMANDS. WO PURPOSEFUL MOVEMENT.\n PULM=INTUBATED & VENTED. SETTINGS-AC, 40%, 650X12, & +5. SATS MID 90'S. AM ABG-7.42/43/67/29/2 W ASAT 95. SX-THICK TANNISH SECRETIONS. BREATH SOUNDS=COURSE THROUGHOUT.\n CV=NSR W RARE ECTOPY. HR 70-80. MAPS 68-51, PADS 33-23, & W 20-18-- ALL REFLECTING WEAN OF DOBUTA FROM 5 T0 0 @ 0100 & DOPA 20 TO 9 @ 0500. ATTEMPTED TO WEAN VASOPRESSIN (FROM 6ML TO 5ML-WO SIGNIF CHG IN DOSE)-DOBUTA OFF & DOPA @ 9-WO SUCCESS- MAPS DROPPED FROM UPPER 50'S TO MID TO UPPER 40'S. CO/CI/SVR-ON DOPA @ 9MCG & VASOPRESSIN @ 0.04- 5.6/2.93/571. HEPARIN INCREASED FROM 400 TO 600U @ 0130 FOR PTT-52.5-- REPEAT 4HRS LATER-67.8.\n GI=TF @ 30ML/HR W MINIMAL RESIDUALS. SM AMT BLACK GUIAC POS STOOL-RECTAL BAG CHGED.\n ENDO=INSULIN GTT INCREASED FROM 2 TO 4 FOR BS 220 & INCREASED AGAIN @ 0600 TO 6 FOR BS 300.\n HEME=0000 HCT 31.3-0530 29.2\n LABS=0000 CA++-1.02 REPLACED W 2 AMPS--AM PENDING.\n ID=T 97.5 TO 96.4--WARMER ADDED--DCED WHEN T 98.6.\n RENAL=REMAINS ON CVVHD. FL REMOVAL APPROX 80ML/HR. REMAIN POS I&O DUE TO AMT OF FL INTAKE W IV'S-ALL GTTS CONCENTRATED TO DECREASE VOLUME.\nA:DECREASING PAO2-?RELATED TO CONTIN POS VOLUME STATUS. TOLERATED DOBUTA WEAN & DC. TOLERATED DOPA WEAN FROM 20 TO 9MCG-UNABLE TO FURTHER WEAN DOPA OR VASOPRESSIN. RISING BS-COVERED W INCREASE IN INSULIN GTT. ?INCREASE CVVHD FLUID WDRAWL VOLUME.\nP: ADEQ SEDATION. ?INCREASE FIO2 TO ADEQ OXYGENATION. ?WO FURTHER ATTEMPT @ WEANING PRESSORS-?GOAL DECREASE VOLUME STATUS VIA CVVHD-INCREASE VOL FL REMOVED/HR---DISCUSSED W HO DURING SHIFT-DECISSION TO STATUS QUO & ADDRESS W RENAL IN AM. PTT. ?NEED FOR TF. FOLLOW BS-TITRATE INSULIN GTT ACCORDINGLY. CK AM LABS-REPLACE AS INDICATED. NORM T. CONTIN TO DISCUSS OVER ALL CODE STATUS W FAMILY-SUPPORT AS NEEDED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-22 00:00:00.000",
"description": "Report",
"row_id": 1364024,
"text": "npn ccu\nfamily discussion- d/t no improvement and pressor/vent/cvvh dependence which was incongruent with patient wishes, family chose to withdraw bp support and cvvh, pt expired rapidly in no distress while on vent\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-19 00:00:00.000",
"description": "Report",
"row_id": 1364014,
"text": "PT. MAINTAINED ON A/C VENTILATION WITH GOOD OXYGENATION AND CURRENTLY WITH STABLE VITALS. PT. IS UNRESPONSIVE. SETTINGS ADJUSTED OVERNIGHT WITH RESULTING ABG'S AS POSTED. PLAN IS TO CONT WITH CURRENT MANAGEMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2147-01-19 00:00:00.000",
"description": "Report",
"row_id": 1364015,
"text": "CCU NSG PROGRESS NOTE 11P-7A/ S/P VT ARREST; BLEED\n\nS- INUTBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\n PT REMAINS IN AF- 98-100 WITH MINIMAL VEA S/P VT ARREST THIS MORNING.\nAMIODORONE 1 MG/ AM LYTES ALL PENDING. ON STANDBY.\nDOPA AT 7MCG- INCREASING TO 8 MCG CURRENTLY FOR MAPS< 60.\nOVERALL, SBP- 77/ MAPS 58-60.\nREMAINS OFF VASOPRESSIN. SEE FLOW FOR CO/CI/SVR.\nHEPARIN RESTARTED AT 800U WITH PTT>150. HELD FOR 2 HOURS AND DECREASED TO 600U 4:15AM.\n\n PT WITH LATE EVE HCT- 31- THIS AM DOWN TO 28.7,\nTO TRANSFUSE WITH ANOTHER UNIT PRBC.\nMUCH ORAL BLEEDING, NASAL OOZING AS WELL AS SOME LEFT GROIN OOZE.\nSLOWED DOWN WITH HOLDING HEPARIN FOR HIGH PTT.\nMOST OOZING IS FROM NASAL AREA- PACKED BY ENT YESTERDAY.\n\nRESP- REMAINS ON VENTILATORY SUPPORT.\n50/650/12 IMV.\nAM ABG WNL.\nSUCTIONED FOR MINIMAL AMT SECRETION.\nMUCH ORAL SECRETION/BLOOD.\nCOARSE BREATH SOUNDS.\n\nID- AFEBRILE, NO ISSUES.\n\nGU- GU IRRIGANT FOR HEMATURIA.\nMINIMAL UO.\nON HEMODIALYSIS- S/P DIALYSIS- 3 LITERS OFF PER REPORT.\n\nGI- NASAL PACKING IN PLACE PER ENT.\nBOWEL SOUNDS (+)- NO STOOL OR GI BLEEDING EVIDENT CURRENTLY.\n\n PT AWAKENED TO STIMULATION- SEDATE ON PROPOFOL GTT.\nNO CALLS FROM FAMILY.\n\nA/ PT S/P CATH/STENT- CURRENTLY INTUBATED S/P VT ARREST C/B BLEEDING ISSUES FROM ANTICOAGULANTS.\n\nCONTINUE TO INCREASE PRESSORS TO GET MAP>60.\nTRANSFUSE TO HCT >30.\nKEEP INTUBATED FOR AIRWAY PROTECTION ESP WITH MUCH ORAL BLEEDING.\nSEDATION/COMFORT.\nCLOSE MONITOR PTT/HCT.\nCONSULT WITH ENT- RE: ORAL/NASAL BLEEDING.\nCLOSELY MONITOR FOR ANY FURTHER VT ON AMIO GTT.\n"
},
{
"category": "Echo",
"chartdate": "2147-01-11 00:00:00.000",
"description": "Report",
"row_id": 95449,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Mitral valve disease.\nHeight: (in) 67\nWeight (lb): 163\nBSA (m2): 1.86 m2\nBP (mm Hg): 135/115\nHR (bpm): 53\nStatus: Inpatient\nDate/Time: at 10:59\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity is mildly dilated. Overall left ventricular systolic\nfunction is severely depressed.\n\nRIGHT VENTRICLE: There is moderate global right ventricular free wall\nhypokinesis.\n\nAORTIC VALVE: A bileaflet aortic valve prosthesis is present. Trace aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification. There is mild thickening of the mitral\nvalve chordae. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitaton.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy. The left ventricular cavity is mildly dilated.\nOverall left ventricular systolic function is severely depressed. There is\nmoderate global right ventricular free wall hypokinesis. A bileaflet aortic\nvalve prosthesis is present. Trace aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen.\nThere is no pericardial effusion.\n\nCompared with the prior report of , there is significant deterioration\nof left ventricular function\n\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-20 00:00:00.000",
"description": "Report",
"row_id": 251807,
"text": "Sinus rhythm. Short P-R interval. Compared to the previous tracing of \nthere is improvement in the inferolateral ST-T wave abnormalities. The rate is\nslower. Ventricular ectopy is absent. Otherwise, no change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-17 00:00:00.000",
"description": "Report",
"row_id": 251808,
"text": "Regular supraventricular rhythm with discrete atrial activity preceding each\nQRS complex (e.g.in lead V1). Ventricular ectopy. Multiple additional\nabnormalities are as previously described. The rhythm is likely sinus\ntachycardia or atrial tachycardia. ST-T wave abnormalities are present but are\nsomewhat improved compared to the previous tracings of .\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-16 00:00:00.000",
"description": "Report",
"row_id": 251809,
"text": "Atrial fibrillation. The low amplitude of the atrial activity makes\ndifferentiation difficult. Multiple additional abnormalities are as previously\ndescribed. Compared to tracing #1 the rate has slowed and atrial fibrillation\nis present. ST segment depressions are improved compared to tracing #1.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-22 00:00:00.000",
"description": "Report",
"row_id": 251805,
"text": "Normal sinus rhythm\n*** if rhythm correct, report below may be invalid ***\nIntraventricular conduction defect\nInferior infarct - age undetermined\nPossible old anterior infarct\nLateral ST-T changes offer additional evidence of ischemia\nSince last ECG, , rhythm change\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-21 00:00:00.000",
"description": "Report",
"row_id": 251806,
"text": "Sinus rhythm. Occasional ventricular ectopy. Compared to the previous tracing\nof there is further improvement in the previously recorded T wave\nabnormalities with some resolution of the ST segment depression and T wave\ninversion previously recorded in leads I, aVL and V4-V6.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-16 00:00:00.000",
"description": "Report",
"row_id": 251810,
"text": "Regular supraventricular rhythm most likely sinus tachycardia. Prior inferior\ninfarction. Prior anteroseptal myocardial infarction. Ventricular ectopy is\npresent. Anterolateral ST-T wave abnormalities persist. Compared to the\nprevious tracing of the rate is faster and more regular with clear\ndiscernible atrial activity in lead VI. Multiple abnormalities persist\nrelatively unchanged.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-16 00:00:00.000",
"description": "Report",
"row_id": 251811,
"text": "Irregular atrial rhythm without clearly discernible P waves, most likely atrial\nfibrillation. Ventricular ectopy is present. Additional abnormalities are as\npreviously described. Compared to the previous tracing of the atrial\nrhythm appears to have changed to atrial fibrillation and the ST-T wave\nabnormalities in the anterior precordial leads have again worsened. Rule out\nactive ischemic process.\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-15 00:00:00.000",
"description": "Report",
"row_id": 251812,
"text": "Sinus rhythm. Since the previous tracing of the rate is more rapid.\nST segment depressions are now noted in leads V2-V6. The abnormalities are\nnon-specific but may be due, in part, to anterior ischemia. Clinical\ncorrelation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-12 00:00:00.000",
"description": "Report",
"row_id": 251813,
"text": "Sinus bradycardia. No significant change from the previous tracing of .\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-11 00:00:00.000",
"description": "Report",
"row_id": 252026,
"text": "Sinus bradycardia with a single ventricular ectopic beat. Prolonged\nP-R interval as previously described. Compared to the previous tracings, the\nT wave inversions and associated ST segment depressions are relatively\nimproved.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-10 00:00:00.000",
"description": "Report",
"row_id": 252027,
"text": "Right-sided leads are submitted. Sinus bradycardia. Old inferior myocardial\ninfarction. No pathologic ST segment elevation in the right-sided leads.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-10 00:00:00.000",
"description": "Report",
"row_id": 252028,
"text": "Sinus bradycardia. Prolonged P-R interval as previously described. Compared to\ntracing #1 multiple abnormalities persist as described.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2147-01-10 00:00:00.000",
"description": "Report",
"row_id": 252029,
"text": "Sinus bradycardia, rate 42. Prolonged A-V conduction with a P-R interval\nof 0.22. Prior inferior myocardial infarction. Downsloping ST segment\ndepressions and T wave inversions in leads I, aVL and V2-V4. Compared to the\nprevious tracing of the rate is significantly slowed and the\nanterolateral ST-T wave abnormalities are more pronounced. This may be due to\nischemia.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-01-18 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 748296,
"text": " 2:43 PM\n RENAL U.S. Clip # \n Reason: PT ANURIC\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n Anuric, rule out hydronephrosis.\n\n RENAL ULTRASOUND:\n The right kidney measures 10.4cm and contains two simple cysts. One is\n exocystic from the lower pole and measures 2.0cm, the second is in the hilum\n of the lower pole and measures 1.7cm. The left kidney measures 10cm. There are\n no masses, hydronephrosis or stones. The bladder is decompressed and the\n ballon from the Foley catheter is seen.\n\n IMPRESSION:\n No hydronephrosis. Normal renal ultrasound.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-01-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748332,
"text": " 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate CHF status\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with cabg, chf, iddm, class 4 heart failure, with worsening\n CHF and respiratory distress was adm for milrinone treatment, s/p cardiac\n catheterisation. s/p V tach arrest , was intubated.\n REASON FOR THIS EXAMINATION:\n evaluate CHF status\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Coronary artery disease and heart failure, status post V-tach arrest\n .\n\n COMPARISONS: \n\n PORTABLE AP SUPINE CHEST: The ET tube, swan ganz catheter, and NG tube are\n unchanged. There is no significant change in the right pleural effusion and\n pattern of congestive failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-01-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748417,
"text": " 7:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pulmonary edema/infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with cabg, chf, iddm, class 4 heart failure, with worsening\n CHF and respiratory distress was adm for milrinone treatment, s/p cardiac\n catheterisation. s/p V tach arrest , was intubated.\n REASON FOR THIS EXAMINATION:\n assess for pulmonary edema/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress s/p V-TACH arrest, intubated.\n\n AP RADIOGRAPH dated is compared with AP radiograph dated .\n\n The ETT, Swan-Ganz catheter and NG tube are unchanged. The cardiac and\n mediastinal contours are unchanged. The patient is s/p median sternotomy and\n CABG. There is diffuse increased opacity in the lung fields bilaterally. The\n right pleural effusion is unchanged.\n\n IMPRESSION: No significant change in the moderate degree of congestive\n failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-01-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748047,
"text": " 8:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: New right IJ cordis with Swan-Ganz catheter.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with cabg, chf, iddm.\n REASON FOR THIS EXAMINATION:\n New right IJ cordis with Swan-Ganz catheter.\n ______________________________________________________________________________\n FINAL REPORT\n History of Swan-Ganz and cordis placement in patient status post CABG.\n\n Status post CABG. Swan-Ganz catheter is in intralobar division of right upper\n lobe. No pneumothorax. There is cardiomegaly with pulmonary vascular\n engorgement, probably interstitial edema and small right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-01-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748309,
"text": " 4:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ET tube and NG tube location. Swan in as well.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with cabg, chf, iddm, s/p cardiac catheterisation. s/p V tach\n arrest this AM, was intubated.\n REASON FOR THIS EXAMINATION:\n assess ET tube and NG tube location. Swan in as well.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P Vtack arrest.\n\n Portable supine radiograph of the chest dated at 4:41 P.M. is\n compared with the portable AP radiograph of the chest dated at 9:01.\n There has been placement of an ETT with tip approximately 4 cm above the\n carina. A NGT is in the stomach. There is no significant change in diffuse\n alveolar and interstitial infiltrates consistent with pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-01-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748106,
"text": " 7:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ASSESS PA catheter placement, pulmonary edema\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with cabg, chf, iddm.\n REASON FOR THIS EXAMINATION:\n ASSESS PA catheter placement, pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old man S/P CABG, re-positioning of pulmonary arterial\n catheter.\n\n Portable AP radiograph of the chest dated at 8:05AM is compared to\n the portable AP radiograph of the chest dated .\n\n The Swan-Ganz catheter has been advanced with tip now in the descending branch\n of the left pulmonary artery. The cardiomediastinal silhouette is stable.\n There is interstitial and alveolar pulmonary edema and a small right pleural\n effusion which are unchanged. There has been median sternotomy and CABG.\n There is no pneumothorax.\n\n IMPRESSION: Swan-Ganz catheter advanced with its tip now in descending branch\n of left pulmonary artery. Stable congestive failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-01-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748193,
"text": " 8:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess PA catheter position, pulmonary edema.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with cabg, chf, iddm, s/p cardiac catheterisation.\n REASON FOR THIS EXAMINATION:\n Assess PA catheter position, pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n 76-year-old man status post cardiac catheterization with CHF.\n\n COMPARISON:\n .\n\n PORTABLE AP SUPINE CHEST: The right internal jugular approach Swan-Ganz\n catheter has been withdrawn slightly. The tip now resides in the left main\n pulmonary artery. There has been interval increase in the interstitial and\n alveolar pulmonary edema as well as slight increase in the right pleural\n effusion. Underlying infection cannot be excluded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-01-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748062,
"text": " 8:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess PA catheter position.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with cabg, chf, iddm.\n REASON FOR THIS EXAMINATION:\n assess PA catheter position.\n ______________________________________________________________________________\n FINAL REPORT\n Chest single film.\n\n History of CABG with placement of pulmonary artery catheter.\n\n Tip of Swan-Ganz catheter is probably entering orifice of left pulmonary\n artery. Status post CABG. No pneumothorax. There is cardiomegaly with\n evidence of interstitial and alveolar pulmonary edema and a small right\n pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-01-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748274,
"text": " 9:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pulmonary edema.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with cabg, chf, iddm, s/p cardiac catheterisation.\n REASON FOR THIS EXAMINATION:\n assess for pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old man S/P CABG with CHF.\n\n COMPARISON: \n\n PORTABLE AP CHEST: The right IJ Swan-Ganz catheter is unchanged with tip in\n the left main pulmonary artery. There is no significant change in\n interstitial and aveolar pulmonary edema. The right costophrenic angle is\n excluded from the film but the right pleural effusion is probably stable.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-01-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 748495,
"text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess pulmonary edema.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with cabg, chf, iddm, class 4 heart failure, with worsening\n CHF and respiratory distress was adm for milrinone treatment, s/p cardiac\n catheterisation. s/p V tach arrest , was intubated.\n REASON FOR THIS EXAMINATION:\n Assess pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress.\n\n CHEST SINGLE VIEW 8:46: There is no change in the degree of CHF compared with\n . Lines and tubes are also unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2147-01-13 00:00:00.000",
"description": "PERSANTINE MIBI",
"row_id": 747941,
"text": "PERSANTINE MIBI Clip # \n Reason: CAD, CARDIOMYOPATHY; EVALUATE FOR REVERSIBILITY AND VIABILITY.\n ______________________________________________________________________________\n FINAL REPORT\n SUMMARY OF EXERCISE DATA FROM THE REPORT OF THE EXERCISE LAB:\n Persantine was infused intravenously for approximately 4 minutes at a dose of\n approximately 0.142 mg/kg/min.\n\n HISTORY: Seventy-six year old male with h/o coronary artery disease and severe\n cardiomyopathy with an ejection fraction of 20%; evaluate for reversibility and\n viability.\n\n INTERPRETATION: One to three minutes after the cessation of infusion,\n MIBI was administered IV.\n\n Image Protocol: Gated SPECT.\n\n Resting perfusion images were obtained with thallium.\n Tracer was injected 15 minutes prior to obtaining the resting images.\n\n The stress images show a moderate perfusion abnormality involving the inferior\n and inferior septal regions with partial reversibility on the resting images.\n Hyperperfusion is also noted in the apex, apical septum and distal anterior\n walls with partial reversibility on the resting images. The patient was brought\n back for delayed redistribution images. The delayed images demonstrate further\n improvement in the inferior wall and septum.\n\n Ejection fraction calculated from gated wall motion images obtained after\n Persantine administration shows a left ventricular ejection fraction of\n approximately 29%. Global hypokinesis is noted with akinesis at the apex. The\n left ventricular cavity is seen to be dilated with an end diastolic volume of\n 229 ml. Prominence of the right ventricle is also noted.\n\n No prior studies were available for comparison.\n\n IMPRESSION: 1) Moderate, partially reversible perfusion abnormalities in the\n inferior and inferior septal regions. Reperfusion on the resting and\n redistribution images is suggestive of viable inferior and inferior septal\n regions. 2) Mild, reversible perfusion defects involving the apex, apical\n septum and distal anterior wall with predominantly viable myocardium. 3)\n Dilated left ventricular cavity with an estimated end diastolic volume of 229\n ml. 4) Globally hypokinetic left ventricle with akinesis at the apex and an\n estimated ejection fraction of 29%. /nkg\n\n\n , M.D.\n , M.D. Approved: MON 10:33 AM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n"
},
{
"category": "Radiology",
"chartdate": "2147-01-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 747706,
"text": " 11:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pt c/o sob, cough, fatigue\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with cabg, chf, iddm\n REASON FOR THIS EXAMINATION:\n pt c/o sob, cough, fatigue\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: COUGH, FATIGUE.\n\n A single view of the chest is compared to a prior study dated .\n There are sternal wires and clips overlying the cardiac silhouette consistent\n with a prior CABG. There is tortuosity and calcification of the aorta. The\n heart is enlarged. There is diffuse perihilar haze suggesting pulmonary edema.\n There is a focal area of consolidation within the right lower lobe which may\n represent a superimposed pneumonia. There is no pneumothorax or large pleural\n effusion. The osseous structures are grossly unremarkable.\n\n IMPRESSION: There is mild congestive failure with a superimposed right lower\n opacity which may represent a pneumonia. A follow up and AP and lateral\n radiograph are recommended.\n\n"
}
] |
70,386 | 189,427 | 1. Diabetic ketoacidosis with type I diabetes: The patient has had multiple admissions for DKA. The likely etiology is that the patient was not taking her for a few days prior to admission. She does state that she was taking lantus. She notes that she often does not take and will often avoid meals due to needle phobia. No evidence of infection in blood, CXR or UA. She was started on gtt and IVF. She had rapid closure of her gap and was switched to SC lantus (40u) and humalog ISS. She was transferred to the floor. On the floor she noted she was at her baseline and was on a stable regimen. consulted and agree with the regimen. She was discharged with a psychiatry appointment at . will contact her with a diabetes appointment. She noted the importance of eating and taking regularly. 2. Anemia, NOS: Her hematocrit initially dropped from 48-34. This was likely dilutional. It was stable upon discharge without evidence of bleed on history or exam. 3. Anxiety: She has significant anxiety, especially related with needles. She was given ativan prn for blood draws. She was continued on her prozac. She will be followed by psychiatry. | IMPRESSION: No acute cardiopulmonary process. COMPARISON: None. Short P-R interval.Indeterminate axis. Non-specific ST-T wave changes. PORTABLE AP CHEST RADIOGRAPH: The cardiac, mediastinal and hilar contours are unremarkable. No previous tracingavailable for comparison. Both lungs appear clear with no focal consolidation, pleural effusion or pneumothorax. Moderate baseline artifact. Sinus tachycardia. | 2 | [
{
"category": "Radiology",
"chartdate": "2119-10-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1214607,
"text": " 8:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: cardiopulm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with diabetes, elevated blood sugar, n/v\n REASON FOR THIS EXAMINATION:\n cardiopulm\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 30-year-old woman with diabetes and elevated blood sugar,\n evaluate for cardiopulmonary process.\n\n COMPARISON: None.\n\n PORTABLE AP CHEST RADIOGRAPH: The cardiac, mediastinal and hilar contours are\n unremarkable. Both lungs appear clear with no focal consolidation, pleural\n effusion or pneumothorax.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n"
},
{
"category": "ECG",
"chartdate": "2119-10-22 00:00:00.000",
"description": "Report",
"row_id": 248667,
"text": "Moderate baseline artifact. Sinus tachycardia. Short P-R interval.\nIndeterminate axis. Non-specific ST-T wave changes. No previous tracing\navailable for comparison.\n\n"
}
] |
12,706 | 175,648 | Hospital course, briefly, by system: 1. DM/Chronic failure: Pt was admitted in DKA to the . Her DKA was managed with insulin and IVF. Her function was noted to be declining so she underwent AV fistula formation and received a central line to begin dialysis during this admission rather than later next month as was originally planned. The patient's anion gap closed with insulin and IVF and she was called out of the on HD#3. The patient underwent three successful rounds of hemodialysis during this admission, and was set up to undergo outpatient hemodialysis on a Tuesday/Thursday/Saturday schedule at the dialysis unit in . Once the patient was transferred to the floor, she continued to have elevated blood sugars >400 in the evening, so her basal glargine was increased to 10 units at bedtime. followed the patient while she was inhouse. 2. CAD Pt's EKG upon presentation demonstrated chronic t-wave inversion and her cardiac enzymes were cycled to rule her out for MI. Of note, the patient did report one episode of chest pain during admission that resolved promptly with nitroglycerin sl. Her EKG demonstrated no changes during this episode. The patient was continued on a beta , , statin, and ACE inhibitor in house. 3. UTI UA was suggestive of a UTI so the patient was given a 3-day course of levofloxacin. 4. HTN Pt was continued on amlodipine, lisinopril, and metoprolol for control of her blood pressure. Upon discharge, the patient's blood pressure ranged from 110-160/40-80s. 5. Hypercholesterolemia The patient was continued on atorvastatin 10 mg qday for cholesterol management. On hospital day #8, the patient was cleared by PT and discharged to home in stable condition. Medications on Admission: - 325 mg qday - multivitamin - Vit D3 400 units qday - albuterol MDI prn - Toprol XL 150 mg qday - isosorbide mononitrate 60 qday - hydralazine 25 mg qid - reglan 10 mg qidachs - FeSO4 325 mg qday - protonix 40 mg qday - lantus 8 units qhs - lasix 40 mg qday - SS humalog - colace 100 mg | micu md aware of decreased u.o. VOIDED SMALL AMT OF CLOUDY URINE.ENDO: BS'S COVERED WITH SSI.NEURO: ALERT AND ORIENTATED.ID: AFEBRILE. +pp/+csm, no edema noted.resp: lungs cta except fine rales at l base. FOLEY D/C'ED. sob resolved with inc. 02. Left atrial abnormality. STARTED ON NORVASC. GU: Fair u/o..followed by renal..creat up to 3.0 Sinus rhythmLVH with secondary ST-T changesLeft atrial abnormalitySince previous tracing of , no significant change Improvement in previously seen CHF. TECHNIQUE: Noncontrast head CT. +vomiting x2 dk brown emesis: 0b+, micu intern aware. x1 episode of left sided cp that pt describes as dull and worse when she takes a deep breath. PT TO HAVE LEFT AV FISTULA PLACEMENT THIS DATE. no ekg changes, troponin level still elevated but sl lower. Cannot exclude hyperkalemia. micu/sicu nsg note: 19:00-7:00events: very hypertensive this shift requiring multiple doses of iv hydralazine, po and iv lopressor with sbp only as low as 150. hr remained stable in the 60S-70S SR. +n/v x2, developed dizziness and cp with one episode of htn. FINGER STICK AT 0400 WAS 63, PT HAD JUICE AND FINGER STICK AT 0600 WAS 130. cp resolved as bp lowered when given iv hydralazine and iv lopressor. QUINTON CATH. hr as low as 62. equal hand grasps/foot pushes.cv: hr ranging 62-72 sr with occas pvcs, bp ranging 150-200/37-72. IS MRSA.CV: HTN MUCH BETTER CONTROLLED TODAY. Following bs q1-2hrs...IVF d51/2 with 20meq at 100hr..Lytes are pnd. CREAT 3.4. am labs essentially unchanged from previous labs.id: t max 98.6 po. RESP: BS'S CLEAR, BUT SOMEWHAT DIM. IN R BASE. ns=147, k=4.2, cl=109, hco3=26. IMPRESSION: 1. O2 SATS FINE. developed congested sounding nonproductive cough. ADDENDUM:GI: NPO AFTER MND FOR CATHETER PLACEMENT. There is stable biapical scarring. Left ventricular hypertrophy withST-T wave abnormalities. RESTED WELL, BATHED AT 0600. PT. PT. PT. PT. BP RESPONDING WELL TO ANTIHYPERTENSIVES. RESP; BS'S CLEAR. no bp, bld draws, ivs in left arm-being saved fo ravf placement in the near future. Sinus rhythm. Cough. IMPRESSION 1. There is a probable small left pleural effusion. Respiratory: RA..sats in 90's. ID: Afebril..? IMPRESSION: Worsening fluid overload/CHF. COMPARISON: CT of the head from . IS EARACHE. cont. PORTABLE AP CHEST: Comparison is made to . PORTABLE AP CHEST: Comparison is made with . VSS, AFEBRILE, IVF AT 75CC (1/2 NS). Vascular catheter in satisfactory position with no pneumothorax. PT HAD A GOOD NITE. monitor cr, u.o., renal to follow. CULTURES NEG. There is an increasing area of patchy opacity in the left retrocardiac region. Sinus rhythmLeft ventricular hypertrophy with ST-T wave abnormalitiesPossible left atrial abnormalitySince previous tracing of , T wave peaking in leads V2-V4 not seen andST-T wave abnormalities more marked NO C/O CHEST PAIN, THOUGH HER ANGINA EQUIV. Neuro: Initially pt appeared confused..didnt know where she was or date..looking for things that here..as bs decreased mental status improving..MAE..cooperative GI: Had been nauseous past few days..currently c/o nausea with any po intake..abdomen soft..non tender. Osseous structures are unchanged. TAKING FLUIDS ONLY.RENAL: IVF'S CHANGED TO 1/2 NS AT 75CC/HR. renal team following pt. IS STILL SMOKING.GI: APPETITE VERY POOR. SELF MOUTH CARE. Clinicalcorrelation is suggested. iv hydralazine, po lopressor. There is stable cardiomegaly. PORTABLE AP CHEST: A right internal jugular catheter has been placed, and terminates within the superior vena cava. COMPARISON: Compared to . TO BE USED FOR AN A/V GRAFT. The cardiac silhouette is enlarged, but stable. DIM. AND DIALYSIS ON THE TOMORROW. given standing dose of 8 units glargine.f/e/n: d5 1/2 ns at 100cc/hr infusing, receiving 2nd liter presently. NON-PRODUCTIVE DRY COUGH. also has nausea with any po intake at baseline. ?dc tonite Social: Pt is divorced..lives with 84y/o mother..who is healthy The ST-T wave changes are diffuse withprominent/peaked precordial T waves. Clip # Reason: PORTACATH PLACEMENT Admitting Diagnosis: DIABETID KETOACIDOSIS FINAL REPORT A chest fluoro was performed without a radiologist present. Even allowing for this, there is likely slight progression of congestive heart failure. CREAT 3.6.NEURO: AWAKE AND ALERT.CV: BP WELL CONTROLLED ON MEDICATIONS.PLAN: TUNNEL CATHETER AND A/V GRAFT PLACEMENT-DIALYSIS AND BED ON . WBC'S 17.0. from mult. pt awaiting avf placement/probable hd. no ekg changes. The sinuses are clear and unremarkable. to monitor bp/hr closely, cont. ?treated for pancreatitis 2 wks ago..MRSA UTI Lines: 2 #20 peripherals..r fem line..? sp02 trending down to 92% during episode of cp. Note that the current study is underpenetrated compared to the previous study. 10 seconds of fluoro time was used. Osseous structures are stable. received total of 40mg iv hydralazine, 20mg iv lopressor, and 50mg po lopressor this shift with sbp only as low as 150s. 2. 2. Nursing note cont: Cardiac: Bradycardic..50's..hypertensive to 180's..given dose of iv hydralizine..with good effect. No new pleural effusions are seen. TRANSFER NOTE WRITTEN. 02 weaned down to 4l nc with 02sat still in 100s.gi/gu: abd soft, nt,nd, flat, +bs, continues with +nausea which she states she has baseline at home but it is worse now. \NO IV'S, BP'S OR PHLEBOTOMY FROM LEFT ARM. 12:07 PM CHEST FLUORO WITHOUT RADIOLOGIST IN O.R. There is vast improvement in the appearance of the pulmonary vasculature with near complete re-expansion of both lower lobes and interval decrease in the size of both pleural effusions. HAD CABG 7 YRS AGO.SOCIAL: MOTHER .PLAN: TRANSFER TO WHEN BED AVAILABLE. No pneumonia. rr 20. REASON FOR THIS EXAMINATION: ?pna FINAL REPORT INDICATION: Diabetic ketoacidosis, cough, increasing white count. There is increased opacity in the retrocardiac left lower lobe, but this is likely due to underpenetration, and is not felt to represent a focal infiltrate. | 15 | [
{
"category": "Radiology",
"chartdate": "2111-08-21 00:00:00.000",
"description": "O CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.",
"row_id": 839586,
"text": " 12:07 PM\n CHEST FLUORO WITHOUT RADIOLOGIST IN O.R. Clip # \n Reason: PORTACATH PLACEMENT\n Admitting Diagnosis: DIABETID KETOACIDOSIS\n ______________________________________________________________________________\n FINAL REPORT\n A chest fluoro was performed without a radiologist present. 10 seconds of\n fluoro time was used. No films submitted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-08-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839453,
"text": " 8:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pna\n Admitting Diagnosis: DIABETID KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with DKA, cough, increasing WBC.\n\n REASON FOR THIS EXAMINATION:\n ?pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diabetic ketoacidosis, cough, increasing white count.\n\n PORTABLE AP CHEST: Comparison is made with . Again seen are sternal\n wires and clips from prior coronary artery bypass surgery. Note that the\n current study is underpenetrated compared to the previous study. Even\n allowing for this, there is likely slight progression of congestive heart\n failure. No new pleural effusions are seen. There is increased opacity in\n the retrocardiac left lower lobe, but this is likely due to underpenetration,\n and is not felt to represent a focal infiltrate. Osseous structures are\n unchanged.\n\n IMPRESSION: Worsening fluid overload/CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839663,
"text": " 8:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: confirm location of central line\n Admitting Diagnosis: DIABETID KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with DKA, cough, increasing WBC. esrd, 1 day s/p central\n line for dialysis today\n REASON FOR THIS EXAMINATION:\n confirm location of central line\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Central line placement. Cough.\n\n COMPARISON: Compared to .\n\n PORTABLE AP CHEST: A right internal jugular catheter has been placed, and\n terminates within the superior vena cava. There is no pneumothorax. The\n cardiac silhouette is enlarged, but stable. There is an increasing area of\n patchy opacity in the left retrocardiac region. There is a probable small\n left pleural effusion.\n\n IMPRESSION\n\n 1. Vascular catheter in satisfactory position with no pneumothorax.\n\n 2. Increasing left basilar opacity, which may related to pneumonia in the\n appropriate clinical setting.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 839322,
"text": " 8:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o failure, infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with DKA, cough\n REASON FOR THIS EXAMINATION:\n r/o failure, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diabetic ketoacidosis and cough.\n\n PORTABLE AP CHEST: Comparison is made to . Again seen are sternal\n wires and clips from prior coronary artery bypass surgery. There is stable\n cardiomegaly. There is vast improvement in the appearance of the pulmonary\n vasculature with near complete re-expansion of both lower lobes and interval\n decrease in the size of both pleural effusions. There are no new focal\n consolidations. Osseous structures are stable. There is stable biapical\n scarring.\n\n IMPRESSION:\n 1. No pneumonia.\n 2. Improvement in previously seen CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-08-19 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 839335,
"text": " 9:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: INCREASED CONFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with dka increasingly confused\n REASON FOR THIS EXAMINATION:\n r/o cerebral edema, bleed\n CONTRAINDICATIONS for IV CONTRAST:\n RENAL FAILURE CR 4.1\n ______________________________________________________________________________\n WET READ: DFDgf WED 11:06 AM\n no acute hemorrhage or edema\n ______________________________________________________________________________\n FINAL REPORT\n NONCONTRAST HEAD CT:\n\n INDICATION: DKA, increasing confusion, rule out cerebral edema or bleed.\n\n COMPARISON: CT of the head from .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no evidence of intracranial hemorrhage or cerebral edema.\n There is no hydrocephalus, mass effect, or shift of normally midline\n structures. There is no evidence of acute infarction. The sinuses are clear\n and unremarkable. The surrounding osseous structures are unremarkable.\n\n IMPRESSION: No evidence of intracranial hemorrhage or cerebral edema.\n\n"
},
{
"category": "ECG",
"chartdate": "2111-08-22 00:00:00.000",
"description": "Report",
"row_id": 157745,
"text": "Sinus rhythm\nLVH with secondary ST-T changes\nLeft atrial abnormality\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2111-08-19 00:00:00.000",
"description": "Report",
"row_id": 157746,
"text": "Sinus rhythm\nLeft ventricular hypertrophy with ST-T wave abnormalities\nPossible left atrial abnormality\nSince previous tracing of , T wave peaking in leads V2-V4 not seen and\nST-T wave abnormalities more marked\n\n"
},
{
"category": "ECG",
"chartdate": "2111-08-19 00:00:00.000",
"description": "Report",
"row_id": 157747,
"text": "Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy with\nST-T wave abnormalities. The ST-T wave changes are diffuse with\nprominent/peaked precordial T waves. Cannot exclude hyperkalemia. Clinical\ncorrelation is suggested. Since the previous tracing of precordial\nT waves are more prominent and peaked.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-08-21 00:00:00.000",
"description": "Report",
"row_id": 1428697,
"text": "PT HAD A GOOD NITE. RESTED WELL, BATHED AT 0600. SELF MOUTH CARE. FINGER STICK AT 0400 WAS 63, PT HAD JUICE AND FINGER STICK AT 0600 WAS 130. PT TO HAVE LEFT AV FISTULA PLACEMENT THIS DATE. VSS, AFEBRILE, IVF AT 75CC (1/2 NS). BP RESPONDING WELL TO ANTIHYPERTENSIVES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-08-21 00:00:00.000",
"description": "Report",
"row_id": 1428698,
"text": "RESP: BS'S CLEAR, BUT SOMEWHAT DIM. IN BASES. O2 SATS 100%.\nGI: NPO SINCE MN.\nRENAL: IV FLUID AT 75CC/HR. CREAT 3.6.\nNEURO: AWAKE AND ALERT.\nCV: BP WELL CONTROLLED ON MEDICATIONS.\nPLAN: TUNNEL CATHETER AND A/V GRAFT PLACEMENT-DIALYSIS AND BED ON .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-08-19 00:00:00.000",
"description": "Report",
"row_id": 1428692,
"text": " 4 ICU nursing admit/progress note:\n 61 y/o female admitted from EW with DKA. Pt found down by mother..called emts..bs over 900 in ew. Sent to ICU for further care.\n PMHX:\n DMI since ..hx of DKA\n CAD..CHF ef 40%\n HTN\n CRI.cr=1.3-1.6\n PVD\n Bilateral carotid stenosis\n MRSA uti \n Pleural effusions..work-up for malignancy neg (current smoker)\nAllergies: KNDA\nSystems Review:\n Endocrine: Arrived in ICU on 12u reg insulin gtt..bs 200's..gtt eventually dc'd and started on ssri. Following bs q1-2hrs...IVF d51/2 with 20meq at 100hr..Lytes are pnd.\n Neuro: Initially pt appeared confused..didnt know where she was or date..looking for things that here..as bs decreased mental status improving..MAE..cooperative\n GI: Had been nauseous past few days..currently c/o nausea with any po intake..abdomen soft..non tender.\n ID: Afebril..??treated for pancreatitis 2 wks ago..MRSA UTI \n Lines: 2 #20 peripherals..r fem line..??dc tonite\n Social: Pt is divorced..lives with 84y/o mother..who is healthy\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-08-19 00:00:00.000",
"description": "Report",
"row_id": 1428693,
"text": "Nursing note cont:\n Cardiac: Bradycardic..50's..hypertensive to 180's..given dose of iv hydralizine..with good effect.\n Respiratory: RA..sats in 90's. rr 20.\n GU: Fair u/o..followed by renal..creat up to 3.0\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-08-20 00:00:00.000",
"description": "Report",
"row_id": 1428694,
"text": "micu/sicu nsg note: 19:00-7:00\nevents: very hypertensive this shift requiring multiple doses of iv hydralazine, po and iv lopressor with sbp only as low as 150. hr remained stable in the 60S-70S SR. +n/v x2, developed dizziness and cp with one episode of htn. no ekg changes, troponin level still elevated but sl lower. (0.14 at 10:30pm/was 0.15 level prior). bs essentially stable only as high as 168 requiring 2 units reg insulin per ss.\n\nneuro: a&ox3, perrla 2mm , able to turn in bed but requires boost in bed as pt weak. following commands appropriately. equal hand grasps/foot pushes.\n\ncv: hr ranging 62-72 sr with occas pvcs, bp ranging 150-200/37-72. x1 episode of left sided cp that pt describes as dull and worse when she takes a deep breath. no ekg changes. cp resolved as bp lowered when given iv hydralazine and iv lopressor. received total of 40mg iv hydralazine, 20mg iv lopressor, and 50mg po lopressor this shift with sbp only as low as 150s. hr as low as 62. +pp/+csm, no edema noted.\n\nresp: lungs cta except fine rales at l base. developed congested sounding nonproductive cough. sp02 trending down to 92% during episode of cp. placed on 2liters nc, increased to 5lnc when pt c/o sl sob with 02 sat up to 100%. sob resolved with inc. 02. 02 weaned down to 4l nc with 02sat still in 100s.\n\ngi/gu: abd soft, nt,nd, flat, +bs, continues with +nausea which she states she has baseline at home but it is worse now. also has nausea with any po intake at baseline. +vomiting x2 dk brown emesis: 0b+, micu intern aware. able to take sips of gingerale with po lopressor later in shift. foley patent draining 18-60cc/hr clear yellow urine. micu md aware of decreased u.o. renal team following pt. pt awaiting avf placement/probable hd. am cr=3.4 (3.6 at 10:30pm).\n\nendo: stable bs only as high as 168 requiring 2 units reg insulin. given standing dose of 8 units glargine.\n\nf/e/n: d5 1/2 ns at 100cc/hr infusing, receiving 2nd liter presently. ns=147, k=4.2, cl=109, hco3=26. am labs essentially unchanged from previous labs.\n\nid: t max 98.6 po. triple lumen femoral line pulled by micu intern and cath tip sent for cx per micu team.\n\nlines: rla #20g and rua #20g patent- placed .\n\nskin: mult small bruising areas on arms-? from mult. venipuncture sites.\n\nsocial: pt lives with mother. no contact with family this shift.\n\nplan: cont. to monitor bp/hr closely, cont. iv hydralazine, po lopressor. cont. to monitor bld sugar q2h with ss regular insulin-if still stable, follow up if can switch to q4hrs. monitor cr, u.o., renal to follow. no bp, bld draws, ivs in left arm-being saved fo ravf placement in the near future.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-08-20 00:00:00.000",
"description": "Report",
"row_id": 1428695,
"text": "RESP; BS'S CLEAR. DIM. IN R BASE. O2 SATS FINE. NON-PRODUCTIVE DRY COUGH. PT. IS STILL SMOKING.\nGI: APPETITE VERY POOR. TAKING FLUIDS ONLY.\nRENAL: IVF'S CHANGED TO 1/2 NS AT 75CC/HR. CREAT 3.4. FOLEY D/C'ED. QUINTON CATH. TO BE PLACED IN IR TOMORROW AM. AND DIALYSIS ON THE TOMORROW. PT. AWARE. VOIDED SMALL AMT OF CLOUDY URINE.\nENDO: BS'S COVERED WITH SSI.\nNEURO: ALERT AND ORIENTATED.\nID: AFEBRILE. WBC'S 17.0. CULTURES NEG. PT. IS MRSA.\nCV: HTN MUCH BETTER CONTROLLED TODAY. STARTED ON NORVASC. NO C/O CHEST PAIN, THOUGH HER ANGINA EQUIV. IS EARACHE. PT. HAD CABG 7 YRS AGO.\nSOCIAL: MOTHER .\nPLAN: TRANSFER TO WHEN BED AVAILABLE. TRANSFER NOTE WRITTEN. \\\nNO IV'S, BP'S OR PHLEBOTOMY FROM LEFT ARM. TO BE USED FOR AN A/V GRAFT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-08-20 00:00:00.000",
"description": "Report",
"row_id": 1428696,
"text": "ADDENDUM:\nGI: NPO AFTER MND FOR CATHETER PLACEMENT.\n"
}
] |
29,483 | 187,941 | The patient was admitted to Gold Surgery for management of his hypotension and possible pneumonia. The patient was admitted to the ICU and started on vanc/levo. The patient had an uneventful ICU course and was transferred to the floor on HD 2. We held the patient's lisinopril and atenolol for hypotension, and the patient was normotensive throughout the hospital course. On , the PTC drain was capped without complications or acute events. Upon discharge, the patient is afebrile with all vitals stable, tolerating po feeds, ambulating, and with pain controlled. The patient will be discharged off of his atenolol and lisinopril with instruction to follow up with PCP to cautiously restart his BP meds. | There is scattered colonic diverticulosis. FINDINGS: CT OF THE ABDOMEN: Note again is made of bilateral pleural effusions, small to moderate in size, with associated bibasilar atelectasis. Comparison is made to the prior CT of the abdomen and pelvis, . The previously seen surgical staples in the right lateral abdominal wall are no longer identified. Some of these collections have slightly increased (Over) 3:09 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: PO (oral or via JT) and IV contrast To evaluate collections, Admitting Diagnosis: CHOLANGITIS FINAL REPORT (REVISED) (Cont) in size and the rest are not significantly changed. As before, the patient is noted to have percutaneous and internal biliary drainage catheters. The phase of enhancement is somewhat suboptimal for evaluation of the vasculature. There is a soft tissue defect in the right lateral abdominal wall, which may be related to prior surgery. A few additional 2-3 cm fluid pockets are seen in the right abdominal wall. TRANSFERRED FROM TO FOR DX OF PERSISTENT HYPOTENSION. There are several fluid collections along the right lateral abdominal wall. A new left lower lobe opacity obscuring the hemidiaphragm and part of the left heart border with leftward mediastinal shift is demonstrated, findings consistent with left lower lobe atelectasis and is new since a prior study. The exact (Over) 3:09 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # Reason: PO (oral or via JT) and IV contrast To evaluate collections, Admitting Diagnosis: CHOLANGITIS FINAL REPORT (REVISED) (Cont) dimensions of those collections are difficult to measure due to poorly defined margins. There are small para-aortic lymph nodes that measure less than 1 cm in short axis. Multiple catheters projecting over the right upper quadrant are demonstrated, new since the prior study and their precise definition is difficult in the absence of clinical history. There is trace amount of pelvic fluid. There is diastasis of the rectus abdominal muscles with bulging of several loops of bowel through the anterior abdominal wall defect. TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and pelvis after administration of 130 cc of intravenous Optiray and oral contrast. There is also a gastrojejunostomy tube in place with distal tip in the proximal jejunum. A small right pleural effusion is also present. The collection medial to the right iliacus muscle appears contiguous with the right lateral abdominal wall collection. There is a percutaneous pigtail drainage catheter in the right upper quadrant just below the edge of the liver. There is a 4 x 7 cm fluid collection in the pelvis just medial to the iliacus muscle. There is another collection in the region of the body of the pancreas that measures 3.6 x 5.5 cm. The evaluation of right lung demonstrates faint opacity in the right upper lobe slightly obscuring the upper portion of the right hilus which might represent atelectasis or developing pneumonia. The gallbladder is not clearly identified. There are innumerable confluent fluid pockets in the region of the head of the pancreas with adjacent extensive stranding/inflammatory changes. Evaluate collections or other interval changes to explain leukocytosis. IMPRESSION: Innumerable intra-abdominal and pelvic fluid collections many of which are contiguous with each other. As before, note is made of innumerable intra-abdominal fluid collections, some of which have slightly increased in size since the prior studies, the rest are not significantly changed. The portal and splenic veins are grossly patent. Some of the collections in the region of the pancreatic head now contain gas pockets within them. Coronal and sagittal reformatted images were also obtained. There is also small left pleural effusion present most likely unchanged compared to the prior film. CONT CURRENT ICU CARE AND ASSESSMENTS. There are multilevel degenerative changes in the spine. PT VOIDING SPONTANEOUSLY W/O DIFFICULTY. There is a pigtail drainage catheter in the right lateral abdomen with its tip just below the edge of the liver. The left portal vein is grossly patent. Portable AP chest radiograph was compared to . The right portal vein is somewhat diminutive and is not well seen. POSITIVE BOWEL SOUNDS. There is small amount of ascites around the liver and spleen that is not significantly changed since the prior examination. This collection now has gas pockets within it. SECOND DRAIN W/ OSTOMY APPLIANCE ATTACHED. A few fluid collections now contain pockets of gas within them, which is new since the prior study. LUNGS COARSE TO DIMINISHED AT BASES. The small and large bowel is normal in caliber. PMH SIGNIFICANT FOR PANCREATITIS , CAD S/P MI 15YRS AGO, HTN, HYPERLIPIDEMIA, OBESITY, OA, BPH, DUODENAL ULCER, DIABETES, A FIB, PERCUTANEOUS CHOLE TUBE , B TKR.UPON ADMIT , PT A/O X3. | 5 | [
{
"category": "Radiology",
"chartdate": "2124-05-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1014890,
"text": " 4:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Dx of PNA at outside hospital, now for f/u\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with ? PNA\n REASON FOR THIS EXAMINATION:\n Dx of PNA at outside hospital, now for f/u\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with pneumonia diagnosed in\n outside hospital.\n\n Portable AP chest radiograph was compared to .\n\n A new left lower lobe opacity obscuring the hemidiaphragm and part of the left\n heart border with leftward mediastinal shift is demonstrated, findings\n consistent with left lower lobe atelectasis and is new since a prior study.\n There is also small left pleural effusion present most likely unchanged\n compared to the prior film. The left upper lung is unremarkable. The\n evaluation of right lung demonstrates faint opacity in the right upper lobe\n slightly obscuring the upper portion of the right hilus which might represent\n atelectasis or developing pneumonia. A small right pleural effusion is also\n present.\n\n Multiple catheters projecting over the right upper quadrant are demonstrated,\n new since the prior study and their precise definition is difficult in the\n absence of clinical history.\n\n Findings were discussed with Dr. over the phone by Dr. at\n the time of dictation.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-06 00:00:00.000",
"description": "Report",
"row_id": 1644249,
"text": "ADMIT NOTE\n72 Y.O. TRANSFERRED FROM TO FOR DX OF PERSISTENT HYPOTENSION. PT HAD JUST RECENTLY BEEN D/C'D FROM S/P PROLONGED HOSPITALIZATION FOR GALLSTONE PANCREATITIS (FOR WHICH HE WAS IN THE FOR 2MO). PMH SIGNIFICANT FOR PANCREATITIS , CAD S/P MI 15YRS AGO, HTN, HYPERLIPIDEMIA, OBESITY, OA, BPH, DUODENAL ULCER, DIABETES, A FIB, PERCUTANEOUS CHOLE TUBE , B TKR.\nUPON ADMIT , PT A/O X3. NO C/O PAIN OR SOB. SATS ACCEPTABLE ON RA. LUNGS COARSE TO DIMINISHED AT BASES. ABD OBESE. POSITIVE BOWEL SOUNDS. MULT DRAINS IN PLACE. PIGTAIL NOTED RSIDE - CAPPED. JP DRAIN W/ SM AMT OF TAN DRAINAGE OUT. SECOND DRAIN W/ OSTOMY APPLIANCE ATTACHED. GTUBE LEFT SIDE, CLAMPED. PT VOIDING SPONTANEOUSLY W/O DIFFICULTY. (+) FLATUS. LABS PENDING. LR @100CC/HR PER ORDERS.\nSTRICT HEMODYNAMIC MONITOR. ASSESS FOR S/S OF INFECTION. PT AND FAMILY TEACHING. CONT CURRENT ICU CARE AND ASSESSMENTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-07 00:00:00.000",
"description": "Report",
"row_id": 1644250,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Patient is and oriented x3, pleasant and co op with care, denies pain.\n\nCV: SB, HR 52-60, no ectopy noted, SBP 100-115,stable through out night,++PP, no edema noted, IVF LR at 100ml/hr.\n\nResp: ON RA, O2 sat 90-96%, LS clear, no cough.\n\nGI: Abd soft but distended,S/B Dr. A (), aware of the distension, +BS, no BM, but passing gas.JP draining pale purulent drain, pig tail clamped, 3'rd drain with very minimal yellowish drain.G tube clamped also.abd op wound wet & dry dressing done.\n\nGU: Voiding clear yellow urine in the urinal adq amt.\n\nEndo: sug q6h, on SSRI.\n\nAct: Pt turns himself with minimal assist, skin intact, rectal & groin area with redness aloe vesta, anti fungal cream applied.\n\nSocial: Wife was at bed side till 2330, updated by RN, and surgery resident.\n\nPlan: Cont monitoring, pulm hygiene, drain and wound care, ? restart feeding, support to pt and family, ? transfer to floor if remains stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2124-05-07 00:00:00.000",
"description": "Report",
"row_id": 1644251,
"text": "Transfer\nPt called out to floor per primary team's orders. Report called to resource nurse 9. Awaiting transport.\n"
},
{
"category": "Radiology",
"chartdate": "2124-05-07 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1014956,
"text": " 3:09 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: PO (oral or via JT) and IV contrast To evaluate collections,\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old man with hypotension, leukocytosis to at OSH.\n REASON FOR THIS EXAMINATION:\n PO (oral or via JT) and IV contrast To evaluate collections, any other interval\n changes to explain leukocytosis at OSH.Please cancel if already performed prior\n to transfer on . Thank you.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n CT OF THE ABDOMEN AND PELVIS:\n\n CLINICAL HISTORY: 76-year-old man with hypotension, leukocytosis to 17,000 at\n outside hospital. Evaluate collections or other interval changes to explain\n leukocytosis.\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the abdomen and\n pelvis after administration of 130 cc of intravenous Optiray and oral\n contrast. Coronal and sagittal reformatted images were also obtained.\n\n Comparison is made to the prior CT of the abdomen and pelvis, .\n\n FINDINGS:\n\n CT OF THE ABDOMEN:\n\n Note again is made of bilateral pleural effusions, small to moderate in size,\n with associated bibasilar atelectasis.\n\n There is small amount of ascites around the liver and spleen that is not\n significantly changed since the prior examination. As before, the patient is\n noted to have percutaneous and internal biliary drainage catheters. There is\n also a gastrojejunostomy tube in place with distal tip in the proximal\n jejunum. There is a percutaneous pigtail drainage catheter in the right upper\n quadrant just below the edge of the liver.\n\n As before, note is made of innumerable intra-abdominal fluid collections, some\n of which have slightly increased in size since the prior studies, the rest are\n not significantly changed. For example, the largest collection is seen just\n superior to the tail of the pancreas, medial to the spleen. This collection\n has slightly increased in size since the prior study and now measures 4.5 x\n 6.9 x 8 cm (previously 3.1 x 5.8 x 7 cm).\n\n There is another collection in the region of the body of the pancreas that\n measures 3.6 x 5.5 cm. This collection is not significantly changed since the\n prior study.\n\n There are innumerable confluent fluid pockets in the region of the head of the\n pancreas with adjacent extensive stranding/inflammatory changes. The exact\n (Over)\n\n 3:09 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: PO (oral or via JT) and IV contrast To evaluate collections,\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n dimensions of those collections are difficult to measure due to poorly defined\n margins. The largest collection in the region of the head of the pancreas\n measures 4 x 6 cm (previously 4 x 5 cm). Some of the collections in the\n region of the pancreatic head now contain gas pockets within them.\n\n There is a pigtail drainage catheter in the right lateral abdomen with its tip\n just below the edge of the liver. There are several fluid collections along\n the right lateral abdominal wall. The largest collection measures 3.3 x 8.2\n cm (previously 4.6 x 9.1 cm). This collection now has gas pockets within it.\n There is a 4 x 7 cm fluid collection in the pelvis just medial to the iliacus\n muscle. This collection did not significantly change in size but has now\n pockets of gas within it. The collection medial to the right iliacus muscle\n appears contiguous with the right lateral abdominal wall collection.\n\n A few additional 2-3 cm fluid pockets are seen in the right abdominal wall.\n\n The liver is grossly unremarkable. There is no intra-hepatic biliary\n dilatation. The gallbladder is not clearly identified. The spleen, adrenal\n glands and kidneys are unchanged since the prior study. There is no evidence\n of hydronephrosis. There are small para-aortic lymph nodes that measure less\n than 1 cm in short axis. The small and large bowel is normal in caliber.\n There is scattered colonic diverticulosis.\n\n CT OF THE PELVIS:\n\n The prostate gland is markedly enlarged and measures 6.4 x 6.2 cm. There is\n trace amount of pelvic fluid. The phase of enhancement is somewhat suboptimal\n for evaluation of the vasculature. The portal and splenic veins are grossly\n patent. The left portal vein is grossly patent. The right portal vein is\n somewhat diminutive and is not well seen.\n\n There is diastasis of the rectus abdominal muscles with bulging of several\n loops of bowel through the anterior abdominal wall defect.\n\n There is a soft tissue defect in the right lateral abdominal wall, which may\n be related to prior surgery. This is unchanged since the prior study. The\n previously seen surgical staples in the right lateral abdominal wall are no\n longer identified. Urinary bladder is grossly unremarkable.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. There\n are multilevel degenerative changes in the spine.\n\n IMPRESSION:\n\n Innumerable intra-abdominal and pelvic fluid collections many of which are\n contiguous with each other. Some of these collections have slightly increased\n (Over)\n\n 3:09 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: PO (oral or via JT) and IV contrast To evaluate collections,\n Admitting Diagnosis: CHOLANGITIS\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n in size and the rest are not significantly changed.\n\n A few fluid collections now contain pockets of gas within them, which is new\n since the prior study. The significance of this finding is not clear in the\n setting of an intraabdominal drain. However, superinfection of gas-\n containing fluid pockets cannot be excluded.\n\n These findings were discussed with Dr. at 14:15 p.m. on .\n\n"
}
] |
20,548 | 104,707 | The patient was admitted for elective ablation and cardiac catheterization. During there ablation procedure there was some bleeding noted and the patient was transferred to the CCU (see below). | The severity of the mitral regurgitationhas slightly increased.IMPRESSION: No intracardiac thrombus. Able to slowly wean dopa and is currently on 18.7 with BP per NBP 94-110/60. Stable post-operative appearance of the cardiomediastinal silhouette. APaced/V sensed perm pmr placed L. After pmr placement, abd distention, firmness and pain noted. C/O LOWER BACK PAIN X1 RESOLVED W/ REPOSITIONING. Able to wean dopa off after unit of bld was given. HX OF AFIB W/ TIA OFF OF COUMADIN ( NO RESIDUALS DEFICIT). Restart meds in am if hemodynamically stable. TEMP MAX 98 PO.A: STABLE S/P RETRO PERITONEAL BLEED AFTER BLOOD PRODUCTS W/ DECREASED NEED FOR DOPAMINE AND INCREASED CVP. Atrial paced rhythmConsider prior inferior myocardial infarctionDiffuse nonspecific low amplitude T wavesSince previous tracing of , atrial flutter absent PA and lateral upright chest radiograph compared to . afib/flutter s/p ablation. Thereis no pericardial effusion.Compared with the report of the prior TEE study (images unavailable forreview) of , the maximum detected LAA emptying velocity hasincreased. PM SITE LEFT SHOULDER, SLIGHTLY SWELLED, UNCHANGED OVER NOC. Per EP lab report, Pt rec'd aflutter ablation today c/b hypotension. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation/flutter.Height: (in) 64Weight (lb): 145BSA (m2): 1.71 m2BP (mm Hg): 140/66HR (bpm): 91Status: InpatientDate/Time: at 10:34Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the report of the prior study (images notavailable) of .LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or theRA/RAA. Mild to moderate (+) mitral regurgitation is seen. NO C/O PAIN RELATED TO PM SITE.RESP: SO SIGN OF DITRESS LS CTA W DIMINISHED BASES. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Cardiac meds remain on hold.Resp: Lungs CTA. HEMATURIA RESOLVING. Good (>20 cm/s) LAA ejection velocity.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. SSS after ablation with 20sec sinus pause. SIPS OF H2O OVER NOC.GU: MARGINAL U/O, 30-70 CC/HR. PR INTERVAL >.30.BP 106/70 MAPS > 60 ON DOPAMINE TITRATED DOWN TO 3MCQ/KG/MIN.CVP >7, UP FROM . Pulses l d/d and r -/d. keep pt pain free c tylenol. Assess for tamponade.Height: (in) 64Weight (lb): 150BSA (m2): 1.73 m2BP (mm Hg): 90/65HR (bpm): 80Status: InpatientDate/Time: at 14:40Test: Portable TTE (Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RAand extending into the RV.LEFT VENTRICLE: Normal LV cavity size.RIGHT VENTRICLE: Normal RV chamber size. Mild to moderate (+)MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. con to monitor for chf. bilat fem pulses dop. hct 29.6 pt currently receiving 1unit PRBC's. TOLERATED BLOOD PRODUCTS VOLUME. To recieve 2units prbc's.Resp - ls are diminished on 4ln/p with sats 96-100%.GI - Abd is firm and distended with +bs. Compared to the previous tracing of atrial fibrillation haschanged to atrial flutter. Dsy is C&D. REC'D 2UPRBC AND 2U FFP. Late transition which isprobably normal. Right ventricular chamber size isnormal. Probable atrial flutter with slow atrial rate and variable ventricularresponse. Compared to theprevious tracing T wave changes are no longer present. COMPARISON: PA and lateral chest x-ray dated . CT CHEST WITHOUT INTRAVENOUS CONTRAST: A right internal jugular central venous catheter terminates in the distal SVC. Incompletely imaged is the inferior margin of a deeper pelvic hematoma, which was previously identified on CT. Again noted is diffuse atherosclerosis. Distended gallbladder. Distended gallbladder. CT confirmed hematoma. STUDY: Unilateral lower extremity venous ultrasound with Doppler, left. Inferior margin of pelvic hematoma seen on CT today is partially imaged. Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH FINAL REPORT (Cont) IMPRESSION: No left lower extremity DVT from popliteal veins to common femoral veins. BILATERAL LOWER EXTREMITY ULTRASOUND: -scale and Doppler son of the bilateral common femoral, superficial femoral, deep femoral, and popliteal veins were performed. There is dampening of normal respiratory variation in the left common femoral vein. Right internal jugular venous catheter is unchanged. The patient has had median sternotomy. Small right renal calcifications could represent nonobstructing stones, or more likely vascular calcifications. Sigmoid diverticula are observed without evidence of diverticulitis. A left-sided pacemaker is seen with leads adjacent to the right atrium and right ventricle. Cardiomegaly and atherosclerosis. A right-sided internal jugular vein central venous catheter is seen with the tip at the mid SVC. LEFT UPPER EXTREMITY ULTRASOUND: -scale and Doppler son of the left internal jugular, subclavian, axillary, brachial, and cephalic veins were performed. Now left upper extremity swelling after pacemaker placement and concern for DVT. Rounded low-attenuation foci in the liver are incompletely characterized on this exam. Had pacer placed via LUE, now had markedly edematous LUE. Liver c/w amiodarone usage. The gallbladder is significantly distended. Pt hypotensive. There are diffuse coronary artery and aortic calcifications. FINDINGS: There is normal 2D grayscale and color Doppler appearance of the veins of the left lower extremity including the common femoral vein, superficial femoral vein, greater saphenous vein, and common popliteal vein. Admitting Diagnosis: CORONARY ARTERY DISEASE\CATH FINAL REPORT (Cont) 4. SUPINE RADIOGRAPH OF THE CHEST: There has been interval placement of a left- sided dual-chamber pacemaker with leads projecting over appropriate locations. The ascending aorta is slightly ectatic, without aneurysmal dilatation, and measures 2.8 cm at widest diameter. echo negative for pericardial effusion REASON FOR THIS EXAMINATION: Retroperitoneal bleed?Intrabdominal bleeding? 4:51 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # Reason: Retroperitoneal bleed?Intrabdominal bleeding? Hyperinflation indicates emphysema. Pleural-based calcification in right anterior lung consistent with prior asbestos exposure. Small bilateral pleural effusions. | 21 | [
{
"category": "Nursing/other",
"chartdate": "2111-04-07 00:00:00.000",
"description": "Report",
"row_id": 1532191,
"text": "CCU Nursing Progress Note 1730\nS: Today was better than yesterday\n\nO: PMH per fhpa. Per EP lab report, Pt rec'd aflutter ablation today c/b hypotension. No nausea or diaphoresis. Pt placed on 10mcgs/kg/ Dopamine. Foley cath placed. SSS after ablation with 20sec sinus pause. APaced/V sensed perm pmr placed L. After pmr placement, abd distention, firmness and pain noted. HCT dropped from 38.8 to 35.6. WBC 10.8. Dopa increased to 20mcgs/kg/min. and pt tx to CT. Per report, 2 venous access on l and 1 on r. CT showed extraperitoneal bleed. Surgery called and pt tx to CCU.\n\nUpon arrival to CCU, Pt on 20mcgs/kg/ of dopamine. Able to slowly wean dopa and is currently on 18.7 with BP per NBP 94-110/60. HR a paced at 80. Pulses l d/d and r -/d. bilat fem pulses dop. No dsgs on bilat groins. Unable to place radial by house staff.\nCVP measured once tlc placed and is 3.\n\nLabs - HCT 36.4. INR 1.7 PTT 128 WBC 18.4. To recieve 2units prbc's.\n\nResp - ls are diminished on 4ln/p with sats 96-100%.\n\nGI - Abd is firm and distended with +bs. c/o intermittent nausea and is medicated with anzimet.\n\nGU - Foley intact slight blood tinged urine.\n\nNeuro - Pt alert and quite groggy. Oriented to person and place. Had rec'd multiple doses of fentanyl and versed in proceedure room.\n\nAccess - angio #22 lle, #20 rle. Dopamine had been infusing via #22 in lle. R IJ TLC placed by card fellow. Site is oozing after dressing placed. Placement confirmed and dopa currently infusing via tlc.\n\nSocial - Family present and have been updated by MD's.\n\nA: Large extraperitoneal bleed post aflutter ablation sheath removal, although hct stable pt cont on max dopamine.\n\nP: Monitor hcts and coags and reverse as necessary monitoring groins and pulses, monitor neuro status for compromise, keep pt and family informed of poc per multidisiciplinary rounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-04-08 00:00:00.000",
"description": "Report",
"row_id": 1532192,
"text": "CCU NPN 1900-0700\n\nSEE ADMIT NOTE FOR FULL DETAIL.\n76 Y/O FEMALE S/P AFLUTTER ABLATION AND PERM PACEMAKER PLACEMENT C/B EXTRA-PERITONEAL BLEED. HX OF AFIB W/ TIA OFF OF COUMADIN ( NO RESIDUALS DEFICIT). INR 1.7 ON ARRIVAL FROM EP LAB.\n\nS/O: SEE CAREVUE FOR COMPLETE OBJ DATA.\nMS: A&0 X3, LETHARGIC AT START OF SHIFT, CLEAR BY 3AM\nCV: DDD A PACED AT WHAT APPEARS TO BE 80, V SENSING. PR INTERVAL >.30.\nBP 106/70 MAPS > 60 ON DOPAMINE TITRATED DOWN TO 3MCQ/KG/MIN.\nCVP >7, UP FROM . REC'D 2UPRBC AND 2U FFP. INR DROP TO 1.3 FROM 1.8. AM HCT PENDING. HEMATOMA LEFT GROIN STABLE, FEM US NEG FOR BLEED. ABD W/O SIGNS OF FURTHER BLEEDING. C/O LOWER BACK PAIN X1 RESOLVED W/ REPOSITIONING. PM SITE LEFT SHOULDER, SLIGHTLY SWELLED, UNCHANGED OVER NOC. NO C/O PAIN RELATED TO PM SITE.\n\n\nRESP: SO SIGN OF DITRESS LS CTA W DIMINISHED BASES. TOLERATED BLOOD PRODUCTS VOLUME. C/O DIFFICULT BREATHING BUT NOT NEW, (REASON FOR ADMIT).\n\nGI: ABD SOFT NT, + BS HYPOACTIVE. SIPS OF H2O OVER NOC.\nGU: MARGINAL U/O, 30-70 CC/HR. HEMATURIA RESOLVING. UA SENT.\nID WBC 18.5 YESTERDAY, GOT VANCO IN LAB, CEFAZOLIN STARTED . TEMP MAX 98 PO.\n\nA: STABLE S/P RETRO PERITONEAL BLEED AFTER BLOOD PRODUCTS W/ DECREASED NEED FOR DOPAMINE AND INCREASED CVP. U/O LOW BUT IMPROVING.\nP: SURGERY FOLLOWING AND MONITORING FOR BLEED. FOLLOW COAGS AND HCT.\nASSESS PM SITE FOR INCREASED SWELLING / HEMATOMA. MONITOR GROIN AND ABD FOR SIGNS OF BLEED. IV ABX. PLAN FOR CARDAIC CATH, CURRENTLY ON HOLD (CAD W/ CABG IN PAST, SOB W/ + STRESS- REASON FOR ADMIT)\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-04-08 00:00:00.000",
"description": "Report",
"row_id": 1532193,
"text": "Nursing Progess Note\n\nO: Please see flow sheet for objective data. Tele remains A paced at rate of 80. Dsy is C&D. Coumadin remains on hold. Able to wean dopa off after unit of bld was given. Cardiac meds remain on hold.\n\nResp: Lungs CTA. O2 sats > 97% on 2l.\n\nNeuro: Pt is alert and oriented. Able to MAE. Maintained on bedrest.\n\nGU/GI: Pt remains NPO until hct is stable. Abd is soft distended with bowel sounds present. No BM today. Hct 31 and 30 given 3rd unit of PRBC's repeat hct coags pending. Foley draining dark concentrated urine. Creat 1.3.\n\nSocial: 3daughters in to visit during the day. Pt lives with daughter in . They are staying at local hotel.\n\nA&P: Maintain hct > 30. Repeat pending. Advance diet if hct is stable. Restart meds in am if hemodynamically stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-04-09 00:00:00.000",
"description": "Report",
"row_id": 1532194,
"text": "S: \"My shoulder and arm hurts.\"\n\nCV: A paced. afib/flutter s/p ablation. NSR. hct 29.6 pt currently receiving 1unit PRBC's. bp 120's-140's.\n\nresp: o2 sats 99% on room air. ls clear. pt c/o SOB c exertion.\n\nGU: pt urinating adequate amount. clear and yellow.\n\nGI: pt may start cardiac diet today. BS (+) (-) BM.\n\nA:75yo femalr on coumadin for afib/flutter s/p ablation c/b large extrapertoneal bleed in pelvis c shift bladder/colon.\n\nP: cont to monitor hct s/p blood transfusion. con to monitor for chf. keep pt pain free c tylenol.\n"
},
{
"category": "Echo",
"chartdate": "2111-04-07 00:00:00.000",
"description": "Report",
"row_id": 78395,
"text": "PATIENT/TEST INFORMATION:\nIndication: Hypotension during EP procedure. Assess for tamponade.\nHeight: (in) 64\nWeight (lb): 150\nBSA (m2): 1.73 m2\nBP (mm Hg): 90/65\nHR (bpm): 80\nStatus: Inpatient\nDate/Time: at 14:40\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV.\n\nLEFT VENTRICLE: Normal LV cavity size.\n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left ventricular cavity size is normal. Right ventricular chamber size is\nnormal. Right ventricular systolic function is normal. There is no pericardial\neffusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2111-04-06 00:00:00.000",
"description": "Report",
"row_id": 78396,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nHeight: (in) 64\nWeight (lb): 145\nBSA (m2): 1.71 m2\nBP (mm Hg): 140/66\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 10:34\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the\nRA/RAA. Good (>20 cm/s) LAA ejection velocity.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Cannot assess RV systolic function.\n\nAORTA: There are complex (>4mm) atheroma in the aortic arch. There are complex\n(>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate (+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve 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 sedated for\nthe TEE. Medications and dosages are listed above (see Test Information\nsection). Local anesthesia was provided by benzocaine topical spray. The\nposterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related\ncomplications. 0.2 mg of IV glycopyrrolate was given as an antisialogogue\nprior to TEE probe insertion. The rhythm appears to be atrial flutter.\nCardiology fellow involved with the patient's care was notified by telephone.\n\nConclusions:\nNo spontaneous echo contrast or thrombus is seen in the body of the left\natrium/left atrial appendage or the body of the right atrium/right atrial\nappendage. No atrial septal defect is seen by 2D or color Doppler. There are\ncomplex (>4mm, non-mobile) atheroma in the aortic arch and descending thoracic\naorta. 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. Mild to moderate (+) mitral regurgitation is seen. There\nis no pericardial effusion.\n\nCompared with the report of the prior TEE study (images unavailable for\nreview) of , the maximum detected LAA emptying velocity has\nincreased. The severity of the mitral regurgitationhas slightly increased.\n\nIMPRESSION: No intracardiac thrombus.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2111-04-15 00:00:00.000",
"description": "Report",
"row_id": 190986,
"text": "Baseline artifact\nAtrial paced rhythm\nQ-Tc interval appears prolonged but is difficult to measure - clinical\ncorrelation is suggested\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2111-04-10 00:00:00.000",
"description": "Report",
"row_id": 190987,
"text": "Atrial pacing with native ventricular conduction. Late transition which is\nprobably normal. Non-diagnostic Q waves in the inferior leads. Compared to the\nprevious tracing T wave changes are no longer present.\n\n"
},
{
"category": "ECG",
"chartdate": "2111-04-08 00:00:00.000",
"description": "Report",
"row_id": 190988,
"text": "Atrial paced rhythm\nConsider prior inferior myocardial infarction\nDiffuse nonspecific low amplitude T waves\nSince previous tracing of , atrial flutter absent\n\n"
},
{
"category": "ECG",
"chartdate": "2111-04-06 00:00:00.000",
"description": "Report",
"row_id": 190989,
"text": "Probable atrial flutter with slow atrial rate and variable ventricular\nresponse. Compared to the previous tracing of atrial fibrillation has\nchanged to atrial flutter.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-04-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 912022,
"text": " 10:47 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for evidence of interstitial dz\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman on amio w/ chronic SOB\n REASON FOR THIS EXAMINATION:\n evaluate for evidence of interstitial dz\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Chronic shortness of breath in a patient on\n amiodarone treatment, evaluation for interstitial disease.\n\n PA and lateral upright chest radiograph compared to .\n\n Cardiac and mediastinal contours are stable in the patient after median\n sternotomy and CABG. The heart size is mildly enlarged. The aorta is\n calcified and tortuous with no evidence of focal dilatation. The lung volumes\n are increased with some distortion of the parenchymal vasculature more in the\n upper lungs suggesting underlying emphysema.\n\n There are several scars in the left lower lobe most probably post-operative.\n There is no evidence of congestive heart failure. There is no new pulmonary\n infiltrates. The mild blunting of costophrenic angles bilaterally is less\n prominent.\n\n IMPRESSION:\n 1. Stable post-operative appearance of the cardiomediastinal silhouette.\n 2. Emphysema.\n 3. Mild post-operative lung changes with no evidence of acute interstitial\n process.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-04-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 912900,
"text": " 7:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pna -v- increased effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with fever and know pleural effusion\n\n REASON FOR THIS EXAMINATION:\n eval pna -v- increased effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:36 A.M., .\n\n HISTORY: Fever and pleural effusion.\n\n IMPRESSION: AP chest compared to and 16:\n\n Small right pleural effusion has increased. Hyperinflation indicates\n emphysema. The patient has had median sternotomy. Heart is normal size.\n There is no pneumothorax. Transvenous right atrial and right ventricular\n pacer leads follow their expected courses.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-04-07 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 912153,
"text": " 4:51 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Retroperitoneal bleed?Intrabdominal bleeding? other?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman post EP study through femoral veins- drop in blood pressure\n and acute abdomen. echo negative for pericardial effusion\n REASON FOR THIS EXAMINATION:\n Retroperitoneal bleed?Intrabdominal bleeding? other?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old woman status post EP study through femoral veins with\n drop in blood pressure, and acute abdomen. Echoes negative for pericardial\n effusion.\n\n TECHNIQUE: Multidetector axial images of the abdomen and pelvis were obtained\n without contrast.\n\n CT ABDOMEN: There is scarring and atelectasis at the lung bases. The liver\n is diffusely high in attenuation. Rounded low-attenuation foci in the liver\n are incompletely characterized on this exam. The gallbladder is significantly\n distended. A small stone is seen in the body of the gallbladder. The\n pancreas, spleen, adrenal glands, left kidney, stomach, and bowel loops are\n unremarkable within the limits of this non-contrast study. Small right renal\n calcifications could represent nonobstructing stones, or more likely vascular\n calcifications. A surgical staple line is noted along the level of the\n hepatic flexure. There is no mesenteric or retroperitoneal lymphadenopathy.\n\n CT PELVIS: There is a large extraperitoneal hematoma centered at the mid left\n pelvis. The hematoma is high attenuation consistent with acute blood. The\n bladder and sigmoid colon are displaced to the right. A Foley catheter is\n noted in the bladder. Sigmoid diverticula are observed without evidence of\n diverticulitis. There is no pelvic or inguinal lymphadenopathy. Stranding\n and small amounts of air are noted in the left groin consistent with the\n recent EP study.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n IMPRESSION:\n\n 1. Large acute extraperitoneal hematoma in the left pelvis. This finding was\n discussed and reviewed with the Cardiology Service while the patient was still\n on the scanner. Vascular Surgery was immediately paged.\n\n 2. Distended gallbladder. Stone and sludge are noted in the gallbladder\n body.\n\n 3. High-attenuation liver suggestive of amiodarone use. Low attenuation\n hepatic foci are not fully characterized on this exam.\n\n (Over)\n\n 4:51 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Retroperitoneal bleed?Intrabdominal bleeding? other?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-04-09 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 912508,
"text": " 7:18 PM\n BILAT LOWER EXT VEINS; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: DVT?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with large expanding hematoma s/p right common femoral vein\n access for aflutter ablation and pacer placement. Concern for HIT as well as\n DVTs.\n REASON FOR THIS EXAMINATION:\n DVT?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old female with concern for DVT.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: -scale and Doppler son of the\n bilateral common femoral, superficial femoral, deep femoral, and popliteal\n veins were performed. There is normal compressibility, waveform,\n augmentation, and flow. No intraluminal echogenic material is identified.\n\n IMPRESSION: No DVT in the bilateral lower extremities.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-04-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 912165,
"text": " 6:09 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval right IJ TLC placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with CAD s/p line placement\n REASON FOR THIS EXAMINATION:\n eval right IJ TLC placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post right internal jugular TLC placement.\n\n Comparison is made to .\n\n SUPINE RADIOGRAPH OF THE CHEST: There has been interval placement of a left-\n sided dual-chamber pacemaker with leads projecting over appropriate locations.\n A right-sided internal jugular vein central venous catheter is seen with the\n tip at the mid SVC. No pneumothorax is seen. There is stable atelectasis in\n the left mid lung and left base. The right lung is clear.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-04-07 00:00:00.000",
"description": "PL FEMORAL VASCULAR US PORT LEFT",
"row_id": 912166,
"text": " 6:33 PM\n FEMORAL VASCULAR US PORT LEFT; FEMORAL VASCULAR US PORT RIGHT Clip # \n Reason: Eval for ongoing bleeding and possible pseudoaneurysm\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with large expanding hematoma s/p right common femoral vein\n access for aflutter ablation and pacer placement. Pt hypotensive. CT\n confirmed hematoma. PT being transferred to the unit\n REASON FOR THIS EXAMINATION:\n Eval for ongoing bleeding and possible pseudoaneurysm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old female with pelvic hematoma after femoral vein access.\n\n BILATERAL GROIN ULTRASOUND: Grayscale and Doppler son of the bilateral\n groins were performed including Doppler analysis of the bilateral common\n femoral arteries, common femoral veins, and superficial femoral veins. There\n are appropriate arterial waveforms in the bilateral common femoral arteries.\n There are appropriate venous waveforms in the bilateral common femoral veins.\n There is dampening of normal respiratory variation in the left common femoral\n vein. There is no evidence of pseudoaneurysm or arteriovenous fistula. No\n groin hematoma is identified. Incompletely imaged is the inferior margin of a\n deeper pelvic hematoma, which was previously identified on CT.\n\n IMPRESSION: No evidence of pseudoaneurysm or arteriovenous fistula. No groin\n hematoma. Inferior margin of pelvic hematoma seen on CT today is partially\n imaged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-04-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 912240,
"text": " 10:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for proper placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with CAD s/p line placement\n\n REASON FOR THIS EXAMINATION:\n evaluate for proper placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post line placement.\n COMPARISON: .\n\n FINDINGS: There has been no significant interval change. Right internal\n jugular venous catheter is unchanged. The lungs are clear. The patient is\n status post CABG with associated postoperative scarring. Dual chamber\n pacemaker leads project appropriate paths. There are no pneumothoraces.\n Cardiac and mediastinal silhouettes are stable.\n\n IMPRESSION: No change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-04-14 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 913081,
"text": " 9:14 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o pna, eval effusionPlease perform in AM \n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with a new dual chamber PM, fever, and crackles\n\n REASON FOR THIS EXAMINATION:\n r/o pna, eval effusionPlease perform in AM \n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST ON \n\n HISTORY: New dual-chamber pacemaker.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Transvenous right atrial and right ventricular pacer leads are continuous from\n the left pectoral pacemaker following the expected courses.\n\n Lungs are hyperinflated indicating emphysema, but clear. The heart is top\n normal in size, and there is no pulmonary vascular congestion. Small\n bilateral pleural effusion is unchanged since . No pneumothorax or\n mediastinal widening.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-04-11 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 912719,
"text": " 10:25 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: amiodarone toxicity.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with SOB x 18 months s/p CABG in ', on amiodarone since\n that time w/ worsening SOB. Liver c/w amiodarone usage. Pt unable to perform\n adequately for PFT evaluation.\n REASON FOR THIS EXAMINATION:\n amiodarone toxicity.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old female with shortness of breath x18 months status\n post coronary artery bypass graft in . Patient is on amiodarone since the\n CABG, with worsening shortness of breath. Evaluate for amiodarone toxicity.\n\n COMPARISON: PA and lateral chest x-ray dated .\n\n TECHNIQUE: MDCT imaging of the chest was performed without intravenous\n contrast. Inspiratory and expiratory images were obtained.\n\n CT CHEST WITHOUT INTRAVENOUS CONTRAST: A right internal jugular central\n venous catheter terminates in the distal SVC. A left-sided pacemaker is seen\n with leads adjacent to the right atrium and right ventricle. The patient is\n status post coronary artery bypass graft with sternal wires and sutures. The\n heart is enlarged. The ascending aorta is slightly ectatic, without\n aneurysmal dilatation, and measures 2.8 cm at widest diameter. There are\n diffuse coronary artery and aortic calcifications. There is no pericardial\n effusion. Small bilateral pleural effusions are seen bilaterally. There is\n no axillary, mediastinal, or hilar lymphadenopathy. On lung windows, mild\n scarring is seen within bilateral lung bases. There is no interstitial\n thickening or areas of consolidation. Pleural-based calcifications are seen\n within the right lung anteriorly. No intraparenchymal nodules or masses are\n identified.\n\n Limited imaging of the upper abdomen reveals a hyperdense liver with a few\n scattered low-attenuation lesions within the right liver lobe, which likely\n represent simple cysts. The gallbladder is enlarged with a moderate amount of\n intraluminal sludge, but no visualized stones. Again noted is diffuse\n atherosclerosis.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous\n abnormalities.\n\n IMPRESSION:\n 1. No definite evidence to support pulmonary amiodarone toxicity.\n 2. Small bilateral pleural effusions.\n 3. Hyperdense liver consistent with patient's known history of amiodarone\n toxicity. A few scattered hypodense lesions within the liver are not\n adequately characterized on this non-contrast study. Ultrasound or MRI is\n recommended for further evaluation.\n (Over)\n\n 10:25 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: amiodarone toxicity.\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Distended gallbladder. Moderate amount of intraluminal sludge.\n 5. Pleural-based calcification in right anterior lung consistent with prior\n asbestos exposure.\n 6. Cardiomegaly and atherosclerosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-04-14 00:00:00.000",
"description": "L UNILAT LOWER EXT VEINS LEFT",
"row_id": 913115,
"text": " 12:58 PM\n UNILAT LOWER EXT VEINS LEFT Clip # \n Reason: nr/o dvt\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with LLE swelling s/p pacer placement.\n REASON FOR THIS EXAMINATION:\n nr/o dvt\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 75-year-old woman with left lower extremity swelling,\n status post pacer placement. Exclude DVT.\n\n STUDY: Unilateral lower extremity venous ultrasound with Doppler, left.\n\n TECHNIQUE: 2D grayscale and color Doppler son was performed of the\n left lower extremity veins.\n\n FINDINGS:\n\n There is normal 2D grayscale and color Doppler appearance of the veins of the\n left lower extremity including the common femoral vein, superficial femoral\n vein, greater saphenous vein, and common popliteal vein. All these veins have\n normal compressibility and augmentation. No evidence of DVT.\n\n IMPRESSION: No left lower extremity DVT from popliteal veins to common\n femoral veins.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-04-09 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 912509,
"text": " 7:18 PM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: dvt?\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with large expanding hematoma s/p right common femoral vein\n access for aflutter ablation and pacer placement. Concern for HIT as well as\n DVTs. Had pacer placed via LUE, now had markedly edematous LUE.\n REASON FOR THIS EXAMINATION:\n dvt?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old female with pelvic hematoma. Now left upper extremity\n swelling after pacemaker placement and concern for DVT.\n\n LEFT UPPER EXTREMITY ULTRASOUND: -scale and Doppler son of the left\n internal jugular, subclavian, axillary, brachial, and cephalic veins were\n performed. There is a pacemaker wire within the left subclavian vein. The\n veins demonstrate normal compressibility, waveform, augmentation, and color\n flow. No intraluminal echogenic material is identified.\n\n IMPRESSION: No evidence of DVT in the left upper extremity.\n\n\n"
}
] |
27,799 | 116,592 | # EtOH withdrawal: Last known drink . Presented with agitation, visual hallucinations, tachycardia, hypertension, consistent with delirium tremens. Also had mild transaminitis that trended down, negative hepatitis serologies. Pt was initially admitted to the MICU and started on a CIWA protocol with diazepam 15 mg IV Q15-30 min for CIWA >10. He was also started on MVI, thiamine, and folate. Initially, he required a 1:1 sitter, restraints, and haldol for agitation, but this was stopped after 1 day. He received over 200 mg IV diazepam during the first day. He was transferred to the floor on after a substantial decrease in his benzo requirement. He was continued on PO diazepam prn, but his CIWA was 6 or less on the floor for 2 days. Social work was consulted and recommended inpatient detoxification. | NO CALLS FROM SISTER, WHO APPEARS TO BE NEXT OF PER CHART/ICU CONSENT.TURNING PT WITH ASSIST AND PT HAS BEEN COMPLIANT WITH TURNING AND ROM.LINES- #18, X 2 PIV- PATENT, SITES DRY/CLEAN/NO REDNESS.A/ PT ADMITTED TO CCU TO MICU SERVICE AS A BORDER FOR ETOH WITHDRAWL, C/B HTN/TACHYCARDIA- CURRENTLY HEMODYNAMICALLY STABLE AND LESS ACUTELY AGITATED WITH CONSISTENTLY DOSING VALIUM PER CIWA SCALE AND GIVING HALDOL TID.CONTINUE TO CLOSELY OBSERVE WITH SITTER 1:1 PER PROTOCOL FOR 4 PT RESTRAINTS AS WELL AS R/O SUICIDAL AS PT HAS LONG HX OF MULTIPLE ATTEMPTS AND DIFFICULT TO ASCERTAIN ETILOGY OF CURRENT ETOH ABUSE/INTOXICATION. Mouth care given as able--not cooperative with this.Resp: lungs clear, sats >98% on RA, no cough.ID: afebrile, resistant to PO temp.Access: PIV X2 (#18), sites intact, IV K infusion slowed d/t above c/o.A: ETOH withdrawal, CIWA <10 without further need for valium thus far.P: ready for transfer to medical floor, awaiting bed. Will recheck K/Mg several hours after last K dose.GI: no po's d/t decreased LOC. CCU NSG PROGRESS NOTE 7P-7A/ S/P ETOH WITHDRAWALS- " THANKS FOR ALL OF YOUR HELP...I FEEL OK.."O- SEE FLOWSHEET FOR OBJECTIVE DATA-CV- VS REMAINS STABLE- HR-80-100 SR, ST. NO VEA.- BP- 116/70-120/80 VIA NBP.RESP- CLEAR LUNGS, APPEARS COMFORTABLE, ROOM AIR- 96-100% VIA 02 SATS.ID- AFEBRILE PT WITH SCALE LESS THAN 10 ALL SHIFT- NO NEED FOR PRN VALIUM NOR HALDOL. BP- 130/104-116/73 VIA NBP.PT CURRENTLY NOT RECEIVING ANY ANTIHTN OF B BLOCKERS.RESP- CLEAR LUNGS, O2 SATS 100-98% ON ROOM AIR, COMFORTABLE BREATHING PATTERN EXCEPT WITH AGITATION.ID- AFEBRILE BY AXILLARY TEMP.GU- FOLEY CATH IN PLACE- GOOD UO- >1300CC/THIS SHIFT- RECEIVING 125/HOUR OF D5 1/2 NS FOR HYDRATION.GI- (+) BOWEL SOUNDS , NO STOOL , (+)FLATUS- NPO- REFUSING EVENING DOSE OF RISPERIDOL PO BUT IS ON HALDOL IV TID. TO REASSESS RISPERIDOL ORDER IN PT DECLINING MED CURRENTLY. "O: see CCU flow sheet for complete objective dataETOH Withdrawal: pt sedated, arouses with verbal stimuli, leg restraints removed this morning. Last Valium dose today @ 0600. (+) BOWEL SOUNDS, NO ISSUES.A/ PT ADMITTED TO MICU SERVICE FOR ETOH INTOXICATION/WITHDRAWAL, REQUIRING 12 HOURS (+) OF VALIUM DOSING PER SCALE. Abd flat, +BS, no stool.Skin: pressure points intact, aloe vesta applied, repositioned q 2 hours, heels suspended on pillows. IV haldol order changed to prn (had only received one dose last evening).CV: HR 90's-->80's NSR, no VEA, SBP 105-120.GU: urine initially amber, now clearer yellow in larger quantities. no phone calls received.A/P:ETOH withdrawal cont to follow CIWA scale and give valium as needed CIWA , to receive valium if CIWA >10--but to have MD assess first. has just started on haldol so that schizophrenic issues will not complicated assessing ETOH withdrawal. in ED tx with ativan and valium transferred to CCU as MICU border at 1300.ETOH withdrawal: following CIWA scale and giving valium as needed. CONTINUE DOCUMENTATION OF CIWA/ AND RESTRAINTS Q 1 HOUR. IMPRESSIONS: No consolidation, but increased opacity at the lung apices may reflect aspiration. DECREASED FREQUENCY OF VALIUM FROM Q 15 MIN TO Q 1 HOUR THIS MORNING. As per Dr. , valium reserved for signs of sympathetic stimulation (^^HR/BP/tremors). CURRENTLY A/O X 3 AND CALM, NO VALIUM SINCE 5PM.CONTINUE TO MONITOR MENTAL STATUS/ SCALE, MEDS AS NEEDED.REASSESS IN AM WITH PSYCH CONSULT FOR OK TO SEND HOME VS NEED FOR TRANSFER TO PSYCH/ETOH FACILITY.INCREASE ACTIVITY AS TOLERATED WITH ASSIST.D/C FOLEY CATHETER ONCE D/C ACTIVE HYDRATION WITH IVF. VALIUM Q 1 HOUR PER CIWA. BUN 4, Cr 0.8, K 2.8--> 10+10+10+40 IV KCl. Otherwise, probably normal for age.No previous tracing available for comparison. CCU NSG PROGRESS NOTE 7P-7A/ ETOH WITHDRAWALS- SPEAKING MOSTLY TO SELF OR VOICES HE HEARS. LEVEL OF ORIENTATION WAXING/.O- SEE FLOWSHEET FOR OBJECTIVE DATA PT REMAINS HEMODYNAMICALLY STABLE WITHOUT FURTHER TACHYCARDIA OR HTN. OVERALL, HR- 80-90'S SR, NO VEA OR SVT. "The only pain is with my f---- IV." Dr notified of CIWA >10 and last dose of valium @ 0600--ok to give 15mg valium. CCU Nursing Progress Note (MICU service)0700-1900Addendum: 1700 CIWA 11, pt stating that he wants to go home, no VS changes. BY LATE EVENING, WITH PERSISTANT VALIUM FOR CIWA>20, PT MUCH LESS AGITATED. Mg 1.6-->2Gm IV Magnesium. CCU NPN:MICU border,see flowsheet for objective data30 yo transferred from with acitve ETOH withdrawal. HR up to 130's & BP 150's/. K/Mg PND. REPLETE LYTES AS NEEDED THIS AM. Continue to monitor CIWA scale, call team to assess for CIWA >10. Pt received 225 mg valium IV the 18 hours of admission. Dried open areas ~ 1cm in diameter with central scab area on tops of both feet and above both ankles. CCU Nursing Progress Note (MICU service)0700-1900S: "what happened, what am I doing here?" Has received 105mg valium IV 15mg at a time. PT ON Q 1 HOUR CIWA SCALE, Q 1 HOUR RESTRAINT FLOWSHEET FOR 4 PT,Q 4 HOUR ORDERS BY INTERN FOR RESTRAINT THROUGHOUT THIS SHIFT CONTINUES. Safety dietary tray as per order, but team reports that pt is NOT deemed a suicide risk. Correlation with dedicated PA and lateral CXR is recommended. Is receiving IV D5 1/2 NS @ 125 cc/hour. LIBERALIZE RESTRAINTS, PERHAPS TRYING 3 PT FROM 4 PT THIS AM.AWAIT CALL FROM SISTER, CALL HER WITH ANY CHANGE IN PROGRESS/STATUS.C/O TO PSYCH FACILITY ONCE MEDICALLY APPROPRIATE. CIWA now <10. PT RECEIVING VALIUM 15 MG Q 15 MINUTES TO Q 1-2 HOURS, FOR TOTAL 120MG FROM 7P-6A. increasing symptoms of ETOH withdrawal,tx with seroquel,atenolol,ativan,haldol and zyprexia. NO CALLS FROM FAMILY THIS SHIFT.DENIES PAIN.GU- FOLEY CATH IN PLACE- GOOD UO- REMAINS ON D5 1/2 NS 125CC/HOUR.GI- LARGE SOFT FORMED BM- G (-)- ATE BOX LUNCH IN ADDITION TO DINNER EARLIER. SINGLE VIEW OF THE CHEST AT 8:55 A.M: There is no focal consolidation or pleural effusion. remains in 4 point restraints. Pt awake, able to drink water without signs of asp, HOB ^ 90 degrees and pt able to eat dinner. | 7 | [
{
"category": "Nursing/other",
"chartdate": "2180-08-14 00:00:00.000",
"description": "Report",
"row_id": 1625914,
"text": "CCU NPN:MICU border,see flowsheet for objective data\n\n30 yo transferred from with acitve ETOH withdrawal. admitted to OH on . increasing symptoms of ETOH withdrawal,tx with seroquel,atenolol,ativan,haldol and zyprexia. HR up to 130's & BP 150's/. in ED tx with ativan and valium transferred to CCU as MICU border at 1300.\n\nETOH withdrawal: following CIWA scale and giving valium as needed. Has received 105mg valium IV 15mg at a time. has just started on haldol so that schizophrenic issues will not complicated assessing ETOH withdrawal. remains in 4 point restraints. continues to hallucinate.recently has been oriented to place and year.\n\nSocial: it is believed he lives with his mother. no phone calls received.\n\nA/P:ETOH withdrawal cont to follow CIWA scale and give valium as needed\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-08-15 00:00:00.000",
"description": "Report",
"row_id": 1625915,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ ETOH WITHDRAWAL\n\nS- SPEAKING MOSTLY TO SELF OR VOICES HE HEARS. SOMETIMES ANSWERING DIRECT QUESTIONS APPROPRIATELY. LEVEL OF ORIENTATION WAXING/.\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT REMAINS HEMODYNAMICALLY STABLE WITHOUT FURTHER TACHYCARDIA OR HTN. OVERALL, HR- 80-90'S SR, NO VEA OR SVT. BP- 130/104-116/73 VIA NBP.PT CURRENTLY NOT RECEIVING ANY ANTIHTN OF B BLOCKERS.\n\nRESP- CLEAR LUNGS, O2 SATS 100-98% ON ROOM AIR, COMFORTABLE BREATHING PATTERN EXCEPT WITH AGITATION.\n\nID- AFEBRILE BY AXILLARY TEMP.\n\nGU- FOLEY CATH IN PLACE- GOOD UO- >1300CC/THIS SHIFT- RECEIVING 125/HOUR OF D5 1/2 NS FOR HYDRATION.\n\nGI- (+) BOWEL SOUNDS , NO STOOL , (+)FLATUS- NPO- REFUSING EVENING DOSE OF RISPERIDOL PO BUT IS ON HALDOL IV TID.\n\n PT ON Q 1 HOUR CIWA SCALE, Q 1 HOUR RESTRAINT FLOWSHEET FOR 4 PT,Q 4 HOUR ORDERS BY INTERN FOR RESTRAINT THROUGHOUT THIS SHIFT CONTINUES. PT RECEIVING VALIUM 15 MG Q 15 MINUTES TO Q 1-2 HOURS, FOR TOTAL 120MG FROM 7P-6A. DECREASED FREQUENCY OF VALIUM FROM Q 15 MIN TO Q 1 HOUR THIS MORNING. BY LATE EVENING, WITH PERSISTANT VALIUM FOR CIWA>20, PT MUCH LESS AGITATED. NO CALLS FROM SISTER, WHO APPEARS TO BE NEXT OF PER CHART/ICU CONSENT.\nTURNING PT WITH ASSIST AND PT HAS BEEN COMPLIANT WITH TURNING AND ROM.\n\nLINES- #18, X 2 PIV- PATENT, SITES DRY/CLEAN/NO REDNESS.\n\nA/ PT ADMITTED TO CCU TO MICU SERVICE AS A BORDER FOR ETOH WITHDRAWL, C/B HTN/TACHYCARDIA- CURRENTLY HEMODYNAMICALLY STABLE AND LESS ACUTELY AGITATED WITH CONSISTENTLY DOSING VALIUM PER CIWA SCALE AND GIVING HALDOL TID.\n\nCONTINUE TO CLOSELY OBSERVE WITH SITTER 1:1 PER PROTOCOL FOR 4 PT RESTRAINTS AS WELL AS R/O SUICIDAL AS PT HAS LONG HX OF MULTIPLE ATTEMPTS AND DIFFICULT TO ASCERTAIN ETILOGY OF CURRENT ETOH ABUSE/INTOXICATION. VALIUM Q 1 HOUR PER CIWA. CONTINUE DOCUMENTATION OF CIWA/ AND RESTRAINTS Q 1 HOUR. REPLETE LYTES AS NEEDED THIS AM. DISCUSS W TEAM PLAN TO ? LIBERALIZE RESTRAINTS, PERHAPS TRYING 3 PT FROM 4 PT THIS AM.\nAWAIT CALL FROM SISTER, CALL HER WITH ANY CHANGE IN PROGRESS/STATUS.\nC/O TO PSYCH FACILITY ONCE MEDICALLY APPROPRIATE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-08-15 00:00:00.000",
"description": "Report",
"row_id": 1625916,
"text": "CCU Nursing Progress Note (MICU service)0700-1900\nS: \"what happened, what am I doing here?\" \"The only pain is with my f---- IV.\" \"I'm going to get out of here.\" \"What did you say about my checking account?\"\n\nO: see CCU flow sheet for complete objective data\n\nETOH Withdrawal: pt sedated, arouses with verbal stimuli, leg restraints removed this morning. Remains in soft limb restraints, order obtained. Threatening to leave, but making no movement to do so. CIWA , to receive valium if CIWA >10--but to have MD assess first. As per Dr. , valium reserved for signs of sympathetic stimulation (^^HR/BP/tremors). Pt received 225 mg valium IV the 18 hours of admission. Last Valium dose today @ 0600. Rare c/o h/a, rare episode of auditory hallucination. Safety dietary tray as per order, but team reports that pt is NOT deemed a suicide risk. IV haldol order changed to prn (had only received one dose last evening).\n\nCV: HR 90's-->80's NSR, no VEA, SBP 105-120.\n\nGU: urine initially amber, now clearer yellow in larger quantities. BUN 4, Cr 0.8, K 2.8--> 10+10+10+40 IV KCl. Mg 1.6-->2Gm IV Magnesium. Will recheck K/Mg several hours after last K dose.\n\nGI: no po's d/t decreased LOC. Is receiving IV D5 1/2 NS @ 125 cc/hour. Abd flat, +BS, no stool.\n\nSkin: pressure points intact, aloe vesta applied, repositioned q 2 hours, heels suspended on pillows. Dried open areas ~ 1cm in diameter with central scab area on tops of both feet and above both ankles. Mouth care given as able--not cooperative with this.\n\nResp: lungs clear, sats >98% on RA, no cough.\n\nID: afebrile, resistant to PO temp.\n\nAccess: PIV X2 (#18), sites intact, IV K infusion slowed d/t above c/o.\n\nA: ETOH withdrawal, CIWA <10 without further need for valium thus far.\n\nP: ready for transfer to medical floor, awaiting bed. Continue to monitor CIWA scale, call team to assess for CIWA >10. Monitor for elopement risk. Continue with skin care, mouth care, frequent position changes.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-08-15 00:00:00.000",
"description": "Report",
"row_id": 1625917,
"text": "CCU Nursing Progress Note (MICU service)0700-1900\nAddendum: 1700 CIWA 11, pt stating that he wants to go home, no VS changes. Dr notified of CIWA >10 and last dose of valium @ 0600--ok to give 15mg valium. CIWA now <10. Pt awake, able to drink water without signs of asp, HOB ^ 90 degrees and pt able to eat dinner. K/Mg PND.\n"
},
{
"category": "Nursing/other",
"chartdate": "2180-08-15 00:00:00.000",
"description": "Report",
"row_id": 1625918,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P ETOH WITHDRAWAL\n\nS- \" THANKS FOR ALL OF YOUR HELP...I FEEL OK..\"\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA-\n\nCV- VS REMAINS STABLE- HR-80-100 SR, ST. NO VEA.- BP- 116/70-120/80 VIA NBP.\n\nRESP- CLEAR LUNGS, APPEARS COMFORTABLE, ROOM AIR- 96-100% VIA 02 SATS.\n\nID- AFEBRILE\n\n PT WITH SCALE LESS THAN 10 ALL SHIFT- NO NEED FOR PRN VALIUM NOR HALDOL. TO REASSESS RISPERIDOL ORDER IN PT DECLINING MED CURRENTLY. PT ALERT, ORIENTED AND ANSWERING ALL QUESTIONS APPROPRIATELY. NO CALLS FROM FAMILY THIS SHIFT.\nDENIES PAIN.\n\nGU- FOLEY CATH IN PLACE- GOOD UO- REMAINS ON D5 1/2 NS 125CC/HOUR.\n\nGI- LARGE SOFT FORMED BM- G (-)- ATE BOX LUNCH IN ADDITION TO DINNER EARLIER. (+) BOWEL SOUNDS, NO ISSUES.\n\nA/ PT ADMITTED TO MICU SERVICE FOR ETOH INTOXICATION/WITHDRAWAL, REQUIRING 12 HOURS (+) OF VALIUM DOSING PER SCALE. CURRENTLY A/O X 3 AND CALM, NO VALIUM SINCE 5PM.\n\nCONTINUE TO MONITOR MENTAL STATUS/ SCALE, MEDS AS NEEDED.\nREASSESS IN AM WITH PSYCH CONSULT FOR OK TO SEND HOME VS NEED FOR TRANSFER TO PSYCH/ETOH FACILITY.\n\nINCREASE ACTIVITY AS TOLERATED WITH ASSIST.\nD/C FOLEY CATHETER ONCE D/C ACTIVE HYDRATION WITH IVF.\n"
},
{
"category": "Radiology",
"chartdate": "2180-08-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1027025,
"text": " 8:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evalute for aspiration or infiltrates\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old man with alcohol W/D\n REASON FOR THIS EXAMINATION:\n evalute for aspiration or infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 30-year-old man with alcohol withdrawal.\n\n COMPARISON: None.\n\n SINGLE VIEW OF THE CHEST AT 8:55 A.M: There is no focal consolidation or\n pleural effusion. Pulmonary vasculature is somewhat engorged at the lung\n apices, with the suggestion of adjacent increased parenchymal opacity.\n However, the heart is not enlarged. There is no hilar or mediastinal\n enlargement. There is no pneumothorax. Soft tissue and bony structures are\n unremarkable.\n\n IMPRESSIONS: No consolidation, but increased opacity at the lung apices may\n reflect aspiration. Correlation with dedicated PA and lateral CXR is\n recommended.\n\n"
},
{
"category": "ECG",
"chartdate": "2180-08-14 00:00:00.000",
"description": "Report",
"row_id": 223763,
"text": "Baseline artifact. Sinus tachycardia. Otherwise, probably normal for age.\nNo previous tracing available for comparison.\n\n"
}
] |
32,287 | 192,269 | Bradycardia Assessment: HR variable throughout am - > pt. place NGT per Dr. Dilantin given a/o. Action: Dilantin 100mg iv q8hrs given. Chief complaint: Seizure, respiratory failure PMHx: 1. Current medications: 1. Chief complaint: PMHx: 1. Chief complaint: PMHx: 1. Chief complaint: PMHx: 1. Chief complaint: PMHx: 1. Chief complaint: PMHx: 1. Chief complaint: PMHx: 1. Hypercholesterolemia ------ Protected Section------ ------ Protected Section Error Entered By: , RN on: 07:26 ------ Extubated at , . Extubated at , . Response: Bradycardia persists, ? Neuro signs q1hr. Neuro signs q2hrs. ABG results repeated post extubation. ABG results repeated post extubation. Adjust dilantin levels. o Left epiletptiform activity on one medication. LeVETiracetam 11. ------ Protected Section ------ AM labs received. Aline/central lines placed. UE pulses palpable. UE pulses palpable. Afebrile. Afebrile. PMHx: 1. BPS. BPS. Thiamine 17. Ongoing EtOH abuse 5. Ongoing EtOH abuse 5. Ongoing EtOH abuse 5. Ongoing EtOH abuse 5. Ongoing EtOH abuse 5. Ongoing EtOH abuse 5. Ongoing EtOH abuse 5. Ongoing EtOH abuse 5. Response: Pt. Check Digoxin level. LP given patient febrile and seized. LP given patient febrile and seized. Propofol gtt started. Received thiamine, cyonacobalamine and folate. Continues on Kepra. Continues on Kepra. Pneumococcal Vac Polyvalent 17. Pneumococcal Vac Polyvalent 17. Has Bradycardic pauses. Chief complaint: Unresponsive/ seizures PMHx: PMH: 1. Chief complaint: Unresponsive/ seizures PMHx: PMH: 1. Meds as needed to keep SBP below 160. Meds as needed to keep SBP below 160. on dilantin iv q 8hrs. Tropnin leak resolving. propofol gtt infusing. To , electiveley intubated. Metoprolol Simvastatin. Metoprolol Simvastatin. LP DONE/febrile and seized. LP DONE/febrile and seized. GCSF if WBC 1 in am Endocrine: ISS prn ID: WBC 2, afebrile, now issue for now Fluids: NS 75 mls /hr Consults:Neurology Billing Diagnosis: Prophylaxis: DVT: Hep sq. NO venodynes Stress ulcer:PPi VAP bundle: + Comments: Communication:Comments: Code status:FULL Disposition:SICU Ketone level : trace. Seizure, without status epilepticus Assessment: opens eyes to name. ------ Protected Section ------ AM labs received. Phenytoin Sodium (IV) 16. Phenytoin Sodium (IV) 16. Glucagon 10. Glucagon 10. Vancomycin 22. Vancomycin 22. CeftriaXONE 7. CeftriaXONE 7. Monitor neuron signs as odered. Monitor neuron signs as odered. Simvastatin 19. Hold digoxin for now. Hold digoxin for now. Bradycardia Assessment: HR variable throughout am - > pt. Tropnin leak resolving. Dilantin given a/o. Received thiamine, cyonacobalamine and folate. ABG results repeated post extubation. ABG results repeated post extubation. Current medications: 1. Current medications: 1. Cardiovascular: Bradycardia with prolongation QT. Cardiovascular: Bradycardia with prolongation QT. Response: Bradycardia persists, ? Extubated at , . Extubated at , . Endocrine: ISS prn BG at goal. Endocrine: ISS prn BG at goal. Aline/central lines placed. Extubated after MRI if no structural abnormalities. Extubated after MRI if no structural abnormalities. Chief complaint: Seizure, respiratory failure PMHx: 1. Chief complaint: Seizure, respiratory failure PMHx: 1. GCSF if WBC 1 in am Endocrine: ISS prn ID: WBC 2, afebrile, now issue for now Fluids: NS 75 mls /hr Consults:Neurology Billing Diagnosis: Prophylaxis: DVT: Hep sq. Encouraged patient to CDB. Encouraged patient to CDB. Recommend starting patient on a multivitamin. sulfate ------ Protected Section Addendum Entered By: , RN on: 19:51 ------ Bradycardia Assessment: Sinus brady 30s-60 SBP 110s then down to SBP 90s when HR in the 30 Action: Atropine kept at bedside, Response: Plan: Continue to monitor, No MS. TrivialMR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. The axis remains leftward with an intraventricularconduction delay that is more right bundle-branch block. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. FINDINGS: NON-CONTRAST CT HEAD: Images are degraded by motion artifact. Left atrial abnormality. Left atrial abnormality. Left atrial abnormality. Normal interatrial septum.No ASD by 2D or color Doppler.LEFT VENTRICLE: Mild symmetric LVH. There is mild symmetric left ventricular hypertrophy. The right P1 segment is hypoplastic. There is dense atherosclerotic calcification of the aortic arch and at the origins of the great vessels without hemodynamically significant stenosis. There is mildpulmonary artery systolic hypertension. Within these limits, cardiac contours appear unchanged. Left anterior fascicular block. Left anterior fascicular block. Left anterior fascicular block. Right bundle-branch blockis less evident and there seems to be a loss of anterior forces. Marked intraventricular conduction defect with an incompleteright bundle-branch block appearance. Restingbradycardia (HR<60bpm).Conclusions:The left atrium is mildly dilated. Possible left ventricularhypertrophy. Trivial mitral regurgitation isseen. The mitral valve leaflets are mildlythickened. Sinus rhythm with modest A-V conduction delay. Sinus rhythm with modest A-V conduction delay. There is dense atherosclerotic calcification at the origins of the vertebral arteries without hemodynamically significant stenosis. The QRS complex is still anintraventricular conduction defect with right bundle-branch block morphologyand diffuse T wave abnormalities. Mild PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor apical views. Endotracheal tube is unchanged, 2.3 cm above the carina. Diffuse subcutaneous edema bilaterally. | 80 | [
{
"category": "Nursing",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 509758,
"text": "Bradycardia\n Assessment:\n HR variable throughout am - > pt. brady to 40 and then up to 60-80s w/o\n interventions or pattern. SBP stable in 90s-110 despite low HR. As day\n progressed, pt\ns HR consistently in low 40s and as low as 38. No change\n in SBP. Frequent PACs/PVCs.\n Action:\n EKG done, cards consulted, lytes aggressively repleted, pacing pads in\n place on pt.\n Response:\n Bradycardia persists, ? sick sinus syndrome per cards/ICU team.\n Plan:\n Cont. to monitor, recheck lytes and keep Mag/Calcium/KCL repleted, call\n cards for further ?s.\n .H/O alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n No seizures noted. Arousable to voice on Propofol gtt, moving UEs\n purposefully, moving LLE on bed, not moving RLE. Following commands\n intermittently. PERRLA 2-3mm and brisk. Tones stiff at times,\n difficult to move extremities.\n Action:\n EEG done this am, hooked up to 24 hour set-up. Dilantin given a/o.\n Aline/central lines placed.\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 510050,
"text": "Demographics\n Day of intubation: 2\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 Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 8mm\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 / Small\n Comments: Remains intubated for airway protection. Currently on PSV\n 10/5 PEEP FIO2 .50.\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 510104,
"text": "SICU\n HPI:\n Patient is a 67 yo man with complicated PMH including EtOH abuse,\n HTN, CAD and hypercholesterolemia who was last seen normal 2 days ago\n but found in same sitting position per neighbor since yesterday.\n Patient reportedly had repeated seizure activity either en route or at\n requiring Ativan then Valium then subsequently loaded\n with 2g of Fosphenytoin.\n Chief complaint:\n Seizure, respiratory failure\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n .\n Current medications:\n 1. 1000 mL NS 2. Calcium Gluconate 3. Chlorhexidine Gluconate 0.12%\n Oral Rinse 4. Dextrose 50% 5. FoLIC Acid\n 6. Furosemide 7. Glucagon 8. Heparin 9. Insulin 10. LeVETiracetam 11.\n Magnesium Sulfate 12. Pantoprazole\n 13. Potassium Chloride 14. Propofol 15. Simvastatin 16. Thiamine 17.\n Venlafaxine\n 24 Hour Events:\n ULTRASOUND - At 04:00 PM\n bilat lower extremities\n : episode of Bradycardia to low 30's and Low BP low 90's, Lines\n neg for DVT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Acyclovir - 04:28 AM\n Ampicillin - 05:48 AM\n Vancomycin - 07:30 AM\n Infusions:\n Propofol - 45 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications:\n Flowsheet Data as of 05:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 35.6\nC (96\n HR: 53 (35 - 63) bpm\n BP: 118/47(68) {91/41(56) - 132/54(78)} mmHg\n RR: 14 (12 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 114.2 kg (admission): 110 kg\n Height: 69 Inch\n Total In:\n 3,947 mL\n 843 mL\n PO:\n Tube feeding:\n 116 mL\n 194 mL\n IV Fluid:\n 3,832 mL\n 649 mL\n Blood products:\n Total out:\n 1,220 mL\n 253 mL\n Urine:\n 1,010 mL\n 253 mL\n NG:\n 210 mL\n Stool:\n Drains:\n Balance:\n 2,727 mL\n 590 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 670 (380 - 780) mL\n PS : 10 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: 7.39/32/196/22/-4\n Ve: 8.6 L/min\n PaO2 / FiO2: 392\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), Sinus tachycardia and bradycardia\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Labs / Radiology\n 71 K/uL\n 7.0 g/dL\n 123 mg/dL\n 1.4 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 114 mEq/L\n 143 mEq/L\n 22.2 %\n 3.3 K/uL\n [image002.jpg]\n 09:55 AM\n 04:39 PM\n 05:51 PM\n 09:51 PM\n 02:12 AM\n 09:43 AM\n 02:50 PM\n 03:58 PM\n 07:49 PM\n 01:46 AM\n WBC\n 6.4\n 5.4\n 5.4\n 3.3\n Hct\n 25.7\n 23.4\n 24.0\n 22.2\n Plt\n 75\n 68\n 77\n 71\n Creatinine\n 1.5\n 1.6\n 1.5\n 1.5\n 1.4\n 1.4\n 1.3\n 1.4\n Troponin T\n 0.12\n TCO2\n 24\n 20\n Glucose\n 157\n 147\n 129\n 119\n 107\n 109\n 109\n 123\n Other labs: PT / PTT / INR:13.7/32.6/1.2, CK / CK-MB / Troponin\n T:176/5/0.12, ALT / AST:20/61, Alk-Phos / T bili:108/0.7,\n Differential-Neuts:89.0 %, Band:5.0 %, Lymph:3.0 %, Mono:3.0 %, Eos:0.0\n %, Lactic Acid:1.1 mmol/L, Albumin:2.7 g/dL, LDH:180 IU/L, Ca:8.2\n mg/dL, Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 67M W/ PMH including EtOH abuse, HTN, CAD and\n hypercholesterolemia who was found in same sitting position per\n neighbor for 24h. reportedly had repeated seizure activity\n with unknown etiology\n Neurologic: Despite sedation on propofol opens eyes to verbal stimuli\n and spontaneously moves L side anti-gravity but do not follow commands.\n Although no obvious asymmetry in tone, patient does not move R as much\n as L and RLE does not move even to noxious\n Stimulation. Also, although both reactive, R pupil slightly larger than\n L\n CTA of head and neck done: No evidence of basilar artery thrombus.\n LP DONE-negative.\n Patient's current hemiparesis may be post-ictal () but seizure\n may have been secondary to vascular event as well.\n Continue Dilantin 100mg TID - would get a level plus albumin with goal\n corrected level between 15~20.level f/up EEG results.left hemispheric\n seizure activity\n Alcohol withdrawal treated with MVI, thiamine, folate\n Cardiovascular: Sudden episodes of sinus brady.EP consulted-no\n indication of pacemaker/recommend repleting electrolytes.episodes of\n sinus bradycardia, cardiology consulted. Patient has pads for external\n pacing if bradycardia becomes unstable hemodynamically. Digoxin hold\n for elevated levels. Continue with lasix and statin Troponin leak\n secondary to demand ischemia in light of poor EF. 2DE:LVEF>55%,mild\n pulm art systolic hypertension\n Pulmonary: Intubated for AW protection wean off the vent as tolerated\n Gastrointestinal / Abdomen: soft\n Nutrition: advance TF to goal\n Renal: Foley 30mls/hr\n Hematology: thrombocytopenia 77.hct 24, f/UP HIT panel\n Endocrine: ISS prn\n Infectious Disease: WBC 9.7, afebrile, now issue for now\n Lines / Tubes / Drains: ET PIV L subclav ,a line\n Wounds:\n Imaging:\n Fluids: NS, 75CC/H HLIV when po>300\n Consults: Neurology\n Billing Diagnosis: Seizure, (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete (Full) - 05:30 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:01 AM\n 22 Gauge - 06:02 AM\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510263,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Pt received sedated on propofol, intubated on CPAP 5/5 40%,\n thick clear secretions.\n HR 30-60s, irregular, wide QRS\n SBP 100-150s, afebrile, SpO2 98% or greater\n Pupils brisk, R ~1mm>L Dr. notified\n No apparent seizure activity, impaired gag, intact cough.\n Withdraws to pain, opens eyes to command on propofol.\n Pancytopenic on AM labs\n Action:\n MRI done this AM after cleared for metal by xray. Off unit\n -1430, accompanied by Dr. to MRI suite D/T bradycardia.\n EEG resumed\n Sedation wake up performed from , currently off\n Heparin held per Dr. pending HIT assay, Heme\n consulted\n EKG done, reviewed by cardiology\n Response:\n MRI report pending, reviewed by neuromed\n Pt off propofol since ~1430, pt awake, alert, nods\n appropriately, MAE.\n SBP stable, HR continues to occasionally drop to 30s without\n significant change in BP\n HIT assay cancelled per heme, heparin given as per Dr. \n Tube feeding resumed at previous rate\n Atropine at bedside, pacer pads on\n Plan:\n Neuro checks Q2hrs per Dr. \n ? extubation in AM\n Repeat labs in AM\n Hold TF after 0400 in AM, ? place NGT per Dr. \n"
},
{
"category": "Nursing",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510095,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Patient continues to be intubated and sedated on propofol.\n Pupils 4-2 mm both equally and briskly reactive to light, right pupil\n 0.5 mm bigger than left at times, both briskly reactive. Able to\n withdraw to nailbed pressure with all extremities. Able to open eyes\n to voice and inconsistently follows commands, able to squeeze hand but\n does not let go, attempted to stick out tounge a couple times when\n asked during night.\n Action:\n Continued with q 1 hour neuro checks,\n Response:\n Neuro status unchanged,\n Plan:\n Continue to monitor, MRI in future?\n Bradycardia\n Assessment:\n Sinus brady 30\ns-60\n SBP 110\ns then down to SBP 90\ns when HR in the 30\n Action:\n Atropine kept at bedside,\n No intervention needed,\n Response:\n SBP did not go below 90\ns despite bradycardic to 30\n Plan:\n Continue to monitor,\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510318,
"text": "Bradycardia; h/o seizure\n Assessment:\n Awake and alert at times. Oriented x self only. Follows\n commands. Often perseverates by repeating same answer to different\n questions. Discussed with neuro MD. No new orders received, but\n believes pt is encephalopathic. Afebrile. Neuro checks q 2 hours.\n Right pupil slightly larger than left. Brisk reaction noted.\n Extubated at , . Placed on 40% face tent. O2 sat\n maintained > 95%. Encouraged patient to CDB. Followed directions at\n times. Later transitioned patient to nasal cannula. O2 sat\n unchanged. ABG results repeated post extubation. Values within normal\n limits.\n Bradycardic at times with heart rhythm in 2^nd degree, type\n II block. Remains connected to defibrillator pads and lifepack.\n Atropine at bedside. HR fluctuating between 40s and 70s. SBP\n maintained throughout evening. UE pulses palpable. LE pulses weak,\n requiring doppler. Skin to as if to indicate a vascular\n issue.\n Abdomen soft, obese. Positive BS throughout abdomen. NPO\n at this time.\n Foley catheter draining clear yellow urine, >30cc/hr during\n shift.\n Skin with multiple breakdowns. See Metavision flowsheet for\n details.\n Plan:\n Pt awaiting permanent pacemaker placement. Monitor HR, SBP closely.\n Continue q 2 hr neuro checks until further notice.\n ------ Protected Section ------\n AM labs received. Repleted Mg. P and K repleted with 15mmol KPhos.\n 0.9 NaCl paused due to Na = 145 and Cl 115. Will discuss further with\n SICU MD.\n ------ Protected Section Addendum Entered By: , RN\n on: 05:41 ------\n Pt with moderate amount liquid black stool. Guaic positive. Informed\n MD of findings as well as results of Na, Cl. Will endorse to am\n shift.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:17 ------\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510267,
"text": "Bradycardia; h/o seizure\n Assessment:\n Awake and alert at times. Oriented x self only. Follows\n commands. Often perseverates by repeating same answer to different\n questions. Discussed with neuro MD. No new orders received, but\n believes pt is encephalopathic. Afebrile. Neuro checks q 2 hours.\n Right pupil slightly larger than left. Brisk reaction noted.\n Extubated at , . Placed on 40% face tent. O2 sat\n maintained > 95%. Encouraged patient to CDB. Followed directions at\n times. Later transitioned patient to nasal cannula. O2 sat\n unchanged. ABG results repeated post extubation. Values within normal\n limits.\n Bradycardic at times with heart rhythm in 2^nd degree, type\n II block. Remains connected to defibrillator pads and lifepack.\n Atropine at bedside. HR fluctuating between 40s and 70s. SBP\n maintained throughout evening. UE pulses palpable. LE pulses weak,\n requiring doppler. Skin to as if to indicate a vascular\n issue.\n Abdomen soft, obese. Positive BS throughout abdomen. NPO\n at this time.\n Foley catheter draining clear yellow urine, >30cc/hr during\n shift.\n Skin with multiple breakdowns. See Metavision flowsheet for\n details.\n Plan:\n Pt awaiting permanent pacemaker placement. Monitor HR, SBP closely.\n Continue q 2 hr neuro checks until further notice.\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510448,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Right pupil 5mm and briskly and left pupil 4mm briskly\n reactive to light\n Oriented to self and at times year\n Pt able to lift and hold arms off bed\n Pt at times perseverates\n Pt able to lift legs off bed\n Pt follows commands\n Continues to keepra\n No seizures noted\n EEG leads discontinued\n MRI suspicious for encephalitis ? HSV\n Action:\n Pt started on Acyliovir\n Response:\n Pt extubated\n Nuero signs every 2hours\n Plan:\n Continue to monitor\n Check neuro signs as ordered\n Acyliovir as ordered\n Bradycardia\n Assessment:\n Pt remain in 1^st AVB\n Pt had transient eposides of hr ot 30\ns-40\ns, pt asymtomatic\n Sbp greater than 180\n Action:\n External pacing pads remain on\n Response:\n Plan:\n Continue to monitor\n ? pacer placement\n ? hydralazine\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 509937,
"text": "HPI:\n Patient is a 67 yo man with complicated PMH\n including EtOH abuse, HTN, CAD and hypercholesterolemia who was\n last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n Chief complaint:\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n Bradycardia\n Assessment:\n Heart rate in the 30-50\ns with pac and pvc\n K 3.9, magnesium 2.5.\n Bp 90-112 syst via aline and cuff pressure.\n Action:\n Electrlolyes drawn and repleted\n Pads applied to chest\n Ekg done as ordered.\n Response:\n Cardiology in to see patient. ? sick sinus syndrome per cardiology.;\n Plan:\n Monitor cardiac status and replete electrolytes as ordered.\n Seizure, without status epilepticus\n Assessment:\n Pupils equal and reactive, #\n Moves right and left arm on the bed.\n No movement in right leg, moves left leg on the bed.\n On propofol 35mcg/kg/min.\n Action:\n Dilantin 100mg iv q8hrs given.\n Neuro signs q1hr.\n Eeg 24hrs\n Mri needed.\n Response:\n Eeg continous,\n Mri needs to be done but due eu critical status, family needs to\n identify patient.\n Neuro sttaus unchanged.\n Plan:\n Monitor neuro status closely.\n Left subclavian line oozing blood. Dr in to see patient.\n Suture placed at the insertion site.\n Line continues to ooze blood. Hct drawn and returned back at 23. dr\n notified. Repeat done and results 24.\n Site being monitored closely.\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 509943,
"text": "SICU\n HPI:\n Patient is a 67 yo man with complicated PMH. including EtOH abuse, HTN,\n CAD and hypercholesterolemia who was last seen normal 2 days ago but\n found in same sitting position per neighbor since yesterday. Patient\n reportedly had repeated seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of Fosphenytoin.\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n 24 Hour Events:\n INVASIVE VENTILATION - START 12:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Acyclovir - 04:28 AM\n Ampicillin - 05:48 AM\n Vancomycin - 07:30 AM\n Infusions:\n Propofol - 35 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:30 AM\n Pantoprazole (Protonix) - 04:47 PM\n Other medications:\n Flowsheet Data as of 12:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.2\nC (99\n HR: 65 (37 - 107) bpm\n BP: 129/53(76) {111/45(-2) - 134/62(86)} mmHg\n RR: 18 (13 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 7,374 mL\n 21 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,074 mL\n 21 mL\n Blood products:\n Total out:\n 1,615 mL\n 0 mL\n Urine:\n 1,215 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 5,759 mL\n 21 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): 495 (136 - 495) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 15 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.30/46/198/22/-3\n Ve: 10 L/min\n PaO2 / FiO2: 396\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: sudden episodes of bradycardia\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Skin: bilateral lower extremity long standing erythematous skin changes\n Neurologic: Sedated\n Labs / Radiology\n 68 K/uL\n 7.4 g/dL\n 129 mg/dL\n 1.5 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 33 mg/dL\n 110 mEq/L\n 142 mEq/L\n 23.4 %\n 5.4 K/uL\n [image002.jpg]\n 11:23 PM\n 09:55 AM\n 04:39 PM\n 05:51 PM\n 09:51 PM\n WBC\n 6.4\n 5.4\n Hct\n 26\n 25.7\n 23.4\n Plt\n 75\n 68\n Creatinine\n 1.5\n 1.6\n 1.5\n Troponin T\n 0.12\n TCO2\n 23\n 24\n Glucose\n 149\n 157\n 147\n 129\n Other labs: PT / PTT / INR:13.7/32.6/1.2, CK / CK-MB / Troponin\n T:176/5/0.12, Lactic Acid:0.7 mmol/L, Albumin:2.9 g/dL, Ca:7.4 mg/dL,\n Mg:2.6 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n BRADYCARDIA, ELECTROLYTE & FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE,\n PERIPHERAL VASCULAR DISEASE (PVD) WITHOUT CRITICAL LIMB ISCHEMIA,\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT\n STATUS EPILEPTICUS\n Assessment and Plan: ASSESSMENT: patient is a 67 yo man with\n complicated PMH including EtOH abuse, HTN, CAD and hypercholesterolemia\n who was last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated seizure\n activity either en route or at requiring Ativan then\n Valium then subsequently loaded with 2g of Fosphenytoin.\n Neuro\n Despite sedation on propofol opens eyes to verbal\n stimuli and spontaneously moves L side anti-gravity but do not follow\n commands. Although no obvious asymmetry in tonepatient does not move R\n as much as L and RLE does not move even to noxious stimulation. Also,\n although both reactive, R pupil slightly larger than L.\n o STAT CTA of head and neck done: No evidence of basilar artery\n thrombus.\n o LP DONE - negative.\n o Patient's current hemiparesis may be post-ictal () but\n seizure may have been secondary to vascular or EtOH as well.\n o Left epiletptiform activity on one medication. Adjust\n dilantin levels. If subtyherapeutic and still seziing start second\n medication.\n o Alcohol withdrawal treated with MVI, thiamine, folate.\n Cardiovascular: episodes of sinus bradycardia, cardiology\n consulted. Patient has pads for external pacing if bradycardia become\n unstable hemodynamically.\n o Digoxin hold for elevated levels. Continue with lasix and\n statin\n o Troponin leak secondary to demand ischemia in light of poor\n EF.\n Pulmonary: Intubated for AW protection\n Gastrointestinal / Abdomen: soft, NT, ND.\n Nutrition: start TF\n Renal:AUOP\n Hematology. Pancytopenia with magaloblastic anemia. Send the\n peripheral smear, hemolysis panel and HIT panel. Add vit B13 and folate\n replacement after assessing for folate levels.\n Endocrine: ISS prn with adequately BG\n ID: no issues.\n Lines / Tubes / Drains: ET PIV L subclav ,a line\n Imaging: CTA of head and neck No basilar artery thrombosis -\n Fluids: 75 mls /hr\n Consults:Neurology\n Billing Diagnosis:\n Prophylaxis:\n DVT: Hep sq. NO venodynes due to PVD\n Stress ulcer:PPi\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n Lines:\n 20 Gauge - 06:01 AM\n 22 Gauge - 06:02 AM\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 PM\n Total time spent: 35\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 510523,
"text": "Patient is a 67 yo man with complicated PMH\n including EtOH abuse, HTN, CAD and hypercholesterolemia who was\n last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n Chief complaint:\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n 1 st degree avb\n Assessment: sys bp via aline 140-180\n Cuff bp 130-140\n No episodes of bradycardia tonite.\n Action: external pacing pads on\n Magnesium repleted\n Hydralazine 10mg iv x2 given.\n Response: no bradycardia tonite\n Plan:: monitor cardiac status\n ? pacer placement.\n Problem seizure\n : alert to name but becomes confused to place and year.\n Moves arms off the bed as can only move legs\n on the bed\n Right pupil #5 and left pupil #4 react\n briskly.\n No seizure activity noted.\n Action: acyclovir iv as ordered with 250cc normal saline\n prior to administration and post med.\n Neuro signs q2hrs.\n Iv keppra given as ordered\n Response: no seizure activity noted tonite\n Plan: continue to monitor neuro signs closely.\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 510509,
"text": "Patient is a 67 yo man with complicated PMH\n including EtOH abuse, HTN, CAD and hypercholesterolemia who was\n last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n Chief complaint:\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 510510,
"text": "SICU\n HPI:\n 67M transferred from for seizures.\n Chief complaint:\n PMHx:\n PMH: HTN, CHF (20%EF), CAD, EtOH, Cirrhotic, CRI, PUD, depression,\n ^chol, neck hematoma, rib and C7 TP fx (MVA )\n PSH: CABG, THR (R),\n MEDS: Effexor 37.5',Lopressor 50'',Omeprazole 20',Ativan 1''',\n Simvastatin 20', Lasix 10'', Digoxin 0.125'\n Current medications:\n 24 Hour Events:\n EKG - At 02:42 PM\n dr. assessed ekg\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Acyclovir - 04:53 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:50 AM\n Hydralazine - 06:51 AM\n Other medications:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.2\nC (99\n HR: 85 (40 - 85) bpm\n BP: 167/65(94) {115/46(65) - 184/102(146)} mmHg\n RR: 27 (15 - 27) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 115.8 kg (admission): 110 kg\n Height: 69 Inch\n Total In:\n 3,273 mL\n 1,505 mL\n PO:\n 160 mL\n 400 mL\n Tube feeding:\n IV Fluid:\n 3,113 mL\n 1,105 mL\n Blood products:\n Total out:\n 2,960 mL\n 990 mL\n Urine:\n 2,960 mL\n 690 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 313 mL\n 515 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///21/\n Physical Examination\n Labs / Radiology\n 82 K/uL\n 8.3 g/dL\n 139 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 112 mEq/L\n 141 mEq/L\n 25.3 %\n 2.8 K/uL\n [image002.jpg]\n 03:58 PM\n 07:49 PM\n 01:46 AM\n 06:13 PM\n 08:09 PM\n 11:29 PM\n 03:01 AM\n 02:18 PM\n 06:00 PM\n 03:15 AM\n WBC\n 3.3\n 2.6\n 2.8\n Hct\n 22.2\n 24.5\n 23.8\n 25.3\n Plt\n 71\n 61\n 82\n Creatinine\n 1.4\n 1.3\n 1.4\n 1.0\n 0.9\n 0.7\n TCO2\n 22\n 23\n Glucose\n 109\n 109\n 123\n 92\n 140\n 115\n 139\n Other labs: PT / PTT / INR:13.7/32.6/1.2, CK / CK-MB / Troponin\n T:176/5/0.12, ALT / AST:20/61, Alk-Phos / T bili:108/0.6,\n Differential-Neuts:60.0 %, Band:5.0 %, Lymph:27.1 %, Mono:9.2 %,\n Eos:3.4 %, Lactic Acid:1.1 mmol/L, Albumin:2.7 g/dL, LDH:180 IU/L,\n Ca:7.5 mg/dL, Mg:1.6 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 67M w/ likely HSV encephalitis\n Neurologic: Dilantin 100 tid (goal 15-20), s/p MVI,thiamine,folate,\n Cardiovascular: sinus brady, EP: pacemaker once other issues resolved,\n external pacing and atropine prn, holding digoxin, troponin leak\n Pulmonary: succesfully extubated, aggressive pulmonary toilet\n Gastrointestinal / Abdomen: no follow, elevated TBili likely \n underlying cirrhosis, will follow\n Nutrition:\n Renal: Cr OK, good UOP\n Hematology: pancytopenia likely ACD + nutritional + cirrhosis, does not\n have HIT per heme.\n Endocrine: ISS prn\n Infectious Disease: WBC 9.7, afebrile, now issue for now\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids:\n Consults: Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 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:\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 510511,
"text": "Patient is a 67 yo man with complicated PMH\n including EtOH abuse, HTN, CAD and hypercholesterolemia who was\n last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n Chief complaint:\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 510513,
"text": "Patient is a 67 yo man with complicated PMH\n including EtOH abuse, HTN, CAD and hypercholesterolemia who was\n last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n Chief complaint:\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n ------ Protected Section------\n ------ Protected Section Error Entered By: , RN\n on: 07:26 ------\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510255,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Pt received sedated on propofol, intubated on CPAP 5/5 40%\n HR 30-60s, irregular, wide QRS\n SBP 100-150s, afebrile, SpO2 98% or greater\n Pupils brisk, R ~1mm>L.\n No apparent seizure activity, impaired gag, intact cough.\n Withdraws to pain, opens eyes to command on propofol.\n Pancytopenic on AM labs\n Action:\n MRI done this AM after cleared for metal by xray\n EEG resumed\n Sedation wake up performed from , currently off\n Heparin held per Dr. pending HIT assay, Heme\n consulted\n Response:\n MRI\n Plan:\n Bradycardia\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 510514,
"text": "Patient is a 67 yo man with complicated PMH\n including EtOH abuse, HTN, CAD and hypercholesterolemia who was\n last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n Chief complaint:\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 510311,
"text": "SICU\n HPI:\n 67M transferred from for seizures.\n Chief complaint:\n seizures\n PMHx:\n PMH: HTN, CHF (20%EF), CAD, EtOH, Cirrhotic, CRI, PUD, depression,\n ^chol, neck hematoma, rib and C7 TP fx (MVA )\n PSH: CABG, THR (R),\n MEDS: Effexor 37.5',Lopressor 50'',Omeprazole 20',Ativan 1''',\n Simvastatin 20', Lasix 10'', Digoxin 0.125'\n Current medications:\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:21 PM\n EEG - At 06:09 PM\n INVASIVE VENTILATION - STOP 08:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:01 AM\n Heparin Sodium (Prophylaxis) - 11:31 PM\n Other medications:\n Flowsheet Data as of 05:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.9\nC (98.5\n HR: 65 (41 - 73) bpm\n BP: 126/51(76) {108/43(63) - 156/98(110)} mmHg\n RR: 14 (12 - 25) insp/min\n SPO2: 100%\n Heart rhythm: 2nd AV W-M1 (Second degree AV Block Wenckebach - Mobitz1)\n Wgt (current): 115.8 kg (admission): 110 kg\n Height: 69 Inch\n Total In:\n 3,121 mL\n 541 mL\n PO:\n Tube feeding:\n 505 mL\n IV Fluid:\n 2,616 mL\n 541 mL\n Blood products:\n Total out:\n 1,823 mL\n 480 mL\n Urine:\n 1,823 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,298 mL\n 61 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 505 (490 - 590) mL\n PS : 5 cmH2O\n RR (Spontaneous): 40\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 28\n PIP: 6 cmH2O\n SPO2: 100%\n ABG: 7.38/38/92./23/-1\n Ve: 5 L/min\n PaO2 / FiO2: 186\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 61 K/uL\n 7.5 g/dL\n 92 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 18 mg/dL\n 115 mEq/L\n 145 mEq/L\n 23.8 %\n 2.6 K/uL\n [image002.jpg]\n 02:12 AM\n 09:43 AM\n 02:50 PM\n 03:58 PM\n 07:49 PM\n 01:46 AM\n 06:13 PM\n 08:09 PM\n 11:29 PM\n 03:01 AM\n WBC\n 5.4\n 3.3\n 2.6\n Hct\n 24.0\n 22.2\n 24.5\n 23.8\n Plt\n 77\n 71\n 61\n Creatinine\n 1.5\n 1.4\n 1.4\n 1.3\n 1.4\n 1.0\n TCO2\n 20\n 22\n 23\n Glucose\n 119\n 107\n 109\n 109\n 123\n 92\n Other labs: PT / PTT / INR:13.7/32.6/1.2, CK / CK-MB / Troponin\n T:176/5/0.12, ALT / AST:20/61, Alk-Phos / T bili:108/0.6,\n Differential-Neuts:89.0 %, Band:5.0 %, Lymph:3.0 %, Mono:3.0 %, Eos:0.0\n %, Lactic Acid:1.1 mmol/L, Albumin:2.7 g/dL, LDH:180 IU/L, Ca:8.3\n mg/dL, Mg:1.8 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 67M transferred from for seizures.\n Neurologic: negative MRI - seizures likely due to alcohol withdrawal\n +/- encephalopathy Dilantin 100 tid (goal 15-20), s/p\n MVI,thiamine,folate,\n Cardiovascular: sinus brady, EP: pacemaker once other issues resolved,\n external pacing and atropine prn, holding digoxin, troponin leak\n Pulmonary: succesfully extubated, aggressive pulmonary toilet\n Gastrointestinal / Abdomen: elevated TBili likely underlying\n cirrhosis\n Nutrition: TF to goal\n Renal: Cr OK, good UOP\n Hematology: pancytopenia likely ACD + nutritional + cirrhosis, does not\n have HIT per heme.\n Endocrine: ISS prn\n Infectious Disease: C 9.7, afebrile, now issue for now\n Lines / Tubes / Drains: ET PIV L subclav ,a line\n Wounds:\n Imaging:\n Fluids: NS\n Consults: Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 PM\n Prophylaxis:\n DVT: SQ UF Heparin\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": "2179-02-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 510601,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Pt. alert, conversant, napping on and off today. Poor short term\n memory. Pt. intermittently oriented to hospital, but never\n date. Pt. states reason is\nI passed out.\n Right pupil 1mm larger\n than left. Strengths equal but extremeties (especially lower) markedly\n weak. No drift noted. Speech ?slightly slurred, but he is missing his\n upper dentures. MRI over weekend suspicious for encephalitis ?HSV.\n Action:\n Pt. redirected and oriented as needed. IV Acyclovir Q8hrs.\n Response:\n Overall neuro assessment unchanged. No signs of withdrawal noted.\n Plan:\n Continue to monitor and treat as indicated. Transfer to 11.\n Bradycardia\n Assessment:\n SR in 80\ns this shift. BPS. No bradycardia or heart block noted.\n Action:\n External pacing pads remain on, atropine at bedside. Cardiology aware.\n Response:\n Pt. with stable heart rate and rhythm.\n Plan:\n Continue to closely monitor. EP/cards following.\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510602,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Pt. alert, conversant, napping on and off today. Poor short term\n memory. Pt. intermittently oriented to hospital, but never\n date. Pt. states reason is\nI passed out.\n Right pupil 1mm larger\n than left. Strengths equal but extremeties (especially lower) markedly\n weak. No drift noted. Speech ?slightly slurred, but he is missing his\n upper dentures. MRI over weekend suspicious for encephalitis ?HSV.\n Action:\n Pt. redirected and oriented as needed. IV Acyclovir Q8hrs.\n Response:\n Pt. slightly more appropriate with each exam. Getting closer to date,\n and aware of place. No signs of withdrawal noted.\n Plan:\n Continue to monitor and treat as indicated. Transfer to 11.\n Bradycardia\n Assessment:\n SR in 80\ns this shift. BPS. No bradycardia or heart block noted.\n Action:\n External pacing pads remain on, atropine at bedside. Cardiology aware.\n Response:\n Pt. with stable heart rate and rhythm.\n Plan:\n Continue to closely monitor. EP/cards following.\n"
},
{
"category": "Respiratory ",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 510252,
"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 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: 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: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: Pt appears comfortable on PS 5/5 FIO2 .50. Possible\n extubation in the AM.\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510661,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Patient is alert and oriented x , aware of self , confused with\n place , but says in the hospital inbetween, Moving all extremities,\n able to lift and hold, Pupils uneuqual, rt is bigger than left but both\n are reactive to light. Following commands, pleasant and co op with\n care.\n Action:\n Q4h neuron checks, SBP goal <160, hydralazine 10mg x 1 for SBP 170\n with effect, then lopressor 10mg indived dose per Dr. \n given, and started with po lopressor 25mg TID. Magnesium and K phos\n replaced with am lab\n Response:\n SBP <160 after IV lopressor, stable Vs, unchanged neuron status, no\n seizure activities.\n Plan:\n Cont ot monitor, pulm hygiene, neuron checks, SBP <160.\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 510740,
"text": "SICU\n HPI:\n 67M transferred from for seizures.\n Chief complaint:\n Seizures\n PMHx:\n Hypertension\n Congestive heart failure (20%EF)\n Coronary artery disease\n Alcohol cirrhosis\n Chronic renal insufficiency\n Peptic ulcer disease\n Depression\n Hypercholesterolemia\n Neck hematoma, rib and C7 transverse process fracture (MVA )\n Current medications:\n Acyclovir\n FoLIC Acid\n Furosemide\n Heparin\n HydrALAzine\n Insulin\n Levetiracetam\n Metoprolol Tartrate\n Pantoprazole\n Simvastatin\n Venlafaxine\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Acyclovir - 04:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:13 AM\n Hydralazine - 01:08 AM\n Other medications:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.1\nC (98.8\n HR: 87 (79 - 97) bpm\n BP: 162/64(89) {111/43(61) - 173/70(100)} mmHg\n RR: 26 (16 - 34) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115.8 kg (admission): 110 kg\n Height: 69 Inch\n Total In:\n 4,394 mL\n 845 mL\n PO:\n 1,160 mL\n Tube feeding:\n IV Fluid:\n 3,234 mL\n 845 mL\n Blood products:\n Total out:\n 2,280 mL\n 850 mL\n Urine:\n 1,980 mL\n 850 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 2,114 mL\n -5 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 77 K/uL\n 8.1 g/dL\n 102 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 8 mg/dL\n 111 mEq/L\n 140 mEq/L\n 24.7 %\n 3.3 K/uL\n [image002.jpg]\n 07:49 PM\n 01:46 AM\n 06:13 PM\n 08:09 PM\n 11:29 PM\n 03:01 AM\n 02:18 PM\n 06:00 PM\n 03:15 AM\n 02:02 AM\n WBC\n 3.3\n 2.6\n 2.8\n 3.3\n Hct\n 22.2\n 24.5\n 23.8\n 25.3\n 24.7\n Plt\n 71\n 61\n 82\n 77\n Creatinine\n 1.3\n 1.4\n 1.0\n 0.9\n 0.7\n 0.7\n TCO2\n 22\n 23\n Glucose\n 109\n 123\n 92\n 140\n 115\n 139\n 102\n Other labs: PT / PTT / INR:12.9/34.5/1.1, CK / CK-MB / Troponin\n T:176/5/0.12, ALT / AST:20/61, Alk-Phos / T bili:108/0.6,\n Differential-Neuts:60.0 %, Band:5.0 %, Lymph:27.1 %, Mono:9.2 %,\n Eos:3.4 %, Lactic Acid:1.1 mmol/L, Albumin:2.7 g/dL, LDH:180 IU/L,\n Ca:7.6 mg/dL, Mg:1.7 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 67M with seizures\n Neurologic: Neuro checks Q: 4 hr, On keppra for Seizure, s/p\n MVI,thiamine,folate\n Cardiovascular: sinus brady asymptomatic, EP: pacemaker once other\n issues resolved, external pacing and atropine prn, holding digoxin,\n troponin leak; Given metoprolol overnight for increasing rate and\n pressures\n Pulmonary: IS, succesfully extubated, aggressive pulmonary toilet\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet\n Renal: Foley, Adequate UO\n Hematology: Stable pancytopenia, WBC 3.3\n Endocrine: RISS\n Infectious Disease: WBC 2.8 ---> 3.3, afebrile, HSV encephalitis\n Lines / Tubes / Drains: Foley, PIV, L SCV TLC, A-line (D/C)\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: Seizure\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\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 Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 510765,
"text": ".H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Seizure, without status epilepticus\n Assessment:\n Pt. has not had any seizure activity recently. Continues on Kepra.\n Neurologically, pt is intact. He states he is more awake and clear\n today than recently. MAE, appropriate and cooperative. Pupils are not\n equal, this is well documented since arrival (this admission). Pt. is\n alert and oriented with slight coaching needed on place, may say he is\n at\n Hosp\n or . Denies pain,\nnever had any pain\n Action:\n Continues on Kepra. Monitor neuron signs as odered.\n Response:\n Stable neuro signs, intact. No seizure activity.\n Plan:\n Cont. to monitor. Cont Kepra\n Bradycardia\n Assessment:\n HR presently in the 80\ns, sinus, no ectopy noted. External pacer pads\n remain in place. Per SICU team, lopressor 25mg po was dc\nd this am and\n pt. was increased on hydralazine prn, 20mg q 6 hr as needed. SBP 140\n 160\ns, goal to keep below 160.\n Action:\n Given hydralazine 20 mg x 1 Monitored HR for changes.\n Response:\n HR remains stable, rate in the 80\ns, sinus. SBP dropped to 130\ns-140\n with hydralazine prn.\n Plan:\n Continue to monitor HR and BP. Meds as needed to keep SBP below 160.\n Maintain pacer pads to externally pace pt. if HR drops down. Cardiology\n to f/u on rhythm issues.\n Peripheral vascular disease (PVD) without critical limb ischemia\n Assessment:\n Pt. has peripheral edema to both legs (and arms). Legs are warm with\n peripheral pulses faintly palpable and easily dopplerable. Legs are\n both red in the calves, swelling as well. Brisk blanching of toes. Pt.\n is able to move legs around in bed without too much difficulty, he has\n not been out of bed as yet.\n Action:\n Monitor circulation to legs.\n Response:\n Adequate pulses to feet, warm\n Plan:\n Continue to monitor circulation to feet.\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 510768,
"text": ".H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Seizure, without status epilepticus\n Assessment:\n Pt. has not had any seizure activity recently. Continues on Kepra.\n Neurologically, pt is intact. He states he is more awake and clear\n today than recently. MAE, appropriate and cooperative. Pupils are not\n equal, this is well documented since arrival (this admission). Pt. is\n alert and oriented with slight coaching needed on place, may say he is\n at\n Hosp\n or . Denies pain,\nnever had any pain\n Action:\n Continues on Kepra. Monitor neuron signs as odered.\n Response:\n Stable neuro signs, intact. No seizure activity.\n Plan:\n Cont. to monitor. Cont Kepra\n Bradycardia\n Assessment:\n HR presently in the 80\ns, sinus, no ectopy noted. External pacer pads\n remain in place. Per SICU team, lopressor 25mg po was dc\nd this am and\n pt. was increased on hydralazine prn, 20mg q 6 hr as needed. SBP 140\n 160\ns, goal to keep below 160.\n Action:\n Given hydralazine 20 mg x 1 Monitored HR for changes.\n Response:\n HR remains stable, rate in the 80\ns, sinus. SBP dropped to 130\ns-140\n with hydralazine prn.\n Plan:\n Continue to monitor HR and BP. Meds as needed to keep SBP below 160.\n Maintain pacer pads to externally pace pt. if HR drops down. Cardiology\n to f/u on rhythm issues.\n Peripheral vascular disease (PVD) without critical limb ischemia\n Assessment:\n Pt. has peripheral edema to both legs (and arms). Legs are warm with\n peripheral pulses faintly palpable and easily dopplerable. Legs are\n both red in the calves, swelling as well. Brisk blanching of toes. Pt.\n is able to move legs around in bed without too much difficulty, he has\n not been out of bed as yet.\n Action:\n Monitor circulation to legs.\n Response:\n Adequate pulses to feet, warm\n Plan:\n Continue to monitor circulation to feet.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n FEVER;SEIZURE\n Code status:\n Full code\n Height:\n 69 Inch\n Admission weight:\n 110 kg\n Daily weight:\n 115.8 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia, ETOH, Renal Failure\n CV-PMH: CHF, Hypertension, MI\n Additional history:\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:47\n Temperature:\n 97.4\n Arterial BP:\n S:161\n D:61\n Respiratory rate:\n 23 insp/min\n Heart Rate:\n 75 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,744 mL\n 24h total out:\n 1,245 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:02 AM\n Potassium:\n 3.6 mEq/L\n 02:02 AM\n Chloride:\n 111 mEq/L\n 02:02 AM\n CO2:\n 21 mEq/L\n 02:02 AM\n BUN:\n 8 mg/dL\n 02:02 AM\n Creatinine:\n 0.7 mg/dL\n 02:02 AM\n Glucose:\n 102 mg/dL\n 02:02 AM\n Hematocrit:\n 24.7 %\n 02:02 AM\n Finger Stick Glucose:\n 115\n 10:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: Sicu B\n Transferred to: 1118\n Date & time of Transfer:\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510309,
"text": "Bradycardia; h/o seizure\n Assessment:\n Awake and alert at times. Oriented x self only. Follows\n commands. Often perseverates by repeating same answer to different\n questions. Discussed with neuro MD. No new orders received, but\n believes pt is encephalopathic. Afebrile. Neuro checks q 2 hours.\n Right pupil slightly larger than left. Brisk reaction noted.\n Extubated at , . Placed on 40% face tent. O2 sat\n maintained > 95%. Encouraged patient to CDB. Followed directions at\n times. Later transitioned patient to nasal cannula. O2 sat\n unchanged. ABG results repeated post extubation. Values within normal\n limits.\n Bradycardic at times with heart rhythm in 2^nd degree, type\n II block. Remains connected to defibrillator pads and lifepack.\n Atropine at bedside. HR fluctuating between 40s and 70s. SBP\n maintained throughout evening. UE pulses palpable. LE pulses weak,\n requiring doppler. Skin to as if to indicate a vascular\n issue.\n Abdomen soft, obese. Positive BS throughout abdomen. NPO\n at this time.\n Foley catheter draining clear yellow urine, >30cc/hr during\n shift.\n Skin with multiple breakdowns. See Metavision flowsheet for\n details.\n Plan:\n Pt awaiting permanent pacemaker placement. Monitor HR, SBP closely.\n Continue q 2 hr neuro checks until further notice.\n ------ Protected Section ------\n AM labs received. Repleted Mg. P and K repleted with 15mmol KPhos.\n 0.9 NaCl paused due to Na = 145 and Cl 115. Will discuss further with\n SICU MD.\n ------ Protected Section Addendum Entered By: , RN\n on: 05:41 ------\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510663,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Patient is alert and oriented x , aware of self , confused with\n place , but says in the hospital inbetween, Moving all extremities,\n able to lift and hold, Pupils uneuqual, rt is bigger than left but both\n are reactive to light. Following commands, pleasant and co op with\n care.\n Action:\n Q4h neuron checks, SBP goal <160, hydralazine 10mg x 1 for SBP 170\n with effect, then lopressor 10mg indived dose per Dr. \n given, and started with po lopressor 25mg TID. Magnesium and K phos\n replaced with am lab\n Response:\n SBP <160 after IV lopressor, stable Vs, unchanged neuron status, no\n seizure activities.\n Plan:\n Cont ot monitor, pulm hygiene, neuron checks, SBP <160.\n Bradycardia\n Assessment:\n H/o Brady cardia with pads intact.\n Action:\n No bardy cardia even after lopressor for HT, stable, atropine at bed\n side.\n Response:\n Cont to monitor, atropine at bed side\n Plan:\n Cont t monitor, follow up by cardiology.\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510664,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Patient is alert and oriented x , aware of self , confused with\n place , but says in the hospital inbetween, Moving all extremities,\n able to lift and hold, Pupils uneuqual, rt is bigger than left but both\n are reactive to light. Following commands, pleasant and co op with\n care.\n Action:\n Q4h neuron checks, SBP goal <160, hydralazine 10mg x 1 for SBP 170\n with effect, then lopressor 10mg indived dose per Dr. \n given, and started with po lopressor 25mg TID. Magnesium and K phos\n replaced with am lab\n Response:\n SBP <160 after IV lopressor, stable Vs, unchanged neuron status, no\n seizure activities.\n Plan:\n Cont ot monitor, pulm hygiene, neuron checks, SBP <160.\n Bradycardia\n Assessment:\n H/o Brady cardia with external pacing pads remains intact.\n Action:\n No brady cardia even after lopressor for HT, stable, atropine at bed\n side.\n Response:\n Cont to monitor, atropine at bed side\n Plan:\n Cont t monitor, follow up by cardiology.\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 509677,
"text": "A 67 year old amitted to the sicu after being found unresponsive by\n his neighbor. To , electiveley intubated.\n Valium ivgiven 2 liters of normal saline given. Head ct done results\n negative. Transferred to the , in the er 2 liters of normal saline\n given. Propofol gtt started. Started on vancomycin, aclycovir,\n cefetrioxone and ampilcillin. Iv. Lumbar punctiure done in the er and\n results stil pending. Droplet precautions initiated.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n temp 99.9\n Action:\n temp q4hrs.\n tedid bath given.\n Response:\n no temp tonite.\n Plan:\n monitor condition closely.\n Seizure, without status epilepticus\n Assessment:\n opens eyes to name. pupils #. reacts briskly.\n moves right and left arm off the bed\n moves left leg on the bed and no movement in right leg.\n as shift continued, patient more awake despite being on propofol gtt.\n no seizure activity noted\n Action:\n neuro signs q1hrs.\n propofol gtt infusing.\n on dilantin iv q 8hrs.\n Response:\n no seizure activity noted.\n Plan:\n monitor condition closely.\n Patient is eu critical . Unable to contact son as number is\n disconnected. Patient does live in an facility.\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 509693,
"text": "SICU\n HPI:\n 67yo man with complicated PMH including EtOH abuse, HTN, CAD and\n hyperchoesterolemia who was last seen normal 2 days ago but found in\n same sitting position per neighbor since yesterday. Patient reportedly\n had repeated seizure activity either en route or at \n requiring Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n On exam, patient is sedated and intubated but opens eyes to verbal\n stimuli and spontaneously moves L side anti-gravity. He does not follow\n commands. Although no obvious asymmetry in tone, patient does not move\n R as much as L and RLE does not move even to noxious stim. Also,\n although both reactive, R pupil slightly larger than L.\n Although limited hx and exam may be confounded by medications, given\n the hx of unresponsiveness with hemiparesis, concerning for posterior\n circulation pathology including basilar atery thrombosis hence will\n order STAT CTA of head and neck to rule out clot. LP given patient\n febrile and seized. Patient's current hemiparesis may be post-ictal\n () but seizure may have been secondary to vascular event as\n well.\n Chief complaint:\n Unresponsive/ seizures\n PMHx:\n PMH:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n Current medications:\n Active Medications EU CRITICAL,\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Acyclovir 5. Ampicillin 6.\n CeftriaXONE 7. Dextrose 50% 8. FoLIC Acid\n 9. Glucagon 10. Heparin 11. Insulin 12. Lorazepam 13. Metoprolol\n Tartrate 14. Omeprazole 15. Phenytoin Sodium (IV)\n 16. Pneumococcal Vac Polyvalent 17. Propofol 18. Simvastatin 19. Sodium\n Chloride 0.9% Flush 20. Thiamine\n 21. Vancomycin 22. Venlafaxine\n 24 Hour Events:\n INVASIVE VENTILATION - START 12:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Acyclovir - 04:28 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.7\nC (99.9\n HR: 67 (47 - 107) bpm\n BP: 113/42(58) {98/40(55) - 145/89(104)} mmHg\n RR: 15 (15 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 464 mL\n PO:\n Tube feeding:\n IV Fluid:\n 464 mL\n Blood products:\n Total out:\n 0 mL\n 285 mL\n Urine:\n 285 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 179 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): 136 (136 - 136) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.29/46/354//-4\n Ve: 12.6 L/min\n PaO2 / FiO2: 708\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n basal)\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished)\n Neurologic: Sedated, patient is sedated propofol and intubated but\n opens eyes to\n verbal stimuli and spontaneously moves L side anti-gravity. He\n does not follow commands. Although no obvious asymmetry in tone,\n patient does not move R as much as L and RLE does not move even\n to noxious stim. Also, although both reactive, R pupil slightly\n larger than L.\n Labs / Radiology\n 149 mg/dL\n 3.8 mEq/L\n 105 mEq/L\n 138 mEq/L\n 26\n [image002.jpg]\n 11:23 PM\n Hct\n 26\n TCO2\n 23\n Glucose\n 149\n Other labs: Lactic Acid:1.0 mmol/L\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT\n STATUS EPILEPTICUS\n Assessment and Plan:\n ASSESSMENT: patient is a 67 yo man with complicated PMH\n including EtOH abuse, HTN, CAD, CHF and hypercholesterolemia who was\n last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n Neurologic:\n patient is sedated propofol and intubated but opens eyes to\n verbal stimuli and spontaneously moves L side anti-gravity. He\n does not follow commands. Although no obvious asymmetry in tone,\n patient does not move R as much as L and RLE does not move even\n to noxious stim. Also, although both reactive, R pupil slightly\n larger than L.\n Given the hx of unresponsiveness with hemiparesis, concerning for\n posterior circulation pathology including basilar artery\n thrombosis STAT CTA of head and neck done: No evidence of basilar\n artery thrombus.\n LP DONE/febrile and seized. Patient's current hemiparesis may be\n post-ictal () but seizure may have been secondary to vascular\n event as well. CSF Preliminary RBCs in CSF.\n Continue Dilantin 100mg TID - would get a level plus albumin with goal\n corrected level between 15~20.\n EEG in the morning.\n IV thiamine and folate - would continue IV thiamine for at least 5\n days. Ketone level : trace.\n Cardiovascular: Metoprolol Simvastatin stable HD Continue home meds\n except for Ativan, Digoxin and Lasix. EF 20 %. Check Digoxin level.\n Keep Mag/K level repleted. Check Cardiac enzymes. Repeat Echo today.\n Has Bradycardic pauses.\n Pulmonary: Intubated for AW protection\n Gastrointestinal / Abdomen: NPO/ PPI\n Nutrition:\n Renal: Foley 30mls/hr\n Hematology: no issues\n Endocrine: ISS prn\n ID: WBC 9.7 vanco/ceftriaxone/acyclovir/ampicillin until CSF CX results\n available.\n Lines / Tubes / Drains: ET PIV: Needs A line.\n Imaging: CTA of head and neck No basilar artery thrombosis -\n Fluids: 75 mls /hr\n Consults:Neurology\n Billing Diagnosis:\n Prophylaxis:\n DVT: Hep sq. NO venodynes\n Stress ulcer:PPi\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 509821,
"text": "SICU\n HPI:\n Patient is a 67 yo man with complicated PMH\n including EtOH abuse, HTN, CAD and hypercholesterolemia who was\n last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n Chief complaint:\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n Current medications:\n 24 Hour Events:\n INVASIVE VENTILATION - START 12:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Acyclovir - 04:28 AM\n Ampicillin - 05:48 AM\n Vancomycin - 07:30 AM\n Infusions:\n Propofol - 35 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:30 AM\n Pantoprazole (Protonix) - 04:47 PM\n Other medications:\n Flowsheet Data as of 12:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.2\nC (99\n HR: 65 (37 - 107) bpm\n BP: 129/53(76) {111/45(-2) - 134/62(86)} mmHg\n RR: 18 (13 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 7,374 mL\n 21 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,074 mL\n 21 mL\n Blood products:\n Total out:\n 1,615 mL\n 0 mL\n Urine:\n 1,215 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 5,759 mL\n 21 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): 495 (136 - 495) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 15 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.30/46/198/22/-3\n Ve: 10 L/min\n PaO2 / FiO2: 396\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: sudden episodes of bradycardia\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Skin: bilateral lower extremity long standing erythematous skin changes\n Neurologic: Sedated\n Labs / Radiology\n 68 K/uL\n 7.4 g/dL\n 129 mg/dL\n 1.5 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 33 mg/dL\n 110 mEq/L\n 142 mEq/L\n 23.4 %\n 5.4 K/uL\n [image002.jpg]\n 11:23 PM\n 09:55 AM\n 04:39 PM\n 05:51 PM\n 09:51 PM\n WBC\n 6.4\n 5.4\n Hct\n 26\n 25.7\n 23.4\n Plt\n 75\n 68\n Creatinine\n 1.5\n 1.6\n 1.5\n Troponin T\n 0.12\n TCO2\n 23\n 24\n Glucose\n 149\n 157\n 147\n 129\n Other labs: PT / PTT / INR:13.7/32.6/1.2, CK / CK-MB / Troponin\n T:176/5/0.12, Lactic Acid:0.7 mmol/L, Albumin:2.9 g/dL, Ca:7.4 mg/dL,\n Mg:2.6 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n BRADYCARDIA, ELECTROLYTE & FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE,\n PERIPHERAL VASCULAR DISEASE (PVD) WITHOUT CRITICAL LIMB ISCHEMIA,\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT\n STATUS EPILEPTICUS\n Assessment and Plan: ASSESSMENT: patient is a 67 yo man with\n complicated PMH\n including EtOH abuse, HTN, CAD and hypercholesterolemia who was\n last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n Neurologic:\n patient is sedated propofol and intubated but opens eyes to\n verbal stimuli and spontaneously moves L side anti-gravity. He\n does not follow commands. Although no obvious asymmetry in tone,\n patient does not move R as much as L and RLE does not move even\n to noxious stim. Also, although both reactive, R pupil slightly\n larger than L.\n Given the hx of unresponsiveness with hemiparesis, concerning for\n posterior circulation pathology including basilar artery\n thrombosis STAT CTA of head and neck done: No evidence of basilar\n artery thrombus.\n LP DONE-negative.\n Patient's current hemiparesis may be post-ictal () but seizure\n may have been secondary to vascular event as well.\n Continue Dilantin 100mg TID - would get a level plus albumin with goal\n corrected level between 15~20.level : 13.4\n f/up EEG results.\n IV thiamine and folate - would continue IV thiamine for at least 5\n days.\n Cardiovascular:Sudden episodes of sinus brady.EP consulted-no\n indication of pacemaker/recommend repleting electrolytes.\n Metoprolol Simvastatin.( Ativan, Digoxin and Lasix- have been held)\n Troponin leak 0.26-0.12\n 2DE:LVEF>55%,mild pulm art systolic hypertension\n Pulmonary: Intubated for AW protection\n Gastrointestinal / Abdomen:soft\n Nutrition:NPO except meds\n Renal: Foley 30mls/hr\n Hematology: thrombocytopenia 75.hct 25.7\n Endocrine: ISS prn\n ID: WBC 9.7\n Lines / Tubes / Drains: ET PIV L subclav ,a line\n Imaging: CTA of head and neck No basilar artery thrombosis -\n Fluids: 75 mls /hr\n Consults:Neurology\n Billing Diagnosis:\n Prophylaxis:\n DVT: Hep sq. NO venodynes due to PVD\n Stress ulcer:PPi\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n Lines:\n 20 Gauge - 06:01 AM\n 22 Gauge - 06:02 AM\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 PM\n Total time spent: 35\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Intensivist Note",
"row_id": 509822,
"text": "SICU\n HPI:\n Patient is a 67 yo man with complicated PMH\n including EtOH abuse, HTN, CAD and hypercholesterolemia who was\n last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n Chief complaint:\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n Current medications:\n 24 Hour Events:\n INVASIVE VENTILATION - START 12:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Acyclovir - 04:28 AM\n Ampicillin - 05:48 AM\n Vancomycin - 07:30 AM\n Infusions:\n Propofol - 35 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:30 AM\n Pantoprazole (Protonix) - 04:47 PM\n Other medications:\n Flowsheet Data as of 12:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.2\nC (99\n HR: 65 (37 - 107) bpm\n BP: 129/53(76) {111/45(-2) - 134/62(86)} mmHg\n RR: 18 (13 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 69 Inch\n Total In:\n 7,374 mL\n 21 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,074 mL\n 21 mL\n Blood products:\n Total out:\n 1,615 mL\n 0 mL\n Urine:\n 1,215 mL\n NG:\n 300 mL\n Stool:\n Drains:\n Balance:\n 5,759 mL\n 21 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): 495 (136 - 495) mL\n PS : 10 cmH2O\n RR (Set): 22\n RR (Spontaneous): 27\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 15 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.30/46/198/22/-3\n Ve: 10 L/min\n PaO2 / FiO2: 396\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: sudden episodes of bradycardia\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft\n Skin: bilateral lower extremity long standing erythematous skin changes\n Neurologic: Sedated\n Labs / Radiology\n 68 K/uL\n 7.4 g/dL\n 129 mg/dL\n 1.5 mg/dL\n 22 mEq/L\n 3.9 mEq/L\n 33 mg/dL\n 110 mEq/L\n 142 mEq/L\n 23.4 %\n 5.4 K/uL\n [image002.jpg]\n 11:23 PM\n 09:55 AM\n 04:39 PM\n 05:51 PM\n 09:51 PM\n WBC\n 6.4\n 5.4\n Hct\n 26\n 25.7\n 23.4\n Plt\n 75\n 68\n Creatinine\n 1.5\n 1.6\n 1.5\n Troponin T\n 0.12\n TCO2\n 23\n 24\n Glucose\n 149\n 157\n 147\n 129\n Other labs: PT / PTT / INR:13.7/32.6/1.2, CK / CK-MB / Troponin\n T:176/5/0.12, Lactic Acid:0.7 mmol/L, Albumin:2.9 g/dL, Ca:7.4 mg/dL,\n Mg:2.6 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n BRADYCARDIA, ELECTROLYTE & FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE,\n PERIPHERAL VASCULAR DISEASE (PVD) WITHOUT CRITICAL LIMB ISCHEMIA,\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT\n STATUS EPILEPTICUS\n Assessment and Plan: ASSESSMENT: patient is a 67 yo man with\n complicated PMH\n including EtOH abuse, HTN, CAD and hypercholesterolemia who was\n last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n Neurologic:\n patient is sedated propofol and intubated but opens eyes to\n verbal stimuli and spontaneously moves L side anti-gravity. He\n does not follow commands. Although no obvious asymmetry in tone,\n patient does not move R as much as L and RLE does not move even\n to noxious stim. Also, although both reactive, R pupil slightly\n larger than L.\n Given the hx of unresponsiveness with hemiparesis, concerning for\n posterior circulation pathology including basilar artery\n thrombosis STAT CTA of head and neck done: No evidence of basilar\n artery thrombus.\n LP DONE-negative.\n Patient's current hemiparesis may be post-ictal () but seizure\n may have been secondary to vascular event as well.\n Continue Dilantin 100mg TID - would get a level plus albumin with goal\n corrected level between 15~20.level : 13.4\n f/up MRI\n f/up EEG results. Left hemisphere epileptiform activty\n IV thiamine and folate - would continue IV thiamine for at least 5\n days.\n Cardiovascular:Sudden episodes of sinus brady.EP consulted-no\n indication of pacemaker/recommend repleting electrolytes.\n Metoprolol Simvastatin.( Ativan, Digoxin and Lasix- have been held)\n Troponin leak 0.26-0.12\n 2DE:LVEF>55%,mild pulm art systolic hypertension\n Pulmonary: Intubated for AW protection\n Gastrointestinal / Abdomen:soft\n Nutrition:NPO except meds\n Renal: Foley 30mls/hr\n Hematology: thrombocytopenia 75.hct 25.7\n Endocrine: ISS prn\n ID: WBC 9.7\n Lines / Tubes / Drains: ET PIV L subclav ,a line\n Imaging: CTA of head and neck No basilar artery thrombosis -\n Fluids: 75 mls /hr\n Consults:Neurology\n Billing Diagnosis:\n Prophylaxis:\n DVT: Hep sq. NO venodynes due to PVD\n Stress ulcer:PPi\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n Lines:\n 20 Gauge - 06:01 AM\n 22 Gauge - 06:02 AM\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 PM\n Total time spent: 35\n"
},
{
"category": "Respiratory ",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 509760,
"text": "Demographics\n Day of mechanical ventilation: 1\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 Tube Type\n ETT:\n Position: 26 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: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Periodic SBT's for conditioning; Comments: Plan to extubate after MRI.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 509874,
"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 Tube Type\n ETT:\n Position: 24cm at teeth\n Route: po\n Type: Standard\n Size: 8mm\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: Clear\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Plan\n Next 24-48 hours: Wean if possible.\n Reason for continuing current ventilatory support: Pt unable to\n protect airway.\n AM\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 510571,
"text": "SICU\n HPI:\n 67M transferred from for seizures.\n Chief complaint:\n PMHx:\n PMH: HTN, CHF (20%EF), CAD, EtOH, Cirrhotic, CRI, PUD, depression,\n ^chol, neck hematoma, rib and C7 TP fx (MVA )\n PSH: CABG, THR (R),\n MEDS: Effexor 37.5',Lopressor 50'',Omeprazole 20',Ativan 1''',\n Simvastatin 20', Lasix 10'', Digoxin 0.125'\n Current medications:\n 24 Hour Events:\n EKG - At 02:42 PM\n dr. assessed ekg\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Acyclovir - 04:53 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:50 AM\n Hydralazine - 06:51 AM\n Other medications:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.2\nC (99\n HR: 85 (40 - 85) bpm\n BP: 167/65(94) {115/46(65) - 184/102(146)} mmHg\n RR: 27 (15 - 27) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 115.8 kg (admission): 110 kg\n Height: 69 Inch\n Total In:\n 3,273 mL\n 1,505 mL\n PO:\n 160 mL\n 400 mL\n Tube feeding:\n IV Fluid:\n 3,113 mL\n 1,105 mL\n Blood products:\n Total out:\n 2,960 mL\n 990 mL\n Urine:\n 2,960 mL\n 690 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 313 mL\n 515 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///21/\n Physical Examination\n Labs / Radiology\n 82 K/uL\n 8.3 g/dL\n 139 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 112 mEq/L\n 141 mEq/L\n 25.3 %\n 2.8 K/uL\n [image002.jpg]\n 03:58 PM\n 07:49 PM\n 01:46 AM\n 06:13 PM\n 08:09 PM\n 11:29 PM\n 03:01 AM\n 02:18 PM\n 06:00 PM\n 03:15 AM\n WBC\n 3.3\n 2.6\n 2.8\n Hct\n 22.2\n 24.5\n 23.8\n 25.3\n Plt\n 71\n 61\n 82\n Creatinine\n 1.4\n 1.3\n 1.4\n 1.0\n 0.9\n 0.7\n TCO2\n 22\n 23\n Glucose\n 109\n 109\n 123\n 92\n 140\n 115\n 139\n Other labs: PT / PTT / INR:13.7/32.6/1.2, CK / CK-MB / Troponin\n T:176/5/0.12, ALT / AST:20/61, Alk-Phos / T bili:108/0.6,\n Differential-Neuts:60.0 %, Band:5.0 %, Lymph:27.1 %, Mono:9.2 %,\n Eos:3.4 %, Lactic Acid:1.1 mmol/L, Albumin:2.7 g/dL, LDH:180 IU/L,\n Ca:7.5 mg/dL, Mg:1.6 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 67M w/ likely HSV encephalitis\n Neurologic: On keppra for Seizure, s/p MVI,thiamine,folate,\n CVS: sinus brady asymptomatic, EP: pacemaker once other issues\n resolved, external pacing and atropine prn, holding digoxin, troponin\n leak\n Pulm: succesfully extubated, aggressive pulmonary toilet\n GI: no follow, elevated TBili likely underlying cirrhosis, will\n follow\n Nutrition: ADAT\n Renal: Cr OK, good UOP\n Hematology: pancytopenia likely ACD + nutritional + cirrhosis, does not\n have HIT per heme. GCSF if WBC 1 in am\n Endocrine: ISS prn\n ID: WBC 2, afebrile, now issue for now\n Fluids: NS 75 mls /hr\n Consults:Neurology\n Billing Diagnosis:\n Prophylaxis:\n DVT: Hep sq. NO venodynes due to PVD\n Stress ulcer:PPI\n VAP bundle: +\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 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:\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Intensivist Note",
"row_id": 510697,
"text": "SICU\n HPI:\n 67M transferred from for seizures.\n Chief complaint:\n Seizures\n PMHx:\n Hypertension\n Congestive heart failure (20%EF)\n Coronary artery disease\n Alcohol cirrhosis\n Chronic renal insufficiency\n Peptic ulcer disease\n Depression\n Hypercholesterolemia\n Neck hematoma, rib and C7 transverse process fracture (MVA )\n Current medications:\n Acyclovir\n FoLIC Acid\n Furosemide\n Heparin\n HydrALAzine\n Insulin\n Levetiracetam\n Metoprolol Tartrate\n Pantoprazole\n Simvastatin\n Venlafaxine\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Acyclovir - 04:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:13 AM\n Hydralazine - 01:08 AM\n Other medications:\n Flowsheet Data as of 06:30 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 37.1\nC (98.8\n HR: 87 (79 - 97) bpm\n BP: 162/64(89) {111/43(61) - 173/70(100)} mmHg\n RR: 26 (16 - 34) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115.8 kg (admission): 110 kg\n Height: 69 Inch\n Total In:\n 4,394 mL\n 845 mL\n PO:\n 1,160 mL\n Tube feeding:\n IV Fluid:\n 3,234 mL\n 845 mL\n Blood products:\n Total out:\n 2,280 mL\n 850 mL\n Urine:\n 1,980 mL\n 850 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 2,114 mL\n -5 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 77 K/uL\n 8.1 g/dL\n 102 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 3.6 mEq/L\n 8 mg/dL\n 111 mEq/L\n 140 mEq/L\n 24.7 %\n 3.3 K/uL\n [image002.jpg]\n 07:49 PM\n 01:46 AM\n 06:13 PM\n 08:09 PM\n 11:29 PM\n 03:01 AM\n 02:18 PM\n 06:00 PM\n 03:15 AM\n 02:02 AM\n WBC\n 3.3\n 2.6\n 2.8\n 3.3\n Hct\n 22.2\n 24.5\n 23.8\n 25.3\n 24.7\n Plt\n 71\n 61\n 82\n 77\n Creatinine\n 1.3\n 1.4\n 1.0\n 0.9\n 0.7\n 0.7\n TCO2\n 22\n 23\n Glucose\n 109\n 123\n 92\n 140\n 115\n 139\n 102\n Other labs: PT / PTT / INR:12.9/34.5/1.1, CK / CK-MB / Troponin\n T:176/5/0.12, ALT / AST:20/61, Alk-Phos / T bili:108/0.6,\n Differential-Neuts:60.0 %, Band:5.0 %, Lymph:27.1 %, Mono:9.2 %,\n Eos:3.4 %, Lactic Acid:1.1 mmol/L, Albumin:2.7 g/dL, LDH:180 IU/L,\n Ca:7.6 mg/dL, Mg:1.7 mg/dL, PO4:1.7 mg/dL\n Assessment and Plan\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 67M with seizures\n Neurologic: Neuro checks Q: 4 hr, On keppra for Seizure, s/p\n MVI,thiamine,folate\n Cardiovascular: Beta-blocker, sinus brady asymptomatic, EP: pacemaker\n once other issues resolved, external pacing and atropine prn, holding\n digoxin, troponin leak; Given metoprolol overnight for increasing rate\n and pressures\n Pulmonary: IS, succesfully extubated, aggressive pulmonary toilet\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet\n Renal: Foley, Adequate UO\n Hematology: Stable pancytopenia, WBC 3.3\n Endocrine: RISS\n Infectious Disease: WBC 2.8 ---> 3.3, afebrile, no issue for now\n Lines / Tubes / Drains: Foley, PIV, L SCV TLC, A-line\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: Seizure\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\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 Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 510361,
"text": "SICU\n HPI:\n 67M transferred from for seizures.\n Chief complaint:\n seizures\n PMHx:\n PMH: HTN, CHF (20%EF), CAD, EtOH, Cirrhotic, CRI, PUD, depression,\n ^chol, neck hematoma, rib and C7 TP fx (MVA )\n PSH: CABG, THR (R),\n MEDS: Effexor 37.5',Lopressor 50'',Omeprazole 20',Ativan 1''',\n Simvastatin 20', Lasix 10'', Digoxin 0.125'\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:21 PM\n EEG - At 06:09 PM\n INVASIVE VENTILATION - STOP 08:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:01 AM\n Heparin Sodium (Prophylaxis) - 11:31 PM\n Other medications:\n Flowsheet Data as of 05:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.9\nC (98.5\n HR: 65 (41 - 73) bpm\n BP: 126/51(76) {108/43(63) - 156/98(110)} mmHg\n RR: 14 (12 - 25) insp/min\n SPO2: 100%\n Heart rhythm: 2nd AV W-M1 (Second degree AV Block Wenckebach - Mobitz1)\n Wgt (current): 115.8 kg (admission): 110 kg\n Height: 69 Inch\n Total In:\n 3,121 mL\n 541 mL\n PO:\n Tube feeding:\n 505 mL\n IV Fluid:\n 2,616 mL\n 541 mL\n Blood products:\n Total out:\n 1,823 mL\n 480 mL\n Urine:\n 1,823 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,298 mL\n 61 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 505 (490 - 590) mL\n PS : 5 cmH2O\n RR (Spontaneous): 40\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 28\n PIP: 6 cmH2O\n SPO2: 100%\n ABG: 7.38/38/92./23/-1\n Ve: 5 L/min\n PaO2 / FiO2: 186\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 61 K/uL\n 7.5 g/dL\n 92 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 18 mg/dL\n 115 mEq/L\n 145 mEq/L\n 23.8 %\n 2.6 K/uL\n [image002.jpg]\n 02:12 AM\n 09:43 AM\n 02:50 PM\n 03:58 PM\n 07:49 PM\n 01:46 AM\n 06:13 PM\n 08:09 PM\n 11:29 PM\n 03:01 AM\n WBC\n 5.4\n 3.3\n 2.6\n Hct\n 24.0\n 22.2\n 24.5\n 23.8\n Plt\n 77\n 71\n 61\n Creatinine\n 1.5\n 1.4\n 1.4\n 1.3\n 1.4\n 1.0\n TCO2\n 20\n 22\n 23\n Glucose\n 119\n 107\n 109\n 109\n 123\n 92\n Other labs: PT / PTT / INR:13.7/32.6/1.2, CK / CK-MB / Troponin\n T:176/5/0.12, ALT / AST:20/61, Alk-Phos / T bili:108/0.6,\n Differential-Neuts:89.0 %, Band:5.0 %, Lymph:3.0 %, Mono:3.0 %, Eos:0.0\n %, Lactic Acid:1.1 mmol/L, Albumin:2.7 g/dL, LDH:180 IU/L, Ca:8.3\n mg/dL, Mg:1.8 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 67M transferred from for seizures.\n Neurologic:AAOx3, negative MRI - seizures likely due to alcohol\n withdrawal +/- encephalopathy (possible herpetic encephalitis). Seizure\n controlled with Keppra. Received thiamine, cyonacobalamine and folate.\n Cardiovascular: HD stable despite sinus brady. EP consulted\n possible\n pacemaker placement in the near future. Avoid nodal agents (hold\n digoxin). Tropnin leak resolving.\n Pulmonary: Extubated. ISS\n Gastrointestinal / Abdomen: Guaiac positive still but stable Hct. LFT\n normal and synthetic function of liver seems intact\n Nutrition: Po intake\n Renal: AUOP\n Hematology: Multiple etiologies pancytopenia but liver cirrhosis and/or\n viral infection. Hematology consult in chart. Unlikely to have HIT but\n panel is still pending.\n Endocrine: ISS prn\n Infectious Disease: Possible herpetic encephalitis. Start acyclovir (?)\n and isolation precaution (?). ID to be invovled.\n Lines / Tubes / Drains: ET PIV L subclav ,a line\n Fluids: NS\n Consults: Neurology\n Billing Diagnosis: encapholopathy\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Communication: Comments:\n Code status: full\n Disposition: sicu\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510692,
"text": "67M transferred from for seizures\n .H/O seizure, without status epilepticus\n Assessment:\n Patient is alert and oriented x , aware of self , confused with\n place , but says in the hospital inbetween, Moving all extremities,\n able to lift and hold, Pupils unequal, rt is bigger than left but both\n are reactive to light. Following commands, pleasant and co op with\n care.\n Action:\n Q4h neuron checks, SBP goal <160, hydralazine 10mg x 1 for SBP 170\n with effect, then lopressor 10mg in divided dose per Dr. \n given, and started with po lopressor 25mg TID. Magnesium and K phos\n replaced with am lab\n Response:\n SBP <160 after IV lopressor, stable Vs, unchanged neuron status, no\n seizure activities.\n Plan:\n Cont ot monitor, pulm hygiene, neuron checks, SBP <160.\n Bradycardia\n Assessment:\n H/o Brady cardia with external pacing pads remains intact.\n Action:\n No brady cardia even after lopressor for HT, stable, atropine at bed\n side.\n Response:\n Cont to monitor, atropine at bed side\n Plan:\n Cont t monitor, follow up by cardiology.\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Intensivist Note",
"row_id": 509650,
"text": "SICU\n HPI:\n 67yo man with complicated PMH including EtOH abuse, HTN, CAD and\n hyperchoesterolemia who was last seen normal 2 days ago but found in\n same sitting position per neighbor since yesterday. Patient reportedly\n had repeated seizure activity either en route or at \n requiring Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n On exam, patient is sedated and intubated but opens eyes to verbal\n stimuli and spontaneously moves L side anti-gravity. He does not follow\n commands. Although no obvious asymmetry in tone, patient does not move\n R as much as L and RLE does not move even to noxious stim. Also,\n although both reactive, R pupil slightly larger than L.\n Although limited hx and exam may be confounded by medications, given\n the hx of unresponsiveness with hemiparesis, concerning for posterior\n circulation pathology including basilar atery thrombosis hence will\n order STAT CTA of head and neck to rule out clot. LP given patient\n febrile and seized. Patient's current hemiparesis may be post-ictal\n () but seizure may have been secondary to vascular event as\n well.\n Chief complaint:\n Unresponsive/ seizures\n PMHx:\n PMH:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n Current medications:\n Active Medications EU CRITICAL,\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Acyclovir 5. Ampicillin 6.\n CeftriaXONE 7. Dextrose 50% 8. FoLIC Acid\n 9. Glucagon 10. Heparin 11. Insulin 12. Lorazepam 13. Metoprolol\n Tartrate 14. Omeprazole 15. Phenytoin Sodium (IV)\n 16. Pneumococcal Vac Polyvalent 17. Propofol 18. Simvastatin 19. Sodium\n Chloride 0.9% Flush 20. Thiamine\n 21. Vancomycin 22. Venlafaxine\n 24 Hour Events:\n INVASIVE VENTILATION - START 12:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Acyclovir - 04:28 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.7\nC (99.9\n T current: 37.7\nC (99.9\n HR: 67 (47 - 107) bpm\n BP: 113/42(58) {98/40(55) - 145/89(104)} mmHg\n RR: 15 (15 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 464 mL\n PO:\n Tube feeding:\n IV Fluid:\n 464 mL\n Blood products:\n Total out:\n 0 mL\n 285 mL\n Urine:\n 285 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 179 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): 136 (136 - 136) mL\n RR (Set): 22\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 126\n PIP: 26 cmH2O\n Plateau: 22 cmH2O\n Compliance: 29.4 cmH2O/mL\n SPO2: 100%\n ABG: 7.29/46/354//-4\n Ve: 12.6 L/min\n PaO2 / FiO2: 708\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n basal)\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished)\n Neurologic: Sedated, patient is sedated propofol and intubated but\n opens eyes to\n verbal stimuli and spontaneously moves L side anti-gravity. He\n does not follow commands. Although no obvious asymmetry in tone,\n patient does not move R as much as L and RLE does not move even\n to noxious stim. Also, although both reactive, R pupil slightly\n larger than L.\n Labs / Radiology\n 149 mg/dL\n 3.8 mEq/L\n 105 mEq/L\n 138 mEq/L\n 26\n [image002.jpg]\n 11:23 PM\n Hct\n 26\n TCO2\n 23\n Glucose\n 149\n Other labs: Lactic Acid:1.0 mmol/L\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT\n STATUS EPILEPTICUS\n Assessment and Plan:\n ASSESSMENT: patient is a 67 yo man with complicated PMH\n including EtOH abuse, HTN, CAD and hypercholesterolemia who was\n last seen normal 2 days ago but found in same sitting position\n per neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiring\n Ativan then Valium then subsequently loaded with 2g of\n Fosphenytoin.\n Neurologic:\n patient is sedated propofol and intubated but opens eyes to\n verbal stimuli and spontaneously moves L side anti-gravity. He\n does not follow commands. Although no obvious asymmetry in tone,\n patient does not move R as much as L and RLE does not move even\n to noxious stim. Also, although both reactive, R pupil slightly\n larger than L.\n Given the hx of unresponsiveness with hemiparesis, concerning for\n posterior circulation pathology including basilar artery\n thrombosis STAT CTA of head and neck done: No evidence of basilar\n artery thrombus.\n LP DONE/febrile and seized. Patient's current hemiparesis may be\n post-ictal () but seizure may have been secondary to vascular\n event as well.\n Continue Dilantin 100mg TID - would get a level plus albumin with goal\n corrected level between 15~20.\n EEG in the morning.\n IV thiamine and folate - would continue IV thiamine for at least 5\n days.\n Cardiovascular: Metoprolol Simvastatin stable HD Continue home meds\n except for Ativan, Digoxin and Lasix.\n Pulmonary: Intubated for AW protection\n Gastrointestinal / Abdomen: NPO ppi\n Nutrition:\n Renal: Foley 30mls/hr\n Hematology: no issues\n Endocrine: ISS prn\n ID: WBC 9.7 vanco/ceftriaxone/acyclovir/ampicillin until CSF result\n available.\n Lines / Tubes / Drains: ET PIV\n Imaging: CTA of head and neck No basilar artery thrombosis -\n Fluids: 75 mls /hr\n Consults:Neurology\n Billing Diagnosis:\n Prophylaxis:\n DVT: Hep sq NO venodynes\n Stress ulcer:PPi\n VAP bundle: +\n Comments:\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 509651,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510289,
"text": "Bradycardia; h/o seizure\n Assessment:\n Awake and alert at times. Oriented x self only. Follows\n commands. Often perseverates by repeating same answer to different\n questions. Discussed with neuro MD. No new orders received, but\n believes pt is encephalopathic. Afebrile. Neuro checks q 2 hours.\n Right pupil slightly larger than left. Brisk reaction noted.\n Extubated at , . Placed on 40% face tent. O2 sat\n maintained > 95%. Encouraged patient to CDB. Followed directions at\n times. Later transitioned patient to nasal cannula. O2 sat\n unchanged. ABG results repeated post extubation. Values within normal\n limits.\n Bradycardic at times with heart rhythm in 2^nd degree, type\n II block. Remains connected to defibrillator pads and lifepack.\n Atropine at bedside. HR fluctuating between 40s and 70s. SBP\n maintained throughout evening. UE pulses palpable. LE pulses weak,\n requiring doppler. Skin to as if to indicate a vascular\n issue.\n Abdomen soft, obese. Positive BS throughout abdomen. NPO\n at this time.\n Foley catheter draining clear yellow urine, >30cc/hr during\n shift.\n Skin with multiple breakdowns. See Metavision flowsheet for\n details.\n Plan:\n Pt awaiting permanent pacemaker placement. Monitor HR, SBP closely.\n Continue q 2 hr neuro checks until further notice.\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 510562,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Pt. alert, conversant, napping on and off today. Poor short term\n memory. Pt. intermittently oriented to hospital, but never\n date. Pt. states reason is\nI passed out.\n Right pupil 1mm larger\n than left. Strengths equal but extremeties (especially lower) markedly\n weak. No drift noted. Speech ?slightly slurred, but he is missing his\n upper dentures. MRI over weekend suspicious for encephalitis ?HSV.\n Action:\n Pt. redirected and oriented as needed. IV Acyclovir Q8hrs.\n Response:\n Overall neuro assessment unchanged. No signs of withdrawal noted.\n Plan:\n Continue to monitor and treat as indicated. Transfer to 11.\n Bradycardia\n Assessment:\n SR in 80\ns this shift. BPS.\n Action:\n External pacing pads remain on\n Response:\n Plan:\n Continue to monitor\n ? pacer placement\n ? hydralazine\n"
},
{
"category": "Nutrition",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 510565,
"text": "Subjective: patient asleep, RN, patient has refused to eat today\n so far.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 110 kg\n 115.8 kg ( 02:00 AM)\n 35.7\n Pertinent medications: Folic Acid, RISS, PRotonix, lasix, CaGluc, KCl,\n Mag, and K PHos repletions, others noted\n Labs:\n Value\n Date\n Glucose\n 139 mg/dL\n 03:15 AM\n Glucose Finger Stick\n 165\n 10:00 AM\n BUN\n 11 mg/dL\n 03:15 AM\n Creatinine\n 0.7 mg/dL\n 03:15 AM\n Sodium\n 141 mEq/L\n 03:15 AM\n Potassium\n 4.0 mEq/L\n 03:15 AM\n Chloride\n 112 mEq/L\n 03:15 AM\n TCO2\n 21 mEq/L\n 03:15 AM\n PO2 (arterial)\n 92. mm Hg\n 11:29 PM\n PCO2 (arterial)\n 38 mm Hg\n 11:29 PM\n pH (arterial)\n 7.38 units\n 11:29 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 11:29 PM\n Albumin\n 2.7 g/dL\n 09:43 AM\n Calcium non-ionized\n 7.5 mg/dL\n 03:15 AM\n Phosphorus\n 1.9 mg/dL\n 03:15 AM\n Ionized Calcium\n 1.10 mmol/L\n 02:50 PM\n Magnesium\n 1.6 mg/dL\n 03:15 AM\n ALT\n 20 IU/L\n 09:43 AM\n Alkaline Phosphate\n 108 IU/L\n 09:43 AM\n AST\n 61 IU/L\n 09:43 AM\n Total Bilirubin\n 0.6 mg/dL\n 01:46 AM\n Triglyceride\n 197 mg/dL\n 01:46 AM\n Phenytoin (Dilantin)\n 12.0 ug/mL\n 02:12 AM\n WBC\n 2.8 K/uL\n 03:15 AM\n Hgb\n 8.3 g/dL\n 03:15 AM\n Hematocrit\n 25.3 %\n 03:15 AM\n Granulocyte count\n 1670 #/uL\n 03:15 AM\n Current diet order / nutrition support: Diet: Regular\n Assessment of Nutritional Status\n 67 year old Male w/ likely HSV encephalitis, now extubated. Patient\n received tube feeds while intubated, but these have been discontinued\n and patient\ns diet was advanced to regular. RN, patient has no\n appetite and has not eaten yet today. Patient is alert to self, but is\n confused otherwise. Will follow up with po intake and tolerance.\n Continue with lyte repletions as you are. Recommend starting patient\n on a multivitamin.\n Following - #\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Intensivist Note",
"row_id": 510358,
"text": "SICU\n HPI:\n 67M transferred from for seizures.\n Chief complaint:\n seizures\n PMHx:\n PMH: HTN, CHF (20%EF), CAD, EtOH, Cirrhotic, CRI, PUD, depression,\n ^chol, neck hematoma, rib and C7 TP fx (MVA )\n PSH: CABG, THR (R),\n MEDS: Effexor 37.5',Lopressor 50'',Omeprazole 20',Ativan 1''',\n Simvastatin 20', Lasix 10'', Digoxin 0.125'\n 24 Hour Events:\n MAGNETIC RESONANCE IMAGING - At 12:21 PM\n EEG - At 06:09 PM\n INVASIVE VENTILATION - STOP 08:30 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 09:01 AM\n Heparin Sodium (Prophylaxis) - 11:31 PM\n Other medications:\n Flowsheet Data as of 05:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.9\nC (98.5\n HR: 65 (41 - 73) bpm\n BP: 126/51(76) {108/43(63) - 156/98(110)} mmHg\n RR: 14 (12 - 25) insp/min\n SPO2: 100%\n Heart rhythm: 2nd AV W-M1 (Second degree AV Block Wenckebach - Mobitz1)\n Wgt (current): 115.8 kg (admission): 110 kg\n Height: 69 Inch\n Total In:\n 3,121 mL\n 541 mL\n PO:\n Tube feeding:\n 505 mL\n IV Fluid:\n 2,616 mL\n 541 mL\n Blood products:\n Total out:\n 1,823 mL\n 480 mL\n Urine:\n 1,823 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,298 mL\n 61 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 505 (490 - 590) mL\n PS : 5 cmH2O\n RR (Spontaneous): 40\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 28\n PIP: 6 cmH2O\n SPO2: 100%\n ABG: 7.38/38/92./23/-1\n Ve: 5 L/min\n PaO2 / FiO2: 186\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 1), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 61 K/uL\n 7.5 g/dL\n 92 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 18 mg/dL\n 115 mEq/L\n 145 mEq/L\n 23.8 %\n 2.6 K/uL\n [image002.jpg]\n 02:12 AM\n 09:43 AM\n 02:50 PM\n 03:58 PM\n 07:49 PM\n 01:46 AM\n 06:13 PM\n 08:09 PM\n 11:29 PM\n 03:01 AM\n WBC\n 5.4\n 3.3\n 2.6\n Hct\n 24.0\n 22.2\n 24.5\n 23.8\n Plt\n 77\n 71\n 61\n Creatinine\n 1.5\n 1.4\n 1.4\n 1.3\n 1.4\n 1.0\n TCO2\n 20\n 22\n 23\n Glucose\n 119\n 107\n 109\n 109\n 123\n 92\n Other labs: PT / PTT / INR:13.7/32.6/1.2, CK / CK-MB / Troponin\n T:176/5/0.12, ALT / AST:20/61, Alk-Phos / T bili:108/0.6,\n Differential-Neuts:89.0 %, Band:5.0 %, Lymph:3.0 %, Mono:3.0 %, Eos:0.0\n %, Lactic Acid:1.1 mmol/L, Albumin:2.7 g/dL, LDH:180 IU/L, Ca:8.3\n mg/dL, Mg:1.8 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 67M transferred from for seizures.\n Neurologic:AAOx3, negative MRI - seizures likely due to alcohol\n withdrawal +/- encephalopathy (possible herpetic encephalitis). Seizure\n controlled with Keppra. Received thiamine, cyonacobalamine and folate.\n Cardiovascular: HD stable despite sinus brady. EP consulted\n possible\n pacemaker placement in the near future. Avoid nodal agents (hold\n digoxin). Tropnin leak resolving.\n Pulmonary: Extubated. ISS\n Gastrointestinal / Abdomen: Guaiac positive still but stable Hct. LFT\n normal and synthetic function of liver seems intact\n Nutrition: Po intake\n Renal: AUOP\n Hematology: Multiple etiologies pancytopenia but liver cirrhosis and/or\n viral infection. Hematology consult in chart. Unlikely to have HIT but\n panel is still pending.\n Endocrine: ISS prn\n Infectious Disease: Possible herpetic encephalitis. Start acyclovir (?)\n and isolation precaution (?). ID to be invovled.\n Lines / Tubes / Drains: ET PIV L subclav ,a line\n Fluids: NS\n Consults: Neurology\n Billing Diagnosis: encapholopathy\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Communication: Comments:\n Code status: full\n Disposition: sicu\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-15 00:00:00.000",
"description": "EP Note",
"row_id": 510554,
"text": "History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: Tele: no pauses for last 24 hours\n that triggered, HR in the 75-90, wide complex RBBB, ? wenckebach.\n Feels better today.\n Medications\n Unchanged\n Physical Exam\n General appearance: NAD\n BP: 124 / 44 mmHg\n HR: 88 bpm\n Tmax C last 24 hours: 37.2 C\n Tmax F last 24 hours: F\n T current C: 36.8 C\n T current F: 98.2 F\n Previous day:\n Weight: 115.8 kg\n Intake: 3,271 mL\n Output: 2,960 mL\n Fluid balance: 311 mL\n Today:\n Intake: 2,614 mL\n Output: 1,750 mL\n Fluid balance: 864 mL\n Cardiovascular: (Auscultation: RRR)\n Labs\n 82\n 8.3\n 139\n 0.7\n 21\n 4.0\n 11\n 112\n 141\n 25.3\n 2.8\n [image002.jpg]\n 09:43 AM\n 03:58 PM\n 07:49 PM\n 01:46 AM\n 06:13 PM\n 11:29 PM\n 03:01 AM\n 02:18 PM\n 06:00 PM\n 03:15 AM\n WBC\n 3.3\n 2.6\n 2.8\n Hgb\n 7.0\n 7.5\n 8.3\n Hct (Serum)\n 22.2\n 24.5\n 23.8\n 25.3\n Plt\n 71\n 61\n 82\n Na+\n 143\n 144\n 144\n 143\n 145\n 142\n 141\n K + (Serum)\n 3.8\n 4.2\n 4.3\n 4.2\n 3.9\n 3.8\n 4.0\n Cl\n 111\n 114\n 113\n 114\n 115\n 113\n 112\n HCO3\n 21\n 21\n 20\n 22\n 23\n 21\n 21\n BUN\n 33\n 32\n 31\n 29\n 18\n 14\n 11\n Creatinine\n 1.4\n 1.4\n 1.3\n 1.4\n 1.0\n 0.9\n 0.7\n Glucose\n 107\n 109\n 109\n 123\n 92\n 140\n 115\n 139\n O2 sat (arterial)\n 97\n ABG: / / / 21 / Values as of 03:15 AM\n Tests\n ECG: (Date: ), rate 80, RBBB, LAFB, ? sinus or atrial ectopic\n with WB.\n Assessment and Plan\n BRADYCARDIA - no significant pauses last 24 hours. Electrolytes\n repleted. Will continue to monitor for now until patient gets to\n floor. consider EP study to look at conduction system +/- PPM once\n patient is on floor and getting ready for discharge. Pt states he is\n willing to followup with physicians if a ppm is needed.\n ELECTROLYTE & FLUID DISORDER, OTHER\n H/O ALCOHOL ABUSE\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510449,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Right pupil 5mm and briskly and left pupil 4mm briskly\n reactive to light\n Oriented to self and at times year\n Pt able to lift and hold arms off bed\n Pt at times perseverates\n Pt able to lift legs off bed\n Pt follows commands\n Continues to keepra\n No seizures noted\n EEG leads discontinued\n MRI suspicious for encephalitis ? HSV\n Action:\n Pt started on Acyliovir\n Response:\n Pt extubated\n Nuero signs every 2hours\n Plan:\n Continue to monitor\n Check neuro signs as ordered\n Acyliovir as ordered\n Bradycardia\n Assessment:\n Pt remain in 1^st AVB\n Pt had transient eposides of hr ot 30\ns-40\ns, pt asymtomatic\n Sbp greater than 180\n Action:\n External pacing pads remain on\n Response:\n Plan:\n Continue to monitor\n ? pacer placement\n ? hydralazine\n ------ Protected Section ------\n Add k 3.8 pt treated with 20meq kcl, Mg 1.9 treated with 2gm of mag.\n sulfate\n ------ Protected Section Addendum Entered By: , RN\n on: 19:51 ------\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Intensivist Note",
"row_id": 510538,
"text": "SICU\n HPI:\n 67M transferred from for seizures.\n Chief complaint:\n PMHx:\n PMH: HTN, CHF (20%EF), CAD, EtOH, Cirrhotic, CRI, PUD, depression,\n ^chol, neck hematoma, rib and C7 TP fx (MVA )\n PSH: CABG, THR (R),\n MEDS: Effexor 37.5',Lopressor 50'',Omeprazole 20',Ativan 1''',\n Simvastatin 20', Lasix 10'', Digoxin 0.125'\n Current medications:\n 24 Hour Events:\n EKG - At 02:42 PM\n dr. assessed ekg\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Acyclovir - 04:53 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:50 AM\n Hydralazine - 06:51 AM\n Other medications:\n Flowsheet Data as of 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 37.2\nC (99\n HR: 85 (40 - 85) bpm\n BP: 167/65(94) {115/46(65) - 184/102(146)} mmHg\n RR: 27 (15 - 27) insp/min\n SPO2: 98%\n Heart rhythm: 1st AV (First degree AV Block)\n Wgt (current): 115.8 kg (admission): 110 kg\n Height: 69 Inch\n Total In:\n 3,273 mL\n 1,505 mL\n PO:\n 160 mL\n 400 mL\n Tube feeding:\n IV Fluid:\n 3,113 mL\n 1,105 mL\n Blood products:\n Total out:\n 2,960 mL\n 990 mL\n Urine:\n 2,960 mL\n 690 mL\n NG:\n Stool:\n 300 mL\n Drains:\n Balance:\n 313 mL\n 515 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///21/\n Physical Examination\n Labs / Radiology\n 82 K/uL\n 8.3 g/dL\n 139 mg/dL\n 0.7 mg/dL\n 21 mEq/L\n 4.0 mEq/L\n 11 mg/dL\n 112 mEq/L\n 141 mEq/L\n 25.3 %\n 2.8 K/uL\n [image002.jpg]\n 03:58 PM\n 07:49 PM\n 01:46 AM\n 06:13 PM\n 08:09 PM\n 11:29 PM\n 03:01 AM\n 02:18 PM\n 06:00 PM\n 03:15 AM\n WBC\n 3.3\n 2.6\n 2.8\n Hct\n 22.2\n 24.5\n 23.8\n 25.3\n Plt\n 71\n 61\n 82\n Creatinine\n 1.4\n 1.3\n 1.4\n 1.0\n 0.9\n 0.7\n TCO2\n 22\n 23\n Glucose\n 109\n 109\n 123\n 92\n 140\n 115\n 139\n Other labs: PT / PTT / INR:13.7/32.6/1.2, CK / CK-MB / Troponin\n T:176/5/0.12, ALT / AST:20/61, Alk-Phos / T bili:108/0.6,\n Differential-Neuts:60.0 %, Band:5.0 %, Lymph:27.1 %, Mono:9.2 %,\n Eos:3.4 %, Lactic Acid:1.1 mmol/L, Albumin:2.7 g/dL, LDH:180 IU/L,\n Ca:7.5 mg/dL, Mg:1.6 mg/dL, PO4:1.9 mg/dL\n Assessment and Plan\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 67M w/ likely HSV encephalitis\n Neurologic: On keppra for Seizure, s/p MVI,thiamine,folate,\n CVS: sinus brady asymptomatic, EP: pacemaker once other issues\n resolved, external pacing and atropine prn, holding digoxin, troponin\n leak\n Pulm: succesfully extubated, aggressive pulmonary toilet\n GI: no follow, elevated TBili likely underlying cirrhosis, will\n follow\n Nutrition: ADAT\n Renal: Cr OK, good UOP\n Hematology: pancytopenia likely ACD + nutritional + cirrhosis, does not\n have HIT per heme. GCSF if WBC 1 in am\n Endocrine: ISS prn\n ID: WBC 2, afebrile, now issue for now\n Fluids: NS 75 mls /hr\n Consults:Neurology\n Billing Diagnosis:\n Prophylaxis:\n DVT: Hep sq. NO venodynes due to PVD\n Stress ulcer:PPI\n VAP bundle: +\n Communication:Comments:\n Code status:FULL\n Disposition:SICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 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:\n Disposition:\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510031,
"text": "Bradycardia\n Assessment:\n Heart rate into the low 30\ns, sinus bradycardia. Rate 30\ns to 64 sinus\n rhythm.\n Action:\n Sicu team notified and aware. Cardiology consult ordered and done.\n Response:\n Hr continues to brady into the 30\ns, at times sbp decreasing in\n tandem. Sicu team and cardiology notified.\n Plan:\n Continue close cardiac monitor and assessment. Keep atropine at\n bedside.\n Seizure, without status epilepticus\n Assessment:\n Pt sedated on propofol at 35mcg/kg/hr. Pt easy to awaken on this\n dose. Opens eyes to voice. Pupils unequal but briskly reactive. At\n times spontaneous movement noted upper extremities. Pt withdraws all\n four limbs to nailbed stimulus. Pt does not follow commands.\n Action:\n Frequent neuro exam done, every hour. EEG done, discontinued this\n afternoon. Pt started on md\ns orders.\n Response:\n No seizures noted this shift, neuro exam unchanged.\n Plan:\n Continue close neuro assessment. Monitor for seizure activity.\n Monitor anti seizure drug levels. Maintain pt safety.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt consistently hypokalemic, hypocalcemic and with low phosphate level.\n Action:\n Frequent labs done to check electrolyte levels, Lytes replaced as\n appropriate and as ordered.\n Response:\n Potassium and phosphate levels within nl limits. Calcium presently\n being replaced.\n Plan:\n Continue serial labs. Replete lytes as needed.\n"
},
{
"category": "Respiratory ",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 509634,
"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 Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 26 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 28 cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n 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: Periodic SBT's for conditioning\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 509792,
"text": "Bradycardia\n Assessment:\n HR variable throughout am - > pt. brady to 40 and then up to 60-80s w/o\n interventions or pattern. SBP stable in 90s-110 despite low HR. As day\n progressed, pt\ns HR consistently in low 40s and as low as 38. No change\n in SBP. Frequent PACs/PVCs.\n Action:\n EKG done, cards consulted, lytes aggressively repleted, pacing pads in\n place on pt.\n Response:\n Bradycardia persists, ? sick sinus syndrome per cards/ICU team.\n Plan:\n Cont. to monitor, recheck lytes and keep Mag/Calcium/KCL repleted, call\n cards for further ?s.\n Seizure, without status epilepticus\n Assessment:\n No seizures noted. Arousable to voice on Propofol gtt, moving UEs\n purposefully, moving LLE on bed, not moving RLE. Following commands\n intermittently. PERRLA 2-3mm and brisk. Tones stiff at times,\n difficult to move extremities.\n Action:\n EEG done this am, hooked up to 24 hour set-up. Dilantin given a/o.\n Aline/central lines placed.\n Response:\n No seizure activity today, pt. beginning to wake up a bit on less\n Propofol gtt, following commands, no s/sx ETOH withdrawal at this time.\n Plan:\n Cont. to monitor, 24 hour EEG, close neuro eval, ? need for MRI in\n future.\n"
},
{
"category": "Nutrition",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 509716,
"text": "Subjective\n Intub/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 175 cm\n 110 kg\n 35.7\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 72.6 kg\n 138%\n 79 kg\n not available\n Diagnosis: FEVER; SEIZURE\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n Food allergies and intolerances: not available\n Pertinent medications: Propofol, Insulin SC, Phenytoin Sodium,\n Pantoprazole, Thiamine, FoLIC Acid, Heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 157 mg/dL\n 09:55 AM\n Glucose Finger Stick\n 171\n 10:00 AM\n BUN\n 31 mg/dL\n 09:55 AM\n Creatinine\n 1.5 mg/dL\n 09:55 AM\n Sodium\n 142 mEq/L\n 09:55 AM\n Potassium\n 3.3 mEq/L\n 09:55 AM\n Chloride\n 108 mEq/L\n 09:55 AM\n TCO2\n 22 mEq/L\n 09:55 AM\n PO2 (arterial)\n 354 mm Hg\n 11:23 PM\n PCO2 (arterial)\n 46 mm Hg\n 11:23 PM\n pH (arterial)\n 7.29 units\n 11:23 PM\n CO2 (Calc) arterial\n 23 mEq/L\n 11:23 PM\n Albumin\n 2.9 g/dL\n 09:55 AM\n Calcium non-ionized\n 6.9 mg/dL\n 09:55 AM\n Phosphorus\n 3.0 mg/dL\n 09:55 AM\n Ionized Calcium\n 1.00 mmol/L\n 11:23 PM\n Magnesium\n 1.5 mg/dL\n 09:55 AM\n Phenytoin (Dilantin)\n 13.4 ug/mL\n 09:55 AM\n WBC\n 6.4 K/uL\n 09:55 AM\n Hgb\n 8.0 g/dL\n 09:55 AM\n Hematocrit\n 25.7 %\n 09:55 AM\n Current diet order / nutrition support: NPO as Diet except Meds;\n GI: Abdominal: Soft, Non-distended, Bowel sounds present\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO\n Estimated Nutritional Needs\n Calories: 1738- (BEE x or / 22-25 cal/kg)\n Protein: 95-110 (1.2-1.4 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\n Specifics:\n 67 year old man who was last seen normal 2 days ago but found in same\n sitting position per neighbor since yesterday. Patient transferred from\n for continue neuro ICU monitoring. Patient is\n currently intub and sedated on Propofol, if unable to extub in the next\n 24-48 hours, consider tube feed as temporary nutrition support.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: Replete with Fiber goal\n 65ml/hr while patient is on Propofol ( 1560kcal/97g protein)\n Goal Tube Feed off Propofol will be: Replete with Fiber\n 80ml/hr (1920kcal/119g protein)\n Check chemistry 10 panel daily, replete prn\n BS management\n Other: \n"
},
{
"category": "Nursing",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510082,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Patient continues to be intubated and sedated on 35 mcg of propofol.\n Pupils 4-2 mm both equally and briskly reactive to light, right pupil\n 0.5 mm bigger than left at times, both briskly reactive. Able to\n withdraw to nailbed pressure with all extremities. Able to open eyes\n to voice and inconsistently follows commands, able to squeeze hand but\n does not let go, attempted to stick out tounge a couple times when\n asked during night.\n Action:\n Continued with q 1 hour neuro checks,\n Response:\n Neuro status unchanged,\n Plan:\n Continue to monitor, MRI in future?\n Bradycardia\n Assessment:\n Sinus brady 30\ns-60\n SBP 110\ns then down to SBP 90\ns when HR in the 30\n Action:\n Atropine kept at bedside,\n No intervention needed,\n Response:\n SBP did not go below 90\ns despite bradycardic to 30\n Plan:\n Continue to monitor,\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 510180,
"text": "SICU\n HPI:\n Patient is a 67 yo man with complicated PMH including EtOH abuse,\n HTN, CAD and hypercholesterolemia who was last seen normal 2 days ago\n but found in same sitting position per neighbor since yesterday.\n Patient reportedly had repeated seizure activity either en route or at\n requiring Ativan then Valium then subsequently loaded\n with 2g of Fosphenytoin.\n Chief complaint:\n Seizure, respiratory failure\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n .\n Current medications:\n 1. 1000 mL NS 2. Calcium Gluconate 3. Chlorhexidine Gluconate 0.12%\n Oral Rinse 4. Dextrose 50% 5. FoLIC Acid\n 6. Furosemide 7. Glucagon 8. Heparin 9. Insulin 10. LeVETiracetam 11.\n Magnesium Sulfate 12. Pantoprazole\n 13. Potassium Chloride 14. Propofol 15. Simvastatin 16. Thiamine 17.\n Venlafaxine\n 24 Hour Events:\n ULTRASOUND - At 04:00 PM\n bilat lower extremities\n : episode of Bradycardia to low 30's and Low BP low 90's, Lines\n neg for DVT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Acyclovir - 04:28 AM\n Ampicillin - 05:48 AM\n Vancomycin - 07:30 AM\n Infusions:\n Propofol - 45 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications:\n Flowsheet Data as of 05:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 35.6\nC (96\n HR: 53 (35 - 63) bpm\n BP: 118/47(68) {91/41(56) - 132/54(78)} mmHg\n RR: 14 (12 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 114.2 kg (admission): 110 kg\n Height: 69 Inch\n Total In:\n 3,947 mL\n 843 mL\n PO:\n Tube feeding:\n 116 mL\n 194 mL\n IV Fluid:\n 3,832 mL\n 649 mL\n Blood products:\n Total out:\n 1,220 mL\n 253 mL\n Urine:\n 1,010 mL\n 253 mL\n NG:\n 210 mL\n Stool:\n Drains:\n Balance:\n 2,727 mL\n 590 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 670 (380 - 780) mL\n PS : 10 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: 7.39/32/196/22/-4\n Ve: 8.6 L/min\n PaO2 / FiO2: 392\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), Sinus tachycardia and bradycardia\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Labs / Radiology\n 71 K/uL\n 7.0 g/dL\n 123 mg/dL\n 1.4 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 114 mEq/L\n 143 mEq/L\n 22.2 %\n 3.3 K/uL\n [image002.jpg]\n 09:55 AM\n 04:39 PM\n 05:51 PM\n 09:51 PM\n 02:12 AM\n 09:43 AM\n 02:50 PM\n 03:58 PM\n 07:49 PM\n 01:46 AM\n WBC\n 6.4\n 5.4\n 5.4\n 3.3\n Hct\n 25.7\n 23.4\n 24.0\n 22.2\n Plt\n 75\n 68\n 77\n 71\n Creatinine\n 1.5\n 1.6\n 1.5\n 1.5\n 1.4\n 1.4\n 1.3\n 1.4\n Troponin T\n 0.12\n TCO2\n 24\n 20\n Glucose\n 157\n 147\n 129\n 119\n 107\n 109\n 109\n 123\n Other labs: PT / PTT / INR:13.7/32.6/1.2, CK / CK-MB / Troponin\n T:176/5/0.12, ALT / AST:20/61, Alk-Phos / T bili:108/0.7,\n Differential-Neuts:89.0 %, Band:5.0 %, Lymph:3.0 %, Mono:3.0 %, Eos:0.0\n %, Lactic Acid:1.1 mmol/L, Albumin:2.7 g/dL, LDH:180 IU/L, Ca:8.2\n mg/dL, Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 67M W/ PMH including EtOH abuse, HTN, CAD and\n hypercholesterolemia who was found in same sitting position per\n neighbor for 24h. reportedly had repeated seizure activity\n with unknown etiology\n Neurologic: Sedated. Seizure are not likely to DT. We will send for MRI\n to assess for organic source of sezirue activity.\n Cardiovascular: Bradycardia with prolongation QT. Aggressive\n electrolyte. Hold digoxin for now. Check the levels tomorrow.\n Pulmonary: Intubated for AW protection wean off the vent as tolerated.\n Extubated after MRI if no structural abnormalities.\n Gastrointestinal / Abdomen: soft\n Nutrition: advance TF to goal. Hold for now.\n Renal: Foley 30mls/hr\n Hematology: thrombocytopenia 77.hct 24, f/UP HIT panel. Hematology\n consult.\n Endocrine: ISS prn BG at goal.\n Infectious Disease: WBC 9.7, afebrile, now issue for now\n Lines / Tubes / Drains: ET PIV L subclav ,a line\n Imaging: MRI to assess for structural abnormalities causing seizures.\n Fluids: NS, 75CC/H HLIV when po>300\n Consults: Neurology\n Billing Diagnosis: Seizure, (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete (Full) - 05:30 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:01 AM\n 22 Gauge - 06:02 AM\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510020,
"text": "Bradycardia\n Assessment:\n Heart rate into the low 30\ns, sinus bradycardia.\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510024,
"text": "Bradycardia\n Assessment:\n Heart rate into the low 30\ns, sinus bradycardia. Rate 30\ns to 64 sinus\n rhythm.\n Action:\n Sicu team notified and aware. Cardiology consult ordered and done.\n Response:\n Hr continues to brady into the 30\ns, at times sbp decreasing in\n tandem. Sicu team and cardiology notified.\n Plan:\n Continue close cardiac monitor and assessment. Keep atropine at\n bedside.\n Seizure, without status epilepticus\n Assessment:\n Pt sedated on propofol at 35mcg/kg/hr. Pt easy to awaken on this\n dose. Opens eyes to voice. Pupils unequal but briskly reactive. At\n times spontaneous movement noted upper extremities. Pt withdraws all\n four limbs to nailbed stimulus. Pt does not follow commands.\n Action:\n Frequent neuro exam done, every hour. EEG done, discontinued this\n afternoon. Pt started on md\ns orders.\n Response:\n No seizures noted this shift, neuro exam unchanged.\n Plan:\n Continue close neuro assessment. Monitor for seizure activity.\n Monitor anti seizure drug levels. Maintain pt safety.\n Electrolyte & fluid disorder, other\n Assessment:\n Pt consistently hypokalemic, hypocalcemic and with low phosphate level.\n Action:\n Frequent labs done to check electrolyte levels, Lytes replaced as\n appropriate and as ordered.\n Response:\n Potassium and phosphate levels within nl limits. Calcium presently\n being replaced.\n Plan:\n Continue serial labs. Replete lytes as needed.\n"
},
{
"category": "Physician ",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Intensivist Note",
"row_id": 510164,
"text": "SICU\n HPI:\n Patient is a 67 yo man with complicated PMH including EtOH abuse,\n HTN, CAD and hypercholesterolemia who was last seen normal 2 days ago\n but found in same sitting position per neighbor since yesterday.\n Patient reportedly had repeated seizure activity either en route or at\n requiring Ativan then Valium then subsequently loaded\n with 2g of Fosphenytoin.\n Chief complaint:\n Seizure, respiratory failure\n PMHx:\n 1. HTN\n 2. CHF - EF 20%\n 3. CAD s/p CABG\n 4. Ongoing EtOH abuse\n 5. Cirrhosis\n 6. Mild CRI\n 7. PUD\n 8. s/p total R hip replacement\n 9. hx of neck hematoma, rib fracture and C7 transverse process\n fracture from high speed MVA in \n 10. Depression\n 11. Hypercholesterolemia\n .\n Current medications:\n 1. 1000 mL NS 2. Calcium Gluconate 3. Chlorhexidine Gluconate 0.12%\n Oral Rinse 4. Dextrose 50% 5. FoLIC Acid\n 6. Furosemide 7. Glucagon 8. Heparin 9. Insulin 10. LeVETiracetam 11.\n Magnesium Sulfate 12. Pantoprazole\n 13. Potassium Chloride 14. Propofol 15. Simvastatin 16. Thiamine 17.\n Venlafaxine\n 24 Hour Events:\n ULTRASOUND - At 04:00 PM\n bilat lower extremities\n : episode of Bradycardia to low 30's and Low BP low 90's, Lines\n neg for DVT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ceftriaxone - 12:00 AM\n Acyclovir - 04:28 AM\n Ampicillin - 05:48 AM\n Vancomycin - 07:30 AM\n Infusions:\n Propofol - 45 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:49 PM\n Other medications:\n Flowsheet Data as of 05:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 35.6\nC (96\n HR: 53 (35 - 63) bpm\n BP: 118/47(68) {91/41(56) - 132/54(78)} mmHg\n RR: 14 (12 - 20) insp/min\n SPO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Wgt (current): 114.2 kg (admission): 110 kg\n Height: 69 Inch\n Total In:\n 3,947 mL\n 843 mL\n PO:\n Tube feeding:\n 116 mL\n 194 mL\n IV Fluid:\n 3,832 mL\n 649 mL\n Blood products:\n Total out:\n 1,220 mL\n 253 mL\n Urine:\n 1,010 mL\n 253 mL\n NG:\n 210 mL\n Stool:\n Drains:\n Balance:\n 2,727 mL\n 590 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 670 (380 - 780) mL\n PS : 10 cmH2O\n RR (Spontaneous): 11\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: 7.39/32/196/22/-4\n Ve: 8.6 L/min\n PaO2 / FiO2: 392\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), Sinus tachycardia and bradycardia\n Respiratory / Chest: (Breath Sounds: Crackles : Bilateral)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Labs / Radiology\n 71 K/uL\n 7.0 g/dL\n 123 mg/dL\n 1.4 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 114 mEq/L\n 143 mEq/L\n 22.2 %\n 3.3 K/uL\n [image002.jpg]\n 09:55 AM\n 04:39 PM\n 05:51 PM\n 09:51 PM\n 02:12 AM\n 09:43 AM\n 02:50 PM\n 03:58 PM\n 07:49 PM\n 01:46 AM\n WBC\n 6.4\n 5.4\n 5.4\n 3.3\n Hct\n 25.7\n 23.4\n 24.0\n 22.2\n Plt\n 75\n 68\n 77\n 71\n Creatinine\n 1.5\n 1.6\n 1.5\n 1.5\n 1.4\n 1.4\n 1.3\n 1.4\n Troponin T\n 0.12\n TCO2\n 24\n 20\n Glucose\n 157\n 147\n 129\n 119\n 107\n 109\n 109\n 123\n Other labs: PT / PTT / INR:13.7/32.6/1.2, CK / CK-MB / Troponin\n T:176/5/0.12, ALT / AST:20/61, Alk-Phos / T bili:108/0.7,\n Differential-Neuts:89.0 %, Band:5.0 %, Lymph:3.0 %, Mono:3.0 %, Eos:0.0\n %, Lactic Acid:1.1 mmol/L, Albumin:2.7 g/dL, LDH:180 IU/L, Ca:8.2\n mg/dL, Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n .H/O SEIZURE, WITHOUT STATUS EPILEPTICUS, BRADYCARDIA, ELECTROLYTE &\n FLUID DISORDER, OTHER, .H/O ALCOHOL ABUSE, PERIPHERAL VASCULAR DISEASE\n (PVD) WITHOUT CRITICAL LIMB ISCHEMIA, FEVER, UNKNOWN ORIGIN (FUO,\n HYPERTHERMIA, PYREXIA), SEIZURE, WITHOUT STATUS EPILEPTICUS\n Assessment and Plan: 67M W/ PMH including EtOH abuse, HTN, CAD and\n hypercholesterolemia who was found in same sitting position per\n neighbor for 24h. reportedly had repeated seizure activity\n with unknown etiology\n Neurologic: Sedated. Seizure are not likely to DT. We will send for MRI\n to assess for organic source of sezirue activity.\n Cardiovascular: Bradycardia with prolongation QT. Aggressive\n electrolyte. Hold digoxin for now. Check the levels tomorrow.\n Pulmonary: Intubated for AW protection wean off the vent as tolerated.\n Extubated after MRI if no structural abnormalities.\n Gastrointestinal / Abdomen: soft\n Nutrition: advance TF to goal. Hold for now.\n Renal: Foley 30mls/hr\n Hematology: thrombocytopenia 77.hct 24, f/UP HIT panel. Hematology\n consult.\n Endocrine: ISS prn BG at goal.\n Infectious Disease: WBC 9.7, afebrile, now issue for now\n Lines / Tubes / Drains: ET PIV L subclav ,a line\n Imaging: MRI to assess for structural abnormalities causing seizures.\n Fluids: NS, 75CC/H HLIV when po>300\n Consults: Neurology\n Billing Diagnosis: Seizure, (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete (Full) - 05:30 PM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:01 AM\n 22 Gauge - 06:02 AM\n Arterial Line - 02:32 PM\n Multi Lumen - 03:19 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510072,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Patient continues to be intubated and sedated on 35 mcg of propofol.\n Pupils 4-2 mm both equally and briskly reactive to light, right pupil\n .5 mm bigger than left at times, both briskly reactive. Able to\n withdraw to nailbed pressure with all extremities. Able to open eyes\n to voice and inconsistently follow commands, able to squeeze hand but\n does not let go, attempted to stick out tounge once during night.\n Action:\n Continued with q 1 hour neuro checks,\n Response:\n Neuro status unchanged,\n Plan:\n Continue to monitor, MRI in future?\n Bradycardia\n Assessment:\n Sinus brady 30\ns-60\n SBP 110\ns then down to SBP 90\ns when HR in the 30\n Action:\n Atropine kept at bedside,\n Response:\n Plan:\n Continue to monitor,\n"
},
{
"category": "Nursing",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510303,
"text": "Bradycardia; h/o seizure\n Assessment:\n Awake and alert at times. Oriented x self only. Follows\n commands. Often perseverates by repeating same answer to different\n questions. Discussed with neuro MD. No new orders received, but\n believes pt is encephalopathic. Afebrile. Neuro checks q 2 hours.\n Right pupil slightly larger than left. Brisk reaction noted.\n Extubated at , . Placed on 40% face tent. O2 sat\n maintained > 95%. Encouraged patient to CDB. Followed directions at\n times. Later transitioned patient to nasal cannula. O2 sat\n unchanged. ABG results repeated post extubation. Values within normal\n limits.\n Bradycardic at times with heart rhythm in 2^nd degree, type\n II block. Remains connected to defibrillator pads and lifepack.\n Atropine at bedside. HR fluctuating between 40s and 70s. SBP\n maintained throughout evening. UE pulses palpable. LE pulses weak,\n requiring doppler. Skin to as if to indicate a vascular\n issue.\n Abdomen soft, obese. Positive BS throughout abdomen. NPO\n at this time.\n Foley catheter draining clear yellow urine, >30cc/hr during\n shift.\n Skin with multiple breakdowns. See Metavision flowsheet for\n details.\n Plan:\n Pt awaiting permanent pacemaker placement. Monitor HR, SBP closely.\n Continue q 2 hr neuro checks until further notice.\n"
},
{
"category": "Respiratory ",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 510118,
"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 :\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: 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: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI=29\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": "2179-02-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 510390,
"text": ".H/O seizure, without status epilepticus\n Assessment:\n Right pupil 5mm and briskly and left pupil 4mm briskly\n reactive to light\n Oriented to self and at times year\n Pt able to lift and hold arms off bed\n Pt at times perseverates\n Pt able to lift legs off bed\n Pt follows commands\n Continues to keepra\n No seizures noted\n EEG leads discontinued\n MRI suspicious for encephalitis ? HSV\n Action:\n Pt started on Acyliovir\n Response:\n Pt extubated\n Nuero signs every 2hours\n Plan:\n Continue to monitor\n Check neuro signs as ordered\n Acyliovir as ordered\n Bradycardia\n Assessment:\n Pt remain in 2 degree avb block\n Pt asymptomatic\n Action:\n External pacing pads remain on\n Response:\n Plan:\n Continue to monitor\n ? pacer placement\n"
},
{
"category": "Echo",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Report",
"row_id": 77512,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Bradycardia.\nWeight (lb): 242\nBP (mm Hg): 102/38\nHR (bpm): 43\nStatus: Inpatient\nDate/Time: at 12:06\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. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\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. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Trivial\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild to\nmoderate [+] TR. Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Resting\nbradycardia (HR<60bpm).\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. Overall left\nventricular systolic function is normal (LVEF>55%). There is no ventricular\nseptal defect. Right ventricular chamber size and free wall motion are normal.\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. There is no mitral valve prolapse. Trivial mitral regurgitation is\nseen. The tricuspid valve leaflets are mildly thickened. There is mild\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2179-02-23 00:00:00.000",
"description": "Report",
"row_id": 188526,
"text": "Sinus rhythm with modest A-V conduction delay. Left atrial abnormality. Right\nbundle-branch block. Left anterior fascicular block. Anterolateral lead\nST-T wave changes are probably primary and are non-specific. Since the previous\ntracing of there is no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2179-02-22 00:00:00.000",
"description": "Report",
"row_id": 188527,
"text": "Sinus rhythm with modest A-V conduction delay. Left atrial abnormality. Right\nbundle-branch block. Left anterior fascicular block. Anterolateral lead\nST-T wave abnormalities are primary and are non-specific. Since the previous\ntracing of there is no significant change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2179-02-19 00:00:00.000",
"description": "Report",
"row_id": 188528,
"text": "Sinus rhythm. Left axis deviation. Right bundle-branch block with left\nanterior fascicular block. Non-specific ST-T wave changes. Compared to the\nprevious tracing there is no significant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Report",
"row_id": 188529,
"text": "Atrial fibrillation is now present. The QRS complex is still an\nintraventricular conduction defect with right bundle-branch block morphology\nand diffuse T wave abnormalities. Since the previous tracing of the\nQRS complex is more narrow. The axis remains leftward with an intraventricular\nconduction delay that is more right bundle-branch block. Diffuse T wave changes\nand ST segment changes are still present.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2179-02-10 00:00:00.000",
"description": "Report",
"row_id": 188745,
"text": "Sinus rhythm. Left atrial abnormality. Prolonged P-R interval with\nintra-atrial conduction delay. Right bundle-branch block. Left axis\ndeviation. Left anterior fascicular block. Possible left ventricular\nhypertrophy. No previous tracing available for comparison.\n\n"
},
{
"category": "ECG",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Report",
"row_id": 188743,
"text": "Mild baseline artifact in the standard leads. Normal sinus rhythm. Frontal\nplane axis minus 73 degrees. Complete right bundle-branch block with a\nQRS duration of 182 milliseconds. Poor R wave progression laterally.\nP-R interval prolongation of 210 milliseconds. Compared to the previous tracing\nof the patient has gone from atrial fibrillation to normal sinus rhythm\nwith marked left axis deviation, complete right bundle-branch block and\nprolonged A-V conduction. There are non-specific secondary ST-T wave changes.\nWithin the contraints of the baseline artifact in several of the leads,\non there appears to be no diagnostic interval change.\n\n"
},
{
"category": "ECG",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Report",
"row_id": 188744,
"text": "Sinus bradycardia. Marked intraventricular conduction defect with an incomplete\nright bundle-branch block appearance. Very prolonged Q-T interval that is\ndiffuse. Since the previous tracing of sinus bradycardia is more\nmarked. The QRS and Q-T intervals are more widened. Right bundle-branch block\nis less evident and there seems to be a loss of anterior forces. This is most\nconsistent with some sort of drug effect, possibly amiodarone, which should be\nconsidered.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1114404,
"text": " 7:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval tube placement and cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with fever, seizure, intubated for airway protection\n REASON FOR THIS EXAMINATION:\n eval tube placement and cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, seizure, intubated for airway protection.\n\n COMPARISON: None.\n\n SUPINE AP VIEW OF THE CHEST: Patient is status post median sternotomy and\n CABG. An endotracheal tube tip terminates approximately 3 cm from the carina.\n Low inspiratory lung volumes are present which accentuates the cardiac and\n mediastinal contours. The cardiac silhouette is likely moderately enlarged.\n The aorta appears tortuous. Patchy opacity within both lung bases likely\n reflects atelectasis. No large pleural effusion or pneumothorax.\n\n IMPRESSION: Bibasilar atelectasis. Low inspiratory lung volumes. Standard\n positioning of the endotracheal tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-19 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 1115654,
"text": " 4:18 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: HX OF LIVER DISEASE, ASSESS FOR SIGNS OF CIRRHOSIS\n Admitting Diagnosis: FEVER;SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with ? hx of cirrhosis and CAD, now w/ pancytopenia\n REASON FOR THIS EXAMINATION:\n assess for signs of Liver cirrhosis\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Liver ultrasound obtained on .\n\n HISTORY: A 67-year-old male with history of cirrhosis, presenting with\n pancytopenia, evaluate for liver disease.\n\n TECHNIQUE: Multiple static grayscale images of the abdomen were obtained and\n submitted for evaluation. Study is limited given patient's body habitus.\n\n FINDINGS: There is diffuse increased echogenicity of the liver. This is\n likely related fatty infiltration. No focal masses identified. Main portal\n vein is patent.\n\n The common duct measures 7 mm, which is within normal limits of size for\n patient's age. Gallbladder is unremarkable in appearance without gallbladder\n wall thickening, pericholecystic fluid, or gallstones.\n\n The pancreas is not visualized. The spleen is enlarged measuring 15.6 cm.\n\n The kidneys are partially visualized and there is no evidence of\n hydronephrosis.\n\n There is ascites.\n\n IMPRESSION:\n\n 1. Diffuse increased echogenicity of the liver is likely related to fatty\n infiltration. However, other forms of liver disease including fibrosis and\n cirrhosis are not excluded. Please clinically correlate.\n\n 2. Ascites and splenomegaly, suggestive of portal hypertension. However, the\n main portal vein does demonstrate hepatopetal flow.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-10 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 1114416,
"text": " 9:08 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: eval for clot in basilar artery\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with unresponsive episode and not moving right extremities\n REASON FOR THIS EXAMINATION:\n eval for clot in basilar artery\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DLrc WED 11:50 PM\n No evidence of basilar artery thrombus.\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: CTA head and neck with and without contrast.\n\n HISTORY: 67-year-old male, unresponsive and not moving extremities, to\n evaluate for clot in the basilar artery.\n\n TECHNIQUE: Multiplanar CTA of the head and neck was performed with and\n without intravenous contrast administration.\n\n COMPARISON: None.\n\n FINDINGS:\n\n NON-CONTRAST CT HEAD: Images are degraded by motion artifact. -white\n differentiation is preserved. The ventricles and cortical sulci are normal in\n size and configuration without evidence of mass effect or shift of the\n normally midline structures. There is no evidence of hemorrhage or acute\n territorial infarction. There is mucosal thickening involving both maxillary\n sinuses and several bilateral ethmoid air cells. No displaced facial bone\n fractures are identified.\n\n CTA HEAD:\n\n This study is technically limited secondary to poor bolus timing. The\n vertebral arteries are codominant and patent. The basilar artery is\n diminutive and patent. There is a fetal posterior circulation on the right.\n The right P1 segment is hypoplastic. There is dense atherosclerotic\n calcification of the cavernous internal carotid arteries without\n hemodynamically significant stenosis. The anterior and posterior\n communicating arteries are visualized. The internal carotid, anterior,\n middle, and posterior cerebral arteries are patent without evidence of\n hemodynamically significant stenosis, occlusion, aneurysm greater than 3 mm or\n arteriovenous malformation.\n\n CTA NECK: This study is technically limited secondary to poor bolus timing.\n There is dense atherosclerotic calcification of the aortic arch and at the\n origins of the great vessels without hemodynamically significant stenosis.\n There is dense atherosclerotic calcification at the origins of the vertebral\n arteries without hemodynamically significant stenosis. The paired vertebral\n arteries are normal in course and caliber without evidence of stenosis or\n (Over)\n\n 9:08 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: eval for clot in basilar artery\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n occlusion.\n\n There is dense atherosclerotic calcification involving the distal right common\n carotid artery extending into the internal and external carotid arteries\n without hemodynamically significant stenosis. There is dense atherosclerotic\n calcification involving the distal left common carotid artery extending into\n the internal and external carotid arteries with approximately 50-55% narrowing\n at the origin of the left internal carotid artery by NASCET criteria. The\n patient is intubated. The thyroid gland is homogeneous. There is biapical\n pleural scarring with atelectasis at the right apex.\n\n IMPRESSION:\n\n 1. Approximately 50-55% stenosis at the origin of the left internal carotid\n artery by NASCET criteria.\n\n 2. Technically limited study demonstrating patent intracranial arterial\n vasculature without evidence of aneurysm or high-grade stenosis.\n\n 3. No acute hemorrhage or infarction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-12 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 1114676,
"text": " 3:46 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: SWELLING BILATERALLY; DVT\n Admitting Diagnosis: FEVER;SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old man with unilateral leg swelling\n REASON FOR THIS EXAMINATION:\n DVT\n ______________________________________________________________________________\n WET READ: CXWc 5:04 PM\n No DVT either lower extremity. Calf veins not visualized.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man with unilateral leg swelling.\n\n COMPARISON: None.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale, color, and Doppler\n ultrasound was used to evaluate the bilateral common femoral, superficial\n femoral, popliteal and calf veins. Calf veins were not visualized on the\n left. On the right, only peroneal veins are visualized in the calf.\n\n Otherwise, the deep veins demonstrate normal compressibility, flow and\n augmentation bilaterally.\n\n Incidentally noted is extensive subcutaneous edema.\n\n IMPRESSION:\n 1. No DVT of either lower extremity. Please note, however, left-sided calf\n veins are not visualized.\n 2. Diffuse subcutaneous edema bilaterally.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-13 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1114755,
"text": " 11:16 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: evaluate for intracranial mass\n Admitting Diagnosis: FEVER;SEIZURE\n Contrast: MAGNEVIST Amt: 22\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with PLEDs r/o intracranial mass\n REASON FOR THIS EXAMINATION:\n evaluate for intracranial mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MR HEAD WITHOUT AND WITH CONTRAST, \n\n HISTORY: Rule out intracranial mass.\n\n Sagittal and axial short TR, short TE spin echo imaging was performed through\n the brain. After administration of 22 cc of Magnevist intravenous contrast,\n axial imaging was performed with , TR, long TE fast spin echo,\n gradient echo, diffusion, and short TR, short TE spin echo technique.\n Sagittal MP-RAGE imaging was performed and reformatted into axial and coronal\n orientations. Comparison to a head CT of .\n\n FINDINGS: There is no evidence of intracranial mass. There is a focal area\n of hyperintensity in the left posterior thalamus on the images. This\n area is hyperintense on the diffusion-weighted images and faintly hypointense\n on the diffusion coefficient maps. This most likely represents a small area\n of infarction. There is no abnormal enhancement after contrast\n administration. Images of the remainder of the brain are somewhat degraded by\n susceptibility artifacts at the skull base. However, no other abnormalities\n are detected.\n\n CONCLUSION: Probable subacute left posterior thalamic infarction. No other\n significant abnormalities are detected.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1116259,
"text": " 3:50 PM\n CHEST (PA & LAT) Clip # \n Reason: lead position\n Admitting Diagnosis: FEVER;SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with pacemaker implant\n REASON FOR THIS EXAMINATION:\n lead position\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: Pacemaker implant, check lead positions.\n\n FINDINGS: PA and lateral chest views were obtained with patient sitting\n upright position. Available for comparison is the next preceding portable\n chest examination of . Previously described findings related\n to bypass surgery are unaltered. The patient is now extubated. A permanent\n pacer in left anterior axillary position is now identified and seen to be\n connected to a dual intracavitary electrode system. Termination points of the\n electrodes compatible with right atrial appendage, as well as right\n ventricular cavity correspondingly. Observe that the right ventricular\n electrode is in a somewhat unusual position, as it points towards the upper\n portion of the interventricular septum, close to the right ventricular outflow\n tract. There is no evidence of any pneumothorax on either side. The\n pulmonary vasculature is not congested and the lateral and posterior pleural\n sinuses remain free. Patient's inability to elevate the left arm obscures to\n some degree, the cardiac area on the lateral view, however, the described\n positions of the electrodes can be identified quite readily.\n\n IMPRESSION: No pneumothorax following permanent pacer placement. Slightly\n unusual position of right ventricular electrode pointing towards the\n interventricular septum, close to the base of outflow tract. Otherwise\n unchanged cardiovascular status.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-19 00:00:00.000",
"description": "R HAND (AP & LAT) SOFT TISSUE RIGHT",
"row_id": 1115666,
"text": " 5:23 PM\n HAND (AP & LAT) SOFT TISSUE RIGHT Clip # \n Reason: assess Right thumb for signs of crystal arthropathy\n Admitting Diagnosis: FEVER;SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cirrhosis, concern for crystal arthropathy\n REASON FOR THIS EXAMINATION:\n assess Right thumb for signs of crystal arthropathy\n ______________________________________________________________________________\n WET READ: 7:09 PM\n Soft tissue swelling overlies the IP joint of the thumb. Again noted is a\n possible juxta-articular erosion in the proximal phalanx in this digit.\n Elsewhere, note is made of joint space narrowing and mild subluxation of the\n second MCP joint as well as mild vascular calcification.\n ______________________________________________________________________________\n FINAL REPORT\n HAND FILMS\n\n HISTORY: Cirrhosis, concern for crystal arthropathy in the right thumb.\n\n FINDINGS: There is soft tissue swelling, most marked about the right first\n interphalangeal joint. Some bony spurs are noted in this region with joint\n space narrowing and sclerosis, consistent with osteoarthritis.\n There is joint space narrowing and mild subluxation at the second metacarpal\n phalangeal joint.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1114706,
"text": " 3:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval interval change\n Admitting Diagnosis: FEVER;SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with seizure\n REASON FOR THIS EXAMINATION:\n Eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 67-year-old male with seizure. Evaluate for interval change.\n\n FINDINGS: Comparison is made to the previous study from .\n\n The left-sided central venous catheter, endotracheal tube are unchanged in\n position. Tip of the endotracheal tube is again 2.3 cm above the carina and\n could be pulled back 2-3 cm for more optimal placement. There is again seen\n patchy density at the lung bases which may represent atelectasis, however,\n this has improved slightly. There has been prominence of the pulmonary\n vascular markings suggestive of mild fluid overload. No pleural effusions are\n seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1114537,
"text": " 3:20 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p left subclavian triple lumen line placement.\n Admitting Diagnosis: FEVER;SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with seizure likely alcohol withdrawal, intubated.\n REASON FOR THIS EXAMINATION:\n s/p left subclavian triple lumen line placement.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST, \n\n INDICATION: Status post left subclavian triple-lumen central venous catheter\n placement.\n\n FINDINGS: Comparison made to , 19:27 hours. Left subclavian\n central venous catheter has been placed, tip visualized in the upper SVC.\n Endotracheal tube is unchanged, 2.3 cm above the carina. Cardiomediastinal\n contours are stable, with evidence of prior median sternotomy and CABG. Lung\n volumes remain low, accentuating the cardiac silhouette. Within these limits,\n cardiac contours appear unchanged. Patchy bibasilar opacities continue to\n likely represent atelectasis. There is no sizeable pleural effusion. There\n is no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-13 00:00:00.000",
"description": "SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING",
"row_id": 1114751,
"text": " 10:46 AM\n SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING; -76 BY SAME PHYSICIANClip # \n Reason: please evaluate for metal\n Admitting Diagnosis: FEVER;SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with urgent need for MRI\n REASON FOR THIS EXAMINATION:\n please evaluate for metal\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: evaluate for metallic density before MRI.\n\n FINDINGS:\n\n SKULL: AP and lateral views of the skull demonstrate no radiopaque foreign\n densities within the expected location of the orbits or intracranially. Dental\n fillings are seen. An endotracheal tube is identified.\n\n AP CHEST: There is an endotracheal tube whose tip is 3.8 cm above the carina\n appropriately sited. There is a nasogastric tube and a left-sided central\n venous catheter with the distal lead tip in the mid SVC. Median sternotomy\n wires are present. There is cardiomegaly. There is no pleural effusions or\n signs for overt pulmonary edema.\n\n AP ABDOMEN: Portion of the nasogastric tube and side port are seen. There\n are no metallic densities within the abdomen or pelvis. There are extensive\n degenerative changes of the lumbar spine.\n\n AP PELVIS: There is a right total hip arthroplasty, without hardware-related\n complications. The distal portion of the femoral stem is not included in the\n field of view. Degenerative changes of the left hip is also seen.\n\n IMPRESSION:\n 1. No metallic densities within the skull, chest, abdomen or pelvis to\n prevent the patient from having an MRI.\n 2. Cardiomegaly.\n 3. Degenerative changes of the lumbar spine.\n 4. Intact right total hip arthroplasty.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-18 00:00:00.000",
"description": "L HAND (AP & LAT) SOFT TISSUE LEFT",
"row_id": 1115501,
"text": " 7:09 PM\n HAND (AP & LAT) SOFT TISSUE LEFT Clip # \n Reason: pls assess for joint space widening, loss of normal architec\n Admitting Diagnosis: FEVER;SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with cirrhosis, stroke, CAD, now w/ red, hot, edematous left\n thumb\n REASON FOR THIS EXAMINATION:\n pls assess for joint space widening, loss of normal architecture.\n ______________________________________________________________________________\n WET READ: 8:44 PM\n Soft tissue swelling noted over the IP joint in the thumb. There is no\n underlying radio-opaque foreign body or osseous abnormalities.\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEWS OF LEFT HAND\n\n INDICATION: Cirrhosis, stroke, erythema of the left thumb, assess for joint\n space widening.\n\n COMPARISON: No prior hand radiographs are available for comparison.\n\n FINDINGS:\n\n There is degenerative change at the distal interphalangeal joints diffusely.\n There is mild degenerative change at the third metacarpophalangeal joint.\n There is moderate joint space narrowing at the interphalangeal joint of the\n left thumb. A possible juxta-articular erosion is seen at the radial aspect\n of the head of the proximal phalanx of the left thumb. There is evidence of\n soft tissue swelling at the left thumb, adjacent to the interphalangeal joint.\n Background vascular calcification is noted.\n\n IMPRESSION:\n\n 1. Degenerative changes as described above.\n\n 2. Soft tissue swelling adjacent to interphalangeal joint of the left thumb\n in addition to a possible juxta articular erosion. Given soft tissue swelling\n and possible erosion, gout should be considered.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-12 00:00:00.000",
"description": "PELVIS PORTABLE",
"row_id": 1114677,
"text": " 3:51 PM\n PELVIS PORTABLE Clip # \n Reason: Eval R hip hardwear\n Admitting Diagnosis: FEVER;SEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n patient is a 67 yo man with complicated PMH including EtOH abuse, HTN, CAD and\n hypercholesterolemia who was last seen normal 2 days ago but found in same\n sitting positionper neighbor since yesterday. Patient reportedly had repeated\n seizure activity either en route or at requiringAtivan then\n Valium then subsequently loaded with 2g ofFosphenytoin.\n REASON FOR THIS EXAMINATION:\n Eval R hip hardwear\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Altered mental status. Possible seizures.\n\n PELVIS:\n\n The film is somewhat underpenetrated. There is evidence of a right total hip\n replacement in a satisfactory position. No fracture is identified, though the\n upper portions of the pelvis are not adequately seen.\n\n IMPRESSION: No evidence of fracture. Limited film.\n\n\n"
}
] |
|
29,304 | 120,540 | MICU COURSE: 63 y/o female with COPD,diabetes, and h/o DVT is transfered from OSH after exploratory laparotomy for bile duct leak following cholecystectomy, also s/p left CVL placement with subsequent PTX s/p left chest tube placement, transferred here for to address continued bile duct leak. done and stent placed without difficulty. Patient electively intubated during procedure and successfully extubated. | - F/u OSH cx data - bowel meds PR PRN # Left PTX: s/p CVL placement and now with chest tube in place. - F/u OSH cx data - bowel meds PR PRN # Left PTX: s/p CVL placement and now with chest tube in place. hospital acquired (Procedure Related, Barotrauma) Assessment: resolved Action: Chest tube removed this pm by thoracic. Arterial Line - 08:30 PM Multi Lumen - 08:30 PM Prophylaxis: DVT: Pneumoboots Stress ulcer: PPI VAP: NA Comments: Communication: Comments: Code status: Full code Disposition: ICU ; may request transfer back to after ERCP # h/o DVT/PE: on coumadin as outpt; holding for now given procedure. # h/o DVT/PE: on coumadin as outpt; holding for now given procedure. Plan: Medicate with dilaudid ivp and. Arterial Line - 08:30 PM Multi Lumen - 08:30 PM Prophylaxis: DVT: Pneumoboots Stress ulcer: PPI VAP: NA Comments: Communication: Comments: Code status: Full code Disposition: ICU Arterial Line - 08:30 PM Multi Lumen - 08:30 PM Prophylaxis: DVT: Pneumoboots Stress ulcer: PPI VAP: NA Comments: Communication: Comments: Code status: Full code Disposition: ICU - wean O2 as torated - NEBS prn - solumedrol 20 mg IV q8H # h/o DVT/PE: on coumadin as outpt; holding for now given procedure. - wean O2 as torated - NEBS prn - solumedrol 20 mg IV q8H # h/o DVT/PE: on coumadin as outpt; holding for now given procedure. - Will obtain a repeat CXR and if stable with no ptx seen, pull her chest tube. - Will obtain a repeat CXR and if stable with no ptx seen, pull her chest tube. She was found to have significant ileus and ascites, and underwent exploratory laparotomy which showed a 2cm hole in the base of the cystic duct with 1 Liter bilious ascites. She was found to have significant ileus and ascites, and underwent exploratory laparotomy which showed a 2cm hole in the base of the cystic duct with 1 Liter bilious ascites. She was found to have significant ileus and ascites, and underwent exploratory laparotomy which showed a 2cm hole in the base of the cystic duct with 1 Liter bilious ascites. She was found to have significant ileus and ascites, and underwent exploratory laparotomy which showed a 2cm hole in the base of the cystic duct with 1 Liter bilious ascites. - wean O2 as torated - NEBS prn - solumedrol 20 mg IV q8H # h/o DVT/PE: on coumadin as outpt; holding for now given procedure. Arterial Line - 08:30 PM Multi Lumen - 08:30 PM Prophylaxis: DVT: Pneumoboots Stress ulcer: PPI VAP: NA Comments: Communication: Comments: Code status: Full code Disposition: ICU Arterial Line - 08:30 PM Multi Lumen - 08:30 PM Prophylaxis: DVT: Pneumoboots Stress ulcer: PPI VAP: NA Comments: Communication: Comments: Code status: Full code Disposition: ICU Lopressor 5 mg IV q2H PRN HR>120 9. Lopressor 5 mg IV q2H PRN HR>120 9. - wean O2 as torated - NEBS prn - solumedrol 20 mg IV q8H 4. h/o DVT/PE: on coumadin as outpt; holding for now - will hold for now; likely can restart after ERCP - hold off on heparin gtt for now since patient has wound, and considering central line placement 5. - wean O2 as torated - NEBS prn - solumedrol 20 mg IV q8H 4. h/o DVT/PE: on coumadin as outpt; holding for now - will hold for now; likely can restart after ERCP - hold off on heparin gtt for now since patient has wound, and considering central line placement 5. # h/o DVT/PE: on coumadin as outpt; holding for now given procedure. Ex lap 1/28/9 2mm defect in Cystic duct remnant sutured. She was found to have significant ileus and ascites, and underwent exploratory laparotomy which showed a 2cm hole in the base of the systic duct with 1 Liter bilious ascites. She was found to have significant ileus and ascites, and underwent exploratory laparotomy which showed a 2cm hole in the base of the systic duct with 1 Liter bilious ascites. - wean O2 as tolerated - NEBS prn - solumedrol 20 mg IV q8H, had been on for possible COPD exacerbation. She was found to have significant ileus and ascites, and underwent exploratory laparotomy which showed a 2cm hole in the base of the cystic duct with 1 Liter bilious ascites. Left PTX: s/p CVL placement and now with chest tube in place. Left PTX: s/p CVL placement and now with chest tube in place. Allergies: Celebrex (Oral) (Celecoxib) Hives; Zithromax (Oral) (Azithromycin) Unknown; Sulfa (Sulfonamides) Unknown; Last dose of Antibiotics: Vancomycin - 12:18 AM Metronidazole - 01:18 AM Infusions: Other ICU medications: Hydromorphone (Dilaudid) - 01:50 AM Other medications: Changes to medical and family history: Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 06:35 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 37.1C (98.7 Tcurrent: 36.9C (98.5 HR: 71 (71 - 89) bpm BP: 112/59(79) {105/56(76) - 175/82(116)} mmHg RR: 11 (10 - 20) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Total In: 74 mL 958 mL PO: TF: IVF: 74 mL 958 mL Blood products: Total out: 150 mL 540 mL Urine: 150 mL 430 mL NG: Stool: Drains: 110 mL Balance: -76 mL 418 mL Respiratory support O2 Delivery Device: High flow neb SpO2: 91% on FiO2 of 50% ABG: ///26/ Physical Examination General Appearance: Overweight / Obese, Anxious Eyes / Conjunctiva: PERRL Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Rhonchorous: diffuse), left sided chest tube in place, dressing C/D/I Abdominal: No(t) Non-tender, Distended, Tender: diffusely, particularly in RLQ, Obese, distended; tympanic to percussion. | 31 | [
{
"category": "Respiratory ",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 363237,
"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: Diagnostic lab\n Reason: Elective\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: 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: Unassisted spontaneous breathing\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt was admitted form the ERCP to unit intubated. Pt was placed on a\n vent weaned and extubated tol well. See respiratory page for more\n information.\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363157,
"text": "61 yo female with h/o DM2, COPD on home O2, h/o DVT/PE, transferred\n from . She underwent cholecystectomy on then\n represented to for abdominal pain. She was found to\n have significant ileus and ascites, and underwent exploratory\n laparotomy which showed a 2cm hole in the base of the cystic duct with\n 1 Liter bilious ascites. There was ischemic bowel with massive ileus\n and distention due to bile peritonitis. Her hospitalization was also\n complicated by a CVL placement with subsequent pneumothorax. A left\n sided chest tube was place, and also a right femoral line was placed.\n She is being transferred here for ERCP in AM to fix the continued bile\n leakage. Of note, she has been treated with vancomycin, metronidazole,\n and levofloxacin at for peritonitis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complained of severe abdominal incision pain upon arrival from\n OSH; given 0.5 mg of dilaudid IV x 2 with fair effect. BP increased to\n the 170\ns systolic when having pain. Received with bupivacaine 0.25% 6\n ml/hr SC infusion via onQ pump started in OR from OSH\n lines\n secured with tagaderm\n Action:\n Started on dilaudid PCA 0.25 mg dose with lock time of 6 min\n maximum\n dose of 1 mg/hr; educated on the use of PCA pump; surgery following\n patient\n abdominal dressing changed\n old sanguinous drainage noted.\n Response:\n Patient in so much pain after repositioning, started on PRN dilaudid\n 0.5 mg q2 hrs prior to turning; patient has many attempts compared to\n dose injected; RR > 8 breaths per minute; sleeping intermittently\n however when she awakens she is in so much pain\n Plan:\n Adjust pain medication\n add basal rate\n Pancreatitis, acute\n Assessment:\n s/p cholecystectomy, JP draining with bile; afebrile WBC 8.0\n Action:\n Continues on vancomycin, flagyl and levofloxacin IV; NPO for now\n started on D51/2NS at 75cc/hr\n Response:\n 80cc of bile from JP drain\n Plan:\n For ERCP in am to correct bile leak\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n s/p unplanned extubation\n came on 50% ventimask sats 87-88% shallow\n non-labored breathing when she came in; lung sounds clear, dim at bases\n no wheezing noted.\n Action:\n Switched to high flow neb 50% FiO2, started on methylprednisolone 20\n mgs Q8hrs, atrovent q6hrs\n Response:\n Sats ~ 92-93% at 50% FiO2; tolerating flat in bed for a short time\n Plan:\n titrate FiO2 to keep sats > 90%\n hospital acquired (Procedure Related, Barotrauma)\n Assessment:\n s/p LSC central line placement at the OSH, developed pneumothorax\n now\n with chest tube L anterior chest wall\n attached to water seal dry\n suction. Oscillating/ fluctuating\n no leak, no crepitus\n Action:\n Continuing assessment on going\n pleur vac changed\n Response:\n Dressing intact, small amount of serosanguious drainage\n Plan:\n ? IP consult\n Diabetes Mellitus (DM), Type II\n Assessment:\n History on IDDM, FS at FM 162\n Action:\n received 1 unit of humalog; kept NPO for procedure, started on D51/2 NS\n at 75cc/hr\n Response:\n No signs and symptoms of hypo or hyperglycemia\n Plan:\n Nutrition consult for TPN\n Received 40 mEq of KCl for K+ of 3.6 last night, am labs pending.\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363291,
"text": "61 yo female with h/o DM2, COPD on home O2, h/o DVT/PE, transferred\n from . She underwent cholecystectomy on then\n represented to for abdominal pain. She was found to\n have significant ileus and ascites, and underwent exploratory\n laparotomy which showed a 2cm hole in the base of the cystic duct with\n 1 Liter bilious ascites. There was ischemic bowel with massive ileus\n and distention due to bile peritonitis. Her hospitalization was also\n complicated by a CVL placement with subsequent pneumothorax. A left\n sided chest tube was place, and also a right femoral line was placed.\n She is being transferred here for ERCP in AM to fix the continued bile\n leakage. She has been treated with vancomycin, metronidazole, and\n levofloxacin at for peritonitis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Screams of pain upon waking up but falls asleep right after,\n intermittently complaining of pain incision site. Suture\n intact, incision no signs of infection.\n Action:\n Received diluadid mgs q2hrs but has been getting 1 mg q2hrs\n together with 0.5 mgs of Ativan IV\n Response:\n Slept well compared to yesterday, tolerating turning better than\n previous night.\n Plan:\n Continue present pain regimen\n Peritonitis, acute\n Assessment:\n s/p cholecystectomy, JP draining with bile; afebrile WBC 8.0 latest,\n s/p ERCP to correct bile leak\n Action:\n Continues on zosyn IV; NPO for now\n started on D51/2NS at 75cc/hr\n Response:\n 50cc of bile from JP drain, afebrile\n Plan:\n Continue to monitor\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n s/p extubation for ERCP - non-labored breathing , lung sounds clear,\n dim at bases\n no wheezing noted.\n Action:\n prednisone tapered, O2 titrated down as tolerated\n Response:\n Sats ~ 92-93% 2 lpm via nasal cannula; tolerating flat in bed for a\n short time\n Plan:\n titrate FiO2 to keep sats > 90%\n Diabetes Mellitus (DM), Type II\n Assessment:\n History on IDDM, FS at MN 164\n Action:\n received 2 unit of humalog; kept NPO for lethargy, continuous on D51/2\n NS at 75cc/hr\n Response:\n No signs and symptoms of hypo or hyperglycemia\n Plan:\n Nutrition consult for TPN\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363126,
"text": "61 yo female with h/o DM2, COPD on home O2, h/o DVT/PE, transferred\n from . She underwent cholecystectomy on then\n represented to for abdominal pain. She was found to\n have significant ileus and ascites, and underwent exploratory\n laparotomy which showed a 2cm hole in the base of the cystic duct with\n 1 Liter bilious ascites. There was ischemic bowel with massive ileus\n and distention due to bile peritonitis. Her hospitalization was also\n complicated by a CVL placement with subsequent pneumothorax. A left\n sided chest tube was place, and also a right femoral line was placed.\n She is being transferred here for ERCP in AM to fix the continued bile\n leakage. Of note, she has been treated with vancomycin, metronidazole,\n and levofloxacin at for peritonitis.\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363127,
"text": "61 yo female with h/o DM2, COPD on home O2, h/o DVT/PE, transferred\n from . She underwent cholecystectomy on then\n represented to for abdominal pain. She was found to\n have significant ileus and ascites, and underwent exploratory\n laparotomy which showed a 2cm hole in the base of the cystic duct with\n 1 Liter bilious ascites. There was ischemic bowel with massive ileus\n and distention due to bile peritonitis. Her hospitalization was also\n complicated by a CVL placement with subsequent pneumothorax. A left\n sided chest tube was place, and also a right femoral line was placed.\n She is being transferred here for ERCP in AM to fix the continued bile\n leakage. Of note, she has been treated with vancomycin, metronidazole,\n and levofloxacin at for peritonitis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complained of severe abdominal incision pain upon arrival from\n OSH; given 0.5 mg of dilaudid IV x 2 with fair effect. BP increased to\n the 170\ns systolic when having pain. Received with bupivacaine 0.25% 6\n ml/hr SC infusion via onQ pump started in OR from OSH\n lines\n secured with tagaderm\n Action:\n Started on dilaudid PCA 0.25 mg dose with lock time of 6 min\n maximum\n dose of 1 mg/hr; educated on the use of PCA pump; surgery following\n patient\n abdominal dressing changed\n old sanguinous drainage noted.\n Response:\n Patient in so much pain after repositioning, started on PRN dilaudid\n 0.5 mg q2 hrs prior to turning; patient has many attempts compared to\n dose injected; RR > 8 breaths per minute; sleeping intermittently\n however when she awakens she is in so much pain\n Plan:\n Adjust pain medication\n add basal rate\n Pancreatitis, acute\n Assessment:\n s/p cholecystectomy, JP draining with bile; afebrile WBC 8.0\n Action:\n Continues on vancomycin, flagyl and levofloxacin IV; NPO for now\n started on D51/2NS at 75cc/hr\n Response:\n 80cc of bile from JP drain\n Plan:\n For ERCP in am to correct bile leak\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n s/p unplanned extubation\n came on 50% ventimask sats 87-88% shallow\n non-labored breathing when she came in; lung sounds clear, dim at bases\n no wheezing noted.\n Action:\n Switched to high flow neb 50% FiO2, started on methylprednisolone 20\n mgs Q8hrs, atrovent q6hrs\n Response:\n Sats ~ 92-93% at 70% FiO2; tolerating flat in bed for a short time\n Plan:\n titrate FiO2 to keep sats > 90%\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363128,
"text": "61 yo female with h/o DM2, COPD on home O2, h/o DVT/PE, transferred\n from . She underwent cholecystectomy on then\n represented to for abdominal pain. She was found to\n have significant ileus and ascites, and underwent exploratory\n laparotomy which showed a 2cm hole in the base of the cystic duct with\n 1 Liter bilious ascites. There was ischemic bowel with massive ileus\n and distention due to bile peritonitis. Her hospitalization was also\n complicated by a CVL placement with subsequent pneumothorax. A left\n sided chest tube was place, and also a right femoral line was placed.\n She is being transferred here for ERCP in AM to fix the continued bile\n leakage. Of note, she has been treated with vancomycin, metronidazole,\n and levofloxacin at for peritonitis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complained of severe abdominal incision pain upon arrival from\n OSH; given 0.5 mg of dilaudid IV x 2 with fair effect. BP increased to\n the 170\ns systolic when having pain. Received with bupivacaine 0.25% 6\n ml/hr SC infusion via onQ pump started in OR from OSH\n lines\n secured with tagaderm\n Action:\n Started on dilaudid PCA 0.25 mg dose with lock time of 6 min\n maximum\n dose of 1 mg/hr; educated on the use of PCA pump; surgery following\n patient\n abdominal dressing changed\n old sanguinous drainage noted.\n Response:\n Patient in so much pain after repositioning, started on PRN dilaudid\n 0.5 mg q2 hrs prior to turning; patient has many attempts compared to\n dose injected; RR > 8 breaths per minute; sleeping intermittently\n however when she awakens she is in so much pain\n Plan:\n Adjust pain medication\n add basal rate\n Pancreatitis, acute\n Assessment:\n s/p cholecystectomy, JP draining with bile; afebrile WBC 8.0\n Action:\n Continues on vancomycin, flagyl and levofloxacin IV; NPO for now\n started on D51/2NS at 75cc/hr\n Response:\n 80cc of bile from JP drain\n Plan:\n For ERCP in am to correct bile leak\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n s/p unplanned extubation\n came on 50% ventimask sats 87-88% shallow\n non-labored breathing when she came in; lung sounds clear, dim at bases\n no wheezing noted.\n Action:\n Switched to high flow neb 50% FiO2, started on methylprednisolone 20\n mgs Q8hrs, atrovent q6hrs\n Response:\n Sats ~ 92-93% at 70% FiO2; tolerating flat in bed for a short time\n Plan:\n titrate FiO2 to keep sats > 90%\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363129,
"text": "61 yo female with h/o DM2, COPD on home O2, h/o DVT/PE, transferred\n from . She underwent cholecystectomy on then\n represented to for abdominal pain. She was found to\n have significant ileus and ascites, and underwent exploratory\n laparotomy which showed a 2cm hole in the base of the cystic duct with\n 1 Liter bilious ascites. There was ischemic bowel with massive ileus\n and distention due to bile peritonitis. Her hospitalization was also\n complicated by a CVL placement with subsequent pneumothorax. A left\n sided chest tube was place, and also a right femoral line was placed.\n She is being transferred here for ERCP in AM to fix the continued bile\n leakage. Of note, she has been treated with vancomycin, metronidazole,\n and levofloxacin at for peritonitis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Complained of severe abdominal incision pain upon arrival from\n OSH; given 0.5 mg of dilaudid IV x 2 with fair effect. BP increased to\n the 170\ns systolic when having pain. Received with bupivacaine 0.25% 6\n ml/hr SC infusion via onQ pump started in OR from OSH\n lines\n secured with tagaderm\n Action:\n Started on dilaudid PCA 0.25 mg dose with lock time of 6 min\n maximum\n dose of 1 mg/hr; educated on the use of PCA pump; surgery following\n patient\n abdominal dressing changed\n old sanguinous drainage noted.\n Response:\n Patient in so much pain after repositioning, started on PRN dilaudid\n 0.5 mg q2 hrs prior to turning; patient has many attempts compared to\n dose injected; RR > 8 breaths per minute; sleeping intermittently\n however when she awakens she is in so much pain\n Plan:\n Adjust pain medication\n add basal rate\n Pancreatitis, acute\n Assessment:\n s/p cholecystectomy, JP draining with bile; afebrile WBC 8.0\n Action:\n Continues on vancomycin, flagyl and levofloxacin IV; NPO for now\n started on D51/2NS at 75cc/hr\n Response:\n 80cc of bile from JP drain\n Plan:\n For ERCP in am to correct bile leak\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n s/p unplanned extubation\n came on 50% ventimask sats 87-88% shallow\n non-labored breathing when she came in; lung sounds clear, dim at bases\n no wheezing noted.\n Action:\n Switched to high flow neb 50% FiO2, started on methylprednisolone 20\n mgs Q8hrs, atrovent q6hrs\n Response:\n Sats ~ 92-93% at 70% FiO2; tolerating flat in bed for a short time\n Plan:\n titrate FiO2 to keep sats > 90%\n hospital acquired (Procedure Related, Barotrauma)\n Assessment:\n s/p LSC central line placement at the OSH, developed pneumothorax\n now\n with chest tube L anterior chest wall\n attached to water seal dry\n suction. Oscillating/ fluctuating\n no leak, no crepitus\n Action:\n Continuing assessment on going\n pleur vac changed\n Response:\n Dressing intact, small amount of serosanguious drainage\n Plan:\n ? IP consult\n Diabetes Mellitus (DM), Type II\n Assessment:\n History on IDDM, FS at FM 162\n Action:\n received 1 unit of humalog; kept NPO for procedure, started on D51/2 NS\n at 75cc/hr\n Response:\n No signs and symptoms of hypo or hyperglycemia\n Plan:\n Nutrition consult for TPN\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363279,
"text": "61 yo female with h/o DM2, COPD on home O2, h/o DVT/PE, transferred\n from . She underwent cholecystectomy on then\n represented to for abdominal pain. She was found to\n have significant ileus and ascites, and underwent exploratory\n laparotomy which showed a 2cm hole in the base of the cystic duct with\n 1 Liter bilious ascites. There was ischemic bowel with massive ileus\n and distention due to bile peritonitis. Her hospitalization was also\n complicated by a CVL placement with subsequent pneumothorax. A left\n sided chest tube was place, and also a right femoral line was placed.\n She is being transferred here for ERCP in AM to fix the continued bile\n leakage. She has been treated with vancomycin, metronidazole, and\n levofloxacin at for peritonitis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Screams of pain upon waking up but falls asleep right after,\n intermittently complain of pain incision site. Suture intact,\n incision no signs of infection.\n Action:\n Received diluadid mgs q2hrs but has been getting 1 mg q2hrs\n together with 0.5 mgs of Ativan IV\n Response:\n Slept well compared to yesterday, tolerating turning better than\n previous night.\n Plan:\n Continue present pain regimej\n Peritonitis, acute\n Assessment:\n s/p cholecystectomy, JP draining with bile; afebrile WBC 8.0 latest,\n s/p ERCP to correct bile leak\n Action:\n Continues on zosyn IV; NPO for now\n started on D51/2NS at 75cc/hr\n Response:\n 50cc of bile from JP drain, afebrile\n Plan:\n Continue to monitor\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n s/p extubation for ERCP - non-labored breathing , lung sounds clear,\n dim at bases\n no wheezing noted.\n Action:\n Switched to high flow neb 50% FiO2, started on methylprednisolone 20\n mgs Q8hrs, atrovent q6hrs\n Response:\n Sats ~ 92-93% at 50% FiO2; tolerating flat in bed for a short time\n Plan:\n titrate FiO2 to keep sats > 90%\n hospital acquired (Procedure Related, Barotrauma)\n Assessment:\n s/p LSC central line placement at the OSH, developed pneumothorax\n resolved\n Action:\n Continuing assessment on going\n pleur vac changed\n Response:\n Dressing intact, small amount of serosanguious drainage\n Plan:\n ? IP consult\n Diabetes Mellitus (DM), Type II\n Assessment:\n History on IDDM, FS at MN 164\n Action:\n received 2 unit of humalog; kept NPO for lethag it, started on D51/2 NS\n at 75cc/hr\n Response:\n No signs and symptoms of hypo or hyperglycemia\n Plan:\n Nutrition consult for TPN\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363374,
"text": "61 yo female with h/o DM2, COPD on home O2, h/o DVT/PE, transferred\n from . She underwent cholecystectomy on then\n represented to for abdominal pain. She was found to\n have significant ileus and ascites, and underwent exploratory\n laparotomy which showed a 2cm hole in the base of the cystic duct with\n 1 Liter bilious ascites. There was ischemic bowel with massive ileus\n and distention due to bile peritonitis. Her hospitalization was also\n complicated by a CVL placement with subsequent pneumothorax. A left\n sided chest tube was place, and also a right femoral line was placed.\n She is being transferred here for ERCP in AM to fix the continued bile\n leakage. She has been treated with vancomycin, metronidazole, and\n levofloxacin at for peritonitis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Screams of pain upon waking up but falls asleep right after,\n intermittently complaining of pain incision site. Suture\n intact, incision no signs of infection.\n Action:\n Received diluadid mgs q2hrs but has been getting 1 mg q2hrs\n together with 0.5 mgs of Ativan IV\n Response:\n Pt. calm when staff in room. Yelling out when alone. Unable to\n determine if Pt. has adequate pain control.\n Plan:\n Continue present pain regimen.\n Peritonitis, acute\n Assessment:\n s/p cholecystectomy, JP draining with bile; afebrile WBC 9.6 this\n morning, s/p ERCP to correct bile leak\n Action:\n Continues on zosyn IV; NPO for now\n started on D51/2NS at 75cc/hr\n Response:\n 125cc of bile from JP drain, afebrile\n Plan:\n Continue to monitor. F/U cx. Data.\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n s/p extubation for ERCP - non-labored breathing , lung sounds clear,\n dim at bases\n no wheezing noted.\n Action:\n prednisone tapered, O2 titrated down as tolerated\n Response:\n Sats ~ 92-93% 2 lpm via nasal cannula; tolerating flat in bed for a\n short time\n Plan:\n titrate FiO2 to keep sats > 90%\n Diabetes Mellitus (DM), Type II\n Assessment:\n History on IDDM, FS at noon 229.\n Action:\n received 4 unit of humalog; kept NPO per GI recs. D51/2 NS at 75cc/hr\n till 1500.\n Response:\n No signs and symptoms of hypo or hyperglycemia\n Plan:\n Nutrition consult for TPN.\n Pt. transferred back to for further care. Pt. going vai\n ED at . Called ED and report given to\n Nursing. Pt. will travel by ACLS ambulance. Will medicate with Ativan\n and Dilaudid prior to transfer so Pt. better tolerates transfer.\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 363332,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:03 AM\n ERCP - At 10:32 AM\n INVASIVE VENTILATION - STOP 11:15 AM\n BLOOD CULTURED - At 12:20 PM\n BLOOD CULTURED - At 12:28 PM\n URINE CULTURE - At 12:28 PM\n ARTERIAL LINE - STOP 09: from outside hospital\n Allergies:\n Celebrex (Oral) (Celecoxib)\n Hives;\n Zithromax (Oral) (Azithromycin)\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 07:52 AM\n Levofloxacin - 08:15 AM\n Piperacillin - 12:14 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:51 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:53 AM\n Lorazepam (Ativan) - 02:38 AM\n Hydromorphone (Dilaudid) - 04:43 AM\n Other medications:\n Changes to medical and 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: 36.7\nC (98.1\n Tcurrent: 36.7\nC (98.1\n HR: 99 (69 - 99) bpm\n BP: 124/68(81) {95/46(58) - 132/71(81)} mmHg\n RR: 24 (11 - 25) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 3,579 mL\n 712 mL\n PO:\n TF:\n IVF:\n 3,579 mL\n 712 mL\n Blood products:\n Total out:\n 1,590 mL\n 545 mL\n Urine:\n 1,440 mL\n 495 mL\n NG:\n Stool:\n Drains:\n 150 mL\n 50 mL\n Balance:\n 1,989 mL\n 167 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 600) mL\n Vt (Spontaneous): 482 (482 - 482) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 17\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 31 cmH2O\n Plateau: 21 cmH2O\n SpO2: 95%\n ABG: ///26/\n Ve: 9.7 L/min\n Physical Examination\n General Appearance: Middle-aged female lying in bed.\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no MRG\n Respiratory / Chest: Coarse breath sounds b/l. Patient left sided\n chest tube in place, dressing C/D/I\n Abdominal: Decreased BS, Distended, diffusely tender particularly in\n RLQ, Obese, distended; tympanic to percussion. bandage in place. C/D/I.\n JP drain present with bilious fluid\n Extremities: 1 + pitting edema b/l\n Skin: Warm, confluent ecchymoses over her arms, multiple scattered\n bruises over her body.\n Neurologic: Sleepy, but arousable. Oriented to person, place, and\n time. Moves all extremities to command.\n Labs / Radiology\n 232 K/uL\n 9.2 g/dL\n 82 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 109 mEq/L\n 143 mEq/L\n 28.8 %\n 9.6 K/uL\n [image002.jpg]\n 09:51 PM\n 05:13 AM\n 03:52 AM\n WBC\n 8.0\n 6.1\n 9.6\n Hct\n 31.0\n 29.0\n 28.8\n Plt\n \n Cr\n 0.9\n 0.9\n 0.8\n Glucose\n 162\n 258\n 82\n Other labs: PT / PTT / INR:15.3/27.9/1.3, ALT / AST:18/25, Alk Phos / T\n Bili:94/0.4, Amylase / Lipase:25/8, Differential-Neuts:93.6 %,\n Lymph:3.9 %, Mono:2.3 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:371 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:1.3 mg/dL\n Assessment and Plan\n HOSPITAL ACQUIRED (PROCEDURE RELATED, BAROTRAUMA)\n DIABETES MELLITUS (DM), TYPE II\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PANCREATITIS, ACUTE\n .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION\n 63 y/o lady with COPD,diabetes, and h/o DVT is transfered from OSH\n after exploratory laparotomy for bile duct leak following\n cholecystectomy, now POD #3, also s/p left CVL placement with\n subsequent PTX s/p left chest tube placement, transferred here for ERCP\n planned for this am to address continued bile duct leak.\n # Bile duct leak: The patient underwent cholecystecomy on ,\n followed by exploratory laparotomy on found to have 2 cm hole at\n cystic duct with bilious drainiage, and 1L of bilious ascites, and\n likely peritonitis given acute abdomen. Currently hemodynamically\n stable, but with significant abdominal pain, and plan for ERCP in AM to\n correct continued bile leak. Her JP fluid grew out gram negative\n rods. LFTs WNL.\n - ERCP this am, will f/u recs\n - Will change her antibiotics to zosyn and continue vanc for broader\n coverage.\n - Appreciate surgical consult, will f/u recs\n - F/u abd X-ray read to look for ileus or obstruction\n - F/u peritoneal culture, will send BCx and Ucx.\n - F/u OSH cx data\n - bowel meds PR PRN\n # Left PTX: s/p CVL placement and now with chest tube in place. no air\n leak noted. On water seal with no Ptx seen on CXR.\n - Continue water seal for now.\n - Will obtain a repeat CXR and if stable with no ptx seen, pull her\n chest tube.\n # COPD: was intubated at postoperatively, but self extubated.\n Transferred on ventimask 50% FIO2, had been increased to 70% overnight,\n but now down to 50% .\n - wean O2 as tolerated\n - NEBS prn\n - Decrease solumedrol to 20 mg IV daily (had been on an equivalent\n dose of prednisone at the OSH).\n # h/o DVT/PE: on coumadin as outpt; holding for now given procedure.\n - will hold for now; likely can restart after ERCP\n # Coagulopathy: The patient has an INR of 1.4. Has been on TPN and NPO\n recently. Likely secondary to dietary deficiency of vitmain K. No\n history of liver failure.\n - Continue to follow.\n # Diabetes: HISS\n # Hypothyroidism: on levothyroxine 112 mcg daily as an outpatient.\n - convert to IV for now 50 mcg daily as NPO\n # Depression: will hold cymbalta for now\n # FULL CODE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:30 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": "2119-02-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 363350,
"text": "Chief Complaint: bile leak\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 63 yo female transferred from OSH for biliary leak requiring ERCP\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:03 AM\n ERCP : biliary stent placed\n INVASIVE VENTILATION - STOP 11:15 AM\n BLOOD CULTURED - At 12:20 PM\n BLOOD CULTURED - At 12:28 PM\n URINE CULTURE - At 12:28 PM\n ARTERIAL LINE - STOP 09: from outside hospital\n Chest tube dc'd by CT \n History obtained from Medical records\n Allergies:\n Celebrex (Oral) (Celecoxib)\n Hives;\n Zithromax (Oral) (Azithromycin)\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 07:52 AM\n Levofloxacin - 08:15 AM\n Piperacillin - 12:14 PM\n Piperacillin/Tazobactam (Zosyn) - 04:51 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Lorazepam (Ativan) - 09:40 AM\n Hydromorphone (Dilaudid) - 09:40 AM\n Other medications:\n atrovent nebs, protonix, vancomycin, synthroid, SSI, solumedrol (for\n COPD)\n Changes to medical and family history:\n DM\n COPD on home oxygen and prednisone\n DVT/PE\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 10:25 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: 35.9\nC (96.7\n HR: 90 (73 - 99) bpm\n BP: 142/71(89) {95/46(58) - 142/71(89)} mmHg\n RR: 19 (11 - 25) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 3,579 mL\n 1,184 mL\n PO:\n TF:\n IVF:\n 3,579 mL\n 1,184 mL\n Blood products:\n Total out:\n 1,590 mL\n 1,265 mL\n Urine:\n 1,440 mL\n 1,215 mL\n NG:\n Stool:\n Drains:\n 150 mL\n 50 mL\n Balance:\n 1,989 mL\n -81 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///26/\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: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), slightly coarse diffusely\n Abdominal: Soft, Bowel sounds present, mild upper abdominal pain, drain\n with bilious fluid\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone:\n Normal\n Labs / Radiology\n 9.2 g/dL\n 232 K/uL\n 82 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 109 mEq/L\n 143 mEq/L\n 28.8 %\n 9.6 K/uL\n [image002.jpg]\n 09:51 PM\n 05:13 AM\n 03:52 AM\n WBC\n 8.0\n 6.1\n 9.6\n Hct\n 31.0\n 29.0\n 28.8\n Plt\n \n Cr\n 0.9\n 0.9\n 0.8\n Glucose\n 162\n 258\n 82\n Other labs: PT / PTT / INR:15.3/27.9/1.3, ALT / AST:18/25, Alk Phos / T\n Bili:94/0.4, Amylase / Lipase:25/8, Differential-Neuts:93.6 %,\n Lymph:3.9 %, Mono:2.3 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:371 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:1.3 mg/dL\n Microbiology: Bd cultures pending\n Urine cultures pending\n Peritoneal fluid pending\n Assessment and Plan\n HOSPITAL ACQUIRED (PROCEDURE RELATED, BAROTRAUMA)\n CT pulled out by thoracics yesterday, with no residual PTX on f/u CXR\n DIABETES MELLITUS (DM), TYPE II\n Hx DVT/PE: on coumadin as outpt . Heparin held due to multiple\n procedures yesterday but will resume today\n .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA)\n Pt on home oxygen and prednisone- converted to solumedrol\n *Biliary leak s/p stent placement: plan Vanc/zosyn x one week\n f/u peritoneal cultures\n NPO until cleared by GI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:30 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 other facility\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 363358,
"text": "Chief Complaint: bile leak\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 63 yo female transferred from OSH for biliary leak requiring ERCP\n 24 Hour Events:\n INVASIVE VENTILATION - START 10:03 AM\n ERCP : biliary stent placed\n INVASIVE VENTILATION - STOP 11:15 AM\n BLOOD CULTURED - At 12:20 PM\n BLOOD CULTURED - At 12:28 PM\n URINE CULTURE - At 12:28 PM\n ARTERIAL LINE - STOP 09: from outside hospital\n Chest tube dc'd by CT \n History obtained from Medical records\n Allergies:\n Celebrex (Oral) (Celecoxib)\n Hives;\n Zithromax (Oral) (Azithromycin)\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Metronidazole - 07:52 AM\n Levofloxacin - 08:15 AM\n Piperacillin - 12:14 PM\n Piperacillin/Tazobactam (Zosyn) - 04:51 AM\n Vancomycin - 08:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:00 AM\n Lorazepam (Ativan) - 09:40 AM\n Hydromorphone (Dilaudid) - 09:40 AM\n Other medications:\n atrovent nebs, protonix, vancomycin, synthroid, SSI, solumedrol (for\n COPD)\n Changes to medical and family history:\n DM\n COPD on home oxygen and prednisone\n DVT/PE\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 10:25 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: 35.9\nC (96.7\n HR: 90 (73 - 99) bpm\n BP: 142/71(89) {95/46(58) - 142/71(89)} mmHg\n RR: 19 (11 - 25) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n Total In:\n 3,579 mL\n 1,184 mL\n PO:\n TF:\n IVF:\n 3,579 mL\n 1,184 mL\n Blood products:\n Total out:\n 1,590 mL\n 1,265 mL\n Urine:\n 1,440 mL\n 1,215 mL\n NG:\n Stool:\n Drains:\n 150 mL\n 50 mL\n Balance:\n 1,989 mL\n -81 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 94%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, obese female. 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: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), slightly coarse diffusely\n Abdominal: Soft, Bowel sounds present, mild upper abdominal pain\n without guarding or rebound, drain with bilious fluid\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone:\n Normal\n Labs / Radiology\n 9.2 g/dL\n 232 K/uL\n 82 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 109 mEq/L\n 143 mEq/L\n 28.8 %\n 9.6 K/uL\n [image002.jpg]\n 09:51 PM\n 05:13 AM\n 03:52 AM\n WBC\n 8.0\n 6.1\n 9.6\n Hct\n 31.0\n 29.0\n 28.8\n Plt\n \n Cr\n 0.9\n 0.9\n 0.8\n Glucose\n 162\n 258\n 82\n Other labs: PT / PTT / INR:15.3/27.9/1.3, ALT / AST:18/25, Alk Phos / T\n Bili:94/0.4, Amylase / Lipase:25/8, Differential-Neuts:93.6 %,\n Lymph:3.9 %, Mono:2.3 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:371 IU/L,\n Ca++:7.5 mg/dL, Mg++:2.1 mg/dL, PO4:1.3 mg/dL\n Microbiology: Bd cultures pending\n Urine cultures pending\n Peritoneal fluid pending\n Assessment and Plan\n HOSPITAL ACQUIRED (PROCEDURE RELATED, BAROTRAUMA)\n CT pulled out by thoracics yesterday, with no residual PTX on f/u CXR\n DIABETES MELLITUS (DM), TYPE II\n Hx DVT/PE: on coumadin as outpt . Heparin held due to multiple\n procedures yesterday but will resume today\n .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA)\n Pt on home oxygen and prednisone- converted to solumedrol\n *Biliary leak s/p stent placement: plan Vanc/zosyn x one week\n f/u peritoneal cultures\n NPO until cleared by GI\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:30 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 other facility\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 363196,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Surgery was consulted given her recent surgery and poor clinical\n status and recommended awaiting the ERCP results.\n This am the patient continues to experience abdominal pain, .\n Allergies:\n Celebrex (Oral) (Celecoxib)\n Hives;\n Zithromax (Oral) (Azithromycin)\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:18 AM\n Metronidazole - 01:18 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 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 (98.5\n HR: 71 (71 - 89) bpm\n BP: 112/59(79) {105/56(76) - 175/82(116)} mmHg\n RR: 11 (10 - 20) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 74 mL\n 958 mL\n PO:\n TF:\n IVF:\n 74 mL\n 958 mL\n Blood products:\n Total out:\n 150 mL\n 540 mL\n Urine:\n 150 mL\n 430 mL\n NG:\n Stool:\n Drains:\n 110 mL\n Balance:\n -76 mL\n 418 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 91% on FiO2 of 50%\n ABG: ///26/\n Physical Examination\n General Appearance: Middle-aged female lying in bed.\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no MRG\n Respiratory / Chest: Coarse breath sounds b/l. Patient left sided\n chest tube in place, dressing C/D/I\n Abdominal: Decreased BS, Distended, diffusely tender particularly in\n RLQ, Obese, distended; tympanic to percussion. bandage in place. C/D/I.\n JP drain present with bilious fluid\n Extremities: 1 + pitting edema b/l\n Skin: Warm, confluent ecchymoses over her arms, multiple scattered\n bruises over her body.\n Neurologic: Sleepy, but arousable. Oriented to person, place, and\n time. Moves all extremities to command.\n Labs / Radiology\n 189 K/uL\n 9.3 g/dL\n 258 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 106 mEq/L\n 141 mEq/L\n 29.0 %\n 6.1 K/uL\n [image002.jpg]\n 09:51 PM\n 05:13 AM\n WBC\n 8.0\n 6.1\n Hct\n 31.0\n 29.0\n Plt\n 229\n 189\n Cr\n 0.9\n 0.9\n Glucose\n 162\n 258\n Other labs: PT / PTT / INR:16.3/29.8/1.5, ALT / AST:17/16, Alk Phos / T\n Bili:106/0.4, Amylase / Lipase:25/8, Differential-Neuts:93.6 %,\n Lymph:3.9 %, Mono:2.3 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:253 IU/L,\n Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n 5:13 am PERITONEAL FLUID\n GRAM STAIN (Final ):\n REPORTED BY PHONE TO @ 6:05A .\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n FLUID CULTURE (Preliminary):\n ANAEROBIC CULTURE (Preliminary):\n Assessment and Plan\n 63 y/o lady with COPD,diabetes, and h/o DVT is transfered from OSH\n after exploratory laparotomy for bile duct leak following\n cholecystectomy, now POD #3, also s/p left CVL placement with\n subsequent PTX s/p left chest tube placement, transferred here for ERCP\n planned for this am to address continued bile duct leak.\n # Bile duct leak: The patient underwent cholecystecomy on ,\n followed by exploratory laparotomy on found to have 2 cm hole at\n cystic duct with bilious drainiage, and 1L of bilious ascites, and\n likely peritonitis given acute abdomen. Currently hemodynamically\n stable, but with significant abdominal pain, and plan for ERCP in AM to\n correct continued bile leak. Her JP fluid grew out gram negative\n rods. LFTs WNL.\n - ERCP this am, will f/u recs\n - Will change her antibiotics to zosyn and continue vanc for broader\n coverage.\n - Appreciate surgical consult, will f/u recs\n - F/u abd X-ray read to look for ileus or obstruction\n - F/u peritoneal culture, will send BCx and Ucx.\n - F/u OSH cx data\n - bowel meds PR PRN\n # Left PTX: s/p CVL placement and now with chest tube in place. no air\n leak noted. On water seal with no Ptx seen on CXR.\n - Continue water seal for now.\n - Will obtain a repeat CXR and if stable with no ptx seen, pull her\n chest tube.\n # COPD: was intubated at postoperatively, but self extubated.\n Transferred on ventimask 50% FIO2, had been increased to 70% overnight,\n but now down to 50% .\n - wean O2 as tolerated\n - NEBS prn\n - Decrease solumedrol to 20 mg IV daily (had been on an equivalent\n dose of prednisone at the OSH).\n # h/o DVT/PE: on coumadin as outpt; holding for now given procedure.\n - will hold for now; likely can restart after ERCP\n # Coagulopathy: The patient has an INR of 1.4. Has been on TPN and NPO\n recently. Likely secondary to dietary deficiency of vitmain K. No\n history of liver failure.\n - Continue to follow.\n # Diabetes: HISS\n # Hypothyroidism: on levothyroxine 112 mcg daily as an outpatient.\n - convert to IV for now 50 mcg daily as NPO\n # Depression: will hold cymbalta for now\n # FULL CODE\n ICU Care\n Nutrition: NPO for ERCP today\n -Had been on TPN, will consult nutrition for TPN recs.\n Glycemic Control:\n Lines: Will have a PICC placed for access for IV antibiotics and lab\n draws. Will pull her A-line and central line once the PICC is placed.\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU ; may request transfer back to after\n ERCP\n"
},
{
"category": "Nursing",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363257,
"text": " hospital acquired (Procedure Related, Barotrauma)\n Assessment:\n resolved\n Action:\n Chest tube removed this pm by thoracic. Cxr done\n Response:\n Pt. more comfortable.\n Plan:\n Drsg remain in place for 24-48hrs. can change if increased drainage\n noted. Reaply tegaderms with 4x4\ns. cont. this for another 24-48hrs.\n Diabetes Mellitus (DM), Type II\n Assessment:\n Elevated bs\ns. probably d/t steroids.\n Action:\n Bs\ns tx\ned with ssi. Steroids decreased to qd.\n Response:\n Bs\ns should return to baseline with decreased solumedrol.\n Plan:\n Check bs\ns q6hrs and treat.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt. slightly more comfortable.\n Action:\n Pt. assessed by surgery (Dr. . Abd drsg . Staples intact.\n No drainage noted. Binder off. Bipuvacaine wire removed. Jp drain in\n place. Draining around incision area ss.\n pt\ns pca pump d/c\ned. Pt. not able to use it properfly and pt. not\n getting adequate relief., inspite of dilaudid ivp inbetween. Pt. also\n c/o fear of dying and very anxious. Medicated several times with ativan\n 0.,5mg ivp and dilaudid 1mg ivp.\n Skin integrity: drsg on upper arm. Pt\ns skin very fragile.\n Social: sister told me that the physicians at implied\n that she would be painfree post ercp?? And able to drink. Pt. aware\n that this isn\nt so.\n Response:\n Pt. much more comfortable. Slept for several hrs. pt. does continue to\n moan at times, but much less then this am.\n Plan:\n Medicate with dilaudid ivp and. Ativan together. If possible. . pt. to\n use binder when oob.\n Pancreatitis, acute\n Assessment:\n Continues with pain post procedure.\n Action:\n To ercp this am. Intubated for the procedure, which she tolerated well.\n Stent placed. Much less drainage noted from the jp drain. Returned to\n the icu and placed on propofol shortterm. Extubated afew hrs later.\n Placed on 50% hi flow. Sats 93-96%. Abd still distended and tender when\n palpated. No bs\ns . may have ice chips.\n Turning better in the bed. Ivf\ns continue at 75cc/hr. levoflox and\n flagyl d/c\ned. Started on zosyn. Afebrile.\n Cv: hemodynamically stablel\n Access: iv aware of picc line placement. Will see her soon.\n Response:\n Successful ercp.\n Plan:\n d/c a-line. Return to tomorrow if bed available.\n Remove triple lumen when picc in place. Cont. on antibiotics.\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 363173,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Surgery was consulted given her recent surgery and poor clinical\n status and recommended awaiting the ERCP results.\n Allergies:\n Celebrex (Oral) (Celecoxib)\n Hives;\n Zithromax (Oral) (Azithromycin)\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:18 AM\n Metronidazole - 01:18 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 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 (98.5\n HR: 71 (71 - 89) bpm\n BP: 112/59(79) {105/56(76) - 175/82(116)} mmHg\n RR: 11 (10 - 20) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 74 mL\n 958 mL\n PO:\n TF:\n IVF:\n 74 mL\n 958 mL\n Blood products:\n Total out:\n 150 mL\n 540 mL\n Urine:\n 150 mL\n 430 mL\n NG:\n Stool:\n Drains:\n 110 mL\n Balance:\n -76 mL\n 418 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 91% on FiO2 of 50%\n ABG: ///26/\n Physical Examination\n General Appearance: Middle-aged female lying in bed in NAD\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no MRG\n Respiratory / Chest: Patient left sided chest tube in place, dressing\n C/D/I\n Abdominal: No(t) Non-tender, Distended, Tender: diffusely, particularly\n in RLQ, Obese, distended; tympanic to percussion. bandage in place.\n C/D/I. JP drain present with bilious fluid\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): A/O x 3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 189 K/uL\n 9.3 g/dL\n 258 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 106 mEq/L\n 141 mEq/L\n 29.0 %\n 6.1 K/uL\n [image002.jpg]\n 09:51 PM\n 05:13 AM\n WBC\n 8.0\n 6.1\n Hct\n 31.0\n 29.0\n Plt\n 229\n 189\n Cr\n 0.9\n 0.9\n Glucose\n 162\n 258\n Other labs: PT / PTT / INR:16.3/29.8/1.5, ALT / AST:17/16, Alk Phos / T\n Bili:106/0.4, Amylase / Lipase:25/8, Differential-Neuts:93.6 %,\n Lymph:3.9 %, Mono:2.3 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:253 IU/L,\n Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n 5:13 am PERITONEAL FLUID\n GRAM STAIN (Final ):\n REPORTED BY PHONE TO @ 6:05A .\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n FLUID CULTURE (Preliminary):\n ANAEROBIC CULTURE (Preliminary):\n Assessment and Plan\n 63 y/o lady with COPD,diabetes, and h/o DVT is transfered from OSH\n after exploratory laparotomy for bile duct leak following\n cholecystectomy, now POD #3, also s/p left CVL placement with\n subsequent PTX s/p left chest tube placement, transferred here for ERCP\n planned for this am to address continued bile duct leak.\n # Bile duct leak: patient underwent cholecystecomy on , followed by\n exploratory laparotomy on found to have 2 cm hole at cystic duct\n with bilious drainiage, and 1L of bilious ascites, and likely\n peritonitis given acute abdomen. Currently hemodynamically stable, but\n with significant abdominal pain, and plan for ERCP in AM to correct\n continued bile leak\n - supine abdominal film to look for ileus or obstruction\n - surgical consult to follow post ex/lap\n - ERCP in AM, NPO for now\n - cont vanco/levo/flagyl for now for bacterial peritonitis in the\n setting of bile duct leak\n - check LFTs, amylase, lipase\n - bowel meds PR PRN\n # Left PTX: s/p CVL placement and now with chest tube in place. no air\n leak noted\n - water seal for now\n - CXR to eval for PTX\n - can attempt repeat CVL on left subclavian to remove femoral CVL\n # COPD: was intubated at postoperatively, but self extubated.\n Transferred on ventimask 50% FIO2.\n - wean O2 as torated\n - NEBS prn\n - solumedrol 20 mg IV q8H\n # h/o DVT/PE: on coumadin as outpt; holding for now given procedure.\n - will hold for now; likely can restart after ERCP\n - hold off on heparin gtt for now since patient has wound, and\n considering central line placement\n # Diabetes: HISS\n # Hypothyroidism: on levothyroxine 112 mcg daily as an outpatient.\n - convert to IV for now 50 mcg daily as NPO\n # Depression: will hold cymbalta for now\n # FULL CODE\n ICU Care\n Nutrition: NPO for ERCP today\n -Had been on TPN, will consult nutrition for TPN recs.\n Glycemic Control:\n Lines: Will need a new central line and A-line placed today as her\n lines were placed at an OSH. Refused line placement overnight.\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 363176,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Surgery was consulted given her recent surgery and poor clinical\n status and recommended awaiting the ERCP results.\n Allergies:\n Celebrex (Oral) (Celecoxib)\n Hives;\n Zithromax (Oral) (Azithromycin)\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:18 AM\n Metronidazole - 01:18 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 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 (98.5\n HR: 71 (71 - 89) bpm\n BP: 112/59(79) {105/56(76) - 175/82(116)} mmHg\n RR: 11 (10 - 20) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 74 mL\n 958 mL\n PO:\n TF:\n IVF:\n 74 mL\n 958 mL\n Blood products:\n Total out:\n 150 mL\n 540 mL\n Urine:\n 150 mL\n 430 mL\n NG:\n Stool:\n Drains:\n 110 mL\n Balance:\n -76 mL\n 418 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 91% on FiO2 of 50%\n ABG: ///26/\n Physical Examination\n General Appearance: Middle-aged female lying in bed in NAD\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no MRG\n Respiratory / Chest: Patient left sided chest tube in place, dressing\n C/D/I\n Abdominal: No(t) Non-tender, Distended, Tender: diffusely, particularly\n in RLQ, Obese, distended; tympanic to percussion. bandage in place.\n C/D/I. JP drain present with bilious fluid\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): A/O x 3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 189 K/uL\n 9.3 g/dL\n 258 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 106 mEq/L\n 141 mEq/L\n 29.0 %\n 6.1 K/uL\n [image002.jpg]\n 09:51 PM\n 05:13 AM\n WBC\n 8.0\n 6.1\n Hct\n 31.0\n 29.0\n Plt\n 229\n 189\n Cr\n 0.9\n 0.9\n Glucose\n 162\n 258\n Other labs: PT / PTT / INR:16.3/29.8/1.5, ALT / AST:17/16, Alk Phos / T\n Bili:106/0.4, Amylase / Lipase:25/8, Differential-Neuts:93.6 %,\n Lymph:3.9 %, Mono:2.3 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:253 IU/L,\n Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n 5:13 am PERITONEAL FLUID\n GRAM STAIN (Final ):\n REPORTED BY PHONE TO @ 6:05A .\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n FLUID CULTURE (Preliminary):\n ANAEROBIC CULTURE (Preliminary):\n Assessment and Plan\n 63 y/o lady with COPD,diabetes, and h/o DVT is transfered from OSH\n after exploratory laparotomy for bile duct leak following\n cholecystectomy, now POD #3, also s/p left CVL placement with\n subsequent PTX s/p left chest tube placement, transferred here for ERCP\n planned for this am to address continued bile duct leak.\n # Bile duct leak: patient underwent cholecystecomy on , followed by\n exploratory laparotomy on found to have 2 cm hole at cystic duct\n with bilious drainiage, and 1L of bilious ascites, and likely\n peritonitis given acute abdomen. Currently hemodynamically stable, but\n with significant abdominal pain, and plan for ERCP in AM to correct\n continued bile leak\n - supine abdominal film to look for ileus or obstruction\n - surgical consult to follow post ex/lap\n - ERCP in AM, NPO for now\n - cont vanco/levo/flagyl for now for bacterial peritonitis in the\n setting of bile duct leak\n - check LFTs, amylase, lipase\n - bowel meds PR PRN\n # Left PTX: s/p CVL placement and now with chest tube in place. no air\n leak noted\n - water seal for now\n - can attempt repeat CVL on left subclavian to remove femoral CVL\n # COPD: was intubated at postoperatively, but self extubated.\n Transferred on ventimask 50% FIO2.\n - wean O2 as torated\n - NEBS prn\n - solumedrol 20 mg IV q8H\n # h/o DVT/PE: on coumadin as outpt; holding for now given procedure.\n - will hold for now; likely can restart after ERCP\n - hold off on heparin gtt for now since patient has wound, and\n considering central line placement\n # Diabetes: HISS\n # Hypothyroidism: on levothyroxine 112 mcg daily as an outpatient.\n - convert to IV for now 50 mcg daily as NPO\n # Depression: will hold cymbalta for now\n # FULL CODE\n ICU Care\n Nutrition: NPO for ERCP today\n -Had been on TPN, will consult nutrition for TPN recs.\n Glycemic Control:\n Lines: Will need a new central line and A-line placed today as her\n lines were placed at an OSH. Refused line placement overnight.\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 363182,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Surgery was consulted given her recent surgery and poor clinical\n status and recommended awaiting the ERCP results.\n This am the patient continues to experience abdominal pain, .\n Allergies:\n Celebrex (Oral) (Celecoxib)\n Hives;\n Zithromax (Oral) (Azithromycin)\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:18 AM\n Metronidazole - 01:18 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 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 (98.5\n HR: 71 (71 - 89) bpm\n BP: 112/59(79) {105/56(76) - 175/82(116)} mmHg\n RR: 11 (10 - 20) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 74 mL\n 958 mL\n PO:\n TF:\n IVF:\n 74 mL\n 958 mL\n Blood products:\n Total out:\n 150 mL\n 540 mL\n Urine:\n 150 mL\n 430 mL\n NG:\n Stool:\n Drains:\n 110 mL\n Balance:\n -76 mL\n 418 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 91% on FiO2 of 50%\n ABG: ///26/\n Physical Examination\n General Appearance: Middle-aged female lying in bed.\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no MRG\n Respiratory / Chest: Coarse breath sounds b/l. Patient left sided\n chest tube in place, dressing C/D/I\n Abdominal: Decreased BS, Distended, diffusely tender particularly in\n RLQ, Obese, distended; tympanic to percussion. bandage in place. C/D/I.\n JP drain present with bilious fluid\n Extremities: 1 + pitting edema b/l\n Skin: Warm, confluent ecchymoses over her arms, multiple scattered\n bruises over her body.\n Neurologic: Sleepy, but arousable. Oriented to person, place, and\n time. Moves all extremities to command.\n Labs / Radiology\n 189 K/uL\n 9.3 g/dL\n 258 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 106 mEq/L\n 141 mEq/L\n 29.0 %\n 6.1 K/uL\n [image002.jpg]\n 09:51 PM\n 05:13 AM\n WBC\n 8.0\n 6.1\n Hct\n 31.0\n 29.0\n Plt\n 229\n 189\n Cr\n 0.9\n 0.9\n Glucose\n 162\n 258\n Other labs: PT / PTT / INR:16.3/29.8/1.5, ALT / AST:17/16, Alk Phos / T\n Bili:106/0.4, Amylase / Lipase:25/8, Differential-Neuts:93.6 %,\n Lymph:3.9 %, Mono:2.3 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:253 IU/L,\n Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n 5:13 am PERITONEAL FLUID\n GRAM STAIN (Final ):\n REPORTED BY PHONE TO @ 6:05A .\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n FLUID CULTURE (Preliminary):\n ANAEROBIC CULTURE (Preliminary):\n Assessment and Plan\n 63 y/o lady with COPD,diabetes, and h/o DVT is transfered from OSH\n after exploratory laparotomy for bile duct leak following\n cholecystectomy, now POD #3, also s/p left CVL placement with\n subsequent PTX s/p left chest tube placement, transferred here for ERCP\n planned for this am to address continued bile duct leak.\n # Bile duct leak: patient underwent cholecystecomy on , followed by\n exploratory laparotomy on found to have 2 cm hole at cystic duct\n with bilious drainiage, and 1L of bilious ascites, and likely\n peritonitis given acute abdomen. Currently hemodynamically stable, but\n with significant abdominal pain, and plan for ERCP in AM to correct\n continued bile leak\n - supine abdominal film to look for ileus or obstruction\n - surgical consult to follow post ex/lap\n - ERCP in AM, NPO for now\n - cont vanco/levo/flagyl for now for bacterial peritonitis in the\n setting of bile duct leak\n - check LFTs, amylase, lipase\n - bowel meds PR PRN\n # Left PTX: s/p CVL placement and now with chest tube in place. no air\n leak noted. On water seal with no Ptx seen on CXR.\n - Continue water seal for now, can consider pulling the tube as she is\n off mechanical ventilation and tolerating water seal.\n - can attempt repeat CVL on left subclavian to remove femoral CVL\n # COPD: was intubated at postoperatively, but self extubated.\n Transferred on ventimask 50% FIO2, had been increased to 70% overnight,\n but now down to 50% .\n - wean O2 as tolerated\n - NEBS prn\n - solumedrol 20 mg IV q8H, had been on for possible COPD exacerbation.\n Will wean down.\n # h/o DVT/PE: on coumadin as outpt; holding for now given procedure.\n - will hold for now; likely can restart after ERCP\n - hold off on heparin gtt for now since patient has wound, and\n considering central line placement\n # Diabetes: HISS\n # Hypothyroidism: on levothyroxine 112 mcg daily as an outpatient.\n - convert to IV for now 50 mcg daily as NPO\n # Depression: will hold cymbalta for now\n # FULL CODE\n ICU Care\n Nutrition: NPO for ERCP today\n -Had been on TPN, will consult nutrition for TPN recs.\n Glycemic Control:\n Lines: Will need a new central line and A-line placed today as her\n lines were placed at an OSH. Refused line placement overnight.\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 363189,
"text": "Chief Complaint: Bile Leak\n Pneumonthorax\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n patient with initial presentation with RUQ pain and s/p CCY post\n operative pain and 2cm defect in cystic duct--she had oversew attempted\n and with evidence of persistent leak patient to for further care.\n Patient had iatrogenic PTX with left sided line placement\n Vanco/Levo/Flagyl continued for peritonitis\n Patient to for further care\n Patient admitted from: Transfer from other hospital, \n History obtained from Medical records\n Allergies:\n Celebrex (Oral) (Celecoxib)\n Hives;\n Zithromax (Oral) (Azithromycin)\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:18 AM\n Metronidazole - 07:52 AM\n Levofloxacin - 08:15 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:53 AM\n Hydromorphone (Dilaudid) - 07:53 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n DVT\n COPD--Chronic Steroids, Home O2\n DM\n Vertebral Fx\n Hypothyroidism\n Enterococcal Bacteremia\n Non Contributory\n Occupation: Lives Independently\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other:\n Review of systems:\n Flowsheet Data as of 09:03 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: 71 (71 - 89) bpm\n BP: 112/59(79) {105/56(76) - 175/82(116)} mmHg\n RR: 11 (10 - 20) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 74 mL\n 1,361 mL\n PO:\n TF:\n IVF:\n 74 mL\n 1,361 mL\n Blood products:\n Total out:\n 150 mL\n 660 mL\n Urine:\n 150 mL\n 550 mL\n NG:\n Stool:\n Drains:\n 110 mL\n Balance:\n -76 mL\n 701 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 91%\n ABG: ///26/\n Physical Examination\n General Appearance: Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Diminished: ), CT--Left--no air leak, on water seal,\n 110cc in 9 hours\n Abdominal: Soft, Tender: RLQ and RUQ with voluntary guarding, Post\n operative wound CDI by report, JP drain with bilious fluid\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 189 K/uL\n 29.0 %\n 9.3 g/dL\n 258 mg/dL\n 0.9 mg/dL\n 19 mg/dL\n 26 mEq/L\n 106 mEq/L\n 4.1 mEq/L\n 141 mEq/L\n 6.1 K/uL\n [image002.jpg]\n 09:51 PM\n 05:13 AM\n WBC\n 8.0\n 6.1\n Hct\n 31.0\n 29.0\n Plt\n 229\n 189\n Cr\n 0.9\n 0.9\n Glucose\n 162\n 258\n Other labs: PT / PTT / INR:15.3/28.8/1.4, ALT / AST:17/16, Alk Phos / T\n Bili:106/0.4, Amylase / Lipase:25/8, Differential-Neuts:93.6 %,\n Lymph:3.9 %, Mono:2.3 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:253 IU/L,\n Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n Imaging: CXR--CT in left chest with kink, small left sided effusion\n Microbiology: Fluid--2+ PMN's, GNR's\n Assessment and Plan\n 61 yo female with history of COPD who presented to with\n cholecystitis. She is s/p CCY with complication of bile leak with\n incomplete response to Exp Lap and now transfer to for ERCP and\n stent to aid in minimization of leak. Of note patient did have PTX and\n is s/p CT. Patient with relatively minimal respiratory compromise\n despite complicated course.\n 1)Cholecystitis/Bile Leak-\n -Dilaudid PCA\n -ERCP today for stent\n -Surgery Eval for support in post operative management and should exp\n lap be required\n 2)Peritonitis-\n -Continue with Vanco/Zosyn given significant GNR\ns seen on initial GS\n from fluid\n -Follow up cultures but GNR coverage would be important\n -Has history of E. Coli in past and would expect to be sensitive\n organism but will broaden coverage based upon clinical course or\n culture data\n -BC to continue\n 3)COPD-Chronic steroids and chronic home O2 would argue for persistent\n and severe COPD\n -Wean solumedrol as possible\n -Assure adequate bronchodilators\n 4) HOSPITAL ACQUIRED (PROCEDURE RELATED, BAROTRAUMA)\n -Ct to water seal\n -Continued moderate drainage\nbut minimal\n -Move to removal with PTX stable\nwe have one film without PTX seen here\n DIABETES MELLITUS (DM), TYPE II\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PANCREATITIS, ACUTE\n .H/O CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD, BRONCHITIS,\n EMPHYSEMA) WITH ACUTE EXACERBATION\n ICU Care\n Nutrition: NPO for now\nContinue TPN\nmove to po with abdominal issues\n (leak and peritonitis)\n Glycemic Control:\n Lines / Intubation:\n Arterial Line - 08:30 PM\nwill D/C today\n Multi Lumen - 08:30 PM\nWould favor change in line today\neven\n move to P-IV\ns at a minimum\nPICC reasonable\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Discussed in detail with patient need to\n change central venous catheters and patient refused.\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n"
},
{
"category": "Nutrition",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 363192,
"text": "Subjective\n Patient NPO\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 90 kg\n 31.8\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 59 kg\n 152\n 67\n Diagnosis: Bile leak\n PMH : DM, COPD, DVT, anxiety, others noted\n Food allergies and intolerances: none noted\n Pertinent medications: 40meq KCl, D51/2NS, \n Labs:\n Value\n Date\n Glucose\n 258 mg/dL\n 05:13 AM\n BUN\n 19 mg/dL\n 05:13 AM\n Creatinine\n 0.9 mg/dL\n 05:13 AM\n Sodium\n 141 mEq/L\n 05:13 AM\n Potassium\n 4.1 mEq/L\n 05:13 AM\n Chloride\n 106 mEq/L\n 05:13 AM\n TCO2\n 26 mEq/L\n 05:13 AM\n Albumin\n 2.6 g/dL\n 09:51 PM\n Calcium non-ionized\n 6.9 mg/dL\n 05:13 AM\n Phosphorus\n 3.1 mg/dL\n 05:13 AM\n Magnesium\n 2.1 mg/dL\n 05:13 AM\n Current diet order / nutrition support: NPO\n GI: abdomen obese/firm with hypoactive 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: 1475-1900 (BEE x or / 22-28 cal/kg)\n Protein: 100 (1.5 g/kg)\n Fluid: per team\n Specifics:\n 63 year old female s/p lap choly on c/b bile leak now s/ ex-lap at\n OSH found with bile duct injury, ischemic bowel, massive ileus\n transferred to for ERCP scheduled for this morning. Consult\n received for TPN recommendations. If TG <400, recommend goal TPN of\n 1.6L (265g dextrose/100g AA/35g lipids) to provide 1651kcal and 100g\n protein. Will follow for plan of care and results of ERCP.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Start with day one standard TPN with 70NaCl, 30NaPO4, 40KCl,\n 10MgSulf, 9Ca.\n 2. Please check triglycerides so lipids may be added if <400\n 3. Continue with , add insulin to TPN PRN.\n 09:42 AM\n"
},
{
"category": "Case Management ",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Case Managment Initial Patient Assessment",
"row_id": 363248,
"text": "Insurance information\n Primary insurance: MEDICARE A B (HOSP MED INS)\n Secondary insurance: MASSHEALTH/SECONDARY TO MEDICARE\n Insurance reviewer::\n Free Care application: N/A\n Status:\n Medicaid application: N/A\n Pre-Hospitalization services:\n DME / Home O[2]:\n Functional Status / Home / Family Assessment:\n Pt. lives with her family in . She was independent with ADL's\n prior to her admission to .\n Primary Contact(s): (son) (\n Health Care Proxy: .\n Dialysis: No\n Referrals Recommended:\n Current plan: Undetermined\n Return to . Per ICU team the ICU attending has spoken to\n her transferring physician at and he has agreed to\n accept her back. Transfer is planned for Saturday .\n Patient (s) to Discharge:\n None\n Patient discussed with multidisciplinary team: Yes\n"
},
{
"category": "Case Management ",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Case Management Discharge Plan",
"row_id": 363252,
"text": "Case manager: \n Pager #: \n Discharge Plan: Acute Hospital\n \n Home with services:\n VNA / Home infusion:\n Acute rehab:\n Skilled nursing facility:\n Patient on Vent: Non-Vent\n Long term care custodial non-Medicare certified:\n : No\n hospital: No\n Hospice inpatient: No\n Hospice home: No\n DME: No\n Transportation: Yes - Ambulance\n Free care pharmacy :\n Patient/Family/Team understand and agree with plan: Yes\n Required documentation: Discharge Summary,Page 1,Page 2\n Comments: Discharge back to following an ERCP.\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 363164,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Surgery was consulted given her recent surgery and poor clinical\n status and recommended awaiting the ERCP results.\n Allergies:\n Celebrex (Oral) (Celecoxib)\n Hives;\n Zithromax (Oral) (Azithromycin)\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:18 AM\n Metronidazole - 01:18 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:50 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:35 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 (98.5\n HR: 71 (71 - 89) bpm\n BP: 112/59(79) {105/56(76) - 175/82(116)} mmHg\n RR: 11 (10 - 20) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 74 mL\n 958 mL\n PO:\n TF:\n IVF:\n 74 mL\n 958 mL\n Blood products:\n Total out:\n 150 mL\n 540 mL\n Urine:\n 150 mL\n 430 mL\n NG:\n Stool:\n Drains:\n 110 mL\n Balance:\n -76 mL\n 418 mL\n Respiratory support\n O2 Delivery Device: High flow neb\n SpO2: 91% on FiO2 of 50%\n ABG: ///26/\n Physical Examination\n General Appearance: Overweight / Obese, Anxious\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: diffuse), left sided chest tube in place, dressing C/D/I\n Abdominal: No(t) Non-tender, Distended, Tender: diffusely, particularly\n in RLQ, Obese, distended; tympanic to percussion. bandage in place.\n C/D/I. JP drain present with bilious fluid\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): A/O x 3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 189 K/uL\n 9.3 g/dL\n 258 mg/dL\n 0.9 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 106 mEq/L\n 141 mEq/L\n 29.0 %\n 6.1 K/uL\n [image002.jpg]\n 09:51 PM\n 05:13 AM\n WBC\n 8.0\n 6.1\n Hct\n 31.0\n 29.0\n Plt\n 229\n 189\n Cr\n 0.9\n 0.9\n Glucose\n 162\n 258\n Other labs: PT / PTT / INR:16.3/29.8/1.5, ALT / AST:17/16, Alk Phos / T\n Bili:106/0.4, Amylase / Lipase:25/8, Differential-Neuts:93.6 %,\n Lymph:3.9 %, Mono:2.3 %, Eos:0.1 %, Albumin:2.6 g/dL, LDH:253 IU/L,\n Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:3.1 mg/dL\n 5:13 am PERITONEAL FLUID\n GRAM STAIN (Final ):\n REPORTED BY PHONE TO @ 6:05A .\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).\n FLUID CULTURE (Preliminary):\n ANAEROBIC CULTURE (Preliminary):\n Assessment and Plan\n ASSESSMENT/PLAN: 63 y/o lady with COPD,diabetes, and h/o DVT is\n transfered from OSH after exploratory laparotomy for bile duct leak\n following cholecystectomy, now POD #2, also s/p left CVL placement with\n subsequent PTX s/p left chest tube placement, transferred here for ERCP\n planned for this am to address continued bile duct leak\n # Bile duct leak: patient underwent cholecystecomy on , followed by\n exploratory laparotomy on found to have 2 cm hole at cystic duct\n with bilious drainiage, and 1L of bilious ascites, and likely\n peritonitis given acute abdomen. Currently hemodynamically stable, but\n with significant abdominal pain, and plan for ERCP in AM to correct\n continued bile leak\n - supine abdominal film to look for ileus or obstruction\n - surgical consult to follow post ex/lap\n - ERCP in AM, NPO for now\n - cont vanco/levo/flagyl for now for bacterial peritonitis in the\n setting of bile duct leak\n - check LFTs, amylase, lipase\n - bowel meds PR PRN\n # Left PTX: s/p CVL placement and now with chest tube in place. no air\n leak noted\n - water seal for now\n - CXR to eval for PTX\n - can attempt repeat CVL on left subclavian to remove femoral CVL\n # COPD: was intubated at postoperatively, but self extubated.\n Transferred on ventimask 50% FIO2.\n - wean O2 as torated\n - NEBS prn\n - solumedrol 20 mg IV q8H\n # h/o DVT/PE: on coumadin as outpt; holding for now given procedure.\n - will hold for now; likely can restart after ERCP\n - hold off on heparin gtt for now since patient has wound, and\n considering central line placement\n # Diabetes: HISS\n # Hypothyroidism: on levothyroxine 112 mcg daily as an outpatient.\n - convert to IV for now 50 mcg daily as NPO\n # Depression: will hold cymbalta for now\n # FULL CODE\n ICU Care\n Nutrition: NPO for ERCP today\n -Had been on TPN, will consult nutrition for TPN recs.\n Glycemic Control:\n Lines: Will need a new central line and A-line placed today as her\n lines were placed at an OSH. Refused line placement overnight.\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 PM\n Prophylaxis:\n DVT: Pneumoboots\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2119-02-09 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 363112,
"text": "TITLE:\n Chief Complaint: Transfered from OSH s/p cholecystectomy with bile\n leak followed by ex lap with drainage of bilious fluid, and\n pneumothorax s/p CVL placement being transferred for ERCP to correct\n continue leak\n HPI:\n 61 yo female with h/o DM2, COPD on home O2, h/o DVT/PE, transferred\n from . She underwent cholecystectomy on then\n represented to for abdominal pain. She was found to\n have significant ileus and ascites, and underwent exploratory\n laparotomy which showed a 2cm hole in the base of the systic duct with\n 1 Liter bilious ascites. There was ischemic bowel with massive ileus\n and distention due to bile peritonitis. Her hospitalization was also\n complicated by a CVL placement with subsequent pneumothorax. A left\n sided chest tube was place, and also a right femoral line was placed.\n She is being transferred here for ERCP in AM to fix the continued bile\n leakage. Of note, she has been treated with vancomycin, metronidazole,\n and levofloxacin at for peritonitis.\n Currently, she states she is having severe pain in her abdomen. She\n denies CP. Her breathing is slightly labored, but she thinks that's\n secondary to her large abdomen. She otherwise denies fevers, chills,\n headache, or any other symptoms. She request pain medications. She\n was on a dilaudid PCA at the OSH.\n Also on chroinc steroids for COPD.\n Patient admitted from: Transfer from other hospital\n History obtained from Patient\n Allergies:\n Celebrex (Oral) (Celecoxib)\n Hives;\n Zithromax (Oral) (Azithromycin)\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n MEDICATIONS ON TRANSFER:\n 1. Fortical 1 spray each nostril every 48 hrs\n 2. Vitamin B12 1000 mcg every 30 days\n 3. Dilaudid PCA (dose unclear)\n 4. Narcan PRN\n 5. Zofran 4 mg IV q6H PRN\n 6. Dilaudid 1 mg q4H PRN\n 7. tylenol 650 mg Q6H PRN\n 8. Lopressor 5 mg IV q2H PRN HR>120\n 9. Fentanyl Citrate 25 mcg q30 mins PRN\n 10. HISS\n 11. Solumedrol 20 mg IV x 3 days\n 12. Spiriva inhaler 1 puff daily\n 13. Advair 500/50 puff \n 14. Xopenex 1.25 mg q4H PRN\n 15. Coumadin 2 mg daily (currently held)\n 16. Protonix 40 mg IV daily\n 17. Levofloxacin 500 mg IV daily\n 18. Metronidazole 500 q8H\n 19. Vancomycin 1 gm q12h\n 20. TPN daily\n ADMISSION MEDICATIONS:\n 1. KCL 40 meq 3 x daily\n 2. Spiriva 18 mcg INH daily\n 3. Fortical 1 spray alternating nostrils daily\n 4. Vitamin D 400 units daily\n 5. Prednisone 30 mg daily\n 6. Mag oxide 400 mg \n 7. MVI daily\n 8. Trazadone 50 mg qhs\n 9. Advair 1 puff \n 10. Amoxicillin 500 mg \n 11. Neurontin 300 mg TID\n 12. Oxycodone 50 mg q6H PRN\n 13. Singulair 10 mg daily\n 14. Cymbalta 60 mg daily\n 15. Lasix 40 mg daily\n 16. Protonix 40 mg \n 17. Synthroid 112 mcg daily\n 18. B12 1000 mcg IM monthly\n 19. Iron 325 mg daily\n 20. Oxycontin 20 mg \n 21. Xopenex 1 puf q4H PRN\n 22. Dilaudid 2 mg PO q4H PRN\n 23. Coumadin 2 mg daily\n 24. Ativan 0.5 mg \n 25. Albuterol INH q4h prn\n 26. Atroven neb q4H PRN\n Past medical history:\n Family history:\n Social History:\n 1. Diabetes\n 2. Chronoc obstructive pulmonary disease\n 3. T9-10 vertebral fractures.\n 4. h/o DVT/PE\n 5. Chronic back pain\n 6. Right knee osteonecrosis s/p right knee replacement \n 7. Hyperthyroidism\n 8. Anxiety\n 9. Enterococcus bactermia\n non contributory\n Occupation: retired\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: lives independantly\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea, No(t) Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Pain: Severe\n Pain location: abdomen\n Flowsheet Data as of 11:44 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: 89 (79 - 89) bpm\n BP: 175/81(115) {116/56(76) - 175/82(116)} mmHg\n RR: 17 (13 - 19) 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 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -150 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n General Appearance: Overweight / Obese, Anxious\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: diffuse), left sided chest tube in place, dressing C/D/I\n Abdominal: No(t) Non-tender, Distended, Tender: diffusely, particularly\n in RLQ, Obese, distended; tympanic to percussion. bandage in place.\n C/D/I. JP drain present with bilious fluid\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): A/O x 3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 229 K/uL\n 10.0 g/dL\n 162 mg/dL\n 0.9 mg/dL\n 22 mg/dL\n 26 mEq/L\n 110 mEq/L\n 3.6 mEq/L\n 145 mEq/L\n 31.0 %\n 8.0 K/uL\n [image002.jpg]\n \n 2:33 A1/29/ 09:51 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.0\n Hct\n 31.0\n Plt\n 229\n Cr\n 0.9\n Glucose\n 162\n Other labs: PT / PTT / INR:16.3/29.8/1.5, ALT / AST:17/16, Alk Phos / T\n Bili:106/0.4, Amylase / Lipase:25/8, Differential-Neuts:96.0 %,\n Lymph:2.0 %, Mono:1.8 %, Eos:0.2 %, Albumin:2.6 g/dL, LDH:253 IU/L,\n Ca++:7.1 mg/dL, Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Imaging: CXR: Pending\n Abd XRY: pending\n ECG: ECG: sinus, no significant ST changes of ECG at OSH\n Assessment and Plan\n ASSESSMENT/PLAN: 63 y/o lady with COPD,diabetes, and h/o DVT is\n transfered from OSH after exploratory laparotomy for bile duct leak\n following cholecystectomy, now POD #2, also s/p left CVL placement with\n subsequent PTX s/p left chest tube placement, transferred here for ERCP\n in AM to address continued bile duct leak\n 1. Bile duct leak: patient underwent cholecystecomy on , followed\n by exploratory laparotomy on found to have 2 cm hole at cystic\n duct with bilious drainiage, and 1L of bilious ascites, and likely\n peritonitis given acute abdomen. Currently hemodynamically stable, but\n with significant abdominal pain, and plan for ERCP in AM to correct\n continued bile leak\n - supine abdominal film to look for ileus or obstruction\n - surgical consult to follow post ex/lap\n - ERCP in AM, NPO for now\n - cont vanco/levo/flagyl for now for bacterial peritonitis in the\n setting of bile duct leak\n - check LFTs, amylase, lipase\n - bowel meds PR PRN\n 2. Left PTX: s/p CVL placement and now with chest tube in place. no air\n leak noted\n - water seal for now\n - CXR to eval for PTX\n - can attempt repeat CVL on left subclavian to remove femoral CVL\n 3. COPD: was intubated at postoperatively, but self extubated.\n Transferred on ventimask 50% FIO2.\n - wean O2 as torated\n - NEBS prn\n - solumedrol 20 mg IV q8H\n 4. h/o DVT/PE: on coumadin as outpt; holding for now\n - will hold for now; likely can restart after ERCP\n - hold off on heparin gtt for now since patient has wound, and\n considering central line placement\n 5. Diabetes: HISS\n 6. Hypothyroidism: on levothyroxine 112 mcg daily\n - convert to IV for now 50 mcg daily\n 7. Depression: will hold cymbalta for now\n 8. FEN: NPO for now. Repelete lytes PRN.\n - TPN recommendations\n 9. PPx: pneumoboots for now; consider restarting coumadin after ERCP,\n can start hep gtt until therapeutic INR. PPI.\n 10. Access: right femoral CVL, left A-line; will place new CVL and\n remove A line\n 11. Communication: patient\n 12. FULL CODE\n 13. Dispo: ERCP in AM\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 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": "Physician ",
"chartdate": "2119-02-10 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 363115,
"text": "TITLE:\n Chief Complaint: Transfered from OSH s/p cholecystectomy with bile\n leak followed by ex lap with drainage of bilious fluid, and\n pneumothorax s/p CVL placement being transferred for ERCP to correct\n continue leak\n HPI:\n 61 yo female with h/o DM2, COPD on home O2, h/o DVT/PE, transferred\n from . She underwent cholecystectomy on then\n represented to for abdominal pain. She was found to\n have significant ileus and ascites, and underwent exploratory\n laparotomy which showed a 2cm hole in the base of the systic duct with\n 1 Liter bilious ascites. There was ischemic bowel with massive ileus\n and distention due to bile peritonitis. Her hospitalization was also\n complicated by a CVL placement with subsequent pneumothorax. A left\n sided chest tube was place, and also a right femoral line was placed.\n She is being transferred here for ERCP in AM to fix the continued bile\n leakage. Of note, she has been treated with vancomycin, metronidazole,\n and levofloxacin at for peritonitis.\n Currently, she states she is having severe pain in her abdomen. She\n denies CP. Her breathing is slightly labored, but she thinks that's\n secondary to her large abdomen. She otherwise denies fevers, chills,\n headache, or any other symptoms. She request pain medications. She\n was on a dilaudid PCA at the OSH.\n Also on chroinc steroids for COPD.\n Patient admitted from: Transfer from other hospital\n History obtained from Patient\n Allergies:\n Celebrex (Oral) (Celecoxib)\n Hives;\n Zithromax (Oral) (Azithromycin)\n Unknown;\n Sulfa (Sulfonamides)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n MEDICATIONS ON TRANSFER:\n 1. Fortical 1 spray each nostril every 48 hrs\n 2. Vitamin B12 1000 mcg every 30 days\n 3. Dilaudid PCA (dose unclear)\n 4. Narcan PRN\n 5. Zofran 4 mg IV q6H PRN\n 6. Dilaudid 1 mg q4H PRN\n 7. tylenol 650 mg Q6H PRN\n 8. Lopressor 5 mg IV q2H PRN HR>120\n 9. Fentanyl Citrate 25 mcg q30 mins PRN\n 10. HISS\n 11. Solumedrol 20 mg IV x 3 days\n 12. Spiriva inhaler 1 puff daily\n 13. Advair 500/50 puff \n 14. Xopenex 1.25 mg q4H PRN\n 15. Coumadin 2 mg daily (currently held)\n 16. Protonix 40 mg IV daily\n 17. Levofloxacin 500 mg IV daily\n 18. Metronidazole 500 q8H\n 19. Vancomycin 1 gm q12h\n 20. TPN daily\n ADMISSION MEDICATIONS:\n 1. KCL 40 meq 3 x daily\n 2. Spiriva 18 mcg INH daily\n 3. Fortical 1 spray alternating nostrils daily\n 4. Vitamin D 400 units daily\n 5. Prednisone 30 mg daily\n 6. Mag oxide 400 mg \n 7. MVI daily\n 8. Trazadone 50 mg qhs\n 9. Advair 1 puff \n 10. Amoxicillin 500 mg \n 11. Neurontin 300 mg TID\n 12. Oxycodone 50 mg q6H PRN\n 13. Singulair 10 mg daily\n 14. Cymbalta 60 mg daily\n 15. Lasix 40 mg daily\n 16. Protonix 40 mg \n 17. Synthroid 112 mcg daily\n 18. B12 1000 mcg IM monthly\n 19. Iron 325 mg daily\n 20. Oxycontin 20 mg \n 21. Xopenex 1 puf q4H PRN\n 22. Dilaudid 2 mg PO q4H PRN\n 23. Coumadin 2 mg daily\n 24. Ativan 0.5 mg \n 25. Albuterol INH q4h prn\n 26. Atroven neb q4H PRN\n Past medical history:\n Family history:\n Social History:\n 1. Diabetes\n 2. Chronoc obstructive pulmonary disease\n 3. T9-10 vertebral fractures.\n 4. h/o DVT/PE\n 5. Chronic back pain\n 6. Right knee osteonecrosis s/p right knee replacement \n 7. Hyperthyroidism\n 8. Anxiety\n 9. Enterococcus bactermia\n non contributory\n Occupation: retired\n Drugs: none\n Tobacco: none\n Alcohol: none\n Other: lives independantly\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\n Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO\n Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, Nausea, No(t) Emesis, No(t) Diarrhea,\n No(t) Constipation\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Pain: Severe\n Pain location: abdomen\n Flowsheet Data as of 11:44 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: 89 (79 - 89) bpm\n BP: 175/81(115) {116/56(76) - 175/82(116)} mmHg\n RR: 17 (13 - 19) 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 150 mL\n Urine:\n 150 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -150 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 93%\n ABG: ///26/\n Physical Examination\n General Appearance: Overweight / Obese, Anxious\n Eyes / Conjunctiva: PERRL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: diffuse), left sided chest tube in place, dressing C/D/I\n Abdominal: No(t) Non-tender, Distended, Tender: diffusely, particularly\n in RLQ, Obese, distended; tympanic to percussion. bandage in place.\n C/D/I. JP drain present with bilious fluid\n Extremities: Right: 1+, Left: 1+\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): A/O x 3, Movement: Purposeful, Tone: Normal\n Labs / Radiology\n 229 K/uL\n 10.0 g/dL\n 162 mg/dL\n 0.9 mg/dL\n 22 mg/dL\n 26 mEq/L\n 110 mEq/L\n 3.6 mEq/L\n 145 mEq/L\n 31.0 %\n 8.0 K/uL\n [image002.jpg]\n \n 2:33 A1/29/ 09:51 PM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 8.0\n Hct\n 31.0\n Plt\n 229\n Cr\n 0.9\n Glucose\n 162\n Other labs: PT / PTT / INR:16.3/29.8/1.5, ALT / AST:17/16, Alk Phos / T\n Bili:106/0.4, Amylase / Lipase:25/8, Differential-Neuts:96.0 %,\n Lymph:2.0 %, Mono:1.8 %, Eos:0.2 %, Albumin:2.6 g/dL, LDH:253 IU/L,\n Ca++:7.1 mg/dL, Mg++:2.2 mg/dL, PO4:3.3 mg/dL\n Imaging: CXR: Pending\n Abd XRY: pending\n ECG: ECG: sinus, no significant ST changes of ECG at OSH\n Assessment and Plan\n ASSESSMENT/PLAN: 63 y/o lady with COPD,diabetes, and h/o DVT is\n transfered from OSH after exploratory laparotomy for bile duct leak\n following cholecystectomy, now POD #2, also s/p left CVL placement with\n subsequent PTX s/p left chest tube placement, transferred here for ERCP\n in AM to address continued bile duct leak\n 1. Bile duct leak: patient underwent cholecystecomy on , followed\n by exploratory laparotomy on found to have 2 cm hole at cystic\n duct with bilious drainiage, and 1L of bilious ascites, and likely\n peritonitis given acute abdomen. Currently hemodynamically stable, but\n with significant abdominal pain, and plan for ERCP in AM to correct\n continued bile leak\n - supine abdominal film to look for ileus or obstruction\n - surgical consult to follow post ex/lap\n - ERCP in AM, NPO for now\n - cont vanco/levo/flagyl for now for bacterial peritonitis in the\n setting of bile duct leak\n - check LFTs, amylase, lipase\n - bowel meds PR PRN\n 2. Left PTX: s/p CVL placement and now with chest tube in place. no air\n leak noted\n - water seal for now\n - CXR to eval for PTX\n - can attempt repeat CVL on left subclavian to remove femoral CVL\n 3. COPD: was intubated at postoperatively, but self extubated.\n Transferred on ventimask 50% FIO2.\n - wean O2 as torated\n - NEBS prn\n - solumedrol 20 mg IV q8H\n 4. h/o DVT/PE: on coumadin as outpt; holding for now\n - will hold for now; likely can restart after ERCP\n - hold off on heparin gtt for now since patient has wound, and\n considering central line placement\n 5. Diabetes: HISS\n 6. Hypothyroidism: on levothyroxine 112 mcg daily\n - convert to IV for now 50 mcg daily\n 7. Depression: will hold cymbalta for now\n 8. FEN: NPO for now. Repelete lytes PRN.\n - TPN recommendations\n 9. PPx: pneumoboots for now; consider restarting coumadin after ERCP,\n can start hep gtt until therapeutic INR. PPI.\n 10. Access: right femoral CVL, left A-line; will place new CVL and\n remove A line\n 11. Communication: patient\n 12. FULL CODE\n 13. Dispo: ERCP in AM\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:30 PM\n Multi Lumen - 08:30 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": "2119-02-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 363319,
"text": "61 yo female with h/o DM2, COPD on home O2, h/o DVT/PE, transferred\n from . She underwent cholecystectomy on then\n represented to for abdominal pain. She was found to\n have significant ileus and ascites, and underwent exploratory\n laparotomy which showed a 2cm hole in the base of the cystic duct with\n 1 Liter bilious ascites. There was ischemic bowel with massive ileus\n and distention due to bile peritonitis. Her hospitalization was also\n complicated by a CVL placement with subsequent pneumothorax. A left\n sided chest tube was place, and also a right femoral line was placed.\n She is being transferred here for ERCP in AM to fix the continued bile\n leakage. She has been treated with vancomycin, metronidazole, and\n levofloxacin at for peritonitis.\n Pain control (acute pain, chronic pain)\n Assessment:\n Screams of pain upon waking up but falls asleep right after,\n intermittently complaining of pain incision site. Suture\n intact, incision no signs of infection.\n Action:\n Received diluadid mgs q2hrs but has been getting 1 mg q2hrs\n together with 0.5 mgs of Ativan IV\n Response:\n Slept well compared to yesterday, tolerating turning better than\n previous night.\n Plan:\n Continue present pain regimen\n Peritonitis, acute\n Assessment:\n s/p cholecystectomy, JP draining with bile; afebrile WBC 8.0 latest,\n s/p ERCP to correct bile leak\n Action:\n Continues on zosyn IV; NPO for now\n started on D51/2NS at 75cc/hr\n Response:\n 50cc of bile from JP drain, afebrile\n Plan:\n Continue to monitor\n .H/O chronic obstructive pulmonary disease (COPD, Bronchitis,\n Emphysema) with Acute Exacerbation\n Assessment:\n s/p extubation for ERCP - non-labored breathing , lung sounds clear,\n dim at bases\n no wheezing noted.\n Action:\n prednisone tapered, O2 titrated down as tolerated\n Response:\n Sats ~ 92-93% 2 lpm via nasal cannula; tolerating flat in bed for a\n short time\n Plan:\n titrate FiO2 to keep sats > 90%\n Diabetes Mellitus (DM), Type II\n Assessment:\n History on IDDM, FS at MN 164\n Action:\n received 2 unit of humalog; kept NPO for lethargy, continuous on D51/2\n NS at 75cc/hr\n Response:\n No signs and symptoms of hypo or hyperglycemia\n Plan:\n Nutrition consult for TPN\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1059980,
"text": " 5:28 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: PTX\n Admitting Diagnosis: BILE LEAK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p chest tube removal\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n WET READ: GWp 7:15 PM\n Chest tube removed, no PTX, L basal atelectasis / effusion GWlms\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Chest tube removal.\n\n Single portable radiograph of the chest excludes the right costophrenic angle.\n There are bilateral pleural effusions, worse on the left than the right,\n similar to that seen on the radiograph obtained earlier the same day. The\n left-sided chest tube has been removed. No pneumothorax is identified.\n Cardiomediastinal contours are similar in appearance. The patient is again\n noted to be status post thoracic and lumbar vertebroplasty. Osseous\n remodeling and flattening of the left humeral head is similar to that present\n on and may represent the sequela of avascular necrosis. A\n radiopaque catheter projects over the right upper quadrant. There is mild\n increased airspace opacity involving both lungs.\n There is linear and plate-like atelectasis involving the left lower lung.\n\n IMPRESSION:\n\n Interval removal of left-sided chest tube. No pneumothorax.\n\n Persistent bilateral pleural effusions, worse on the left than the right.\n\n AVN of the left humeral head, unchanged.\n\n Mild CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-10 00:00:00.000",
"description": "ERCP BILIARY ONLY BY GI UNIT",
"row_id": 1060386,
"text": " 4:33 PM\n ERCP BILIARY ONLY BY GI UNIT Clip # \n Reason: Please review ERCP images done \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old female. S/p ccy 1/20/9 complicated by bile leak. Ex lap 1/28/9 2mm\n defect in Cystic duct remnant sutured. Left sided pneumothorax after central\n line insertion. Hx of COPD - O2 dependent. Transfered from to\n for ERCP.\n REASON FOR THIS EXAMINATION:\n Please review ERCP images done \n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cholecystectomy complicated by bile leak.\n\n ERCP.\n\n COMPARISON: None.\n\n FINDINGS: Sixteen spot fluoroscopic images were obtained during ERCP and are\n provided for review. Scout radiograph demonstrates a drainage catheter along\n the inferior aspect of the liver margin. Multiple skin staples are seen\n projecting over the inferior aspect of the field of view and radiodense\n material is seen within at least one vertebral body, which is likely related\n to prior kyphoplasty surgery. Following injection of contrast into the\n biliary tree, there is mild dilatation of the common bile duct. No luminal\n filling defects were seen. There is either minimal contrast extravasation\n from the cystic duct remnant or rather simply visualization of the cystic duct\n remnant without contrast extravasation. Additional delayed imaging may have\n been helpful in making this assessment. A plastic stent catheter was\n positioned at the end of the procedure. For full details, please refer to the\n patient's ERCP note from the same day.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1059776,
"text": " 9:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate vs pulmonary edema and pneumothorax\n Admitting Diagnosis: BILE LEAK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with COPD, s/p abdominal surgery for bile leak with O2\n requirement s/p left CVL placement c/b pneumothorax\n REASON FOR THIS EXAMINATION:\n eval for infiltrate vs pulmonary edema and pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:12 P.M. ON \n\n HISTORY: Abdominal surgery for bile leak. Hypoxia. Left central venous line\n placement, rule out pneumothorax.\n\n IMPRESSION: AP chest compared to , most recent prior chest\n radiograph:\n\n Tubing projected over the left lower hemithorax could be a pleural drain,\n impinges on the mediastinum and then could be folded quite sharply, to the\n point of occlusion. Clinical examination recommended. Thickening of the left\n apical pleural margin extends into the mediastinum is new concerning for\n hematoma related to line insertion attempt. No radiopaque central venous\n catheter is seen. Mild left lower lobe atelectasis is new. Heart size is\n normal. Stomach is moderately distended with air and a right upper quadrant\n drainage catheter is at the lower margin of the liver.\n\n I discussed these findings with the house officer who answered Dr\n page at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-09 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 1059777,
"text": " 9:53 PM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: eval for ileus or obstruction\n Admitting Diagnosis: BILE LEAK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with COPD, s/p abdominal surgery for bile leak with O2\n requirement s/p left CVL placement c/b pneumothorax\n REASON FOR THIS EXAMINATION:\n eval for ileus or obstruction\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw 12:33 PM\n Air-filled minimally distended loops of colon which may represent ileus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post abdominal surgery for bile leak with oxygen requirement.\n\n COMPARISON: None.\n\n TWO SUPINE ABDOMINAL RADIOGRAPHS:\n\n FINDINGS: There are air-filled minimally distended loops of colon. Small bowel\n loops are not distended. Equivocal contrast which may be from a prior CT or\n barium study is apparent in the area of the cecum. Surgical staples project\n over the patient's low abdomen and there is a drainage catheter along the\n inferior margin of the liver. There are extensive degenerative changes of the\n spine and at multiple levels, there is radiodense material seen within the\n vertebral bodies related to prior kyphoplasty procedures. There is a right-\n sided femoral catheter line whose tip projects just superior to the femoral\n head. An additional catheter projects over the left femoral head, which may\n represent an additional femoral catheter, but would recommend clinical\n correlation. Minimal bibasilar atelectasis is seen and there is a left-sided\n chest tube. No evidence for pneumothorax, however, the lungs are not well\n evaluated on this study. Air is seen in a distended stomach.\n\n IMPRESSION: Air-filled stomach and minimally air-filled colonic loops. No\n evidence for obstruction. Residual oral contrast material seen in the area of\n the cecum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-09 00:00:00.000",
"description": "P ABDOMEN (SUPINE ONLY) PORT",
"row_id": 1059778,
"text": ", S. MED 9:53 PM\n ABDOMEN (SUPINE ONLY) PORT Clip # \n Reason: eval for ileus or obstruction\n Admitting Diagnosis: BILE LEAK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with COPD, s/p abdominal surgery for bile leak with O2\n requirement s/p left CVL placement c/b pneumothorax\n REASON FOR THIS EXAMINATION:\n eval for ileus or obstruction\n ______________________________________________________________________________\n PFI REPORT\n Air-filled minimally distended loops of colon which may represent ileus.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-02-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1059873,
"text": " 11:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pneumothorax, planning for d/c of chest tube if\n Admitting Diagnosis: BILE LEAK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman s/p pneumothorax and chest tube, stable respiratory status\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax, planning for d/c of chest tube if stable x-ray\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:45 A.M., .\n\n HISTORY: Prior pneumothorax. Chest tube in place.\n\n IMPRESSION: AP chest compared to 10:12 p.m. on :\n\n Left basal pleural tube is sharply folded as it impinges on the mediastinum,\n and may be effectively occluded. Pleural effusion, if any, is small. No\n pneumothorax. Lobular thickening of the left apical pleural margin could be\n either loculated effusion or extrapleural hematoma from attempted line\n placement, as discussed with the house officer caring for this patient earlier\n in the day. Severe left lung atelectasis is unchanged.\n\n Marked azygos distention in part reflects supine positioning nevertheless\n indicates elevated central venous pressure or volume. The heart is probably\n not enlarged.\n\n"
}
] |
20,130 | 104,449 | He presented on to hospital after he had an epidsode of tachycardia to 160 at followed by hypotension after treatment with IV lopressor. He was given a 1 L fluid bolus, to which his pressure responded. Questionable episode of atrial fibrillation. Upon presentation he was in normal sinue rhythym but denies dizziness, SOB, or CP. Currently he is asymptomatic with the exception of lower abdominal discomfort. Pt admitted to 10 for observation. On hospital day #2 pt was monitored on telemetry. Cardiology was consulted, and pt was started on diltiazem 30mg PO QID and Lopressor 25 PO TID for better rate control. He was transfered to the ICU for monitoring of recurrent Atrial flutter. His Digoxin was discontinued. Pt initially declined to undergo cardiac catheterization procedure to ablate aberrant pacemaker focus and was continually monitored by telemetry. On pt decided to undergo cardiac catheterization procedure. His amiodarone was discontinued and his coumadin was discontinued to get his INR<2.0 for the ablative procedure by electrophysiology. On , Pt was given 1 unit FFP and taken to electrophysiology labs for ablation of aberrant atrial focus. Pt did well post-procedure and remained in normal sinue rhythym. He was discharged to home w/ VNA services on on Coumadin 1mg, FK506 1mg PO BID, and rapamycin 4mg qday. Per Cards his INR is to remain and he is to follow-up in cardiology clinic. | Distal pulses palp.Resp status: bbs clear diminish bibas. There has been interval removal of a right internal jugular venous catheter. A few small epicardial lymph nodes and diaphragmatic lymph nodes are identified, unchanged from previous examination. Mild coronary artery calcification is seen. Mild mitral annularcalcification. Sinus rhythm with top normal P-R interval. PATIENT/TEST INFORMATION:Indication: Atrial fibrillation/flutter.Height: (in) 67Weight (lb): 171BSA (m2): 1.89 m2BP (mm Hg): 150/70HR (bpm): 88Status: InpatientDate/Time: at 14:12Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). IMPRESSION: Multiple dilated loops of small and large bowel, with air-fluid levels consistent with an ileus. Compared to the previous tracing of atrial flutteris now present. Abd soft distended w + bowel snds. Bun/Cr^ see carevue for details.Heme/Id: hct stable wbc flat. Simple cysts are identified in the left kidney unchanged from previous. The left atrium is mildly dilated.2. TECHNIQUE: Multidetector CT acquisitions of the abdomen and pelvis were acquired after the administration of oral contrast only. 3)Bilateral renal calculi in a pattern suggesting nephrocalcinosis . Normal regional LV systolic function.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending aorta diameter.AORTIC VALVE: Normal aortic valve leaflets (3). No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. CT OF ABDOMEN: The liver appears normal. Sinus rhythmBorderline first degree A-V blockST-T configuration consistent with early repolarization pattern/ normal variantSince previous tracing of , no significant change Regional left ventricular wall motionis normal.3. There is mild symmetric left ventricular hypertrophy with normal cavitysize and systolic function (LVEF>55%). ABDOMEN, THREE VIEWS: There are staples seen in the right upper quadrant. REPORT: There is bilateral gynecomastia present. There is probably some periportal tracking, based on the apparent presence of an attenuation difference either side of the portal vessel.A stent is seen in the SMA. rt brth snds slt less audible.Dry nonprod cough.Gu status: huo bdline icteric. Trivial MR. LV inflow pattern c/w impaired relaxation.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Compared with the findings of the prior study, there hasbeen no significant change.Conclusions:1. There are minimal ill-defined patchy left lower lobe opacities consistent with atelectasis. COMPARISON: CT from . Trivial mitralregurgitation is seen.4. Anemia is likely, based on the attenuation of the aortic wall and the left ventricle. Minimal patchy left lower lobe atelectasis. COMMENTS: Single portable AP view of the chest is reviewed and compared to AP view of the chest from . Tmax 97.8A/P:Hyperglycemic-> titrate gtt to gluc <120. There are distended loops of small and large bowel. For evaluation to rule out intra-abdominal pathology. obstruction CONTRAINDICATIONS for IV CONTRAST: Poor renal function FINAL REPORT CT OF ABDOMEN AND PELVIS. Changes of portal hypertension are manifest throughout the abdomen and pelvis. The heart size is at the upper limits of normal for the patient's age. Cont po lopr and dilt. Surgical skin staples are noted over the right upper abdominal quadrant. Air is seen distally as far as the rectum. The degree of large bowel distention is now less than from previous examination, although this large bowel is still distended to 6.5 cm in the transverse colon. Compared to the previous tracing of cardiac rhythm nowsinus mechanism. CONCLUSION: 1)Examination is limited by lack of intravenous contrast, but allowing for this there has been little change from , with some mild large and small bowel distention, likely in keeping with postoperative ileus. Within both renal parenchyma, there are focal areas of increased attenuation, largely based in the medullary region, consistent with medullary nephrocalcinosis with calculus formation. CT OF PELVIS: A Foley catheter is identified within the bladder which contains air.The amount of intra-abdominal and pelvic fluid and anasarca have all slightly increased from previous study. 2:30 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # CT RECONSTRUCTION Reason: ? Extensive retroperitoneal and intra-abdominal varices are seen. (Over) 2:30 PM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # CT RECONSTRUCTION Reason: ? Compared with the findings of the prior study of , there has been nosignificant change. Multiple air-fluid levels are noted in both the colon as well as the small bowel. Ct mon showed FOS. The mitral valve leaflets are mildly thickened. There is borderline or mild distention to approximately 3 cm. obstruction Admitting Diagnosis: RAPID ATRIAL FIBRILLATION;STATUS POST LIVER TRANSPLANT FINAL REPORT (Cont) Again in the right flank and anterior abdominal wall postsurgical defects are seen. Diffuse non-specificST-T wave changes. Both adrenal glands are normal. The right kidney measures 9.8 cm in CC dimensions. 7:55 PM ABDOMEN (SUPINE & ERECT) Clip # Reason: ? The heart size is normal. Some degenerative disease identified in the lower spine levels. INDICATION: The patient is status post liver transplantation. The left kidney measures 12.8 cm. Overall this is unchanged from previous examination. Non-diagnostic repolarizationabnormalities. Atrial flutter with a rapid ventricular response. The spleen is enlarged and measures 18.6 cm in maximum dimensions. | 9 | [
{
"category": "Nursing/other",
"chartdate": "2117-08-13 00:00:00.000",
"description": "Report",
"row_id": 1527000,
"text": "FOCUS: CONDITION UPDATE\nD: PATIENT TRANSFERRED FROM 10 TO SICU DURING EARLY AM FOR CONTROL OF RAPID A FLUTTER.\nOTHER VSS DURING THIS TIME, PATIENT STARTED ON DILT. DRIP AT 15MG/HR, MAG TREATED WITH 2 GM MAG.\nHEART RATE SLOWLY DECREASED, PO DILT AND PO LOPRESSOR STARTED, DRIP OFF AT 1530 WITH HEART RATE IN MID 70S.\nOOB TO CHAIR, MINIMAL APPETITE.\nBLOOD SUGARS TREATED WITH SLIDING SCALE TODAY, WILL RESUME REGULAR DOSING WHEN TOLERATING POS.\nALL OTHER MEDS RESUMED.\n?TRANSFER TO FLOOR LATER OR TOMORROW.\nHO AWARE OF ABOVE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-08-14 00:00:00.000",
"description": "Report",
"row_id": 1527001,
"text": "Update\nO: See carevue for details.\n\nGi status: glucoses > 400. PM dose of 70/30 insulin.Insulin gtt started and titrated to glucose <120.Pt taking in cl liqs. Abd soft distended w + bowel snds. Up to commode x 2 for lg brwn stool.\n\nNeuro status: aaoriented , asking for sleeping med.Slept in long naps after ambien for sleep.C/o abd pain and med for same w oxycodone.\n\nCv status: aflutter-> afib-> converted to nsr.BP stable. Distal pulses palp.\n\nResp status: bbs clear diminish bibas. rt brth snds slt less audible.Dry nonprod cough.\n\nGu status: huo bdline icteric. Bun/Cr^ see carevue for details.\n\nHeme/Id: hct stable wbc flat. Tmax 97.8\n\nA/P:Hyperglycemic-> titrate gtt to gluc <120. Cont po lopr and dilt. Check labs results, replete lytes as needed.\n\n"
},
{
"category": "Echo",
"chartdate": "2117-08-12 00:00:00.000",
"description": "Report",
"row_id": 69155,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter.\nHeight: (in) 67\nWeight (lb): 171\nBSA (m2): 1.89 m2\nBP (mm Hg): 150/70\nHR (bpm): 88\nStatus: Inpatient\nDate/Time: at 14:12\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Trivial MR. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Compared with the findings of the prior study, there has\nbeen no significant change.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. There is mild symmetric left ventricular hypertrophy with normal cavity\nsize and systolic function (LVEF>55%). Regional left ventricular wall motion\nis normal.\n3. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n4. Compared with the findings of the prior study of , there has been no\nsignificant change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-08-12 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 877878,
"text": " 7:55 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ? obstruction or pathology\n Admitting Diagnosis: RAPID ATRIAL FIBRILLATION;STATUS POST LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with increased distension, abd pain. Ct mon showed FOS.\n REASON FOR THIS EXAMINATION:\n ? obstruction or pathology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man status post liver transplant, with abdominal pain\n and distention.\n\n ABDOMEN, THREE VIEWS: There are staples seen in the right upper quadrant.\n Multiple air-fluid levels are noted in both the colon as well as the small\n bowel. There are distended loops of small and large bowel. Air is seen\n distally as far as the rectum.\n\n IMPRESSION: Multiple dilated loops of small and large bowel, with air-fluid\n levels consistent with an ileus. Suggest close followup.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-08-14 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 878050,
"text": " 2:30 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: ? obstruction\n Admitting Diagnosis: RAPID ATRIAL FIBRILLATION;STATUS POST LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p liver transplant w/ abd tenderness please use oral\n contrast only no IV due to poor renal fct\n REASON FOR THIS EXAMINATION:\n ? obstruction\n CONTRAINDICATIONS for IV CONTRAST:\n Poor renal function\n ______________________________________________________________________________\n FINAL REPORT\n CT OF ABDOMEN AND PELVIS.\n\n INDICATION: The patient is status post liver transplantation. Increasing\n intra-abdominal pain. For evaluation to rule out intra-abdominal pathology.\n\n TECHNIQUE: Multidetector CT acquisitions of the abdomen and pelvis were\n acquired after the administration of oral contrast only.\n\n COMPARISON: CT from .\n\n MULTIPLANAR REFORMATS:\n\n The images were reformatted at an offline workstation. The generated\n reformatted images were invaluable in evaluating the pathology demonstrated.\n\n REPORT:\n\n There is bilateral gynecomastia present. A few small epicardial lymph nodes\n and diaphragmatic lymph nodes are identified, unchanged from previous\n examination. Anemia is likely, based on the attenuation of the aortic wall and\n the left ventricle. Mild coronary artery calcification is seen.\n\n CT OF ABDOMEN: The liver appears normal.\n\n No focal hepatic lesions are seen. No gross intra- or extrahepatic biliary\n dilatation is identified. The site of the patient's arterial and venous\n anastomosis is seen, but the integrity of these vessels cannot be assessed\n because of the lack of intravenous contrast. There is probably some\n periportal tracking, based on the apparent presence of an attenuation\n difference either side of the portal vessel.A stent is seen in the SMA. The\n spleen is enlarged and measures 18.6 cm in maximum dimensions. The right\n kidney measures 9.8 cm in CC dimensions. The left kidney measures 12.8 cm.\n Within both renal parenchyma, there are focal areas of increased attenuation,\n largely based in the medullary region, consistent with medullary\n nephrocalcinosis with calculus formation. Simple cysts are identified in the\n left kidney unchanged from previous.\n Both adrenal glands are normal.\n Extensive retroperitoneal and intra-abdominal varices are seen.\n (Over)\n\n 2:30 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n CT RECONSTRUCTION\n Reason: ? obstruction\n Admitting Diagnosis: RAPID ATRIAL FIBRILLATION;STATUS POST LIVER TRANSPLANT\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Again in the right flank and anterior abdominal wall postsurgical defects are\n seen.\n\n The degree of large bowel distention is now less than from previous\n examination, although this large bowel is still distended to 6.5 cm in the\n transverse colon. There is borderline or mild distention to approximately 3\n cm. Overall this is unchanged from previous examination.\n\n CT OF PELVIS: A Foley catheter is identified within the bladder which\n contains air.The amount of intra-abdominal and pelvic fluid and anasarca have\n all slightly increased from previous study.\n CT OF BONES:\n No new abnormality is seen.\n Some degenerative disease identified in the lower spine levels.\n\n CONCLUSION:\n\n 1)Examination is limited by lack of intravenous contrast, but allowing for\n this there has been little change from , with some mild large\n and small bowel distention, likely in keeping with postoperative ileus.\n Changes of portal hypertension are manifest throughout the abdomen and pelvis.\n\n 2)Generalized increase in the amount of fluid in all compartments.\n\n 3)Bilateral renal calculi in a pattern suggesting nephrocalcinosis .\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2117-08-20 00:00:00.000",
"description": "Report",
"row_id": 155232,
"text": "Sinus rhythm with top normal P-R interval. Non-diagnostic repolarization\nabnormalities. Compared to the previous tracing of cardiac rhythm now\nsinus mechanism.\n\n"
},
{
"category": "ECG",
"chartdate": "2117-08-12 00:00:00.000",
"description": "Report",
"row_id": 155233,
"text": "Atrial flutter with a rapid ventricular response. Diffuse non-specific\nST-T wave changes. Compared to the previous tracing of atrial flutter\nis now present.\n\n"
},
{
"category": "ECG",
"chartdate": "2117-08-11 00:00:00.000",
"description": "Report",
"row_id": 155234,
"text": "Sinus rhythm\nBorderline first degree A-V block\nST-T configuration consistent with early repolarization pattern/ normal variant\nSince previous tracing of , no significant change\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-08-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 877904,
"text": " 6:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: new aflutter, ?chf\n Admitting Diagnosis: RAPID ATRIAL FIBRILLATION;STATUS POST LIVER TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61yo man s/p liver transplant, now w/ decreased O2 sats\n\n REASON FOR THIS EXAMINATION:\n new aflutter, ?chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old male status post liver transplant, now with decreased\n O2 sats.\n\n COMMENTS: Single portable AP view of the chest is reviewed and compared to AP\n view of the chest from .\n\n Surgical skin staples are noted over the right upper abdominal quadrant. The\n heart size is normal. There has been interval removal of a right internal\n jugular venous catheter. There is no evidence of pneumothorax. There are\n minimal ill-defined patchy left lower lobe opacities consistent with\n atelectasis. The lungs are otherwise clear. The heart size is at the upper\n limits of normal for the patient's age.\n\n IMPRESSION:\n 1. Minimal patchy left lower lobe atelectasis.\n 2. No evidence of pneumothorax.\n\n"
}
] |
29,028 | 173,546 | Given the extent of his hemorrhage and neurologic deficits, the patient was admitted to the neurologic ICU for further monitoring and observation. Given his DNI status, the patient was started on BiPap overnight for respiratory difficulties associated with his COPD. His home medications and nebulizer treatments were given as needed by respiratory therapy. His neurologic examination remained relatively stable the following morning, with left-sided hemiplegia and extinction to the left on double simultaneous stimulation. Interestingly, he was able to minimally wiggle the fingers on his left-side when wiggling his right fingers. He passed speech and swallow and was advanced to an oral diet. Unfortunately, his respiratory status deteriorated and his daughter/ HCP decided to temporally suspend his DNI status in the hopes that a brief intubation might allow for stabilization of his condition. He was then bronched and found to have tracheomalacia. Respirology was consulted and a stent was offered as treatment for this, however after careful discussion, his daughter declined the stent and requested his extubation. Multiple conversations were had offering both the stent or more definitive treatment with surgery for his trachea however she stated repeatedly that her father did not want surgery and did not want temporizing measures to extend his life such as would occur with a stent. He was therefore extubated and made CMO shortly thereafter. He was treated with a morphine drip, ativan and scopolamine. He expired the following day. | There remains some patchy opacity at the lung bases, likely atelectasis or aspiration. At the right lung base, the discrete atelectasis has appeared. LS diminished bilaterally.GI: +BS. remains 180s with SS coverageID: afebrile.SKIN: coccyx with small abrasion noted > barrier cream applied. Right parietal bleed. +1edema to feet notedRESP: LS very diminished, right side more so. Mild mass effect on the body of the right lateral ventricle, unchanged. The inferior sagittal sinus is faintly visualized, which can be a normal variant. clear t/o > IH given by respiratory therapy. IMPRESSION: Slight hypoventilation at both lung bases. FINDINGS: In comparison to the previous examination of , a nasogastric tube and an endotracheal tube have been placed. This suggests a degree of underlying tracheomalacia, although the trachea does remain patent. There are atherosclerotic calcifications of the aorta. PIV x1 for access.RESP: pt w/ discoordinate breathing pattern-pt using accessory muscles & "belly breathing." Wider transverse than AP dimension of the trachea below the ET tube terminus suggests a degree of underlying tracheomalacia, although the trachea and airways to the segmental level remain patent. Patent major intracranial venous sinuses. The anterior inferior cerebellar arteries are faintly visualized. need Ca++ repletionENDO: BS covered with RISS. Hazy bibasilar opacities are most consistent with minimal atelectasis. IMPRESSION: Unremarkable abdomen. FINAL REPORT STUDY: CT head without contrast. The transparency of the lung parenchyma is near normal, only at both lung bases, slight signs of hypoventilations are seen. Pt had bedside bronch, tol well. Bibasilar haze most consistent with atelectasis. IMPRESSION: Cardiomegaly, no gross edema. The major intracranial cisterns are preserved. stent procedure. There are tiny punctate foci of susceptibility in the right temporal lobe (series 10; image 13), which may represent tiny foci of calcification versus microhemorrhages. Patent major intracranial arteries. The left transverse and the sigmoid sinuses are narrow in caliber which may be related to hypoplasia. PRN Ativan available for anxietyCV: ST. HR 100s. TECHNIQUE: Non-contrast CT of the chest. --pt currently appears comfortable w/decreased work of breathing. +BM x2GU: Foley. AP UPRIGHT PORTABLE CHEST: Compared to . The nasogastric tube is in standard position. There are no larger pleural effusions. PRIOR STUDY: CT of the head without contrast done on . FINDINGS: Study is limited by slight motion artifact. A small 2 mm in width subdural collection layers along the posterior falx cerebri at this level. Within these limitations, noted is the periphery rim enhancement of the hematoma, which may be related to the subacute blood in the periphery or blood brain barrier breakdown. There are background centrilobular emphysematous changes and atelectasis at both lung bases. This portable study is severely limited in its marked rotation, motion artifact and exclusion of the left CP angle. Emphysema. IMPRESSION: Large acute right frontoparietal parenchymal hemorrhage with surrounding vasogenic edema and small adjacent subdural hemorrhage. The -white matter differentiation is grossly preserved. PNA Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK FINAL REPORT (Cont) ABG sent htis am-WNL.GI: Abd softly distended, BS+. PT STARTED ON LEVAQUIN.GI-ABD SOFTLY DISTENDED WITH HYPOACTIVE BS. MAg Citrate, bowel meds and fleets enema given with one moderate sized formed BM passed this shift. Wheezing resolves with MDI treatments. Mouth care given per VAP protocol.GI-NPO, OGT to LCWS with bilious output. NICARDIPINE GTT WEANED OFF AND RE-STARTED PRN. Resp CarePt remains in resp distress and has been placed on and off NIPPV. ALB nebs given. GLYCOPRYROLATE.MUCOMYST.CPT. AM ABG 7.34/39/80/22. AM ABG 7.47/36/119/27. CONTINUE WITH RESP.SUPPORT/DIURESES/BP CONTROL/ ATIVAN.GU- SOLUMEDROL 60MG IV X1. Pt remains a DNI. Left pupil surgical 4mm and NR, right pupil 2-3mm and reactive. Pt remains on fentanyl/midaz. Abdomen slightly firm and moderately distended, present bowel sounds. New PIV placed to left AC, PIVx3 to left FA. PT STARTED ON IVG. (-)EDEMA. Pt F/C with right side. BS are clear with diminished RS base. A/Ox3, moves R extremities with normal strength and + sensation noted in both RUE/RLE. MRI still needs attending read-per resident hasnt worsened.CV: HR 80's NSR, ABP (correlates with cuff) maintained 140-160 (goal)systolic and map <113. REFILL. NPO maintained.GU: Foley placed this am-immediate return of 380cc amber urine, marginal output for rest of day. Pt was dnr/dni and was reversed as per hcp for ct. Pt was then intubated with Ett 8 and taped @ 22 lip. Alb nebs given Q4 with fair effect. wheezes in R lobes. Neuro checks q4hours while intubated maintain sedation and comfort.CV-NSR (?1st degree HB) rate 60-70's without ectopy. Pt reports his last BM was . ***TSICU NURSING PROGRESS NOTE***PT CONTINUED ON THIS AM. Coverage per RISS.SKIN: Skin slightly flushed-unremarkable though.ID: Afebrile.SOCIAL: Pt's daughter-HCP, and other family memebers into visit.POC: Continue to monitor resp. Resp: pt on a/c 22/550/+10/40%. Urine continues to be icteric. +PP.RESP-DECOMPENSATING RESP STATUS THROUGHOUT SHIFT REQUIRING MULTIPLE INTERVENTIONS INCLUDING BIPAP/PS.NEBS PRN.CONTINUOUS NEBS. LASIX 20MG IVP AND GTT TO FOLLOW WITH SMALL DIURESES. Right radial arterial line with sharp waveform, SBP ranging 100-140's, pt becomes hyperdymanic off sedation. (SEE CAREVUE FOR #S AND ABG'S)NT SXD FOR MODERATE AMT THICK YELLOWISH/GREEN SPUTUM. SPEC SENT FOR CX. LASIX 10MG X1 & 20MG X1 WITH LASIX GTT . PREDNISONE 10MG QD. @ 1MG/HR. T/SICU NURSING PROGRESS NOTE*PLEASE SEE CAREVUE FOR EXACT DATA*REVIEW OF SYSTEMS:NEURO-Pt sedated on Midazolam 3mg/hr and Fentanyl 40mcgs/hr, off sedation pt with spontaneous eye opening. Continues on Solumedrol and Robinul. No facial droop noted-L sided buccal muscles slightly weaker then R side. NSR-ST >110-120 WITH DYSPNEA. 100% NRB. L extremies weak with diminshed sensation. Pt bronched at bedside to assess airway, "floppy" airway noted ?tracheal/bronchial malacia. Diffuse non-specific ST-T wavechanges. resp rate 8-16. grimacing occasionally with mouth care & turns. Vent settings @ a/c 22/550/+10/40%. APPROX 1000, PT BECAME BRADYCARDIC, 1010 PT NOTIFIED. Moderate cough and gag. Last set of cardaic enzymes to be sent at 1600-neg thus far.RESP: Lungs dimished in all fields, with occ. NPO.GU-SCANT CLOUDY/SEDIMENT URINE 10-20CC/HR. ALERT/ORIENTED X3. CT with results pending. | 24 | [
{
"category": "Radiology",
"chartdate": "2191-01-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 995094,
"text": " 4:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate, effusion\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with COPD, tracheomalacia, intubated for respiratory distress\n REASON FOR THIS EXAMINATION:\n assess for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress, assessment for infiltrate or effusion.\n\n COMPARISON: .\n\n FINDINGS: In comparison to the previous examination of , a\n nasogastric tube and an endotracheal tube have been placed. The nasogastric\n tube is in standard position. The tip of the endotracheal tube is 6 cm above\n the carina. The lung volumes are unchanged as compared to the previous\n examination. At the right lung base, the discrete atelectasis has appeared.\n There are no larger pleural effusions. The transparency of the lung\n parenchyma is near normal, only at both lung bases, slight signs of\n hypoventilations are seen. The size of the cardiac silhouette is at the upper\n range of normal. No pneumonia, no overhydration.\n\n IMPRESSION: Slight hypoventilation at both lung bases. No substantial\n pleural effusions, no signs of overhydration, no signs of pneumonia.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2190-12-30 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 994748,
"text": " 10:50 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for increased bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with intraparenchymal bleed at OSH, developed L hemiparesis\n there, eval for extensions\n REASON FOR THIS EXAMINATION:\n eval for increased bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JRCi 12:37 AM\n Parenchymal hemorrage within the left parietal region with associated small\n amount of subdural blood along the posterior falx. No clear evidence of\n interventricular extension, shift or herniation.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT head without contrast.\n\n INDICATION: 84-year-old male with intraparenchymal bleed at outside hospital\n developing left hemiparesis. Please evaluate.\n\n COMPARISON: None.\n\n FINDINGS: Study is limited by slight motion artifact. There is a large acute\n right frontoparietal parenchymal hemorrhage measuring 6.5 x 2.8 cm in greatest\n axial dimension, with associated surrounding vasogenic edema. A small 2 mm in\n width subdural collection layers along the posterior falx cerebri at this\n level. No significant mass effect, shift of normally midline structures, or\n hydrocephalus is detected. There is no definite evidence of intraventricular\n hemorrhage. The major intracranial cisterns are preserved. The -white\n matter differentiation is grossly preserved.\n\n No acute fracture is detected. The visualized paranasal sinuses and mastoid\n air cells are clear.\n\n IMPRESSION:\n\n Large acute right frontoparietal parenchymal hemorrhage with surrounding\n vasogenic edema and small adjacent subdural hemorrhage. No significant mass\n effect or shift of normally midline structures is demonstrated at this time.\n There is no evidence of herniation or interventricular spread of hemorrhage.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-12-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994746,
"text": " 10:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, mediastinum\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with new onset afib, intraparnehchymal bleed from OSH, O2 sat\n 90s diffuse wheezing, COPD hx. Says at baseline breathing\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 84-year-old male with new onset atrial fibrillation and diffuse\n wheezing with history of COPD.\n\n COMPARISON: None.\n\n FINDINGS: Study is limited given rotation. Bibasilar haze most consistent\n with atelectasis. The lungs are otherwise clear. The cardiomediastinal\n silhouette is normal in appearance. No large effusion or pneumothorax is\n detected.\n\n IMPRESSION:\n\n 1. Hazy bibasilar opacities are most consistent with minimal atelectasis.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-12-31 00:00:00.000",
"description": "MRA BRAIN W/O CONTRAST",
"row_id": 994807,
"text": " 10:56 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA BRAIN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: eval underlying etiology of bleed, eval for evidence of mass\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with R parietal intraparenchymal hemorrhage\n REASON FOR THIS EXAMINATION:\n eval underlying etiology of bleed, eval for evidence of mass, amyloidosis; pls\n do MRV and MRA to rule out venous sinus\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw SAT 5:48 PM\n\n LArge right parieto-occipital hematoma.\n No major venous sinus thrombosis or major arterial occlusion\n Post-contrast limited\n To repeat after hematoma resolves for underlying vascular lesions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old male patient with right parietal intraparenchymal\n hemorrhage, to evaluate for underlying etiology of bleed, with evidence of\n mass, amyloidosis, please do MRV and MRA to rule out venous sinus thrombosis\n and aneurysm.\n\n PRIOR STUDY: CT of the head without contrast done on .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed\n including axial FLAIR, gradient echo, and diffusion sequences, without and\n with IV contrast. 3D TOF MR angiogram as well as 2D TOF MR venogram were\n performed, with maximum intensity projection reformations.\n\n FINDINGS:\n\n MRI OF THE BRAIN: Again noted is a large area of intraparenchymal hematoma in\n the right parietol and medial occipital lobes, with fluid-fluid level, with\n susceptibility on the gradient echo sequences. No other areas of hemorrhage\n are noted. There are tiny punctate foci of susceptibility in the right\n temporal lobe (series 10; image 13), which may represent tiny foci of\n calcification versus microhemorrhages.\n\n On the axial FLAIR sequence, multiple FLAIR hyperintense lesions are noted in\n the cerebral white matter diffusely on both sides, most likely representing\n sequelae of chronic small-vessel occlusive disease, given the patient's age.\n\n The study is significantly limited due to motion artifacts.\n\n Restricted diffusion in the area of the hematoma, is difficult to assess due\n to the presence of hemorrhage. No areas of restricted diffusion are noted\n otherwise.\n\n (Over)\n\n 10:56 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA BRAIN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: eval underlying etiology of bleed, eval for evidence of mass\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is mass effect on the body of the right lateral ventricle, from the\n intraparenchymal hematoma.\n\n The post-contrast images are significantly limited due to motion artifacts.\n Within these limitations, noted is the periphery rim enhancement of the\n hematoma, which may be related to the subacute blood in the periphery or blood\n brain barrier breakdown.\n\n No large vascular lesions are noted. However, the sequences are extremely\n limited for assessment due to motion artifacts.\n\n 3D TOF MR ANGIOGRAM OF THE HEAD:\n\n There is contour irregularity of the petrous portion of the right intracranial\n internal carotid artery and the middle cerebral arteries on both sides,\n related to atherosclerotic disease. However, there is no focal fluid limiting\n stenosis, occlusion, or aneurysm more than 3 mm, within the resolution of MR\n angiogram.\n The anterior inferior cerebellar arteries are faintly visualized.\n\n There is increased signal noted in the right mastoid air cells, representing\n fluid versus mucosal thickening.\n\n 3D TOF MR VENOGRAM OF THE INTRACRANIAL VENOUS SINUSES: The superior sagittal\n sinus, the internal cerebral veins, the straight sinus, transverse and the\n sigmoid sinuses on both sides are patent. The left transverse and the sigmoid\n sinuses are narrow in caliber which may be related to hypoplasia. There is no\n increased signal on the T1 or the gradient echo sequences, to suggest\n thrombosis within the left transverse or sigmoid sinuses. No collaterals are\n noted in this area to suggest abnormality. The inferior sagittal sinus is\n faintly visualized, which can be a normal variant.\n\n IMPRESSION:\n\n 1. Large intraparenchymal hematoma in the right parieto-occipital lobes,\n measuring 5.6 x 3.3 cm in the anteroposterior and transverse dimensions, with\n fluid-fluid level, suggesting acute hematoma.\n\n Mild mass effect on the body of the right lateral ventricle, unchanged.\n\n 2. Patent major intracranial arteries.\n\n 3. Patent major intracranial venous sinuses.\n\n (Over)\n\n 10:56 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA BRAIN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: eval underlying etiology of bleed, eval for evidence of mass\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n Contrast: MAGNEVIST Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 4. Post-contrast image is significantly limited due to motion artifacts.\n\n 5. To repeat the study, for reevaluation of any underlying vascular lesions,\n after resolution of the hematoma.\n\n 6. Sequelae of chronic small-vessel occlusive disease in both cerebral\n hemispheres.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-01-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994911,
"text": " 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulmonary edema\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with resp distress requiring bipap\n REASON FOR THIS EXAMINATION:\n eval for pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Respiratory distress. Evaluate for pulmonary edema.\n\n CHEST AP:\n\n The heart is enlarged. Some movement artifact is present. No gross pulmonary\n edema is present. Blunting of the left costophrenic angle is present.\n\n IMPRESSION: Cardiomegaly, no gross edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2191-01-01 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 995001,
"text": " 11:40 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: COPD, ? PNA\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with COPD, now w/ acute exacerbation\n REASON FOR THIS EXAMINATION:\n assess upper airway for tracheomalacia / obstructive lesions, also ? PNA\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal insufficiency\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84-year-old male with history of emphysema, now with exacerbation\n requiring intubation. Concern for underlying tracheomalacia, endobronchial\n lesion, or pneumonia.\n\n COMPARISON: Chest radiographs , and 12, .\n\n TECHNIQUE: Non-contrast CT of the chest.\n\n CT OF THE CHEST WITHOUT IV CONTRAST: The endotracheal tube is in satisfactory\n position with tip approximately 5.5 cm above the carina. A nasogastric tube\n terminates in the stomach. There are atherosclerotic calcifications of the\n aorta. No pathologically enlarged lymph nodes are present in the axilla,\n mediastinum, or hila. There are background centrilobular emphysematous changes\n and atelectasis at both lung bases. Dependent opacification is noted at the\n base of the left lower lobe, which is more likely related to atelectasis. The\n airways are patent to the segmental level. The inferior trachea just above\n the carina is noted to have wider transverse dimension than AP dimension\n (estimated at 28 mm TV x 17 mm AP, allowing for rotation). This suggests a\n degree of underlying tracheomalacia, although the trachea does remain patent.\n\n BONE WINDOWS: There are extensive degenerative changes and osteophyte\n formation throughout the visualized thoracic spine.\n\n IMPRESSION:\n\n 1. Dependent opacification at the base of the left lower lobe is most likely\n due to atelectasis.\n\n 2. Emphysema.\n\n 3. Wider transverse than AP dimension of the trachea below the ET tube\n terminus suggests a degree of underlying tracheomalacia, although the trachea\n and airways to the segmental level remain patent. Tracheomalacia would be\n better evaluated with a dedicated CT of the trachea with dynamic maneuvers if\n the patient can tolerate this.\n\n\n\n (Over)\n\n 11:40 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: COPD, ? PNA\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-12-31 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 994846,
"text": " 3:29 PM\n PORTABLE ABDOMEN Clip # \n Reason: Check for underlying process behind abdominal distention\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with history of COPD, presents with right parietal bleed, has\n abdominal distention\n REASON FOR THIS EXAMINATION:\n Check for underlying process behind abdominal distention\n ______________________________________________________________________________\n WET READ: BTCa 7:42 PM\n Air mixed with stool seen throughout the colon to the level of the rectum. No\n evidence of obstruction, pneumatosis or abnormal calcifications. Degenerative\n changes in lower lumbar spine.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Increasing abdominal distention. Right parietal bleed.\n\n ABDOMEN:\n\n The distribution of gas in the abdomen is unremarkable. Gas is seen as far as\n the rectum. There is no evidence of obstruction.\n\n IMPRESSION: Unremarkable abdomen. No evidence of obstruction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-12-31 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994764,
"text": " 6:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate\n Admitting Diagnosis: STROKE-TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old man with L sided hemiparesis, IPH; respiratory distress on\n admission w/ ?R sided infiltrate on CXR\n REASON FOR THIS EXAMINATION:\n assess for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old with left hemiparesis, intraparenchymal hemorrhage,\n respiratory distress. Evaluate for infiltrate.\n\n AP UPRIGHT PORTABLE CHEST: Compared to . This portable study is\n severely limited in its marked rotation, motion artifact and exclusion of the\n left CP angle. Allowing for this, there is no overt pulmonary edema nor gross\n consolidation. There remains some patchy opacity at the lung bases, likely\n atelectasis or aspiration.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-03 00:00:00.000",
"description": "Report",
"row_id": 1639001,
"text": "NPN: 1900-0730\nROS:\n\nNEURO: patient remains sedated on midaz & fentanyl. when meds are off patient consistently follows commands & opens eyes to voice. with drips on patient will occasionally follow commands and will open eyes to voice. no movement noted to left side, although right arm is purposeful towards tube and right leg moves on bed. right pupil 4>2 briskly reactive, left pupil ~4 - NR, surgical pupil\n\nCV: patient with ?1st degree block > bradycardic at times to HR of 50s, otherwise SR 60-80s. irregular at times. PACs at times. ABP stable, corrolating with NBP. +pp. +1edema to feet noted\n\nRESP: LS very diminished, right side more so. clear t/o > IH given by respiratory therapy. orally intubated and vented on settings as charted in carevue. ABG improved. O2 sat 96-100%\n\nGI: OGT to suctionwith bilious output. abdomen firmly distended, +bowel sounds, +flatus, No BM overnight! senna, colace & ducolax given with no response yet.\n\nGU: foely with marginal urine out. yellow with small amount of sediment. ? need Ca++ repletion\n\nENDO: BS covered with RISS. remains 180s with SS coverage\n\nID: afebrile.\n\nSKIN: coccyx with small abrasion noted > barrier cream applied. otherwise skin intact\n\nSOCIAL: no family contact overnight\n\nPLAN: DR. to speak with family this am regarding ? intervention for trachial collapse. tighten sliding scale. ? start feeding if to remain intubated. continue to monitor & support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-03 00:00:00.000",
"description": "Report",
"row_id": 1639002,
"text": "***TSICU NURSING PROGRESS NOTE 7A-7P***\n--please see carevue for exact data--\n\nEVENTS: family meeting @ approx 1645. MD Sun, NeuroMed team, SW & RNs attended. pts daughter (HCP) & other family member present. pts family informed & questions were answered RE: pts prognosis, interventional options-stent, sugery etc, DNR/DNI, . after discussing w/other family members & understanding all aspects & options of care, pts daughter(HCP) made decision to make pt .\n\nNEURO: pt on Morphine gtt, currently @ 5mg/hr for pain control. PRN Ativan available for anxiety\n\nCV: ST. HR 100s. BPs 130s-180s/70-80s. skin warm, dry, intact. pt afebrile. PIV x1 for access.\n\nRESP: pt w/ discoordinate breathing pattern-pt using accessory muscles & \"belly breathing.\"--pt currently appears comfortable w/decreased work of breathing. RR 7-12. LS diminished bilaterally.\n\nGI: +BS. +BM x2\n\nGU: Foley. adequate amber urine w/ sediment\n\nPLAN: maintain comfort. titrate morphine gtt for adequate comfort/pain control.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-02 00:00:00.000",
"description": "Report",
"row_id": 1638997,
"text": "NPN continued:\n\npulmonary team to assess cause of SOB. Pt was intubated against his own wishes as of one day ago. DNR status remains, DNI stauts will be reinstituted post extubation, probable tracheal malacia per CT scan causing stridor and airway obstruction, pulmonary may recommend tracheal stenting and bronchoscopy before extubation, CMV 40% 550 x 22 10 PEEP and adequate ventilation/oxygenation via blood gas, O2 sats > 93% this shift with improved oxygentation on R side, Occasional alarms for Pip's in the 40's, suctioned for thick yellow secreations initially then scant secreations, pink dried blood clotting removed via subglottal suctioning, coarse wheezing airways requiring frequent albuterol administrations, NSR 60-80 on sedation, hypertension as high as 180 mmHg and HR >120 with dyspnea preintubation, dusky LE's with delayed capillary refill, blunted cyanotic extremity tips, 2 PIV's for access, propofol and fent for sedation at low doses, nicardipine gtt ordered but not need, oliguria with brown cloudy urine, azotemia with elevated BUN and creatinine, elevated blood sugars secondary to steroid administration, red fungal rash noted along perineum, R PIV removed due to ecchymosis, OGT placed, magnesium citrate given to stimulate BM, docusate and senna given to stim BM, dulcolax PR given to stimulate BM, abdomen remains firm distended and obese, bed rest orederd with SCD's, L sided hemiplegia with neglect, continues to move R side of body, no longer following commads with sedation running dispite low doses.\n\nA: Unfortunate induvidual suffering from impaired neurological function and decompensationg respiratory system requiring medical intervention to correct.\n\nPlan: Monitor and assess neurological function as ordered, sedate and pain meds until extunation, wean off ventilator this shift unless new change in plan, consider bronchcoscopy prior to extunation, educate family and pt. Continue to monitor and assess as orederd.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-02 00:00:00.000",
"description": "Report",
"row_id": 1638998,
"text": "Resp Care\nPt remains intubated on CMV, no ventchanges, no abg's. Pt had bedside bronch, tol well. ?? stent procedure. Plan to continue with current tx, ?? surgical procedure and family meeting.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-02 00:00:00.000",
"description": "Report",
"row_id": 1638999,
"text": "T/SICU NURSING PROGRESS NOTE\n\n*PLEASE SEE CAREVUE FOR EXACT DATA*\n\nREVIEW OF SYSTEMS:\n\nNEURO-Pt sedated on Midazolam 3mg/hr and Fentanyl 40mcgs/hr, off sedation pt with spontaneous eye opening. Left pupil surgical 4mm and NR, right pupil 2-3mm and reactive. Moderate cough and gag. Pt F/C with right side. Left side flaccid, pt only able to shrug shoulder, nods \"no\" to feeling sensation when applied to left side. Neuro checks q4hours while intubated maintain sedation and comfort.\n\nCV-NSR (?1st degree HB) rate 60-70's without ectopy. Right radial arterial line with sharp waveform, SBP ranging 100-140's, pt becomes hyperdymanic off sedation. New PIV placed to left AC, PIVx3 to left FA. Compression boots for prophylaxis.\n\nRESP-Pt orally intubated #8ETT 22LL, continues on CMV TV550, R22, P10 40%, no vent changes made this shift. Lung sounds very diminished on right side, slightly coarse with occ expiratory wheeze on left. Wheezing resolves with MDI treatments. Pt bronched at bedside to assess airway, \"floppy\" airway noted ?tracheal/bronchial malacia. BAP sent, moderate amounts of yellow thick secretions during bronch, however minimal secretions when suctioning pt via ETT. Continues on Solumedrol and Robinul. Mouth care given per VAP protocol.\n\nGI-NPO, OGT to LCWS with bilious output. Abdomen slightly firm and moderately distended, present bowel sounds. MAg Citrate, bowel meds and fleets enema given with one moderate sized formed BM passed this shift. Continue to monitor. Famotidine daily.\n\nGU-INwelling foley catheter (?traumatic insertion) site with bloody drainage. Dark yellow concentrated urine, clearing throughout shift. Pt bolused with 500cc 5%Albumin with moderate response, IVF started. BUN/Creatinine elevated (2.5) Urine culture sent.\n\nENDO-RISS thightened today, blood sugars elevated, pt continues on steroids.\n\n, pt continues on Levoquin, BAL and urine culture pending.\n\nSOCIAL-Pts daughter and grandson in to visit this shift. They spoke with pulmonary, neuromedicine, ICU resident and RN re: POC based on bronch results. Possibility of stent placement dicussed with family, also stressed importance of keeping patients wishes in mind and option of comfort measures. Stenting to be discussed with Dr (IP)tomorrow morning. If family cannot be present (due to weather) they wish to discuss over phone. Family appriopirately distressed with decision making.\n\nPLAN-Maintain sedation and comfort, monitor for changes in neuro status, monitor hemodynamics, labs at , continue to provide pt and family with updated poc and emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-03 00:00:00.000",
"description": "Report",
"row_id": 1639000,
"text": "Resp: pt on a/c 22/550/+10/40%. BS are clear with diminished RS base. Suctioned for small amount of thick secretions. MDI's administered alb/atr with no adverse reactions. No changes noc. Pt remains on fentanyl/midaz. AM ABG 7.47/36/119/27. RSBI=no resps. Plan: pending IP assessment, possible or for sent placement?\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-01 00:00:00.000",
"description": "Report",
"row_id": 1638994,
"text": "NEURO-STATUS REMAINS UNCHANGED WITH LEFT SIDE HEMIPARESIS AND SLIGHT SENSATION TO TOUCH. FULL MOVEMENT AND SENSATION ON RT.FOLLOWS ALL COMMANDS. SPEECH CLEAR. SMILE SYMETRICAL. 100% FOCAL CONTACT WHEN SPEAKING WITH PT. ALERT/ORIENTED X3. IS OF SOUND MIND FOR DECISION MAKING AND STATES THAT HE DOES NOT WANT TO BE INTUBATED FOR WORSENING RESP DISTRESS.\n\nCV- AFEBRILE. NSR-ST >110-120 WITH DYSPNEA. BP GOAL 140-160. NICARDIPINE GTT WEANED OFF AND RE-STARTED PRN. (-)EDEMA. SKIN WARM/DRY. BIALTERAL FEET DUSKY WITH DELAYED CAP. REFILL. +PP.\n\nRESP-DECOMPENSATING RESP STATUS THROUGHOUT SHIFT REQUIRING MULTIPLE INTERVENTIONS INCLUDING BIPAP/PS.NEBS PRN.CONTINUOUS NEBS. 100% NRB. HELI-OX. NC. LASIX 10MG X1 & 20MG X1 WITH LASIX GTT .@ 1MG/HR. SOLUMEDROL 60MG IV X1. PREDNISONE 10MG QD. GLYCOPRYROLATE.MUCOMYST.CPT. PT BECOMING MORE AGITATED WITH EACH INTERVENTION REQUIRING ATIVAN PRN.(SEE CAREVUE FOR #S AND ABG'S)NT SXD FOR MODERATE AMT THICK YELLOWISH/GREEN SPUTUM. SPEC SENT FOR CX. PT STARTED ON LEVAQUIN.\n\nGI-ABD SOFTLY DISTENDED WITH HYPOACTIVE BS. NO STOOL. NO FLATUS. NPO.\n\nGU-SCANT CLOUDY/SEDIMENT URINE 10-20CC/HR. PT STARTED ON IVG. LASIX 10MG IVP WITH GREAT RESPONSE FOLLOWED BY DECLINIING U/O. LASIX 20MG IVP AND GTT TO FOLLOW WITH SMALL DIURESES. 40-50CC/HR.\n\nLABS-NO REPLACEMENTS REQUIRED.\n\nPLAN- FAMILY CALLED TO COME BACK IN TO DISCUSS TX PLAN FOR PT. CONTINUE WITH RESP.SUPPORT/DIURESES/BP CONTROL/ ATIVAN.\n\n\nGU-\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-02 00:00:00.000",
"description": "Report",
"row_id": 1638995,
"text": "Resp: Pt Placed on NIV at beginning of shift due to ^ wob and desaturation with no significant improvement. Pt was dnr/dni and was reversed as per hcp for ct. Pt was then intubated with Ett 8 and taped @ 22 lip. CT with results pending. Vent settings @ a/c 22/550/+10/40%. AM ABG 7.34/39/80/22. Plan: Pt to be extubated pending IP assessment of ct results.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-02 00:00:00.000",
"description": "Report",
"row_id": 1638996,
"text": "NPN:\n\nS: Pt is a 84 yo male suffering from R sided parietal hemorrhagic stroke with L sided hemiparesis, pt has also been experiencing a significiant amount of respiratory distress requiring resulting in endotracheal intubation.\n\nO: Pt was suffering from respiratory decompensation for greater than 12 hrs, all noninvasive respiratory modalities used with little improvement, pt was clearly experiencing a significant amount of discomfort by 2100 , famlity called in for emergent meeting, family spoke with the pulmonary team and the ICU resident regarding invasive and noninvasive options, health care proxy decided to have her father intubated only for a short duration until a CT could be obtained and the Pulmonary team could better asseess the cause fo\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-04 00:00:00.000",
"description": "Report",
"row_id": 1639003,
"text": "NPN:\npatient made earlier in the day by family. patient appears comfortable on 5 mg/hr IV morphine with occasional 2mg boluses for turns. resp rate 8-16. grimacing occasionally with mouth care & turns. turned occasionally for comfort only. ? transfer to floor today to provide family more privacy and less busy environment. continue to provide emotional support to family and comfort to patient.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-04 00:00:00.000",
"description": "Report",
"row_id": 1639004,
"text": "***TSICU NURSING PROGRESS NOTE***\n\nPT CONTINUED ON THIS AM. MORPHINE GTT ON @ 5MG/HR. PT APPEARED COMFORTABLE, SATS SLOWLY DECLINED TO 60S. APPROX 1000, PT BECAME BRADYCARDIC, 1010 PT NOTIFIED. TIME OF DEATH 1010. FAMILY NOTIFIED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-31 00:00:00.000",
"description": "Report",
"row_id": 1638990,
"text": "Admission Note\n\nPt is a 84 yo male with COPD on home 02, presents to with L sided hemiparesis, found to have a R sided parietal interparenchymal hemorrhage.\n\nPMH: COPD, O2 at home only intermitently, Macular degeneration, cataracts, retinal hemorrhage.\n\nMEDS: Spiriva, Ativan, Albuterol, Advair, Oxygen.\n\nSocial: Lives alone with home health aid daily, daughter lives in MA, estranged from son, old history of smoking 60 yrs ago.\n\nCT Scan: Parenchymal hemorrhage with no shift or herniation\n\nNeuro: Hemiparesis L side, some L sided visual deficits, clear speech, symmetrical face, follows all commands, pleasant affect, alert and oriented x 4.\nCV: NSR---> afib, rate 80-90, goal blp 140-160 mmHg, nicardipine gtt if needed, palp pedal pulses with some clubbing, aline placed, PIV's for access.\nResp:Tachypnea, shallow resp depth, breath sounds coarse and wheezing, moderate cough, no sputum production, O2 sats > 95% on 3.0 L/min NC, pursed lip breathing, BIPAP in ER.\nGU: Voids via urinal but not urine yet since admission to .\nGI: Firm distended abdomen with active bowel sounds, NPO.\nEndo: Sliding scale insulin coverage\nMS:bed rest\nInteg: clean intact skin.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2190-12-31 00:00:00.000",
"description": "Report",
"row_id": 1638991,
"text": "NPN 0700-1900\nPLEASE SEEC AREVUE FOR SPECIFIC DATA\n\nEVENTS:Pt traveled to MRI this mornining for imaging of head. During MRI pt was slightly restless and per Dr. order was given 2mg Midazolam IVP-following this pt's BP dropped to 90's systolic and O2 sats were briefly 85-88%, pt was still mentating at this time. Dr came down to assess pt and upon arrival vs retuned to pt's baseline-no intervention required.\n\nNEURO: No c/o pain. A/Ox3, moves R extremities with normal strength and + sensation noted in both RUE/RLE. L extremies weak with diminshed sensation. No movement in LLE, but strength in LUE has improved from this am=> + hand grasp, no shoulder shrug though. L pupil 4mm (cataracts) NR/ R pupil 3mm and brsikly reacts to light. Strong cough/gag. No facial droop noted-L sided buccal muscles slightly weaker then R side. Able to recite words after 5 min. MRI still needs attending read-per resident hasnt worsened.\n\nCV: HR 80's NSR, ABP (correlates with cuff) maintained 140-160 (goal)systolic and map <113. Skin warm/well perfused, +pp. Last set of cardaic enzymes to be sent at 1600-neg thus far.\n\nRESP: Lungs dimished in all fields, with occ. wheezes in R lobes. Alb nebs given Q4 with fair effect. Breathing appeared labored for much of day-(pt/family reports this is his baseline) pt goes into coughing fits when speaking for extended periods of time. NC 3L -O2 sats 94-100%. RR 13-25. ABG sent htis am-WNL.\n\nGI: Abd softly distended, BS+. Pt reports his last BM was . NPO maintained.\n\nGU: Foley placed this am-immediate return of 380cc amber urine, marginal output for rest of day. Urine continues to be icteric. NS at 30cc/hr.\n\nENDO: Blood glucose 150-170, trending down. Coverage per RISS.\n\nSKIN: Skin slightly flushed-unremarkable though.\n\nID: Afebrile.\n\nSOCIAL: Pt's daughter-HCP, and other family memebers into visit.\n\nPOC: Continue to monitor resp. status.\n f/u MRI results\n neuro Q1\n update/support family\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-01 00:00:00.000",
"description": "Report",
"row_id": 1638992,
"text": "NPN\n\nS: Pt is and 84 yo male admitted to with a R parietal hemorrhagic stroke resulting in L sided hemiparesis and neglect.\n\nO: L sided hemiparesis with some impaired sensation to pain on L UE, follows all commands, speech is clear, HOH R ear, wears glasses, NSR 70-90's, goal blp 140-160 mmHg, nicardipine gtt used intermittently to maintain adequate blood pressure, palp pedal pulses, COPD, NC 02 with 2-4 L/min, sats > 95% this shift, some tachypnea noted, brown dark urine changing to red and cloudy, IVF at 80cc, tol small amts of PO liquids advance to regular diet, firm distended abdomen, RISS with coverage required, skin clean and dry, remains on bed rest throughout the night, some neck apin noted---> responds well to cervical hot packs and tylenol.\n\nA: Unfortunate male suffering from neurological impairments due to hemorrhagic.\n\nPlan: Continue to monitor and assess as ordered, transfer to SDU or neurological floor, prepare for d/c from ICU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2191-01-01 00:00:00.000",
"description": "Report",
"row_id": 1638993,
"text": "Resp Care\nPt remains in resp distress and has been placed on and off NIPPV. Pt remains a DNI. ALB nebs given. Pt refusing NIV and remains on NC.\nNo other changes noted.\n"
},
{
"category": "ECG",
"chartdate": "2190-12-31 00:00:00.000",
"description": "Report",
"row_id": 216982,
"text": "Artifact is present. Sinus tachycardia. Diffuse non-specific ST-T wave\nchanges. No previous tracing available for comparison.\n\n"
}
] |
8,481 | 162,685 | Prior to transfer to medicine service: . 67 year old man who is s/p MVA with resulting traumatic brain injury, including: depressed right skull fracture, subarachnoid, subdural, and epidural hemorrhage, and sagittal sinus laceration. He underwent right-sided hemicraniectomy, evacuation of hematoma, and dural repair of the superior sagittal sinus. . His hospital course was complicated by what was thought to be a superior saggital thrombosis, and interval development of fevers without a clear microbiological source. He has had a single positive blood culture with coag positive staph growing - his CVL was removed and has no growth to date. He has had three sputum samples, two with MSSA and one with E. Coli, all in the abscence of radiographic evidence of pneumonia. A single stool sample is negative for c. difficile. . He was given empiric perioperative vancomycin and gentamicin x 3 doses starting on /7, and then started on vancomycin and zosyn from , and nafcillin from , for empiric coverage of fevers. He was also on dilantin from and then changed to keppra. . His LFT's and pancreatitic enzymes were noted to be elevated on with his ALT peaking at 258, alk phos at 623, and lipase at 623, they are all now trending down. He has also had a progressive leukocytosis with a peak at 22.6, his differential is left-shifted, but there is no eosinophilia. He also had a morbiliform rash on his trunk. | FINDINGS: Patient is status post contrast-enhanced CT of the torso, limiting comparison to prior study in terms of intracranial hemorrhage. There is suggestion of uncal herniation noted. Shoddy intraperitoneal lymphadenopathy is seen. A right-sided right subclavian central line tip is not optimally visualized, but appears to overlie the lower SVC. Please perform CTV to exclude superior sagittal sinus thrombosis. Incidental note is made of asymmetrical enlargement of the psoas musculature. Air and contrast from a prior CT are seen throughout the colon to the level of the rectum. Areas of intraparenchymal hemorrhage are again identified and unchanged. TECHNIQUE: Non-contrast head CT. This demonstrates an inferior vena cava located at the level of the L2 vertebral body. There has been interval decrease in pneumocephalus underlying the craniectomy site. NO DEFINITE SUPERIOR SAGITTAL SINUS THROMBOSIS AS THE SUPERIOR SAGITTAL SINUS OPACIFIES WITH CONTRAST BUT THERE IS SOME ADJACENT FLUID THAT BE CAUSING MASS EFFECT ON THE SINUS. Right femoral central venous catheter is noted. HYPODENSITY OF LEFT CEREBELLUM SEEN ON ONE SLICE () ONLY IS NOT CONFIRMED ON CTV IMAGES AND IS APPARENTLY ARTIFACTUAL. CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid, and prostate appear unremarkable. Comminuted calvarial fractures and subgaleal hematoma again noted. Assessment of prevertebral soft tissues is limited by endotracheal tube. Extensive bilateral hemorrhagic contusions, status post right-sided craniectomy. TECHNIQUE: Non-contrast head CT scan. TECHNIQUE: Non-contrast head CT scan. There is a left-sided central venous catheter with distal tip in the mid SVC. Right temporal fracture again visualized. Extensive subarachnoid hemorrhage involving both cerebral convexities and most prominent of the right frontal region is similar to the prior study. CHEST, SINGLE AP VIEW A tracheostomy tube is in place. Surrounding the sites of hemorrhage, there has been interval decrease in attenuation of the adjacent brain parenchyma consistent with evolving infarction and edema. Right upper quadrant ultrasound to rule out portal vein obstruction and Budd-Chiari syndrome. There is redemonstration of the right hemicraniectomy defect. There is a suggestion of uncal herniation noted." s/p partial crainectomy. There has been interval appearance of a longitudinally extensive, but relatively , slightly hyperdense left cerebral hemispheric subdural hemorrhage causing effacement of the contiguous cerebral sulci. Status post partial craniectomy. 1.2cm frontal transfalcine shift to L Multiple hemmorhagic contusions Refer to head CT for eval of SAH / SDH MRV BRAIN: Superior sagittal sinus only faintly seen. I am very concerned that this represents either sagittal sinus thrombosis, or sagitta;l sinus compression from the edema MRA BRAIN: Intracranial arteries are normal, though there is mass effect on the R MCA by the edema MD FINAL REPORT EXAM: MRI brain and MRA and MRV of the head. The massive quantity of subarachnoid hemorrhage, the small right parafalcine interhemispheric subdural hemorrhage, as well as small left cerebral convexity subdural hemorrhage are all redemonstrated. TECHNIQUE: Noncontrast head CT. Patchy linear opacities are seen at both mid lung zones, likely a subsegmental atelectasis. The extensive subarachnoid hemorrhage previously seen is redemonstrated. NOTE: A wet , provided by Dr. indicated, "Massive new edema. CONCLUSION: Status post right hemicraniectomy, with multiple abnormalities that have developed since the prior study, described in detail above. TECHNIQUE: Non-contrast head CT. FINDINGS: Since the previous study, a right hemicraniectomy has been performed, through which there is moderate herniation of the right cerebral hemisphere. CONTRAINDICATIONS for IV CONTRAST: intracranial hemorrhage FINAL REPORT NON-CONTRAST HEAD CT SCAN HISTORY: Venous sinus bleed. +PP.Resp: Pt cont on c-pap: . No BM but bowel regimen started. CXR shows ETT @ clavicles level,patchy opacities @ mid lungs zones.? Resp Care Note:Pt cont intub with OETT and mech vent as per Carevue. Staples to cranial incsion x 2, intact, approximated, scant drainage. Wean vent as tol. R fem introducer/CVL. Withdrawal to nailbed pressure in RLE. See carevue for ABGs, HO aware. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Resp Care Note:Pt cont intub with OETT and on mech vent as per Carevue. Lung sounds ess clear after suct sm th tan sput. A-line dampened, following NIBP. Abd soft with hypo bs. Pt cont on mannitol, and dilantin.CV: ST, no ectopy. Foley patent with adeq UO. Abd soft non-tender non-distended, on Protonix, started on TF Repleate with fiber goal 80cc/hr.ID: On vanco and genta post op doses. Levo weaned down, IVF cont at 125/hr. Decerebrate posturing in LUE and LLE. L corneal absent, R corneal intact. Lytes WNL. Repeat head CT this am. Pt continues on dilantin and mannitol. A-line dampened with no blood return, folling NIBP. Cspine,logroll precautions maintained at all times CV- MP ST 110-130, no VEA.BP 110-130's systolic by aline. Cont PSV. Dilantin and Mannitol as ordered.CV: HR 110-130's ST no ectopy noted. Pulses+, palpable, extremities cool. T/SICU RN Progress NoteEvents of day: Weaned off Neo, Head CT, Left subclavian quad lumen placed, Right femoral line removed.Neuro: Moves right hand spontaneously, not to command, attempts to localized/withdraw with RUE to pain. Discussed pt's status and POC.Plan: Neuro checks q2hr. Skin w/d/i. Maintain SBP <150, prn metoprolol. Nursing Progress NoteNo significant eventsNeuro: Pt not sedated. Nursing Progress NoteNo Significant EventsNeuro: Pt not sedated. Lung sounds coarse suct sm th tan sput. LSCTAB, dim in bilat bases. LSCTAB, dim in bilat bases. Pt had BM x1 this shift, med brown formed stool.GU: Foley draining adequate amts CYU. Nursing Progress NoteID: Tmax 100.9. | 55 | [
{
"category": "Radiology",
"chartdate": "2109-03-06 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 947609,
"text": " 3:02 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line exchange\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with recent crainectomy now febrile\n REASON FOR THIS EXAMINATION:\n line exchange\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE VIEW. LINE PLACEMENT\n\n Comparison is made with prior study dated .\n\n There is no pneumothorax. Left subclavian vein catheter tip is in the lower\n SVC. Tip of the endotracheal tube is 6 cm above the carina. There has been\n partial resolution of left lower lobe atelectasis. There is no pleural\n effusion. NG tube tip is in the stomach. Cardiac size is top normal.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 947093,
"text": " 12:20 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change?\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with venous sinus hemmorhage\n REASON FOR THIS EXAMINATION:\n interval change?\n CONTRAINDICATIONS for IV CONTRAST:\n hemmorhage\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 60-year-old male with venous sinus hemorrhage, referred for\n assessment of interval change.\n\n COMPARISON: Prior head CTs from and .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Direct comparison is made to the most recent head CT of at\n 8:20 a.m. Again demonstrated is prior partial right hemicraniectomy. There\n has been interval decrease in pneumocephalus underlying the craniectomy site.\n Extensive subarachnoid hemorrhage involving both cerebral convexities and most\n prominent of the right frontal region is similar to the prior study.\n Intraparenchymal hemorrhage of the right frontal lobe is also not\n significantly changed. Surrounding the sites of hemorrhage, there has been\n interval decrease in attenuation of the adjacent brain parenchyma consistent\n with evolving infarction and edema. Mass effect from the large hemorrhagic\n contusions is similar to the prior study. Blood in the occipital of the\n left lateral ventricle is stable. There is increased fluid layering within the\n ethmoid, maxillary and sphenoid sinuses. No definite new areas of\n intracranial hemorrhage are identified.\n\n IMPRESSION: Evolution of bilateral extraaxial and right frontal\n intraparenchymal hemorrhage with associated edema and infarction.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-18 00:00:00.000",
"description": "VEN DUP EXTEXT BIL (MAP/DVT)",
"row_id": 949313,
"text": " 10:01 AM\n DUP EXTEXT BIL (MAP/DVT) Clip # \n Reason: assess for DVTs\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p MVA and traumatic brain injury, s/p hemicraniectomy and b/l\n upper ext swelling, L>R\n REASON FOR THIS EXAMINATION:\n assess for DVTs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Bilateral upper extremity swelling, rule out DVT.\n\n COMPARISONS: .\n\n BILATERAL UPPER EXTREMITY ULTRASOUND: scale and Doppler son were\n performed of the upper extremities including the jugular, subclavian,\n axillary, and brachial veins bilaterally. Venous structures demonstrate\n normal flow, compressibility, waveforms, and augmentation without evidence of\n intraluminal thrombus. The cephalic and basilic veins were not able to be\n imaged.\n\n IMPRESSION: No evidence of DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-19 00:00:00.000",
"description": "O L-SPINE (AP & LAT) IN O.R.",
"row_id": 949456,
"text": " 10:07 AM\n L-SPINE (AP & LAT) IN O.R.; SPINAL FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: IVC FILTER PLACEMENT\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n FINAL REPORT\n LUMBAR SPINE, ONE VIEW.\n\n INDICATION: IVC filter placement.\n\n FINDINGS: A single AP view of the lumbar spine was obtained in the operating\n room without a radiologist present. This demonstrates an inferior vena cava\n located at the level of the L2 vertebral body. Please refer to operative\n report for full details.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 949105,
"text": " 10:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Signs of infiltrate?\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with fevers, positive sputum cx.\n REASON FOR THIS EXAMINATION:\n Signs of infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fevers, positive sputum culture, question infiltrate.\n\n CHEST, SINGLE AP VIEW\n\n A tracheostomy tube is in place. An NG-type tube is present. It curves over\n the upper abdomen, presumably extending into the small bowel, but clinical\n correlation is requested. The heart is not enlarged, though there is left\n ventricular configuration. Mild vascular haziness could represent minimal\n fluid overload, but no overt CHF is identified. No focal infiltrate or\n effusion is seen. A right-sided right subclavian central line tip is not\n optimally visualized, but appears to overlie the lower SVC. No pneumothorax\n is detected. Faint increased density in the colon presumably represents\n residual contrast from the previous imaging study.\n\n IMPRESSION: No new infiltrate detected. Mild vascular blurring could relate\n to respiratory motion or might indicate a very small amount of fluid overload.\n No overt CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-15 00:00:00.000",
"description": "CTA HEAD W&W/O C & RECONS",
"row_id": 949021,
"text": " 5:28 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Please perform CTV to assess sup sagg sinus thrombus\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with sup sagg sinus thrombus\n REASON FOR THIS EXAMINATION:\n Please perform CTV to assess sup sagg sinus thrombus\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKXa SAT 3:16 AM\n NO SIGNIFICANT CHANGE IN APPEARANCE OF BRAIN C/W . HYPODENSITY OF LEFT\n CEREBELLUM SEEN ON ONE SLICE () ONLY IS NOT CONFIRMED ON CTV IMAGES AND IS\n APPARENTLY ARTIFACTUAL. NO DEFINITE SUPERIOR SAGITTAL SINUS THROMBOSIS AS THE\n SUPERIOR SAGITTAL SINUS OPACIFIES WITH CONTRAST BUT THERE IS SOME ADJACENT\n FLUID THAT BE CAUSING MASS EFFECT ON THE SINUS. MAJOR CIRCLE OF \n BRANCHES PATENT AND OTHER DURAL VENOUS SINUSES PATENT. \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old man with superior sagittal sinus thrombosis. Please\n perform CTV to exclude superior sagittal sinus thrombosis.\n\n TECHNIQUE: A non-contrast head CT was also performed. Then a CT with IV\n contrast was performed with delayed images through the brain to assess the\n venous sinuses.\n\n FINDINGS: A non-contrast head CT demonstrates the prior hemicraniectomy with\n brain herniation through the surgical defect. There is extensive white matter\n hypodensity, which has slightly progressed since prior examination.\n Specifically, now there is more hypodensity in the region of the right\n occipital lobe as well as right parietal lobe. Areas of intraparenchymal\n hemorrhage are again identified and unchanged. There is no evidence of uncal\n herniation. A small amount of subfalcine herniation is again present. There\n is a small amount of parafalcine low attenuation (CSF) fluid.\n\n Examination of the CTV demonstrates no evidence of sagittal sinus thrombosis.\n The transverse and sigmoid sinuses are also patent. Straight sinus is also\n patent as is the vein of .\n\n IMPRESSION: There is no evidence of venous sinus thrombosis.\n\n Extensive bilateral hemorrhagic contusions, status post right-sided\n craniectomy.\n\n The white matter hypodensity appears to have slightly progressed in the region\n of the right parietal and occipital lobes.\n\n\n (Over)\n\n 5:28 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: Please perform CTV to assess sup sagg sinus thrombus\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 948021,
"text": " 8:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess interval change\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with fevers, positive sputum cx\n REASON FOR THIS EXAMINATION:\n Assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 67-year-old man with fevers and positive sputum culture. Assess\n interval change.\n\n FINDINGS: Comparison is made to the previous study from .\n\n There is a tracheostomy. The sideport of the nasogastric tube is at the\n gastroesophageal junction and could be advanced for more optimal placement.\n There is a left-sided central venous catheter with distal tip in the mid SVC.\n The cardiac silhouette is mildly prominent. There is no focal consolidation,\n overt pulmonary edema, or pleural effusions.\n\n IMPRESSION:\n\n No signs of acute cardiopulmonary process.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-12 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 948510,
"text": " 2:59 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: Please pass into the jejunum NGT for TF\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n Contrast: CONRAY Amt: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with severe brain injury requiring TF\n REASON FOR THIS EXAMINATION:\n Please pass into the jejunum NGT for TF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old male with severe brain injury requiring tube\n feedings.\n\n NASOINTESTINAL PLACEMENT: The patient was placed supine on the fluoroscopic\n table. The right naris was prepped with lidocaine jelly. Under fluoroscopic\n guidance, an 8 French 120 cm - feeding tube was inserted into\n the right naris and advanced through the esophagus into the stomach. The tube\n was then advanced through the pyloric valves and into the proximal small\n bowel. Injection of approximately 5 ml of Conray contrast demonstrates that\n the tip is located at the ligament of Treitz in the fourth portion of the\n duodenum. The patient tolerated the procedure well without complications.\n\n IMPRESSION: Successful nasointestinal tube placement with the tip within the\n distal fourth portion of the duodenum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 947724,
"text": " 10:17 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess interval change\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p R hemicraniectomy\n REASON FOR THIS EXAMINATION:\n Assess interval change\n CONTRAINDICATIONS for IV CONTRAST:\n Not indicated\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST :\n\n HISTORY: Status post hemicraniectomy, assess interval change.\n\n Contiguous axial images were obtained through the brain. No contrast was\n administered. Comparison to a head CT of .\n\n FINDINGS: There have been no significant changes since the previous study.\n Again demonstrated are extensive bifrontal hemorrhagic contusions, far more\n severe on the right than left. Again identified is right hemispheric mass\n effect and right to left midline shift. This patient is status post a right\n temporal and frontal craniectomy. Brain herniates through the craniectomy\n defect. This appears unchanged since the prior study.\n\n CONCLUSION: No change since . Prior skull fracture,\n extensive hemorrhagic contusions, status post craniectomy with brain\n herniating through the craniectomy defect.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-10 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 948167,
"text": " 3:56 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Assess for pancreatitis / intra-abd process causing WBC elev\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man s/p trauma (ped vs. car), now w/ elevated LFT's , pancreas\n enzymes\n REASON FOR THIS EXAMINATION:\n Assess for pancreatitis / intra-abd process causing WBC elevations.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 67-year-old man status post trauma (hit by a car), now with elevated\n LFTs, pancreatic enzymes, evaluate for pancreatitis.\n\n TECHNIQUE: Multidetector CT images of the abdomen and pelvis were performed\n after the administration of oral and intravenous contrast. Coronal and\n sagittal reformatted images were obtained.\n\n COMPARISON: Findings are compared with prior CT dated .\n\n CT OF THE LUNG BASES WITH INTRAVENOUS CONTRAST: Evaluation of the lung bases\n demonstrates bibasilar atelectasis. The cardiac silhouette is within normal\n limits in size.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Examination is slightly limited\n due to patient's inability to hold his hands over his head. Streak artifact\n is seen coursing through the liver and spleen. No gross abnormalities of the\n liver or spleen are noted. Evaluation of the intra and extrahepatic biliary\n tree is within normal limits. The gallbladder is unremarkable. The adrenal\n glands and kidneys are within normal limits. No large fluid collections are\n visualized surrounding the pancreas, however the degree of streak artifact\n surrounding the pancreas limits detection for subtle fluid collections.\n However, no large fluid collections surrounding the pancreas are spleen. There\n is normal pancreatic enhancement. The splenic vein is patent. No collateral\n return is seen. Shoddy intraperitoneal lymphadenopathy is seen. There is no\n ascites within the abdomen.\n\n Oral contrast is visualized progressing as far as the sigmoid colon. There is\n no evidence for obstruction. The abdominal aorta is within normal limits in\n size.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The prostate gland is enlarged.\n Foley catheter is visualized inflated within a partially collapsed bladder.\n There is a small amount of presacral fluid. Incidental note is made of\n asymmetrical enlargement of the psoas musculature.\n\n CT OF THE OSSEOUS STRUCTURES: Evaluation of the osseous structures\n demonstrates no evidence for acute fracture.\n\n IMPRESSION:\n 1. Limited evaluation of the upper abdomen due to patient's arm lying at his\n (Over)\n\n 3:56 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: Assess for pancreatitis / intra-abd process causing WBC elev\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n side causing streak artifact across these organs.\n 2. No gross abnormality of the pancreas is appreciated. No radiographic\n findings to suggest complications of pancreatitis.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-14 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 948820,
"text": " 10:58 AM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: Please place 2nd -jejunal feeding tube; first tube was p\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with severe brain injury requiring TF\n REASON FOR THIS EXAMINATION:\n Please place 2nd -jejunal feeding tube; first tube was pulled out into\n stomach.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old male with severe brain injury requiring tube\n feedings.\n\n NASOINTESTINAL FEEDING TUBE PLACEMENT: The patient was placed supine on the\n fluoroscopic table. The in situ feeding tube was removed and the right naris\n was prepped with lidocaine jelly. Under fluoroscopic guidance, an 8 French\n 120 cm - feeding tube was inserted into the right naris and\n advanced through the esophagus into the stomach. The tube was then advanced\n through the pyloric valve and into the proximal small bowel. Injection of\n approximately 5 ml of Conray demonstrates that the tip is located past the\n ligament of Treitz in the proximal jejunum. The patient tolerated the\n procedure well without complications.\n\n IMPRESSION: Successful nasointestinal tube placement with the tip within the\n proximal jejunum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 946890,
"text": " 9:45 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: Comparison with the prior study performed on at 7:00\n p.m. demonstrates minimal interval worsening of the right subdural hemorrhage.\n There is suggestion of uncal herniation noted. These findings were discussed\n with the neurosurgery nurse practitioner, Chip at 8:20 a.m. on\n .\n\n\n 9:45 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with sdh and sah s/p bolt placement\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man with subdural and subarachnoid hemorrhage, status\n post bolt placement, evaluate for interval change.\n\n COMPARISON: Comparison is made to study performed three hours earlier.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: Patient is status post contrast-enhanced CT of the torso, limiting\n comparison to prior study in terms of intracranial hemorrhage. Again seen is\n high-density material within the sulci of the frontal lobes bilaterally, as\n well as in the right extra-axial space consistent with subarachnoid and\n subdural hematoma. Again seen is mass effect on the right lateral ventricle\n with leftward shift of normally midline structures by approximately 8 mm. This\n does not appear significantly changed from prior study. Suprasellar cistern\n is not well evaluated secondary to high-density material within, possibly\n blood and contrast. The appearance does not appear significantly changed from\n prior study, again possibly concerning for impending herniation although not\n well evaluated. Patient is status post bolt placement in the right frontal\n lobe. Comminuted calvarial fractures and subgaleal hematoma again noted.\n\n IMPRESSION: Status post ICP monitor placement in the right frontal lobe.\n Direct comparison to prior study is limited because of interval contrast\n administration for CT of the torso, allowing for additional contrast bolus,\n there does not appear to be significant change from prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-01 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 946868,
"text": " 6:54 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ? bleed?\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man struck by car. LOC.\n REASON FOR THIS EXAMINATION:\n ? bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd FRI 8:27 PM\n no evidence of acute traumatic intraabdominal or intrathoracic injury\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man struck by car, loss of consciousness.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired axial images of the chest, abdomen and pelvis were\n obtained with IV contrast. Multiplanar reformatted images were also\n displayed.\n\n CT OF THE CHEST WITH IV CONTRAST: There is no evidence of acute aortic\n injury. No evidence of segmental pulmonary embolism. No pathologically\n enlarged mediastinal, hilar, or axillary lymphadenopathy is identified.\n\n No evidence of pneumothorax. Dependent opacities seen within the lungs\n bilaterally, suggesting atelectasis. No focal consolidation or pleural\n effusion is seen.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: Small rounded hypodensities seen within\n the left lobe of the liver (series 2, image 67) possibly representing simple\n cyst, but too small to characterize by CT. The liver otherwise appears\n unremarkable. The gallbladder, pancreas, spleen, adrenal glands, and kidneys\n appear unremarkable. Visualized portions of the bowel appear within normal\n limits. No evidence of free air or free fluid within the abdomen.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid, and prostate appear\n unremarkable. Small amount of air is seen within the bladder likely secondary\n to Foley catheterization. No free fluid seen within the pelvis. Right\n femoral central venous catheter is noted.\n\n BONE WINDOWS: No suspicious lytic or blastic lesion is identified. Likely\n congenital spondylolysis within the lumbar spine is noted.\n\n IMPRESSION: No evidence of acute traumatic intra-abdominal or intrathoracic\n injury.\n (Over)\n\n 6:54 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: ? bleed?\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-01 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 946866,
"text": " 6:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man struck by car. LOC\n REASON FOR THIS EXAMINATION:\n bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd FRI 7:45 PM\n large comminuted calvarial fracture with apparent depression in parietal\n region. large assoc. subgaleal hematoma.\n\n subarachnoid and subdural hematoma, with leftwards shift of ~8mm. mass effect\n on right lateral ventricle. suprasellar cistern appears irregular, concerning\n for impending uncal/transtentorial herniation\n\n hemorrhage along lateral left globe\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man struck by car, loss of consciousness, evaluate\n for bleed.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: Large comminuted, slightly depressed calvarial fractures are\n identified. Fractures are seen traversing the vertex of the skull, extending\n down the right temporal bone and left parietal bone. There is slight\n deformity of the skull, with apparent depression of the parietal skull.\n\n High-density material is seen within the sulci of the frontal lobes\n bilaterally, as well as in the right parietals consistent with a subarachnoid\n hemorrhage. High-density material is also seen along the falx, tentorium, and\n layering in the right extra-axial space, consistent with subdural hematoma.\n There is evidence of mass effect on the right lateral ventricle, with leftward\n shift of normally midline structures by approximately 8 mm. Suprasellar\n cistern appears irregular, and third and fourth ventricles are not well\n visualized, concerning for impending herniation. Temporal horns appear\n patent.\n\n Large subgaleal hematomas are also identified, greater in the right frontal\n region.\n\n High-density material is also seen along the medial and lateral aspects of the\n left globe, indicating prior surgery.\n\n IMPRESSION:\n 1. Large comminuted, predominantly transversely oriented calvarial fracture,\n with apparent depression of the parietal skull. Large associated subgaleal\n hematoma is also noted.\n (Over)\n\n 6:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: bleed?\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Subarachnoid and subdural hematomas, with mass effect on the right lateral\n ventricle and leftward shift of normally midline structures by approximately 8\n mm. There is also concern for impending central herniation.\n 3. Post-operative changes are seen about left globe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-01 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 946867,
"text": " 6:54 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: fracture?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man struck by car. LOC.\n REASON FOR THIS EXAMINATION:\n fracture?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd FRI 8:34 PM\n no acute fracture, cervical spondylosis\n ich better evaluated on head ct\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man struck by car, evaluate for fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the cervical spine were obtained.\n Coronal and sagittal reformatted images were also displayed.\n\n FINDINGS: There is no evidence of acute fracture. Assessment of prevertebral\n soft tissues is limited by endotracheal tube. Degenerative change is seen\n throughout the cervical spine with osteophyte formation and disc space\n narrowing noted at multiple levels. Calcification in the posterior soft\n tissues possibly represents calcification of the nuchal ligament.\n Intracranial hemorrhages are better evaluated on head CT performed the same\n day. Dependent changes noted at the lung apices.\n\n IMPRESSION: No evidence of acute fracture. Cervical spondylosis.\n Intracranial hemorrhage better evaluated on head CT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-01 00:00:00.000",
"description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST",
"row_id": 946869,
"text": " 7:04 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: Please evaluate for facial fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with AMS (GCS7)after hit by car at unk speed. Difficult\n intubation 2/2 blood in oropharynx\n REASON FOR THIS EXAMINATION:\n Please evaluate for facial fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KCLd FRI 11:30 PM\n possible minimally displaced fracture of right superior orbital rim.\n\n right temporal bone fracture, and calvarial fractures again seen, better\n evaluated on head ct\n\n ich better evaluated on head ct\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man hit by a car, evaluate for facial fracture.\n\n TECHNIQUE: Axial non-contrast images of the facial bones were obtained.\n Coronal reformatted images were also displayed.\n\n There is slight cortical irregularity at the superior orbital rim , this\n possibly represents a non-displaced fracture. No other orbital fractures are\n identified. Again seen is fracture through the right temporal bone. Scout\n images again demonstrate large comminuted fracture through the cranium most\n fully evaluated on head CT. Intracranial hemorrhage is also better evaluated\n on head CT.\n\n IMPRESSION: Possible minimally displaced fracture of the right superior\n orbital rim. No other orbital fractures identified. Right temporal fracture\n again visualized. Scout films better demonstrate comminuted calvarial\n fractures, which are better seen on head CT. Intracranial hemorrhage, better\n evaluated on head CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-12 00:00:00.000",
"description": "P ABDOMEN U.S. (COMPLETE STUDY) PORT",
"row_id": 948471,
"text": " 12:02 PM\n ABDOMEN U.S. (COMPLETE STUDY) PORT Clip # \n Reason: Please perform right upper quadrant ultrasound with doppler\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with head injury now with increase LFTs and amylase and lipase\n REASON FOR THIS EXAMINATION:\n Please perform right upper quadrant ultrasound with doppler flow in portal vein\n to rule out Budd Chiari syndrome\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: ABDOMINAL ULTRASOUND \n\n HISTORY: 67-year-old man with head injury and increased LFTs, amylase and\n lipase. Right upper quadrant ultrasound to rule out portal vein obstruction\n and Budd-Chiari syndrome.\n\n Comparison made to prior CT abdomen dated . No prior ultrasound study\n is available.\n\n FINDINGS: The liver is normal in size and appearance. No focal hepatic\n lesions are identified. No intra or extrahepatic biliary ductal dilatation.\n The main portal vein is widely patent and demonstrates normal hepatopetal\n flow. The gallbladder contains sludge, but is otherwise unremarkable. No\n gallstones are seen.\n\n IMPRESSION:\n 1. Essentially normal Doppler ultrasound of the liver, without signs of\n portal vein thrombosis or Budd-Chiari syndrome.\n 2. Gallbladder sludge.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-13 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 948700,
"text": " 4:09 PM\n PORTABLE ABDOMEN Clip # \n Reason: please eval placement of dobhoff - need it to be post pylori\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with craiotomy/ dobhoff\n REASON FOR THIS EXAMINATION:\n please eval placement of dobhoff - need it to be post pyloric / appears to have\n come out slightly - but pt still with gastric rush in gastric region on\n assessment of tube placment. thanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate Dobbhoff tube placement.\n\n COMPARISONS: .\n\n AP SUPINE ABDOMEN: Tip of a nasogastric tube is seen in the proximal stomach.\n Air and contrast from a prior CT are seen throughout the colon to the level of\n the rectum. There are no dilated loops of large or small bowel. No definite\n free air is identified on this single supine view. Visualized osseous\n structures are unremarkable.\n\n IMPRESSION:\n 1. Tip of Dobbhoff feeding tube in the proximal stomach, not post-pyloric.\n 2. No evidence of obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-12 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 948444,
"text": " 10:10 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: dvt\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ICH in sicu\n\n REASON FOR THIS EXAMINATION:\n dvt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Head injury. Bed bound. Screening for DVT.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Using the linear probe, -\n scale and color Doppler son of the common femoral, superficial femoral,\n and popliteal vessels were performed bilaterally. There is no intraluminal\n thrombus. The vessels demonstrate normal flow, compressibility, respiratory\n variability, and augmentation.\n\n IMPRESSION: No DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 946949,
"text": " 9:47 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: new line\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with recent crainectomy\n REASON FOR THIS EXAMINATION:\n new line\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: CT chest dated .\n\n INDICATION.\n\n FINDINGS: Single frontal radiograph of the chest demonstrates an ET tube with\n distal tip at the level of the clavicles. The left subclavian line is\n demonstrated with distal tip overlying the mid SVC. There is an NG tube\n visualized with side port overlying the fundus of the stomach. The\n cardiomediastinal silhouette is within normal limits. The aorta is tortuous.\n Patchy linear opacities are seen at both mid lung zones, likely a subsegmental\n atelectasis. There is no evidence of pneumothorax after line placement.\n There are no pleural effusions.\n\n IMPRESSION: No evidence of pneumothorax status post left central line\n placement. Scattered subsegmental atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-06 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 947546,
"text": " 9:45 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: ICH IN SICU BED REST R/O DVT\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ICH in sicu\n REASON FOR THIS EXAMINATION:\n r/o dvts\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Bilateral lower limb duplex.\n\n INDICATION: ICH.\n\n FINDINGS: The right common femoral vein, right saphenofemoral junction, right\n superficial femoral vein, and right popliteal veins are all normal to\n compression and augmentation with no evidence of any DVT. The left common\n femoral vein, left saphenofemoral junction, left superficial femoral vein and\n left popliteal veins are all normal to compression and augmentation. No\n evidence of DVT.\n\n IMPRESSION: No evidence of any DVT in either lower extremity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-09 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 948001,
"text": " 1:41 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA BRAIN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: **PLEASE also perform MRV to assess sinus patency. ** MRI/A\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with massive SAH blood/ R frontal contusion/ R frontal SDH\n REASON FOR THIS EXAMINATION:\n **PLEASE also perform MRV to assess sinus patency. ** MRI/A to assess for\n diffuse axonal injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DJD SAT 4:44 AM\n MRI BRAIN:\n S/P R craniotomy/decompression\n Large amounts of edema in R frontal and parietal lobes and to lesser extent, L\n frontal and parietal lobe.\n 1.2cm frontal transfalcine shift to L\n Multiple hemmorhagic contusions\n Refer to head CT for eval of SAH / SDH\n\n MRV BRAIN:\n Superior sagittal sinus only faintly seen. Abundant collaterals. I am very\n concerned that this represents either sagittal sinus thrombosis, or sagitta;l\n sinus compression from the edema\n\n MRA BRAIN:\n Intracranial arteries are normal, though there is mass effect on the R MCA by\n the edema\n\n MD\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI brain and MRA and MRV of the head.\n\n CLINICAL INFORMATION: Patient with numbness of subarachnoid hemorrhage and\n subdural hematoma and right frontal contusion, for further evaluation to\n exclude brain injury and sinus thrombosis.\n\n TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial\n images of the brain were acquired. 3D time-of-flight MRA of the circle of\n was obtained and 2D time-of-flight MRV of the head were acquired.\n\n FINDINGS, BRAIN MRI:\n\n Correlation was made with the head CT of . Extensive hemorrhagic\n contusions are visualized involving right cerebral hemisphere in the frontal,\n parietal and temporal lobes with a craniectomy defect and slight herniation of\n the brain contents through the defect. Hemorrhagic contusions are also seen\n involving left frontal lobe and left parietal lobe. Subdural hematoma is seen\n along the falx along both convexities and also along the tentorium and\n posterior fossa. The subdural hematomas are small in size with a maximum\n (Over)\n\n 1:41 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA BRAIN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: **PLEASE also perform MRV to assess sinus patency. ** MRI/A\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n width of 5 mm. Intraventricular blood is visualized in the occipital of\n the left lateral ventricle. A small amount of intraparenchymal blood is seen\n in the cerebellum as well. There is no hydrocephalus. Extensive soft tissue\n changes are seen in the paranasal sinuses and mastoid air cells which could be\n related to intubation.\n\n On the T2-weighted images, near the convexity in the parietal region,\n increased signal is seen within the superior sagittal sinus. The remaining\n anterior portion of the superior sagittal sinus demonstrate decreased width of\n the flow void which could be secondary to compression. Increased signal\n within the sinus is suspicious for thrombus.\n\n IMPRESSION: Extensive brain contusions and small subdural hematomas\n bilaterally, along the falx and tentorium as described above. Suspicion for\n increased signal within the mid portion of superior sagittal sinus in the\n parietal region which could indicate a thrombus or slow flow.\n\n MRA OF THE HEAD:\n\n The head MRA demonstrates hypoplastic A1 segment of the right anterior\n cerebral artery. The right MCA appears slightly small in caliber than the\n left which could be due to bone contusion and swelling in the right cerebral\n hemisphere. No vascular occlusion is identified. Slight prominence of the\n anterior communicating artery is seen but no discrete aneurysm is identified.\n\n IMPRESSION: Except for slight vascular stretching in the distribution of\n right middle cerebral artery which could be due to brain swelling in this\n region, no vascular occlusion is identified.\n\n MRV OF THE HEAD:\n\n The head MRV demonstrates flow in both transverse sinuses as well as in deep\n venous system. However, the superior sagittal sinus is not well visualized.\n In its anterior portion, some flow is seen in the superior sagittal sinus, but\n in the mid portion in parietal region, no discrete flow channel is identified\n and collateral venous channels are visualized. This is suspicious for\n thrombosis in this region. Alternatively, this could be secondary to\n compression by surrounding brain edema and subdural hematoma.\n\n IMPRESSION: Superior sagittal sinus appears distorted and narrowed with a\n question of thrombosis in its mid portion in the parietal region. Transverse\n sinuses and the deep venous system is patent.\n\n (Over)\n\n 1:41 AM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA BRAIN W/O CONTRAST; -59 DISTINCT PROCEDURAL SERVICE\n Reason: **PLEASE also perform MRV to assess sinus patency. ** MRI/A\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 948048,
"text": " 12:16 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: f/u CT\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with head trauma; now with ? sup sag sinus thrombus\n REASON FOR THIS EXAMINATION:\n f/u CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old male with head trauma.\n\n COMPARISON: MRI/MRA of the brain from earlier the same day and CT of the head\n from .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: The patient is status post a right craniectomy with brain\n herniating through the defect, as before. There is extensive contusion\n involving the right frontal and parietal regions and to a lesser extent the\n left frontal region with surrounding extensive edema. The degree of midline\n shift appears similar to the study with prominence of the third\n ventricle and the temporal of the right lateral ventricle, also\n unchanged. The suprasellar cistern remains well visualized. Opacification of\n several ethmoid air cells and mastoid air cells persists.\n\n IMPRESSION: Extensive bilateral evolving hemorrhagic contusions, status post\n right-sided craniectomy, and leftward subfalcine herniation are all similar in\n appearance over the past two days. Basal cisterns remain well visualized.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-10 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 948180,
"text": " 6:12 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Central line placement\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with fevers, positive sputum cx\n\n REASON FOR THIS EXAMINATION:\n Central line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever. Central line placement.\n\n Single portable radiograph of the chest demonstrates a nasogastric tube with\n its tip in the stomach. The proximal side port is at the level of the GE\n junction. The nasogastric tube should be advanced. There has been interval\n placement of a right subclavian central venous catheter with its tip in the\n SVC. Left subclavian central venous catheter and tracheostomy tube are\n unchanged. No effusion. No pneumoperitoneum. No pneumothorax.\n\n IMPRESSION:\n\n Interval placement of right subclavian central venous catheter with its tip in\n the SVC. No pneumothorax.\n\n Nasogastric tube with its tip in the stomach. The proximal side port of the\n nasogastric tube is at the level of the GE junction. The nasogastric tube\n should be advanced.\n\n No consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-01 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 946858,
"text": " 6:17 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: injury?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man struck by car\n REASON FOR THIS EXAMINATION:\n injury?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 60-year-old man status post motor vehicle pedestrian accident.\n\n CHEST, AP: No prior studies are available for comparison. The patient is\n intubated. An endotracheal tube lies at 4 cm above the carina. There is\n mediastinal widening, particularly of the right paratracheal stripe with total\n mediastinal widening up to 11 cm in diameter. There is no pleural effusion,\n left apical cap, or evidence of pneumothorax. The lungs are clear.\n\n PELVIS, AP VIEW: There is no evidence of fracture, dislocation, or bony\n destruction.\n\n IMPRESSION: Status post intubation. Widening of the mediastinum, for which\n correlation with the planned CT torso is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 946899,
"text": " 12:30 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Needs immediate post op CT in next 30 minutes, in OR \n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p hemicraniectomy with head swelling during surgery\n REASON FOR THIS EXAMINATION:\n Needs immediate post op CT in next 30 minutes, in OR now\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KMcd SAT 3:30 AM\n Massive new edema. Now midline shift to the right. New intraventricular blood.\n New collection along the falx superiorly.\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN\n\n HISTORY: Status post right hemicraniectomy with head swelling during surgery.\n Post-operative CT scan requested.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n COMPARISON STUDY: study performed at 22:10 hours and\n reported by Dr. as revealing, \"Minimal interval worsening of right\n subdural hemorrhage. There is a suggestion of uncal herniation noted.\"\n\n NOTE: A wet , provided by Dr. indicated, \"Massive new edema.\n Now midline shift to the right. New intraventricular blood. New collection\n along the falx superiorly.\"\n\n FINDINGS: Since the previous study, a right hemicraniectomy has been\n performed, through which there is moderate herniation of the right cerebral\n hemisphere. There has been interval appearance of a longitudinally extensive,\n but relatively , slightly hyperdense left cerebral hemispheric subdural\n hemorrhage causing effacement of the contiguous cerebral sulci. Maximal width\n of this hemorrhage is approximately 7 mm. There is also a spindle-shaped low-\n density right superior parafalcine subdural fluid collection that has evolved\n since the previous study, as well. There is increase in the amount of\n hemorrhage likely along the inferior aspect of the right frontal lobe,\n presumably representing a hemorrhagic contusion. Extensive subarachnoid\n hemorrhage is again seen. There is now a small amount of blood sedimenting\n within the left occipital . There is approximately 7-mm rightward\n subfalcine herniation. Along the anterior aspect of the hemicraniectomy defect\n are collections of gas, presumably post-operative in nature in both intra- as\n well as extradural in locale. There is also more extensive hemorrhage along\n the right parietal convexity surface of the brain. The extensive subarachnoid\n hemorrhage previously seen is redemonstrated.\n\n CONCLUSION: Status post right hemicraniectomy, with multiple abnormalities\n that have developed since the prior study, described in detail above.\n\n\n (Over)\n\n 12:30 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Needs immediate post op CT in next 30 minutes, in OR \n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-04 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 947204,
"text": " 9:36 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change?\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with venous sinus bleed. s/p partial crainectomy.\n REASON FOR THIS EXAMINATION:\n interval change?\n CONTRAINDICATIONS for IV CONTRAST:\n intracranial hemorrhage\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN\n\n HISTORY: Venous sinus bleed. Status post partial craniectomy. Assess for\n interval change.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n COMPARISON STUDY: Non-contrast head CT scan from .\n\n FINDINGS: There has been no significant change in the appearance of the scan\n compared to the prior study of . Once again, there are extensive\n areas of subarachnoid hemorrhage including a large collection of blood in the\n right parietal vertex region and the right frontal lobe. There is a large\n area of low absorption also noted along the medial and superior aspect of the\n right cerebral hemisphere, extending into the right frontal lobe surrounding\n some of the hemorrhagic areas described above. There is also low absorption\n in the left frontal lobe immediately and inferiorly. The low density areas\n certainly could represent infarctions due to either direct brain damage or\n entrapment of feeding arteries due to subfalcine herniation. At this time,\n however, there is no subfalcine herniation detected. No uncal or hippocampal\n herniation is seen. There is redemonstration of the right hemicraniectomy\n defect. There are air/fluid levels within the sphenoid sinus and the left\n maxillary sinus with a mild-to-moderate degree of opacification of the ethmoid\n sinuses. These findings presumably relate to the intubated state of the\n patient.\n\n CONCLUSION: Stable, but grossly abnormal study as noted above.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-12 00:00:00.000",
"description": "LP UNILAT UP EXT VEINS US LEFT PORT",
"row_id": 948443,
"text": " 10:09 AM\n UNILAT UP EXT VEINS US LEFT PORT Clip # \n Reason: R/o L SCV clot\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year man with ICH in 5, ?central fevers\n REASON FOR THIS EXAMINATION:\n R/o L SCV clot\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Intracranial hemorrhage. Assess for left subclavian clot.\n\n LEFT UPPER EXTREMITY VENOUS ULTRASOUND: Using the linear probe, grayscale and\n color Doppler son of the left internal jugular, subclavian, axillary,\n brachial, and basilic veins was performed. The cephalic vein was not\n visualized. The remaining vessels demonstrate normal flow and respiratory\n variability, with compression where appropriate.\n\n IMPRESSION: No evidence of DVT in the left upper extremity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 947431,
"text": " 2:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for swelling, progression\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ICH, s/p hemi-craniectomy.\n REASON FOR THIS EXAMINATION:\n Assess for swelling, progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HEAD CT\n\n INDICATION: 60-year-old male with ICH, status post hemicraniectomy, please\n assess for swelling and progression.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Overall, there has not been a significant change when compared to\n prior study of . There are again seen extensive areas of\n subarachnoid hemorrhage, including a large collection in the right parietal\n vertex. Large areas of low attenuation within the right cerebral hemisphere\n superiorly are again noted to surround these regions of hemorrhage, and could\n represent evolving infarction or direct brain injury. There remains no\n evidence of subfalcine, uncal, or hippocampal herniation. Right\n hemicraniectomy defect is unchanged. Air-fluid levels within the sphenoid\n sinus and left maxillary sinus are generally unchanged. Mild-to-moderate\n opacification of the ethmoid sinuses is stable.\n\n IMPRESSION: Generally unchanged appearance of multiple severe brain\n abnormalities.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-02 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 946936,
"text": " 7:52 AM\n CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN # \n Reason: eval for increased blood\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ped vs mv. s/p craniectomy\n REASON FOR THIS EXAMINATION:\n eval for increased blood\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NON-CONTRAST HEAD CT SCAN\n\n HISTORY: Status post motor vehicle accident and craniectomy. Evaluate for\n increased blood.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n COMPARISON STUDY: Non-contrast head CT scan of the same day, performed seven\n hours earlier.\n\n In the seven hour interval between studies, there is slightly more hemorrhage\n seen within the left occipital . The rightward shift of normally midline\n structures seems little altered in extent and the ventricular size appears to\n be stable, as well.\n\n There does appear to be somewhat more conspicuous hypodensity within the right\n frontal lobe and along the medial aspect of the left frontal lobe. These\n findings are of concern for infarction, possibly secondary to entrapment of\n the anterior cerebral arteries, as well as coexistent hemorrhagic contusions.\n There is somewhat more edema around the large right parietal convexity\n hemorrhage as well. The massive quantity of subarachnoid hemorrhage, the\n small right parafalcine interhemispheric subdural hemorrhage, as well as small\n left cerebral convexity subdural hemorrhage are all redemonstrated.\n\n CONCLUSION: Increasing edema in multiple areas of the brain of concern for\n ongoing infarction versus evolution of hemorrhagic contusions.\n\n ADDENDUM: There is somewhat increased preseptal right-sided periorbital soft\n tissue swelling which extends towards the temporalis muscle. Is there any\n concern for coagulopathic process?\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-06 00:00:00.000",
"description": "MR CERVICAL SPINE W/O CONTRAST",
"row_id": 947580,
"text": " 12:40 PM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: unstable c-spine?\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with traumatic head injury. still in c-collar.\n REASON FOR THIS EXAMINATION:\n unstable c-spine?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Severe traumatic head injury resulting in inability to clinically\n assess the cervical spine.\n\n COMPARISON: No previous cervical spine MRI. Cervical spine CT dated , is available for correlation.\n\n TECHNIQUE: Sagittal T1-weighted, T2-weighted, and STIR images of the cervical\n spine were obtained, with axial T2-weighted and gradient echo images from C2/3\n through C7/T1 interspaces.\n\n CERVICAL SPINE MRI WITHOUT INTRAVENOUS CONTRAST: The vertebral alignment is\n normal. There are no signal abnormalities in the bone marrow, in the spinal\n ligaments, paraspinal soft tissues, or the spinal cord to suggest acute\n traumatic injury. Mildly elevated T2 signal in the paratracheal and\n paraesophageal soft tissues, which are distinct from the prevertebral soft\n tissues, is felt to be related to instrumentation and/or secretions.\n Spondylosis without significant central canal narrowing is present at C4/5,\n C5/5, and C6/7.\n\n Findings were discussed with Dr. at 6 p.m. on .\n\n IMPRESSION:\n\n 1. No evidence of traumatic injuries in the cervical spine. Please note that\n ligamentous injury cannot be definitively excluded by MRI.\n\n 2. Cervical spondylosis without central canal narrowing.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2109-03-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 947483,
"text": " 8:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for pulmonary process/consolidation\n Admitting Diagnosis: S/P PEDESTRIAN STRUCK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with recent crainectomy now febrile\n\n REASON FOR THIS EXAMINATION:\n Assess for pulmonary process/consolidation\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST:\n\n REASON FOR EXAM: Patient with recent craniectomy with fever.\n\n Comparison is made with prior study dated .\n\n FINDINGS: ET tube tip is in adequate position. NG tube tip is out of view.\n Left lower lobe retrocardiac atelectasis is new.\n\n IMPRESSION: New left lower lobe atelectasis.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-06 00:00:00.000",
"description": "Report",
"row_id": 1374680,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds sl coarse after suct mod=>lge th tan sput. ABGs stable; no vent changes required overnoc. Cont PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-06 00:00:00.000",
"description": "Report",
"row_id": 1374681,
"text": "T/SICU Nursing 19-07\nNeuro: Remains off sedatives. Does not open eyes or regard examiner or follow commands. Pupils 4mm with disconjugate gaze, both briskly reactive and accomodating to light. Gag and cough are intact. Left corneal reflex absent to impaired at best, right corneal reflex intact. Moves RUE non-purposefully, at best localizes to ETT or nailbed pressure to the LUE but not to sternal rub or trapezius pinch. RLE withdraws to nailbed pressure. LUE postures with nailbed pressure. LLE withdraws vs postures to nailbed pressure, toes upgoing.\n\nPain: No clear signs of pain, hypertensive without tachycardia or tachypnea, no grimace.\n\nResp: Lungs are clear but diminished in all fields. Suctioned for *copious* amounts of thick yellow sputum. ABG reveals uncompensated metabolic alkalosis with good oxygenation. Remains on low vent settings, unchanged this shift. Oral secretions are foul smelling and copious in amount. SPO2 remains in high 90's.\n\nCV: Sinus rhythm without ectopy. Rate 77-96. BP 134-159/48-70. Goal SBP per neurosurgery notes is <160. Left radial arterial line was dampened and did not draw , new right radial arterial line was inserted by Dr. . It has a sharp waveform but does not correlate with the NBP cuff - per Dr. we will follow NBP pressures as per the past few days. Left quad lumen CVL patent, CVP transduces sharply . Strong palpable distal pulses.\n\nGI: Abdomen obese vs distended. Bowel sounds normoactive. Was tolerating tube feeds at goal, however now off pre-procedure. Gave dulcolax PR with resulting small soft brown BM.\n\nGU: Foley to gravity drains yellow urine with occasional clots in large amounts. Diuresed with mannitol as ordered.\n\nEndo: Insulin gtt titrated scale; was off for many hours overnight after tube feeds were shut off, however BG is rising so gtt restarted.\n\nLytes: Repleted potassium PO, rechecked level is normal.\n\nSkin: Right hemicrani staples OTA, clean and dry. Right eye hematoma red/purple without drainage.\n\nID: Tmax 102.1 --> applied cooling blanket (which lowered temperature, however induced shivering, so shut off), gave tylenol, and applied ice packs to axilla and groin. Pan-cultured.\n\nSocial: No family contact overnight.\n\nPlan:\nMaintain safety\nq2 hr neuro checks\nTrach & PEG today\nTight sugar control\nPromote normothermia\nNotify team of acute changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-06 00:00:00.000",
"description": "Report",
"row_id": 1374682,
"text": "Respiratory Therapy\n\nPt trached at bedside this shift w/ #8.0 Portex trach, bronched for copious thick bloody secretions. Travelled to and from MRI for head scan w/out incident. Currently on A/C ventilation, will wean back to PSV when appropriate.\n\nPlan: maintain support; when sedation wears off and secretions are under control ?trach collar\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-06 00:00:00.000",
"description": "Report",
"row_id": 1374683,
"text": "NPN 0700-1900\n Pt to MRI neck to check for ligamentus injury. Results pending. Percutaneous Trach done at bedside.\n Neuro- Neuro exam unchanged. Exam to Q4h. Dr spoke with wife today. Sutures intact. Mannitol changed to Q8h.\n Resp- Placed on AC for vent placement. Still somewhat sedate from procedure and remains on full support. Lungs very coarse with diminished bases. Copious amt thick tan foul smelling sputum. bronchoscopy done with trach today and sputum spec sent. Vanco and zosyn started for PNA coverage.\n CV- SR without ectopy. Aline with fling, using NBP as well. Tylenol for temp. TLC rewired due to placement. Metabolis alkalosis ? 2 to mannitol diuresis. Skin w/d/i.\n GI/GU- TF restarted after trach at 80cc/h. Pt had small stool. Foley patent with good UO.\n Plan- PEG to be placed when pt WBCs down and afebrile. Rehab screen to be done. Seen by PT/OT will be back with splints tommorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-07 00:00:00.000",
"description": "Report",
"row_id": 1374684,
"text": "RESPIRATORY CARE:\n\nPt remains trached, #8 percutaneous. Ventilator weaned and removed, pt placed on 40% trache mask without event. Pt continues to have moderate amounts bloody secretions. BS's coarse at times. See flowsheet for further pt data. Will follow for trache care protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-07 00:00:00.000",
"description": "Report",
"row_id": 1374685,
"text": "T/SICU Nursing 19-07\nNeuro: Exam unchanged. RUE localizes to LUE nailbed pressure. LUE postures to nailbed pressure. Bilat LE's withdraw to pain. PERRL. Left corneal reflex impaired to absent, right intact. Gag, cough intact.\n\nPain: Treated for pain as evidenced by hypertension with morphine with good effect.\n\nResp: Weened quickly to trach mask, tolerating well. ABG reveals metabolic alkalosis with borderline PaO2, FiO2 increased and SPO2 is 98-100%. Lungs are coarse in all fields. Trach had some scant bleeding from the insertion site that is now stopped since the vent tubing is no longer pulling on it. Cough is strong, and bloody sputum has returned to thick yellow matter.\n\nCV: Sinus rhythm without ectopy. Vital signs stable, see flowsheets for data. Right radial arterial line transduces sharply and now correlates well with the NBP. Palpable distal pulses.\n\nGI: Abdomen softly distended vs obese, tolerating tube feeds at goal with no residuals. Had one small brown loose BM. Bowel sounds present.\n\nGU: Foley to gravity, mannitol ween continues, osmolality approaching threshold to hold dose.\n\nEndo: RISS with coverage as ordered; tightened by ICU resident.\n\nLytes: Gave 40meq KCL PO, others normal.\n\nID: Tmax 101.7 responding well to tylenol.\n\nSocial: No family contact overnight.\n\nPlan: Maintain safety. Obtain helmet so pt can get OOB. Pain management. Pulmonary toileting. Needs PEG. Rehab screen.\n"
},
{
"category": "ECG",
"chartdate": "2109-03-01 00:00:00.000",
"description": "Report",
"row_id": 208571,
"text": "Irregular sinus bradycardia\nLeft axis deviation - possible left anterior fascicular block\nInferior T wave changes may be due to myocardial ischemia\nPrecordial peaked T waves\nClinical correlation is suggested\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-04 00:00:00.000",
"description": "Report",
"row_id": 1374675,
"text": "NPN 7a-7p\n\nEvents: CT scan 0930---> no significant changes.\n\nNeuro: GCS ; PERRLA @ 3mm, Flexor withdrawl to painful stimuli R UE and R LE; Decerebrate posturing L UE/LE in response to painful stimuli; Triple flexion of L LE with plantar surface stimulation; unable to localize with R UE with sternal rub and trap squeeze; Mannitol q 6 hrs; R hemicraniectomy; cervical collar; impaired cornael reflex on L but present; gag and cough reflexes intact.\n\nCV: NSR 70-90 bpm; BP 110-140 sys; Keep BP less than 140-160; palp periph pulses 2+; L central line; L radial a-line; boot; SC heparin; Hct 30.0 (sig drop by 10 points).\n\nResp: Clear UL and diminished bases; weak cough, suction with mod amt thick yellow/tan secretions; limited ROM due to R hemicraniectomy; CPAP tol > 12hrs with Sats >98% and shallow rates in 20-26 range, MV 9.0-12.0; 40% Fio2; 5 Peep-5 psupp, a-line unable to draw blood.\n\nGI: soft distended abdomen, no BM, insulin gtt, TF at goal of 80cc/hr with 0 residuals, GT flush 30 ml q 6, bowel regimen initiated.\n\nGU: clear yellow urine with adeq output, occ sediment noted in foley, BUN and creatinine WNL's, KVO fluids.\n\nEndo: Insulin gtt, variable adjustments, hypoglycemic at 1100 with appropriate response to amp D50%.\n\nSkin: R hemicrani site intact with staples, some serous drainage noted, no s/s infection, L UE + edema, decreasing facial edema.\n\nPain: monitor vitals, no s/s pt experiencing pain.\n\nMS: Cerv collar, bedrest with HOB > 30.\n\nSocial: Family in to visit, discussed potential for organ donation if prognosis is grim, discussed possible treatment options \r(trach-peg) and rehab.\n\nAssessmet: TBI/SAH/SDH with possible diffuse axonal injury.\n\nPlan: Cont to monitor and assess as ordered, q 2 NS, mannitol as ordered, monitor serum osmo and sodium, BP < 140-160 sys, q 1 BS, plan for family meeting end of week, watch for falling hct, monitor for BM.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-02 00:00:00.000",
"description": "Report",
"row_id": 1374666,
"text": "T/SICU RN Progress Note\nEvents of day: Weaned off Neo, Head CT, Left subclavian quad lumen placed, Right femoral line removed.\n\nNeuro: Moves right hand spontaneously, not to command, attempts to localized/withdraw with RUE to pain. Pupils equal and reactive slightly sluggish. + cough and gag slightly impaired. Does not respond to painful stimuli in other extremities. Dilantin and Mannitol as ordered.\n\nCV: HR 110-130's ST no ectopy noted. ABP systolic 100's remains on levophed to maintain goal ABP. CVP 6-12. P-boots.\n\nResp: Remains intubated see CareVue for vent settings, RR set at 20, + breathing over vent. Lungs clear decreased in the bases.\n\nGU/GI: Foley with clear yellow urine. Abd soft non-tender non-distended, on Protonix, started on TF Repleate with fiber goal 80cc/hr.\n\nID: On vanco and genta post op doses. Tmax 102.7 tylenol given, cool bath, fan is on.\n\nSkin/Mobility: Skin grossly intact, remains on logroll, bedrest with c-collar on at all times.\n\nSocial: Wife and daughters in to visit, updated, support given. Social work and ICU attending spoke with family and updated.\n\nPlan: Monitor neuro signs, titrate levophed as tolerated, montior temperature, continue to support family and patient, follow plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-02 00:00:00.000",
"description": "Report",
"row_id": 1374667,
"text": "Patient remains on mechanical ventilation,changed to heated system.Suctioned for moderate amount of bloody thick sputum,BS coarse.Metabolic acidosis persists despite high rate.Patient febrile with occasional PAC's. CXR shows ETT @ clavicles level,patchy opacities @ mid lungs zones.? ETT position vs where it's taped @lips.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-03 00:00:00.000",
"description": "Report",
"row_id": 1374668,
"text": "Resp Care Note:\n\nPt cont intub with OETT and mech vent as per Carevue. Lung sounds ess clear after suct sm th tan sput. Pt in NARD on current vent settings; no vent changes required overnoc. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-03 00:00:00.000",
"description": "Report",
"row_id": 1374669,
"text": "Nursing Progress Note 1900-0700\n Neurologically unchanged overnight, weaning Levophed to off.\n Review of Systems\n Neuro- unable to assess pupils, corneals or eye opening d/t swelling.Cold packs to eyes w/small improvement. Faint Babinski bilateral LE's, cont to move RUE spontaneously, moves hand slowly toward ETT- soft restraint maintained.no movement or withdrawal of LUE.Gag,cough intact. Cspine,logroll precautions maintained at all times\n CV- MP ST 110-130, no VEA.BP 110-130's systolic by aline. Levo weaned down, IVF cont at 125/hr. LSC CVL, R radial Aline, peripheral heplock all intact.pulses+,palpable,pboots on hct 43\n Resp- remains on full vent support, CMV20/550/50%/8. RR high20's, sao2 98%. LS clear, sl coarse rul, sxn for brown thin secretions\n GI- trophic tf started, currently at 30cc/hr, aspirate 30-40cc coffee ground appearance.BS hypoactive to absent, abd soft.\n GU- Foley in place, u/o qs, clr yellow\n Skin- intact except craini wound-see carevue\n ID- postop abx finished, tmax 101.7. wbc 19, trending up\n Endo- insulin drip at 3u, bs 100-120's\n Plan- Cont to monitor neuro status\n Advance tf as tolerated\n maintain safety\n Update, support family, involve SW as needed\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-03 00:00:00.000",
"description": "Report",
"row_id": 1374670,
"text": "Patient remains on mechanical ventilation went to CT scan again result pending.BS diminished,suctioned for small amount of thick brown sputum.Responds to painful stimuli mild progression observed,ABG aceeptable despite hyperventilation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-02 00:00:00.000",
"description": "Report",
"row_id": 1374664,
"text": "Resp Care Note:\n\nPt received from ER intub and placed on mech vent as per Carevue. Pt transported to OR without incident. Lung sounds ess clear. ABGs intention resp alkalosis with good oxygenation; able to wean FIO2. Cont mech vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-02 00:00:00.000",
"description": "Report",
"row_id": 1374665,
"text": "TSICU Admit Note 1900-0700\n 67yo male admitted s/p pedestrian struck by at low rate of speed(est 5-7mph).Wife present at scene, reports +LOC.Pt intubated at scene, brought to . Initial head CT shows large comminuted calverial fx, depressed parietal skull fx, large subgaleal hematoma, SDH,SAH, L 8mm shift w/mass effect of R lateral ventricle, and hemmorhage of L lateral globe.No other significant injuries, Cspine/TLS not cleared yet.\n Pt emergently to OR for change in status/worsening CT, 2000cc bleed in OR w/ massive fluid rescusitation, returned to on Levo and Neo. Essentially stable overnight on pressors, 2u add'l pc's given.No improvement in neuro status.\n No significant PMH per wife- takes , sulfa allergy, detached retina R eye in past, otherwise healthy.\n Review of Systems\nNeuro- PERL @2mm, sl. sluggish. GCS7, no eye opening or corneals,impaired cough/gag, only moves RUE spontaneously, not to commands. No response to pain in other extremities, no movement.Off Propofol,Fent since return from OR\nCV- MP SR-ST in 110's, BP high 90's-110's, on Levo/Neo.aline L radial artery,good waveform noted. R fem introducer/CVL. IVF at 125, Levo now @ 0.17mcg/kg/min, Neo @ 0.7mcg/kg/min. Pulses+, palpable, extremities cool. Pboots in place, awaiting pump\nResp- full vent support CMV550/50%/25/8. co2=30-32 on last abg, sao299%.LS clear-difficult intubation per ED\nGI-NG L nares to lws, dg dk brown bilious secretions. BS absent at this time-Protonix started\nGU- u/o adequate, clear yellow via Foley\nSkin- intact, see carevue\nSocial- married, two married daughters, all in at bedside. Phone numbers on board, all questions answered\nPlan- support BP as needed\n Monitor neuro status\n Medicate for pain/sedation as needed\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-04 00:00:00.000",
"description": "Report",
"row_id": 1374676,
"text": "pt transported to CT for brain image. He was PSV trialed throughout shift without incidence. Plan is to monitor mental status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-05 00:00:00.000",
"description": "Report",
"row_id": 1374677,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th pale yellow sput. Pt in NARD on current vent settings; no vent changes required overnoc. Cont PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-05 00:00:00.000",
"description": "Report",
"row_id": 1374678,
"text": "Nursing Progress Note\nNo Significant Events\n\nNeuro: Pt not sedated. Does not open eyes or follow commands. PERRLA, 3mm, brisk. L corneal absent, R corneal intact. Purposeful movements towards ETT with RUE. Withdrawal to nailbed pressure in RLE. Decerebrate posturing in LUE and LLE. Cough and gag intact. Pt continues on dilantin and mannitol. C-spine precautions maintained.\n\nCV: NSR, no ectopy. HR 80-90's. SBP 110-130's. A-line dampened with no blood return, folling NIBP. Lytes WNL. HCT 27.8. L hand with +2 edema, elevated with pillows. Cap refill <3 sec in all ext. +PP.\n\nResp: Pt cont on c-pap: . Sats 98-100%. RR 20-27. LSCTAB, dim in bilat bases. Sx several times producing copious amts yellow thin secretions. Pt will occasionally have episodes of hiccups.\n\nGI: Abd soft, nt, nd. +BS. Tolerating TF at goal rate of 80 ml/hr. Residuals <5ml. Pt had BM x1 this shift, med brown formed stool.\n\nGU: Foley draining adequate amts CYU. Diuresing well to mannitol.\n\nEndo: Pt cont on insulin gtt. BS remain stable at 4units/hr.\n\nID: Tmax 101.1. No abx coverage at this time. WBC trending down.\n\nSkin: Incision to craniectomy stapled, and open to air. D+I.\n\nSocial: No contact with family this shift.\n\nPlan: Cont neuro checks q2hr. Maintain SBP <150, prn metoprolol. Pulm toilet. ?discontinue insulin gtt and begin ss. Maintain skin integrity. Cont to support pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-05 00:00:00.000",
"description": "Report",
"row_id": 1374679,
"text": "NPN 7a-7p\n\nEvents: To CT scan at 1400, some improvements made per NSURG, R UE more active and able to localize this shift, other neuro signs remain the same, consent obtained for trach and peg .\n\nNeuro: R hemicraniectomy; localizes to pain R UE; withdraws to pain R LE; Triple flexion LLE with plantar surface stimulation; Decerebrate posturing L UE with painful stimuli; diminished corneal reflex on L; fair gag and cough reflexes; noticed pt resisting R eye lid opening during gtt administration; some increased shoulder girdle motion in L UE with posturing.\n\nCV: NSR, a-line damp; NIBP 140's systolic; palp pedal pulses, sc heparin, boots, L central venous line, PIV removed R hand, generalized + edema( > in L UE).\n\nResp: CPAP 5/5/40%, MV , Sats 98-100%, thick yellow sputum req ETT suctioning,clear upper lobes and diminished lower lobes, shallow resp depth a t times with rates between 22-26.\n\nGI: No BM, soft distended abdomen, bowel regimen, + BS, no TF residuals, TF at goal.\n\nGU: Urine output WNL's, clear yellow, IVF KVO, Mannitol q 6 with sodium and serum osmo WNL's, lytes WNL's (boarderline phos).\n\nEndo: q 1-2 hr fingersticks, tol 4.0 units/hr this 12 hr shift with no adjuistments made.\n\nSkin: Staples R hemicrani intact with minimal serous drainage, pressure sore sites CDI.\n\n\nMS: C collar remains, BR with > 30, PROM when able, plan to order multipodus boots this evening.\n\nID: decreasing WBC, mild fever in 100's PO.\n\nSocial: Family in, would like to plan a meeting with NSURG .\n\nPlan: Hold feedings at 2400, prep for trach/peg , NS q2, MRI ordered for C-spine, protect R Cranial Hemisphere, monitor blood sugar levels, check phenytoin level with am labs, change VAP set up this evening, OT and PT consults ordered, plan for splinting/casting to prevent loss of jt range of motion, continue to monitor and assess as ordered.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-03 00:00:00.000",
"description": "Report",
"row_id": 1374671,
"text": "NPN 0700-1900\n Pt is 60yo s/p ped struck with closed head injury- SDH, SAH, bil frontal contusions- with 8mm shift. To OR for evac and large volume blood loss. Craniectomy done . Presently withdraws/localizes with RUE. Withdraws RLE and no movement on L side. TLS cleared and HOB at 45 degrees. Facial edema improved and able to manually open eyelids. Pupils r-3, l-3.5, briskly reactive. Intact cough, impaired gag.\n Repeat Head CT today with results explained to family by Dr. . He also discussed plan of care and pt prognosis. Family need alot of reenforcement and repeated explainations on pathology and POC. Repeat head CT in am.\n Resp- Lungs coarse with diminished bases. Scant tan secretions. Vent settings unchanged. See carevue for ABGs, HO aware.\n ST 100-120s, no ectopy. Maintaining BP off levophed and was htn at times. Metoprolol ordered PRN for SBP.140, not required this shift. IVF KVO. Insulin gtt off and restart ssic.\n Afebrile. Skin w/d/i. Staples to cranial incsion x 2, intact, approximated, scant drainage.\n Abd soft with hypo bs. TF increased to 70cc with low residuals, goal 80cc/h. Foley patent with adeq UO. No BM but bowel regimen started.\n\n Plan- Family to discuss treatment options, expalined to them by Dr , if pt's edema worsenens. Restart Insulin gtt if BG uncontrolled on SSIC. Provide ongoing support for family. Would benefit from SW consult tommorrow. Repeat Head CT in AM.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-04 00:00:00.000",
"description": "Report",
"row_id": 1374672,
"text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm th tan sput. ABGs stable; no vent changes required overnoc. Cont mech vent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-04 00:00:00.000",
"description": "Report",
"row_id": 1374673,
"text": "Nursing Progress Note\nID: Tmax 100.9. No abx coverage at this time\n"
},
{
"category": "Nursing/other",
"chartdate": "2109-03-04 00:00:00.000",
"description": "Report",
"row_id": 1374674,
"text": "Nursing Progress Note\nNo significant events\n\nNeuro: Pt not sedated. Does not opens eyes or follow commands. Occasional purposeful movement in RUE. RLE withdraws to pain. Decorticate posturing in and LL extremeties. HO Almed to assess. PERRLA, 3mm, brisk. Cough and gag impaired. Pt cont on mannitol, and dilantin.\n\nCV: ST, no ectopy. HR 100-110's. A-line dampened, following NIBP. SBP 110-140's, maintaining <150. Pt does become hyperdynamic with pain/turning. Cap refill <3sec in all ext. +PP.\n\nResp: Pt cont on CMV: 20x500/5/40. No vent changes made overnight. Most recent ABG wnl. Sats 96-100%. Pt overbreathing vent up to 30bpm. LSCTAB, dim in bilat bases. Sx several times for lrg amts thick tan sputum. Will attempt Cpap later this morning.\n\nGI: Abd soft, nt, nd. +BS. Tolerating TF at goal rate, no residuals. No BM this shift.\n\nGU: Foley draining qs CYU.\n\nEndo: Pt cont on insulin gtt. see careview for exact values.\n\nSkin: Craniectomy site staples. D+I, no drainage, open to air.\n\nSocial: Family spoke on phone to Dr (neurosurg) last evening. Discussed pt's status and POC.\n\nPlan: Neuro checks q2hr. Repeat head CT this am. PRN metoprolol for SBP>150. Pulm toilet. Wean vent as tol. Cont to titrate insulin to goal BS. Cont to support pt and family.\n\n"
}
] |
18,109 | 153,846 | The patient was admitted on and underwent an uncomplicated coronary artery bypass graft times three with left internal mammary artery to the left anterior descending artery, reverse saphenous vein graft to the circumflex marginal, reverse saphenous vein graft to the right posterior descending artery. The patient tolerated the procedure well and was transported to the Cardiothoracic Surgery Intensive Care Unit intubated and in stable condition. The patient was extubated overnight. On postoperative day one, he was noted to have electrocardiogram changes concerning for ischemia. He was therefore started on a rule out myocardial infarction protocol. He started Lasix, aspirin, and Lopressor. His nitroglycerin drip was weaned. The subsequent cardiac enzymes all came back within normal limits. Therefore, he ruled out for a myocardial infarction. On postoperative day two, his Foley was discontinued. His Lopressor was increased, and he was started on an ACE inhibitor. He was tolerating p.o. intake. His pacing wires were discontinued. His chest tube put out 345 cc over the prior day, and it was decided to keep the chest tube. As the patient deemed hemodynamically stable and ambulating, the decision was made to transfer the patient to the floor. Unfortunately, there were no beds available, and the patient stayed overnight in the unit. On postoperative day three, the patient went into a rapid atrial fibrillation with hypotension. Lopressor at 20 mg intravenously was given with no change in heart rate. He remained hypotensive. He was given an amiodarone bolus and an amiodarone drip was started. He remained in atrial fibrillation throughout the day with a rate in the 110s to 140s. It was decided that the patient should stay overnight in the unit to monitor his heart rate and blood pressure. On postoperative day four, the patient remained in atrial fibrillation. He was however hemodynamically stable. His amiodarone drip was converted to p.o. He was started on Coumadin. As the patient was hemodynamically stable, he was transferred to the floor. On postoperative day five, the patient noted substernal chest pain somewhat similar to his anginal pain. He also said that he felt diaphoretic. A 12-lead electrocardiogram was performed which demonstrated no evidence of acute ischemic changes compared to his prior electrocardiograms. Nonetheless, his presentation was concerning, and a Cardiology consultation was obtained. Their feelings were that the pain was most likely not of cardiac origin, but that cardiac enzymes should be cycled nonetheless. This was done, and the levels were all negative. On postoperative day six, the patient had no complaints of chest pain. On postoperative day seven, the patient was tolerating p.o., was pain free, and was able to walk 500 feet without hemodynamic instability. His central venous line was discontinued. On postoperative day eight, the patient had remained afebrile with stable hemodynamics, tolerating p.o., and making adequate amounts of urine. Physical Therapy had assessed the patient, and he was able to climb a flight of stairs with no hemodynamic instability. It was thus decided that he was stable enough to go home without services, and he was subsequently discharged on (on postoperative day eight) in stable and good condition. | POST-OP EKG W/ LAT ST ELEVATIONS. RECHECK ABG IN A.M. MSO4 PRN. NAUSEA NOW RESOLVED.G.U. OKAY TO HAVE SBP UP THE 120S PER DR. .CONTINUES TO REQUIRE BOTH NC AND OFM O2. PLAN TO WEAN FIO2 AFTER DIURESIS. Diffuse T wave flattening probablysecondary to the previously noted myocardial infarctions. ON ARRIVAL ABG REVEALED RESP. NOTIFIED AND EXAMINED PT. OR COURSE COMPLICATED PT AORTIC ROOT BLEED, GOAL IS TO MAINTAIN SBP<110. Will extubate pending ABGs. MSO4 GIVEN.PLAN TO MONITOR SBP AS LOPRESSOR IS ABSORBED. STABLEP. : PT HAD SM EMESIS AFTER SEEN BY DR. . Incisions CDI.Alert, oriented. Normal sinus rhythm, rate 76Consider left atrial enlargementPossible acute Anterior infarctSince last ECG, atrial fibrillation goneAbnormal ECG CONT TO TITRATE DRIPS PRN AND PROVIDE COMFORT MEASURES. Normal sinus rhythm, rate 76Early transitionBorderline low voltage in frontal leadsAnterior Lateral ST segment elevation - Consider pericarditisAbnormal ECG PR TYLENOL GIVEN. Pt tol wean well. PT TRYING TO REST BUT BP STILL IN 120'S.PLAN: CHECKING CK/MB, ALSO CREAT TO SEE IF TORADOL POSSIBLE. Normal sinus rhythm, rate 77Anterior Lateral ST segment elevation - Consider pericarditisSince last ECG, no significant changeAbnormal ECG CXR PENDING. TEMP ON ARRIVAL 94.5, BAIR HUGGER APPLIED.A. Keeping SBP <110 with Ntg gtt. ON PT A CABG X 3 LIMA-LAD, SVG-OM-PDA. NEO/NTG FREQ TITRATED TO MAINTAIN SBP 90-110 RANGE. Continue to support until ready to extubate. REQUESTED TO KEEP SBP <110 AT REPORT. Pt using incentive spirometer, cough/deep breathing. MINIMAL CT OUTPUT.G.I. HR 80'S NSR. DR. DR. Sedatives given. ABG pending. LASIX GIVEN. Q waves in leads I, aVL and V2-V6 consistent with previousmyocardial infarction in the lateral, anteroseptal and possibly anterior leftventricular walls, age undetermined. : LATEST DOCUMENTED CR =1.3 FROM ; TORADOL NOT ORDERED. Pacing set at demand rate. ABG POST-EXTUBATION WNL EXCEPT FOR PAO2 IN 60'S. NOTIFIED OF INCREASED NTG NEEDS. updateRESP: PROPOFOL WEANED OFF AND PT EXTUBATED TO .50 COOL AEROSOL FT @ 2120. UO ADEQ.ASSESS: PAIN BE DUE TO POSITIONING IN OR; PT DENIES THAT IT IS ANGINA. PLAN TO SEE IF O2 REQUIREMENTS DECREASE AFTER LASIX GIVEN.PT C/O BURNING BACK DISCOMFORT. Percocet controlling pain. CT OUTPUT MINIMAL, UP FROM ON PROPOFOL INFUSION. Clinical correlation is suggested. Was able to wean FIO2 to 6L/NC throughout day. MSO4 GIVEN W/ LITTLE EFFECT. INCREASED LOPRESSOR GIVEN. CXR PERFORMED AND PT WAS SUCTIONED FOR THICK, WHITE SECRETIONS. PT REPOSITIONED, BACK MASSAGED, AND ICE BAG APPLIED TO AREA W/ SOME RELIEF. Vt 550-650 RR 25-30. nsg updatept warmed to normothermic, reversed, weaned propofol, pt awake and anxious, med for incisional pain with mso4 with good effectinitial difficulty with oxygenation resolved, ambued and suctioned, spo2 markedly improved, fio2 weaned to 50%, peep decreased to 5, pt taking spontaneous breaths with good volumes, weaned to pressure supporthemodynamically requiring small doses of neo to keep sbp >90 <110minimal ct output, dropped hr to 60's with reversal, a- paced to 80 with improved bpu/o qs, recieved 1 liter RLfamily in to visit, spoke with Dr A- stable post opP- wean and extubatemaintain good bp control Replacing K+ and Mg+.Resp: Breath sounds clear apexes, diminished bases. The right IJ line terminates in the mid-SVC. cardiac rhythme is a.fib. There has been interval removal of the ETT. Neuro: Intact.CV: A-febrile. CONT PULM. PORTABLE CHEST: The right IJ line terminates near the cavoatrial junction. PO2 on ABG low. compalanit of incisional cp and covered with percocet and mso4. PT STILL REQUIRING SMALL DOSE OF NTG. Hypotension. Chest tube is seen with its tip overlying the mid to upper lung zone, unchanged from prior. The left-sided chest tube is in place. IMPRESSION: 1) Left-sided pleural effusion. BP WNL. NTG WEANED TO OFF. Amiodarone gtt. Amiodarone bolus, amiodarone gtt started. PROB: HYPERTENSIONCV: BP LABILE, PT TREATED WITH LOPRESSOR AND CAPTOPRIL, INITIALLY WITH SOME EFFECT. There is a left-sided pleural effusion. LUNGS CLEAR, DIM AT BASES. The left-sided chest tube has been removed. 2) Left greater than right basilar atelectasis with small left-sided pleural effusion. IMPRESSION: Low lung volumes. BP LESS LABILE.PLAN: CONT TO MONITOR BP.ENCOURAGE IS AND DB.PT COOPERATIVE ABOUT DOING INCENTIVE SPIRONMETRY Q 1HR. The patient is s/p CABG. There is a small left pleural effusion with a possible trace right pleural effusion. VSS.PLAN===WEAN NTG. cont. Sats mid to low 90's on 6LNC. Pt. BP stable now. COMPARISONS: AP portable radiograph dated . The hilar and mediastinal contours are grossly unchanged. Strong cough.GI: BS present. pt on amiodarone at 1mg. PT voids per urinal. Uses incentive spirometer, cough/deep breaths. IMPRESSION: 1) Small bilateral pleural effusions, without evidence of new focal infiltrates. The heart size is within normal limits. c/o chest pain, EKG done, given, NP notified. "Not hungry yet." pt voiding well.plan===should be able to transfer out today if heart rate stable. The right IJ line is seen with its tip at the junction of the SVC and right atrium. vss. vss. Became hypotensive, back to bed.Alert, oriented. check with MD to see if amiod. Patchy bibasilar opacities are noted, left greater than right, likely due to atelectasis. A-fib rate 90-120. Heart size and mediastinal and hilar contours are stable. should be decreased to .5mg. Recommend upright radiograph when clinically feasible. 2) Good placement of right IJ line and chest tube. The heart size and mediastinal and hilar contours are stable. 3) Lines and tubes as described. Percocets for pain. New opacification in the retrocardiac space. TRANSFER TO FLOOR. PORTABLE CHEST: The endotracheal tube appears curved towards the tip, angled towards the right tracheal wall. O2 SATS 94>% AM PAO2 FROM ABG IS 68. resp.toileting. URINE OUTPUT STABLE. CURRENTLY ON 4MGC. No stool.GU: Diuresing with lasix. The endotracheal tube appears somewhat curved towards the tip and is directed towards the right tracheal wall. Received scheduled po lopressor dose also.Pacing wires secured to chest.Lungs clear. Right IJ double lumen in place. LASIX THIS AM WITH GOOD RESPONSE. Comparison to prior study from . Comparison to prior study from at 7:46AM. | 21 | [
{
"category": "Nursing/other",
"chartdate": "2108-09-24 00:00:00.000",
"description": "Report",
"row_id": 1500458,
"text": "nsg update\npt warmed to normothermic, reversed, weaned propofol, pt awake and anxious, med for incisional pain with mso4 with good effect\n\ninitial difficulty with oxygenation resolved, ambued and suctioned, spo2 markedly improved, fio2 weaned to 50%, peep decreased to 5, pt taking spontaneous breaths with good volumes, weaned to pressure support\n\nhemodynamically requiring small doses of neo to keep sbp >90 <110\nminimal ct output, dropped hr to 60's with reversal, a- paced to 80 with improved bp\n\nu/o qs, recieved 1 liter RL\n\nfamily in to visit, spoke with Dr \n\nA- stable post op\n\nP- wean and extubate\nmaintain good bp control\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-25 00:00:00.000",
"description": "Report",
"row_id": 1500459,
"text": "update\nRESP: PROPOFOL WEANED OFF AND PT EXTUBATED TO .50 COOL AEROSOL FT @ 2120. VOICE AUDIBLE, SPO2 96-98%. ABG POST-EXTUBATION WNL EXCEPT FOR PAO2 IN 60'S. C&DB ENC AND 3LNPO2 ADDED.\n\nCOMFORT: INITIALLY PT DENIED PAIN, BUT SHORTLY AFTER EXTUBATION C/O SEVERE PAIN ALONG SPINE IN UPPER BACK. PAIN DESCRIBED AS MUSCULAR AND \"WORSE THAN THE SURGERY PAIN\". PT REPOSITIONED, BACK MASSAGED, AND ICE BAG APPLIED TO AREA W/ SOME RELIEF. MSO4 GIVEN W/ LITTLE EFFECT. DR. NOTIFIED AND EXAMINED PT. PR TYLENOL GIVEN. PT STILL C/O PAIN BUT SAYS TYLENOL AND ICE ARE HELPING.\n\nCV: BP LABILE DEPENDING ON COMFORT LEVEL AND MVMT. NEO/NTG FREQ TITRATED TO MAINTAIN SBP 90-110 RANGE. HR 80'S NSR. MINIMAL CT OUTPUT.\n\nG.I.: PT HAD SM EMESIS AFTER SEEN BY DR. . NAUSEA NOW RESOLVED.\n\nG.U.: LATEST DOCUMENTED CR =1.3 FROM ; TORADOL NOT ORDERED. UO ADEQ.\n\nASSESS: PAIN BE DUE TO POSITIONING IN OR; PT DENIES THAT IT IS ANGINA. POST-OP EKG W/ LAT ST ELEVATIONS. PT TRYING TO REST BUT BP STILL IN 120'S.\n\nPLAN: CHECKING CK/MB, ALSO CREAT TO SEE IF TORADOL POSSIBLE. CONT TO TITRATE DRIPS PRN AND PROVIDE COMFORT MEASURES. RECHECK ABG IN A.M. MSO4 PRN. AVOID PO'S FOR NOW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-25 00:00:00.000",
"description": "Report",
"row_id": 1500460,
"text": "Sinus rhythm, no ectopy. Pacing set at demand rate. Keeping SBP <110 with Ntg gtt. IV Lopressor given x 2 due to increasing Ntg gtt demand not controlling BP.\nLungs clear, very decreased in bases. Pt using incentive spirometer, cough/deep breathing. No sputum rasied. Was able to wean FIO2 to 6L/NC throughout day. Currently back on 6L/NC and 50% face tent due to decreasing sats. ABG pending. CT D/C'd by PA.\nPt only taking liquids, refuses food. No N/V.\nLasix given x 2 with good results.\nSkin intact. Incisions CDI.\nAlert, oriented. Percocet controlling pain. OOB to chair.\nPlan: Monitor in ICU tonight, control BP better before going to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-25 00:00:00.000",
"description": "Report",
"row_id": 1500461,
"text": "UPDATE\nASSISTED BACK TO BED. REQUESTED TO KEEP SBP <110 AT REPORT. SBP INCREASING TO 120S. INCREASED LOPRESSOR GIVEN. LASIX GIVEN. NTG GTT INCREASED. DR. NOTIFIED OF INCREASED NTG NEEDS. OKAY TO HAVE SBP UP THE 120S PER DR. .\n\nCONTINUES TO REQUIRE BOTH NC AND OFM O2. PLAN TO SEE IF O2 REQUIREMENTS DECREASE AFTER LASIX GIVEN.\n\nPT C/O BURNING BACK DISCOMFORT. HE STATES THAT HE HAS THIS DISCOMFORT AT HOME. HIS WIFE MASSAGES HIS BACK FOR HIS DISCOMFORT AT HOME. MSO4 GIVEN.\n\nPLAN TO MONITOR SBP AS LOPRESSOR IS ABSORBED. PLAN TO WEAN FIO2 AFTER DIURESIS. PROBABLE TRANSFER OUT OF THE UNIT TOMORROW.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-24 00:00:00.000",
"description": "Report",
"row_id": 1500456,
"text": "CSRU ADMIT NOTE\nPT IS A 73 DYR OLD MALE WITH HX OF MI X 3, ADMITTED WITH RECENT EPISODES OF ANGINA, CATH REVEALED SEVERE 3VSL DISEASE WITH AN EF 40-50%. ON PT A CABG X 3 LIMA-LAD, SVG-OM-PDA. OR COURSE COMPLICATED PT AORTIC ROOT BLEED, GOAL IS TO MAINTAIN SBP<110. CT OUTPUT MINIMAL, UP FROM ON PROPOFOL INFUSION. ON ARRIVAL ABG REVEALED RESP. ACIDOSIS AND PO2 82 ON 100%; PEEP INCREASED TO 7.5 AND RATE INCREASED TO 14. CXR PERFORMED AND PT WAS SUCTIONED FOR THICK, WHITE SECRETIONS. CXR PENDING. TEMP ON ARRIVAL 94.5, BAIR HUGGER APPLIED.\nA. STABLE\nP. SUPPORT OXYGENATION, FOLLOW-UP ABG, AWAITING RESULT CXR, MONITOR FOR SIGNS OF BLEEDING, WARM PATIENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-24 00:00:00.000",
"description": "Report",
"row_id": 1500457,
"text": "Respiratory Care Note\n\n Pt recieved with 7.5 ET tube taped and secure at lip.Pt currently on CPAP 5 peep 10 IPS 50%. Vt 550-650 RR 25-30. Pt very anxious when awake. Sedatives given. Pt tol wean well. Will extubate pending ABGs. Continue to support until ready to extubate.\n"
},
{
"category": "ECG",
"chartdate": "2108-09-27 00:00:00.000",
"description": "Report",
"row_id": 150760,
"text": "Atrial fibrillation with rapid ventricular response of 134\nProbable acute Anterior infarct\nAbnormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2108-09-29 00:00:00.000",
"description": "Report",
"row_id": 150990,
"text": "Normal sinus rhythm, rate 76\nConsider left atrial enlargement\nPossible acute Anterior infarct\nSince last ECG, atrial fibrillation gone\nAbnormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2108-09-24 00:00:00.000",
"description": "Report",
"row_id": 150991,
"text": "Normal sinus rhythm, rate 76\nEarly transition\nBorderline low voltage in frontal leads\nAnterior Lateral ST segment elevation - Consider pericarditis\nAbnormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2108-09-25 00:00:00.000",
"description": "Report",
"row_id": 150992,
"text": "Normal sinus rhythm, rate 77\nAnterior Lateral ST segment elevation - Consider pericarditis\nSince last ECG, no significant change\nAbnormal ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2108-09-23 00:00:00.000",
"description": "Report",
"row_id": 150993,
"text": "Normal sinus rhythm. Q waves in leads I, aVL and V2-V6 consistent with previous\nmyocardial infarction in the lateral, anteroseptal and possibly anterior left\nventricular walls, age undetermined. Diffuse T wave flattening probably\nsecondary to the previously noted myocardial infarctions. No previous tracing\navailable for comparison. Clinical correlation is suggested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 742492,
"text": " 2:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/decreased pO2-r/o PTX/hemothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n s/p CABG w/decreased pO2-r/o PTX/hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old male S/P CABG with decreased oxygenation.\n\n Comparison to prior study from .\n\n PORTABLE CHEST: The endotracheal tube appears curved towards the tip, angled\n towards the right tracheal wall. It terminates approximately 3-4 cm above the\n carina. The right IJ line terminates in the mid-SVC. The left-sided chest\n tube is in place. Heart size and mediastinal and hilar contours are stable.\n There is a left-sided pleural effusion. No definite evidence for\n pneumothorax.\n\n IMPRESSION:\n\n 1) Left-sided pleural effusion.\n\n 2) No definite evidence of pneumothorax on this supine projection. Recommend\n upright radiograph when clinically feasible.\n\n 3) Lines and tubes as described. The endotracheal tube appears somewhat\n curved towards the tip and is directed towards the right tracheal wall.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-09-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 742536,
"text": " 7:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, :\n\n INDICATION: Hypoxia.\n\n COMPARISONS: AP portable radiograph dated .\n\n FINDINGS: The heart is enlarged. The hilar and mediastinal contours are\n grossly unchanged. The heart size and lungs appear somewhat prominent due to\n the lower lung volumes. There is a small left pleural effusion with a\n possible trace right pleural effusion. New opacification in the retrocardiac\n space. The right IJ line is seen with its tip at the junction of the SVC and\n right atrium. Chest tube is seen with its tip overlying the mid to upper lung\n zone, unchanged from prior. The patient is s/p CABG. There has been interval\n removal of the ETT.\n\n IMPRESSION:\n 1) Small bilateral pleural effusions, without evidence of new focal\n infiltrates. There may be new atelectasis in the retrocardiac space.\n 2) Good placement of right IJ line and chest tube.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-09-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 742574,
"text": " 6:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct's out\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n s/p ct's out\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 72-year-old male S/P CABG, removal of chest tube.\n\n Comparison to prior study from at 7:46AM.\n\n PORTABLE CHEST: The right IJ line terminates near the cavoatrial junction.\n The left-sided chest tube has been removed. There is no evidence of\n pneumothorax. Patchy bibasilar opacities are noted, left greater than right,\n likely due to atelectasis. There is also likely a small effusion on the left.\n The heart size and mediastinal and hilar contours are stable.\n\n IMPRESSION:\n\n 1) No evidence of pneumothorax S/P chest tube removal.\n\n 2) Left greater than right basilar atelectasis with small left-sided pleural\n effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-09-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 742339,
"text": " 5:04 PM\n CHEST (PA & LAT) Clip # \n Reason: r./o chf, infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with cad, for cabg this admit. please do after 4 pm\n REASON FOR THIS EXAMINATION:\n r./o chf, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CAD, pre-op for CABG.\n\n No comparisons.\n\n PA AND LATERAL CHEST: There are low lung volumes which likely contributes to\n the appearance of crowded vessels at the lung bases. Allowing for this, there\n is no definite pulmonary edema or focal consolidation. The heart size is\n within normal limits.\n\n IMPRESSION: Low lung volumes. No definite pulmonary edema or pneumonia.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-26 00:00:00.000",
"description": "Report",
"row_id": 1500462,
"text": " 0530 UNEVENTFUL NIGHT. PT STILL REQUIRING SMALL DOSE OF NTG. CURRENTLY ON 4MGC. O2 SATS 94>% AM PAO2 FROM ABG IS 68. URINE OUTPUT STABLE. VSS.\n\nPLAN===WEAN NTG. CONT PULM. TOILETING. TRANSFER TO FLOOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-26 00:00:00.000",
"description": "Report",
"row_id": 1500463,
"text": "PROB: HYPERTENSION\n\nCV: BP LABILE, PT TREATED WITH LOPRESSOR AND CAPTOPRIL, INITIALLY WITH SOME EFFECT. DOSES INCREASED DURING DAY. NTG WEANED TO OFF. MED FOR PAIN WITH GOOD EFFECT.\n\nRESP: CONT ON NP AND FM. O2 SATS 93% ON 6L/NP. LUNGS CLEAR, DIM AT BASES. LASIX THIS AM WITH GOOD RESPONSE. COUGHING AND RAISING THICK TAN.\n\nGU: FOLEY D/CD, URINE LEAKING AROUND CATH SITE.LASIX WITH GOOD RESPONSE X1.\n\nGI: APPETITE IMPROVING. TAKING SOUP AND FLUIDS.\n\nPT: AMB IN UNIT, TOLERATED WELL. SITTING UP IN CHAIR MOST OF DAY, LIKES CHAIR BETTER THAN BED.\n\nASSESSMENT: DOING BETTER. BP LESS LABILE.\n\nPLAN: CONT TO MONITOR BP.\nENCOURAGE IS AND DB.\nPT COOPERATIVE ABOUT DOING INCENTIVE SPIRONMETRY Q 1HR.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-27 00:00:00.000",
"description": "Report",
"row_id": 1500464,
"text": " 0430 uneventful night. vss. pt complaint of incisional pain and covered with 4mg mso4. pt started on HTN meds and ntg gtt off yesterday. pt has dificulty urinating and has drbbling when voiding 2ndary to prostate hyperplasia. pt states he takes cardura for his prostate and requests for it. md aware of cardura and will discuss in am rounds.\n\nPLAN===should transfer to floor titrate o2.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-27 00:00:00.000",
"description": "Report",
"row_id": 1500465,
"text": "Pt went into rapid afib with hypotension this a.m. Back to bed. Lopressor 20 mg IV total given by NP. No change in HR. Hypotension. Amiodarone bolus, amiodarone gtt started. Pt has remained in afib throughout day with rate 110-140's. BP stable now. Received scheduled po lopressor dose also.Pacing wires secured to chest.\nLungs clear. PO2 on ABG low. 6L/NC and 50% face tent. Uses incentive spirometer, cough/deep breaths. No sputum raised.\nSkin intact. Right IJ double lumen in place. A-line D/C'd.\nUrine output adequate.\nPt ate 50% breakfast, no lunch.\nPt up to side of bed with PT. Became hypotensive, back to bed.\nAlert, oriented. Percocets for pain. Pt. c/o chest pain, EKG done, given, NP notified. Pt said cp gone 15 minutes later.\nPlan: Keep in ICU tonight, monitor HR and BP. PT will walk with pt tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-28 00:00:00.000",
"description": "Report",
"row_id": 1500466,
"text": " 0430 uneventful night. pt on amiodarone at 1mg. vss. cardiac rhythme is a.fib. bit more anxious tonight. unable to get much sleep. compalanit of incisional cp and covered with percocet and mso4. able to titrate nc to 3 liter and fio2 to 40%. pt voiding well.\n\nplan===should be able to transfer out today if heart rate stable. check with MD to see if amiod. should be decreased to .5mg. cont. resp.toileting.\n"
},
{
"category": "Nursing/other",
"chartdate": "2108-09-28 00:00:00.000",
"description": "Report",
"row_id": 1500467,
"text": "Neuro: Intact.\n\nCV: A-febrile. A-fib rate 90-120. No ectopy. BP WNL. Amiodarone gtt. Replacing K+ and Mg+.\n\nResp: Breath sounds clear apexes, diminished bases. Sats mid to low 90's on 6LNC. Strong cough.\n\nGI: BS present. \"Not hungry yet.\" No stool.\n\nGU: Diuresing with lasix. PT voids per urinal. Prostate hypertrophy.\n\nSkin: Incisions clean, dry, and OTA.\n\nPain: Percoset for incisional pain.\n\nSoc: No contact with family on this shift yet.\n\nPlan: Transfer to .\n"
}
] |
29,541 | 194,040 | Mild (1+) mitral regurgitationis seen. The right ventricular cavity is mildlydilated Tricuspid annular plane systolic excursion is normal (1.7 cm)consistent with normal right ventricular systolic function. No aortic regurgitation is seen.The mitral valve leaflets are mildly thickened. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The mitral valveappears structurally normal with trivial mitral regurgitation. There are simpleatheroma in the ascending aorta. Mild tomoderate [+] TR. Moderate PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. No TEErelated complications.Conclusions:The left atrium and right atrium are normal in cavity size. Right ventricular chamber size is normal withborderline normal free wall function. Borderline normal RV systolicfunction.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Tissue Doppler imagingsuggests a normal left ventricular filling pressure (PCWP<12mmHg). Mild (1+) MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Septa nuckle 1.45 cm.There are ingradients for present but no active obstruction at the time ofTEE.LEFT ATRIUM: Normal LA and RA cavity sizes.LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2Dimages. TDI E/e' < 8, suggesting normal PCWP(<12mmHg).LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Three aorticvalve leaflets.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal sinus rhythm. TASPE normal (>=1.6cm)AORTA: Simple atheroma in ascending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). Moderate tosevere [3+] tricuspid regurgitation is seen. No VSD.RIGHT VENTRICLE: Normal RV chamber size. The aortic valve leaflets (3) appearstructurally normal with good leaflet excursion and no aortic stenosis oraortic regurgitation. Normal interatrial septum.No ASD by 2D or color Doppler.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolicfunction (LVEF>55%). Left atrial abnormality.Compared to the previous tracing of no diagnostic interim change. There is moderatepulmonary artery systolic hypertension. The diameters of aorta at the sinus,ascending and arch levels are normal. Rightventricular chamber size and free wall motion are normal. Non-specific ST-T wave abnormalities. Compared to the previoustracing of no diagnostic interim change. Moderate to severe [3+] TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Tracing is within normal limits. The aortic valve leaflets (3) are mildlythickened but aortic stenosis is not present. Slight diffuse ST segment depression. Suboptimalimage quality - body habitus.Conclusions:The left atrium is mildly dilated. No PS.Physiologic PR.GENERAL COMMENTS: A TEE was performed in the location listed above. There is no pericardial effusion. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded. No other diagnostic abnormality. No atrial septal defect is seen by 2D orcolor Doppler. Overall leftventricular systolic function is normal (LVEF>55%). /PL ratio< 1.7. Compared to the previoustracing of T waves are somewhat more prominent but this tracing iswithin normal limitsTRACING #1 Left ventricular wall thickness, cavity size, and globalsystolic function are normal (LVEF>55%). No resting LVOT gradient. There is noventricular septal defect. No AR. No AS. No AS. Delayed R wavetransition. The tricuspid valve leaflets are mildly thickened. Due to suboptimal technical quality,a focal wall motion abnormality cannot be fully excluded. Sinus rhythm. Sinus tachycardia with occasional atrial premature beats. The rightventricular free wall is hypertrophied. No TS. Compared to tracing #1 nodiagnostic interim change.TRACING #2 No MS. RV hypertrophy.Mildly dilated RV cavity. Overall normal LVEF (>55%). PASP 55 mm of Hg.C- distance <1.9. Sinus tachycardia. PATIENT/TEST INFORMATION:Indication: PE Arrest 3 nights ago while in the OR.Height: (in) 67Weight (lb): 190BSA (m2): 1.98 m2BP (mm Hg): 163/101HR (bpm): 77Status: InpatientDate/Time: at 15:58Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. I certifyI was present in compliance with HCFA regulations. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Status: InpatientDate/Time: at 05:18Test: Portable TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:61 years old patient brought for acute intestinal obstruction and perforation.Coded after the end of the surgery and came back to sinus rhythm and normalhemodynamics after atropine and CPR.Echo was done.Normal EF>50%E/e'= 4.5Normal MV and AVModerate to severe TR with RV hypertrophy. There are three aortic valve leaflets. | 6 | [
{
"category": "Echo",
"chartdate": "2173-08-17 00:00:00.000",
"description": "Report",
"row_id": 95788,
"text": "PATIENT/TEST INFORMATION:\nIndication: PE Arrest 3 nights ago while in the OR.\nHeight: (in) 67\nWeight (lb): 190\nBSA (m2): 1.98 m2\nBP (mm Hg): 163/101\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 15:58\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum.\nNo ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic\nfunction.\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. No MS. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild to\nmoderate [+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size, and global\nsystolic function are normal (LVEF>55%). Due to suboptimal technical quality,\na focal wall motion abnormality cannot be fully excluded. There is no\nventricular septal defect. Right ventricular chamber size is normal with\nborderline normal free wall function. 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. Mild (1+) mitral regurgitation\nis seen. The tricuspid valve leaflets are mildly thickened. There is moderate\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2173-08-14 00:00:00.000",
"description": "Report",
"row_id": 95789,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nStatus: Inpatient\nDate/Time: at 05:18\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n61 years old patient brought for acute intestinal obstruction and perforation.\nCoded after the end of the surgery and came back to sinus rhythm and normal\nhemodynamics after atropine and CPR.\nEcho was done.\nNormal EF>50%\nE/e'= 4.5\nNormal MV and AV\nModerate to severe TR with RV hypertrophy. PASP 55 mm of Hg.\nC- distance <1.9. /PL ratio< 1.7. Septa nuckle 1.45 cm.\nThere are ingradients for present but no active obstruction at the time of\nTEE.\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Overall normal LVEF (>55%). TDI E/e' < 8, suggesting normal PCWP\n(<12mmHg).\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. RV hypertrophy.\nMildly dilated RV cavity. TASPE normal (>=1.6cm)\n\nAORTA: Simple atheroma in ascending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. Three aortic\nvalve leaflets.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to severe [3+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. No TEE\nrelated complications.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Overall left\nventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging\nsuggests a normal left ventricular filling pressure (PCWP<12mmHg). Right\nventricular chamber size and free wall motion are normal. The right\nventricular free wall is hypertrophied. The right ventricular cavity is mildly\ndilated Tricuspid annular plane systolic excursion is normal (1.7 cm)\nconsistent with normal right ventricular systolic function. There are simple\natheroma in the ascending aorta. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis or\naortic regurgitation. There are three aortic valve leaflets. The mitral valve\nappears structurally normal with trivial mitral regurgitation. Moderate to\nsevere [3+] tricuspid regurgitation is seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-20 00:00:00.000",
"description": "Report",
"row_id": 260534,
"text": "Sinus tachycardia with occasional atrial premature beats. Delayed R wave\ntransition. Non-specific ST-T wave abnormalities. Left atrial abnormality.\nCompared to the previous tracing of no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-18 00:00:00.000",
"description": "Report",
"row_id": 260766,
"text": "Sinus rhythm. Slight diffuse ST segment depression. Compared to tracing #1 no\ndiagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-18 00:00:00.000",
"description": "Report",
"row_id": 260767,
"text": "Normal sinus rhythm. Tracing is within normal limits. Compared to the previous\ntracing of T waves are somewhat more prominent but this tracing is\nwithin normal limits\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2173-08-14 00:00:00.000",
"description": "Report",
"row_id": 260768,
"text": "Sinus tachycardia. No other diagnostic abnormality. Compared to the previous\ntracing of no diagnostic interim change.\n\n"
}
] |
|
27,403 | 131,497 | 1) Acetaminophen overdose: The patient took over 100 pills of Tylenol p.m. by her account. On presentation to Hospital 30 hours after ingestion, she had an acetaminophen level of 89.9 mcg/mL, placing her at high risk for fulminant hepatic failure. She was treated with N-acetylcysteine at Hospital as noted in HPI. At , she was treated with N-acetylcysteine 50 mg/kg every 4 hours. She did well during her stay in the MICU and was able to be called out to the floor on day 2. Her transaminases continued to trend down and her INR remained stable below 2.0 after peaking on the first hospital day, and the N-acetylcysteine was stopped after 5 days of treatment. A repeat serum acetaminophen level was negative. She had no encephalopathy or other evidence of liver failure, and her mild coagulopathy continually improved. 2) Diphenhydramine overdose: The patient overdosed on Tylenol p.m., which contains both acetaminophen and diphenhydramine. Likely as a result of this ingestion, the patient experienced sedation, urinary retention, and visual hallucination. However, these symptoms had resolved by the time the patient was transferred to and her foley was discontinued. 3) Suicide attempt: While at , the patient was followed by the psychiatric consult service. She had a 1:1 sitter during her first and second hospital days. This was discontinued during the second hospital day at the recommendation of the psychiatric service. The patient's outpatient psychiatric providers were contact to obtain collateral information, which is described under PMH and in psychiatric consult notes. She currently denies suicidal ideations, but will need inpatient psychiatric placement now that she is medically cleared. 4) Renal dysfunction: The patient presented with mildly elevated creatinine and mild proteinuria. It is unclear if this was acute or chronic. The patient's renal function was followed closely during her hospitalization given the risk of kidney injury from acetaminophen overdose. Her creatinine improved from 1.3 to 1.0 during admission. 5) UTI: Complicated due to presence of foley early during her hospitalization. Pt denies urinary symptoms, but initially had mild suprapubic tenderness. Urine culture grew Citrobacter, sensitive to ciprofloxacin. She is to complete a 7 day course of ciprofloxacin. 6) Disposition: Patient is medically cleared for transfer to inpatient psychiatry. This is evidenced by dramatic improvement in her LFTs. Physical therapy has evaluated the patient and believes she can ambulate independently. | Action: Mucomyst given q4hrs per orders; blood sugars monitored closely risk of hypoglycemia. HPI: 45 yr odl woman s/p Tylenol overdose 24 Hour Events: EKG - At 12:30 AM BLOOD CULTURED - At 03:30 AM URINE CULTURE - At 03:30 AM Allergies: Phenothiazines Unknown; Lithobid (Oral) (Lithium Carbonate) Unknown; Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 11:17 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 38.1C (100.5 Tcurrent: 36.6C (97.8 HR: 47 (43 - 69) bpm BP: 80/51(55) {80/40(55) - 150/66(86)} mmHg RR: 13 (13 - 18) insp/min SpO2: 96% Heart rhythm: SB (Sinus Bradycardia) Height: 72 Inch Total In: 480 mL 937 mL PO: 350 mL 200 mL TF: IVF: 130 mL 737 mL Blood products: Total out: 920 mL 1,800 mL Urine: 920 mL 1,800 mL NG: Stool: Drains: Balance: -440 mL -863 mL Respiratory support O2 Delivery Device: Nasal cannula SpO2: 96% ABG: ///22/ Physical Examination Gen: lying in bed, conversant HEENT: PEERL o/p dry Chest: CTA CV: brady RR Abd: soft mild tenderness to palp in RUQ Ext:no edema Neuro: A and O x 3 , hand tremor, hyporeflexic Labs / Radiology 12.6 g/dL 199 K/uL 102 mg/dL 1.3 mg/dL 22 mEq/L 4.0 mEq/L 17 mg/dL 114 mEq/L 144 mEq/L 35.8 % 9.2 K/uL [image002.jpg] 06:31 PM 03:22 AM WBC 9.1 9.2 Hct 38.4 35.8 Plt 249 199 Cr 1.3 1.3 Glucose 89 102 AST 2622 (down from 4482) ALT 4521(down from 5685) T Bili 1.1 (1.7) LDH CXR: no infiltrates Assessment and Plan 45 year old w/ schizoaffective disorder s/p tylenol overdose with evolving liver damage 1) Tylenol OD a. NAC 50 mg/kg every 4 hours for the next 24 hours b. Tranplant work up underway with psych and Hepatology LFTs are slightly down today which is encouraging but we need to trend this closely in light of the height of her initial Tylenol level and time to NAC. She was transferred to for further care due to non-resolving LFTs. She was transferred to for further care due to non-resolving LFTs. She was transferred to for further care due to non-resolving LFTs. She was transferred to for further care due to non-resolving LFTs. She was transferred to for further care due to non-resolving LFTs. She was transferred to for further care due to non-resolving LFTs. She was transferred to for further care due to non-resolving LFTs. She was transferred to for further care due to non-resolving LFTs. She was transferred to for further care due to non-resolving LFTs. She was transferred to for further care due to non-resolving LFTs. She was transferred to for further care due to non-resolving LFTs. 2) Psych: off 1:1 sitter in place, denies , need re eval for placement once medically cleared. 2) Psych: off 1:1 sitter in place, denies , need re eval for placement once medically cleared. Allergies: Phenothiazines Unknown; Lithobid (Oral) (Lithium Carbonate) Unknown; Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: Changes to medical and family history: Continues to feel well. Appreciate liver consultation 2) Diphenhydramine OD: Patient exhibited one sign of diphenhydramine OD with hallucinations which the patient states have resolved. # Diphenhydramine OD: Patient exhibited hallucinations, somnolence, and urinary retention which resolved prior to admission and have not been a problem since. - Continue NAC as above - Monitor for signs and symptoms of fulminant hepatic failure. Demographics Attending MD: D. Admit diagnosis: TYLENOL OVERDOSE Code status: Full code Height: 72 Inch Admission weight: 123 kg Daily weight: Allergies/Reactions: Phenothiazines Unknown; Lithobid (Oral) (Lithium Carbonate) Unknown; Precautions: No Additional Precautions PMH: CV-PMH: Additional history: Schizoaffective Disorder -per patient h/o intentional OD in the past GERD s/p Hernia Repair s/p tonsillectomy s/ Cyst Surgery / Procedure and date: Latest Vital Signs and I/O Non-invasive BP: S:105 D:60 Temperature: 97.3 Arterial BP: S: D: Respiratory rate: 15 insp/min Heart Rate: 55 bpm Heart rhythm: SB (Sinus Bradycardia) O2 delivery device: None O2 saturation: 86% % O2 flow: 2 L/min FiO2 set: 24h total in: 1,063 mL 24h total out: 2,950 mL Pertinent Lab Results: Sodium: 145 mEq/L 03:06 AM Potassium: 3.7 mEq/L 03:06 AM Chloride: 114 mEq/L 03:06 AM CO2: 21 mEq/L 03:06 AM BUN: 19 mg/dL 03:06 AM Creatinine: 1.2 mg/dL 03:06 AM Glucose: 121 mg/dL 03:06 AM Hematocrit: 36.1 % 03:06 AM Finger Stick Glucose: 83 12:00 PM Valuables / Signature Patient valuables: Other valuables: clothes, shoes, book bag, picture frame, flowers. Recommend (1) 1:1 sitter, (2) Hold risperidone for now, (3) monitor sensorium and cognition, and (4) further psychiatric evaluation if transplant is considered. Mildly diaphoretic. - Continue NAC as above - Monitor for signs and symptoms of fulminant hepatic failure. - Continue NAC as above - Monitor for signs and symptoms of fulminant hepatic failure. - Continue NAC as above - Monitor for signs and symptoms of fulminant hepatic failure. - No further treatment at this time 3) Hepatic injury Currently, the patient appears well, but her LFTs show evidence of hepatic injury. - No further treatment at this time # Hepatic injury Currently, the patient appears well, but her LFTs show evidence of hepatic injury. - Neutrophos x 1 to treat mild hypophosphatemia. - Neutrophos x 1 to treat mild hypophosphatemia. 1) Liver Damage Tylenol OD a. She was transferred to for further care due to non-resolving LFTs. She was transferred to for further care due to non-resolving LFTs. HPI: 24 Hour Events: EKG - At 12:30 AM BLOOD CULTURED - At 03:30 AM URINE CULTURE - At 03:30 AM Allergies: Phenothiazines Unknown; Lithobid (Oral) (Lithium Carbonate) Unknown; Last dose of Antibiotics: Infusions: Other ICU medications: Other medications: Changes to medical and family history: PMH, SH, FH and ROS are unchanged from Admission except where noted above and below Review of systems is unchanged from admission except as noted below Review of systems: Flowsheet Data as of 11:17 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since 12 AM Tmax: 38.1C (100.5 Tcurrent: 36.6C (97.8 HR: 47 (43 - 69) bpm BP: 80/51(55) {80/40(55) - 150/66(86)} mmHg RR: 13 (13 - 18) insp/min SpO2: 96% Heart rhythm: SB (Sinus Bradycardia) Height: 72 Inch Total In: 480 mL 937 mL PO: 350 mL 200 mL TF: IVF: 130 mL 737 mL Blood products: Total out: 920 mL 1,800 mL Urine: 920 mL 1,800 mL NG: Stool: Drains: Balance: -440 mL -863 mL Respiratory support O2 Delivery Device: Nasal cannula SpO2: 96% ABG: ///22/ Physical Examination Gen: lying in bed, conversant HEENT: PEERL o/p dry Chest: CTA CV: brady RR Abd: soft mild tenderness to palp in RUQ Ext:no edema Neuro: A and O x 3 , hand tremor, hyporeflexic Labs / Radiology 12.6 g/dL 199 K/uL 102 mg/dL 1.3 mg/dL 22 mEq/L 4.0 mEq/L 17 mg/dL 114 mEq/L 144 mEq/L 35.8 % 9.2 K/uL [image002.jpg] 06:31 PM 03:22 AM WBC 9.1 9.2 Hct 38.4 35.8 Plt 249 199 Cr 1.3 1.3 Glucose 89 102 AST 2622(4482) ALT 4521(5685) T Bili 1.1 (1.7) LDH CXR: no infiltrates Assessment and Plan 45 year old w/ schizoaffective disorder s/p tylenol overdose with evolving liver damage 1) Tylenol OD a. NAC 50 mg/kg every 4 hours for the next 24 hours b. Tranplant work up underway with psych and Hepatology LFTs are slightly down today which is encouraging but we need to trend this closely. | 41 | [
{
"category": "Nursing",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Generic Note",
"row_id": 340335,
"text": "TITLE:\n 45-year-old woman with a history of schizoaffective disorder with bip.\n On Wed ~10:15, she reports taking about 100 tablets Tylenol PM +\n Nyquil, with intention of completing a suicide. She subsequently told\n someone and was taken to the ED (approx 30 hours after ingestion).\n Vomited, so received Mucomyst intravenously. Peak & current labs as\n noted\n INR 1.2 --> 1.9\n ALT 244 --> 1783\n AST 265 --> 1851\n Bili 1.7\n Last Tylenol level was 10\n Poisoning / Overdose, Acetaminophen (Tylenol, APAP)\n Assessment:\n Post acetaminophen OD.\n Action:\n Started on iv Acetylcysteine 1650 mgs Q 4 hourly. Toxicology consulted.\n Response:\n Will monitor labs.\n Plan:\n Continue IV acetylcysteine as per orders. Will follow up on am labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complained of non-focal aches on the back & sides when asked. No\n complaints of chest pain, but verbalized that she could feel her heart\n was pumping with some effort. HR in 40\ns to 50\ns even when the pt is\n awake & talking. No stomach pain at present.\n Action:\n Informed Intern & Resident. EKG done. No new changes noted. Emotional\n support provided.\n Response:\n Pt slept off & on .\n Plan:\n Continue to monitor pain. Continue Emotional support as needed.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 100.5 orally @ MN.\n Action:\n Blood & urine cultures sent. Chest X-ray done.\n Response:\n Temp 99.2 orally in am.\n Plan:\n Continue monitoring temp curve, follow up on cultures. Pt currently\n not on any antibiotics.\n"
},
{
"category": "Nursing",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Generic Note",
"row_id": 340336,
"text": "TITLE:\n 45 y/o female with schizoaffective d/o transferred from \n Hospital to for further care due to deteriorating liver function.\n The patient states that on Wed at 10:15 am she took 100 tylenol PM\n (acetaminophen, and diphenhydramine) and 3 tablets of Nyquil\n (dextromethorphan, pseudoephedrine, acetaminophen, doxylamine). The\n patient reports that she wanted to die and fell asleep after taking all\n the pills. Patient was suprised to wake-up and went to her day program\n on Thurs am. At her day program at Mental Health Program\n she told her psychiatrist about her suicide attempt and was immediately\n transferred to Hospital. In ED she was started on oral Mucamyst\n which she vomited. She was then stated on Mucamyst 18.4gm loading, 6.1\n gm for 4 hours, then 12.3gms until transfer to . The patient was\n in the Hospital ICU where her went from INR 1.2 to 1.9 and ALT\n 244 to 1783, AST 265 to 1851, and Biliribin 1.7 on transfer. She was\n transferred to for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently ------.\n Patient reports visual hallucinations of people. Patient confirms the\n drugs she took to OD and denies taking any other medications\n 45-year-old woman with a history of schizoaffective disorder with bip.\n On Wed ~10:15, she reports taking about 100 tablets Tylenol PM +\n Nyquil, with intention of completing a suicide. She subsequently told\n someone and was taken to the ED (approx 30 hours after ingestion).\n Vomited, so received Mucomyst intravenously. Peak & current labs as\n noted\n INR 1.2 --> 1.9\n ALT 244 --> 1783\n AST 265 --> 1851\n Bili 1.7\n Last Tylenol level was 10\n Poisoning / Overdose, Acetaminophen (Tylenol, APAP)\n Assessment:\n Post acetaminophen OD.\n Action:\n Started on iv Acetylcysteine 1650 mgs Q 4 hourly. Toxicology consulted.\n Response:\n Will monitor labs.\n Plan:\n Continue IV acetylcysteine as per orders. Will follow up on am labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complained of non-focal aches on the back & sides when asked. No\n complaints of chest pain, but verbalized that she could feel her heart\n was pumping with some effort. HR in 40\ns to 50\ns even when the pt is\n awake & talking. No stomach pain at present.\n Action:\n Informed Intern & Resident. EKG done. No new changes noted. Emotional\n support provided.\n Response:\n Pt slept off & on .\n Plan:\n Continue to monitor pain. Continue Emotional support as needed.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 100.5 orally @ MN.\n Action:\n Blood & urine cultures sent. Chest X-ray done.\n Response:\n Temp 99.2 orally in am.\n Plan:\n Continue monitoring temp curve, follow up on cultures. Pt currently\n not on any antibiotics.\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340476,
"text": "Chief Complaint: tylenol OD\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI: 45 yr odl woman s/p Tylenol overdose\n 24 Hour Events:\n EKG - At 12:30 AM\n BLOOD CULTURED - At 03:30 AM\n URINE CULTURE - At 03:30 AM\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\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 11:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 36.6\nC (97.8\n HR: 47 (43 - 69) bpm\n BP: 80/51(55) {80/40(55) - 150/66(86)} mmHg\n RR: 13 (13 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n 480 mL\n 937 mL\n PO:\n 350 mL\n 200 mL\n TF:\n IVF:\n 130 mL\n 737 mL\n Blood products:\n Total out:\n 920 mL\n 1,800 mL\n Urine:\n 920 mL\n 1,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -440 mL\n -863 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Gen: lying in bed, conversant\n HEENT: PEERL o/p dry\n Chest: CTA\n CV: brady RR\n Abd: soft mild tenderness to palp in RUQ\n Ext:no edema\n Neuro: A and O x 3 , hand tremor, hyporeflexic\n Labs / Radiology\n 12.6 g/dL\n 199 K/uL\n 102 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 114 mEq/L\n 144 mEq/L\n 35.8 %\n 9.2 K/uL\n [image002.jpg]\n 06:31 PM\n 03:22 AM\n WBC\n 9.1\n 9.2\n Hct\n 38.4\n 35.8\n Plt\n 249\n 199\n Cr\n 1.3\n 1.3\n Glucose\n 89\n 102\n AST 2622 (down from 4482)\n ALT 4521(down from 5685)\n T Bili 1.1 (1.7)\n LDH \n CXR: no infiltrates\n Assessment and Plan\n 45 year old w/ schizoaffective disorder s/p tylenol overdose with\n evolving liver damage\n 1) Tylenol OD\n a. NAC 50 mg/kg every 4 hours for the next 24 hours\n b. Tranplant work up underway with psych and Hepatology\n LFTs are slightly down today which is encouraging but we\n need to trend this closely in light of the height of her initial\n Tylenol level and time to NAC. No overt mental status changes\n or asterixis.\n c. Psych: 1:1 sitter in place, denies SI, need to get final\n decision re is she clear for listing, may be an issue as she is not\n allowed to have her meds at home alone for more than a fgew days at a\n time. Does not live with family\n but all this needs to be sorted out\n with Transplant team, SW, and Psych by protocol.\n ICU Care\n Nutrition: reg diet\n Glycemic Control: q6\n watch for lows\n Lines:\n 20 Gauge - 05:32 PM\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: with pt and family\n Code status: Full code\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Generic Note",
"row_id": 340286,
"text": "TITLE:\n 45-year-old woman with a history of schizoaffective disorder with bip.\n On Wed ~10:15, she reports taking about 100 tablets Tylenol PM +\n Nyquil, with intention of completing a suicide. She subsequently told\n someone and was taken to the ED (approx 30 hours after ingestion).\n Vomited, so received Mucomyst intravenously. Peak & current labs as\n noted\n INR 1.2 --> 1.9\n ALT 244 --> 1783\n AST 265 --> 1851\n Bili 1.7\n Last Tylenol level was 10\n"
},
{
"category": "Nursing",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Generic Note",
"row_id": 340288,
"text": "TITLE:\n 45-year-old woman with a history of schizoaffective disorder with bip.\n On Wed ~10:15, she reports taking about 100 tablets Tylenol PM +\n Nyquil, with intention of completing a suicide. She subsequently told\n someone and was taken to the ED (approx 30 hours after ingestion).\n Vomited, so received Mucomyst intravenously. Peak & current labs as\n noted\n INR 1.2 --> 1.9\n ALT 244 --> 1783\n AST 265 --> 1851\n Bili 1.7\n Last Tylenol level was 10\n Poisoning / Overdose, Acetaminophen (Tylenol, APAP)\n Assessment:\n Post acetaminophen OD.\n Action:\n Started on iv Acetylcysteine 1650 mgs Q 4 hourly. Toxicology consulted.\n Response:\n AM Labs pending.\n Plan:\n Continue IV acetylcysteine as per orders. Will follow up on am labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complained of non-focal aches on the back & sides when asked. No\n complaints of chest pain, but verbalized that she could feel her heart\n was pumping with some effort. HR in 40\ns to 50\ns even when the pt is\n talking & is awake. No stomach pain at present.\n Action:\n Informed Intern & Resident. EKG done. No new changes noted. Emotional\n support provided.\n Response:\n Pt slept off & on .\n Plan:\n Continue to monitor for pains\n"
},
{
"category": "Nursing",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Generic Note",
"row_id": 340291,
"text": "TITLE:\n 45-year-old woman with a history of schizoaffective disorder with bip.\n On Wed ~10:15, she reports taking about 100 tablets Tylenol PM +\n Nyquil, with intention of completing a suicide. She subsequently told\n someone and was taken to the ED (approx 30 hours after ingestion).\n Vomited, so received Mucomyst intravenously. Peak & current labs as\n noted\n INR 1.2 --> 1.9\n ALT 244 --> 1783\n AST 265 --> 1851\n Bili 1.7\n Last Tylenol level was 10\n Poisoning / Overdose, Acetaminophen (Tylenol, APAP)\n Assessment:\n Post acetaminophen OD.\n Action:\n Started on iv Acetylcysteine 1650 mgs Q 4 hourly. Toxicology consulted.\n Response:\n AM Labs pending.\n Plan:\n Continue IV acetylcysteine as per orders. Will follow up on am labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complained of non-focal aches on the back & sides when asked. No\n complaints of chest pain, but verbalized that she could feel her heart\n was pumping with some effort. HR in 40\ns to 50\ns even when the pt is\n talking & is awake. No stomach pain at present.\n Action:\n Informed Intern & Resident. EKG done. No new changes noted. Emotional\n support provided.\n Response:\n Pt slept off & on .\n Plan:\n Continue to monitor for pains\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 100.5 orally.\n Action:\n Response:\n Fever continues\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-07 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 340268,
"text": "TITLE:\n Chief Complaint: tylenol overdose\n HPI:\n 45 y/o female with schizoaffective d/o and bipolar disorder\n transferrred Wed at 10:15 am patient reports taking 100 tylenol PM\n (acetaminophen, and diphenhydramine) and 3 tablets of Nyquil\n (dextromethorphan, pseudoephedrine, acetaminophen, doxylamine). The\n patient reports that she wanted to die and fell asleep after taking all\n the pills. Patient was suprise to wake-up and went to her day program\n on Thurs am. From her day program at Mental Health\n Program she told her psychiatrist and was immediately transferred to\n Hospital. In ED she was started on oral Mucamyst which she\n vomited. She was then stated on Mucamyst 18.4gm loading, 6.1 gm for 4\n hours, then 12.3gms until transfer to . The patient was in the\n Hospital ICU where her went from INR 1.2 to 1.9 and ALT 244 to\n 1783, AST 265 to 1851, and Biliribin 1.7 on transfer. She was\n transferred to for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently ------.\n Patient reports visual hallucinations of people. Patient confirms the\n drugs she took to OD and denies taking any other medications.\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Schizoaffective Disorder -per patient h/o intentional OD in the past\n GERD\n s/p Hernia Repair\n s/p tonsillectomy\n s/ Cyst\n ------\n Occupation: ------\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: attends psychiatric day program\n Review of systems:\n Flowsheet Data as of 05:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 53 (50 - 53) bpm\n BP: 108/45(58) {108/45(58) - 108/45(58)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n Gen: NAD, resting in bed\n HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus, CN\n II\nXII intact\n Neck: No JVD, supple, thyroid --\n Pulm: CTA b/l, mild rales b/l bases\n Cardiac: Brady, regular rhythm, no m/r/g, nlS1, S2\n Abdomen: hypoactive bowel sounds, mildly distended abdomen, diffusely\n tender without rebound or guarding.\n Extremities: warm well perfused\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Skin: No jaundice, no rashes\n Neurologic: Responds to: voice, alert and oriented *3, Movement: \n biceps, triceps, wrist extensors, dorsi/plantarflexion, noted to fine\n resting tremor b/l hands, (+) asterixis, Tone: wnl, Sensation: intact\n to light touch *4 extremities, Reflexes: 1+ brachioradialis, absent\n patellar and ankle b/l, Coordination: finger to nose intact bilaterally\n Psych: flat affect, attentive\n Labs / Radiology\n [image002.jpg]\n ECG: sinus brady, rate 40, nl axis, nl intervals, early r wave V1,\n diffuse non-specific ST-Twave changes, with marked T wave flattening, u\n waves\n Assessment and Plan\n 1) Tylenol OD\n a. NAC previously dosed at OSH for a total of 300 mg /kg total\n over 21 hours. Will continue at 50 mg/kg every 4 hours for the next 24\n hours\n 2) Diphenhydramine OD: Patient exhibited one sign of\n diphenhydramine OD with hallucinations which the patient states have\n resolved. ECG does not show significant QTc prolongation\n a. Will monitor for signs of anhidrosis, anhydrotic hyperthermia,\n nonreactive mydriasis, delirium; hallucinations, urinary retention.\n b. No further treatment at this time\n 3) Liver Damage\n a. Continue NAC 17.5 mg/kg/hr continuous\n b. Consult psych and get old records to determine if she will be a\n transplant candidate\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:34 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": "2159-09-07 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 340276,
"text": "TITLE:\n Chief Complaint: tylenol overdose\n HPI:\n 45 y/o female with schizoaffective d/o transferred from \n Hospital to for further care due to deteriorating liver function.\n The patient states that on Wed at 10:15 am she took 100 tylenol PM\n (acetaminophen, and diphenhydramine) and 3 tablets of Nyquil\n (dextromethorphan, pseudoephedrine, acetaminophen, doxylamine). The\n patient reports that she wanted to die and fell asleep after taking all\n the pills. Patient was suprised to wake-up and went to her day program\n on Thurs am. At her day program at Mental Health Program\n she told her psychiatrist about her suicide attempt and was immediately\n transferred to Hospital. In ED she was started on oral Mucamyst\n which she vomited. She was then stated on Mucamyst 18.4gm loading, 6.1\n gm for 4 hours, then 12.3gms until transfer to . The patient was\n in the Hospital ICU where her went from INR 1.2 to 1.9 and ALT\n 244 to 1783, AST 265 to 1851, and Biliribin 1.7 on transfer. She was\n transferred to for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently ------.\n Patient reports visual hallucinations of people. Patient confirms the\n drugs she took to OD and denies taking any other medications.\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Schizoaffective Disorder\n -per patient h/o intentional OD in the past,\n - Dr. \n - per Dr. psychiatrist for 16 yrs, but not past yrs, who was\n on-call is not aware of any suicide attempts on emergency line\n \n - mostly manic, few depressive episodes, mild paranoia\n - prior hx of needing mobile treatment team twice a day to assist with\n medications\n GERD\n s/p Hernia Repair\n s/p tonsillectomy\n s/ Cyst\n No hx of CAD, Cancer, DM, HTN, HL\n Occupation:unemployed\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: attends psychiatric day program, lives home alone by herself\n Review of systems: no dysphagia or dysphonia, no current visual changes\n or symptoms,\n Flowsheet Data as of 05:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 53 (50 - 53) bpm\n BP: 108/45(58) {108/45(58) - 108/45(58)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n Gen: NAD, resting in bed\n HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus, CN\n II\nXII intact\n Neck: No JVD, supple, thyroid --\n Pulm: CTA b/l, mild rales b/l bases\n Cardiac: Brady, regular rhythm, no m/r/g, nlS1, S2\n Abdomen: hypoactive bowel sounds, mildly distended abdomen, diffusely\n tender without rebound or guarding.\n Extremities: warm well perfused\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Skin: No jaundice, no rashes\n Neurologic: Responds to: voice, alert and oriented *3, Movement: \n biceps, triceps, deltoids, hip flexion, knee flexion and extension,\n wrist extensors, dorsi/plantarflexion, noted to fine resting tremor b/l\n hands, (+) asterixis, Tone: wnl, Sensation: intact to light touch *4\n extremities, Reflexes: 1+ brachioradialis, 1+biceps absent patellar and\n ankle b/l, Coordination: finger to nose intact and heel to shin\n bilaterally. Patient also able to spell world backwards and do serial\n 7s.\n Psych: flat affect, attentive\n Labs / Radiology\n [image002.jpg]\n ECG: sinus brady, rate 40, nl axis, nl intervals, early r wave V1,\n diffuse non-specific ST-Twave changes, with marked T wave flattening, u\n waves\n Assessment and Plan\n 45 year old\n 1) Tylenol OD\n a. NAC previously dosed at OSH for a total of 300 mg /kg total\n over 21 hours. Will continue at 50 mg/kg every 4 hours for the next 24\n hours\n 2) Diphenhydramine OD: Patient exhibited one sign of\n diphenhydramine OD with hallucinations which the patient states have\n resolved. ECG does not show significant QTc prolongation\n a. Will monitor for signs of anhidrosis, anhydrotic hyperthermia,\n nonreactive mydriasis, delirium; hallucinations, urinary retention.\n b. No further treatment at this time\n 3) Liver Damage\n a. Continue NAC as above\n b. Consult psych and get old records to determine if she will be\n a transplant candidate\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:34 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": "2159-09-08 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 340384,
"text": "TITLE: MICU RESIDENT ACCEPT NOTE\n Chief Complaint: tylenol overdose\n HPI:\n 45 y/o female with schizoaffective d/o transferred from \n Hospital to for further care due to deteriorating liver function.\n The patient states that on Wed at 10:15 am she took 100 tylenol PM\n (acetaminophen, and diphenhydramine) and 3 tablets of Nyquil\n (dextromethorphan, pseudoephedrine, acetaminophen, doxylamine). The\n patient reports that she wanted to die and fell asleep after taking all\n the pills. Patient was suprised to wake-up and went to her day program\n on Thurs am. At her day program at Mental Health Program\n she told her psychiatrist about her suicide attempt and was immediately\n transferred to Hospital. In ED she was started on oral Mucamyst\n which she vomited. She was then stated on Mucamyst 18.4gm loading, 6.1\n gm for 4 hours, then 12.3gms until transfer to . The patient was\n in the Hospital ICU where labs progressed INR 1.2 to 1.9 and\n ALT 244 to 1783, AST 265 to 1851, and Biliribin 1.7 on transfer. She\n was transferred to for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently no suicidal.\n Patient reports after OD visual hallucinations of people, but states\n she does not currently have them. Patient confirms the drugs she took\n to OD and denies taking any other medications.\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Risperdal 50mg q2week last dose \n Nexium 40mg daily\n Past medical history:\n Family history:\n Social History:\n Schizoaffective Disorder\n -per patient h/o intentional OD in the past,\n - Dr. \n - per Dr. psychiatrist for 16 yrs, but not past yrs, who was\n on-call is not aware of any suicide attempts on emergency line\n \n - mostly manic, few depressive episodes, mild paranoia\n - prior hx of needing mobile treatment team twice a day to assist with\n medications, currently goes to psych center to pick up meds twice a\n week\n - per , case manager at Health. Ms. has been\n psychiatrically hospitalized in , 4x from 88-89 at or\n RI state, for psychotic symptoms, for self defeating\n behavior, intrusive thoughts that maker her feel unsafe, regression,\n for SI and HI, for SI.\n h/o sexual abuse at group home circa 90-92\n GERD\n s/p Hernia Repair\n s/p tonsillectomy\n s/ Cyst\n No hx of CAD, Cancer, DM, HTN, HL\n Occupation:unemployed\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: attends psychiatric day program, lives home alone by herself\n Review of systems: no dysphagia or dysphonia, no current visual changes\n or symptoms, no chest pain, no shortness of breath, as per HPI\n Flowsheet Data as of 05:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 53 (50 - 53) bpm\n BP: 108/45(58) {108/45(58) - 108/45(58)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n Gen: NAD, resting in bed\n HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus, CN\n II\nXII intact\n Neck: No JVD, supple\n Pulm: CTA b/l, mild rales b/l bases\n Cardiac: Brady, regular rhythm, no m/r/g, nlS1, S2\n Abdomen: hypoactive bowel sounds, mildly distended abdomen, diffusely\n tender without rebound or guarding.\n Extremities: warm well perfused\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Skin: No jaundice, no rashes\n Neurologic: Responds to: voice, alert and oriented *3, Movement: \n biceps, triceps, deltoids, hip flexion, knee flexion and extension,\n wrist extensors, dorsi/plantarflexion, noted to fine resting tremor b/l\n hands, (+) asterixis, Tone: wnl, Sensation: intact to light touch *4\n extremities, Reflexes: 1+ brachioradialis, 1+biceps absent patellar and\n ankle b/l, Coordination: finger to nose intact and heel to shin\n bilaterally. Patient also able to spell world backwards and do serial\n 7s.\n Psych: flat affect, attentive\n Labs / Radiology\n 199\n 12.6\n 102\n 1.3\n 17\n 22\n 114\n 4.0\n 144\n 35.8\n 9.2\n [image002.jpg]\n Ca: 9.2 Mg: 2.0 P: 2.5\n ALT: 4521\n AP: 50\n Tbili: 1.1\n Alb: 3.8\n AST: 2622\n LDH: \n Dbili:\n TProt:\n : 50\n Lip: 77\n Comments:\n ALT: Verified By Dilution\n PT: 19.0\n INR: 1.8\n Color\n Straw\n Appear\n Clear\n SpecGr\n 1.007\n pH\n 5.0\n Urobil\n Neg\n Bili\n Neg\n Leuk\n Tr\n Bld\n Lge\n Nitr\n Neg\n Prot\n 30\n Glu\n Neg\n Ket\n Neg\n RBC\n \n WBC\n 0-2\n Bact\n Few\n Yeast\n None\n Epi\n \n ECG: sinus brady, rate 40, nl axis, nl intervals, early r wave V1,\n diffuse non-specific ST-Twave changes, with marked T wave flattening, u\n waves\n Assessment and Plan\n 45 year old\n 1) Tylenol OD\n a. NAC previously dosed at OSH for a total of 300 mg /kg total\n over 21 hours. Will continue at 50 mg/kg every 4 hours for the next 24\n hours\n 2) Diphenhydramine OD: Patient exhibited one sign of\n diphenhydramine OD with hallucinations which the patient states have\n resolved. ECG does not show significant QTc prolongation\n a. Will monitor for signs of anhidrosis, anhydrotic hyperthermia,\n nonreactive mydriasis, delirium; hallucinations, urinary retention.\n b. No further treatment at this time\n 3) Liver Damage\n a. Continue NAC as above\n b. Consult psych and get old records to determine if she will be\n a transplant candidate\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:34 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": "2159-09-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340526,
"text": "TITLE: 45 y/o female with schizoaffective d/o transferred from \n Hospital to for further care due to deteriorating liver function.\n The patient states that on Wed at 10:15 am she took 100 tylenol PM\n (acetaminophen, and diphenhydramine) and 3 tablets of Nyquil\n (dextromethorphan, pseudoephedrine, acetaminophen, doxylamine). The\n patient reports that she wanted to die and fell asleep after taking all\n the pills. Patient was suprised to wake-up and went to her day program\n on Thurs am. At her day program at Mental Health Program\n she told her psychiatrist about her suicide attempt and was immediately\n transferred to Hospital.\n In ED she was started on oral Mucomyst which she vomited. She was then\n started on Mucomyst 18.4gm loading, 6.1 gm for 4 hours, then 12.3gms\n until transfer to . The patient was in the Hospital ICU\n where her went from INR 1.2 to 1.9 and ALT 244 to 1783, AST 265 to\n 1851, and Biliribin 1.7 on transfer.\n She was transferred to for further care due to non-resolving\n LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. Patient reports visual hallucinations of\n people which has currently resolved.\n Update: Pt having a quiet day with stable VS and in NAD. Pt cont\n to receive Q4 hr Acetylcysteine dosing s/p Tylenol OD with BS sitter\n maintained around the clock. Family visiting today, very supportive.\n INR now down to 1.5 with LFT\ns continuing to trend downward.\n .H/O suicidality / Suicide Attempt\n Assessment:\n Pt s/p Tylenol PM OD on . However, pt has been appropriate all\n day, AAO times three, MAE, OOB to chair, asking appropriate questions.\n Pt has a flat affect. No inappropriate behavior exhibited. Psych\n eval performed @ BS @ 17:20.\n Action:\n 1 to 1 sitter maintained today. However, per Psych will d/c sitter @\n this time. Pt is now okay to sign out AMA.\n Response:\n Pt doing well, coping adequately though affect is flat (baseline?).\n Plan:\n Cont to provide supportive and safe pt care environment.\n Hepatitis, acute toxic (including alcoholic, acetaminophen, etc.)\n Assessment:\n Pt with elevated though falling LFT\ns/INR. No issues of alt MS .\n Action:\n Following Q12 hr labs around the clock.\n Response:\n Pts trend is downward and hopeful. MS is stable. PO intake improving.\n Plan:\n Will cont to follow daily labs over the next 2+ days to better gauge\n liver fxn.\n Poisoning / Overdose, Acetaminophen (Tylenol, APAP)\n Assessment:\n Pt s/p Tylenol PM OD on .\n Action:\n Pt cont to receive Q4 hr Acetylcystine as ordered. Following FS\n closely 2^nd high risk of hypoglycemia.\n Response:\n LFT/INR values cont to drop. No hypoglycemic FS values today.\n Plan:\n Cont to follow LFT\ns, provide IV Acetylcystine as ordered.\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-07 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 340262,
"text": "Chief Complaint: Tylenol overdose\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 45-year-old woman with a history of schizoaffective disorder with bip.\n On Wed ~10:15, she reports taking about 100 tablets Tylenol PM +\n Nyquil, with intention of completing a suicide. She subsequently told\n someone and was taken to the ED (approx 30 hours after ingestion).\n Vomited, so received Mucomyst intravenously.\n INR 1.2 --> 1.9\n ALT 244 --> 1783\n AST 265 --> 1851\n Bili 1.7\n Last Tylenol level was 10\n Patient admitted from: Transfer from other hospital, Hospital\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n schizoaffective disorder with biplor features\n hx of intentional ingestions\n GERD\n cyst\n Occupation: Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: attends a psychiatric day program\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: Abdominal pain, No(t) Nausea, Emesis, emesis/nausea\n at RIH\n Flowsheet Data as of 06:38 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 56 (50 - 56) bpm\n BP: 120/59(75) {108/45(58) - 120/59(75)} mmHg\n RR: 18 (13 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL, anicteric\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : scant basilar crackles)\n Abdominal: Soft, Obese\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, location, Movement: Purposeful,\n Tone: Normal, resting tremor bilaterally. Normal strength. No\n asterixis. Oriented x 3 and can do serial 7s.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Labs from are pending.\n Labs from Hospital are reviewed and are particularly notable\n for those reviewed in the HPI.\n ECG: OSH EKG: Normal sinus brady. U wave.\n Assessment and Plan\n 45 y/o woman with massive Tylenol ingestion. Level of 89 about 30\n hours after apparent ingestion suggests that she is at high risk of\n hepatic toxicity. Co-ingestion with Benadryl seems to have cleared.\n Intravenous NAC\n Serial labs\n Hepatology consult\n Psychiatry consult now, since it is possible she may come to\n needing consideration of transplantation\n o Call patient\ns mother\n o to reach patient\ns psychiatrist\n Sitter and suicide precautions\n It is not completely clear which way she will go. She is at high risk\n for fulminant hepatic failure and will need very close observation and\n treatment over the next days.\n Other issues as per ICU team note.\n ICU Care\n Nutrition:\n Glycemic Control: Comments: follow FSBS. Watch for hypoglycemia.\n Lines / Intubation:\n 20 Gauge - 05:32 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340520,
"text": "TITLE:\n .H/O suicidality / Suicide Attempt\n Assessment:\n Action:\n Response:\n Plan:\n Hepatitis, acute toxic (including alcoholic, acetaminophen, etc.)\n Assessment:\n Action:\n Response:\n Plan:\n Poisoning / Overdose, Acetaminophen (Tylenol, APAP)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2159-09-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340585,
"text": "This is a 45 y/o female with schizoaffective d/o, who was transferred\n from Hospital for further care due to deteriorating liver\n function. The patient states that on Wed at 10:15 am, she took ~100\n Tylenol PM tabs (Acetaminophen and Diphenhydramine) and 3 tablets of\n Nyquil. The patient reports that she wanted to die and fell asleep\n after taking all of the pills. She was surprised to wake-up the\n following day (Thursday) and went to her day program in the am. While\n at her day program (at Mental Health Program) she told\n her psychiatrist about her suicide attempt, and was immediately\n transferred to Hospital.\n In the ED, she was started on oral Mucomyst, which she vomited. She was\n then given a Mucomyst load, followed by q4hr infusions. The patient was\n in the Hospital ICU where her INR went from 1.2 to 1.9, ALT\n from 244 to 1783, and AST from 265 to 1851. Of note, her Bilirubin was\n 1.7 on transfer.\n She was transferred to for further care, due to rising LFTs.\n While in MICU 6, the pt has continued to receive q4hr Mucomyst\n infusions. Her INR/LFTs are trending down at this time.\n Hepatitis, acute toxic (including alcoholic, acetaminophen, etc.)\n Assessment:\n LFTs remain elevated at this time.\n Action:\n Labs/LFTs monitored closely; Mucomyst given per orders.\n Response:\n LFTs are trending down; pt without complaints.\n Plan:\n Continue to follow labs; continue q4hr Mucomyst per orders.\n Poisoning / Overdose, Acetaminophen (Tylenol, APAP)\n Assessment:\n Pt is s/p Tylenol PM O/D on .\n Action:\n Mucomyst given q4hrs per orders; blood sugars monitored closely \n risk of hypoglycemia.\n Response:\n LFTs trending down; pt\ns blood sugar stable overnight.\n Plan:\n Continue to follow labs; Mucomyst per orders.\n Risk for Suicide\n Assessment:\n Pt is s/p OD (suicide attempt); however, she denies SI at this time.\n Action:\n Psych c/s\ned yesterday; 1:1 sitter d/c\ned per Psych recs; safe\n environment maintained.\n Response:\n Pt a&o x 3; appropriate, though flat affect; denies SI; no complaints.\n Plan:\n Continue to provide emotional support to pt; maintain safe environment.\n"
},
{
"category": "Nursing",
"chartdate": "2159-09-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340264,
"text": "45-year-old woman with a history of schizoaffective disorder with bip.\n On Wed ~10:15, she reports taking about 100 tablets Tylenol PM +\n Nyquil, with intention of completing a suicide. She subsequently told\n someone and was taken to the ED (approx 30 hours after ingestion).\n Vomited, so received Mucomyst intravenously. Peak & current labs as\n noted\n INR 1.2 --> 1.9\n ALT 244 --> 1783\n AST 265 --> 1851\n Bili 1.7\n Last Tylenol level was 10\n On arrival here, complains of diffuse abdominal pain. Denies nausea at\n this point. Does have some headache.\n Neuro: A&Ox3 pleasant & cooperative with care. MAE independently. Pt\n with c/o mild HA team aware. + fine tremors especially in upper\n extremities. 1: 1 sitter at bedside\n Resp: LCTA bilaterally, RR 16-18 even and unlabored. Sats 96-98\n Cardiac: SB with rates 40-50\ns. EKG done. Hemodynamically stable. +\n 2 pt/dp bilaterally no edema\n GI: Regular diet ordered. + BS in 4 quadrents no vomiting since this\n AM. Last BM \n Renal: Foley draining adequate amounts of clear yellow urine\n Skin: Intact no current issues\n Social: Lives alone Mother called and updated by RN, team to call\n mother and give a full update. Full Code\n Plan:\n 1. Liver consult, awaiting admission orders\n 2. Labs pending\n 3. 1:1 sitter for suicide precautions\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340712,
"text": "Chief Complaint: tylenol overdose\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n URINE CULTURE - At 05:07 PM\n EKG - At 06:15 AM\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\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 10:18 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: 37.2\nC (98.9\n HR: 75 (43 - 88) bpm\n BP: 106/57(66) {80/51(55) - 141/71(85)} mmHg\n RR: 15 (13 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 2,145 mL\n 603 mL\n PO:\n 780 mL\n TF:\n IVF:\n 1,365 mL\n 603 mL\n Blood products:\n Total out:\n 2,460 mL\n 2,600 mL\n Urine:\n 2,460 mL\n 2,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -1,997 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: warm\n Neurologic: Attentive, conversant\n Labs / Radiology\n 12.4 g/dL\n 212 K/uL\n 121 mg/dL\n 1.2 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 19 mg/dL\n 114 mEq/L\n 145 mEq/L\n 36.1 %\n 8.9 K/uL\n [image002.jpg]\n 06:31 PM\n 03:22 AM\n 02:40 PM\n 03:06 AM\n WBC\n 9.1\n 9.2\n 8.9\n Hct\n 38.4\n 35.8\n 36.1\n Plt\n 249\n 199\n 212\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n Glucose\n 89\n 102\n 165\n 121\n Other labs:\n PT / PTT / INR:16.2/29.2/ 1.5 (1.8)\n ALT / AST:2507 (3702) /527 (1291)\n Alk Phos 46 - T Bili 0.8,\n Amylase / Lipase:50/77\n Assessment and Plan\n 45 year old w/ schizoaffective disorder s/p tylenol overdose with\n improving LFTS\n 1) Tylenol OD\n a. NAC 50 mg/kg every 4 hours, repeating Tylenol level, watching\n LFTS. D/c when neg Tylenol level and LFTS less than 1000.\n b. Tranplant work up underway with psych and Hepatology but not\n likely to need Transplantation at this point. Will follow rajectory of\n exam and labs.\n 2) Psych: off 1:1 sitter in place, denies , need re eval for\n placement once medically cleared.\n ICU Care\n Nutrition: reg diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: with pt, mother and brother\n status: Full code\n Disposition :Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-07 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 340259,
"text": "TITLE:\n Chief Complaint: tylenol overdose\n HPI:\n 45 y/o female with schizoaffective d/o and bipolar disorder\n transferrred Wed at 10:15 am patient reports taking 100 tylenol PM\n (acetaminophen, and diphenhydramine) and 3 tablets of Nyquil\n (dextromethorphan, pseudoephedrine, acetaminophen, doxylamine). The\n patient reports that she wanted to die and fell asleep after taking all\n the pills. Patient was suprise to wake-up and went to her day program\n on Thurs am. From her day program at Mental Health\n Program she told her psychiatrist and was immediately transferred to\n Hospital. In ED she was started on oral Mucamyst which she\n vomited. She was then stated on Mucamyst 18.4gm loading, 6.1 gm for 4\n hours, then 12.3gms until transfer to . The patient was in the\n Hospital ICU where her went from INR 1.2 to 1.9 and ALT 244 to\n 1783, AST 265 to 1851, and Biliribin 1.7 on transfer. She was\n transferred to for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently ------.\n Patient reports visual hallucinations of people. Patient confirms the\n drugs she took to OD and denies taking any other medications.\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Schizoaffective Disorder -per patient h/o intentional OD in the past\n GERD\n s/p Hernia Repair\n s/p tonsillectomy\n s/ Cyst\n ------\n Occupation: ------\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: attends psychiatric day program\n Review of systems:\n Flowsheet Data as of 05:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 53 (50 - 53) bpm\n BP: 108/45(58) {108/45(58) - 108/45(58)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n Gen: NAD, resting in bed\n HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus, CN\n II\nXII intact\n Neck: No JVD, supple, thyroid --\n Pulm: CTA b/l, mild rales b/l bases\n Cardiac: Brady, regular rhythm, no m/r/g, nlS1, S2\n Abdomen: hypoactive bowel sounds, mildly distended abdomen, diffusely\n tender without rebound or guarding.\n Extremities: warm well perfused\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Skin: No jaundice, no rashes\n Neurologic: Responds to: voice, alert and oriented *3, Movement: \n biceps, triceps, wrist extensors, dorsi/plantarflexion, noted to fine\n resting tremor b/l hands, (+) asterixis, Tone: wnl, Sensation: intact\n to light touch *4 extremities, Reflexes: 1+ brachioradialis, absent\n patellar and ankle b/l, Coordination: finger to nose intact bilaterally\n Psych: flat affect, attentive\n Labs / Radiology\n [image002.jpg]\n ECG: sinus brady, rate 40, nl axis, nl intervals, early r wave V1,\n diffuse non-specific ST-Twave changes, with marked T wave flattening, u\n waves\n Assessment and Plan\n 1) Tylenol OD\n a. NAC 130 mg/kg/hr continuous\n 2) Diphenhydramine OD\n 3) Liver Damage\n a. Continue NAC NAC 130 mg/kg/hr continuous\n b. Consult psych and get old records to determine if she will be a\n transplant candidate\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:34 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": "2159-09-07 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 340254,
"text": "Chief Complaint: Tylenol overdose\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 45-year-old woman with a history of schizoaffective disorder with bip.\n On Wed ~10:15, she reports taking about 100 tablets Tylenol PM +\n Nyquil, with intention of completing a suicide. She subsequently told\n someone and was taken to the ED (approx 30 hours after ingestion).\n Vomited, so received Mucomyst intravenously.\n INR 1.2 --> 1.9\n ALT 244 --> 1783\n AST 265 --> 1851\n Bili 1.7\n Last Tylenol level was 10\n On arrival here, complains of diffuse abdominal pain. Denies nausea at\n this point. Does have some headache.\n 45 y/o female with schizoaffective d/o and bipolar disorder\n transferrred Wed at 10:15 am patient reports taking 100 tylenol PM and\n 3 tablets of nyquil. Patient reports that she wanted to die and fell\n asleep after taking all the pills. Patient was suprise to wake-up and\n went to her day program on Thurs am. From her day program at Mental Health Program she told her psychiatrist and was\n immediately transferred to Hospital. In ED she was started on\n oral mucamyst which she vomited. She was then stated on Mucamyst 18.4gm\n loading, 6.1 gm for 4 hours, then 12.3gms for -----. The patient was in\n the Hospital ICU where her INR 1.2 to 1.9 and ALT 244 to 1783,\n AST 265 to 1851, and Biliribin 1.7 on transfer. She was transferred to\n for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently ------.\n Patient confirms the drugs she took to OD and denies taking any other\n medications.\n Patient admitted from: Transfer from other hospital, Hospital\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n schizoaffective disorder with biplor features\n hx of intentional ingestions\n GERD\n cyst\n Occupation: Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: attends a psychiatric day program\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: Abdominal pain, No(t) Nausea, Emesis, emesis/nausea\n at RIH\n Flowsheet Data as of 06:38 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 56 (50 - 56) bpm\n BP: 120/59(75) {108/45(58) - 120/59(75)} mmHg\n RR: 18 (13 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL, anicteric\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Crackles : scant basilar crackles)\n Abdominal: Soft, Obese\n Extremities: Right: Trace, Left: Trace\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): person, place, location, Movement: Purposeful,\n Tone: Normal, resting tremor bilaterally. Normal strength.\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: Labs from are pending.\n Labs from Hospital are reviewed and are particularly notable\n for those reviewed in the HPI.\n ECG: OSH EKG: Normal sinus brady. U wave.\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control: Comments: follow FSBS. Watch for hypoglycemia.\n Lines / Intubation:\n 20 Gauge - 05:32 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340690,
"text": "Chief Complaint:\n 24 Hour Events:\n 1:1 sitter d/c\nd per psychiatry\n -Liver service felt patient stable, not worsening (asked for a Tylenol\n level)\n -Toxicology service recommended NAC 100 mg/kg over 16 hours,\n recommended continuing NAC until INR normal, transaminases < 1000, and\n patient clinically well.\n -Psych consult service saw patient, recommended (1) coordinate with\n mother and sister regarding disposition, (2) d/c 1:1 sitter, (3)\n patient will likely require inpatient psychiatric treatment when she\n leaves here and cannot leave AMA, (4) obtain collateral information re:\n prior psych history.\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Continues to feel well. Tolerating PO. Mild < abdominal pain.\n Has not had BM since admission. Denies current suicidal ideation. ROS\n otherwise negative.\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.6\nC (99.7\n HR: 49 (44 - 88) bpm\n BP: 141/68(85) {80/51(55) - 141/71(85)} mmHg\n RR: 14 (13 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n 2,145 mL\n 561 mL\n PO:\n 780 mL\n TF:\n IVF:\n 1,365 mL\n 561 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,700 mL\n Urine:\n 2,460 mL\n 1,700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -1,139 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n Gen: NAD.\n HEENT: Anicteric. No conjunctival injection or exudate. Moist mucus\n membranes.\n Neck:\n Supple.\n Chest/lungs: Normal respiratory effort. Symmetric with good\n expansion. Vesicular breath sounds throughout. No wheezes, rales, or\n rhonchi.\n CV: No JVD. RRR. Normal s1 and s2. No M/G/R.\n Abd: Normal bound sounds. Obese. Non-distended. Soft. Mild to\n moderate RUQ and suprapubic tenderness. No masses. Liver and spleen\n not palpated.\n Extremities: Trace lower extremity edema.\n Peripheral vascular: Extremities warm and well-perfused. Radial\n pulses 2+ bilaterally.\n Neuro:\n Mental status: Alert and oriented x 3. Attentive. Spells world\n backward correctly. Flat affect.\n Cranial nerves: 2. PERRL 4 mm to 3 mm bilaterally. Fields full to\n confrontation. 3,4,6. Does not fully abduct right eye on rightward\n gaze or left eye on leftward gaze. Extraocular movements otherwise\n intact. 5. Normal masseter strength and tone. Facial sensation full.\n 7. Facial movement full. 8. Hearing intact to finger rub bilaterally.\n 9,10. Palate elevates in midline. 11. SCM and trapezius strength\n full. 12. Tongue protrudes in midline with no fasciculation.\n Motor: Normal bulk or tone. Resting tremor in both upper\n extremities. No asterixis. No pronator drift. Strength 5/5 in\n deltoids, biceps, triceps, wrist extensors, hip extensors, knee\n flexors, knee extensors, ankle dorsiflexors, and ankle plantar flexors.\n Sensory: Sensation to light touch intact distally in all 4\n extremities.\n Reflexes: Brachioradialis reflex 1+ bilaterally. Patellar, ankle\n jerk, and triceps reflexes absent bilaterally.\n Coordination: Finger-to-nose intact on right, mildly impaired on left.\n Labs / Radiology\n 212 K/uL\n 12.4 g/dL\n 121 mg/dL\n 1.2 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 19 mg/dL\n 114 mEq/L\n 145 mEq/L\n 36.1 %\n 8.9 K/uL\n [image002.jpg]\n 06:31 PM\n 03:22 AM\n 02:40 PM\n 03:06 AM\n WBC\n 9.1\n 9.2\n 8.9\n Hct\n 38.4\n 35.8\n 36.1\n Plt\n 249\n 199\n 212\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n Glucose\n 89\n 102\n 165\n 121\n Other labs: PT / PTT / INR:16.2/29.2/1.5, ALT / AST:2507/527, Alk Phos\n / T Bili:46/0.8, Amylase / Lipase:50/77, Differential-Neuts:83.2 %,\n Lymph:12.4 %, Mono:3.2 %, Eos:0.8 %, Albumin:3.6 g/dL, LDH:264 IU/L,\n Ca++:9.3 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 45 year old with schizoaffective disorder transferred from \n Hospital with Tylenol overdose and rising LFTs.\n # Tylenol OD\n The patient had a very significant Tylenol ingestion and\n began NAC 30 hours post-ingestion. NAC previously dosed at OSH for a\n total of 300 mg /kg total over 21 hours. We have continued NAC here at\n 50 mg/kg every 4 hours.\n - Continue NAC at 50 mg/kg every 4 hours.\n # Diphenhydramine OD: Patient exhibited hallucinations, somnolence, and\n urinary retention which resolved prior to admission and have not been a\n problem since. ECG does not show significant QTc prolongation. Foley,\n placed at Hospital due to urinary retention, was pulled\n yesterday, and the patient has been able to urinate.\n - No further treatment at this time\n # Hepatic injury\n The patient had a very large acetaminophen overdose,\n and she began N-acetylcysteine late. Consequently, there was initially\n concern that the patient would develop fulminant hepatic failure.\n Signs of fulminant hepatic failure include cerebral edema,\n encephalopathy, coagulopathy, sepsis, circulatory dysfunction, GI\n bleeding, metabolic acidosis, hypoglycemia, and hypophosphatemia. The\n patient has not exhibited any of these signs other than an elevated\n INR, which is now trending down and was 1.5 this morning. The\n patient\ns LFTs peaked on the evening of and have improved since.\n - Continue NAC as above\n - Monitor for signs and symptoms of fulminant hepatic failure.\n - Repeat LFTs and chemistries Q24 hours.\n - Dextrose 50% 12.5 IV PRN blood glucose < 70.\n - Psych consulted to begin evaluation of whether patient is a\n transplant candidate. It seems unlikely that this will be necessary at\n this point, but certainly it would be important to have psych on board\n if things were to deteriorate.\n # Suicidality\n Since admission, the patient has denied a current\n desire to harm herself, although she acknowledge that her ingestion,\n which she regrets, was with suicidal intent. Psych feels that the\n patient is stable enough to do without a 1:1 sitter for now. However,\n she will need extensive psychiatric follow-up, and will likely require\n inpatient psychiatric care when she is medically stable.\n - Appreciate psych recs\n - Work with psych consult service, patient\ns outpatient psychiatrist\n providers, and patient\ns family to obtain information on patient\n psychiatric history and develop a\n # Abnormal U/A\n Likely due to Foley. Urine culture sent. Antibiotics\n not indicated at this time.\n -f/u urine culture\n # Constipation\n Patient has not had BM since admission. Says she\n generally does not have frequent BMs.\n -could extend bowel regimen\n ICU Care\n Nutrition: Regular diet as tolerated.\n Glycemic Control: Dextrose 12.5 gm IV PRN for blood glucose < 70.\n Lines: PIV x 2\n 20 Gauge - 05:32 PM\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT: Pneumoboots while in bed. No heparin SC given risk of\n coagulopathy in the setting of hepatic injury.\n Stress ulcer: omeprazole 40 mg PO daily\n VAP:\n Comments:\n Communication: Comments: patient, patient\ns mother \n , )\n Code status: Full code\n Disposition: Call out to 10, liver service.\n This note was written by , HMS IV, to be cosigned by the\n on-call MICU resident. The on-call MICU intern needed to log in to the\n MetaVision system for me because my level of MetaVision access does not\n permit me to edit notes.\n"
},
{
"category": "Nursing",
"chartdate": "2159-09-09 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 340703,
"text": "TITLE: 45 y/o female with schizoaffective d/o transferred from \n Hospital to for further care due to deteriorating liver function.\n The patient states that on Wed at 10:15 am she took 100 tylenol PM\n (acetaminophen, and diphenhydramine) and 3 tablets of Nyquil\n (dextromethorphan, pseudoephedrine, acetaminophen, doxylamine). The\n patient reports that she wanted to die and fell asleep after taking all\n the pills. Patient was suprised to wake-up and went to her day program\n on Thurs am. At her day program at Mental Health Program\n she told her psychiatrist about her suicide attempt and was immediately\n transferred to Hospital.\n In ED she was started on oral Mucomyst which she vomited. She was then\n started on Mucomyst 18.4gm loading, 6.1 gm for 4 hours, then 12.3gms\n until transfer to . The patient was in the Hospital ICU\n where her went from INR 1.2 to 1.9 and ALT 244 to 1783, AST 265 to\n 1851, and Biliribin 1.7 on transfer.\n She was transferred to for further care due to non-resolving\n LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. Patient reports visual hallucinations of\n people which has currently resolved.\n Update: Pt having a quiet day with stable VS and in NAD. Pt cont\n to receive Q4 hr Acetylcysteine dosing s/p Tylenol OD with BS sitter\n maintained around the clock. Family visiting today, very supportive.\n INR now down to 1.5 with LFT\ns continuing to trend downward.\n .H/O suicidality / Suicide Attempt\n Assessment:\n Pt s/p Tylenol PM OD on . However, pt has been appropriate all\n day, AAO times three, MAE, OOB to chair, asking appropriate questions.\n Pt has a flat affect. No inappropriate behavior exhibited. Psych\n eval performed @ BS @ 17:20.\n Action:\n 1 to 1 sitter maintained today. However, per Psych will d/c sitter @\n this time. Pt is now okay to sign out AMA.\n Response:\n Pt doing well, coping adequately though affect is flat (baseline?).\n Plan:\n Cont to provide supportive and safe pt care environment.\n Hepatitis, acute toxic (including alcoholic, acetaminophen, etc.)\n Assessment:\n Pt with elevated though falling LFT\ns/INR. No issues of alt MS .\n Action:\n Following Q12 hr labs around the clock.\n Response:\n Pts trend is downward and hopeful. MS is stable. PO intake improving.\n Plan:\n Will cont to follow daily labs over the next 2+ days to better gauge\n liver fxn.\n Poisoning / Overdose, Acetaminophen (Tylenol, APAP)\n Assessment:\n Pt s/p Tylenol PM OD on .\n Action:\n Pt cont to receive Q4 hr Acetylcystine as ordered. Following FS\n closely 2^nd high risk of hypoglycemia.\n Response:\n LFT/INR values cont to drop. No hypoglycemic FS values today.\n Plan:\n Cont to follow LFT\ns, provide IV Acetylcystine as ordered.\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n TYLENOL OVERDOSE\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 123 kg\n Daily weight:\n Allergies/Reactions:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: Schizoaffective Disorder -per patient h/o\n intentional OD in the past\n GERD\n s/p Hernia Repair\n s/p tonsillectomy\n s/ Cyst\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:105\n D:60\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 55 bpm\n Heart rhythm:\n SB (Sinus Bradycardia)\n O2 delivery device:\n None\n O2 saturation:\n 86% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,063 mL\n 24h total out:\n 2,950 mL\n Pertinent Lab Results:\n Sodium:\n 145 mEq/L\n 03:06 AM\n Potassium:\n 3.7 mEq/L\n 03:06 AM\n Chloride:\n 114 mEq/L\n 03:06 AM\n CO2:\n 21 mEq/L\n 03:06 AM\n BUN:\n 19 mg/dL\n 03:06 AM\n Creatinine:\n 1.2 mg/dL\n 03:06 AM\n Glucose:\n 121 mg/dL\n 03:06 AM\n Hematocrit:\n 36.1 %\n 03:06 AM\n Finger Stick Glucose:\n 83\n 12:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: clothes, shoes, book bag, picture frame, flowers.\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: micu6\n Transferred to: 10\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2159-09-07 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340242,
"text": "45 y/o female with schizoaffective d/o and bipolar disorder\n transferrred Wed at 10:15 am patient reports taking 100 tylenol PM and\n 3 tablets of nyquil. Patient reports that she wanted to die and fell\n asleep after taking all the pills. Patient was suprise to wake-up and\n went to her day program on Thurs am. From her day program at Mental Health Program she told her psychiatrist and was\n immediately transferred to Hospital. In ED she was started on\n oral mucamyst which she vomited. She was then stated on Mucamyst 18.4gm\n loading, 6.1 gm for 4 hours, then 12.3gms for -----. The patient was in\n the Hospital ICU where her INR 1.2 to 1.9 and ALT 244 to 1783,\n AST 265 to 1851, and Biliribin 1.7 on transfer. She was transferred to\n for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently ------.\n Patient confirms the drugs she took to OD and denies taking any other\n medications.\n Hepatitis, acute toxic (including alcoholic, acetaminophen, etc.)\n Assessment:\n Action:\n Response:\n Plan:\n Risk for Suicide\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-07 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 340243,
"text": "TITLE:\n Chief Complaint: tylenol overdose\n HPI:\n 45 y/o female with schizoaffective d/o and bipolar disorder\n transferrred Wed at 10:15 am patient reports taking 100 tylenol PM and\n 3 tablets of nyquil. Patient reports that she wanted to die and fell\n asleep after taking all the pills. Patient was suprise to wake-up and\n went to her day program on Thurs am. From her day program at Mental Health Program she told her psychiatrist and was\n immediately transferred to Hospital. In ED she was started on\n oral mucamyst which she vomited. She was then stated on Mucamyst 18.4gm\n loading, 6.1 gm for 4 hours, then 12.3gms until transfer to . The\n patient was in the Hospital ICU where her went from INR 1.2 to\n 1.9 and ALT 244 to 1783, AST 265 to 1851, and Biliribin 1.7 on\n transfer. She was transferred to for further care due to\n non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently ------.\n Patient confirms the drugs she took to OD and denies taking any other\n medications.\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Schizoaffective Disorder\n GERD\n s/p Hernia Repair\n s/p tonsillectomy\n s/ Cyst\n ------\n Occupation: ------\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: attends psychiatric day program\n Review of systems:\n Flowsheet Data as of 05:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 53 (50 - 53) bpm\n BP: 108/45(58) {108/45(58) - 108/45(58)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n Gen: NAD, resting in bed\n HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus, CN\n II\nXII intact\n Neck: No JVD, supple, thyroid --\n Pulm: CTA b/l, mild rales b/l bases\n Cardiac: Brady, regular rhythm, no m/r/g, nlS1, S2\n Abdomen: hypoactive bowel sounds, mildly distended abdomen, diffusely\n tender without rebound or guarding.\n Extremities: warm well perfused\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Skin: No jaundice, no rashes\n Neurologic: Responds to: voice, alert and oriented *3, Movement: \n biceps, triceps, wrist extensors, dorsi/plantarflexion, noted to fine\n resting tremor b/l hands, (+) asterixis, Tone: wnl, Sensation: intact\n to light touch *4 extremities, Reflexes: 1+ brachioradialis, absent\n patellar and ankle b/l, Coordination: finger to nose intact bilaterally\n Psych: flat affect, attentive\n Labs / Radiology\n [image002.jpg]\n ECG: sinus brady, rate 40, nl axis, nl intervals, early r wave V1,\n diffuse non-specific ST-Twave changes, with marked T wave flattening\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:34 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": "2159-09-08 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 340369,
"text": "TITLE: MICU RESIDENT ACCEPT NOTE\n Chief Complaint: tylenol overdose\n HPI:\n 45 y/o female with schizoaffective d/o transferred from \n Hospital to for further care due to deteriorating liver function.\n The patient states that on Wed at 10:15 am she took 100 tylenol PM\n (acetaminophen, and diphenhydramine) and 3 tablets of Nyquil\n (dextromethorphan, pseudoephedrine, acetaminophen, doxylamine). The\n patient reports that she wanted to die and fell asleep after taking all\n the pills. Patient was suprised to wake-up and went to her day program\n on Thurs am. At her day program at Mental Health Program\n she told her psychiatrist about her suicide attempt and was immediately\n transferred to Hospital. In ED she was started on oral Mucamyst\n which she vomited. She was then stated on Mucamyst 18.4gm loading, 6.1\n gm for 4 hours, then 12.3gms until transfer to . The patient was\n in the Hospital ICU where labs progressed INR 1.2 to 1.9 and\n ALT 244 to 1783, AST 265 to 1851, and Biliribin 1.7 on transfer. She\n was transferred to for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently no suicidal.\n Patient reports after OD visual hallucinations of people, but states\n she does not currently have them. Patient confirms the drugs she took\n to OD and denies taking any other medications.\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Schizoaffective Disorder\n -per patient h/o intentional OD in the past,\n - Dr. \n - per Dr. psychiatrist for 16 yrs, but not past yrs, who was\n on-call is not aware of any suicide attempts on emergency line\n \n - mostly manic, few depressive episodes, mild paranoia\n - prior hx of needing mobile treatment team twice a day to assist with\n medications\n GERD\n s/p Hernia Repair\n s/p tonsillectomy\n s/ Cyst\n No hx of CAD, Cancer, DM, HTN, HL\n Occupation:unemployed\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: attends psychiatric day program, lives home alone by herself\n Review of systems: no dysphagia or dysphonia, no current visual changes\n or symptoms,\n Flowsheet Data as of 05:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 53 (50 - 53) bpm\n BP: 108/45(58) {108/45(58) - 108/45(58)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n Gen: NAD, resting in bed\n HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus, CN\n II\nXII intact\n Neck: No JVD, supple, thyroid --\n Pulm: CTA b/l, mild rales b/l bases\n Cardiac: Brady, regular rhythm, no m/r/g, nlS1, S2\n Abdomen: hypoactive bowel sounds, mildly distended abdomen, diffusely\n tender without rebound or guarding.\n Extremities: warm well perfused\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Skin: No jaundice, no rashes\n Neurologic: Responds to: voice, alert and oriented *3, Movement: \n biceps, triceps, deltoids, hip flexion, knee flexion and extension,\n wrist extensors, dorsi/plantarflexion, noted to fine resting tremor b/l\n hands, (+) asterixis, Tone: wnl, Sensation: intact to light touch *4\n extremities, Reflexes: 1+ brachioradialis, 1+biceps absent patellar and\n ankle b/l, Coordination: finger to nose intact and heel to shin\n bilaterally. Patient also able to spell world backwards and do serial\n 7s.\n Psych: flat affect, attentive\n Labs / Radiology\n [image002.jpg]\n ECG: sinus brady, rate 40, nl axis, nl intervals, early r wave V1,\n diffuse non-specific ST-Twave changes, with marked T wave flattening, u\n waves\n Assessment and Plan\n 45 year old\n 1) Tylenol OD\n a. NAC previously dosed at OSH for a total of 300 mg /kg total\n over 21 hours. Will continue at 50 mg/kg every 4 hours for the next 24\n hours\n 2) Diphenhydramine OD: Patient exhibited one sign of\n diphenhydramine OD with hallucinations which the patient states have\n resolved. ECG does not show significant QTc prolongation\n a. Will monitor for signs of anhidrosis, anhydrotic hyperthermia,\n nonreactive mydriasis, delirium; hallucinations, urinary retention.\n b. No further treatment at this time\n 3) Liver Damage\n a. Continue NAC as above\n b. Consult psych and get old records to determine if she will be\n a transplant candidate\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:34 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": "2159-09-08 00:00:00.000",
"description": "Generic Note",
"row_id": 340341,
"text": "TITLE:\n 45 y/o female with schizoaffective d/o transferred from \n Hospital to for further care due to deteriorating liver function.\n The patient states that on Wed at 10:15 am she took 100 tylenol PM\n (acetaminophen, and diphenhydramine) and 3 tablets of Nyquil\n (dextromethorphan, pseudoephedrine, acetaminophen, doxylamine). The\n patient reports that she wanted to die and fell asleep after taking all\n the pills. Patient was suprised to wake-up and went to her day program\n on Thurs am. At her day program at Mental Health Program\n she told her psychiatrist about her suicide attempt and was immediately\n transferred to Hospital.\n In ED she was started on oral Mucomyst which she vomited. She was then\n started on Mucomyst 18.4gm loading, 6.1 gm for 4 hours, then 12.3gms\n until transfer to . The patient was in the Hospital ICU\n where her went from INR 1.2 to 1.9 and ALT 244 to 1783, AST 265 to\n 1851, and Biliribin 1.7 on transfer.\n She was transferred to for further care due to non-resolving\n LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. Patient reports visual hallucinations of\n people which has currently resolved.\n Last Tylenol level was 10\n Poisoning / Overdose, Acetaminophen (Tylenol, APAP)\n Assessment:\n Post acetaminophen OD.\n Action:\n Started on iv Acetylcysteine 1650 mgs in 250 mls D5W Q 4 hourly.\n Toxicology consulted.\n Response:\n Will monitor labs.\n Plan:\n Continue IV acetylcysteine as per orders. Will follow up on am labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complained of non-focal aches on the back & sides when asked. No\n complaints of chest pain, but verbalized that she could feel her heart\n was pumping with some effort. HR in 40\ns to 50\ns even when the pt is\n awake & talking. No abdominal pain at present.\n Action:\n Informed Intern & Resident. EKG done. No new changes noted. Emotional\n support provided.\n Response:\n Pt slept off & on.\n Plan:\n Continue to monitor pain. Continue Emotional support as needed.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 100.5 orally @ MN.\n Action:\n Blood & urine cultures sent. Chest X-ray done.\n Response:\n Temp 99.2 orally in am.\n Plan:\n Continue monitoring temp curve, follow up on cultures. Pt currently\n not on any antibiotics.\n O2 sats 93 to 94 on room air .Started on 2 lits O2 via NC. O2 sats\n improved 96 to 97 %.\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-07 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 340235,
"text": "TITLE:\n Chief Complaint: tylenol overdose\n HPI:\n 45 y/o female with schizoaffective d/o and bipolar disorder\n transferrred Wed at 10:15 am patient reports taking 100 tylenol PM and\n 3 tablets of nyquil. Patient reports that she wanted to die and fell\n asleep after taking all the pills. Patient was suprise to wake-up and\n went to her day program on Thurs am. From her day program at Mental Health Program she told her psychiatrist and was\n immediately transferred to Hospital. In ED she was started on\n oral mucamyst which she vomited. She was then stated on Mucamyst 18.4gm\n loading, 6.1 gm for 4 hours, then 12.3gms for -----. The patient was in\n the Hospital ICU where her INR 1.2 to 1.9 and ALT 244 to 1783,\n AST 265 to 1851, and Biliribin 1.7 on transfer. She was transferred to\n for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently ------.\n Patient confirms the drugs she took to OD and denies taking any other\n medications.\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Schizoaffective Disorder\n GERD\n s/p Hernia Repair\n s/p tonsillectomy\n s/ Cyst\n ------\n Occupation: ------\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: attends psychiatric day program\n Review of systems:\n Flowsheet Data as of 05:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 53 (50 - 53) bpm\n BP: 108/45(58) {108/45(58) - 108/45(58)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n 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 [image002.jpg]\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:34 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": "2159-09-07 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 340240,
"text": "TITLE:\n Chief Complaint: tylenol overdose\n HPI:\n 45 y/o female with schizoaffective d/o and bipolar disorder\n transferrred Wed at 10:15 am patient reports taking 100 tylenol PM and\n 3 tablets of nyquil. Patient reports that she wanted to die and fell\n asleep after taking all the pills. Patient was suprise to wake-up and\n went to her day program on Thurs am. From her day program at Mental Health Program she told her psychiatrist and was\n immediately transferred to Hospital. In ED she was started on\n oral mucamyst which she vomited. She was then stated on Mucamyst 18.4gm\n loading, 6.1 gm for 4 hours, then 12.3gms for -----. The patient was in\n the Hospital ICU where her INR 1.2 to 1.9 and ALT 244 to 1783,\n AST 265 to 1851, and Biliribin 1.7 on transfer. She was transferred to\n for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently ------.\n Patient confirms the drugs she took to OD and denies taking any other\n medications.\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Schizoaffective Disorder\n GERD\n s/p Hernia Repair\n s/p tonsillectomy\n s/ Cyst\n ------\n Occupation: ------\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: attends psychiatric day program\n Review of systems:\n Flowsheet Data as of 05:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 53 (50 - 53) bpm\n BP: 108/45(58) {108/45(58) - 108/45(58)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n Gen: NAD, resting in bed\n HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus, CN\n II\nXII intact\n Neck: No JVD, supple, thyroid --\n Pulm: CTA b/l, mild rales b/l bases\n Cardiac: Brady, regular rhythm, no m/r/g, nlS1, S2\n Abdomen: hypoactive bowel sounds, mildly distended abdomen, diffusely\n tender without rebound or guarding.\n Extremities: warm well perfused\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Skin: No jaundice, no rashes\n Neurologic: Responds to: voice, alert and oriented *3, Movement: \n biceps, triceps, wrist extensors, dorsi/plantarflexion, noted to fine\n resting tremor b/l hands, (+) asterixis, Tone: wnl, Sensation: intact\n to light touch *4 extremities, Reflexes: 1+ brachioradialis, absent\n patellar and ankle b/l, Coordination: finger to nose intact bilaterally\n Psych: flat affect, attentive\n Labs / Radiology\n [image002.jpg]\n ECG: sinus brady, rate 40, nl axis, nl intervals, early r wave V1,\n diffuse non-specific ST-Twave changes, with marked T wave flattening\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:34 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": "2159-09-07 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 340249,
"text": "TITLE:\n Chief Complaint: tylenol overdose\n HPI:\n 45 y/o female with schizoaffective d/o and bipolar disorder\n transferrred Wed at 10:15 am patient reports taking 100 tylenol PM and\n 3 tablets of Nyquil (dextromethorphan, pseudoephedrine, acetaminophen,\n doxylamine). The patient reports that she wanted to die and fell asleep\n after taking all the pills. Patient was suprise to wake-up and went to\n her day program on Thurs am. From her day program at Mental Health Program she told her psychiatrist and was immediately\n transferred to Hospital. In ED she was started on oral Mucamyst\n which she vomited. She was then stated on Mucamyst 18.4gm loading, 6.1\n gm for 4 hours, then 12.3gms until transfer to . The patient was\n in the Hospital ICU where her went from INR 1.2 to 1.9 and ALT\n 244 to 1783, AST 265 to 1851, and Biliribin 1.7 on transfer. She was\n transferred to for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently ------.\n Patient reports visual hallucinations of people. Patient confirms the\n drugs she took to OD and denies taking any other medications.\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Schizoaffective Disorder -per patient h/o intentional OD in the past\n GERD\n s/p Hernia Repair\n s/p tonsillectomy\n s/ Cyst\n ------\n Occupation: ------\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: attends psychiatric day program\n Review of systems:\n Flowsheet Data as of 05:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 53 (50 - 53) bpm\n BP: 108/45(58) {108/45(58) - 108/45(58)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n Gen: NAD, resting in bed\n HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus, CN\n II\nXII intact\n Neck: No JVD, supple, thyroid --\n Pulm: CTA b/l, mild rales b/l bases\n Cardiac: Brady, regular rhythm, no m/r/g, nlS1, S2\n Abdomen: hypoactive bowel sounds, mildly distended abdomen, diffusely\n tender without rebound or guarding.\n Extremities: warm well perfused\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Skin: No jaundice, no rashes\n Neurologic: Responds to: voice, alert and oriented *3, Movement: \n biceps, triceps, wrist extensors, dorsi/plantarflexion, noted to fine\n resting tremor b/l hands, (+) asterixis, Tone: wnl, Sensation: intact\n to light touch *4 extremities, Reflexes: 1+ brachioradialis, absent\n patellar and ankle b/l, Coordination: finger to nose intact bilaterally\n Psych: flat affect, attentive\n Labs / Radiology\n [image002.jpg]\n ECG: sinus brady, rate 40, nl axis, nl intervals, early r wave V1,\n diffuse non-specific ST-Twave changes, with marked T wave flattening, u\n waves\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:34 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": "2159-09-09 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340678,
"text": "Chief Complaint: tylenol overdose\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n URINE CULTURE - At 05:07 PM\n EKG - At 06:15 AM\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\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 10:18 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: 37.2\nC (98.9\n HR: 75 (43 - 88) bpm\n BP: 106/57(66) {80/51(55) - 141/71(85)} mmHg\n RR: 15 (13 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 72 Inch\n Total In:\n 2,145 mL\n 603 mL\n PO:\n 780 mL\n TF:\n IVF:\n 1,365 mL\n 603 mL\n Blood products:\n Total out:\n 2,460 mL\n 2,600 mL\n Urine:\n 2,460 mL\n 2,600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -1,997 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///21/\n Physical Examination\n General Appearance: Overweight / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 12.4 g/dL\n 212 K/uL\n 121 mg/dL\n 1.2 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 19 mg/dL\n 114 mEq/L\n 145 mEq/L\n 36.1 %\n 8.9 K/uL\n [image002.jpg]\n 06:31 PM\n 03:22 AM\n 02:40 PM\n 03:06 AM\n WBC\n 9.1\n 9.2\n 8.9\n Hct\n 38.4\n 35.8\n 36.1\n Plt\n 249\n 199\n 212\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n Glucose\n 89\n 102\n 165\n 121\n Other labs:\n PT / PTT / INR:16.2/29.2/ 1.5 (1.8)\n ALT / AST:2507 (3702) /527 (1291)\n Alk Phos 46 - T Bili 0.8,\n Amylase / Lipase:50/77\n Assessment and Plan\n 45 year old w/ schizoaffective disorder s/p tylenol overdose with\n improving LFTS\n 1) Tylenol OD\n a. NAC 50 mg/kg every 4 hours, repeating Tylenol level, watching\n LFTS. D/c when neg level and LFTS less than 1000\n b. Tranplant work up underway with psych and Hepatology but no\n need for it now\n No overt mental status changes or asterixis.\n 2) Psych: off 1:1 sitter in place, denies , need re eval for\n placement once medically cleared.\n ICU Care\n Nutrition: reg diet\n Glycemic Control:\n Lines:\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: PPI\n Communication: with pt, mother and brother\n status: Full code\n Disposition :Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 340399,
"text": "TITLE: MICU RESIDENT ACCEPT NOTE\n Chief Complaint: tylenol overdose\n HPI:\n 45 y/o female with schizoaffective d/o transferred from \n Hospital to for further care due to deteriorating liver function.\n The patient states that on Wed at 10:15 am she took 100 tylenol PM\n (acetaminophen, and diphenhydramine) and 3 tablets of Nyquil\n (dextromethorphan, pseudoephedrine, acetaminophen, doxylamine). The\n patient reports that she wanted to die and fell asleep after taking all\n the pills. Patient was suprised to wake-up and went to her day program\n on Thurs am. At her day program at Mental Health Program\n she told her psychiatrist about her suicide attempt and was immediately\n transferred to Hospital. In ED she was started on oral Mucamyst\n which she vomited. She was then stated on Mucamyst 18.4gm loading, 6.1\n gm for 4 hours, then 12.3gms until transfer to . The patient was\n in the Hospital ICU where labs progressed INR 1.2 to 1.9 and\n ALT 244 to 1783, AST 265 to 1851, and Biliribin 1.7 on transfer. She\n was transferred to for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently no suicidal.\n Patient reports after OD visual hallucinations of people, but states\n she does not currently have them. Patient confirms the drugs she took\n to OD and denies taking any other medications.\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Risperdal 50mg q2week last dose \n Nexium 40mg daily\n Past medical history:\n Family history:\n Social History:\n Schizoaffective Disorder\n -per patient h/o intentional OD in the past,\n - Dr. \n - per Dr. psychiatrist for 16 yrs, but not past yrs, who was\n on-call is not aware of any suicide attempts on emergency line\n \n - mostly manic, few depressive episodes, mild paranoia\n - prior hx of needing mobile treatment team twice a day to assist with\n medications, currently goes to psych center to pick up meds twice a\n week\n - per , case manager at Health. Ms. has been\n psychiatrically hospitalized in , 4x from 88-89 at or\n RI state, for psychotic symptoms, for self defeating\n behavior, intrusive thoughts that maker her feel unsafe, regression,\n for SI and HI, for SI.\n h/o sexual abuse at group home circa 90-92\n GERD\n s/p Hernia Repair\n s/p tonsillectomy\n s/ Cyst\n No hx of CAD, Cancer, DM, HTN, HL\n Occupation:unemployed\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: attends psychiatric day program, lives home alone by herself\n Review of systems: no dysphagia or dysphonia, no current visual changes\n or symptoms, no chest pain, no shortness of breath, as per HPI\n Flowsheet Data as of 05:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 53 (50 - 53) bpm\n BP: 108/45(58) {108/45(58) - 108/45(58)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n Gen: NAD, resting in bed\n HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus, CN\n II\nXII intact\n Neck: No JVD, supple\n Pulm: CTA b/l, mild rales b/l bases\n Cardiac: Brady, regular rhythm, no m/r/g, nlS1, S2\n Abdomen: hypoactive bowel sounds, mildly distended abdomen, diffusely\n tender without rebound or guarding.\n Extremities: warm well perfused\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Skin: No jaundice, no rashes\n Neurologic: Responds to: voice, alert and oriented *3, Movement: \n biceps, triceps, deltoids, hip flexion, knee flexion and extension,\n wrist extensors, dorsi/plantarflexion, noted to fine resting tremor b/l\n hands, (+) asterixis, Tone: wnl, Sensation: intact to light touch *4\n extremities, Reflexes: 1+ brachioradialis, 1+biceps absent patellar and\n ankle b/l, Coordination: finger to nose intact and heel to shin\n bilaterally. Patient also able to spell world backwards and do serial\n 7s.\n Psych: flat affect, attentive\n Labs / Radiology\n 199\n 12.6\n 102\n 1.3\n 17\n 22\n 114\n 4.0\n 144\n 35.8\n 9.2\n [image002.jpg]\n Ca: 9.2 Mg: 2.0 P: 2.5\n PT: 19.0\n INR: 1.8\n Color\n Straw\n Appear\n Clear\n SpecGr\n 1.007\n pH\n 5.0\n Urobil\n Neg\n Bili\n Neg\n Leuk\n Tr\n Bld\n Lge\n Nitr\n Neg\n Prot\n 30\n Glu\n Neg\n Ket\n Neg\n RBC\n \n WBC\n 0-2\n Bact\n Few\n Yeast\n None\n Epi\n \n am labs\n Urinalysis\n ALT: 4521\n AP: 50\n Tbili: 1.1\n Alb: 3.8\n AST: 2622\n LDH: \n Dbili:\n TProt:\n : 50\n Lip: 77\n Comments: 1800\n ALT: Verified By Dilution\n ALT: 5685\n AP: 54\n Tbili: 1.1\n Alb: 4.0\n AST: 4482\n LDH:\n Dbili:\n TProt:\n : 58\n Lip: 78\n ECG: sinus brady, rate 40, nl axis, nl intervals, early r wave V1,\n diffuse non-specific ST-Twave changes, with marked T wave flattening, u\n waves\n Assessment and Plan\n 45 year old schizoaffective disorder transferred from OSH after suicide\n attempt and Tylenol overdose and AST/ALT in thousands.\n 1) Tylenol OD\n a. NAC previously dosed at OSH for a total of 300 mg /kg total\n over 21 hours. Will continue at 50 mg/kg every 4 hours for the next 24\n hours\n b. Appreciate liver consultation\n 2) Diphenhydramine OD: Patient exhibited one sign of\n diphenhydramine OD with hallucinations which the patient states have\n resolved. ECG does not show significant QTc prolongation\n a. Will monitor for signs of anhidrosis, anhydrotic hyperthermia,\n nonreactive mydriasis, delirium; hallucinations, urinary retention.\n b. No further treatment at this time\n c. Consult toxicology\n 3) Liver Damage\n a. Continue NAC as above\n b. Consult psych and get old records to determine if she will be\n a transplant candidate\n c. Appreciate liver consultation\n 4) GERD : continue nexium 40mg daily\n 5) dfgh\n ICU Care\n Nutrition: full regular diet\n Glycemic Control:\n Lines:\n 20 Gauge - 05:34 PM\n Prophylaxis:\n DVT: inr 1.8\n Stress ulcer: nexium\n VAP: N/A\n Comments:\n Communication: patient, patient\ns mother\n status: Full code\n Disposition: MICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Generic Note",
"row_id": 340401,
"text": "TITLE:\n 45 y/o female with schizoaffective d/o transferred from \n Hospital to for further care due to deteriorating liver function.\n The patient states that on Wed at 10:15 am she took 100 tylenol PM\n (acetaminophen, and diphenhydramine) and 3 tablets of Nyquil\n (dextromethorphan, pseudoephedrine, acetaminophen, doxylamine). The\n patient reports that she wanted to die and fell asleep after taking all\n the pills. Patient was suprised to wake-up and went to her day program\n on Thurs am. At her day program at Mental Health Program\n she told her psychiatrist about her suicide attempt and was immediately\n transferred to Hospital.\n In ED she was started on oral Mucomyst which she vomited. She was then\n started on Mucomyst 18.4gm loading, 6.1 gm for 4 hours, then 12.3gms\n until transfer to . The patient was in the Hospital ICU\n where her went from INR 1.2 to 1.9 and ALT 244 to 1783, AST 265 to\n 1851, and Biliribin 1.7 on transfer.\n She was transferred to for further care due to non-resolving\n LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. Patient reports visual hallucinations of\n people which has currently resolved.\n Last Tylenol level was 10\n Poisoning / Overdose, Acetaminophen (Tylenol, APAP)\n Assessment:\n Post acetaminophen OD.\n Action:\n Started on iv Acetylcysteine 1650 mgs in 250 mls D5W Q 4 hourly.\n Toxicology consulted.\n Response:\n Will monitor labs.\n Plan:\n Continue IV acetylcysteine as per orders. Will follow up on am labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complained of non-focal aches on the back & sides when asked. No\n complaints of chest pain, but verbalized that she could feel her heart\n was pumping with some effort. HR in 40\ns to 50\ns even when the pt is\n awake & talking. No abdominal pain at present.\n Action:\n Informed Intern & Resident. EKG done. No new changes noted. Emotional\n support provided.\n Response:\n Pt slept off & on.\n Plan:\n Continue to monitor pain. Continue Emotional support as needed.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T-max 100.5 orally @ MN.\n Action:\n Blood & urine cultures sent. Chest X-ray done.\n Response:\n Temp 99.2 orally in am.\n Plan:\n Continue monitoring temp curve, follow up on cultures. Pt currently\n not on any antibiotics.\n O2 sats 93 to 94 on room air .Started on 2 lits O2 via NC. O2 sats\n improved 96 to 97 %.\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340404,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 12:30 AM\n BLOOD CULTURED - At 03:30 AM\n URINE CULTURE - At 03:30 AM\n Started N-acetylcystine per liver recs\n Psych Eval in consideration for xplant and for suicidality\n 0:23 developed feverl to 100.5, O2 sat to 90s, \"heart feals like its\n having trouble beating\". EKG NS brady. Nl ax/int/morp. No STTW\n changes. Stuff sent\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.3\nC (99.2\n HR: 44 (43 - 58) bpm\n BP: 124/52(69) {107/40(57) - 150/66(86)} mmHg\n RR: 17 (13 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n 480 mL\n 444 mL\n PO:\n 350 mL\n TF:\n IVF:\n 130 mL\n 444 mL\n Blood products:\n Total out:\n 920 mL\n 1,150 mL\n Urine:\n 920 mL\n 1,150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -440 mL\n -706 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 199 K/uL\n 12.6 g/dL\n 102 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 114 mEq/L\n 144 mEq/L\n 35.8 %\n 9.2 K/uL\n [image002.jpg]\n 06:31 PM\n 03:22 AM\n WBC\n 9.1\n 9.2\n Hct\n 38.4\n 35.8\n Plt\n 249\n 199\n Cr\n 1.3\n 1.3\n Glucose\n 89\n 102\n Other labs: PT / PTT / INR:19.0/35.3/1.8, ALT / AST:4521/2622, Alk Phos\n / T Bili:50/1.1, Amylase / Lipase:50/77, Differential-Neuts:83.2 %,\n Lymph:12.4 %, Mono:3.2 %, Eos:0.8 %, Albumin:3.8 g/dL, LDH: IU/L,\n Ca++:9.2 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 45 year old\n 1) Tylenol OD\n a. NAC previously dosed at OSH for a total of 300 mg /kg total\n over 21 hours. Will continue at 50 mg/kg every 4 hours for the next 24\n hours\n 2) Diphenhydramine OD: Patient exhibited one sign of\n diphenhydramine OD with hallucinations which the patient states have\n resolved. ECG does not show significant QTc prolongation\n a. Will monitor for signs of anhidrosis, anhydrotic hyperthermia,\n nonreactive mydriasis, delirium; hallucinations, urinary retention.\n b. No further treatment at this time\n 3) Liver Damage\n a. Continue NAC as above\n b. Consult psych and get old records to determine if she will be\n a transplant candidate\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:32 PM\n 18 Gauge - 07:01 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": "2159-09-08 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 340405,
"text": "TITLE: MICU RESIDENT ACCEPT NOTE\n Chief Complaint: tylenol overdose\n HPI:\n 45 y/o female with schizoaffective d/o transferred from \n Hospital to for further care due to deteriorating liver function.\n The patient states that on Wed at 10:15 am she took 100 tylenol PM\n (acetaminophen, and diphenhydramine) and 3 tablets of Nyquil\n (dextromethorphan, pseudoephedrine, acetaminophen, doxylamine). The\n patient reports that she wanted to die and fell asleep after taking all\n the pills. Patient was suprised to wake-up and went to her day program\n on Thurs am. At her day program at Mental Health Program\n she told her psychiatrist about her suicide attempt and was immediately\n transferred to Hospital. In ED she was started on oral Mucamyst\n which she vomited. She was then stated on Mucamyst 18.4gm loading, 6.1\n gm for 4 hours, then 12.3gms until transfer to . The patient was\n in the Hospital ICU where labs progressed INR 1.2 to 1.9 and\n ALT 244 to 1783, AST 265 to 1851, and Biliribin 1.7 on transfer. She\n was transferred to for further care due to non-resolving LFTs.\n Upon arrival, the patient endorsed diffuse abdominal pain. The patient\n regrets her suicide attempt. She reports she is currently no suicidal.\n Patient reports after OD visual hallucinations of people, but states\n she does not currently have them. Patient confirms the drugs she took\n to OD and denies taking any other medications.\n History obtained from Medical records\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Risperdal 50mg q2week last dose \n Nexium 40mg daily\n Past medical history:\n Family history:\n Social History:\n Schizoaffective Disorder\n -per patient h/o intentional OD in the past,\n - Dr. \n - per Dr. psychiatrist for 16 yrs, but not past yrs, who was\n on-call is not aware of any suicide attempts on emergency line\n \n - mostly manic, few depressive episodes, mild paranoia\n - prior hx of needing mobile treatment team twice a day to assist with\n medications, currently goes to psych center to pick up meds twice a\n week\n - per , case manager at Health. Ms. has been\n psychiatrically hospitalized in , 4x from 88-89 at or\n RI state, for psychotic symptoms, for self defeating\n behavior, intrusive thoughts that maker her feel unsafe, regression,\n for SI and HI, for SI.\n h/o sexual abuse at group home circa 90-92\n GERD\n s/p Hernia Repair\n s/p tonsillectomy\n s/ Cyst\n No hx of CAD, Cancer, DM, HTN, HL\n Occupation:unemployed\n Drugs: no\n Tobacco: no\n Alcohol: no\n Other: attends psychiatric day program, lives home alone by herself\n Review of systems: no dysphagia or dysphonia, no current visual changes\n or symptoms, no chest pain, no shortness of breath, (+) fatigue, as\n per HPI\n Flowsheet Data as of 05:57 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.3\n Tcurrent: 36.3\nC (97.3\n HR: 53 (50 - 53) bpm\n BP: 108/45(58) {108/45(58) - 108/45(58)} mmHg\n RR: 13 (13 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 97%\n Physical Examination\n Gen: NAD, resting in bed\n HEENT: anicteric scerla, PERRL 5mm-3mm b/l, EOMI, no nystagmus, CN\n II\nXII intact\n Neck: No JVD, supple\n Pulm: CTA b/l, mild rales b/l bases\n Cardiac: Brady, regular rhythm, no m/r/g, nlS1, S2\n Abdomen: hypoactive bowel sounds, mildly distended abdomen, diffusely\n tender without rebound or guarding.\n Extremities: warm well perfused\n Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+),\n (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Skin: No jaundice, no rashes\n Neurologic: Responds to: voice, alert and oriented *3, Movement: \n biceps, triceps, deltoids, hip flexion, knee flexion and extension,\n wrist extensors, dorsi/plantarflexion, noted to fine resting tremor b/l\n hands, (+) asterixis, Tone: wnl, Sensation: intact to light touch *4\n extremities, Reflexes: 1+ brachioradialis, 1+biceps absent patellar and\n ankle b/l, Coordination: finger to nose intact and heel to shin\n bilaterally. Patient also able to spell world backwards and do serial\n 7s.\n Psych: flat affect, attentive\n Labs / Radiology\n 199\n 12.6\n 102\n 1.3\n 17\n 22\n 114\n 4.0\n 144\n 35.8\n 9.2\n [image002.jpg]\n Ca: 9.2 Mg: 2.0 P: 2.5\n PT: 19.0\n INR: 1.8\n Color\n Straw\n Appear\n Clear\n SpecGr\n 1.007\n pH\n 5.0\n Urobil\n Neg\n Bili\n Neg\n Leuk\n Tr\n Bld\n Lge\n Nitr\n Neg\n Prot\n 30\n Glu\n Neg\n Ket\n Neg\n RBC\n \n WBC\n 0-2\n Bact\n Few\n Yeast\n None\n Epi\n \n am labs\n Urinalysis\n ALT: 4521\n AP: 50\n Tbili: 1.1\n Alb: 3.8\n AST: 2622\n LDH: \n Dbili:\n TProt:\n : 50\n Lip: 77\n Comments: 1800\n ALT: Verified By Dilution\n ALT: 5685\n AP: 54\n Tbili: 1.1\n Alb: 4.0\n AST: 4482\n LDH:\n Dbili:\n TProt:\n : 58\n Lip: 78\n ECG: sinus brady, rate 40, nl axis, nl intervals, early r wave V1,\n diffuse non-specific ST-Twave changes, with marked T wave flattening, u\n waves\n Assessment and Plan\n 45 year old schizoaffective disorder transferred from OSH after suicide\n attempt and Tylenol overdose and AST/ALT in thousands.\n 1) Liver Damage Tylenol OD\n a. Continue NAC as above\n b. Consult psych and get old records to determine if she will be\n a transplant candidate\n c. Appreciate liver consultation\n d. monitoring of liver function\n 2) Tylenol OD\n a. NAC previously dosed at OSH for a total of 300 mg /kg total\n over 21 hours. Will continue at 50 mg/kg every 4 hours for the next 24\n hours\n b. Appreciate liver consultation\n 3) Diphenhydramine OD: Patient exhibited one sign of\n diphenhydramine OD with hallucinations which the patient states have\n resolved. ECG does not show significant QTc prolongation\n a. Will monitor for signs of anhidrosis, anhydrotic hyperthermia,\n nonreactive mydriasis, delirium; hallucinations, urinary retention.\n b. No further treatment at this time\n c. Consult toxicology\n 4) GERD : continue nexium 40mg daily\n 5) Suicide Attempt\n a. 1:1 sitter\n b. Appreciate psychiatry recommendations\n c. Patient on depot risperdal next due this upcoming Tuesday, due\n to hepatic clearance, will hold for now per psych. Patient does have\n history of frank psychosis and fecal smearing once wks off psych\n meds\n 6) Renal dysfunction: Cr mildly elevated for this inactive\n female, protein in urine\n a. Monitor cr\n b. Follow-up urine\n ICU Care\n Nutrition: full regular diet\n Glycemic Control: monitor for hypoglycemia, 0.5 amp dextrose 50% prn\n for bg<70\n Lines:\n 20 Gauge - 05:34 PM\n Prophylaxis:\n DVT: inr 1.8, boots\n Stress ulcer: nexium\n VAP: N/A\n Comments:\n Communication: patient, patient\ns mother ,\n : spoke with mother at length regarding guarded nature of\n patient\ns prognosis and recommended that family visit.\n Code status: Full code\n Disposition: MICU for now\n"
},
{
"category": "Nursing",
"chartdate": "2159-09-09 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 340573,
"text": "This is a 45 y/o female with schizoaffective d/o, who was transferred\n from Hospital for further care due to deteriorating liver\n function. The patient states that on Wed at 10:15 am, she took ~100\n Tylenol PM tabs (Acetaminophen and Diphenhydramine) and 3 tablets of\n Nyquil. The patient reports that she wanted to die and fell asleep\n after taking all of the pills. She was surprised to wake-up the\n following day (Thursday) and went to her day program in the am. While\n at her day program (at Mental Health Program) she told\n her psychiatrist about her suicide attempt, and was immediately\n transferred to Hospital.\n In the ED, she was started on oral Mucomyst, which she vomited. She was\n then given a Mucomyst load, followed by q4hr infusions. The patient was\n in the Hospital ICU where her INR went from 1.2 to 1.9, ALT\n from 244 to 1783, and AST from 265 to 1851. Of note, her Bilirubin was\n 1.7 on transfer.\n She was transferred to for further care due to rising LFTs. While\n in MICU 6, the pt has continued to receive q4hr Mucomyst infusions. Her\n INR/LFTs are trending down.\n Hepatitis, acute toxic (including alcoholic, acetaminophen, etc.)\n Assessment:\n Action:\n Response:\n Plan:\n Poisoning / Overdose, Acetaminophen (Tylenol, APAP)\n Assessment:\n Action:\n Response:\n Plan:\n Risk for Suicide\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340503,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n EKG - At 12:30 AM\n BLOOD CULTURED - At 03:30 AM\n URINE CULTURE - At 03:30 AM\n Liver service consulted. Recommend (1) N-acetylcysteine at 50 mg/kg\n every 4 hours, (2) Consult psych, and (3) Speak with patient\n outpatient psychiatrist.\n Started N-acetylcysteine per liver recs.\n Psychiatry consulted in consideration for transplant and for\n suicidality. Recommend (1) 1:1 sitter, (2) Hold risperidone for now,\n (3) monitor sensorium and cognition, and (4) further psychiatric\n evaluation if transplant is considered.\n 00:23. Patient developed fever to 100.5, O2 sat to 90s, \"heart feals\n like its having trouble beating\". EKG NS brady. Nl ax/int/morp. No\n STTW changes. Urine and blood cultures sent. O2 by nasal cannula at 2\n L/min.\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 37.3\nC (99.2\n HR: 44 (43 - 58) bpm\n BP: 124/52(69) {107/40(57) - 150/66(86)} mmHg\n RR: 17 (13 - 18) insp/min\n SpO2: 97%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n 480 mL\n 444 mL\n PO:\n 350 mL\n TF:\n IVF:\n 130 mL\n 444 mL\n Blood products:\n Total out:\n 920 mL\n 1,150 mL\n Urine:\n 920 mL\n 1,150 mL\n NG:\n Stool:\n Drains:\n Balance:\n -440 mL\n -706 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///22/\n Physical Examination\n Gen: NAD. Mildly diaphoretic.\n HEENT: Anicteric. Mucus membranes slightly dry.\n Neck: Supple.\n Resp: CTAB.\n CV: No JVD. Bradycardic. S1 and S2. Quiet murmur at left sternal\n border heard when patient supine but not when seated.\n Abd: Normal bowel sounds. Non-distended. No shifting dullness.\n Soft. Mildly tender in RUQ and moderately tender just below umbilicus\n but not above pubis.\n Ext: 1+ pedal and ankle edema bilaterally.\n Neuro:\n Mental status: Alert and oriented x 3. Attentive. Spells\nworld\n backward\n. Flat, inappropriate affect given situation.\n Cranial nerves: PERRL 4 mm to 3 mm. Does not full abduct right eye\n during rightward gaze or left eye during leftward gaze. Extraocular\n movements otherwise intact. Normal masseter strength and tone.\n Facial sensation and movement full. Hearing intact to finger rub.\n Palate elevates in midline. Normal trapezius and SCM strength and\n tone. Tongue protrudes in midline with no fasciculation.\n Motor: Resting tremer bilaterally in upper extremities, unchanged with\n movement or targeting. No asterixis. Strength 5/5 bilaterally in\n deltoids, biceps, triceps, wrist extension, handgrip, hip flexion, knee\n flexion, knee extension, ankle dorsiflexion, and ankle plantarflexion.\n Sensory: Light touch intact distally in all 4 extremities.\n Coordination: Finger-to-nose intact.\n Reflexes: Brachioradialis 1+ bilaterally. Biceps 1+ on left, not\n elicited on right although exam limited by blood pressure cuff.\n Patellar, ankle, and triceps reflexes absent bilaterally.\n Lines: PIV x 2 RUE.\n Labs / Radiology\n 199 K/uL\n 12.6 g/dL\n 102 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 114 mEq/L\n 144 mEq/L\n 35.8 %\n 9.2 K/uL\n [image002.jpg]\n 06:31 PM\n 03:22 AM\n WBC\n 9.1\n 9.2\n Hct\n 38.4\n 35.8\n Plt\n 249\n 199\n Cr\n 1.3\n 1.3\n Glucose\n 89\n 102\n Other labs: PT / PTT / INR:19.0/35.3/1.8, ALT / AST:4521/2622, Alk Phos\n / T Bili:50/1.1, Amylase / Lipase:50/77, Differential-Neuts:83.2 %,\n Lymph:12.4 %, Mono:3.2 %, Eos:0.8 %, Albumin:3.8 g/dL, LDH: IU/L,\n Ca++:9.2 mg/dL, Mg++:2.0 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n 45 year old with schizoaffective disorder transferred from \n Hospital with Tylenol overdose and rising LFTs.\n 1) Tylenol OD\n The patient\ns overdose is in the toxic range.\n NAC previously dosed at OSH for a total of 300 mg /kg total over 21\n hours.\n - Will continue at 50 mg/kg every 4 hours for the next 24 hours\n 2) Diphenhydramine OD: Patient exhibited one sign of\n diphenhydramine OD with hallucinations which the patient states have\n resolved. ECG does not show significant QTc prolongation.\n - Will monitor for signs of anhidrosis, anhydrotic hyperthermia,\n nonreactive mydriasis, delirium; hallucinations, urinary retention.\n - No further treatment at this time\n 3) Hepatic injury\n Currently, the patient appears well, but her\n LFTs show evidence of hepatic injury. The patient Tylenol overdose was\n in the toxic range, and she began N-acetylcysteine late. This puts the\n patient at high risk for fulminant hepatic failure. Complications of\n fulminant hepatic failure include cerebral edema, encephalopathy,\n coagulopathy, sepsis, circulatory dysfunction, GI bleeding, metabolic\n acidosis, hypoglycemia, and hypophosphatemia.\n - Continue NAC as above\n - Monitor for signs and symptoms of fulminant hepatic failure.\n - Neuro checks Q4H.\n - Repeat LFTs and chemistries Q12 hours.\n - Neutrophos x 1 to treat mild hypophosphatemia.\n - Dextrose 50% 12.5 IV PRN blood glucose < 70.\n - Psych consulted to begin evaluation of whether patient is a\n transplant candidate.\n 4) Suicidality\n The patient currently denies a desire to harm\n herself and regrets her ingestion.\n - 1:1 sitter\n - Psych following\n - Family to see patient today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:32 PM\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT: Pneumoboots while in bed. Will avoid heparin for now given\n patient\ns coagulopathy.\n Stress ulcer: Omeprazole 40 mg PO daily. Patient takes a PPI for GERD\n as an outpatient.\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340456,
"text": "Chief Complaint: tylenol OD\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n EKG - At 12:30 AM\n BLOOD CULTURED - At 03:30 AM\n URINE CULTURE - At 03:30 AM\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\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 11:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 36.6\nC (97.8\n HR: 47 (43 - 69) bpm\n BP: 80/51(55) {80/40(55) - 150/66(86)} mmHg\n RR: 13 (13 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n 480 mL\n 937 mL\n PO:\n 350 mL\n 200 mL\n TF:\n IVF:\n 130 mL\n 737 mL\n Blood products:\n Total out:\n 920 mL\n 1,800 mL\n Urine:\n 920 mL\n 1,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -440 mL\n -863 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Gen: lying in bed, conversant\n HEENT: PEERL o/p dry\n Chest: CTA\n CV: brady RR\n Abd: soft mild tenderness to palp in RUQ\n Ext:no edema\n Neuro: A and O x 3 , hand tremor, hyporeflexic\n Labs / Radiology\n 12.6 g/dL\n 199 K/uL\n 102 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 114 mEq/L\n 144 mEq/L\n 35.8 %\n 9.2 K/uL\n [image002.jpg]\n 06:31 PM\n 03:22 AM\n WBC\n 9.1\n 9.2\n Hct\n 38.4\n 35.8\n Plt\n 249\n 199\n Cr\n 1.3\n 1.3\n Glucose\n 89\n 102\n AST 2622(4482)\n ALT 4521(5685)\n T Bili 1.1 (1.7)\n LDH \n CXR: no infiltrates\n Assessment and Plan\n 45 year old w/ schizoaffective disorder s/p tylenol overdose with\n evolving liver damage\n 1) Tylenol OD\n a. NAC 50 mg/kg every 4 hours for the next 24 hours\n b. Tranplant work up underway with psych and Hepatology\n LFTs are slightly down today which is encouraging but we need to trend\n this closely.\n 2) Diphenhydramine OD: ECG does not show significant QTc\n prolongation and does not have any clinical attributes\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:32 PM\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 340459,
"text": "Chief Complaint: tylenol OD\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n EKG - At 12:30 AM\n BLOOD CULTURED - At 03:30 AM\n URINE CULTURE - At 03:30 AM\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\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 11:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.1\nC (100.5\n Tcurrent: 36.6\nC (97.8\n HR: 47 (43 - 69) bpm\n BP: 80/51(55) {80/40(55) - 150/66(86)} mmHg\n RR: 13 (13 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n 480 mL\n 937 mL\n PO:\n 350 mL\n 200 mL\n TF:\n IVF:\n 130 mL\n 737 mL\n Blood products:\n Total out:\n 920 mL\n 1,800 mL\n Urine:\n 920 mL\n 1,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n -440 mL\n -863 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n Gen: lying in bed, conversant\n HEENT: PEERL o/p dry\n Chest: CTA\n CV: brady RR\n Abd: soft mild tenderness to palp in RUQ\n Ext:no edema\n Neuro: A and O x 3 , hand tremor, hyporeflexic\n Labs / Radiology\n 12.6 g/dL\n 199 K/uL\n 102 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 114 mEq/L\n 144 mEq/L\n 35.8 %\n 9.2 K/uL\n [image002.jpg]\n 06:31 PM\n 03:22 AM\n WBC\n 9.1\n 9.2\n Hct\n 38.4\n 35.8\n Plt\n 249\n 199\n Cr\n 1.3\n 1.3\n Glucose\n 89\n 102\n AST 2622(4482)\n ALT 4521(5685)\n T Bili 1.1 (1.7)\n LDH \n CXR: no infiltrates\n Assessment and Plan\n 45 year old w/ schizoaffective disorder s/p tylenol overdose with\n evolving liver damage\n 1) Tylenol OD\n a. NAC 50 mg/kg every 4 hours for the next 24 hours\n b. Tranplant work up underway with psych and Hepatology\n LFTs are slightly down today which is encouraging but we\n need to trend this closely in light of the height of her initial\n Tylenol level and time to NAC. No overt mental status changes\n or asterixis.\n c. Psych: 1:1 sitter in place, denies SI, need to get final\n decision re is she clear for listing, may be an issue as she is not\n allowed to have her meds at home alone for more than a fgew days at a\n time. Does not live with family\n but all this needs to be sorted out\n with Transplant team, SW, and Psych by protocol.\n ICU Care\n Nutrition: reg diet\n Glycemic Control: q6\n watch for lows\n Lines:\n 20 Gauge - 05:32 PM\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer:\n Communication: with pt and family\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2159-09-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340605,
"text": "Chief Complaint:\n 24 Hour Events:\n 1:1 sitter d/c\nd per psychiatry\n - liver felt patient stable, not worsening (asked for a Tylenol level)\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.6\nC (99.7\n HR: 49 (44 - 88) bpm\n BP: 141/68(85) {80/51(55) - 141/71(85)} mmHg\n RR: 14 (13 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n 2,145 mL\n 561 mL\n PO:\n 780 mL\n TF:\n IVF:\n 1,365 mL\n 561 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,700 mL\n Urine:\n 2,460 mL\n 1,700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -1,139 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 212 K/uL\n 12.4 g/dL\n 121 mg/dL\n 1.2 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 19 mg/dL\n 114 mEq/L\n 145 mEq/L\n 36.1 %\n 8.9 K/uL\n [image002.jpg]\n 06:31 PM\n 03:22 AM\n 02:40 PM\n 03:06 AM\n WBC\n 9.1\n 9.2\n 8.9\n Hct\n 38.4\n 35.8\n 36.1\n Plt\n 249\n 199\n 212\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n Glucose\n 89\n 102\n 165\n 121\n Other labs: PT / PTT / INR:16.2/29.2/1.5, ALT / AST:2507/527, Alk Phos\n / T Bili:46/0.8, Amylase / Lipase:50/77, Differential-Neuts:83.2 %,\n Lymph:12.4 %, Mono:3.2 %, Eos:0.8 %, Albumin:3.6 g/dL, LDH:264 IU/L,\n Ca++:9.3 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 45 year old with schizoaffective disorder transferred from \n Hospital with Tylenol overdose and rising LFTs.\n # Tylenol OD\n The patient\ns overdose is in the toxic range. NAC\n previously dosed at OSH for a total of 300 mg /kg total over 21 hours.\n - Will continue at 50 mg/kg every 4 hours for the next 24 hours\n # Diphenhydramine OD: Patient exhibited one sign of diphenhydramine OD\n with hallucinations which the patient states have resolved. ECG does\n not show significant QTc prolongation.\n - Will monitor for signs of anhidrosis, anhydrotic hyperthermia,\n nonreactive mydriasis, delirium; hallucinations, urinary retention.\n - No further treatment at this time\n # Hepatic injury\n Currently, the patient appears well, but her LFTs\n show evidence of hepatic injury. The patient Tylenol overdose was in\n the toxic range, and she began N-acetylcysteine late. This puts the\n patient at high risk for fulminant hepatic failure. Complications of\n fulminant hepatic failure include cerebral edema, encephalopathy,\n coagulopathy, sepsis, circulatory dysfunction, GI bleeding, metabolic\n acidosis, hypoglycemia, and hypophosphatemia.\n - Continue NAC as above\n - Monitor for signs and symptoms of fulminant hepatic failure.\n - Neuro checks Q4H.\n - Repeat LFTs and chemistries Q12 hours.\n - Neutrophos x 1 to treat mild hypophosphatemia.\n - Dextrose 50% 12.5 IV PRN blood glucose < 70.\n - Psych consulted to begin evaluation of whether patient is a\n transplant candidate.\n # Suicidality\n The patient currently denies a desire to harm herself\n and regrets her ingestion.\n - 1:1 sitter\n - Psych following\n - Family to see patient today\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:32 PM\n 18 Gauge - 07:01 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": "2159-09-09 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 340689,
"text": "Chief Complaint:\n 24 Hour Events:\n 1:1 sitter d/c\nd per psychiatry\n -Liver service felt patient stable, not worsening (asked for a Tylenol\n level)\n -Toxicology service recommended NAC 100 mg/kg over 16 hours,\n recommended continuing NAC until INR normal, transaminases < 1000, and\n patient clinically well.\n -Psych consult service saw patient, recommended (1) coordinate with\n mother and sister regarding disposition, (2) d/c 1:1 sitter, (3)\n patient will likely require inpatient psychiatric treatment when she\n leaves here and cannot leave AMA, (4) obtain collateral information re:\n prior psych history.\n Allergies:\n Phenothiazines\n Unknown;\n Lithobid (Oral) (Lithium Carbonate)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Continues to feel well. Tolerating PO. Mild < abdominal pain.\n Has not had BM since admission. Denies current suicidal ideation. ROS\n otherwise negative.\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.6\nC (99.7\n Tcurrent: 37.6\nC (99.7\n HR: 49 (44 - 88) bpm\n BP: 141/68(85) {80/51(55) - 141/71(85)} mmHg\n RR: 14 (13 - 18) insp/min\n SpO2: 93%\n Heart rhythm: SB (Sinus Bradycardia)\n Height: 72 Inch\n Total In:\n 2,145 mL\n 561 mL\n PO:\n 780 mL\n TF:\n IVF:\n 1,365 mL\n 561 mL\n Blood products:\n Total out:\n 2,460 mL\n 1,700 mL\n Urine:\n 2,460 mL\n 1,700 mL\n NG:\n Stool:\n Drains:\n Balance:\n -315 mL\n -1,139 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 93%\n ABG: ///21/\n Physical Examination\n Gen: NAD.\n HEENT: Anicteric. No conjunctival injection or exudate. Moist mucus\n membranes.\n Neck:\n Supple.\n Chest/lungs: Normal respiratory effort. Symmetric with good\n expansion. Vesicular breath sounds throughout. No wheezes, rales, or\n rhonchi.\n CV: No JVD. RRR. Normal s1 and s2. No M/G/R.\n Abd: Normal bound sounds. Obese. Non-distended. Soft. Mild to\n moderate RUQ and suprapubic tenderness. No masses. Liver and spleen\n not palpated.\n Extremities: Trace lower extremity edema.\n Peripheral vascular: Extremities warm and well-perfused. Radial\n pulses 2+ bilaterally.\n Neuro:\n Mental status: Alert and oriented x 3. Attentive. Spells world\n backward correctly. Flat affect.\n Cranial nerves: 2. PERRL 4 mm to 3 mm bilaterally. Fields full to\n confrontation. 3,4,6. Does not fully abduct right eye on rightward\n gaze or left eye on leftward gaze. Extraocular movements otherwise\n intact. 5. Normal masseter strength and tone. Facial sensation full.\n 7. Facial movement full. 8. Hearing intact to finger rub bilaterally.\n 9,10. Palate elevates in midline. 11. SCM and trapezius strength\n full. 12. Tongue protrudes in midline with no fasciculation.\n Motor: Normal bulk or tone. Resting tremor in both upper\n extremities. No asterixis. No pronator drift. Strength 5/5 in\n deltoids, biceps, triceps, wrist extensors, hip extensors, knee\n flexors, knee extensors, ankle dorsiflexors, and ankle plantar flexors.\n Sensory: Sensation to light touch intact distally in all 4\n extremities.\n Reflexes: Biceps, triceps, brachioradialis, patellar, and ankle jerk\n reflexes 2+ bilaterally.\n Coordination: Finger-to-nose intact bilaterally.\n Labs / Radiology\n 212 K/uL\n 12.4 g/dL\n 121 mg/dL\n 1.2 mg/dL\n 21 mEq/L\n 3.7 mEq/L\n 19 mg/dL\n 114 mEq/L\n 145 mEq/L\n 36.1 %\n 8.9 K/uL\n [image002.jpg]\n 06:31 PM\n 03:22 AM\n 02:40 PM\n 03:06 AM\n WBC\n 9.1\n 9.2\n 8.9\n Hct\n 38.4\n 35.8\n 36.1\n Plt\n 249\n 199\n 212\n Cr\n 1.3\n 1.3\n 1.2\n 1.2\n Glucose\n 89\n 102\n 165\n 121\n Other labs: PT / PTT / INR:16.2/29.2/1.5, ALT / AST:2507/527, Alk Phos\n / T Bili:46/0.8, Amylase / Lipase:50/77, Differential-Neuts:83.2 %,\n Lymph:12.4 %, Mono:3.2 %, Eos:0.8 %, Albumin:3.6 g/dL, LDH:264 IU/L,\n Ca++:9.3 mg/dL, Mg++:1.8 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n 45 year old with schizoaffective disorder transferred from \n Hospital with Tylenol overdose and rising LFTs.\n # Tylenol OD\n The patient had a very significant Tylenol ingestion and\n began NAC 30 hours post-ingestion. NAC previously dosed at OSH for a\n total of 300 mg /kg total over 21 hours. We have continued NAC here at\n 50 mg/kg every 4 hours.\n - Continue NAC at 50 mg/kg every 4 hours.\n # Diphenhydramine OD: Patient exhibited hallucinations, somnolence, and\n urinary retention which resolved prior to admission and have not been a\n problem since. ECG does not show significant QTc prolongation. Foley,\n placed at Hospital due to urinary retention, was pulled\n yesterday, and the patient has been able to urinate.\n - No further treatment at this time\n # Hepatic injury\n The patient had a very large acetaminophen overdose,\n and she began N-acetylcysteine late. Consequently, there was initially\n concern that the patient would develop fulminant hepatic failure.\n Signs of fulminant hepatic failure include cerebral edema,\n encephalopathy, coagulopathy, sepsis, circulatory dysfunction, GI\n bleeding, metabolic acidosis, hypoglycemia, and hypophosphatemia. The\n patient has not exhibited any of these signs other than an elevated\n INR, which is now trending down and was 1.5 this morning. The\n patient\ns LFTs peaked on the evening of and have improved since.\n - Continue NAC as above\n - Monitor for signs and symptoms of fulminant hepatic failure.\n - Repeat LFTs and chemistries Q24 hours.\n - Dextrose 50% 12.5 IV PRN blood glucose < 70.\n - Psych consulted to begin evaluation of whether patient is a\n transplant candidate. It seems unlikely that this will be necessary at\n this point, but certainly it would be important to have psych on board\n if things were to deteriorate.\n # Suicidality\n Since admission, the patient has denied a current\n desire to harm herself, although she acknowledge that her ingestion,\n which she regrets, was with suicidal intent. Psych feels that the\n patient is stable enough to do without a 1:1 sitter for now. However,\n she will need extensive psychiatric follow-up, and will likely require\n inpatient psychiatric care when she is medically stable.\n - Appreciate psych recs\n - Work with psych consult service, patient\ns outpatient psychiatrist\n providers, and patient\ns family to obtain information on patient\n psychiatric history and develop a\n # Abnormal U/A\n Likely due to Foley. Urine culture sent. Antibiotics\n not indicated at this time.\n -f/u urine culture\n # Constipation\n Patient has not had BM since admission. Says she\n generally does not have frequent BMs.\n -could extend bowel regimen\n ICU Care\n Nutrition: Regular diet as tolerated.\n Glycemic Control: Dextrose 12.5 gm IV PRN for blood glucose < 70.\n Lines: PIV x 2\n 20 Gauge - 05:32 PM\n 18 Gauge - 07:01 PM\n Prophylaxis:\n DVT: Pneumoboots while in bed. No heparin SC given risk of\n coagulopathy in the setting of hepatic injury.\n Stress ulcer: omeprazole 40 mg PO daily\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Call out to 10, liver service.\n"
},
{
"category": "Radiology",
"chartdate": "2159-09-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1032393,
"text": " 3:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: TYLENOL OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with fever and shortness of breath\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST FROM AT 0425 HOURS\n\n HISTORY: Fever and shortness of breath. Evaluate for pneumonia.\n\n COMMENT: AP view of the chest was provided. No prior study for comparison.\n\n Discoid atelectasis at the left lung base. Right lung is clear. Cardiac\n silhouette is normal in size. No evidence of pleural effusion.\n\n IMPRESSION: No radiographic evidence of pneumonia.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2159-09-09 00:00:00.000",
"description": "Report",
"row_id": 221679,
"text": "Sinus bradycardia. Otherwise, normal tracing. Compared to the previous\ntracing of no significant change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2159-09-08 00:00:00.000",
"description": "Report",
"row_id": 221680,
"text": "Sinus bradycardia. Otherwise, normal tracing. Compared to the previous\ntracing of no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2159-09-07 00:00:00.000",
"description": "Report",
"row_id": 221681,
"text": "Sinus bradycardia. Baseline tracing artifact. Otherwise, normal tracing.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
8,619 | 167,915 | 81F CAD, HTN, PPM admitted to MICU for hypoxic respiratory failure and shock of unknown etiology, now thought to be cardiogenic in nature since an infectious work up was unrevealing. Pt. transferred to the floor on and now being diuresed and further assessed for CHF. The following issues were investigated during her hospitalization: Cardiogenic vs. Septic Shock In the MICU, patient was quickly weaned off pressors and extubated on . She was being ruled out for an infectious etiology of her shock and was empirically started on Vancomycin/Levofloxacin/Flagyl. CXR, Chest CT and abdominal CT showed no source of infection and pt. remained afebrile. She had leukocytosis of 12.6 upon admission to the MICU and blood cultures were significant for 1/4 bottles of gram positive cocci in clusters, Coagulase (-). Upon her transfer to the floor, both Levofloxacin and Flagyl had been discontinued and Vancomycin was discontinued on the floor since the pt. had no source of infection and was not thought to be colonized by MRSA since coagulase was negative. She remained afebrile on the floor and had no need to be restart antibiotics. A cardiogenic cause of shock was also pursued and an done in the MICU revealed an EF of 30% and focal hypo/akinesis of the apical free wall of the apical free wall of the right ventricle. Pt. was r/o x 3 for an MI. Repeat TTE showed EF to be 20% with apical akinesis. Given this new cardiomyopathy, she was taken for cardiac catheterization which revealed no new critical disease. SPEP/UPEP/TSH/Fe studies were all within normal limits. The most likely etiology for new cardiomyopathy is tachycardia induced (or secondary to pacing). She was started on Coreg, aldactone, losartan. Amiodarone was substitued for norpace (for atrial fibrillation). She was diuresed as possible and will need repeat TTE in 1 month. She may need Biventricular pacer in the future and will follow up with Dr. . She was maintained on her cardiac regimen of ASA, coreg, statin, . Hypoxia/Respiratory Failure Per MICU notes and admission radiographs, exact source of decompensation remains unclear. There was no documented temperature above 99.8 while in the MICU and only a mild leukocytosis on admission without bands. In the absence of an infection and with the low EF and edema on CXR, the likely cause of the hypoxia was thought to be pulmonary edema. Pt was transferred to the floor on 4 liters of oxygen with o2 saturation ranging from 94-97% and was agressively diuresed with Lasix 20 mg IV BID. A repeat was done on and results are as above. The patient was followed by cardiology and for cardiac optimization afterload reduction was started with Losartan 25 mg po qd. Aldactone, Coreg, losartan were continued with diuresis as possible. # TRANSAMINITIS On admission, the patient's LFTs were elevated (AST as high as 140, ALT as high as 170). Once she was transferred to the floor, they were followed with serial labs and gradually decreased to AST 47 and ALT 97. Cause of transaminitis was likely passive congestion/shock and had improved at time of discharge. She will require LFT monitoring given Amiodarone therapy. | Moderate (2+) MR.TRICUSPID VALVE: Physiologic TR. GI: Abd lg and soft, bs hypoactive. Mitral valve disease.Height: (in) 61Weight (lb): 143BSA (m2): 1.64 m2BP (mm Hg): 109/49HR (bpm): 69Status: InpatientDate/Time: at 09:38Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Mild LA enlargement. RV function depressed.AORTA: Normal aortic root diameter. Right ventricular systolicfunction appears depressed.4.The ascending aorta is mildly dilated.5.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion. pt also on triple antibiotic, temp low, micu team aware. (prior CT negative for PE)CV: DDD pacer, vpaced. P: Diuresis and vent wean as tolerated, following lytes, cardiac enzymes and hct. Hypoxic resp. Mild PA systolic hypertension.PERICARDIUM: No pericardial effusion.Conclusions:1. Right radial Aline with good waveform and correlation to NBP, CVP= , Right femoral TLC site C/D/I and all ports patent.Resp: Remains intubated, lungs coarse upper lobes and diminished at bilat bases, ETtube suctioned for scant amt of thick yellow and oral suctioned for tan sputum, Vent settings 450-40%-AC=16-Peep=5 with ABG at 10pm= 7.41-35-73 with Sats 94-97%. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. Elongated LA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness. CT w/ evidence of PNA, on triple abx. Intubated and transferred to CSRU, recieved today to micu from CSRU.Neuro: Pt remains lightly sedated on Fent/Midaz gtts, arouses to voice/stimuli. CV: Vpaced, map >65, levophed gtt titrated and weaned off this am. There is focal hypo/akinesis ofthe apical free wall of the right ventricle. Pulm: See RT notes/vent changes, abg's. Normal RVsystolic function.AORTA: Normal aortic root diameter. Skin: Surfaces grossly intact, trace edema noted peripherally, pedal pulses present by doppler. Borderline PA systolic hypertension.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.Conclusions:1.The left atrium is normal in size. LS clear to coarse upper, diminished lower. hr pt still recievieng lasix and lung clearer today.Id pt afebrile, cht remains stable no transfusions required.Pt has Hl in L far arm patent, R groin tlc dc'd this amA/P transfer to floor today, follow bs q6, contiue with lasix , as ordered Neuro: Sedated with versed/fentanyl gtts, opens eyes spontaneously, mae/perrl. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. edema, cont. Mildly dilated ascending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). PATIENT/TEST INFORMATION:Indication: Congestive heart failure.Height: (in) 61Weight (lb): 143BSA (m2): 1.64 m2BP (mm Hg): 100/60Status: InpatientDate/Time: at 10:52Test: TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. Moderate (2+) mitralregurgitation is seen.6.There is borderline pulmonary artery systolic hypertension.7.There is no pericardial effusion.Compared to the previous study, the mitral regurgitation is less, while themid portion of the inferoseptum and the anterior wall is now severelyhypokinetic, along with increased dyssynchrony. npo, ogt to lcs, soft/distended, hypoactive bowel sounds. Focal apical hypokinesis of RV freewall. BS=bilat with good aeration anteriorly. Moderate to severe (3+)MR.TRICUSPID VALVE: Moderate [2+] TR. Right ventricular systolicfunction is normal.4. Trace AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. The left atrium is elongated.2.Left ventricular wall thicknesses are normal. Abd soft, hypoactive BS. The left ventricle appears dyssnchronous with 12 segment SD>33ms. with diuresis Cont. Moderate to severe (3+)mitral regurgitation is seen.7.Moderate [2+] tricuspid regurgitation is seen.8.There is mild pulmonary artery systolic hypertension.9.There is no pericardial effusion. TSI demonstrates significant LV dyssynchrony with significantseptal wall contraction delay (vs. lateral wall). Compared to the previous tracing of nosignificant change. MMV mode attempted and patient noted to be without spontaneous respirations over set minute ventilation. Weaning FIO2 and PEEP as tolerated. ECHO done in CSRU today, indicative of depressed LV and RV function, as well as 3+ MR, and 2+ TR. hypoxic and hypotensive, pt on sepsis protocol. On Flagyl, Levoflox, and Vanco. ]RIGHT VENTRICLE: Normal RV chamber size. Normal ascending aorta diameter.AORTIC VALVE: Normal aortic valve leaflets (3). The left ventricle appearsdyssnchronous with 12 segment SD >33ms.LV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -akinetic; basal anteroseptal - hypo; mid anteroseptal - akinetic; basalinferoseptal - hypo; mid inferoseptal - akinetic; basal inferior - hypo; midinferolateral - akinetic; anterior apex - akinetic; septal apex- akinetic;inferior apex - akinetic; lateral apex - akinetic; apex - dyskinetic;RIGHT VENTRICLE: Normal RV wall thickness. pressure areas intact, scleroedema present. Normal LV cavity size. Normal LV cavity size. Lactate= 1.3 this am. Trace aortic regurgitation is seen.5.The mitral valve leaflets are mildly thickened. Likely cardiogenic given ECHO today. The left ventricular cavitysize is normal. The left ventricular cavitysize is normal. IJ and carotid into the mediastinum. vpaced via ppm, has widening qrs in ED, rpt ekg done in csru revealed no further changes. PP by doppler. HCT stable. No AI is seen.6.The mitral valve leaflets are mildly thickened. Respiratory carePt recieved from EW intubated with 7.5 et taped at 21 at lip. Respiratory Therapypt remains orally int. BS=bilat, decreased bases. Presently with Right Fem. On Levophed gtt 0.010, attempted to wean off unsuccessfully. ABD soft/dist,BS +, no BM.access: Fem line staying untill morning.endo: didi not require coverage.social: full code, family visited/updated.plan: cont monitoring resp/cv status lytes repleted as needed. wbc 12.4A/P: Shock of unclear etiology, cardiogenic vs. septic shock vs ?adrenal insufficiency. Tissue synchronization imaging demonstrates significant leftventricular dyssynchrony with the septal wall contracting 318 ms later thanthe lateral wall. MAE.Resp: Vented on A/C 40/450/10peep. Severe globalLV hypokinesis. received from ED, with dopa infusing at 25mcg/kg/min and prop 20, both weaned off and shifted to levophed and versed/fentanyl gtts. npn 7a-7pFull CodeAllergy: Azithromycin.Please see carevue for additional data.81y/o p/w one day of acute dyspnea. Right ventricular chamber size is normal. Right ventricular chamber size is normal. Atrial sesnsed and ventricular paced rhythm. Endo: Ssc with regular insulin. Foley patent, adeq. There is severe global left ventricular hypokinesis withakinesis of the apical third of the LV. Blood culture reported to be + gram positive cocci. Plan to wean FIO2 as tolerated. No BM.GU: Foley to CD draining clear yellow urine > 30 ml/hrID: afebrile. | 20 | [
{
"category": "Echo",
"chartdate": "2154-08-14 00:00:00.000",
"description": "Report",
"row_id": 101306,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nHeight: (in) 61\nWeight (lb): 143\nBSA (m2): 1.64 m2\nBP (mm Hg): 100/60\nStatus: Inpatient\nDate/Time: at 10:52\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. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severely\ndepressed LVEF. TSI demonstrates significant LV dyssynchrony with significant\nseptal wall contraction delay (vs. lateral wall). The left ventricle appears\ndyssnchronous with 12 segment SD >33ms.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nakinetic; basal anteroseptal - hypo; mid anteroseptal - akinetic; basal\ninferoseptal - hypo; mid inferoseptal - akinetic; basal inferior - hypo; mid\ninferolateral - akinetic; anterior apex - akinetic; septal apex- akinetic;\ninferior apex - akinetic; lateral apex - akinetic; apex - dyskinetic;\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: Normal aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR.\n\nTRICUSPID VALVE: Physiologic TR. Borderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1.The left atrium is normal in size. The left atrium is elongated.\n2.Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is severely\ndepressed. Tissue synchronization imaging demonstrates significant left\nventricular dyssynchrony with the septal wall contracting 318 ms later than\nthe lateral wall. The left ventricle appears dyssnchronous with 12 segment SD\n>33ms. Resting regional wall motion abnormalities include dyskinesis of the\napex with akinesis of the apical, inferior and and septal walls.\n3. Right ventricular chamber size is normal. Right ventricular systolic\nfunction is normal.\n4. The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. Trace aortic regurgitation is seen.\n5.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen.\n6.There is borderline pulmonary artery systolic hypertension.\n7.There is no pericardial effusion.\n\nCompared to the previous study, the mitral regurgitation is less, while the\nmid portion of the inferoseptum and the anterior wall is now severely\nhypokinetic, along with increased dyssynchrony. The hypokinesis of the apical\nportion of the RV is not appreciated on the present study. The PA pressures\nare less than previous.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2154-08-09 00:00:00.000",
"description": "Report",
"row_id": 101307,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Mitral valve disease.\nHeight: (in) 61\nWeight (lb): 143\nBSA (m2): 1.64 m2\nBP (mm Hg): 109/49\nHR (bpm): 69\nStatus: Inpatient\nDate/Time: at 09:38\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Severe global\nLV hypokinesis. Severely depressed LVEF. [Intrinsic LV systolic function\nlikely depressed given the severity of valvular regurgitation.]\n\nRIGHT VENTRICLE: Normal RV chamber size. Focal apical hypokinesis of RV free\nwall. RV function depressed.\n\nAORTA: Normal aortic root diameter. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Moderate [2+] TR. Mild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is mildly dilated. The left atrium is elongated.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. There is severe global left ventricular hypokinesis with\nakinesis of the apical third of the LV. Overall left ventricular systolic\nfunction is severely depressed. [Intrinsic left ventricular systolic function\nis likely more depressed given the severity of valvular regurgitation.]\n3. Right ventricular chamber size is normal. There is focal hypo/akinesis of\nthe apical free wall of the right ventricle. Right ventricular systolic\nfunction appears depressed.\n4.The ascending aorta is mildly dilated.\n5.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. No AI is seen.\n6.The mitral valve leaflets are mildly thickened. Moderate to severe (3+)\nmitral regurgitation is seen.\n7.Moderate [2+] tricuspid regurgitation is seen.\n8.There is mild pulmonary artery systolic hypertension.\n9.There is no pericardial effusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-08-09 00:00:00.000",
"description": "Report",
"row_id": 1376518,
"text": "Nurses progress note 0700-12noon. Neuro: Sedated with versed/fentanyl gtts, opens eyes spontaneously, mae/perrl. Minimal english per pts son, pt doesn't follow commands or respond to questions. CV: Vpaced, map >65, levophed gtt titrated and weaned off this am. Pulm: See RT notes/vent changes, abg's. Lungs clear bilaterally, 02 sats 98%, no sputum production. GU: diuresis initiated this am with hourly uo 40 to >300cc/hr clear yellow. GI: Abd lg and soft, bs hypoactive. To begin tube feeds. Skin: Surfaces grossly intact, trace edema noted peripherally, pedal pulses present by doppler. Endo: Ssc with regular insulin. Soc: Husband and english speaking children. P: Diuresis and vent wean as tolerated, following lytes, cardiac enzymes and hct. Keep family up to date on poc with interpreter prn. Pt transfering from CSRu to MICU 7.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-08-09 00:00:00.000",
"description": "Report",
"row_id": 1376519,
"text": "npn 7a-7p\nFull Code\nAllergy: Azithromycin.\nPlease see carevue for additional data.\n\n81y/o p/w one day of acute dyspnea. Had had a couple of days of increasing orthopnea. In ED Sats 85% on RA, attempted NRB,and Bipap unsuccessfully. Intubated and transferred to CSRU, recieved today to micu from CSRU.\nNeuro: Pt remains lightly sedated on Fent/Midaz gtts, arouses to voice/stimuli. Primarily Russian speaking, also hard of hearing-hearing aid in place. Does not follow commands likely language barrier. MAE.\nResp: Vented on A/C 40/450/10peep. LS clear to coarse upper, diminished lower. Sats 99-100%. (prior CT negative for PE)\nCV: DDD pacer, vpaced. 65-75. SBP 102-114. On Levophed gtt 0.010, attempted to wean off unsuccessfully. ECHO done in CSRU today, indicative of depressed LV and RV function, as well as 3+ MR, and 2+ TR. HCT stable. PP by doppler. Lasix. Of NOTE:s/p attempt at left IJ line placement where CXR demonstraed line btw. IJ and carotid into the mediastinum. Line removed. Presently with Right Fem. line.\nGI/GU: OGT patent,TF implemented today Promote w/ Fiber, at 10cc/hr, goal 50cc/hr. Abd soft, hypoactive BS. Foley patent, adeq. clear yellow urine out.\nENDO: RISS. Endocrine following hyperparathyroidism.\nSkin: w/d/i.\nID: afeb. On Flagyl, Levoflox, and Vanco. wbc 12.4\nA/P: Shock of unclear etiology, cardiogenic vs. septic shock vs ?adrenal insufficiency. Likely cardiogenic given ECHO today. CT w/ evidence of PNA, on triple abx. f/u on cx data. Wean Levo. gtt as tol. Hypoxic resp. distress prob. pul. edema, cont. with diuresis Cont. providing supportive care.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-08-09 00:00:00.000",
"description": "Report",
"row_id": 1376516,
"text": "Respiratory care\nPt recieved from EW intubated with 7.5 et taped at 21 at lip. Pt remains on same A/C settings however fio2 weaned to 60% after abg 727/43/144/21-6/100, See carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-08-09 00:00:00.000",
"description": "Report",
"row_id": 1376517,
"text": "csru nursing updated\n81 y/o female admitted from ED due to increasing SOB/dyspnea, not responded to cpap and bipap. intubated in ED, cxr +pulm edema, ctscan (-) for PE, ?pneumonia. hypoxic and hypotensive, pt on sepsis protocol. received from ED, with dopa infusing at 25mcg/kg/min and prop 20, both weaned off and shifted to levophed and versed/fentanyl gtts. sbp presently 100 with map>60, uop adequate. vpaced via ppm, has widening qrs in ED, rpt ekg done in csru revealed no further changes. pt also on triple antibiotic, temp low, micu team aware. warming measures taken, pt on warm blanket. sedated and fully ventilated, pt very agitated when lightened, mae's nothing to command. npo, ogt to lcs, soft/distended, hypoactive bowel sounds. pressure areas intact, scleroedema present. daughter phoned and updated\n\nplan: echo in am\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-08-09 00:00:00.000",
"description": "Report",
"row_id": 1376520,
"text": "Respiratory Care:\n Patient recieved from CSRU intubated and on full vent support. BS=bilat with good aeration anteriorly. Weaning FIO2 and PEEP as tolerated. Vent checked, alarms audible. ET tube secure 21cm at lip.See Carevue flowsheet for specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-08-09 00:00:00.000",
"description": "Report",
"row_id": 1376521,
"text": "Resp Care:\n Patient weaned to PSV with periods of apnea. She remains on fentanyl for comfort. MMV mode attempted and patient noted to be without spontaneous respirations over set minute ventilation. She was then changed back to assist control until less sedate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-08-10 00:00:00.000",
"description": "Report",
"row_id": 1376522,
"text": "MICU Nursing Note 1900-0700\nEvents: Pt remains off vasopressors all night, Sedated on IV Fentanyl and IV Versed gtt, blood culture reported as Positive for gram positive cocci.\n\nNeuro: Sedated on IV Fentanyl at 100mcgs/hr and IV Versed at 3 mg/hr. Arouses to voice and to touch and then settles back down, moving all extremities, does not follow commands--(? if d/t language barrier?), PEARL, bilat soft wrist restraints to prevent pt from pulling at lines and tubes.\n\nCardiac: HR 57-90's SB/SR with occasional and intermittant Vpacing, BP= 102-140's/40's. Right radial Aline with good waveform and correlation to NBP, CVP= , Right femoral TLC site C/D/I and all ports patent.\n\nResp: Remains intubated, lungs coarse upper lobes and diminished at bilat bases, ETtube suctioned for scant amt of thick yellow and oral suctioned for tan sputum, Vent settings 450-40%-AC=16-Peep=5 with ABG at 10pm= 7.41-35-73 with Sats 94-97%. Repeat ABG this am 7.41-36-68------FI02 increased to 50 % at present time with Sats 97%.\nMV=.\n\nGI: OGtube placement checked by auscultation, Abd softly distended with + hypoactive bowel sounds all quads, Tolerating FS Promote with fiber at 20 ml/hr at present with minimal residuals. No BM.\n\nGU: Foley to CD draining clear yellow urine > 30 ml/hr\n\nID: afebrile. Blood culture reported to be + gram positive cocci. Lactate= 1.3 this am. Continues on IV Flagyl and IV Levofloxacin\nWBC= 11.6\n\nEndo: fingersticks WNL and no coverage required.\n\nSkin: grossly intact.\n\nSocial: husband/daughter in to visit during evening hours and spent time talking with MD---updated on pt's condition and POC---support offered. husband took pt's hearing aid home with him\n\nPlan: Aggressive pulmonary toiletting and diuresis, Continue antibx, Wean vent and sedation as tolerated, Advance tube feedings to goal as tolerated, Support pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-08-10 00:00:00.000",
"description": "Report",
"row_id": 1376523,
"text": "Respiratory Therapy\npt remains orally int. on full ventilatory support. BS coarse W dim. bases. PaO2 trended down to 68 overnight, FiO2 increased to .5. Plan: wean as tol.\n"
},
{
"category": "ECG",
"chartdate": "2154-08-16 00:00:00.000",
"description": "Report",
"row_id": 302144,
"text": "Atrial sensed ventricular paced\nNo change from previous\n\n"
},
{
"category": "ECG",
"chartdate": "2154-08-16 00:00:00.000",
"description": "Report",
"row_id": 302145,
"text": "Regular ventricular pacing. Compared to the previous tracing of no\nsignificant change.\n\n"
},
{
"category": "ECG",
"chartdate": "2154-08-15 00:00:00.000",
"description": "Report",
"row_id": 302146,
"text": "Regular ventricular pacing\nPacemaker rhythm - no further analysis\nSince previous tracing, fully paced\n\n"
},
{
"category": "ECG",
"chartdate": "2154-08-15 00:00:00.000",
"description": "Report",
"row_id": 302147,
"text": "Demand pacing\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2154-08-09 00:00:00.000",
"description": "Report",
"row_id": 302148,
"text": "Atrial sesnsed and ventricular paced rhythm. Pacemaker rhythm - no further\nanalysis. Compared to the previous tracing no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2154-08-08 00:00:00.000",
"description": "Report",
"row_id": 302149,
"text": "Atrial sensed and ventricular paced rhythm. Pacemaker rhythm - no further\nanalysis. Compared to the previous tracing no significant change.\nTRACING #1\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-08-10 00:00:00.000",
"description": "Report",
"row_id": 1376524,
"text": "MIcu Nursing note \n\nNeuro pt is awake and alert, following commands, hands in soft restraints until she was extubated, pt understands some english and responds to questions.\n\nCv pt off pressors and now is more hypertensive will restart her antihypertensives thsie evening norvas/isosobide, pt in an out of paced rythum durring the day. Bp 150-160/70-80\n\nresp pt weened and extubated this afternoon (see care view) pt placed on 60% cool face mask. rr 16-20 lung sounds course throughtout. ptrio to extubation suctioning for mall amount so tan secreation, pt was having more oral tan thick secreations, prior to extubation suction for large thick tan green secreation orally, sputum sent for culture,\nrepeat abg on 60% 7.37/38/83/23. pt given chest pt this afternoon.\n\nGI tube feed on hold at 12 pm , abd soft distended bsx4\npt taking po meds with sips.\n\nGU pt has foley passing yellow urine. pt given lasix 20mg iv in between each unit pt response 200-400 cc hr\n\nId pt afebrile wbc 11.6\nendo pt's bs 105 at 12pm no coverage needed\nPt seen my cardiology this afternoon with recomendations to restart htn med and lasix. they will follow pt.\nheme hct 28 -26 this am pt transfused with 2 units prbs this afternoon\nA/P ween fio2 as tol, encourage pulm toilet, may need lyte replacement this evening post lasix, repeat hct tongith and follow hcts\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-08-10 00:00:00.000",
"description": "Report",
"row_id": 1376525,
"text": "Respiratory Care Note:\n Patient weaned and extubated without incident. BS=bilat, decreased bases. She is on a 60% cool neb with SaO2>96%. Plan to wean FIO2 as tolerated. Patient with strong, moist, non-productive cough at times. Noted large amount of tenacious green secretions suctioned from oropharynx pre-extubation- sent for culture.\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-08-11 00:00:00.000",
"description": "Report",
"row_id": 1376526,
"text": "1900-7000 rn notes micu\n\nneuro: A/ox3, follows commands, opens eyes spont,MAE.pt said,she afraid to fall asleep, stop breathing and not wake up,start Ativan 0.5 mg IV PRN, received one dose with minimal effect. pt slept total 1-2hr.\n\nresp: received with NC 4L , pt desat to 90%,put on coolneb 50%, sat increased to 95-96%, LS clear dim at bases. cont with deep breathing and encourage to cough.\n\ncv: HR 70-80's, NSR, start Norvask 10mg d/t ABP 155-160/70's,increased Issorbide to 20mg TID, given Lasix 20mg IV. K 3.3 and Phos 2.6, given KPhos IV.morning labs pending. mornign HCT 37. Tmax 98.9.\n\ngi/gu: foley, drainge uellow clear urine 200-400cc/hr as respone to Lasix. ABD soft/dist,BS +, no BM.\n\naccess: Fem line staying untill morning.\n\nendo: didi not require coverage.\n\nsocial: full code, family visited/updated.\n\nplan: cont monitoring resp/cv status\n lytes repleted as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2154-08-11 00:00:00.000",
"description": "Report",
"row_id": 1376527,
"text": "Micu Nurisng note \n\nNeuro, pt is awake and alert following commands. pt oob-chair with 2 assists, pt up since 10 am this morning, family in visiting\n\nCv pt hemodynamically stable Bp 129/41 -14-/60 hr 88 paced,\nResp pt On 4L n/c lungs clear,\nGi pt advacned to diet, told well\nGU pt has foley which continues to pass clear yellow urine 120-400 cc. hr pt still recievieng lasix and lung clearer today.\nId pt afebrile, cht remains stable no transfusions required.\nPt has Hl in L far arm patent, R groin tlc dc'd this am\nA/P transfer to floor today, follow bs q6, contiue with lasix , as ordered\n"
}
] |
29,575 | 190,771 | BRIEF ICU COURSE NEURO Improved markedly, following commands, alert and attentive within 2 days, but remained disoriented. EEG was done showing no PLEDS or triphasic waves, but some in sharp transients in the occipital leads, not interpreted as epileptic but also not classic POSTs. 3 pushbutton events for increased HR and and bilateral arm shaking NOS had no EEG correlate suspect for seizure activity. No AEDs were started. Repeat LP opening pressure 16.5 cm H2O, 176 WBC (mono 81% lymph 17%) 33 RBC Prot 125 Glc 78. Started on steroids 1000 mg MP for 5 days for a suspicion of ADEM. CSF MS package negative. Read of EEG from days following pending. ID Febrile up to 104.1, now afebrile. White count on arrival 18.6 with left shift (86% PMN), now 9.6. Repeat LP opening pressure 16.5 cm H2O, 176 WBC (mono 81% lymph 17%) 33 RBC Prot 125 Glc 78.UCx negative. BCx , 18, 19, 20 x 2 (PICC and periph IV) NGTD. VRE and MRSA x 2 pending. HSV PCR -1 and -2 OSH (Per Dr fax ) negative. CSF studies sent here AF Cx-, viral Cx-, bact Cx-, fungal Cx-. Gram stain no organisms, 2+ PMN. HSV, CMV, EBV, HHV-6, VZV, Lyme pending. CSF cryptococcal Ag negative. EEE and West- not sent. On Vancomycin 1000 Q12, Ceftriaxone Q12, Acyclovir 600 Q8. CARDIO TTE negative. No active issues. Bloodpressures well controlled w/o medication. PULM CXR negative for infiltration on . FEN/Endo/Tox Started on TF, Replete w/fiber full strength goal of 60 cc but now waking up. Maintenance IVF 40 cc/hr with 20 KCl, now off. No electrolyte abnormalities. Utox and Stox on arrival negative. B-HCG negative. GI On bowel regimen. No issues reported by nursing. HEME Stable Hct/Hb. White count normalized. Coags normal. PPx Pneumoboots, bowel regimen, SC Heparin | Normal ascending aortadiameter. Pt did receive contrast with MRI at OSH.Skin: Intact. HO aware.ID: Remains febrile w/ TM 102.8. IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Heart size top normal. Tachy up to 110s when agitated; self-limited. The estimated pulmonary artery systolic pressure isnormal. The appearance of the ventricles and extra-axial CSF spaces is unchanged. ABLE TO OBTAIN RECTAL TEMP, 99.9. PATIENT/TEST INFORMATION:Indication: Endocarditis.Weight (lb): 126BP (mm Hg): 125/64HR (bpm): 82Status: InpatientDate/Time: at 15:36Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. Otherwise, lesions are largely unchanged in the periventricular right frontal lobe, right greater than left medial temporal lobes, bilateral caudate heads, bilateral putamen, bilateral thalami, and bilateral corona radiata. IMPRESSION: AP chest centered at the diaphragm, excluding the lung apices compared to : New feeding tube with a wire stylet still in place ends in the mid stomach. IV RN ABLE TO PLACE #22 IN RIGHT ARM AND PT WILL BE ASSESSED THIS AM FOR PICC PLACEMENT.RESP- LUNGS CLEAR, NO O2 REQUIRED.GI/GU- ABD SOFT, NO BM OVER NIGHT. Lower lungs are clear and previous vascular plethora has resolved. TYLENOL GIVEN AS SCHEDULED. UOP ADEQUATE.ID- TMAX 100.4 AXILLARY. HR 90's NSR with no ectopy SBP 110-120's hemodynamically stable making adequate amts of urine. Pt started on antibiotic coverage, acyclovir and decadron and treansferred to .Pt arrived here lethargic, minimally opening eyes. IMPRESSION: Overall, little change to multiple lesions in the brain; findings again may be consistent with ADEM. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic diameter at the sinus level. Neuro status wax/wane, at best Pt oriented to self and hospital but not to date. Noted a small dry; non-raised rash to right flank. ORIENTED TO PERSON AND OCCASIONALLY "HOSPITAL", BUT MILD CONFUSION EVIDENT WHEN SPEAKING TO PT. Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Mild pulmonary and mediastinal vascular congestion suggest mild cardiac decompensation or volume overload. Essentially stable hyperintensity is seen in the bilateral right greater than left medial temporal lobes, bilateral caudate heads,pons, bilateral thalami, right caudate, right putamen and bilateral corona radiata. Doxycycline D/C'd. vasculitis, or ADEM. The ventricles are unchanged in size. No mass orvegetation on mitral valve.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. SINGLE SUPINE BEDSIDE RADIOGRAPH OF THE CHEST AT 9:45 A.M.: There has been interval placement of a left PICC terminating 1-2 cm below the anticipated cavoatrial junction. Cooling blanket on for temps >101.0. Still needs TTE. The aortic valveleaflets (3) appear structurally normal with good leaflet excursion and noaortic regurgitation. When eyes were open, pt did not focus and generally drifted her eyes to the right. Follow temps-cooling blaket/tylenol PRN. Hemodynamically has remained stable.Resp: Lungs CTA. There is minimal mucosal thickening in some ethmoid air cells. Multiplanar T1-weighted imaging was then performed after administration of IV gadolinium. NO SEIZURE ACTIVITY NOTED, CONTINUOUS EEG MONITORING.CV- BP STABLE VIA CUFF. The cardiomediastinal silhouette and pulmonary vasculature are normal. Pt's LS are clear bilaterally, abdomen is soft with positive bowel sounds and pt's skin is intact.Pt's temp 103.7 upon arrival to SICU. MR HEAD BEFORE AND AFTER IV CONTRAST: No new lesions are seen compared to the most recent study of . TTE to be done today to r/o endocarditis. Ceftriaxone added. Condition UpdateD: See carevue flowsheet for specifics Patient remains febrile with tmax 102.5 while receiving tylenol ATC on triple IV antibiotics. Normal aortic arch diameter.AORTIC VALVE: Normal aortic valve leaflets (3). Soft limb restraints applied after doboff placement, as pt was very strong and purposful trying to pull out tube.CV: HR 70-80s/ NSR w/ no ectopy. No masses orvegetations on aortic valve.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Continues on Vanco and Acyclovir. Cont EEG on no witnessed seizure activity. No immediate post- procedure complications. Rightventricular chamber size and free wall motion are normal. Continue antibiotic/acyclovir coverage. IMPRESSION: Mild interval progression of some lesions in the brain. 11:47 PM CHEST (PORTABLE AP) Clip # Reason: ? Given the acute symptoms, neoplasm is thought to be unlikely. Admitting Diagnosis: HEMMORRHAGIC ENCEPHALOMYELITIS Contrast: MAGNEVIST Amt: 14 MEDICAL CONDITION: 49F with ADEM REASON FOR THIS EXAMINATION: Please eval for interval change of prior lesions. PERIPHERAL IVS INFILTRATING AT BEGINNING OF THE SHIFT. Abd/ SNT w/ +BS x4. Heart size normal. Dexamethasone D/C'd and started on Methypredisolone 1000mg IV Qday for possible ADEM (acute disseminated encephalomyelitis).Neuro: Lethargic, but arousable. Neuro checks and EEG overnight. TECHNIQUE: Axial T1, T2, FLAIR, gradient echo, and diffusion-weighted imaging as well as sagittal T1-weighted imaging was performed prior to administration of IV contrast. Leftventricular wall thickness, cavity size and regional/global systolic functionare normal (LVEF >55%) There is no ventricular septal defect. Given 650mg tylenol PR and coolong blanket applied. There has been mild progression of lesions along the lateral aspect of the right temporal as well as in the left putamen. Follows commands inconsistently, MAE with equal strength only short answers. CSF tubes 1&2 + for WBC/RBC; otherwise results pending. Tylenol ATC. FSBS covered with RISS. Doboff placed @ 1100 at bedside and confirmed by CXR. Speach/swallow not ordered yet d/t pt's inconsistent mental status. 1:39 PM MR HEAD W & W/O CONTRAST Clip # Reason: Please eval for interval change of prior lesions. | 12 | [
{
"category": "Radiology",
"chartdate": "2182-04-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1014118,
"text": " 10:01 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: picc placement\n Admitting Diagnosis: HEMMORRHAGIC ENCEPHALOMYELITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with encephalitis\n REASON FOR THIS EXAMINATION:\n picc placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old woman with encephalitis, please evaluate for PICC\n placement.\n\n COMPARISON: .\n\n SINGLE SUPINE BEDSIDE RADIOGRAPH OF THE CHEST AT 9:45 A.M.: There has been\n interval placement of a left PICC terminating 1-2 cm below the anticipated\n cavoatrial junction. There is no mediastinal widening or pneumothorax. There\n is no pleural effusion. The lungs are clear. The cardiomediastinal silhouette\n and pulmonary vasculature are normal. A Dobbhoff tube is seen to extend into\n the stomach.\n\n IMPRESSION: Left PICC terminating within the right atrium. No immediate post-\n procedure complications.\n\n"
},
{
"category": "Echo",
"chartdate": "2182-04-15 00:00:00.000",
"description": "Report",
"row_id": 85047,
"text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis.\nWeight (lb): 126\nBP (mm Hg): 125/64\nHR (bpm): 82\nStatus: Inpatient\nDate/Time: at 15:36\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler. Normal IVC diameter (<2.1cm) with >55% decrease during respiration\n(estimated RAP (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 aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\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. No masses or vegetations are seen on the aortic valve.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. No mass or vegetation is\nseen on the mitral valve. The estimated pulmonary artery systolic pressure is\nnormal. There is no pericardial effusion.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-16 00:00:00.000",
"description": "Report",
"row_id": 1645335,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\n PT TO VOICE, SLEEPING INTERMITTENTLY THROUGHOUT THE NIGHT. DENIES PAIN. PUPILS EQUAL AND REACTIVE. MAE. ORIENTED TO PERSON AND OCCASIONALLY \"HOSPITAL\", BUT MILD CONFUSION EVIDENT WHEN SPEAKING TO PT. NO SEIZURE ACTIVITY NOTED, CONTINUOUS EEG MONITORING.\nCV- BP STABLE VIA CUFF. PERIPHERAL IVS INFILTRATING AT BEGINNING OF THE SHIFT. IV RN ABLE TO PLACE #22 IN RIGHT ARM AND PT WILL BE ASSESSED THIS AM FOR PICC PLACEMENT.\nRESP- LUNGS CLEAR, NO O2 REQUIRED.\nGI/GU- ABD SOFT, NO BM OVER NIGHT. UOP ADEQUATE.\nID- TMAX 100.4 AXILLARY. DIFFICULT TO TAKE ORAL TEMP, PT NOT ALWAYS COOPERATIVE AT BITES THERMOMETER. ABLE TO OBTAIN RECTAL TEMP, 99.9. TYLENOL GIVEN AS SCHEDULED.\n HUSBAND AND OTHER FAMILY MEMBERS IN TO VISIT IN THE EVENING. HUSBAND STATING THAT PT IS SHOWING LESS SIGNS OF CONFUSION WHEN HAVING CONVERSATIONS WITH HER IN VIETNAMESE. TRANSFER OUT WHEN BED AVAILABLE IN STEP DOWN UNIT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-16 00:00:00.000",
"description": "Report",
"row_id": 1645336,
"text": "NEURO; A&OX , PT STATES SHE IS IN OR IN A HOSPITAL, BUT NOT CONSISTENT, MAE, FOLLOWS SIMPLE COMMANDS, PERL @2 AND BRISK, POSITIVE COUGH, PT FREQUENTLY NOT ABLE TO IDENTIFY DATE BUT RECOGNIZES FAMILY MEMBERS AND NAMES THEM PROPERLY, DENIES PAIN, WAXES AND WANES\nCONTINUOUS EEG IN PLACE\n\nCARDIOVASCULAR; HR 80'S-90'S SR, SYS 110-130'S, TEMP MAX 99, EXTREMITIES WARM,\nPIC LINE PLACED LEFT UPPER ARM, CXR CONFIRMED PLACEMENT AND IV NURSE PULLED LINE BACK FROM 45CM TO 43 CM\n\nRESPIR; LUNGS CLEAR, 02 SAT 99% ON R/A\n\nGI; DOBOFF TUBE FEEDING AT 50CC/HR,INCONTINENT OF SOFT SEMI-FORMED STOOL X2,\n\nENDOCRINE; BS 128-168, SLIDING SCALE,\n\nPLAN; TRANSFER OUT OF SICU TO STEPDOWN WHEN BED AVAILABLE, FREQUENT NEURO CHECKS, MRI WHEN EEG LEADS OFF,\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-14 00:00:00.000",
"description": "Report",
"row_id": 1645331,
"text": "admission note\nPt admitted from at 2130. Pt is a 49 year old vietnamese speaking female who presented to after experiencing 2 days of nausea/vomiting, fevers and lethargy. Pt had LP, head CT and MRI done at OSH. MRI showing diffuse lesions present-likely related to herpes simplex encephalitis or possibly multiple embolic strokes. Pt started on antibiotic coverage, acyclovir and decadron and treansferred to .\nPt arrived here lethargic, minimally opening eyes. When eyes were open, pt did not focus and generally drifted her eyes to the right. Pt's pupils are 3mm bilaterally and briskly reactive to light. When pt's husband was here to translate, the patient did follow some simple commands although she was confused during her conversations. Pt noted to move all extremities however she moves right upper and lower extremities more than left on observation. No seizure activity noted. Pt's LS are clear bilaterally, abdomen is soft with positive bowel sounds and pt's skin is intact.\nPt's temp 103.7 upon arrival to SICU. Given 650mg tylenol PR and coolong blanket applied. Urine sent for culture/tox screen, blood cultures obtained and CXR done.\nPLAN-Monitor neuro signs and call HO with any changes. Follow temps-cooling blaket/tylenol PRN. Plan for TTE today to assess for vegitation. Continue antibiotic/acyclovir coverage.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-14 00:00:00.000",
"description": "Report",
"row_id": 1645332,
"text": "0700-1900\nShift Events: LP done at bedside @ 1200. CSF tubes 1&2 + for WBC/RBC; otherwise results pending. Continuous EEG setup @ 1600; will continue until D/C'd by neurology. Mental status continues to wax and wane. Still needs TTE. Will repeat MRI in 48 hours. Dexamethasone D/C'd and started on Methypredisolone 1000mg IV Qday for possible ADEM (acute disseminated encephalomyelitis).\n\nNeuro: Lethargic, but arousable. Intermittently awake with eyes open. Does not speak, but follows commands; will wiggle toes and squeeze with RUE, does not squeeze with left hand, but does w/d to painful stimuli and able to lift and hold if stimulated with pain. PERRL, but does not focus or track. Moves legs in bed and will bend and hold knees if stimulated. Right side remains significantly stronger than Left. Soft limb restraints applied after doboff placement, as pt was very strong and purposful trying to pull out tube.\nCV: HR 70-80s/ NSR w/ no ectopy. Tachy up to 110s when agitated; self-limited. BP 100-120/60. Hemodynamically has remained stable.\nResp: Lungs CTA. SATs 97-100% on RA.\nGI: NPO. Doboff placed @ 1100 at bedside and confirmed by CXR. TF started, replete w/ fiber @ 20cc/hour; residual 100cc @ 1500; increased to 40cc/hour. Goal 70cc/hour. Abd/ SNT w/ +BS x4. FSBS covered with RISS. NS w/ 20KCL @ 40cc/hour.\nGU: Foley w/ adequate UOP. NS 250cc bolus to be given prior and after Acyclovir doses for renal prohylaxsis. Pt did receive contrast with MRI at OSH.\nSkin: Intact. Noted a small dry; non-raised rash to right flank. HO aware.\nID: Remains febrile w/ TM 102.8. Tylenol ATC. Doxycycline D/C'd. Ceftriaxone added. Continues on Vanco and Acyclovir. Last set of cultures sent yesterday; NTD. WBC 18; cont to rise. Cooling blanket on for temps >101.0. Will repeat MRI in 48 hours. Still needs TTE to r/o veggies and possible embolic showers; order active.\nSocial: Husband at bedside most of the day. He and his nefhew were updated extensively by ICU team and Neuro team of plan of care. Had multiple visitors in the afternoon and family needs consistant reinforcement with ICU visiting regulations. Patient does primarily speak vietnamese; but understands english according to husband and does follow some commands in english.\n\nPLAN: ICU monitoring. Pulmonary toilet. Neuro checks and EEG overnight. Echo tomorrow. Advance TF to goal. Anbx and tylenol ATC. Cooling blanket PRN. MRI later this week. Labs pending.\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-15 00:00:00.000",
"description": "Report",
"row_id": 1645333,
"text": "npn 7p-7a (please also see carevue flownotes for objective data)\n\n49F w/ rapids onset progressive h/a, n/v, lethargy, fever over two days, went to primary physician, as output, symptoms continued to progress, went to ; + nucchal rigidity; CT neg, MRI positive for diffuse scattered patchy areas, w/ hemorhagic component, Rt side more than left; transfer to decided;\n\nIn preparation for from , pt had witnessed seizure lasting approx 30 sec, became unresponsive, w/ downward gaze toward rt, hypotension, sbp down to 80; received 1 mg ativan, returned to baseline, intubation deferred, w/ plan to intubate en route if needed.\n\nSince here at , received lumbar tap, + RBCs, +WBCs, and protein in some tubes; started on abx, anti-viral, steroids;\nInitially had noticable left sided weakness compared to right;\nHowever this night, seems to have increased movement also of left side;\nMovements of all extremities observed;\n\nStarted on continuous EEG at 16:00; to be continued until neurology desires d/c; nursing to push noted button as any activity suspicious of sz activity;\n\nThis night, bil arm subtle shaking and stiffness noted at same time of increase from hrt rate NSR 70's/80's up to hi 90's/low 100's; button on cont EEG system pushed x3 so far, w/ questionable symptoms noted on recording sheet at bedside on EEG machine;\n\nT done q 2 hrs this night to not miss if occurs; T increased to 101.3 Ax at 02:15; blood cx's drawn at this time, along w/ a.m. labs; urine hcg ordered, sent at this time;\n\nFS increased to q 4 hrs from q 6 hrs for improved blood sugar control, d/t pt receiving high dose steroids, and tube feeding;\n\nAlso given anti-emetic q 8 hrs, to prevent n/v or dry heaving, to prevent neurological/brain insult d/t increased IVH w/ wretching, if hemorhagic encphalomylelitis present;\n\nVisitors in this eve; pt's mental status continues to wax and wean, pt alert and Ox3 at approx 21:30/22:00, visitors to communicate w/ patient, patient able to answer more complex questions (such as name of visitors mother); pt looking around the hospital room at that time, making appropriate remarks about surrounding;\n However a few hours later, pt returned to significantly decreased responsiveness;\n\nPt receiving abx/anti-viral; SCD's on, receiving hep SQ; also receiving H2 blocker;\n\nAccording to Stroke Attending note, pt's differential diagnosis still rather broad;\n\nPLAN:\n1) cont EEG in place, note activity questionable for sz activity\n2) q 1 hr neuro signs\n3) check results a.m. labs\n4) FS q 4 hrs\n5) anti-emetic q 8 hrs to prevent wretching\n6) advance tube feeds as ordered as tolerates\n7) pt to have echo yet to check for cardiac vegetation\n"
},
{
"category": "Nursing/other",
"chartdate": "2182-04-15 00:00:00.000",
"description": "Report",
"row_id": 1645334,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient remains febrile with tmax 102.5 while receiving tylenol ATC on triple IV antibiotics. HR 90's NSR with no ectopy SBP 110-120's hemodynamically stable making adequate amts of urine. IVF KVO'd d/t TF at goal via dobhoff. TTE to be done today to r/o endocarditis. Continue to await results of cultures and LP. F/U MRI to be done tomorrow.\n Neuro status wax/wane, at best Pt oriented to self and hospital but not to date. Follows commands inconsistently, MAE with equal strength only short answers. Speach/swallow not ordered yet d/t pt's inconsistent mental status. Cont EEG on no witnessed seizure activity.\n Family/friends in to visit throughout the day.\nPLAN:\n Transfer to neuro stepdown when bed avail\n f/u with test results/culture results\n Cont EEG\n Notify H.O. with any changes\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1013852,
"text": " 10:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: new dobhoff placement\n Admitting Diagnosis: HEMMORRHAGIC ENCEPHALOMYELITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with MS changes\n REASON FOR THIS EXAMINATION:\n new dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 10:20 P.M. ON .\n\n HISTORY: Mental status changes. New feeding tube.\n\n IMPRESSION: AP chest centered at the diaphragm, excluding the lung apices\n compared to :\n\n New feeding tube with a wire stylet still in place ends in the mid stomach.\n Lower lungs are clear and previous vascular plethora has resolved. Heart size\n normal. No pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-23 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1015178,
"text": " 1:39 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please eval for interval change of prior lesions.\n Admitting Diagnosis: HEMMORRHAGIC ENCEPHALOMYELITIS\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49F with ADEM\n REASON FOR THIS EXAMINATION:\n Please eval for interval change of prior lesions.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 49-year-old female with ADEM.\n\n COMPARISON: MR head of .\n\n TECHNIQUE: Axial T1, T2, FLAIR, gradient echo, and diffusion-weighted imaging\n as well as sagittal T1-weighted imaging was performed prior to administration\n of IV contrast. Multiplanar T1-weighted imaging was then performed after\n administration of IV gadolinium.\n\n MR HEAD BEFORE AND AFTER IV CONTRAST: No new lesions are seen compared to the\n most recent study of . Small lesions within the pons appear more\n discrete and a small lesion in the left centrum semiovale has decreased in\n size slightly. Otherwise, lesions are largely unchanged in the\n periventricular right frontal lobe, right greater than left medial temporal\n lobes, bilateral caudate heads, bilateral putamen, bilateral thalami, and\n bilateral corona radiata. Again faint enhancement is seen in many of these\n lesions. Many lesions demonstrate central regions of restricted diffusion.\n Susceptibility dropout is again noted in many of these lesions as well. The\n appearance of the ventricles and extra-axial CSF spaces is unchanged. The soft\n tissue and osseous structures are unremarkable. There is minimal mucosal\n thickening in some ethmoid air cells.\n\n IMPRESSION: Overall, little change to multiple lesions in the brain; findings\n again may be consistent with ADEM.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1013807,
"text": " 11:47 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pneumonia\n Admitting Diagnosis: HEMMORRHAGIC ENCEPHALOMYELITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with high-grade fever\n REASON FOR THIS EXAMINATION:\n ? pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:40 P.M., \n\n HISTORY: High fever.\n\n IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\n Heart size top normal. Mild pulmonary and mediastinal vascular congestion\n suggest mild cardiac decompensation or volume overload. No pleural effusion\n or pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2182-04-18 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1014590,
"text": " 8:34 PM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: r/o herpetic lesions; please schedule for \n Admitting Diagnosis: HEMMORRHAGIC ENCEPHALOMYELITIS\n Contrast: MAGNEVIST Amt: 14\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with encephalopathy\n REASON FOR THIS EXAMINATION:\n r/o herpetic lesions; please schedule for \n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Encephalopathy, rule out herpes.\n\n FINDINGS: Comparison is made with outside study .\n\n There has been mild progression of lesions along the lateral aspect of the\n right temporal as well as in the left putamen. Essentially stable\n hyperintensity is seen in the bilateral right greater than left medial\n temporal lobes, bilateral caudate heads,pons, bilateral thalami, right\n caudate, right putamen and bilateral corona radiata. A right frontal\n periventricular lesion is also enlarged slightly. No avid enhancement is seen\n in these lesions. There is faint enhancement in the right frontal\n periventricular lesion which has slightly increased in size. Right parietal\n corona radiata and the left parietal corona radiata lesions also demonstrate\n faint enhancement. Many of the lesions demonstrate central restricted\n diffusion. Susceptibility dropout is noted in many of these lesions. This\n can be seen with fungal and brain infections.\n\n\n The ventricles are unchanged in size.\n\n IMPRESSION:\n\n Mild interval progression of some lesions in the brain. Differential includes\n viral encephalitis, fungal infection. vasculitis, or ADEM. Given the acute\n symptoms, neoplasm is thought to be unlikely.\n\n"
}
] |
6,590 | 113,027 | The patient was taken to the catheterization laboratory shortly after arrival at . Please see the catheterization report for full details. In summary, the catheterization reported showed left main and three vessel disease with a left ventricular ejection fraction of 20% to 25%. Cardiothoracic surgery was consulted and the patient was accepted for coronary artery bypass grafting. On the morning of , the patient was brought to the Operating Room, at which time, he underwent coronary artery bypass grafting times four. Please see the Operating Room for full details. In summary, the patient had coronary artery bypass grafting times four with a left internal mammary artery to the left anterior descending artery, vein graft to the posterior descending artery and a vein graft to the obtuse marginal and diagonal sequentially. His bypass time was 99 minutes and crossclamp times was 83 minutes. The patient tolerated the procedure well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient's mean arterial pressure was 87 and central venous pressure 24. He was in a sinus rhythm of 100. He had propofol at 25 mcg/kg/minute, nitroglycerin at 0.5 mcg/kg/minute, Neo-Synephrine at 2.5 mcg/kg/minute and milrinone at 0.5 mcg/kg/minute. The patient was somewhat hypoxic in the immediate postoperative period. He was therefore kept sedated and ventilated throughout the course of his operative day. On the morning of postoperative day number one, the patient's sedation was discontinued, he was weaned from the ventilator and eventually extubated. He did well throughout the remainder of postoperative day number one until late in the afternoon, at which time he went into a rapid atrial fibrillation with a ventricular response rate of 80 to 140. He was begun at that time on an amiodarone drip. His rapid atrial rate was associated with some hypotension, which was controlled with his Neo-Synephrine drip. An initial attempt to wean the patient off his milrinone was unsuccessful and he was therefore returned to 0.5 mcg/kg/minute. On postoperative day number two, the patient was successfully weaned from his milrinone drip, however, he did remain on his Neo-Synephrine and amiodarone drips. Later in that day, the patient converted to a sinus rhythm and his amiodarone drip was converted to oral amiodarone. On postoperative day number four, the patient was off all vasoactive intravenous medications. He remained hemodynamically stable in sinus rhythm and he was transferred to Six for continuing postoperative care and cardiac rehabilitation. Once on the floor, the patient continued to progress slowly. His activity level was increased with the assistance of the nursing staff and physical therapy. His diet was advanced to a regular diet. On postoperative day number six, he was deemed stable and ready for transfer to rehabilitation for continuing cardiac rehabilitation following his coronary artery bypass grafting. | RECHECK ABG AFTER DIURESIS. MILRINONE WEANED OFF. BP STABLE- INITIALLY ON NTG, NOW OFF. AMIODORONE IV GTT OFF AND PO DOSING BEGUN. CHF with effusions. + GENERALIZED EDEMA.RESP: PT DENIES SOB. PLACED ON AGGRESTAT, HEPARIN AND NTG. WILL D/C CORDIS AND A-LINE. ABG PH 7.48 PC02 30 AND P02 64. CONT TO ENC C&DB. HCT 29 AFTER 1UPRBC. STABLE >2;SWAN D/C'D, CORDIS LEFT IN.RESP: PT STATES ABLE TO TAKE DEEPER BREATHS TODAY. ?WEAN MILIRONE AS WELL. LS CTA. OFF MILRINONE. EPICARDIAL WIRES: 2A/2V.RESP: INTUBATED. : CABGX3: LIMA->LAD, SVG->PDA, OM1 (DIAG SEQUENTIAL). WILL MONITOR AND TITRATE VENT AS TOL. ABG'S BORDERLINE. A-V conduction delay.P-R interval 0.23. P-R interval 0.23. The rate hasincreased. .PT GIVEN 1U PRBC'S FOR LOW BP'S, LOW URINE'S AND HCT 27.9. PT DIURESING AT THIS TIME AND MED WITH MS04 2MG X2 WITH NOTED BETTER SAT'S. LAST GLUC 148.A/P: VS MORE STABLE NOW THAT OUT OF AF; NO LONGER REQ SUPPORT OF PACER, NEO. WEAN O2 AS TOL. SPO2 MID 90'S.A: UNSTABLE AF NOW BETTER CONTROLLED AFTER MGSO4 AND AMIO BOLUS. PRESENTED TO OSH ON WITH CP. : ADEQ UO. MONITOR C.I. CA BOLUS GIVEN GI- NGT TO LCS, ABSENT BS. Post-op CABG. YET.G.U. MGSO4 IV BOLUS GIVEN AND AMIODORONE IV BOLUS AND DRIP STARTED. MD IN AM IN REGARDS TO FOLLOW CXR. +BS.G.U. RR AND SPO2 WNL. Prior inferiormyocardial infarction. +BS. +MI WITH PEAK CK 2532. PT W/ RESP ALKALOSIS BY ABG. PERCOCET FOR DISCOMFORT.G.I. CTX3. CTX3. A-V conduction delay. PT REMAINS ON AMIODARONE. EKG: NEW BBB. DP PULSES AUDIBLE BY DOPPLER, PT PULSES ABSENT BILAT. TELE: MP AFIB WITH V-RESPONSE 110-130'S. GLOBAL HK, MODERATE SYSTOLIC VENTRICULAR DYSFXN. BP STABLE, OFF ALL GTTS. LYTES DRAWN AND MAG. UPDATECV: REMAINS IN AF ON AMIODORONE GTT, HR 80'S-120. PT ARRIVED TO FLOOR ON MILRINONE, PROP, NTG. YESTERDAY'S CXR REPORTEDLY SL "WET". TRANSFERRED TO FOR CATH. PROGRESS AS TOL. TEAM AWARE- WILL RECHECK EKG THIS PM. There is new right bundle-branch block compared to theprevious tracing of and appearance of atrial ectopy. C.I. I.S. IMPRESSION: 1. IMPRESSION: Post CABG. HCT ONLY 27, TRANSFUSE WITH 1UPRBC SLOWLY. SBP 120-130 OFF NEO. Noprevious tracing available for comparison. ABLE TO MAE, FOLLOWS COMMANDS.CV: PT DENIES CP, PALP, SOB. FREQ QUESTIONS ANSWERED.A/P: REMAINS IN AF-REQUIRING INCREASED BP SUPPORT(NEO). LS CTA, DIMINISHED AT BASES. GU- U/O ADQUATE BUT SLOWING DOWN AS AM PROGRESSES. WILL REPEAT ABG THIS AM.CARDIOVAS; INITALLY IN AFIB 80-90'S AND PT ON AMIODARONE AT 0.5MG/MIN. PLAN ASSESS EFFECT OF SC MSO4, RECHECK HCT. Sinus rhythm. PT GIVEN PERCOCET FOR DISCOMFORT. Prior anteroseptal myocardial infarction. WEANING NEO, PLAN ? REC'G LOPRESSOR FOR RATE CONTROL. TRANSFER TO 6 CANCELLED AND PT GIVEN LOPRESSOR 2.5 MG IVP X1 WITH SBP DOWN TO 90'S TRANSIENTLY. MIN DRNG.GI: OG TUBE INTACT. Rule out active lateral ischemic process. DP/PT PULSES AUDIBLE BY DOPPLER BILAT. ADD O2. HR 70'S, SBP 110. DIURESING WELL AFTER LASIX.ENDO: INSULIN GTT OFF. CSRU NURSING NOTE:80YO PT WITH CHRONIC STABLE ANGINA. CT'S AND R FEM A&V SHEATHS D/C'D IN A.M. BY DR . PA PRESSURES STABLE. PT SL UNSTEADY ON FEET, NEEDS P.T.PT INSTRUCTED ON PLAN OF CARE, MEDICATIONS, AFIB, AND POST-OP COURSE. Chest tube removal. DR NOTIFIED AND IN TO SEE PT. FEM SITE C&D, DISTAL PULSES INTACT. EPICARDIAL WIRES- 2A/2V. There is perihilar haziness bilaterally compatible with CHF but improved from . PORTABLE AP CHEST: The patient is post CABG. PT ON COLACE .GU; URINE OP WNL.PLAN; TRANSFER TO 6 TODAY IF REMAINS STABLE Clinical correlation is suggested.TRACING #1 Lines and tubes as above. CATH : SHOWED 3V CAD LMAIN AND RCA. PUPILS: RT REACTIVE, 2MM, LT 3MM- NONREACTIVE (S/P LENS IMPLANT).CV: TELE: ST- HR 110-120. LUNGS DIMINISHED @ BASES. PERCOCET W/ MILD RELIEF. NOTED AT 830AM PT WENT BACK INTO AFIB 90-120'S. PATIENT WITH SLIGHTLY IMPROVING ABG, PLAN TO SLOWLY WEAN DOWN FIO2, KEEP AT 7.5PEEP. +FLATUS, NO B.M. INITALLY AT SHIFT CHANGE PT IN 1 DEGREE AVB RATE OF 70-80'S. TRANSFERABG IMPROVED AFTER GD DIURESIS FROM LASIX. ALT CARDIAC RHYTHMAT APPROX 1315 HR CHANGED FROM 1ST DEG AVB TO A FIB W/ UNSTABLE RATE OF 80-140 AND CORRESPONDING HYPOTENSION TO SBP 80'S(ALREADY ON NEO @ 1.75 MCG/KG/MIN). Improving CHF 3. UPDATECV: A-PACED MOST OF SHIFT W/ UNDERLYING 1ST DEG AVB IN 60'S, NO ECTOPY. INSTRUCTED. COMPARISONS: PORTABLE AP CHEST: The ET tube, NG tube and left chest tubes have been removed. BS ABSENT. DRAINING LG AMTS CLEAR URINE.INC: INCIS TO STERNUM, RT LE WITH DSD, NO DRNG NOTED.PLAN: ?WEAN AS TOL. ST segment depression in leads I, II and aVL with ST segmentdepression in leads V5-V6. ?? CSRU NURSING NOTE:NEURO: PT ALERT AND ORIENTED. PERCOCET W/ ONLY MILD RELIEF. NOW 92% AFTER TURNING TO L SIDE.NEURO/COMFORT: A&O. TITRATE NEO AS ORDERED, PRESENTLY ON 1.5 MCG/KG/MIN. REMAINS ON MILRINONE WITH CO/CI STABLE. ABD SOFT. NO BM.GU: FOLEY INTACT. MSO4 SC GIVEN THIS EVE. PT REMAINED IN AFIB OVER NOC CONTROLLED VENT. ? ? 2. : TAKING SIPS H2O AND PO MEDS W/O DIFFICULTY. DISCOMFORT LESSENED BY PERCOCET.P: CONT TO MONITOR HR AND SPO2 CLOSELY AND TITRATE NEO AS NEEDED TO KEEP MAP>60. CONVERTED TO NSR 60'S WITH DROP IN CI TO 1.88 WITH SLOWER RATE SO PT AT 86 WITH CI 2.16 THIS AM.GI; TAKING AND TOLERATING PO'S WITH NO C/O NAUSEA. BS 118 INSULIN AT 1U/HR. LAVAGED WITH 10CCNS, SUNCTIONED FOR MODERATE BLOODY SECRETIONS. PT PASSING FLATUS, NO BM. 7P-7A; NURSING SHIFT SUMMARY;NEURO; UNREMARKABLE.CARDIOVAS; ALINE DC'D AT SHIFT CHANGE AND PT TO BE TRANSFERED TO 6 AT APPROX. C&R THICK, OLD BLOODY SPUTUM X 1. CONT TO NEED LASIX (OR DIAMOX) AS WGT STILL 8 KG >PRE-OP. 6 NOTIFIED. Low limb leadvoltage. USING IS WITH ENCOURAGEMENT.GI: ABD SOFT, NONTENDER. 7P-7A; SHIFT SUMMARY;NEURO; ALERT AND ORIENTED FOLLOWING COMMANDS AND MAE'S WELL.RESP; LUNGS CLEAR BUT SHALLOW BREATHING AT TIMES PT C/O PAIN WITH DEEP BREATHS. | 16 | [
{
"category": "Nursing/other",
"chartdate": "2175-12-23 00:00:00.000",
"description": "Report",
"row_id": 1349073,
"text": "ALT CARDIAC RHYTHM\nAT APPROX 1315 HR CHANGED FROM 1ST DEG AVB TO A FIB W/ UNSTABLE RATE OF 80-140 AND CORRESPONDING HYPOTENSION TO SBP 80'S(ALREADY ON NEO @ 1.75 MCG/KG/MIN). PT ALSO NOTED MORE CHEST DISCOMFORT.\n DR NOTIFIED BY PHONE. MGSO4 IV BOLUS GIVEN AND AMIODORONE IV BOLUS AND DRIP STARTED. NEO INCREASED TO 2.3 MCG/KG/MIN. O2 UP TO 5LNC FOR OXYGENATION SUPPORT. PT GIVEN PERCOCET FOR DISCOMFORT.\n AF RATE MORE CONTROLLED @ 80-120 RANGE AND SBP INITIALLY IMPROVED TO 110 RANGE BUT NOW BACK TO 90. PERCOCET W/ MILD RELIEF. SPO2 MID 90'S.\nA: UNSTABLE AF NOW BETTER CONTROLLED AFTER MGSO4 AND AMIO BOLUS. DISCOMFORT LESSENED BY PERCOCET.\nP: CONT TO MONITOR HR AND SPO2 CLOSELY AND TITRATE NEO AS NEEDED TO KEEP MAP>60.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-12-23 00:00:00.000",
"description": "Report",
"row_id": 1349074,
"text": "UPDATE\nCV: REMAINS IN AF ON AMIODORONE GTT, HR 80'S-120. UNABLE TO WEAN NEO<2 MCG/KG/MIN IN ORDER TO KEEP MAP>60. CT'S AND R FEM A&V SHEATHS D/C'D IN A.M. BY DR . FEM SITE C&D, DISTAL PULSES INTACT. MILRINONE WEANED OFF. C.I.>2.\n\nRESP: LUNGS CLEAR BUT PT HAS AUDIBLE UPPER RESP PHLEGM WHICH HE IS HAVING DIFFICULTY RAISING. I.S. INSTRUCTED. O2 INCREASED TO 5L NC WHEN AF STARTED TO KEEP SPO2 IN MID 90'S. NOW 92% AFTER TURNING TO L SIDE.\n\nNEURO/COMFORT: A&O. C/O CHEST INCISIONAL PAIN, DIFFICULTY TAKING DEEP BREATHS. PERCOCET W/ ONLY MILD RELIEF. MSO4 SC GIVEN THIS EVE. PT NOW SLEEPING.\n\nG.I.: TAKING SIPS H2O AND PO MEDS W/O DIFFICULTY. +BS.\n\nG.U.: LASIX THIS A.M. FOR LOW UO->GD DIURESIS AND ADEQ UO MOST OF SHIFT; NOW DROPPING AGAIN TO ~20ML/HR.\n\nSOCIAL: GRANDCHILDREN VISITING MOST OF DAY. FREQ QUESTIONS ANSWERED.\n\nA/P: REMAINS IN AF-REQUIRING INCREASED BP SUPPORT(NEO). PAIN NOT YET ADEQ CONTROLLED. PLAN ASSESS EFFECT OF SC MSO4, RECHECK HCT. CONT TO ENC C&DB. ADD O2. MONITOR C.I. OFF MILRINONE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-12-24 00:00:00.000",
"description": "Report",
"row_id": 1349075,
"text": " 7P-7A; SHIFT SUMMARY;\n\nNEURO; ALERT AND ORIENTED FOLLOWING COMMANDS AND MAE'S WELL.\n\nRESP; LUNGS CLEAR BUT SHALLOW BREATHING AT TIMES PT C/O PAIN WITH DEEP BREATHS. SAT'S MARGINAL AT 92/94% ON 5LN/C AND PT NOTED TO MOUTH BREATHE WHEN ASLEEP.PT PLACED ON OFM 35% BUT PT REFUSED TO WEAR AFTER AWHILE SO PT ON 5LNC AT THIS TIME. ABG PH 7.48 PC02 30 AND P02 64. PT DIURESING AT THIS TIME AND MED WITH MS04 2MG X2 WITH NOTED BETTER SAT'S. WILL REPEAT ABG THIS AM.\n\nCARDIOVAS; INITALLY IN AFIB 80-90'S AND PT ON AMIODARONE AT 0.5MG/MIN. .PT GIVEN 1U PRBC'S FOR LOW BP'S, LOW URINE'S AND HCT 27.9. BP REQUIRING NEO AT 2.5 MCG/KG/MIN INITALLY AND NOW DOWN TO 1.25 THIS AM WITH BEING AND AFTER BLOOD. CONVERTED TO NSR 60'S WITH DROP IN CI TO 1.88 WITH SLOWER RATE SO PT AT 86 WITH CI 2.16 THIS AM.\n\nGI; TAKING AND TOLERATING PO'S WITH NO C/O NAUSEA. NO BM THIS SHIFT BS PRESENT AND PT ON COLACE PO BID.\n\nGU; URINE OP 16-20CC SEVERAL HOURS AND DR AWARE AND PT GIVEN LASIX 10 MG IVP AFTER UNIT OF BLOOD WITH URINE OP WNL.\n\nCOMFORT; PT ON TORADOL 15MG IVP Q6 AND PT ALSO GIVEN MSO4 2MG IVP FOR PAIN X2 WITH INSPIRATION IN HOPES TO DECREASE PAIN AND INCREASE OXYGENATION.\n\nENDO; BLD SUGARS LOW 100'S ON 1U INSULIN GTT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-12-22 00:00:00.000",
"description": "Report",
"row_id": 1349069,
"text": "CSRU NURSING NOTE:\n\n80YO PT WITH CHRONIC STABLE ANGINA. PRESENTED TO OSH ON WITH CP. PLACED ON AGGRESTAT, HEPARIN AND NTG. +MI WITH PEAK CK 2532. TRANSFERRED TO FOR CATH. CATH : SHOWED 3V CAD LMAIN AND RCA. GLOBAL HK, MODERATE SYSTOLIC VENTRICULAR DYSFXN. TAKEN IMMEDIATELY TO OR.\n\nPMHX: MI ()\n STABLE ANGINA\n ETT () STOPPED AFTER 2 MIN FOR CP- CONSERVATIVELY MANAGED\n AFIB ()\n CVA ()\n OA\n BPH\n GLAUCOMA\n LEFT LENS IMPLANT\n\nALLG: NKDA\n\nMEDS AT HOME: LOPRESSOR (25MG ), DIGOXIN (0.25MG QD), TYLENOL (650MG ), RELAFEN, GLAUCOMA GTTS.\n\n: CABGX3: LIMA->LAD, SVG->PDA, OM1 (DIAG SEQUENTIAL). EF ONLY 30%, STARTED ON DOBUTAMINE INTRA-OP ->TACHY-ARRHYTHMIAS, SWITCHED TO MILRINONE. PT ARRIVED TO FLOOR ON MILRINONE, PROP, NTG. HAD EPISODE OF HYPOXEMIA INTRA-OP, REC'D 10MG LASIX. CTX3. EPICARDIAL WIRES- 2A/2V. FEM ART AND SHEATHS INTACT. NO HEMATOMA/BLEEDING.\n\nNEURO: PT SEDATED ON PROPOFOL. PUPILS: RT REACTIVE, 2MM, LT 3MM- NONREACTIVE (S/P LENS IMPLANT).\n\nCV: TELE: ST- HR 110-120. EKG: NEW BBB. TEAM AWARE- WILL RECHECK EKG THIS PM. BP STABLE- INITIALLY ON NTG, NOW OFF. REMAINS ON MILRINONE WITH CO/CI STABLE. PA PRESSURES STABLE. DP PULSES AUDIBLE BY DOPPLER, PT PULSES ABSENT BILAT. EPICARDIAL WIRES: 2A/2V.\n\nRESP: INTUBATED. ABG'S BORDERLINE. WILL MONITOR AND TITRATE VENT AS TOL. LS CTA. CTX3. MIN DRNG.\n\nGI: OG TUBE INTACT. ABD SOFT. BS ABSENT. NO BM.\n\nGU: FOLEY INTACT. DRAINING LG AMTS CLEAR URINE.\n\nINC: INCIS TO STERNUM, RT LE WITH DSD, NO DRNG NOTED.\n\nPLAN: ?WEAN AS TOL. MONITOR EKG, BP, CO/CI, LABS. PROGRESS AS TOL.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-12-22 00:00:00.000",
"description": "Report",
"row_id": 1349070,
"text": "PATIENT WITH SLIGHTLY IMPROVING ABG, PLAN TO SLOWLY WEAN DOWN FIO2, KEEP AT 7.5PEEP. LAVAGED WITH 10CCNS, SUNCTIONED FOR MODERATE BLOODY SECRETIONS. HCT ONLY 27, TRANSFUSE WITH 1UPRBC SLOWLY. TITRATE NEO AS ORDERED, PRESENTLY ON 1.5 MCG/KG/MIN. GIVING 2GMS CALCIUM GLUCONATE/2GMS MAGSO4 AS WELL. LOPRESSOR UP TO 5MG IV TO BE GIVEN Q4HRS/PRN TO HR LESS THAN , 1MG IV GIVEN HR FROM 107 DOWN TO 95.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-12-23 00:00:00.000",
"description": "Report",
"row_id": 1349071,
"text": "PATIENT WITH FAIRLY UNEVENTFUL NIGHT. CV SR IN THE 90'S WITH RARE PVC, NOTED ONLY GIVEN 1MG LOPRESSOR IV THRU THE NIGHT. HCT 29 AFTER 1UPRBC. REMAINS ON NEO AT 2.5 TO KEEP SBP IN THE L; 100'S, WILL ATTEMPT TO WEAN NEO AS PATIENT WAKES UP MORE. RESP- WEANING FROM VENT, ON WITH 5PEEP WITH SAO2 97% WITH RR15-20, WILL CHECK NIF/ABG SOON. ??? MD IN AM IN REGARDS TO FOLLOW CXR. GU- U/O ADQUATE BUT SLOWING DOWN AS AM PROGRESSES. GI- NGT TO LCS, ABSENT BS. ENDOCRINE- ON INSULIN DRIP AT 3U/HR WITH GOOD CONTROL BS IN THE 130'S. PAIN TREATED WITH TORADOL BOLUS AT 2AM, ALONG WITH 2MG IV. PROPOFOL OFF SINCE 3AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-12-23 00:00:00.000",
"description": "Report",
"row_id": 1349072,
"text": "PATIENT EXTUBATED THIS AM, TO 70%SHOVEL MASK WITH GOOD SAO2 POST 96%, RR18-22, SEDATED WITH 2MG MSO4 IV FOR STERNAL DISCOMFORT, REPOSITIONED IN BED. BS 118 INSULIN AT 1U/HR. WEANING NEO, PLAN ???WEAN MILIRONE AS WELL. CA BOLUS GIVEN\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-12-25 00:00:00.000",
"description": "Report",
"row_id": 1349079,
"text": "CSRU NURSING NOTE:\n\nNEURO: PT ALERT AND ORIENTED. ABLE TO MAE, FOLLOWS COMMANDS.\n\nCV: PT DENIES CP, PALP, SOB. TELE: MP AFIB WITH V-RESPONSE 110-130'S. NO ECTOPY NOTED. PT REMAINS ON AMIODARONE. REC'G LOPRESSOR FOR RATE CONTROL. BP STABLE, OFF ALL GTTS. EPICARDIAL WIRES INTACT- 2A/2V. UNABLE TO A PACE SECONDARY TO AFIB, AND HAVING DIFFICULTY LAST PM GETTING V-SENSE AND CAPTURE. UNABLE TO ASSESS THIS AM SECONDARY TO TACHYCARDIA. DP/PT PULSES AUDIBLE BY DOPPLER BILAT. + GENERALIZED EDEMA.\n\nRESP: PT DENIES SOB. LS CTA, DIMINISHED AT BASES. STRONG COUGH, PRODUCING SPUTUM AT TIMES. USING IS WITH ENCOURAGEMENT.\n\nGI: ABD SOFT, NONTENDER. +BS. PT PASSING FLATUS, NO BM. PT WITHOUT DIFFICULTY.\n\nGU: FOLEY INTACT. RESPONDING WELL TO LASIX.\n\nPAIN: PT PERCOCET WITH GOOD RELIEF.\n\nINTEG: INC TO STERNUM AND LE INTACT WITH DSD. NO DRNG NOTED.\n\nACTIVITY: PT OOB TO CHAIR WITH 2 ASSIST. PT SL UNSTEADY ON FEET, NEEDS P.T.\n\nPT INSTRUCTED ON PLAN OF CARE, MEDICATIONS, AFIB, AND POST-OP COURSE. PT VERBALIZES UNDERSTANDING AND IN AGREEMENT.\n\nPLAN: TX TO 6, MONTOR AFIB, CONTROL RATE, INCREASE ACTIVITY AS .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-12-25 00:00:00.000",
"description": "Report",
"row_id": 1349080,
"text": "NURSING ADDENDUM:\n\nV-WIRES WITHOUT SENSE OR CAPTURE. STILL IN AFIB, UNABLE TO ASSESS ATRIAL WIRES.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-12-24 00:00:00.000",
"description": "Report",
"row_id": 1349076,
"text": "UPDATE\nCV: A-PACED MOST OF SHIFT W/ UNDERLYING 1ST DEG AVB IN 60'S, NO ECTOPY. NOW OWN RATE UP TO 80 SO PACER PLACED TO A DEMAND. SBP 120-130 OFF NEO. AMIODORONE IV GTT OFF AND PO DOSING BEGUN. C.I. STABLE >2;SWAN D/C'D, CORDIS LEFT IN.\n\nRESP: PT STATES ABLE TO TAKE DEEPER BREATHS TODAY. PT W/ RESP ALKALOSIS BY ABG. LUNGS DIMINISHED @ BASES. C&R THICK, OLD BLOODY SPUTUM X 1. SPO2 99% ON 5L NC AND .40 FT. PT NOT REQUIRING FT WHILE UP IN CHAIR. YESTERDAY'S CXR REPORTEDLY SL \"WET\". LASIX 20 MG GIVEN THIS EVE.\n\nACTIVITY/COMFORT: OOB TO CHAIR X 2 HRS W/ ASSIST OF 2. TIRES QUICKLY AFTER ACTIVITY. PERCOCET FOR DISCOMFORT.\n\nG.I.: EATING SM MEALS. +FLATUS, NO B.M. YET.\n\nG.U.: ADEQ UO. DIURESING WELL AFTER LASIX.\n\nENDO: INSULIN GTT OFF. LAST GLUC 148.\n\nA/P: VS MORE STABLE NOW THAT OUT OF AF; NO LONGER REQ SUPPORT OF PACER, NEO. CONT TO NEED LASIX (OR DIAMOX) AS WGT STILL 8 KG >PRE-OP. RECHECK ABG AFTER DIURESIS. WEAN O2 AS TOL. TRANSFER TO FLOOR LIKELY TOMORROW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-12-24 00:00:00.000",
"description": "Report",
"row_id": 1349077,
"text": "TRANSFER\nABG IMPROVED AFTER GD DIURESIS FROM LASIX. RR AND SPO2 WNL. CURRENTLY PT NAPPING. HR 70'S, SBP 110. PT TO TRANSFER TO FLOOR THIS EVE PER DR. . 6 NOTIFIED. WILL D/C CORDIS AND A-LINE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2175-12-25 00:00:00.000",
"description": "Report",
"row_id": 1349078,
"text": " 7P-7A; NURSING SHIFT SUMMARY;\n\nNEURO; UNREMARKABLE.\n\nCARDIOVAS; ALINE DC'D AT SHIFT CHANGE AND PT TO BE TRANSFERED TO 6 AT APPROX. 8PM. NOTED AT 830AM PT WENT BACK INTO AFIB 90-120'S. INITALLY AT SHIFT CHANGE PT IN 1 DEGREE AVB RATE OF 70-80'S. DR NOTIFIED AND IN TO SEE PT. TRANSFER TO 6 CANCELLED AND PT GIVEN LOPRESSOR 2.5 MG IVP X1 WITH SBP DOWN TO 90'S TRANSIENTLY. PT REMAINED IN AFIB OVER NOC CONTROLLED VENT. RATE 80-100 WITH MAP70'S ALL NOC. PACER OFF WITH AFIB UNABLE TO PLACE IN DEMAND D/T FAILURE TO SENSE PROPERLY. LYTES DRAWN AND MAG. AND POTASSIUM REPLETED.\n\nGI; TAKING PO'S WITH C/O'S NAUSEA X1 NO EMESIS AND MED WITH REGLAN 10MG IV PER ORDERS WITH GOOD EFFECT. BS PRESENT DID REQUEST BEDPAN X1 WITH NO BM BUT PASSING FLATUS. PT ON COLACE .\n\nGU; URINE OP WNL.\n\nPLAN; TRANSFER TO 6 TODAY IF REMAINS STABLE\n"
},
{
"category": "ECG",
"chartdate": "2175-12-22 00:00:00.000",
"description": "Report",
"row_id": 154170,
"text": "Sinus tachycardia, rate 120, with frequent atrial ectopy. A-V conduction delay.\nP-R interval 0.23. There is new right bundle-branch block compared to the\nprevious tracing of and appearance of atrial ectopy. The rate has\nincreased. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2175-12-21 00:00:00.000",
"description": "Report",
"row_id": 154171,
"text": "Sinus rhythm. A-V conduction delay. P-R interval 0.23. Prior inferior\nmyocardial infarction. Prior anteroseptal myocardial infarction. Low limb lead\nvoltage. ST segment depression in leads I, II and aVL with ST segment\ndepression in leads V5-V6. Rule out active lateral ischemic process. No\nprevious tracing available for comparison. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-12-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 750269,
"text": " 7:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pAo2 IS lower than expected on FiO2 of 100%, periop s/p CABG\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with\n REASON FOR THIS EXAMINATION:\n pAo2 IS lower than expected on FiO2 of 100%\n periop s/p CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PA02 lower than expected. Post-op CABG.\n\n PORTABLE AP CHEST: The patient is post CABG. The ET tube is well positioned in\n the mid trachea. The NG tube courses below the diaphragm and appears to coil\n within the fundus with tip in the stomach. There are two left sided chest\n tubes. There is a right Swan-Ganz catheter with tip in the main pulmonary\n artery. There are diffuse interstitial and alveolar opacities in the lungs\n compatible with CHF. There are also bilateral pleural effusions.\n\n IMPRESSION: Post CABG. Lines and tubes as above. CHF with effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2175-12-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 750295,
"text": " 10:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ct removal\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p cab\n REASON FOR THIS EXAMINATION:\n ct removal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post CABG. Chest tube removal.\n\n COMPARISONS: \n\n PORTABLE AP CHEST: The ET tube, NG tube and left chest tubes have been\n removed. There is a right swan ganz catheter with tip in main pulmonary\n artery. There is perihilar haziness bilaterally compatible with CHF but\n improved from . There is increased retrocardiac density, most likely\n left lower lobe atelectasis, not significantly changed. No pneumothorax.\n\n IMPRESSION:\n 1. No pneumothorax.\n 2. Improving CHF\n 3. Left lower lobe atelectasis, not significantly changed.\n\n"
}
] |
26,724 | 135,445 | 80 y/o male with parkinsonism, autonomic instability, who was admitted to CCU following PEA arrest, likely secondary to aspiration, now s/p Arctic sun protocol, re-warmed and off sedation, with anoxic brain injury and worsening cerebral edema on CT scan, with flat lining EEG, no brainstem reflexes, and no spontaneous breathing. . # s/p PEA arrest: unlikely to be from primary cardiac etiology, at this time most like due to hypoxia from possible aspiration event given that main laboratory abnormality is hypoxia and also with new bilateral infiltrate. No evidence of pericardial effusion on echo, no evidence of pneumothorax. No evidence of acute MI on admission. He did have a lactic acidosis, likely prolonged pea arrest in the field. He was in sinus tachycardia with occasional 2nd degree heart block type I on telemetry since admission. He was bolused with amiodarone and lidocaine in the field and started on an amiodarone gtt by EMS. In the CCU, pt went into PEA arrest again. CPR was performed, epi x 1 and atropine x 1 given, with cardiac function returning within 3-5 minutes. CT scan showed diffuse anoxic brain injury with poor prognosis (flat EEG, CT head showing worsening cerebral edema, physical exam without brainstem reflexes). Pt completed Arctic sun cooling, then warming protocol. His sedation was weaned when re-warmed. Neuro evaluated the patient, and noted absence of brainstem reflexes, fixed dilated pupils, and no response to cold caloric testing. Pt was made DNR/DNI. Amiodarone gtt was discontinued as PEA arrest felt to be very unlikely to be primary cardiac. Apnea test, combined with neuro eval, confirmed brain death and patient was pronounced dead at 4:23 pm on . Family at bedside, declined autopsy. Organ bank felt that pt is not a candidate for organ donation. . #Hypoxia - Most likely etiology of PEA arrest, with significant AA gradient. Unclear etiology at this time, possibly aspiration event given LLL opacity and air bronchograms on CXR. Pulmonary embolus was a consideration; however no evidence of right heart strain on echocardiogram or PE on CTA. Initially started on vancomycin and zosyn for aspiration pneumonia, but discontinued when family transitioned patient to CMO status. . #Anoxic Brain Injury - head ct on admission with evidence of global anoxic injury likely prolonged PEA arrest of unknown duration. Pt completed cooling protocol, then rewarmed, with unchanged exam. He was taken off fentanyl/versed with no brainstem reflexes and poor prognosis, as per neuro. 72 hour EEG showed no waveform. . # Hypotesion/Autonomic Instability - long h/o labile BP and severe orthostasis. He is on numerous doses of midodrine at baseline as well as salt tabs. Per his family it is not unusual for him to have blood pressure in the 80's - 90's systolic then up to the 160's in the evening. Anoxic injury likely contributing to labile BP. . # Dispo: patient declared brain dead at 4:23 pm on . Extubated soon thereafter. Family at bedside, declined autopsy. Patient did not qualify for organ donation. | Pt w/probable prolong hypoxic period - called emts - found in PEA - resuscitated -to OSH then.transferred to for further management. -d/c amiodarone gtt as PEA arrest seems very unlikely to be primary cardiac -monitor on telemetry -on artic sun cooling protocol x18 hours, monitor coagulation profile -blood, sputum, urine cultures pending . -d/c amiodarone gtt as PEA arrest seems very unlikely to be primary cardiac -monitor on telemetry -on artic sun cooling protocol x18 hours, monitor coagulation profile -blood, sputum, urine cultures pending . PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 70Weight (lb): 160BSA (m2): 1.90 m2BP (mm Hg): 130/91HR (bpm): 70Status: InpatientDate/Time: at 07:35Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Hyperdynamic LVEF >75%. #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate trending down now that HD stable. #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate trending down now that HD stable. #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate trending down now that HD stable. #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate trending down now that HD stable. #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate trending down now that HD stable. Hypotension (not Shock) Assessment: of note he has autonomic dysfunction and require midodrine and salt to maintain bp. check lytes Hypoxemia Assessment: presented hypoxemic-intubated & vented. -monitor serial lactates, trending down and now normal . Reviewed overnight course., Pt.No neurologic signs of life Agree with Dr.s note. Told that pts EEG is flat lining. Foley X ~2ys with h/o klebsiella UTI, and Pseudomonas UTI resistant to cipro. Foley X ~2ys with h/o klebsiella UTI, and Pseudomonas UTI resistant to cipro. Bair hugger applied for hypothermia. Bair hugger applied for hypothermia. Bair hugger applied for hypothermia. Action: repeat head ct. sedation-fentanyl & versed dced. criticade clear was applied to coccyx. # FEN: NPO for now, NGT in place, replete lytes prn . foley X ~2yrs with h/o klebsiella and pseudomonas uti-resistant to cipro. Unclear etiology at this time, possibly aspiration event given LLL opacity and air bronchograms on CXR. Unclear etiology at this time, possibly aspiration event given LLL opacity and air bronchograms on CXR. -monitor serial lactates, trending down, currently 2.2 . Hypothyroidism, GERD. Hypothyroidism, GERD. For EMS pulseless/apneic in PEA, given epi/atropine, then developed VF, defibrillated x 4 with ROSC. For EMS pulseless/apneic in PEA, given epi/atropine, then developed VF, defibrillated x 4 with ROSC. -monitor serial lactates, trending down and now normal . -monitor serial lactates, trending down and now normal . -monitor serial lactates, trending down and now normal . -monitor serial lactates, trending down and now normal . -monitor serial lactates, trending down and now normal . -monitor serial lactates, trending down and now normal . -monitor serial lactates, trending down and now normal . Pt w/probable prolong hypoxic period - called emts - found in PEA - resuscitated -to OSH then.transferred to for further management. Midodrine given as ordered Response: Remains w/ extremely labile BPs w/o any changes in Dopa. Of note he has autonomic dysfunction and require midodrine and salt to maintain BP. Of note he has autonomic dysfunction and require midodrine and salt to maintain BP. Of note he has autonomic dysfunction and require midodrine and salt to maintain BP. Unclear etiology at this time, possibly aspiration event given LLL opacity and air bronchograms on CXR. Unclear etiology at this time, possibly aspiration event given LLL opacity and air bronchograms on CXR. Unclear etiology at this time, possibly aspiration event given LLL opacity and air bronchograms on CXR. Unclear etiology at this time, possibly aspiration event given LLL opacity and air bronchograms on CXR. Compared to previoustracing of sinus tachycardia is no longer present.TRACING #1 Unclear etiology at this time, possibly aspiration event given LLL opacity and air bronchograms on CXR. Unclear etiology at this time, possibly aspiration event given LLL opacity and air bronchograms on CXR. Unclear etiology at this time, possibly aspiration event given LLL opacity and air bronchograms on CXR. Pt w/probable prolong hypoxic period - called emts - found in PEA - resuscitated -to OSH then.transferred to for further management. -Head CT concerning for smaller ventricular size, ?worsening cerebral edema, no obvious herniation . -Head CT concerning for smaller ventricular size, ?worsening cerebral edema, no obvious herniation . -Head CT concerning for smaller ventricular size, ?worsening cerebral edema, no obvious herniation . Again noted is hypodensity within the region of the bilateral basal ganglia and thalami. Told that pts EEG is flat lining. Told that pts EEG is flat lining. Again noted is opacification of the left maxillary and left ethmoid sinuses, likely secondary to intubation. Cardiac silhouette is upper limits of normal in size with left ventricular configuration, and the aorta remains tortuous. Cont antibx as ordered, awaiting Zosyn approval by ID Impaired Skin Integrity Assessment: coccyx area thinned & darkened; blanching skin remains intact ; area of ? | 76 | [
{
"category": "Physician ",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384506,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:39 AM\n NASAL SWAB - At 10:30 AM\n BLOOD CULTURED - At 12:27 PM\n URINE CULTURE - At 12:30 PM\n ARTERIAL LINE - START 01:02 PM\n SPUTUM CULTURE - At 02:15 PM\n BLOOD CULTURED - At 02:20 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 11:30 PM\n Vancomycin - 12:10 AM\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 66 (61 - 107) bpm\n BP: 92/63(74) {88/61(71) - 150/95(117)} mmHg\n RR: 16 (0 - 28) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,606 mL\n 590 mL\n PO:\n TF:\n IVF:\n 1,486 mL\n 590 mL\n Blood products:\n Total out:\n 778 mL\n 800 mL\n Urine:\n 778 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,828 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%, Vent Dependant\n PIP: 31 cmH2O\n Plateau: 27 cmH2O\n SpO2: 100%\n ABG: 7.41/42/179/26/2\n Ve: 8.4 L/min\n PaO2 / FiO2: 298\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 109 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n Glucose\n 132\n 109\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 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": "2177-09-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384510,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:39 AM\n NASAL SWAB - At 10:30 AM\n BLOOD CULTURED - At 12:27 PM\n URINE CULTURE - At 12:30 PM\n ARTERIAL LINE - START 01:02 PM\n SPUTUM CULTURE - At 02:15 PM\n BLOOD CULTURED - At 02:20 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 11:30 PM\n Vancomycin - 12:10 AM\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 66 (61 - 107) bpm\n BP: 92/63(74) {88/61(71) - 150/95(117)} mmHg\n RR: 16 (0 - 28) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,606 mL\n 590 mL\n PO:\n TF:\n IVF:\n 1,486 mL\n 590 mL\n Blood products:\n Total out:\n 778 mL\n 800 mL\n Urine:\n 778 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,828 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%, Vent Dependant\n PIP: 31 cmH2O\n Plateau: 27 cmH2O\n SpO2: 100%\n ABG: 7.41/42/179/26/2\n Ve: 8.4 L/min\n PaO2 / FiO2: 298\n Physical Examination\n VS: T=34 celsius on artic sun BP=107/81 HR= 150 regular RR=18 O2 sat=\n 98% AC 100%/550/16/5\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, unable to ausculate lung bases as artic sun\n cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 109 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n Glucose\n 132\n 109\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 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": "Echo",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Report",
"row_id": 69115,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 70\nWeight (lb): 160\nBSA (m2): 1.90 m2\nBP (mm Hg): 130/91\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 07:35\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Hyperdynamic LVEF >75%. Abnormal systolic flow contour at\nrest, but no LVOT obstruction.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Emergency study performed by the cardiology fellow on call.\n\nConclusions:\nLeft ventricular systolic function is hyperdynamic (EF>75%). There is an\nabnormal systolic flow signal at rest, but left ventricular outflow\nobstruction was not assessed during this study. Right ventricular chamber size\nand free wall motion are normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion. No aortic regurgitation is\nseen. The mitral valve leaflets are structurally normal. No mitral\nregurgitation is seen. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Hyperdynamic LV function without evidence of wall motion\nabnormality. There is an abnormal systolic Doppler color signal seen in the\nLVOT during systole, likely due to hyperdynamic function although LVOT\nobstruction is not excluded on the basis of this study. No pathologic valvular\nabnormality seen.\n\nCompared with the prior study (images reviewed) of , LV function is\nmore hyperdynamic and the patient is more tachycardic.\n\n\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384601,
"text": "80 y/o M w/ parkinsons, dysautonomia , PEA arrested at home. Artic sun\n cooling protocol initiated. PEA arrested evening . Re-warmed 11:00\n .\n Repeat Head CT showing evidence of severe global cortical edema.\n Family meeting yesterday\n aware of grave condition and grim prognosis\n Hypotension (not Shock)\n Assessment:\n SBPs ranging from 50-205.\n Action:\n Dopa maintained to keep MAPs >60\n Response:\n Remains w/ extremely labile BPs, especially w/ turning difficult to\n wean Dopa\n Plan:\n Wean Dopa as tolerated\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Unresponsive to all stim, no corneals, no cough/gag. Not overbreathing\n vent. Remains off sedation since yesterday. Temp down to 35.1 R.\n Action:\n Neuro checks to assess for any change, continuous EEG in place. Bair\n hugger applied for hypothermia.\n Response:\n NO change, remains unresponsive. Brain waves flat per neurology.\n Normothermic.\n Plan:\n Continue supportive care. Family mtg today with neuro and CCU team\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384602,
"text": "80 y/o M w/ parkinsons, dysautonomia, PEA arrested at home. Artic sun\n cooling protocol initiated. PEA arrested evening . Re-warmed 11:00\n .\n Repeat Head CT showing evidence of severe global cortical edema.\n Family meeting yesterday\n aware of grave condition and grim prognosis\n Hypotension (not Shock)\n Assessment:\n SBPs ranging from 50-205.\n Action:\n Dopa maintained to keep MAPs >60\n Response:\n Remains w/ extremely labile BPs, especially w/ turning difficult to\n wean Dopa\n Plan:\n Wean Dopa as tolerated\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Unresponsive to all stim, no corneals, no cough/gag. Not overbreathing\n vent. Remains off sedation since yesterday. Temp down to 35.1 R.\n Action:\n Neuro checks to assess for any change, continuous EEG in place. Bair\n hugger applied for hypothermia.\n Response:\n NO change, remains unresponsive. Brain waves flat per neurology.\n Normothermic.\n Plan:\n Continue supportive care. Family mtg today with neuro and CCU team\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384682,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt remains intubated, on vent, since family awaiting other members to\n arrive before making final decision re: transition to CMO.\n - neuro evaluated patient and assessment is brain death based on EEG,\n physical exam.\n - apnea test has not been performed, as family seems to be trending\n toward terminal extubation and declining at this time\n - organ bank called to notify about patients status; they\n closed the case as pt has not had formal apnea testing done\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 09:29 PM\n Piperacillin/Tazobactam (Zosyn) - 01:40 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 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 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.6\n HR: 97 (69 - 115) bpm\n BP: 107/75(87) {78/47(58) - 203/120(151)} mmHg\n RR: 12 (8 - 15) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 2,188 mL\n 245 mL\n PO:\n TF:\n IVF:\n 1,948 mL\n 245 mL\n Blood products:\n Total out:\n 6,240 mL\n 3,000 mL\n Urine:\n 6,240 mL\n 3,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,052 mL\n -2,755 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 RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 99%\n ABG: ////\n Ve: 5.8 L/min\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 128 K/uL\n 12.3 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.9 %\n 9.4 K/uL\n [image002.jpg]\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n 05:30 AM\n 05:44 AM\n WBC\n 8.1\n 9.3\n 9.4\n Hct\n 38.2\n 37.2\n 37.9\n Plt\n 148\n 134\n 128\n Cr\n 0.7\n 0.7\n 0.8\n TropT\n 0.29\n 0.15\n 0.10\n TCO2\n 26\n 28\n 25\n 25\n 29\n 32\n Glucose\n 132\n 109\n 103\n 132\n 96\n Other labs: PT / PTT / INR:17.3/38.9/1.5, CK / CKMB /\n Troponin-T:808/21/0.10, ALT / AST:145/139, Alk Phos / T Bili:86/0.3,\n Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, Ca++:8.3 mg/dL, Mg++:2.3\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation, now on Arctic sun protocol with diffuse\n anoxic brain injury on CT scan.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n - diffuse anoxic brain injury with poor prognosis (flat EEG, CT head\n showing worsening cerebral edema, physical exam without brainstem\n reflexes)\n - completed Arctic sun cooling protocol, now re-warmed\n - now DNR/DNI, family meeting with neuro this AM regarding possible\n terminal extubation\n -off amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -CE\ns trending downward\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol completed, now rewarmed\n -off fentanyl/versed with no brainstem reflexes and poor prognosis, as\n per neuro\n - appreciate neurology care/input\n - 48 hour EEG (showing flat line as per neuro)\n - No corneal reflex this AM. Low likelihood of regaining cortical\n function.\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down and now normal\n .\n #Transaminitis - likely ischemic insult\n - trending downward\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n # FEN: NPO for now, NGT in place, replete lytes prn\n .\n # Dispo: DNR/DNI, wife has living will and is HCP, discussing goals of\n care and possible terminal extubation, as pt would not want to live\n like this, per family.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:02 PM\n 20 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": "2177-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384685,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt remains intubated, on vent, since family awaiting other members to\n arrive before making final decision re: transition to CMO.\n - neuro evaluated patient and assessment is brain death based on EEG,\n physical exam.\n - apnea test has not been performed, as family seems to be trending\n toward terminal extubation and declining at this time\n - organ bank called to notify about patients status; they\n closed the case as pt has not had formal apnea testing done. Stating\n that pt needs to have all formal testing completed prior to their\n speaking with pt re: organ donation.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 09:29 PM\n Piperacillin/Tazobactam (Zosyn) - 01:40 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 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 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.6\n HR: 97 (69 - 115) bpm\n BP: 107/75(87) {78/47(58) - 203/120(151)} mmHg\n RR: 12 (8 - 15) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 2,188 mL\n 245 mL\n PO:\n TF:\n IVF:\n 1,948 mL\n 245 mL\n Blood products:\n Total out:\n 6,240 mL\n 3,000 mL\n Urine:\n 6,240 mL\n 3,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,052 mL\n -2,755 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 RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 99%\n ABG: ////\n Ve: 5.8 L/min\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 128 K/uL\n 12.3 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.9 %\n 9.4 K/uL\n [image002.jpg]\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n 05:30 AM\n 05:44 AM\n WBC\n 8.1\n 9.3\n 9.4\n Hct\n 38.2\n 37.2\n 37.9\n Plt\n 148\n 134\n 128\n Cr\n 0.7\n 0.7\n 0.8\n TropT\n 0.29\n 0.15\n 0.10\n TCO2\n 26\n 28\n 25\n 25\n 29\n 32\n Glucose\n 132\n 109\n 103\n 132\n 96\n Other labs: PT / PTT / INR:17.3/38.9/1.5, CK / CKMB /\n Troponin-T:808/21/0.10, ALT / AST:145/139, Alk Phos / T Bili:86/0.3,\n Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, Ca++:8.3 mg/dL, Mg++:2.3\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 y/o male with parkinsonism,\n autonomic instability, who was admitted to CCU following PEA arrest,\n likely secondary to aspiration, now s/p Arctic sun protocol, re-warmed\n and off sedation, with anoxic brain injury and worsening cerebral\n edema on CT scan, flat lining EEG, no brainstem reflexes, and no\n spontaneous breathing.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n - diffuse anoxic brain injury with poor prognosis (flat EEG, CT head\n showing worsening cerebral edema, physical exam without brainstem\n reflexes)\n - completed Arctic sun cooling protocol, now re-warmed\n - now DNR/DNI, family waiting for other members before making final\n decision re: CMO/terminal extubation\n - off amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n - monitor on telemetry\n - Organ bank notified of patient; they closed the case\n stating that the patient needs to have all formal testing completed\n prior to their speaking with patient. Unclear if this is actually the\n case, after reviewing our brain death policy.\n - will need to speak with family re: CMO status, apnea testing (which\n they have deferred up to this point), and terminal extubation, since\n the family states that the patient would not want to live like this.\n - can be formally declared brain dead, if does not pass apnea test\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -CE\ns trending downward\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol completed, now re-warmed, with unchanged exam\n -off fentanyl/versed with no brainstem reflexes and poor prognosis, as\n per neuro\n - appreciate neurology care/input\n - 72 hour EEG completed (showing flat line as per neuro)\n - No corneal reflex this AM. Low likelihood of regaining cortical\n function.\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down and now normal\n .\n #Transaminitis - likely ischemic insult\n - trending downward\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n # FEN: NPO for now, NGT in place, replete lytes prn\n .\n # Dispo: DNR/DNI, wife has living will and is HCP, discussing goals of\n care and possible terminal extubation, as pt would not want to live\n like this, per family.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Social Work",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 384582,
"text": "Social Work: Family referred to SW by nursing staff as he was admitted\n s/p cardiac arrest, currently on CCU. SW met with pt\ns wife and 2 of\n his \ns and a grandson. They were in the process of relaying course\n of events, when neuro team came in to provide update re: pt\ns clinical\n status. Family appropriately tearful as they learned pt has sustained\n significant injury to his brain, with little chance of meaningful\n recovery. Family report pt has siblings, other children and\n grandchildren who have yet to be informed about this current status.\n Family state they know that pt would not want to be sustained with no\n hope for meaningful recovery, but feel they are just taking in the\n news, and are not ready to make decisions about goals of care. SW\n validated their feelings and provided empathic listening. Advised\n family to encourage others to visit, if desired, and to receive an\n update so other family members can begin to process information about\n pt\ns status. SW will follow with team to support family coping.\n"
},
{
"category": "Social Work",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 384586,
"text": "Social Work: Family referred to SW by nursing staff as he was admitted\n s/p cardiac arrest, currently on CCU. SW met with pt\ns wife and 2 of\n his \ns and a grandson. They were in the process of relaying course\n of events, when neuro team came in to provide update re: pt\ns clinical\n status. Family appropriately tearful as they learned pt has sustained\n significant injury to his brain, with little chance of meaningful\n recovery. Family report pt has siblings, other children and\n grandchildren who have yet to be informed about this current status.\n Family state they know that pt would not want to be sustained with no\n hope for meaningful recovery, but feel they are just taking in the\n news, and are not ready to make decisions about goals of care. SW\n validated their feelings and provided empathic listening. Advised\n family to encourage others to visit, if desired, and to receive an\n update so other family members can begin to process information about\n pt\ns status. SW will follow with team to support family coping.\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: , RN\n on: 18:06 ------\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384591,
"text": "Pt is an 80 yo man w/PMHx including primary autonomic dysfunction\n w/very labile blood pressure, neurogenic bladder - foley ~2yrs with h/o\n klebsiella and pseudomonas UTI-resistant to cipro; Hypothyroidism,\n GERD; small bowel obstruction and constipation. empty sella\n syndrone.\n On , pt found apneicin bed by wife after she awoke to hear irreg\n breathing by pt who wears bipap machine at night. Pt w/probable\n prolong hypoxic period - called emt\ns - found in PEA - resuscitated\n -to OSH then.transferred to for further management. He arrived in\n ew ~ @ 0645 - hemodynamically stable. Arctic sun intiated at\n 0845 w/goal 34 degrees achieved at 1-30 admitted to CCU for further\n medical management.\n anoxic brain damage\n Assessment:\n Remains unresponsive to all stimuli\n no cough, gag, corneals, pupils\n 5mm on right, 6mm on left\n not reactive; pt very rigid in AM, now more\n flaccid; continuous EEG in place\n brain waves flat per neurology; pt\n re-warmed per Arctic sun protocol\n Action:\n pt re-warmed per Arctic sun protocol and reached goal 37 C at 1100; no\n sedation since Versed/Fentanyl d/c\nd ~ 0130; , Neurology met with wife\n and 2 daughters (, ) this am and gave prognostic assessment\n of pt\n Response:\n No change in neurological exam throughout day\n Plan:\n Continue to monitor neurological status for change; Continue to keep pt\n and family informed of any change in pt condition.\n Hypoxemia\n Assessment:\n PaO2 marginal on 50% Fio2; + pneumonia by CXR\n Action:\n Pt returned to FiO2 60%; VAP protocol continues, minimal secretions by\n suction; lungs clear to diminished at bases; BC\ns positive\n repeat\n sent\n Response:\n Improved ABG on increased FiO2;\n Plan:\n Continue to provide oral care and pulmonary hygiene. Await results of\n cultures. Suction as needed. Cont antibx as ordered, awaiting Zosyn\n approval by ID\n Impaired Skin Integrity\n Assessment:\n coccyx area thinned & darkened; blanching\n skin remains intact ; area\n of ? skin tears vs defib burn on pts chest\n Action:\n turned Q 2 hrs side to side. Criticaid/ triple cream applied to\n coccyx; chest cleaned with NS\n presently open to air\n Response:\n areas unchanged\n Plan:\n Continue to turn q2 hrs; keep skin well lubricated.\n Hypotension (not Shock)\n Assessment:\n Pt w/primary autonomic dysfunction and maintained on Midodrine and salt\n to maintain BP - baseline BP labile BP in CCU continues to be labile\n w/SBP range 40\ns/ - 190\n Action:\n Dopamine gtt up and down to keep BP in normal range\npresently on\n Dopamine 5mcgs/min; Continues on Midodrine.\n Response:\n BP remains labile\n Plan:\n Wean/titrate Dopa as needed.\n Potential for Ineffective Coping\n Assessment:\n Pt\ns daughter identified to RN the potential for conflict among\n family members (wife, 4 children) regarding decision-making for patient\n Action:\n Family meeting this AM with neurology team, CCU resident (), SW\n ( ), RN, neuron relayed to family news of poor prognosis;\n social worker involved and spent time with family,\n Chaplains also involved and providing support\n Response:\n Family is considering DNR status but is awaiting 1 son to visit after\n work before any decisions are made\n Plan:\n CCU team to meet with family again once everyone is present; Keep all\n family members informed of any changes in patients condition, Encourage\n family members to keep patient\ns wishes in mind when making decisions\n regarding pt\ns care; Social service, chaplains to remain involved to\n support family.\n ------ Protected Section ------\n Pt\ns son arrived to hospital; , his mother and 2 sisters\n and given update by CCU resident . After\n discussion with family, pt made a DNR; family awaits neurology input in\n AM before making any further decisions regarding plan of care for pt.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:26 ------\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384680,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt remains intubated, on vent, since family awaiting other members to\n arrive before making final decision re: transition to CMO.\n - neuro evaluated patient and assessment is brain death based on EEG,\n physical exam.\n - apnea test has not been performed, as family seems to be trending\n toward terminal extubation and declining at this time\n - organ bank called to notify about patients status; they\n closed the case as pt has not had formal apnea testing done\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 09:29 PM\n Piperacillin/Tazobactam (Zosyn) - 01:40 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 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 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.6\n HR: 97 (69 - 115) bpm\n BP: 107/75(87) {78/47(58) - 203/120(151)} mmHg\n RR: 12 (8 - 15) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 2,188 mL\n 245 mL\n PO:\n TF:\n IVF:\n 1,948 mL\n 245 mL\n Blood products:\n Total out:\n 6,240 mL\n 3,000 mL\n Urine:\n 6,240 mL\n 3,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,052 mL\n -2,755 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 RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 99%\n ABG: ////\n Ve: 5.8 L/min\n Physical Examination\n Labs / Radiology\n 128 K/uL\n 12.3 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.9 %\n 9.4 K/uL\n [image002.jpg]\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n 05:30 AM\n 05:44 AM\n WBC\n 8.1\n 9.3\n 9.4\n Hct\n 38.2\n 37.2\n 37.9\n Plt\n 148\n 134\n 128\n Cr\n 0.7\n 0.7\n 0.8\n TropT\n 0.29\n 0.15\n 0.10\n TCO2\n 26\n 28\n 25\n 25\n 29\n 32\n Glucose\n 132\n 109\n 103\n 132\n 96\n Other labs: PT / PTT / INR:17.3/38.9/1.5, CK / CKMB /\n Troponin-T:808/21/0.10, ALT / AST:145/139, Alk Phos / T Bili:86/0.3,\n Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, Ca++:8.3 mg/dL, Mg++:2.3\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:02 PM\n 20 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": "2177-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384681,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt remains intubated, on vent, since family awaiting other members to\n arrive before making final decision re: transition to CMO.\n - neuro evaluated patient and assessment is brain death based on EEG,\n physical exam.\n - apnea test has not been performed, as family seems to be trending\n toward terminal extubation and declining at this time\n - organ bank called to notify about patients status; they\n closed the case as pt has not had formal apnea testing done\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 09:29 PM\n Piperacillin/Tazobactam (Zosyn) - 01:40 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 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 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.6\n HR: 97 (69 - 115) bpm\n BP: 107/75(87) {78/47(58) - 203/120(151)} mmHg\n RR: 12 (8 - 15) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 2,188 mL\n 245 mL\n PO:\n TF:\n IVF:\n 1,948 mL\n 245 mL\n Blood products:\n Total out:\n 6,240 mL\n 3,000 mL\n Urine:\n 6,240 mL\n 3,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,052 mL\n -2,755 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 RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 99%\n ABG: ////\n Ve: 5.8 L/min\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 128 K/uL\n 12.3 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.9 %\n 9.4 K/uL\n [image002.jpg]\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n 05:30 AM\n 05:44 AM\n WBC\n 8.1\n 9.3\n 9.4\n Hct\n 38.2\n 37.2\n 37.9\n Plt\n 148\n 134\n 128\n Cr\n 0.7\n 0.7\n 0.8\n TropT\n 0.29\n 0.15\n 0.10\n TCO2\n 26\n 28\n 25\n 25\n 29\n 32\n Glucose\n 132\n 109\n 103\n 132\n 96\n Other labs: PT / PTT / INR:17.3/38.9/1.5, CK / CKMB /\n Troponin-T:808/21/0.10, ALT / AST:145/139, Alk Phos / T Bili:86/0.3,\n Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, Ca++:8.3 mg/dL, Mg++:2.3\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:02 PM\n 20 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": "2177-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384687,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt remains intubated, on vent, since family awaiting other members to\n arrive before making final decision re: transition to CMO.\n - neuro evaluated patient and assessment is brain death based on EEG,\n physical exam.\n - apnea test has not been performed, as family seems to be trending\n toward terminal extubation and declining at this time\n - organ bank called to notify about patients status; they\n closed the case as pt has not had formal apnea testing done. Stating\n that pt needs to have all formal testing completed prior to their\n speaking with pt re: organ donation.\n - spoke with organ bank again this AM; they will come and\n speak with family this time.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 09:29 PM\n Piperacillin/Tazobactam (Zosyn) - 01:40 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 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 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.6\n HR: 97 (69 - 115) bpm\n BP: 107/75(87) {78/47(58) - 203/120(151)} mmHg\n RR: 12 (8 - 15) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 2,188 mL\n 245 mL\n PO:\n TF:\n IVF:\n 1,948 mL\n 245 mL\n Blood products:\n Total out:\n 6,240 mL\n 3,000 mL\n Urine:\n 6,240 mL\n 3,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,052 mL\n -2,755 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 RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 99%\n ABG: ////\n Ve: 5.8 L/min\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 128 K/uL\n 12.3 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.9 %\n 9.4 K/uL\n [image002.jpg]\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n 05:30 AM\n 05:44 AM\n WBC\n 8.1\n 9.3\n 9.4\n Hct\n 38.2\n 37.2\n 37.9\n Plt\n 148\n 134\n 128\n Cr\n 0.7\n 0.7\n 0.8\n TropT\n 0.29\n 0.15\n 0.10\n TCO2\n 26\n 28\n 25\n 25\n 29\n 32\n Glucose\n 132\n 109\n 103\n 132\n 96\n Other labs: PT / PTT / INR:17.3/38.9/1.5, CK / CKMB /\n Troponin-T:808/21/0.10, ALT / AST:145/139, Alk Phos / T Bili:86/0.3,\n Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, Ca++:8.3 mg/dL, Mg++:2.3\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 y/o male with parkinsonism,\n autonomic instability, who was admitted to CCU following PEA arrest,\n likely secondary to aspiration, now s/p Arctic sun protocol, re-warmed\n and off sedation, with anoxic brain injury and worsening cerebral\n edema on CT scan, flat lining EEG, no brainstem reflexes, and no\n spontaneous breathing.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n - diffuse anoxic brain injury with poor prognosis (flat EEG, CT head\n showing worsening cerebral edema, physical exam without brainstem\n reflexes)\n - completed Arctic sun cooling protocol, now re-warmed\n - now DNR/DNI, family waiting for other members before making final\n decision re: CMO/terminal extubation\n - off amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n - monitor on telemetry\n - Organ bank notified of patient; they closed the case\n stating that the patient needs to have all formal testing completed\n prior to their speaking with patient. Unclear if this is actually the\n case, after reviewing our brain death policy.\n - will need to speak with family re: CMO status, apnea testing (which\n they have deferred up to this point), and terminal extubation, since\n the family states that the patient would not want to live like this.\n - can be formally declared brain dead, if does not pass apnea test\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -CE\ns trending downward\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol completed, now re-warmed, with unchanged exam\n -off fentanyl/versed with no brainstem reflexes and poor prognosis, as\n per neuro\n - appreciate neurology care/input\n - 72 hour EEG completed (showing flat line as per neuro)\n - No corneal reflex this AM. Low likelihood of regaining cortical\n function.\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down and now normal\n .\n #Transaminitis - likely ischemic insult\n - trending downward\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n # FEN: NPO for now, NGT in place, replete lytes prn\n .\n # Dispo: DNR/DNI, wife has living will and is HCP, discussing goals of\n care and possible terminal extubation, as pt would not want to live\n like this, per family.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer:\n VAP: mouth care\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: DNR/DNI, wife has living will and is HCP, discussing goals\n of care and possible terminal extubation, as pt would not want to live\n like this, per family. organ bank coming to speak with\n family today.\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384672,
"text": "80 y/o M w/ OSA, parkinsons, syncope orthostatic hypotension,\n primary autonomic dysfunction w/ very labile BPs--on Midodrine and salt\n to maintain BP at home. Admitted to CCU s/p PEA arrest and\n resuscitation at home. Cooled by artic sun protocol in CCU, re-warmed\n 11:00 yesterday. Head CT: Global anoxic injury prolonged PEA arrest\n of unknown duration, w/ repeat head CT showing evidence of severe\n global cortical edema. Brain waves flat and likelihood of significant\n recovery nears zero. Family meeting yesterday\n aware of grim\n prognosis. Now DNR. ***NEOB aware of pt, called last night\n will call\n today to get update on pt status.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Pt unresponsive to all stimulation, NSR hr 80-110, dopa 4.5mcg, bp\n labile.\n Action:\n Family support\n Response:\n Waiting for family to make a decision about pts care\n Plan:\n No changes c medical management family will be in the a.m. ? CMO\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384512,
"text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 09:39 AM\n NASAL SWAB - At 10:30 AM\n BLOOD CULTURED - At 12:27 PM\n URINE CULTURE - At 12:30 PM\n ARTERIAL LINE - START 01:02 PM\n SPUTUM CULTURE - At 02:15 PM\n BLOOD CULTURED - At 02:20 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 11:30 PM\n Vancomycin - 12:10 AM\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 66 (61 - 107) bpm\n BP: 92/63(74) {88/61(71) - 150/95(117)} mmHg\n RR: 16 (0 - 28) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,606 mL\n 590 mL\n PO:\n TF:\n IVF:\n 1,486 mL\n 590 mL\n Blood products:\n Total out:\n 778 mL\n 800 mL\n Urine:\n 778 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,828 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%, Vent Dependant\n PIP: 31 cmH2O\n Plateau: 27 cmH2O\n SpO2: 100%\n ABG: 7.41/42/179/26/2\n Ve: 8.4 L/min\n PaO2 / FiO2: 298\n Physical Examination\n VS: T=34 celsius on artic sun BP=107/81 HR= 150 regular RR=18 O2 sat=\n 98% AC 100%/550/16/5\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, unable to ausculate lung bases as artic sun\n cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 109 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n Glucose\n 132\n 109\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n o telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n -d/c amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n -on artic sun cooling protocol x18 hours, monitor coagulation profile\n -blood, sputum, urine cultures pending\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -trend CE's to peak\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient with PaO2 in the 90's on 100%FIO2. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram.\n -wean FIO2 as tolerated\n -will start abx if concern for pneumonia vs pneumonitis\n -consider CTA to eval for PE if remains hypoxic without clear cause\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unkown duration.\n -cooling protocol\n -low dose fentanyl/versed advised by cardiac arrest consult in case he\n is in a locked in state even though\n - neurology consult in the am\n -48 hour EEG\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates\n .\n #Transaminitis - likely ischemic insult\n -monitor trend\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, no evidence of\n infection on UA.\n .\n FEN: NPO for now, NGT in place, change to OGT if prolonged intubation,\n replete lytes prn, consider starting tube feeds in the AM\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 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": "2177-09-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384515,
"text": "Chief Complaint:\n 24 Hour Events:\n Went into wenckebach rhythm. A-lined and BP correlating with cuff\n pressures. Head CT showing diffuse anoxic brain injury. EEG done. Pt\n with high FIO2 requirements (80%). Lactate trending down.\n At hrs, pt brady'ed and went into PEA arrest --> CPR started,\n given atropine x 1, epi x 1, came out of arrest into sinus tach, BP\n 220s after 3-4 mins of PEA arrest.\n Head CT and CTA ordered to look for worsening cerebreal edema, ?PE.\n Head CT shows ventricles are slightly smaller in size compared with the\n morning head ct suggesting progression of cerebral edema, although lot\n of artifact on study from MRI leads. Chest CT shows bilateral\n infiltrates could be c/w aspiration pneumonia, no pulmonary embolus\n although one small area in the LLL subsegmental branch that could be\n c/w PE. He was started on vanc/zosyn to cover for aspiration\n pneumonia. In addition, one set of blood cultures returned with both\n bottles with GPC's in pairs, second set with no growth thus far.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 11:30 PM\n Vancomycin - 12:10 AM\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 66 (61 - 107) bpm\n BP: 92/63(74) {88/61(71) - 150/95(117)} mmHg\n RR: 16 (0 - 28) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,606 mL\n 590 mL\n PO:\n TF:\n IVF:\n 1,486 mL\n 590 mL\n Blood products:\n Total out:\n 778 mL\n 800 mL\n Urine:\n 778 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,828 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%, Vent Dependant\n PIP: 31 cmH2O\n Plateau: 27 cmH2O\n SpO2: 100%\n ABG: 7.41/42/179/26/2\n Ve: 8.4 L/min\n PaO2 / FiO2: 298\n Physical Examination\n VS: T=34 celsius on artic sun BP=107/81 HR= 150 regular RR=18 O2 sat=\n 98% AC 100%/550/16/5\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, unable to ausculate lung bases as artic sun\n cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 109 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n Glucose\n 132\n 109\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n o telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n -d/c amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n -on artic sun cooling protocol x18 hours, monitor coagulation profile\n -blood, sputum, urine cultures pending\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -trend CE's to peak\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient with PaO2 in the 90's on 100%FIO2. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram.\n -wean FIO2 as tolerated\n -will start abx if concern for pneumonia vs pneumonitis\n -consider CTA to eval for PE if remains hypoxic without clear cause\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unkown duration.\n -cooling protocol\n -low dose fentanyl/versed advised by cardiac arrest consult in case he\n is in a locked in state even though\n - neurology consult in the am\n -48 hour EEG\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates\n .\n #Transaminitis - likely ischemic insult\n -monitor trend\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, no evidence of\n infection on UA.\n .\n FEN: NPO for now, NGT in place, change to OGT if prolonged intubation,\n replete lytes prn, consider starting tube feeds in the AM\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384732,
"text": "Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "General",
"chartdate": "2177-09-24 00:00:00.000",
"description": "ICU Event Note",
"row_id": 384745,
"text": "Clinician: Resident\n Called to the bedside to pronounce death. Patient is a 80 y/o male\n with Parkinsonism s/p PEA arrest from suspected aspiration, with\n diffuse anoxic brain injury. Patient examinted, pupils fixed and\n dilated at 6 mm, no spontaneous breathing, cranial nerve testing,\n brainstem reflexes, apnea testing performed. Time of death 4:23 pm.\n Family present at bedside. Offered autopsy and family declined. organ donation group spoke with family, and patient is not a\n candidate for organ donation.\n , PGY1\n Total time spent: 45 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384746,
"text": "Pt. was extubated and taken off the vent at approx. 2045. wife and\n children came back into the room and spent time with pt.\n Explained to family procedure of calling funeral home. Family left ~\n 2130.\n"
},
{
"category": "Consult",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Physician Consult Progress Note",
"row_id": 384370,
"text": "Consult requested by: Dr \n Chief Complaint: s/p cardiac arrest\n 24 Hour Events:\n Pt is an 80M , wife heard pt making sounds in his sleep while\n wearing his usual CPAP mask, then noted that he was not breathing,\n cyanotic, called 911. For EMS pulseless/apneic in PEA, given\n epi/atropine, then developed VF, defibrillated x 4 with ROSC.\n Intubated. Amio bolus, started gtt. On Dopamine. Unclear total\n no-flow/low-flow times.\n .\n PMHx: Parkinsonism, orthostatic hypoTN on Midodrine, UTI with chronic\n indwelling foley\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive, Intubated, comatose\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 36 cmH2O\n Plateau: 34 cmH2O\n ABG: ///24/\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: Intubated\n Eyes / Conjunctiva: Pupils dilated, L pupil 4.5, R pupil 4,\n non-reactive\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft\n Extremities: Right: 1+, Left: 1+\n Skin: Cool\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:7.1 mmol/L\n Imaging: CT head: bilat basal ganglia hypodensity c/w anoxic event\n ECG: St 127, LAD, IVCD, NSST-T changes\n Assessment and Plan\n .\n Assessment: 80M s/p cardiac arrest, with ROSC, etiology of arrest\n unclear, possible primary respiratory arrest.\n .\n Recommendations:\n .\n # ARREST: Investigation of etiology per ED/primary team\n - No plan for cath now per cardiology\n .\n # NEUROPROTECTION:\n - Therapeutic hypothermia: Given hx arrest with ROSC < 12 h ago, poor\n neuro status post event, and absence of clear contraindications, would\n cool pt with Arctic Sun to goal temp 33-34 degrees C x 18 hours, then\n rewarm as per protocol\n - While cooling, monitor for coagulopathy\n - Discontinue cooling if pt becomes severely hemodynamically unstable\n (please contact us to discuss if this occurs)\n - Once rewarmed would aim for normothermia, avoid hyperthermia\n - Avoid increased ICP: HOB > 30 degrees, maintain normal pCO2 35-40\n - Avoid hyperglycemia\n - Continuous EEG x next 48 hours to evaluate for seizures\n - If evidence of sz activity, would treat with benzodiazepines and\n consult Neurology\n - Follow up CT head results\n .\n Please page with questions, we will follow along with team.\n .\n , MD\n EM-Critical Care Fellow\n Pager \n or\n , MD\n Pager \n"
},
{
"category": "Consult",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Physician Consult Progress Note",
"row_id": 384371,
"text": "Consult requested by: Dr \n Chief Complaint: s/p cardiac arrest\n 24 Hour Events:\n Pt is an 80M , wife heard pt making sounds in his sleep while\n wearing his usual CPAP mask, then noted that he was not breathing,\n cyanotic, called 911. For EMS pulseless/apneic in PEA, given\n epi/atropine, then developed VF, defibrillated x 4 with ROSC.\n Intubated. Amio bolus, started gtt. On Dopamine. Unclear total\n no-flow/low-flow times.\n .\n PMHx: Parkinsonism, orthostatic hypoTN on Midodrine, UTI with chronic\n indwelling foley\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive, Intubated, comatose\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: Unable to obtain\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 Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 36 cmH2O\n Plateau: 34 cmH2O\n ABG: ///24/\n Ve: 8.5 L/min\n Physical Examination\n General Appearance: Intubated\n Eyes / Conjunctiva: Pupils dilated, L pupil 4.5, R pupil 4,\n non-reactive\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous: )\n Abdominal: Soft\n Extremities: Right: 1+, Left: 1+\n Skin: Cool\n Neurologic: Responds to: Unresponsive, Movement: No spontaneous\n movement, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Other labs: Lactic Acid:7.1 mmol/L\n Imaging: CT head: bilat basal ganglia hypodensities c/w anoxic event\n ECG: St 127, LAD, IVCD, NSST-T changes\n Assessment and Plan\n .\n Assessment: 80M s/p cardiac arrest, with ROSC, etiology of arrest\n unclear, possible primary respiratory arrest.\n .\n Recommendations:\n .\n # ARREST: Investigation of etiology per ED/primary team\n - No plan for cath now per cardiology\n .\n # NEUROPROTECTION:\n - Therapeutic hypothermia: Given hx arrest with ROSC < 12 h ago, poor\n neuro status post event, and absence of clear contraindications, would\n cool pt with Arctic Sun to goal temp 33-34 degrees C x 18 hours, then\n rewarm as per protocol\n - While cooling, monitor for coagulopathy\n - Discontinue cooling if pt becomes severely hemodynamically unstable\n (please contact us to discuss if this occurs)\n - Once rewarmed would aim for normothermia, avoid hyperthermia\n - Avoid increased ICP: HOB > 30 degrees, maintain normal pCO2 35-40\n - Avoid hyperglycemia\n - Continuous EEG x next 48 hours to evaluate for seizures\n - If evidence of sz activity, would treat with benzodiazepines and\n consult Neurology\n - Follow up CT head results\n - Research team will offer corticosteroid trial to family if patient\n remains on vasopressor support\n .\n Please page with questions, we will follow along with team.\n .\n , MD\n EM-Critical Care Fellow\n Pager \n or\n , MD\n Pager \n"
},
{
"category": "Nursing",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384379,
"text": "PMH: Primary autonomic dysfunction. Very labile blood pressure.\n Neurogenic bladder. Foley X ~2ys with h/o klebsiella UTI, and\n Pseudomonas UTI resistant to cipro. Hypothyroidism, GERD. OSA. \n SMall bowel obstruction and constipation. Empty sella syndrone.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular fibrillation (VF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384380,
"text": "PMH: Primary autonomic dysfunction. Very labile blood pressure.\n Neurogenic bladder. Foley X ~2ys with h/o klebsiella UTI, and\n Pseudomonas UTI resistant to cipro. Hypothyroidism, GERD. OSA. \n SMall bowel obstruction and constipation. Empty sella syndrone.\n This 80y old male was found apnic due to the alarm on his bipap machine\n by his wife. She called EMTs and he was in PEA. He was transported to\n OSH where he was resusitated. He was shocked ~5 times for VF, intubated\n and eventually stabilized. He was transported to on Amiodarone\n 1mg and dopamine at 5mic/kilo.\n He arrived in EW ~0645 and was hemodynamically stable. Arctic sun was\n intiated at 0845. His rectal temp on initiation was 34.8 and foley\n probe 32.9 (new foley placed). He was transported to CCU via head CT.\n His neuro exam showed no nuerologic response to any stimuli.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Action:\n Response:\n Plan:\n Ventricular fibrillation (VF)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 384652,
"text": "Demographics\n Day of mechanical ventilation: 3\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: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\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: Attempted PS, but no spontaneous breaths.\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: waiting for family meeting to come up with care plan.\n"
},
{
"category": "Social Work",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 384653,
"text": "SOCIAL WORK: Case discussed with team; pt made DNR last night and has\n had f/u neuro testing with no improvement found. SW met with pt\ns wife\n and 3 \ns in family waiting area. Wife repeated her memory of events\n on the night pt arrested. SW provided emotional support and engaged\n family in sharing positive memories. They express awareness that pt\n would not want to be maintained on life support under the\n circumstances. They anticipate pt\ns son coming in this evening, and\n that they will likely plan to make pt . SW supported family in\n processing their feelings. Discussed potential ideas to include\n grandchildren in bereavement process. Pt\ns oldest is\n developmentally delayed and in a group home. Family planning to\n contact group home to begin to prepare her for bereavement process.\n Family expressed appreciation for support from staff during this time.\n SW will follow-up with family tomorrow if pt remains in the hospital.\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384655,
"text": "80 y/o M w/ OSA, parkinsons, syncope orthostatic hypotension,\n primary autonomic dysfunction w/ very labile BPs--on Midodrine and salt\n to maintain BP at home. Admitted to CCU s/p PEA arrest and\n resuscitation at home. Cooled by artic sun protocol in CCU, re-warmed\n 11:00 yesterday. Head CT: Global anoxic injury prolonged PEA arrest\n of unknown duration, w/ repeat head CT showing evidence of severe\n global cortical edema. Brain waves flat and likelihood of significant\n recovery nears zero. Family meeting yesterday\n aware of grim\n prognosis. Now DNR. ***NEOB aware of pt, called last night\n will call\n today to get update on pt status.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Tele sinus rhythm. Dopamine at 4mcgs/kg/min. BP remains labile. Pt\n unresponsive to any stimuli. Pupils are non reactive. No gag no cough\n no spontaneous respirations. Seen by neuro.\n Action:\n No change in medical management. Awaiting other family members to come\n in prior to terminal extubation.\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 384734,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\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 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: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\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: Comfort measures only\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Apnea test for brain death (1615)\n Comments: pt met brain death criteria via apnea test\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384735,
"text": "80 y/o M w/ OSA, parkinsons, syncope orthostatic hypotension,\n primary autonomic dysfunction w/ very labile BPs--on Midodrine and salt\n to maintain BP at home. Admitted to CCU s/p PEA arrest and\n resuscitation at home. Cooled by artic sun protocol in CCU, re-warmed\n 11:00 yesterday. Head CT: Global anoxic injury prolonged PEA arrest\n of unknown duration, w/ repeat head CT showing evidence of severe\n global cortical edema. Brain waves flat and likelihood of significant\n recovery nears zero. Family meeting yesterday\n aware of grim\n prognosis. Now DNR. ***NEOB aware of pt, pt was declared brain dead\n today by Dr . NEOB here to speak with family who wishes to go\n ahead with donation of liver.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Tele sinus rhythm. BP remains labile ranging from 60\ns-200\ns. Dopamine\n at 5mcgs/kg/min this am. Absent gag, cough & spontaneous respirations.\n Pupils are nonreactive. No spontaneous movement. Apnea test performed\n by Dr .\n Action:\n Family spoke with NEOB and wish to go ahead with donation of liver.\n Lytes amd LFT\ns drawn. Lytes being repleted. Dopamine ^\nd to\n 7mcgs/kg/min.\n Response:\n No change in neuro status.\n Plan:\n To continue supportive care until liver can be donated. replete lytes.\n MAP>65. Provide emotional support to family. Family to be notified\n before pt goes to the OR.\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384484,
"text": "pmh: primary autonomic dysfunction. very labile blood pressure.\n neurogenic bladder. foley X ~2yrs with h/o klebsiella and pseudomonas\n uti-resistant to cipro. Hypothyroidism. gerd. small bowel\n obstruction and constipation. empty sella syndrone.\n this 80y old male was found apnic due to the alarm on his bipap machine\n by his wife. probable prolong hypoxic period. called emt\ns and he was\n found in pea. he was transported to osh where he was resusitated.\n transferred to for further management. he arrived in ew ~ @\n 0645 and was hemodynamically stable. arctic sun was intiated at 0845.\n admitted to ccu for further medical management.\n anoxic brain damage\n Assessment:\n unresponsive to all stimuli. continuous eeg inplace. Maintaining\n target temp-34 degree c. on low dose sedation-fentanyl & versed.\n Action:\n repeat head ct. sedation-fentanyl & versed dced. Warming initiated @\n 0500-0.5degree increase q1hr x6hrs to goal 37 degree c.\n Response:\n remains unresponsive, with no neurological functioning. repeat head\n ct-increasing sweeling. continuous eeg-essentially flat per neuron\n coverage.\n Plan:\n continue to monitor neurological status for change. rewarm. maintain 37\n degree c post warming. address code status with family.\n dysrhythmia-pea\n Assessment:\n -electriacal conduction without mechanical response.\n Action:\n cpr. Medications-atropine & epinephrine.\n Response:\n restoration of rhythm to af with stabke bp on dopamine gtt.\n Plan:\n monitor for change in rhythm status. continue to cycle cks. check lytes\n Hypoxemia\n Assessment:\n presented hypoxemic-intubated & vented. gradual improvement of sats &\n po2. ct chest/cxr-aspiration pna without pulm emboli.\n Action:\n weaned fio2 to 60%. vap protocol followed. abx started.\n Response:\n tolerating decreased fio2. minimal ett secretions.\n Plan:\n continue with oral and pulmonary hygiene. await results of cultures.\n suction as needed.\n Impaired Skin Integrity\n Assessment:\n coccyx area thinned & darkened. area blanches. without broken down\n areas\n Action:\n pt being turned Q 2 hrs side to side. criticade clear was applied to\n coccyx.\n Response:\n no worsening of area around coccyx has occurred. no new areas of\n breakdown seen.\n Plan:\n continue to turn q2 hrs and keep skin well lubricated.\n Hypotension (not Shock)\n Assessment:\n of note he has autonomic dysfunction and require midodrine and salt to\n maintain bp. at baseline BP labile and is often in low 80s with pt\n being asymptomatic. Tolerating slow dopa wean.\n Action:\n continues on midodrine. Slow dopa wean.\n Response:\n tolerating slow dopa wean.\n Plan:\n continue with midodrine. wean dopamine as tolerated.\n 1900-0700 events:pea arrest requiring cpr & meds.\n ct head & chest-increasing cerebral\n swelling & without pulm emboli.\n social:family present-wife & daughters. updated by team. Informed of\n poor prognosis. remains full code-to be readdressed in am.\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384729,
"text": "Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Critical Care Attending - Brain Death Note",
"row_id": 384731,
"text": "TITLE: Critical Care Attending Note\n Asked to discuss role of BD testing and management of NEOB referral by\n CCU team. Case reviewed in detail. Mr. , and his family, are\n known to me from prior MICU admission. As of this morning, his exam was\n c/w BD though testing had not been performed. I discussed further\n management at length with CCU team, NEOB team, neurology attending and\n family in two separate family meetings today. At our first meeting, I\n discussed the rationale for formal BD testing to clarify his current\n condition (alive v dead), and family understood the logic for this\n testing. BD testing undertaken this afternoon, form completed per\n protocol, apnea test notable for rise in pCO2 from 44 to 70 without\n respiratory efforts, other findings c/w prior exams by neuro and all\n c/w BD, time of death at 1623 on this date. These findings were relayed\n to NEOB. At my second meeting with the family, which included \n , family liason from NEOB, we discussed the implications of the\n findings on BD testing, specifically that Mr. was deceased.\n Mr. introduced the idea of solid organ (specifically liver)\n donation, and the family agreed to move forward with formal evaluation,\n which is currently underway. We will notify admitting of Mr.\n \ns death, while we continue to support organ function with\n pressors, fluids, inotropes, steroids, etc as advised by NEOB. Above\n d/w family, CCU team and NEOB in detail. I am available by page ()\n or cell () if questions arise.\n Total time: 240 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 384466,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Airway\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: Tan / 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 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 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 CT\n 2200\n None\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384610,
"text": "80 y/o M w/ OSA, parkinsons, syncope orthostatic hypotension,\n primary autonomic dysfunction w/ very labile BPs--on Midodrine and salt\n to maintain BP at home. Admitted to CCU s/p PEA arrest and\n resuscitation at home. Cooled by artic sun protocol in CCU, re-warmed\n 11:00 yesterday. Head CT: Global anoxic injury prolonged PEA arrest\n of unknown duration, w/ repeat head CT showing evidence of severe\n global cortical edema. Brain waves flat per neurology. Family meeting\n yesterday\n aware of grim prognosis. Now DNR. NEOB aware of pt, called\n last night\n will call today to get update on pt status.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Unresponsive to all stim, no corneals, no cough/gag. Not overbreathing\n vent. Remains off sedation since :30 yesterday. No seizure activity\n noted. Temp gradually down to 96.1R.\n Action:\n Neuro checks to assess for any change\n continuous EEG in place.\n HOB up 30 degrees to decrease ICP.\n Bair hugger applied for hypothermia.\n Response:\n NO change, remains unresponsive. Now normothermic.\n Plan:\n Continue tp monitor neuron status,\n supportive care. Family mtg today with neuro and CCU team.\n Keep NEOB informed.\n Hypotension (not Shock)\n Assessment:\n SBPs ranging from 50-205, very low BPs especially w/ turning in bed.\n UOP 100-600cc/hr\n Action:\n Dopa maintained and titrated up and down to keep BPs normal\n range\n Midodrine given as ordered\n Response:\n Remains w/ extremely labile BPs w/o any changes in Dopa. Not able to\n wean off. AM Lactate\n Plan:\n Wean Dopa as tolerated\n Hypoxemia\n Assessment:\n 02 sats 97-98% on 60%. + LLL PNA by CXR. GPC in sputum and blood\n Action:\n VAP protocol maintained\n Abx given as ordered\n Response:\n Stable, very minimal secretions.\n Plan:\n VAP care\n abx\n Impaired Skin Integrity\n Assessment:\n coccyx area thinned & darkened; blanching\n skin remains intact ; area\n of ? skin tears vs defib burn on pts chest\n Action:\n Freq small turns/shifts in bed as pt BP extremely labile.\n Criticaid/ triple cream applied to coccyx; chest\n presently\n open to air\n Response:\n areas unchanged\n Plan:\n Continue to turn q2 hrs; keep skin well lubricated.\n Ineffective Coping\n Assessment:\n Mult fam members in last evening/night. Tearful about pt condition.\n Action:\n Emotional support provided to updated on pt condition\n frequently. Encouraged to go home to rest and to call with any\n questions overnight.\n Response:\n Family appearing to understand pt status\n Plan:\n Continue supportive care, family meeting today.\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384611,
"text": "80 y/o M w/ OSA, parkinsons, syncope orthostatic hypotension,\n primary autonomic dysfunction w/ very labile BPs--on Midodrine and salt\n to maintain BP at home. Admitted to CCU s/p PEA arrest and\n resuscitation at home. Cooled by artic sun protocol in CCU, re-warmed\n 11:00 yesterday. Head CT: Global anoxic injury prolonged PEA arrest\n of unknown duration, w/ repeat head CT showing evidence of severe\n global cortical edema. Brain waves flat and likelihood of significant\n recovery nears zero. Family meeting yesterday\n aware of grim\n prognosis. Now DNR. ***NEOB aware of pt, called last night\n will call\n today to get update on pt status.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Unresponsive to all stim, no corneals, no cough/gag. Not overbreathing\n vent. Remains off sedation since :30 yesterday. No seizure activity\n noted. Temp gradually down to 96.1R.\n Action:\n Neuro checks to assess for any change\n continuous EEG in place.\n HOB up 30 degrees to decrease ICP.\n Bair hugger applied for hypothermia.\n Response:\n NO change, remains unresponsive. Now normothermic.\n Plan:\n Continue to monitor neuro status,\n supportive care. Family mtg today with neuro and CCU team.\n Keep NEOB informed.\n Hypotension (not Shock)\n Assessment:\n SBPs ranging from 50-205, very low BPs especially w/ turning in bed.\n UOP 100-600cc/hr\n Action:\n Dopa maintained and titrated up and down to keep BPs normal\n range\n Midodrine given as ordered\n Response:\n Remains w/ extremely labile BPs w/o any changes in Dopa. Not able to\n wean off.\n Plan:\n Wean Dopa as tolerated\n Impaired Skin Integrity\n Assessment:\n coccyx area thinned & darkened; blanching\n skin remains intact ; area\n of ? skin tears vs defib burn on pts chest\n Action:\n Freq small turns/shifts in bed as pt BP extremely labile.\n Criticaid/ triple cream applied to coccyx; chest\n presently\n open to air\n Response:\n areas unchanged\n Plan:\n Continue to turn q2 hrs; keep skin well lubricated.\n Ineffective Coping\n Assessment:\n Mult fam members in last evening/night. Tearful\n Action:\n Emotional support provided to updated on pt condition\n frequently. Encouraged to go home to rest and to call with any\n questions overnight.\n Response:\n Family appearing to understand pt status and appearing to appropriately\n cope with the situation\n Plan:\n Continue supportive care, family meeting today.\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384612,
"text": "80 y/o M w/ OSA, parkinsons, syncope orthostatic hypotension,\n primary autonomic dysfunction w/ very labile BPs--on Midodrine and salt\n to maintain BP at home. Admitted to CCU s/p PEA arrest and\n resuscitation at home. Cooled by artic sun protocol in CCU, re-warmed\n 11:00 yesterday. Head CT: Global anoxic injury prolonged PEA arrest\n of unknown duration, w/ repeat head CT showing evidence of severe\n global cortical edema. Brain waves flat and likelihood of significant\n recovery nears zero. Family meeting yesterday\n aware of grim\n prognosis. Now DNR. ***NEOB aware of pt, called last night\n will call\n today to get update on pt status.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Unresponsive to all stim, no corneals, no cough/gag. Not overbreathing\n vent. Remains off sedation since :30 yesterday. No seizure activity\n noted. Temp gradually down to 96.1R.\n Action:\n Neuro checks to assess for any change\n continuous EEG in place.\n Bair hugger applied for hypothermia.\n Response:\n NO change, remains unresponsive. Now normothermic.\n Plan:\n Continue to monitor neuro status,\n supportive care. Family mtg today with neuro and CCU team.\n f/u w/ NEOB\n Hypotension (not Shock)\n Assessment:\n SBPs ranging from 50-205, very low BPs especially w/ turning in bed.\n UOP 100-600cc/hr\n Action:\n Dopa maintained and titrated up and down to keep BPs normal\n range\n Midodrine given as ordered\n Response:\n Remains w/ extremely labile BPs w/o any changes in Dopa. Not able to\n wean off.\n Plan:\n Wean Dopa as tolerated\n Ineffective Coping\n Assessment:\n Mult fam members in last evening/night. Tearful\n Action:\n Emotional support provided, updated on pt condition\n frequently. Encouraged to go home to rest and to call with any\n questions overnight.\n Response:\n Family appearing to understand pt status and appearing to appropriately\n cope with the situation\n Plan:\n Continue supportive care, family meeting today.\n Impaired Skin Integrity\n Assessment:\n coccyx area thinned & darkened; blanching\n skin remains intact ; area\n of ? skin tears vs defib burn on pts chest\n Action:\n Freq small turns/shifts in bed as pt BP extremely labile.\n Criticaid/ triple cream applied to coccyx; chest\n presently\n open to air\n Response:\n areas unchanged\n Plan:\n Continue to turn q2 hrs; keep skin well lubricated.\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384636,
"text": "Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384640,
"text": "Chief Complaint:\n 24 Hour Events:\n Went into wenckebach rhythm. A-lined and BP correlating with cuff\n pressures. Head CT showing diffuse anoxic brain injury. EEG done. Pt\n with high FIO2 requirements (80%). Lactate trending down.\n At hrs, pt brady'ed and went into PEA arrest --> CPR started,\n given atropine x 1, epi x 1, came out of arrest into sinus tach, BP\n 220s after 3-4 mins of PEA arrest.\n Called by neuro fellow, stating that pt may be in non-convulsive\n status. Explained that pt was just PEA arrested, and was given CPR.\n Told that pt\ns EEG is flat lining.\n Head CT and CTA ordered to look for worsening cerebreal edema, ?PE.\n Head CT shows ventricles are slightly smaller in size compared with the\n morning head ct suggesting progression of cerebral edema, although lot\n of artifact on study from MRI leads. Chest CT shows bilateral\n infiltrates could be c/w aspiration pneumonia, no pulmonary embolus\n although one small area in the LLL subsegmental branch that could be\n c/w PE. He was started on vanc/zosyn to cover for aspiration\n pneumonia. In addition, one set of blood cultures returned with both\n bottles with GPC's in pairs, second set with no growth thus far.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 11:30 PM\n Vancomycin - 12:10 AM\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 66 (61 - 107) bpm\n BP: 92/63(74) {88/61(71) - 150/95(117)} mmHg\n RR: 16 (0 - 28) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,606 mL\n 590 mL\n PO:\n TF:\n IVF:\n 1,486 mL\n 590 mL\n Blood products:\n Total out:\n 778 mL\n 800 mL\n Urine:\n 778 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,828 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%, Vent Dependant\n PIP: 31 cmH2O\n Plateau: 27 cmH2O\n SpO2: 100%\n ABG: 7.41/42/179/26/2\n Ve: 8.4 L/min\n PaO2 / FiO2: 298\n Physical Examination\n VS: T=34 celsius on artic sun BP=107/81 HR= 150 regular RR=18 O2 sat=\n 98% AC 100%/550/16/5\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 109 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n Glucose\n 132\n 109\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation, now on Arctic sun protocol with diffuse\n anoxic brain injury on CT scan.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n -d/c amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n -on artic sun cooling protocol x18 hours, monitor coagulation profile\n -PEA arrested overnight again, with unclear precipitant, but suspected\n to be related to progressive cerebral edema.\n -Head CT concerning for smaller ventricular size, ?worsening cerebral\n edema, no obvious herniation\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -trend CE's to peak\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol\n -low dose fentanyl/versed advised by cardiac arrest consult in case he\n is in a locked in state (can likely stop when warmed)\n - neurology consult in the am\n -48 hour EEG (showing flat line as per neuro)\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down, currently 2.2\n .\n #Transaminitis - likely ischemic insult\n -monitor trend\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n FEN: NPO for now, NGT in place, change to OGT if prolonged intubation,\n replete lytes prn, consider starting tube feeds in the AM\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Bowel regimen: senna, docusate\n VAP:\n Comments:\n Communication: Comments:\n Code status: full code for now\n Disposition: CCU\n ------ Protected Section ------\n Attending\ns Note.\n Reviewed overnight course.\n No neurological recovery Examined Pt and agree with Dr.\ns note\n Spent 40 mins on case.\n \n ------ Protected Section Addendum Entered By: \n on: 11:43 ------\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384641,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Patient DNR/DNI.\n - The family would like another family meeting today to update them on\n any progress in order to make any further decisions about proceeding\n with de-escalation of care.\n - Neuro says to continue 72 hours of EEG monitoring, but have little\n hope for any functional recovery.\n - Blood pressure labile, especially after patient is moved in bed->\n fluctuated from 50s-60s systolic to 200s in matter of minutes.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:30 AM\n Infusions:\n Dopamine - 4.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:30 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 04:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 86 (64 - 106) bpm\n BP: 94/53(68) {49/37(41) - 205/113(152)} mmHg\n RR: 12 (0 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 1,693 mL\n 316 mL\n PO:\n TF:\n IVF:\n 1,533 mL\n 256 mL\n Blood products:\n Total out:\n 4,680 mL\n 900 mL\n Urine:\n 4,680 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,987 mL\n -584 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 97%\n ABG: 7.45/40/116//4\n Ve: 5.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n CXR - L sided effusion, bilateral atelectasis with superimposed\n infiltrates from possible aspiration\n Micro blood cx NGTD, sputum with 3+ GPC and sparse GNR\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n 25\n 25\n 29\n Glucose\n 132\n 109\n 103\n 132\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation, now on Arctic sun protocol with diffuse\n anoxic brain injury on CT scan.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n - diffuse anoxic brain injury with poor prognosis (flat EEG, CT head\n showing worsening cerebral edema, physical exam without brainstem\n reflexes)\n - completed Arctic sun cooling protocol, now re-warmed\n - now DNR/DNI, family meeting with neuro this AM regarding possible\n terminal extubation\n -off amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -CE\ns trending downward\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol completed, now rewarmed\n -off fentanyl/versed with no brainstem reflexes and poor prognosis, as\n per neuro\n - appreciate neurology care/input\n - 48 hour EEG (showing flat line as per neuro)\n - No corneal reflex this AM. Low likelihood of regaining cortical\n function.\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down and now normal\n .\n #Transaminitis - likely ischemic insult\n - trending downward\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n # FEN: NPO for now, NGT in place, replete lytes prn\n .\n # Dispo: DNR/DNI, wife has living will and is HCP, discussing goals of\n care and possible terminal extubation, as pt would not want to live\n like this, per family.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP: mouth care\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: discussing goals of care, transitioning to possible CMO\n and possible terminal extubation, as pt would not want to live like\n this\n ------ Protected Section ------\n Attending\ns Note.\n Reviewed overnight course.,\n Pt.No neurologic signs of life\n Agree with Dr.\ns note.\n Need family discussion on continued support therapy.\n Spent 45 mins on case.\n \n ------ Protected Section Addendum Entered By: \n on: 11:45 ------\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384618,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Patient DNR/DNI.\n - The family would like another family meeting today to update them on\n any progress in order to make any further decisions about proceeding\n with de-escalation of care.\n - Neuro says to continue 72 hours of EEG monitoring, but have little\n hope for any functional recovery.\n - Blood pressure labile, especially after patient is moved in bed->\n fluctuated from 50s-60s systolic to 200s in matter of minutes.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:30 AM\n Infusions:\n Dopamine - 4.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:30 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 04:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 86 (64 - 106) bpm\n BP: 94/53(68) {49/37(41) - 205/113(152)} mmHg\n RR: 12 (0 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 1,693 mL\n 316 mL\n PO:\n TF:\n IVF:\n 1,533 mL\n 256 mL\n Blood products:\n Total out:\n 4,680 mL\n 900 mL\n Urine:\n 4,680 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,987 mL\n -584 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 97%\n ABG: 7.45/40/116//4\n Ve: 5.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n 25\n 25\n 29\n Glucose\n 132\n 109\n 103\n 132\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation, now on Arctic sun protocol with diffuse\n anoxic brain injury on CT scan.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n - diffuse anoxic brain injury with poor prognosis (flat EEG, CT head\n showing worsening cerebral edema, physical exam without brainstem\n reflexes)\n - completed Arctic sun cooling protocol, now re-warmed\n - now DNR/DNI, family meeting with neuro this AM regarding possible\n terminal extubation\n -off amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -CE\ns trending downward\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol completed, now rewarmed\n -off fentanyl/versed with no brainstem reflexes and poor prognosis, as\n per neuro\n - appreciate neurology care/input\n - 48 hour EEG (showing flat line as per neuro)\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down and now normal\n .\n #Transaminitis - likely ischemic insult\n - trending downward\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n # FEN: NPO for now, NGT in place, replete lytes prn\n .\n # Dispo: DNR/DNI, wife has living will and is HCP, discussing goals of\n care and possible terminal extubation, as pt would not want to live\n like this, per family.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP: mouth care\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: discussing goals of care, transitioning to possible CMO\n and possible terminal extubation, as pt would not want to live like\n this\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384619,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Patient DNR/DNI.\n - The family would like another family meeting today to update them on\n any progress in order to make any further decisions about proceeding\n with de-escalation of care.\n - Neuro says to continue 72 hours of EEG monitoring, but have little\n hope for any functional recovery.\n - Blood pressure labile, especially after patient is moved in bed->\n fluctuated from 50s-60s systolic to 200s in matter of minutes.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:30 AM\n Infusions:\n Dopamine - 4.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:30 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 04:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 86 (64 - 106) bpm\n BP: 94/53(68) {49/37(41) - 205/113(152)} mmHg\n RR: 12 (0 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 1,693 mL\n 316 mL\n PO:\n TF:\n IVF:\n 1,533 mL\n 256 mL\n Blood products:\n Total out:\n 4,680 mL\n 900 mL\n Urine:\n 4,680 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,987 mL\n -584 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 97%\n ABG: 7.45/40/116//4\n Ve: 5.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n CXR - L sided effusion, bilateral atelectasis with superimposed\n infiltrates from possible aspiration\n Micro blood cx NGTD, sputum with 3+ GPC and sparse GNR\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n 25\n 25\n 29\n Glucose\n 132\n 109\n 103\n 132\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation, now on Arctic sun protocol with diffuse\n anoxic brain injury on CT scan.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n - diffuse anoxic brain injury with poor prognosis (flat EEG, CT head\n showing worsening cerebral edema, physical exam without brainstem\n reflexes)\n - completed Arctic sun cooling protocol, now re-warmed\n - now DNR/DNI, family meeting with neuro this AM regarding possible\n terminal extubation\n -off amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -CE\ns trending downward\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol completed, now rewarmed\n -off fentanyl/versed with no brainstem reflexes and poor prognosis, as\n per neuro\n - appreciate neurology care/input\n - 48 hour EEG (showing flat line as per neuro)\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down and now normal\n .\n #Transaminitis - likely ischemic insult\n - trending downward\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n # FEN: NPO for now, NGT in place, replete lytes prn\n .\n # Dispo: DNR/DNI, wife has living will and is HCP, discussing goals of\n care and possible terminal extubation, as pt would not want to live\n like this, per family.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP: mouth care\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: discussing goals of care, transitioning to possible CMO\n and possible terminal extubation, as pt would not want to live like\n this\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384625,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Patient DNR/DNI.\n - The family would like another family meeting today to update them on\n any progress in order to make any further decisions about proceeding\n with de-escalation of care.\n - Neuro says to continue 72 hours of EEG monitoring, but have little\n hope for any functional recovery.\n - Blood pressure labile, especially after patient is moved in bed->\n fluctuated from 50s-60s systolic to 200s in matter of minutes.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:30 AM\n Infusions:\n Dopamine - 4.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:30 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 04:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 86 (64 - 106) bpm\n BP: 94/53(68) {49/37(41) - 205/113(152)} mmHg\n RR: 12 (0 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 1,693 mL\n 316 mL\n PO:\n TF:\n IVF:\n 1,533 mL\n 256 mL\n Blood products:\n Total out:\n 4,680 mL\n 900 mL\n Urine:\n 4,680 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,987 mL\n -584 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 97%\n ABG: 7.45/40/116//4\n Ve: 5.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n CXR - L sided effusion, bilateral atelectasis with superimposed\n infiltrates from possible aspiration\n Micro blood cx NGTD, sputum with 3+ GPC and sparse GNR\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n 25\n 25\n 29\n Glucose\n 132\n 109\n 103\n 132\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation, now on Arctic sun protocol with diffuse\n anoxic brain injury on CT scan.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n - diffuse anoxic brain injury with poor prognosis (flat EEG, CT head\n showing worsening cerebral edema, physical exam without brainstem\n reflexes)\n - completed Arctic sun cooling protocol, now re-warmed\n - now DNR/DNI, family meeting with neuro this AM regarding possible\n terminal extubation\n -off amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -CE\ns trending downward\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol completed, now rewarmed\n -off fentanyl/versed with no brainstem reflexes and poor prognosis, as\n per neuro\n - appreciate neurology care/input\n - 48 hour EEG (showing flat line as per neuro)\n - No corneal reflex this AM. Low likelihood of regaining cortical\n function.\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down and now normal\n .\n #Transaminitis - likely ischemic insult\n - trending downward\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n # FEN: NPO for now, NGT in place, replete lytes prn\n .\n # Dispo: DNR/DNI, wife has living will and is HCP, discussing goals of\n care and possible terminal extubation, as pt would not want to live\n like this, per family.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP: mouth care\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: discussing goals of care, transitioning to possible CMO\n and possible terminal extubation, as pt would not want to live like\n this\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384626,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Patient DNR/DNI.\n - The family would like another family meeting today to update them on\n any progress in order to make any further decisions about proceeding\n with de-escalation of care.\n - Neuro says to continue 72 hours of EEG monitoring, but have little\n hope for any functional recovery.\n - Blood pressure labile, especially after patient is moved in bed->\n fluctuated from 50s-60s systolic to 200s in matter of minutes.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:30 AM\n Infusions:\n Dopamine - 4.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:30 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 04:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 86 (64 - 106) bpm\n BP: 94/53(68) {49/37(41) - 205/113(152)} mmHg\n RR: 12 (0 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 1,693 mL\n 316 mL\n PO:\n TF:\n IVF:\n 1,533 mL\n 256 mL\n Blood products:\n Total out:\n 4,680 mL\n 900 mL\n Urine:\n 4,680 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,987 mL\n -584 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 97%\n ABG: 7.45/40/116//4\n Ve: 5.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n CXR - L sided effusion, bilateral atelectasis with superimposed\n infiltrates from possible aspiration\n Micro blood cx NGTD, sputum with 3+ GPC and sparse GNR\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n 25\n 25\n 29\n Glucose\n 132\n 109\n 103\n 132\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation, now on Arctic sun protocol with diffuse\n anoxic brain injury on CT scan.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n - diffuse anoxic brain injury with poor prognosis (flat EEG, CT head\n showing worsening cerebral edema, physical exam without brainstem\n reflexes)\n - completed Arctic sun cooling protocol, now re-warmed\n - now DNR/DNI, family meeting with neuro this AM regarding possible\n terminal extubation\n -off amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -CE\ns trending downward\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol completed, now rewarmed\n -off fentanyl/versed with no brainstem reflexes and poor prognosis, as\n per neuro\n - appreciate neurology care/input\n - 48 hour EEG (showing flat line as per neuro)\n - No corneal reflex this AM. Low likelihood of regaining cortical\n function.\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down and now normal\n .\n #Transaminitis - likely ischemic insult\n - trending downward\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n # FEN: NPO for now, NGT in place, replete lytes prn\n .\n # Dispo: DNR/DNI, wife has living will and is HCP, discussing goals of\n care and possible terminal extubation, as pt would not want to live\n like this, per family.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP: mouth care\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: discussing goals of care, transitioning to possible CMO\n and possible terminal extubation, as pt would not want to live like\n this\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384715,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt remains intubated, on vent, since family awaiting other members to\n arrive before making final decision re: transition to CMO.\n - neuro evaluated patient and assessment is brain death based on EEG,\n physical exam.\n - apnea test has not been performed, as family seems to be trending\n toward terminal extubation and declining at this time\n - organ bank called to notify about patients status; they\n closed the case as pt has not had formal apnea testing done. Stating\n that pt needs to have all formal testing completed prior to their\n speaking with pt re: organ donation.\n - spoke with organ bank again this AM; they will come and\n speak with family this time.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 09:29 PM\n Piperacillin/Tazobactam (Zosyn) - 01:40 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 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 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.6\n HR: 97 (69 - 115) bpm\n BP: 107/75(87) {78/47(58) - 203/120(151)} mmHg\n RR: 12 (8 - 15) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 2,188 mL\n 245 mL\n PO:\n TF:\n IVF:\n 1,948 mL\n 245 mL\n Blood products:\n Total out:\n 6,240 mL\n 3,000 mL\n Urine:\n 6,240 mL\n 3,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,052 mL\n -2,755 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 RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 99%\n ABG: ////\n Ve: 5.8 L/min\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 128 K/uL\n 12.3 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.9 %\n 9.4 K/uL\n [image002.jpg]\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n 05:30 AM\n 05:44 AM\n WBC\n 8.1\n 9.3\n 9.4\n Hct\n 38.2\n 37.2\n 37.9\n Plt\n 148\n 134\n 128\n Cr\n 0.7\n 0.7\n 0.8\n TropT\n 0.29\n 0.15\n 0.10\n TCO2\n 26\n 28\n 25\n 25\n 29\n 32\n Glucose\n 132\n 109\n 103\n 132\n 96\n Other labs: PT / PTT / INR:17.3/38.9/1.5, CK / CKMB /\n Troponin-T:808/21/0.10, ALT / AST:145/139, Alk Phos / T Bili:86/0.3,\n Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, Ca++:8.3 mg/dL, Mg++:2.3\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 y/o male with parkinsonism,\n autonomic instability, who was admitted to CCU following PEA arrest,\n likely secondary to aspiration, now s/p Arctic sun protocol, re-warmed\n and off sedation, with anoxic brain injury and worsening cerebral\n edema on CT scan, flat lining EEG, no brainstem reflexes, and no\n spontaneous breathing.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n - diffuse anoxic brain injury with poor prognosis (flat EEG, CT head\n showing worsening cerebral edema, physical exam without brainstem\n reflexes)\n - completed Arctic sun cooling protocol, now re-warmed\n - now DNR/DNI, family waiting for other members before making final\n decision re: CMO/terminal extubation\n - off amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n - monitor on telemetry\n - Organ bank notified of patient; they closed the case\n stating that the patient needs to have all formal testing completed\n prior to their speaking with patient. Unclear if this is actually the\n case, after reviewing our brain death policy.\n - will need to speak with family re: CMO status, apnea testing (which\n they have deferred up to this point), and terminal extubation, since\n the family states that the patient would not want to live like this.\n - can be formally declared brain dead, if does not pass apnea test\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -CE\ns trending downward\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis but will\n d/c as we are moving to CMO\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol completed, now re-warmed, with unchanged exam\n -off fentanyl/versed with no brainstem reflexes and poor prognosis, as\n per neuro\n - appreciate neurology care/input\n - 72 hour EEG completed (showing flat line as per neuro)\n - No corneal reflex this AM. Low likelihood of regaining cortical\n function.\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down and now normal\n .\n #Transaminitis - likely ischemic insult\n - trending downward\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n # FEN: NPO for now, NGT in place, replete lytes prn\n .\n # Dispo: DNR/DNI, wife has living will and is HCP, discussing goals of\n care and possible terminal extubation, as pt would not want to live\n like this, per family. Will d/c Abx and those medications not\n supporting BP.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer:\n VAP: mouth care\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: DNR/DNI, wife has living will and is HCP, discussing goals\n of care and possible terminal extubation, as pt would not want to live\n like this, per family. organ bank coming to speak with\n family today.\n ------ Protected Section ------\n Attending\ns Note\n Reviewed overnight course.\n No change.examined Pt\n Agree with Dr.\ns note\n Spent 40 mins on case\n \n ------ Protected Section Addendum Entered By: \n on: 11:47 ------\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384603,
"text": "80 y/o M w/ OSA, parkinsons, syncope orthostatic hypotension,\n primary autonomic dysfunction w/ very labile BPs--on Midodrine and salt\n to maintain BP at home. Apneic, PEA at home . Cooled by artic sun\n protocol in CCU, re-warmed 11:00 yesterday. Head CT: Global anoxic\n injury w/ repeat showing evidence of severe global cortical edema.\n Family meeting yesterday\n aware of grave condition and grim prognosis.\n Now DNR.\n Hypotension (not Shock)\n Assessment:\n SBPs ranging from 50-205, very low BPs w/ turning in bed. UOP\n 140-600/hrs.\n Action:\n Dopa maintained to keep MAPs >60\n Response:\n Remains w/ extremely labile BPs w/o any changes in Dopa. Not able to\n wean off\n Plan:\n Wean Dopa as tolerated\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Unresponsive to all stim, no corneals, no cough/gag. Not overbreathing\n vent. Remains off sedation since :30 yesterday. Temp gradually down\n to 35.1 R.\n Action:\n Neuro checks to assess for any change, continuous EEG in place. Bair\n hugger applied for hypothermia.\n Response:\n NO change, remains unresponsive. Brain waves flat per neurology.\n Normothermic.\n Plan:\n Continue supportive care. Family mtg today with neuro and CCU team\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384605,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n There is indecisiveness among family members about his code status, but\n the decision was made yesterday to make the patient DNR/DNI. The\n family would like another family meeting today to update them on any\n progress in order to make any further decisions about proceeding with\n de-escalation of care. Neuro says to continue 72 hours of EEG\n monitoring, but have little hope for any functional recovery. Blood\n pressure labile, especially after patient is moved in bed-> fluctuated\n from 50s-60s systolic to 200s in matter of minutes.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:30 AM\n Infusions:\n Dopamine - 4.5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:30 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 04:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 86 (64 - 106) bpm\n BP: 94/53(68) {49/37(41) - 205/113(152)} mmHg\n RR: 12 (0 - 16) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 1,693 mL\n 316 mL\n PO:\n TF:\n IVF:\n 1,533 mL\n 256 mL\n Blood products:\n Total out:\n 4,680 mL\n 900 mL\n Urine:\n 4,680 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -2,987 mL\n -584 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 550) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 17 cmH2O\n Compliance: 41.7 cmH2O/mL\n SpO2: 97%\n ABG: 7.45/40/116//4\n Ve: 5.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 132 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.9 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n 25\n 25\n 29\n Glucose\n 132\n 109\n 103\n 132\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation, now on Arctic sun protocol with diffuse\n anoxic brain injury on CT scan.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n -d/c amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n -on artic sun cooling protocol x18 hours, monitor coagulation profile\n -PEA arrested overnight again, with unclear precipitant, but suspected\n to be related to progressive cerebral edema.\n -Head CT concerning for smaller ventricular size, ?worsening cerebral\n edema, no obvious herniation\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -trend CE's to peak\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol\n -low dose fentanyl/versed advised by cardiac arrest consult in case he\n is in a locked in state (can likely stop when warmed)\n - neurology consult in the am\n -48 hour EEG (showing flat line as per neuro)\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down, currently 2.2\n .\n #Transaminitis - likely ischemic insult\n -monitor trend\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n FEN: NPO for now, NGT in place, change to OGT if prolonged intubation,\n replete lytes prn, consider starting tube feeds in the AM\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384607,
"text": "80 y/o M w/ OSA, parkinsons, syncope orthostatic hypotension,\n primary autonomic dysfunction w/ very labile BPs--on Midodrine and salt\n to maintain BP at home. Admitted to CCU s/p PEA arrest and\n resuscitation at home. Cooled by artic sun protocol in CCU, re-warmed\n 11:00 yesterday. Head CT: Global anoxic injury prolonged PEA arrest\n of unknown duration, w/ repeat head CT showing evidence of severe\n global cortical edema. Brain waves flat per neurology. Family meeting\n yesterday\n aware of grim prognosis. Now DNR. NEOB aware of pt, called\n last night\n will call today to get update on pt status.\n Hypotension (not Shock)\n Assessment:\n SBPs ranging from 50-205, very low BPs especially w/ turning in bed.\n UOP 100-600cc/hr\n Action:\n Dopa maintained to keep MAPs >60.\n Midodrine given as ordered\n Response:\n Remains w/ extremely labile BPs w/o any changes in Dopa. Not able to\n wean off. AM Lactate\n Plan:\n Wean Dopa as tolerated\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Unresponsive to all stim, no corneals, no cough/gag. Not overbreathing\n vent. Remains off sedation since :30 yesterday. No seizure activity\n noted. Temp gradually down to 96.1R.\n Action:\n Neuro checks to assess for any change\n continuous EEG in place.\n HOB up 30 degrees to decrease ICP.\n Bair hugger applied for hypothermia.\n Response:\n NO change, remains unresponsive. Now normothermic.\n Plan:\n Continue supportive care. Family mtg today with neuro and\n CCU team.\n Keep NEOB informed.\n due to hypoxia from possible aspiration event given that main\n laboratory abnormality is hypoxia and also with new left sided\n infiltrate.\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384699,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt remains intubated, on vent, since family awaiting other members to\n arrive before making final decision re: transition to CMO.\n - neuro evaluated patient and assessment is brain death based on EEG,\n physical exam.\n - apnea test has not been performed, as family seems to be trending\n toward terminal extubation and declining at this time\n - organ bank called to notify about patients status; they\n closed the case as pt has not had formal apnea testing done. Stating\n that pt needs to have all formal testing completed prior to their\n speaking with pt re: organ donation.\n - spoke with organ bank again this AM; they will come and\n speak with family this time.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 09:29 PM\n Piperacillin/Tazobactam (Zosyn) - 01:40 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 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 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.6\n HR: 97 (69 - 115) bpm\n BP: 107/75(87) {78/47(58) - 203/120(151)} mmHg\n RR: 12 (8 - 15) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 2,188 mL\n 245 mL\n PO:\n TF:\n IVF:\n 1,948 mL\n 245 mL\n Blood products:\n Total out:\n 6,240 mL\n 3,000 mL\n Urine:\n 6,240 mL\n 3,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,052 mL\n -2,755 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 RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 99%\n ABG: ////\n Ve: 5.8 L/min\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 128 K/uL\n 12.3 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.9 %\n 9.4 K/uL\n [image002.jpg]\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n 05:30 AM\n 05:44 AM\n WBC\n 8.1\n 9.3\n 9.4\n Hct\n 38.2\n 37.2\n 37.9\n Plt\n 148\n 134\n 128\n Cr\n 0.7\n 0.7\n 0.8\n TropT\n 0.29\n 0.15\n 0.10\n TCO2\n 26\n 28\n 25\n 25\n 29\n 32\n Glucose\n 132\n 109\n 103\n 132\n 96\n Other labs: PT / PTT / INR:17.3/38.9/1.5, CK / CKMB /\n Troponin-T:808/21/0.10, ALT / AST:145/139, Alk Phos / T Bili:86/0.3,\n Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, Ca++:8.3 mg/dL, Mg++:2.3\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 y/o male with parkinsonism,\n autonomic instability, who was admitted to CCU following PEA arrest,\n likely secondary to aspiration, now s/p Arctic sun protocol, re-warmed\n and off sedation, with anoxic brain injury and worsening cerebral\n edema on CT scan, flat lining EEG, no brainstem reflexes, and no\n spontaneous breathing.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n - diffuse anoxic brain injury with poor prognosis (flat EEG, CT head\n showing worsening cerebral edema, physical exam without brainstem\n reflexes)\n - completed Arctic sun cooling protocol, now re-warmed\n - now DNR/DNI, family waiting for other members before making final\n decision re: CMO/terminal extubation\n - off amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n - monitor on telemetry\n - Organ bank notified of patient; they closed the case\n stating that the patient needs to have all formal testing completed\n prior to their speaking with patient. Unclear if this is actually the\n case, after reviewing our brain death policy.\n - will need to speak with family re: CMO status, apnea testing (which\n they have deferred up to this point), and terminal extubation, since\n the family states that the patient would not want to live like this.\n - can be formally declared brain dead, if does not pass apnea test\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -CE\ns trending downward\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis but will\n d/c as we are moving to CMO\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol completed, now re-warmed, with unchanged exam\n -off fentanyl/versed with no brainstem reflexes and poor prognosis, as\n per neuro\n - appreciate neurology care/input\n - 72 hour EEG completed (showing flat line as per neuro)\n - No corneal reflex this AM. Low likelihood of regaining cortical\n function.\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down and now normal\n .\n #Transaminitis - likely ischemic insult\n - trending downward\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n # FEN: NPO for now, NGT in place, replete lytes prn\n .\n # Dispo: DNR/DNI, wife has living will and is HCP, discussing goals of\n care and possible terminal extubation, as pt would not want to live\n like this, per family. Will d/c Abx and those medications not\n supporting BP.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer:\n VAP: mouth care\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: DNR/DNI, wife has living will and is HCP, discussing goals\n of care and possible terminal extubation, as pt would not want to live\n like this, per family. organ bank coming to speak with\n family today.\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384700,
"text": "Chief Complaint:\n 24 Hour Events:\n - pt remains intubated, on vent, since family awaiting other members to\n arrive before making final decision re: transition to CMO.\n - neuro evaluated patient and assessment is brain death based on EEG,\n physical exam.\n - apnea test has not been performed, as family seems to be trending\n toward terminal extubation and declining at this time\n - organ bank called to notify about patients status; they\n closed the case as pt has not had formal apnea testing done. Stating\n that pt needs to have all formal testing completed prior to their\n speaking with pt re: organ donation.\n - spoke with organ bank again this AM; they will come and\n speak with family this time.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 06:19 PM\n Vancomycin - 09:29 PM\n Piperacillin/Tazobactam (Zosyn) - 01:40 AM\n Infusions:\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 09:00 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 06:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (99\n Tcurrent: 35.9\nC (96.6\n HR: 97 (69 - 115) bpm\n BP: 107/75(87) {78/47(58) - 203/120(151)} mmHg\n RR: 12 (8 - 15) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.2 kg (admission): 76.5 kg\n Total In:\n 2,188 mL\n 245 mL\n PO:\n TF:\n IVF:\n 1,948 mL\n 245 mL\n Blood products:\n Total out:\n 6,240 mL\n 3,000 mL\n Urine:\n 6,240 mL\n 3,000 mL\n NG:\n Stool:\n Drains:\n Balance:\n -4,052 mL\n -2,755 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 RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 22 cmH2O\n Plateau: 19 cmH2O\n SpO2: 99%\n ABG: ////\n Ve: 5.8 L/min\n Physical Examination\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 128 K/uL\n 12.3 g/dL\n 96 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 116 mEq/L\n 152 mEq/L\n 37.9 %\n 9.4 K/uL\n [image002.jpg]\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n 10:03 AM\n 12:19 PM\n 03:36 PM\n 04:10 PM\n 05:30 AM\n 05:44 AM\n WBC\n 8.1\n 9.3\n 9.4\n Hct\n 38.2\n 37.2\n 37.9\n Plt\n 148\n 134\n 128\n Cr\n 0.7\n 0.7\n 0.8\n TropT\n 0.29\n 0.15\n 0.10\n TCO2\n 26\n 28\n 25\n 25\n 29\n 32\n Glucose\n 132\n 109\n 103\n 132\n 96\n Other labs: PT / PTT / INR:17.3/38.9/1.5, CK / CKMB /\n Troponin-T:808/21/0.10, ALT / AST:145/139, Alk Phos / T Bili:86/0.3,\n Lactic Acid:0.9 mmol/L, Albumin:3.5 g/dL, Ca++:8.3 mg/dL, Mg++:2.3\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 y/o male with parkinsonism,\n autonomic instability, who was admitted to CCU following PEA arrest,\n likely secondary to aspiration, now s/p Arctic sun protocol, re-warmed\n and off sedation, with anoxic brain injury and worsening cerebral\n edema on CT scan, flat lining EEG, no brainstem reflexes, and no\n spontaneous breathing.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n - diffuse anoxic brain injury with poor prognosis (flat EEG, CT head\n showing worsening cerebral edema, physical exam without brainstem\n reflexes)\n - completed Arctic sun cooling protocol, now re-warmed\n - now DNR/DNI, family waiting for other members before making final\n decision re: CMO/terminal extubation\n - off amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n - monitor on telemetry\n - Organ bank notified of patient; they closed the case\n stating that the patient needs to have all formal testing completed\n prior to their speaking with patient. Unclear if this is actually the\n case, after reviewing our brain death policy.\n - will need to speak with family re: CMO status, apnea testing (which\n they have deferred up to this point), and terminal extubation, since\n the family states that the patient would not want to live like this.\n - can be formally declared brain dead, if does not pass apnea test\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -CE\ns trending downward\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis but will\n d/c as we are moving to CMO\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol completed, now re-warmed, with unchanged exam\n -off fentanyl/versed with no brainstem reflexes and poor prognosis, as\n per neuro\n - appreciate neurology care/input\n - 72 hour EEG completed (showing flat line as per neuro)\n - No corneal reflex this AM. Low likelihood of regaining cortical\n function.\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down and now normal\n .\n #Transaminitis - likely ischemic insult\n - trending downward\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n # FEN: NPO for now, NGT in place, replete lytes prn\n .\n # Dispo: DNR/DNI, wife has living will and is HCP, discussing goals of\n care and possible terminal extubation, as pt would not want to live\n like this, per family. Will d/c Abx and those medications not\n supporting BP.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: heparin SQ\n Stress ulcer:\n VAP: mouth care\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: DNR/DNI, wife has living will and is HCP, discussing goals\n of care and possible terminal extubation, as pt would not want to live\n like this, per family. organ bank coming to speak with\n family today.\n"
},
{
"category": "Nutrition",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 384709,
"text": "Comments:\n Patient screened per ICU protocol, currenlty pending family decicion\n regardin goal of care, please page nutrition if any service is needed.\n \n"
},
{
"category": "Physician ",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 384409,
"text": "Chief Complaint: s/p PEA arrest\n HPI:\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation. His wife reports that on the day prior\n to admission he was in his usual state of health without any\n complaints. He went to bed at 11pm with his CPAP on. His wife awoke\n at 1:30AM and noted that he had a strange breathing pattern. She again\n awoke at 2:30 am and noted that he continued to be breathing strangely\n and then made several soft choking noises and stopped breathing. She\n attempted to awaken him with no response so she called EMS who\n reportedly arrived withing 5-10minutes.\n .\n On EMS arrival he was noted to be in PEA arrest he was given 7mg\n epinephrine, 2mg atropine, 2 amps sodium bicarb, 100mg lidocaine, 300mg\n amiodarone, DCCV x 5. He was started on amiodarone gtt and dopamine\n gtt. His pupils were noted to be fixed and dilated by EMS.\n .\n On review of systems, his wife denies any prior history of stroke, TIA,\n deep venous thrombosis, pulmonary embolism, bleeding at the time of\n surgery, myalgias, joint pains, cough, hemoptysis, black stools or red\n stools. He does not have any recent fevers, chills or rigors. Cardiac\n review of systems is notable for absence of chest pain, paroxysmal\n nocturnal dyspnea, orthopnea, ankle edema, palpitations.\n .\n In the ED, initial vitals were T34.8 rectal 128/77 HR 122 sinus\n tachycardia RR 18 99% RA. He had an EKG showing sinus tachycardia and\n a bedside echocardiogram showing hyperdynamic LV function, no wall\n motion abnormalities. He was started on artic sun protocol however his\n initial temperature was 34 degrees celsius. He had a head CT which\n showed evidence of global anoxic insult. He was admitted to the CCU\n for further care.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Midazolam (Versed) - 0.5 mg/hour\n Fentanyl - 25 mcg/hour\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n MEDICATIONS:\n AMANTADINE - 100 mg three times a day\n CARBIDOPA-LEVODOPA 25 mg-100 mg Tablet - 1 Tablet(s) \n CITALOPRAM 20mg daily\n MIDODRINE - 10mg q6am, 10mg q10am, 5mg q2pm and 5mg at 6pm (hold 2pm\n and 6pm doses for sbp >160)\n SODIUM CHLORIDE - 1G Tablet - TAKE UP TO TEN TABLETS A DAY\n TRIMETHOPRIM-SULFAMETHOXAZOLE 800 mg-160 mg Tablet 1 tab \n prilosec 20mg daily\n levothyroxine 50mcg daily\n Past medical history:\n Family history:\n Social History:\n -Parkinsonism\n -Autonomic Instability\n - Syncopal events since secondary to orthostatic\n hypotension\n - h/o positive tilt table test and othostatic hypotension,\n followed Dr. at \n -Neurogenic bladder\n - Has had foley catheter for 2 years due to urinary frequency\n - h/o Klebsiella and Pseuodomonal UTIs in , Enterobacter\n urosepsis\n -Hypothyroidism\n -Chronic low back pain\n -GERD\n -OSA\n -Hospital admission for partial small bowel obstruction and\n constipation \n -Empty sella syndrome - endocrine w/u negative\n -Benign bladder mass - s/p cystoscopy and biopsy\n -h/o idiopathic pancytopenia\n Mother - DM, passed away at 84\n Father - colon CA, passed away at 67\n Occupation:\n Drugs: denies\n Tobacco: remote history of ~15 pack years of smoking\n Alcohol: denies\n Other: lives with wife who assists him with all ADLs/IADL's\n Review of systems:\n Flowsheet Data as of 05:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 93 (76 - 105) bpm\n BP: 127/84(101) {104/71(83) - 127/84(101)} mmHg\n RR: 9 (9 - 28) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,822 mL\n PO:\n TF:\n IVF:\n 762 mL\n Blood products:\n Total out:\n 0 mL\n 555 mL\n Urine:\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,267 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 36 cmH2O\n Plateau: 29 cmH2O\n SpO2: 98%\n ABG: 7.39/39/94./24/0\n Ve: 8.5 L/min\n PaO2 / FiO2: 94\n Physical Examination\n VS: T=34 celsius on artic sun BP=107/81 HR= 150 regular RR=18 O2 sat=\n 98% AC 100%/550/16/5\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, unable to ausculate lung bases as artic sun\n cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 148 K/uL\n 12.3 g/dL\n 38.2 %\n 8.1 K/uL\n [image002.jpg]\n \n 2:33 A8/9/ 01:32 PM\n \n 10:20 P8/9/ 04:21 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 8.1\n Hct\n 38.2\n Plt\n 148\n TC02\n 24\n Other labs: Lactic Acid:4.0 mmol/L\n Fluid analysis / Other labs: ABG: 7.37/44/90/26\n lactate 7.1\n .\n 6:45 am Na 141 K 3.9 Cl 98 HCO 24 BUN 23 Creat 1 Gluc 303 AG: 19\n CKMB 12 Trop:0.16\n AST 374 ALT 109 AP 114 Lip 38 Tbili 0.4 alb 4.1\n WBC 9.9 HCT 40.9 PLT 166\n Serum tox: negative\n Urine tox: negative\n .\n UA: large blood, nitr neg, leukocytes neg, 0-2 epi\n Imaging: Head CT (prelim) - interval development of\n hypo-attenuation of bilateral basal ganglia, corpus callosum and\n thalamus since and diffuse loss of grey-white matter\n differentiation compatible with acute anoxic event. No evidence of\n hemorrhage or mass effect. Normal ventricles, air fluid level in left\n maxillary sinus with mucosal thickening of ethmoid and left frontal\n sinuses.\n No acute fractures.\n .\n CXR (prelim) - mild pulmonary edema, retrocardiac airspace opacity\n could represent atelectasis vs infection, probable small left pleural\n effusion, NGT in stomach, ET tube 3.3cm above the carina.\n Microbiology: Sputum Culture: pending\n Blood culture: pending\n Urine culture: pending\n ECG: 6:26 EKG: sinus tachycardia at 127 bpm, left axis\n deviation, left anterior fasicular block, QTc poor baseline upsloping\n ST depressions in V2-V4. Compared with prior EKG from \n tachycardia is new as are the likely rate related ST depressions in\n precordial leads, otherwise no significant changes.\n Assessment and Plan\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n o telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n -d/c amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n -on artic sun cooling protocol x18 hours, monitor coagulation profile\n -blood, sputum, urine cultures pending\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -trend CE's to peak\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient with PaO2 in the 90's on 100%FIO2. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram.\n -wean FIO2 as tolerated\n -will start abx if concern for pneumonia vs pneumonitis\n -consider CTA to eval for PE if remains hypoxic without clear cause\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unkown duration.\n -cooling protocol\n -low dose fentanyl/versed advised by cardiac arrest consult in case he\n is in a locked in state even though\n - neurology consult in the am\n -48 hour EEG\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates\n .\n #Transaminitis - likely ischemic insult\n -monitor trend\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, no evidence of\n infection on UA.\n .\n FEN: NPO for now, NGT in place, change to OGT if prolonged intubation,\n replete lytes prn, consider starting tube feeds in the AM\n .\n ACCESS: three 18G PIV's, left radial aline\n .\n PROPHYLAXIS:\n -DVT ppx with heparin sq\n -Pain management with fentanyl gtt\n -Bowel regimen with colace/senna\n -famotidine for stress ulcer prophylaxis\n -RISS q6 hours\n .\n CODE: full (confirmed with family)\n .\n COMM: with wife\n .\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 384410,
"text": "Chief Complaint: s/p PEA arrest\n HPI:\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation. His wife reports that on the day prior\n to admission he was in his usual state of health without any\n complaints. He went to bed at 11pm with his CPAP on. His wife awoke\n at 1:30AM and noted that he had a strange breathing pattern. She again\n awoke at 2:30 am and noted that he continued to be breathing strangely\n and then made several soft choking noises and stopped breathing. She\n attempted to awaken him with no response so she called EMS who\n reportedly arrived withing 5-10minutes.\n .\n On EMS arrival he was noted to be in PEA arrest he was given 7mg\n epinephrine, 2mg atropine, 2 amps sodium bicarb, 100mg lidocaine, 300mg\n amiodarone, DCCV x 5. He was started on amiodarone gtt and dopamine\n gtt. His pupils were noted to be fixed and dilated by EMS.\n .\n On review of systems, his wife denies any prior history of stroke, TIA,\n deep venous thrombosis, pulmonary embolism, bleeding at the time of\n surgery, myalgias, joint pains, cough, hemoptysis, black stools or red\n stools. He does not have any recent fevers, chills or rigors. Cardiac\n review of systems is notable for absence of chest pain, paroxysmal\n nocturnal dyspnea, orthopnea, ankle edema, palpitations.\n .\n In the ED, initial vitals were T34.8 rectal 128/77 HR 122 sinus\n tachycardia RR 18 99% RA. He had an EKG showing sinus tachycardia and\n a bedside echocardiogram showing hyperdynamic LV function, no wall\n motion abnormalities. He was started on artic sun protocol however his\n initial temperature was 34 degrees celsius. He had a head CT which\n showed evidence of global anoxic insult. He was admitted to the CCU\n for further care.\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Amiodarone - 0.5 mg/min\n Midazolam (Versed) - 0.5 mg/hour\n Fentanyl - 25 mcg/hour\n Dopamine - 5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n MEDICATIONS:\n AMANTADINE - 100 mg three times a day\n CARBIDOPA-LEVODOPA 25 mg-100 mg Tablet - 1 Tablet(s) \n CITALOPRAM 20mg daily\n MIDODRINE - 10mg q6am, 10mg q10am, 5mg q2pm and 5mg at 6pm (hold 2pm\n and 6pm doses for sbp >160)\n SODIUM CHLORIDE - 1G Tablet - TAKE UP TO TEN TABLETS A DAY\n TRIMETHOPRIM-SULFAMETHOXAZOLE 800 mg-160 mg Tablet 1 tab \n prilosec 20mg daily\n levothyroxine 50mcg daily\n Past medical history:\n Family history:\n Social History:\n -Parkinsonism\n -Autonomic Instability\n - Syncopal events since secondary to orthostatic\n hypotension\n - h/o positive tilt table test and othostatic hypotension,\n followed Dr. at \n -Neurogenic bladder\n - Has had foley catheter for 2 years due to urinary frequency\n - h/o Klebsiella and Pseuodomonal UTIs in , Enterobacter\n urosepsis\n -Hypothyroidism\n -Chronic low back pain\n -GERD\n -OSA\n -Hospital admission for partial small bowel obstruction and\n constipation \n -Empty sella syndrome - endocrine w/u negative\n -Benign bladder mass - s/p cystoscopy and biopsy\n -h/o idiopathic pancytopenia\n Mother - DM, passed away at 84\n Father - colon CA, passed away at 67\n Occupation:\n Drugs: denies\n Tobacco: remote history of ~15 pack years of smoking\n Alcohol: denies\n Other: lives with wife who assists him with all ADLs/IADL's\n Review of systems:\n Flowsheet Data as of 05:08 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 93 (76 - 105) bpm\n BP: 127/84(101) {104/71(83) - 127/84(101)} mmHg\n RR: 9 (9 - 28) insp/min\n SpO2: 98%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 3,822 mL\n PO:\n TF:\n IVF:\n 762 mL\n Blood products:\n Total out:\n 0 mL\n 555 mL\n Urine:\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 3,267 mL\n Respiratory\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 36 cmH2O\n Plateau: 29 cmH2O\n SpO2: 98%\n ABG: 7.39/39/94./24/0\n Ve: 8.5 L/min\n PaO2 / FiO2: 94\n Physical Examination\n VS: T=34 celsius on artic sun BP=107/81 HR= 150 regular RR=18 O2 sat=\n 98% AC 100%/550/16/5\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, unable to ausculate lung bases as artic sun\n cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 148 K/uL\n 12.3 g/dL\n 38.2 %\n 8.1 K/uL\n [image002.jpg]\n \n 2:33 A8/9/ 01:32 PM\n \n 10:20 P8/9/ 04:21 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 8.1\n Hct\n 38.2\n Plt\n 148\n TC02\n 24\n Other labs: Lactic Acid:4.0 mmol/L\n Fluid analysis / Other labs: ABG: 7.37/44/90/26\n lactate 7.1\n .\n 6:45 am Na 141 K 3.9 Cl 98 HCO 24 BUN 23 Creat 1 Gluc 303 AG: 19\n CKMB 12 Trop:0.16\n AST 374 ALT 109 AP 114 Lip 38 Tbili 0.4 alb 4.1\n WBC 9.9 HCT 40.9 PLT 166\n Serum tox: negative\n Urine tox: negative\n .\n UA: large blood, nitr neg, leukocytes neg, 0-2 epi\n Imaging: Head CT (prelim) - interval development of\n hypo-attenuation of bilateral basal ganglia, corpus callosum and\n thalamus since and diffuse loss of grey-white matter\n differentiation compatible with acute anoxic event. No evidence of\n hemorrhage or mass effect. Normal ventricles, air fluid level in left\n maxillary sinus with mucosal thickening of ethmoid and left frontal\n sinuses.\n No acute fractures.\n .\n CXR (prelim) - mild pulmonary edema, retrocardiac airspace opacity\n could represent atelectasis vs infection, probable small left pleural\n effusion, NGT in stomach, ET tube 3.3cm above the carina.\n Microbiology: Sputum Culture: pending\n Blood culture: pending\n Urine culture: pending\n ECG: 6:26 EKG: sinus tachycardia at 127 bpm, left axis\n deviation, left anterior fasicular block, QTc poor baseline upsloping\n ST depressions in V2-V4. Compared with prior EKG from \n tachycardia is new as are the likely rate related ST depressions in\n precordial leads, otherwise no significant changes.\n Assessment and Plan\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n o telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n -d/c amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n -on artic sun cooling protocol x18 hours, monitor coagulation profile\n -blood, sputum, urine cultures pending\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -trend CE's to peak\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient with PaO2 in the 90's on 100%FIO2. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram.\n -wean FIO2 as tolerated\n -will start abx if concern for pneumonia vs pneumonitis\n -consider CTA to eval for PE if remains hypoxic without clear cause\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unkown duration.\n -cooling protocol\n -low dose fentanyl/versed advised by cardiac arrest consult in case he\n is in a locked in state even though\n - neurology consult in the am\n -48 hour EEG\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates\n .\n #Transaminitis - likely ischemic insult\n -monitor trend\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, no evidence of\n infection on UA.\n .\n FEN: NPO for now, NGT in place, change to OGT if prolonged intubation,\n replete lytes prn, consider starting tube feeds in the AM\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384414,
"text": "PMH: Primary autonomic dysfunction. Very labile blood pressure.\n Neurogenic bladder. Foley X ~2ys with h/o klebsiella UTI, and\n Pseudomonas UTI resistant to cipro. Hypothyroidism, GERD. OSA. \n SMall bowel obstruction and constipation. Empty sella syndrone.\n This 80y old male was found apnic due to the alarm on his bipap machine\n by his wife. She called EMTs and he was in PEA. He was transported to\n OSH where he was resusitated. He was shocked ~5 times for VF, intubated\n and eventually stabilized. He was transported to on Amiodarone\n 1mg and dopamine at 5mic/kilo.\n He arrived in EW ~0645 and was hemodynamically stable. Arctic sun was\n intiated at 0845. His rectal temp on initiation was 34.8 and foley\n probe 32.9 (new foley placed). He was transported to CCU via head CT.\n His neuro exam showed no nuerologic response to any stimuli.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Pt reached goal cooling temp of 34 at 1030 and has remained there. He\n has no shivering. His pupils are large, and do not respond to light. He\n has catarcts and has had surgery in one eye. He has no cranial nerve\n fuction. He arms and legs are rigid, but this was true prior to this\n event. No spontaneous movements were seen, no response to noxious\n stimuli. He had head CT which showed no bleed, but ? hypoxic injury.\n Action:\n Cooling will continue until 0430 . He is receiving fentanyl\n 25mic/min and versed .5mg/hr to ensure if he is unable to respond he\n will be comfortable. He had EEG monitoring placed that will continue\n over the next few days.\n Response:\n Pt remains unresponsive, with no neurological functioning. He has\n remained at goal temp since 1030.\n Plan:\n Continue to monitor neurological status for change. Continue sedation\n until warming. If he shivers add paralytic . Begin warming at\n 0430.\n Ventricular fibrillation (VF)\n Assessment:\n Pt has has had no ectopy since arrival. He arrived in ST 110, but hr\n dropped to 70-80s and he appeared to be in A-fib. EKG difficult to\n evaluate due to difficulty obtaining flat baseline. He may be in\n Wenkebach droping every 4^th beat, but it is difficult to find\n consistent p-wave. He arrived on amiodarone 1mg which was d/c to .5mg\n at 1000.\n Action:\n As he has no ectopy amiodarone was d/c at 1700. He is on tele and\n lytes are being monitored. CKs are being cycled.\n Response:\n He continues to be ectopy free.\n Plan:\n Monitor for change in rhythm status.\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Upon arrival the skin around his coccyx appears thinned and of a darker\n color. One area appeared more purple and suspicious for DTI. The skin\n would . There were no broken areas. Pt does not move at all on\n his own. Skin is very dry.\n Action:\n Pt being turned Q 2 hrs side to side. When Coccyx assessed again darker\n areas were gone and there does not appear to be DTI. Criticade clear\n was applied to coccyx. The rest of his skin was lubricated with aloe\n vest moisture barrier cream. His heels are elevated on pillow.\n Response:\n No worsening of area around coccyx has occurred. No new areas of\n breakdown seen.\n Plan:\n Continue to turn Q 2 hrs and keep skin well lubricated.\n"
},
{
"category": "Respiratory ",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 384418,
"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: 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 Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: 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 Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Pt on artic sun protocol, eeg 24 hrs .\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384429,
"text": "PMH: Primary autonomic dysfunction. Very labile blood pressure.\n Neurogenic bladder. Foley X ~2ys with h/o klebsiella UTI, and\n Pseudomonas UTI resistant to cipro. Hypothyroidism, GERD. OSA. \n SMall bowel obstruction and constipation. Empty sella syndrone.\n This 80y old male was found apnic due to the alarm on his bipap machine\n by his wife. She called EMTs and he was in PEA. He was transported to\n OSH where he was resusitated. He was shocked ~5 times for VF, intubated\n and eventually stabilized. He was transported to on Amiodarone\n 1mg and dopamine at 5mic/kilo.\n He arrived in EW ~0645 and was hemodynamically stable. Arctic sun was\n intiated at 0845. His rectal temp on initiation was 34.8 and foley\n probe 32.9 (new foley placed). He was transported to CCU via head CT.\n His neuro exam showed no nuerologic response to any stimuli.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Pt reached goal cooling temp of 34 at 1030 and has remained there. He\n has no shivering. His pupils are large, and do not respond to light. He\n has catarcts and has had surgery in one eye. He has no cranial nerve\n fuction. He arms and legs are rigid, but this was true prior to this\n event. No spontaneous movements were seen, no response to noxious\n stimuli. He had head CT which showed no bleed, but ? hypoxic injury.\n Action:\n Cooling will continue until 0430 . He is receiving fentanyl\n 25mic/min and versed .5mg/hr to ensure if he is unable to respond he\n will be comfortable. He had EEG monitoring placed that will continue\n over the next few days.\n Response:\n Pt remains unresponsive, with no neurological functioning. He has\n remained at goal temp since 1030.\n Plan:\n Continue to monitor neurological status for change. Continue sedation\n until warming. If he shivers add paralytic . Begin warming at\n 0430.\n Ventricular fibrillation (VF)\n Assessment:\n Pt has has had no ectopy since arrival. He arrived in ST 110, but hr\n dropped to 70-80s and he appeared to be in A-fib. EKG difficult to\n evaluate due to difficulty obtaining flat baseline. He may be in\n Wenkebach droping every 4^th beat, but it is difficult to find\n consistent p-wave. He arrived on amiodarone 1mg which was d/c to .5mg\n at 1000.\n Action:\n As he has no ectopy amiodarone was d/c at 1700. He is on tele and\n lytes are being monitored. CKs are being cycled.\n Response:\n He continues to be ectopy free.\n Plan:\n Monitor for change in rhythm status.\n Hypoxemia\n Assessment:\n Pt arrived on full ventilatory support AC 550 X 16 with no\n overbreathing, 5 PEEP and 100%. He was sating 97-98%. He had minimal\n secretions down ET tube, but much more secretions orally. His lungs\n sounded clear, though diminished at the bases. Once a-line was in gas\n sent and it was 7.39/39/94/24.\n Action:\n PO2 lower than expected. Pt continued with VAP protocol. HOB kept at\n ~45 degrees and he was turned Q 2 hr. He was suction for small amts\n thick tan sputum and sample sent. At 1730 FIO2 decreased to 80%.\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Upon arrival the skin around his coccyx appears thinned and of a darker\n color. One area appeared more purple and suspicious for DTI. The skin\n would . There were no broken areas. Pt does not move at all on\n his own. Skin is very dry.\n Action:\n Pt being turned Q 2 hrs side to side. When Coccyx assessed again darker\n areas were gone and there does not appear to be DTI. Criticade clear\n was applied to coccyx. The rest of his skin was lubricated with aloe\n vest moisture barrier cream. His heels are elevated on pillow.\n Response:\n No worsening of area around coccyx has occurred. No new areas of\n breakdown seen.\n Plan:\n Continue to turn Q 2 hrs and keep skin well lubricated.\n Hypotension (not Shock)\n Assessment:\n Pt arrived on dopamine at 5.4 mic/kilo. Bp in low 100s. Of note he has\n autonomic dysfunction and require midodrine and salt to maintain BP. At\n baseline BP labile and is often in low 80s with pt being asymptomatic.\n Action:\n Numerous attempts made to decrease dopamine, but bp always dropped to\n low 80s or 70s. Midodrine ordered and given with initial improvement in\n bp, but further attempts to decrease dopamine again resulted in bp in\n 70s.\n Response:\n Dopamine now on 5mci/kilo with bp ranging 90-115/70s.\n Plan:\n Continue with midodrine. Wean dopamine as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384431,
"text": "PMH: Primary autonomic dysfunction. Very labile blood pressure.\n Neurogenic bladder. Foley X ~2ys with h/o klebsiella UTI, and\n Pseudomonas UTI resistant to cipro. Hypothyroidism, GERD. OSA. \n SMall bowel obstruction and constipation. Empty sella syndrone.\n This 80y old male was found apnic due to the alarm on his bipap machine\n by his wife. She called EMTs and he was in PEA. He was transported to\n OSH where he was resusitated. He was shocked ~5 times for VF, intubated\n and eventually stabilized. He was transported to on Amiodarone\n 1mg and dopamine at 5mic/kilo.\n He arrived in EW ~0645 and was hemodynamically stable. Arctic sun was\n intiated at 0845. His rectal temp on initiation was 34.8 and foley\n probe 32.9 (new foley placed). He was transported to CCU via head CT.\n His neuro exam showed no nuerologic response to any stimuli.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Pt reached goal cooling temp of 34 at 1030 and has remained there. He\n has no shivering. His pupils are large, and do not respond to light. He\n has catarcts and has had surgery in one eye. He has no cranial nerve\n fuction. He arms and legs are rigid, but this was true prior to this\n event. No spontaneous movements were seen, no response to noxious\n stimuli. He had head CT which showed no bleed, but ? hypoxic injury.\n Action:\n Cooling will continue until 0430 . He is receiving fentanyl\n 25mic/min and versed .5mg/hr to ensure if he is unable to respond he\n will be comfortable. He had EEG monitoring placed that will continue\n over the next few days.\n Response:\n Pt remains unresponsive, with no neurological functioning. He has\n remained at goal temp since 1030.\n Plan:\n Continue to monitor neurological status for change. Continue sedation\n until warming. If he shivers add paralytic . Begin warming at\n 0430.\n Ventricular fibrillation (VF)\n Assessment:\n Pt has has had no ectopy since arrival. He arrived in ST 110, but hr\n dropped to 70-80s and he appeared to be in A-fib. EKG difficult to\n evaluate due to difficulty obtaining flat baseline. He may be in\n Wenkebach droping every 4^th beat, but it is difficult to find\n consistent p-wave. He arrived on amiodarone 1mg which was d/c to .5mg\n at 1000.\n Action:\n As he has no ectopy amiodarone was d/c at 1700. He is on tele and\n lytes are being monitored. CKs are being cycled with 2^nd now 917, with\n MB pending.\n Response:\n He continues to be ectopy free.\n Plan:\n Monitor for change in rhythm status. Continue to cycle CKs next due\n ~1am.\n Hypoxemia\n Assessment:\n Pt arrived on full ventilatory support AC 550 X 16 with no\n overbreathing, 5 PEEP and 100%. He was sating 97-98%. He had minimal\n secretions down ET tube, but much more secretions orally. His lungs\n sounded clear, though diminished at the bases. Once a-line was in gas\n sent and it was 7.39/39/94/24. Lactate initially elevated to 7.\n Action:\n PO2 lower than expected. Pt continued with VAP protocol. HOB kept at\n ~45 degrees and he was turned Q 2 hr. He was suction for small amts\n thick tan sputum and sample sent as well as full set of cultures. At\n 1730 FIO2 decreased to 80%.Lactate decreasing to 4.\n Response:\n Pt tolerating lower FIO2 with gas on 80% 7.41/39/80/0/26. Lactate now\n 2.4.\n Plan:\n Continue with oral and pulmonary hygiene. Await results of cultures.\n Suction as needed.\n Impaired Skin Integrity\n Assessment:\n Upon arrival the skin around his coccyx appears thinned and of a darker\n color. One area appeared more purple and suspicious for DTI. The skin\n would . There were no broken areas. Pt does not move at all on\n his own. Skin is very dry.\n Action:\n Pt being turned Q 2 hrs side to side. When Coccyx assessed again darker\n areas were gone and there does not appear to be DTI. Criticade clear\n was applied to coccyx. The rest of his skin was lubricated with aloe\n vest moisture barrier cream. His heels are elevated on pillow.\n Response:\n No worsening of area around coccyx has occurred. No new areas of\n breakdown seen.\n Plan:\n Continue to turn Q 2 hrs and keep skin well lubricated.\n Hypotension (not Shock)\n Assessment:\n Pt arrived on dopamine at 5.4 mic/kilo. Bp in low 100s. Of note he has\n autonomic dysfunction and require midodrine and salt to maintain BP. At\n baseline BP labile and is often in low 80s with pt being asymptomatic.\n Action:\n Numerous attempts made to decrease dopamine, but bp always dropped to\n low 80s or 70s. Midodrine ordered and given with initial improvement in\n bp, but further attempts to decrease dopamine again resulted in bp in\n 70s.\n Response:\n Dopamine now on 5mci/kilo with bp ranging 90-115/70s.\n Plan:\n Continue with midodrine. Wean dopamine as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384437,
"text": "PMH: Primary autonomic dysfunction. Very labile blood pressure.\n Neurogenic bladder. Foley X ~2ys with h/o klebsiella UTI, and\n Pseudomonas UTI resistant to cipro. Hypothyroidism, GERD. OSA. \n SMall bowel obstruction and constipation. Empty sella syndrone.\n This 80y old male was found apnic due to the alarm on his bipap machine\n by his wife. She called EMTs and he was in PEA. He was transported to\n OSH where he was resusitated. He was shocked ~5 times for VF, intubated\n and eventually stabilized. He was transported to on Amiodarone\n 1mg and dopamine at 5mic/kilo.\n He arrived in EW ~0645 and was hemodynamically stable. Arctic sun was\n intiated at 0845. His rectal temp on initiation was 34.8 and foley\n probe 32.9 (new foley placed). He was transported to CCU via head CT.\n His neuro exam showed no nuerologic response to any stimuli.\n He has NG tube draining G- clear to yellow fluid. He has minimal bowel\n sounds. Urine output is 20-50cc/hr and he is net positive. His wife and\n 3 of his 4 daughters and his son have been here all day. They are aware\n of the severity of what has occurred and are aware he may have suffered\n anoxic injury. They are supportive of each other.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Pt reached goal cooling temp of 34 at 1030 and has remained there. He\n has no shivering. His pupils are large, and do not respond to light. He\n has catarcts and has had surgery in one eye. He has no cranial nerve\n fuction. He arms and legs are rigid, but this was true prior to this\n event. No spontaneous movements were seen, no response to noxious\n stimuli. He had head CT which showed no bleed, but ? hypoxic injury.\n Action:\n Cooling will continue until 0430 . He is receiving fentanyl\n 25mic/min and versed .5mg/hr to ensure if he is unable to respond he\n will be comfortable. He had EEG monitoring placed that will continue\n over the next few days.\n Response:\n Pt remains unresponsive, with no neurological functioning. He has\n remained at goal temp since 1030.\n Plan:\n Continue to monitor neurological status for change. Continue sedation\n until warming. If he shivers add paralytic . Begin warming at\n 0430.\n Ventricular fibrillation (VF)\n Assessment:\n Pt has has had no ectopy since arrival. He arrived in ST 110, but hr\n dropped to 70-80s and he appeared to be in A-fib. EKG difficult to\n evaluate due to difficulty obtaining flat baseline. He may be in\n Wenkebach droping every 4^th beat, but it is difficult to find\n consistent p-wave. He arrived on amiodarone 1mg which was d/c to .5mg\n at 1000. His K+ was 3.5 and he will be replaced with 40 meq IV.\n Action:\n As he has no ectopy amiodarone was d/c at 1700. He is on tele and\n lytes are being monitored. CKs are being cycled with 2^nd now 917, with\n MB pending. K\n Response:\n He continues to be ectopy free.\n Plan:\n Monitor for change in rhythm status. Continue to cycle CKs next due\n ~1am. Check lytes\n Hypoxemia\n Assessment:\n Pt arrived on full ventilatory support AC 550 X 16 with no\n overbreathing, 5 PEEP and 100%. He was sating 97-98%. He had minimal\n secretions down ET tube, but much more secretions orally. His lungs\n sounded clear, though diminished at the bases. Once a-line was in gas\n sent and it was 7.39/39/94/24. Lactate initially elevated to 7.\n Action:\n PO2 lower than expected. Pt continued with VAP protocol. HOB kept at\n ~45 degrees and he was turned Q 2 hr. He was suction for small amts\n thick tan sputum and sample sent as well as full set of cultures. At\n 1730 FIO2 decreased to 80%.Lactate decreasing to 4.\n Response:\n Pt tolerating lower FIO2 with gas on 80% 7.41/39/80/0/26. Lactate now\n 2.4.\n Plan:\n Continue with oral and pulmonary hygiene. Await results of cultures.\n Suction as needed.\n Impaired Skin Integrity\n Assessment:\n Upon arrival the skin around his coccyx appears thinned and of a darker\n color. One area appeared more purple and suspicious for DTI. The skin\n would . There were no broken areas. Pt does not move at all on\n his own. Skin is very dry.\n Action:\n Pt being turned Q 2 hrs side to side. When Coccyx assessed again darker\n areas were gone and there does not appear to be DTI. Criticade clear\n was applied to coccyx. The rest of his skin was lubricated with aloe\n vest moisture barrier cream. His heels are elevated on pillow.\n Response:\n No worsening of area around coccyx has occurred. No new areas of\n breakdown seen.\n Plan:\n Continue to turn Q 2 hrs and keep skin well lubricated.\n Hypotension (not Shock)\n Assessment:\n Pt arrived on dopamine at 5.4 mic/kilo. Bp in low 100s. Of note he has\n autonomic dysfunction and require midodrine and salt to maintain BP. At\n baseline BP labile and is often in low 80s with pt being asymptomatic.\n Action:\n Numerous attempts made to decrease dopamine, but bp always dropped to\n low 80s or 70s. Midodrine ordered and given with initial improvement in\n bp, but further attempts to decrease dopamine again resulted in bp in\n 70s.\n Response:\n Dopamine now on 5mci/kilo with bp ranging 90-115/70s.\n Plan:\n Continue with midodrine. Wean dopamine as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384565,
"text": "Pt is an 80 yo man w/PMHx including primary autonomic dysfunction\n w/very labile blood pressure, neurogenic bladder - foley ~2yrs with h/o\n klebsiella and pseudomonas UTI-resistant to cipro; Hypothyroidism,\n GERD; small bowel obstruction and constipation. empty sella\n syndrone.\n On , pt found apneicin bed by wife after she awoke to hear irreg\n breathing by pt who wears bipap machine at night. Pt w/probable\n prolong hypoxic period - called emt\ns - found in PEA - resuscitated\n -to OSH then.transferred to for further management. He arrived in\n ew ~ @ 0645 - hemodynamically stable. Arctic sun intiated at\n 0845 w/goal 34 degrees achieved at 1-30 admitted to CCU for further\n medical management.\n anoxic brain damage\n Assessment:\n Remains unresponsive to all stimuli\n no cough, gag, corneals, pupils\n 5mm on right, 6mm on left\n not reactive; pt very rigid in AM, now more\n flaccid; continuous EEG in place\n brain waves flat per neurology; pt\n re-warmed per Arctic sun protocol\n Action:\n pt re-warmed per Arctic sun protocol and reached goal 37 C at 1100; no\n sedation since Versed/Fentanyl d/c\nd ~ 0130; , Neurology met with wife\n and 2 daughters (, ) this am and gave prognostic assessment\n of pt\n Response:\n No change in neurological exam throughout day\n Plan:\n Continue to monitor neurological status for change; Continue to keep pt\n and family informed of any change in pt condition.\n Hypoxemia\n Assessment:\n PaO2 marginal on 50% Fio2; + pneumonia by CXR\n Action:\n Pt returned to FiO2 60%; VAP protocol continues, minimal secretions by\n suction; lungs clear to diminished at bases; BC\ns positive\n repeat\n sent\n Response:\n Improved ABG on increased FiO2;\n Plan:\n Continue to provide oral care and pulmonary hygiene. Await results of\n cultures. Suction as needed. Cont antibx as ordered, awaiting Zosyn\n approval by ID\n Impaired Skin Integrity\n Assessment:\n coccyx area thinned & darkened; blanching\n skin remains intact ; area\n of ? skin tears vs defib burn on pts chest\n Action:\n turned Q 2 hrs side to side. Criticaid/ triple cream applied to\n coccyx; chest cleaned with NS\n presently open to air\n Response:\n areas unchanged\n Plan:\n Continue to turn q2 hrs; keep skin well lubricated.\n Hypotension (not Shock)\n Assessment:\n Pt w/primary autonomic dysfunction and maintained on Midodrine and salt\n to maintain BP - baseline BP labile BP in CCU continues to be labile\n w/SBP range 40\ns/ - 190\n Action:\n Dopamine gtt up and down to keep BP in normal range\npresently on\n Dopamine 5mcgs/min; Continues on Midodrine.\n Response:\n BP remains labile\n Plan:\n Wean/titrate Dopa as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384567,
"text": "Pt is an 80 yo man w/PMHx including primary autonomic dysfunction\n w/very labile blood pressure, neurogenic bladder - foley ~2yrs with h/o\n klebsiella and pseudomonas UTI-resistant to cipro; Hypothyroidism,\n GERD; small bowel obstruction and constipation. empty sella\n syndrone.\n On , pt found apneicin bed by wife after she awoke to hear irreg\n breathing by pt who wears bipap machine at night. Pt w/probable\n prolong hypoxic period - called emt\ns - found in PEA - resuscitated\n -to OSH then.transferred to for further management. He arrived in\n ew ~ @ 0645 - hemodynamically stable. Arctic sun intiated at\n 0845 w/goal 34 degrees achieved at 1-30 admitted to CCU for further\n medical management.\n anoxic brain damage\n Assessment:\n Remains unresponsive to all stimuli\n no cough, gag, corneals, pupils\n 5mm on right, 6mm on left\n not reactive; pt very rigid in AM, now more\n flaccid; continuous EEG in place\n brain waves flat per neurology; pt\n re-warmed per Arctic sun protocol\n Action:\n pt re-warmed per Arctic sun protocol and reached goal 37 C at 1100; no\n sedation since Versed/Fentanyl d/c\nd ~ 0130; , Neurology met with wife\n and 2 daughters (, ) this am and gave prognostic assessment\n of pt\n Response:\n No change in neurological exam throughout day\n Plan:\n Continue to monitor neurological status for change; Continue to keep pt\n and family informed of any change in pt condition.\n Hypoxemia\n Assessment:\n PaO2 marginal on 50% Fio2; + pneumonia by CXR\n Action:\n Pt returned to FiO2 60%; VAP protocol continues, minimal secretions by\n suction; lungs clear to diminished at bases; BC\ns positive\n repeat\n sent\n Response:\n Improved ABG on increased FiO2;\n Plan:\n Continue to provide oral care and pulmonary hygiene. Await results of\n cultures. Suction as needed. Cont antibx as ordered, awaiting Zosyn\n approval by ID\n Impaired Skin Integrity\n Assessment:\n coccyx area thinned & darkened; blanching\n skin remains intact ; area\n of ? skin tears vs defib burn on pts chest\n Action:\n turned Q 2 hrs side to side. Criticaid/ triple cream applied to\n coccyx; chest cleaned with NS\n presently open to air\n Response:\n areas unchanged\n Plan:\n Continue to turn q2 hrs; keep skin well lubricated.\n Hypotension (not Shock)\n Assessment:\n Pt w/primary autonomic dysfunction and maintained on Midodrine and salt\n to maintain BP - baseline BP labile BP in CCU continues to be labile\n w/SBP range 40\ns/ - 190\n Action:\n Dopamine gtt up and down to keep BP in normal range\npresently on\n Dopamine 5mcgs/min; Continues on Midodrine.\n Response:\n BP remains labile\n Plan:\n Wean/titrate Dopa as needed.\n Potential for Ineffective Coping\n Assessment:\n Pt\ns daughter identified to RN the potential for conflict among\n family members (wife, 4 children) regarding decision-making for patient\n Action:\n Family meeting this AM with neurology team, CCU resident (), SW\n ( ), RN, neuron relayed to family news of poor prognosis;\n social worker involved and spent time with family,\n Chaplains also involved and providing support\n Response:\n Family is considering DNR status but is awaiting 1 son to visit after\n work before any decisions are made\n Plan:\n CCU team to meet with family again once everyone is present; Keep all\n family members informed of any changes in patients condition, Encourage\n family members to keep patient\ns wishes in mind when making decisions\n regarding pt\ns care; Social service, chaplains to remain involved to\n support family.\n"
},
{
"category": "Respiratory ",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 384579,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n 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: 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 / None\n Comments: No cough response with sxn. No gag response with oral sxn.\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: AC 500 x12 x 60% peep 5\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, Hemodynimic instability, Underlying illness not resolved. Cont\n current support at this time. Per Neuro team, poor neuro prognosis.\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384668,
"text": "Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384669,
"text": "80 y/o M w/ OSA, parkinsons, syncope orthostatic hypotension,\n primary autonomic dysfunction w/ very labile BPs--on Midodrine and salt\n to maintain BP at home. Admitted to CCU s/p PEA arrest and\n resuscitation at home. Cooled by artic sun protocol in CCU, re-warmed\n 11:00 yesterday. Head CT: Global anoxic injury prolonged PEA arrest\n of unknown duration, w/ repeat head CT showing evidence of severe\n global cortical edema. Brain waves flat and likelihood of significant\n recovery nears zero. Family meeting yesterday\n aware of grim\n prognosis. Now DNR. ***NEOB aware of pt, called last night\n will call\n today to get update on pt status.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Pt unresponsive to all stimulation, NSR hr 80-110, dopa 4.5mcg, bp\n labile.\n Action:\n Response:\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2177-09-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 384670,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\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 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 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: Triggering synchronously\n Plan\n Next 24-48 hours: Pt to be evaluated by team and family in the AM plan\n of care\n Reason for continuing current ventilatory support:\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384522,
"text": "Chief Complaint:\n 24 Hour Events:\n Went into wenckebach rhythm. A-lined and BP correlating with cuff\n pressures. Head CT showing diffuse anoxic brain injury. EEG done. Pt\n with high FIO2 requirements (80%). Lactate trending down.\n At hrs, pt brady'ed and went into PEA arrest --> CPR started,\n given atropine x 1, epi x 1, came out of arrest into sinus tach, BP\n 220s after 3-4 mins of PEA arrest.\n Head CT and CTA ordered to look for worsening cerebreal edema, ?PE.\n Head CT shows ventricles are slightly smaller in size compared with the\n morning head ct suggesting progression of cerebral edema, although lot\n of artifact on study from MRI leads. Chest CT shows bilateral\n infiltrates could be c/w aspiration pneumonia, no pulmonary embolus\n although one small area in the LLL subsegmental branch that could be\n c/w PE. He was started on vanc/zosyn to cover for aspiration\n pneumonia. In addition, one set of blood cultures returned with both\n bottles with GPC's in pairs, second set with no growth thus far.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 11:30 PM\n Vancomycin - 12:10 AM\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 66 (61 - 107) bpm\n BP: 92/63(74) {88/61(71) - 150/95(117)} mmHg\n RR: 16 (0 - 28) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,606 mL\n 590 mL\n PO:\n TF:\n IVF:\n 1,486 mL\n 590 mL\n Blood products:\n Total out:\n 778 mL\n 800 mL\n Urine:\n 778 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,828 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%, Vent Dependant\n PIP: 31 cmH2O\n Plateau: 27 cmH2O\n SpO2: 100%\n ABG: 7.41/42/179/26/2\n Ve: 8.4 L/min\n PaO2 / FiO2: 298\n Physical Examination\n VS: T=34 celsius on artic sun BP=107/81 HR= 150 regular RR=18 O2 sat=\n 98% AC 100%/550/16/5\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 109 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n Glucose\n 132\n 109\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation, now on Arctic sun protocol with diffuse\n anoxic brain injury on CT scan.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n -d/c amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n -on artic sun cooling protocol x18 hours, monitor coagulation profile\n -PEA arrested overnight again, with unclear precipitant, but suspected\n to be related to progressive cerebral edema.\n -Head CT concerning for smaller ventricular size, ?worsening cerebral\n edema, no obvious herniation\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -trend CE's to peak\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol\n -low dose fentanyl/versed advised by cardiac arrest consult in case he\n is in a locked in state (can likely stop when warmed)\n - neurology consult in the am\n -48 hour EEG (showing flat line)\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down, currently 2.2\n .\n #Transaminitis - likely ischemic insult\n -monitor trend\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n FEN: NPO for now, NGT in place, change to OGT if prolonged intubation,\n replete lytes prn, consider starting tube feeds in the AM\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 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": "2177-09-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384524,
"text": "Chief Complaint:\n 24 Hour Events:\n Went into wenckebach rhythm. A-lined and BP correlating with cuff\n pressures. Head CT showing diffuse anoxic brain injury. EEG done. Pt\n with high FIO2 requirements (80%). Lactate trending down.\n At hrs, pt brady'ed and went into PEA arrest --> CPR started,\n given atropine x 1, epi x 1, came out of arrest into sinus tach, BP\n 220s after 3-4 mins of PEA arrest.\n Called by neuro fellow, stating that pt may be in non-convulsive\n status. Explained that pt was just PEA arrested, and was given CPR.\n Told that pt\ns EEG is flat lining.\n Head CT and CTA ordered to look for worsening cerebreal edema, ?PE.\n Head CT shows ventricles are slightly smaller in size compared with the\n morning head ct suggesting progression of cerebral edema, although lot\n of artifact on study from MRI leads. Chest CT shows bilateral\n infiltrates could be c/w aspiration pneumonia, no pulmonary embolus\n although one small area in the LLL subsegmental branch that could be\n c/w PE. He was started on vanc/zosyn to cover for aspiration\n pneumonia. In addition, one set of blood cultures returned with both\n bottles with GPC's in pairs, second set with no growth thus far.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 11:30 PM\n Vancomycin - 12:10 AM\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 66 (61 - 107) bpm\n BP: 92/63(74) {88/61(71) - 150/95(117)} mmHg\n RR: 16 (0 - 28) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,606 mL\n 590 mL\n PO:\n TF:\n IVF:\n 1,486 mL\n 590 mL\n Blood products:\n Total out:\n 778 mL\n 800 mL\n Urine:\n 778 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,828 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%, Vent Dependant\n PIP: 31 cmH2O\n Plateau: 27 cmH2O\n SpO2: 100%\n ABG: 7.41/42/179/26/2\n Ve: 8.4 L/min\n PaO2 / FiO2: 298\n Physical Examination\n VS: T=34 celsius on artic sun BP=107/81 HR= 150 regular RR=18 O2 sat=\n 98% AC 100%/550/16/5\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 109 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n Glucose\n 132\n 109\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation, now on Arctic sun protocol with diffuse\n anoxic brain injury on CT scan.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n -d/c amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n -on artic sun cooling protocol x18 hours, monitor coagulation profile\n -PEA arrested overnight again, with unclear precipitant, but suspected\n to be related to progressive cerebral edema.\n -Head CT concerning for smaller ventricular size, ?worsening cerebral\n edema, no obvious herniation\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -trend CE's to peak\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol\n -low dose fentanyl/versed advised by cardiac arrest consult in case he\n is in a locked in state (can likely stop when warmed)\n - neurology consult in the am\n -48 hour EEG (showing flat line as per neuro)\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down, currently 2.2\n .\n #Transaminitis - likely ischemic insult\n -monitor trend\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n FEN: NPO for now, NGT in place, change to OGT if prolonged intubation,\n replete lytes prn, consider starting tube feeds in the AM\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Bowel regimen: senna, docusate\n VAP:\n Comments:\n Communication: Comments:\n Code status: full code for now\n Disposition: CCU\n"
},
{
"category": "Physician ",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 384525,
"text": "Chief Complaint:\n 24 Hour Events:\n Went into wenckebach rhythm. A-lined and BP correlating with cuff\n pressures. Head CT showing diffuse anoxic brain injury. EEG done. Pt\n with high FIO2 requirements (80%). Lactate trending down.\n At hrs, pt brady'ed and went into PEA arrest --> CPR started,\n given atropine x 1, epi x 1, came out of arrest into sinus tach, BP\n 220s after 3-4 mins of PEA arrest.\n Called by neuro fellow, stating that pt may be in non-convulsive\n status. Explained that pt was just PEA arrested, and was given CPR.\n Told that pt\ns EEG is flat lining.\n Head CT and CTA ordered to look for worsening cerebreal edema, ?PE.\n Head CT shows ventricles are slightly smaller in size compared with the\n morning head ct suggesting progression of cerebral edema, although lot\n of artifact on study from MRI leads. Chest CT shows bilateral\n infiltrates could be c/w aspiration pneumonia, no pulmonary embolus\n although one small area in the LLL subsegmental branch that could be\n c/w PE. He was started on vanc/zosyn to cover for aspiration\n pneumonia. In addition, one set of blood cultures returned with both\n bottles with GPC's in pairs, second set with no growth thus far.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 11:30 PM\n Vancomycin - 12:10 AM\n Infusions:\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 02:00 PM\n Heparin Sodium (Prophylaxis) - 12:09 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n HR: 66 (61 - 107) bpm\n BP: 92/63(74) {88/61(71) - 150/95(117)} mmHg\n RR: 16 (0 - 28) insp/min\n SpO2: 100%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 4,606 mL\n 590 mL\n PO:\n TF:\n IVF:\n 1,486 mL\n 590 mL\n Blood products:\n Total out:\n 778 mL\n 800 mL\n Urine:\n 778 mL\n 800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,828 mL\n -210 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: FiO2 > 60%, Vent Dependant\n PIP: 31 cmH2O\n Plateau: 27 cmH2O\n SpO2: 100%\n ABG: 7.41/42/179/26/2\n Ve: 8.4 L/min\n PaO2 / FiO2: 298\n Physical Examination\n VS: T=34 celsius on artic sun BP=107/81 HR= 150 regular RR=18 O2 sat=\n 98% AC 100%/550/16/5\n Gen: intubated, unresponsive to any stimulus, no posturing noted\n HEENT: NC AT, intubated pupils are fixed and dilated at 6mm\n bilaterally, right pupil appears to be post surgical, left eye with\n large cataract visible\n Neck: right EJ 18G iv in place, no significant jvd\n CV: RRR s1 s2 no appreciable murmur\n Lungs: CTAB anteriorly, decreased BS posteriorly, unable to ausculate\n lung bases as artic sun cooling pads in place, no wheezing\n Abd: distended, soft, unable to assess for tenderness given mental\n status, positive bowel sounds\n Ext: cool, palpable DP's bilaterally\n Labs / Radiology\n 134 K/uL\n 12.1 g/dL\n 109 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 4.2 mEq/L\n 24 mg/dL\n 106 mEq/L\n 141 mEq/L\n 37.2 %\n 9.3 K/uL\n [image002.jpg]\n 01:32 PM\n 04:21 PM\n 06:18 PM\n 03:02 AM\n 03:19 AM\n WBC\n 8.1\n 9.3\n Hct\n 38.2\n 37.2\n Plt\n 148\n 134\n Cr\n 0.7\n 0.7\n TropT\n 0.29\n 0.15\n TCO2\n 24\n 26\n 28\n Glucose\n 132\n 109\n Other labs: PT / PTT / INR:16.5/29.2/1.5, CK / CKMB /\n Troponin-T:1066/52/0.15, ALT / AST:176/289, Alk Phos / T Bili:86/0.3,\n Lactic Acid:2.2 mmol/L, Albumin:3.5 g/dL, Ca++:7.7 mg/dL, Mg++:2.2\n mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK)\n HYPOXEMIA\n IMPAIRED SKIN INTEGRITY\n ANOXIC BRAIN DAMAGE (ANOXIC ENCEPHALOPATHY, HYPOXIC ISCHEMIC)\n VENTRICULAR FIBRILLATION (VF)\n Mr. is an 80 yo M with PMH of parkinsonism, autonomic\n instability and labile blood pressures admitted to the CCU following\n PEA arrest and resuscitation, now on Arctic sun protocol with diffuse\n anoxic brain injury on CT scan.\n .\n # s/p PEA arrest, unlikely to be from primary cardiac etiology, at this\n time most like due to hypoxia from possible aspiration event given that\n main laboratory abnormality is hypoxia and also with new left sided\n infiltrate. No evidence of pericardial effusion on echo, no evidence\n of pneumothorax. No evidence of acute MI on admission. He does have a\n lactic acidosis, likely prolonged pea arrest in the field. He has\n been in sinus tachycardia with occasional 2nd degree heart block type I\n on telemetry since admission. He was bolused with amiodarone and\n lidocaine in the field and started on an amiodarone gtt by EMS.\n -d/c amiodarone gtt as PEA arrest seems very unlikely to be primary\n cardiac\n -monitor on telemetry\n -on artic sun cooling protocol x18 hours, monitor coagulation profile\n -PEA arrested overnight again, with unclear precipitant, but suspected\n to be related to progressive cerebral edema.\n -Head CT concerning for smaller ventricular size, ?worsening cerebral\n edema, no obvious herniation\n .\n # CORONARIES: No evidence of acute ischemia on EKG, no evidence of wall\n motion abnormality on echo on admission. Cardiac enzymes slightly\n elevated however expected in the setting of several DCCV.\n -trend CE's to peak\n -serial EKG's\n .\n # PUMP: Echocardiogram on admission with hyperdynamic LV in the setting\n of resuscitation with numerous epinephrine boluses. No evidence of\n wall motion abnormality or major valvular lesions.\n .\n #Hypoxia - Most likely etiology of PEA arrest, still with significant\n AA gradient, but PaO2 improving with FIO2 of 60. Unclear etiology at\n this time, possibly aspiration event given LLL opacity and air\n bronchograms on CXR. Pulmonary embolus is also a consideration however\n no evidence of right heart strain on echocardiogram or PE on CTA.\n -wean FIO2 as tolerated\n -started vancomycin and zosyn for pneumonia vs. pneumonitis\n -CTA without PE, but awaiting final read\n .\n #Anoxic Brain Injury - head ct on admission with evidence of global\n anoxic injury likely prolonged PEA arrest of unknown duration.\n -cooling protocol\n -low dose fentanyl/versed advised by cardiac arrest consult in case he\n is in a locked in state (can likely stop when warmed)\n - neurology consult in the am\n -48 hour EEG (showing flat line as per neuro)\n .\n #Lactic acidosis - PEA arrest and prolonged hypoperfusion, lactate\n trending down now that HD stable.\n -monitor serial lactates, trending down, currently 2.2\n .\n #Transaminitis - likely ischemic insult\n -monitor trend\n .\n # Hypotesion/Autonomic Instability - long h/o labile BP and severe\n orthostasis. He is on numerous doses of midodrine at baseline as well\n as salt tabs. Per his family it is not unusual for him to have blood\n pressure in the 80's - 90's systolic then up to the 160's in the\n evening. Anoxic injury likely contributing to labile BP\n -continue midodrine four times daily\n -on dopamine currently to maintain MAP >60\n -monitor urine output\n .\n #Urinary retention - chronic indwelling foley catheter, await urine cx.\n .\n FEN: NPO for now, NGT in place, change to OGT if prolonged intubation,\n replete lytes prn, consider starting tube feeds in the AM\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:00 AM\n Arterial Line - 01:02 PM\n 20 Gauge - 04:00 PM\n Prophylaxis:\n DVT:\n Bowel regimen: senna, docusate\n VAP:\n Comments:\n Communication: Comments:\n Code status: full code for now\n Disposition: CCU\n"
},
{
"category": "Nursing",
"chartdate": "2177-09-23 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 384658,
"text": "80 y/o M w/ OSA, parkinsons, syncope orthostatic hypotension,\n primary autonomic dysfunction w/ very labile BPs--on Midodrine and salt\n to maintain BP at home. Admitted to CCU s/p PEA arrest and\n resuscitation at home. Cooled by artic sun protocol in CCU, re-warmed\n 11:00 yesterday. Head CT: Global anoxic injury prolonged PEA arrest\n of unknown duration, w/ repeat head CT showing evidence of severe\n global cortical edema. Brain waves flat and likelihood of significant\n recovery nears zero. Family meeting yesterday\n aware of grim\n prognosis. Now DNR. ***NEOB aware of pt, pt is not a candidate for\n transplant.\n Anoxic brain damage (Anoxic encephalopathy, Hypoxic ischemic)\n Assessment:\n Tele sinus rhythm. Dopamine at 4mcgs/kg/min. BP remains labile. Pt\n unresponsive to any stimuli. Pupils are non reactive. No gag no cough\n no spontaneous respirations. Seen by neuro team. Family met with neuro\n regarding overall prognosis.\n Action:\n No change in medical management. Awaiting other family members to come\n in prior to terminal extubation.\n Response:\n No change in neuro status. BP remains labile.\n Plan:\n Extubation later today after all family members have visited.\n"
},
{
"category": "ECG",
"chartdate": "2177-09-22 00:00:00.000",
"description": "Report",
"row_id": 157971,
"text": "Possibly sinus rhythm. Technically difficult tracing. Left axis deviation. Left\nanterior fascicular block. Compared to tracing #1 blocked atrial premature\nbeats are no longer present.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Report",
"row_id": 157972,
"text": "Baseline artifact which makes discerning the underlying atrial rhythm\ndifficult. It is possibly sinus rhythm with blocked atrial premature beats.\nLeft axis deviation. Left anterior fascicular block. Compared to previous\ntracing of sinus tachycardia is no longer present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2177-09-21 00:00:00.000",
"description": "Report",
"row_id": 157973,
"text": "Sinus tachycardia. Left anterior fascicular block. Non-specific\nintraventricular conduction delay. Early transition. Non-specific\nST-T wave changes. Compared to the previous tracing of sinus\ntachycardia is present. ST-T wave changes are new.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-09-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1092516,
"text": " 6:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man intubated s/p cardiac arrest\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY DATED \n\n HISTORY: 80-year-old man indicated status post cardiac arrest. Question\n acute process.\n\n COMPARISON: .\n\n FINDINGS: A single AP view of the chest was obtained. The cardiac silhouette\n is unchanged in size given differences in lung volume. The lung volumes are\n low. There is mild pulmonary edema. There is a retrocardiac airspace opacity\n with loss of the left costophrenic border. There is a probable left pleural\n effusion. Also noted is mediastinal air adjacent to the left heart boarder. No\n pneumothorax is identified. Rib deformities are noted on the left which may\n reflect rib fractures secondary to recent CPR. An NG tube terminates in an\n air- distended stomach. An endotracheal tube terminates 3.3 cm above the\n carina. No acute osseous abnormalities are identified.\n\n IMPRESSION:\n\n Small amount of mediastinal air and left sided rib deformities which could\n represent fractures secondary to recent CPR.\n\n Mild pulmonary edema with a small left pleural effusion. Retrocardiac\n airspace opacity likely represents atelectais. Clinical correlation is\n recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-09-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1092524,
"text": " 8:19 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for ICH\n Admitting Diagnosis: POST CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with cardiac arrest\n REASON FOR THIS EXAMINATION:\n eval for ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 80-year-old male status post cardiac arrest.\n Evaluate for intracranial hemorrhage.\n\n EXAMINATION: Non-contrast head CT.\n\n COMPARISON: Head CT from .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n intravenous contrast was administered.\n\n FINDINGS: There has been interval development of hypoattenuation involving\n the bilateral basal ganglia and thalami since examination from , and\n diffuse cerebral cortical swelling. These findings indicate global\n anoxic injury in the setting of known history of cardiac arrest. There is no\n acute hemorrhage. The ventricles have decreased in size due to cerebral\n edema.\n\n There is fluid in the left maxillary and frontal sinuses, likely related to\n the endotracheal tube. The bones are unremarkable.\n\n IMPRESSION: Global anoxic injury with cerebral edemal. No acute hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-09-21 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1092611,
"text": " 9:19 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for progression of cerebral edema, ?herniation\n Admitting Diagnosis: POST CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with anoxic brain injury s/p pea arrest at home, with repeated\n PEA arrest\n REASON FOR THIS EXAMINATION:\n evaluate for progression of cerebral edema, ?herniation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT THE HEAD DATED \n\n HISTORY: 80-year-old man with anoxic brain injury status post PEA arrest x2.\n\n COMPARISON: .\n\n FINDINGS: Contiguous axial images through the brain were obtained. The study\n is significantly limited secondary to streak artifact from multiple metallic\n scalp leads. Again noted is hypodensity within the region of the bilateral\n basal ganglia and thalami. The ventricles are smaller in comparison to the\n prior study, likely indicating increasing cerebral edema. No definite\n intraparenchymal hemorrhage or extra-axial fluid is identified. However, this\n cannot be adequately assessed on the current study given the degree of streak\n artifact. Evaluation of the patency of the basal cisterns is limited\n secondary to artifact. However, some CSF is noted around the\n perimesencephalic cistern. No calvarium abnormalities are identified. Again\n noted is opacification of the left maxillary and left ethmoid sinuses, likely\n secondary to intubation.\n\n IMPRESSION:\n\n Markedly limited study secondary to streak artifact from metallic scalp leads.\n Hypodensities within the bilateral basal ganglia and thalami in addition to\n decreasing size of the lateral ventricles, which are barely visible, all\n suggestive of increasing cerebral edema. A repeat evaluation may be obtained\n once the metallic scalp leads have been removed.\n\n These findings were communicated to Dr. on at 4:00 a.m.\n\n NOTE ADDED AT ATTENDING REVIEW: I agree with the above interpretation.\n However, in addition to diffuse hypodensity of the deep grey matter\n structures, there is strking hypodensity of essentially all cortical grey\n matter. This is so severe that the cortex is of lower density than the white\n matter. This is associated with effacement of cortical sulci. These findings\n indicate severe global cortical edema. Given the history, this is most likely\n due to global hypoperfusion and infarction.\n (Over)\n\n 9:19 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for progression of cerebral edema, ?herniation\n Admitting Diagnosis: POST CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-09-21 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1092612,
"text": " 9:20 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evaluate for PE\n Admitting Diagnosis: POST CARDIAC ARREST\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with anoxic brain injury s/p pea arrest at home, with repeated\n PEA arrest, evaluate for PE as cause\n REASON FOR THIS EXAMINATION:\n evaluate for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MBue MON 4:49 AM\n\n PRELIMINARY REPORT: LOW DENSITY FOCUS IN REGION OF SUBBSEGMENTAL BRANCH OF LLL\n PULMONARY ARTERY MOST LIKELY REPRESENT A TORTUOUS DISTAL ARTERY (3:50). TINY\n SUBSEGMENTAL PE IS UNLIKELY BUT CANNOT BE EXCLUDED. NO LARGE PE IDENTIFIED.\n BIBASILAR AIRSPACE OPACITIES WITH AIR BRONCHOGRAMS NOTED DEPENDANTLY AT LEAST\n IN PART SECONDARY TO ATELECTASIS. INFECTION CANNOT BE EXCLUDED. SMALL RT\n PLEURAL EFFUSION. LT PLEURAL CALCIFICATION.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80 year-old man with anoxic brain injury and repeated episodes of\n pulseless electrical activity. Please evaluate for pulmonary embolism.\n\n Comparison is made to the prior CT of the chest of .\n\n TECHNIQUE: Axial MDCT images of the chest were obtained after administration\n of 100 mL of Optiray intravenously. Multiplanar reformatted images were then\n acquired.\n\n CTA OF THE CHEST: No filling defect is noted within the main pulmonary artery\n and its branches to suggest pulmonary embolism. The endotracheal tube and NG\n tube are in the standard position. Incidental note is made of an aberrant\n origin of the left carotid from the innominate artery. No pathologically\n enlarged mediastinal nodes are noted.\n\n Small bilateral pleural effusions are noted. The effusion on the left side\n has a subpulmonic component. Diffuse atelectasis of the left lower lobe and\n right lower lobe are visualized. Incidental note is made of bilateral\n calcified pleural plaques suggesting prior asbestos exposure.\n\n The stomach is severely distended. The visualized part of the upper abdomen\n including the spleen appear unremarkable. Both adrenal glands appear\n slightly prominent. Calcified granulomas of the liver dome are noted.\n\n BONE WINDOWS: No concerning lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n\n 1. No pulmonary embolism.\n\n (Over)\n\n 9:20 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evaluate for PE\n Admitting Diagnosis: POST CARDIAC ARREST\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Right lower lobe and left lower lobe atelectasis and small bilateral\n pleural effusions.\n\n 3. Calcified pleural plaques suggesting prior asbestos exposure .\n\n 4. Severely distended stomach.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-09-21 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1092613,
"text": ", I. 9:20 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: evaluate for PE\n Admitting Diagnosis: POST CARDIAC ARREST\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with anoxic brain injury s/p pea arrest at home, with repeated\n PEA arrest, evaluate for PE as cause\n REASON FOR THIS EXAMINATION:\n evaluate for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n\n PRELIMINARY REPORT: LOW DENSITY FOCUS IN REGION OF SUBBSEGMENTAL BRANCH OF LLL\n PULMONARY ARTERY MOST LIKELY REPRESENT A TORTUOUS DISTAL ARTERY (3:50). TINY\n SUBSEGMENTAL PE IS UNLIKELY BUT CANNOT BE EXCLUDED. NO LARGE PE IDENTIFIED.\n BIBASILAR AIRSPACE OPACITIES WITH AIR BRONCHOGRAMS NOTED DEPENDANTLY AT LEAST\n IN PART SECONDARY TO ATELECTASIS. INFECTION CANNOT BE EXCLUDED. SMALL RT\n PLEURAL EFFUSION. LT PLEURAL CALCIFICATION.\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-09-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1092570,
"text": " 2:21 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate ETT position, ?pulmonary edema or evolving infiltra\n Admitting Diagnosis: POST CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p pea arrest ? aspiration, intubated on cooling protocol\n REASON FOR THIS EXAMINATION:\n evaluate ETT position, ?pulmonary edema or evolving infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post cardiac arrest, ET tube placed, check position.\n\n CHEST: The tip of the endotracheal tube lies 3.2 cm from the carinal angle,\n unchanged since prior chest x-ray. There has been resolution of the\n mediastinal air since the prior chest x-ray. A left pleural effusion is again\n noted, unchanged.\n\n IMPRESSION: Resolution of mediastinal air. Endotracheal tube position\n satisfactory.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2177-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1092647,
"text": " 8:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate ETT, NGT placement\n Admitting Diagnosis: POST CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p PEA arrest, on cooling protocol, ?pneumonia\n REASON FOR THIS EXAMINATION:\n evaluate ETT, NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n COMPARISON: .\n\n INDICATION: Tube and line assessment.\n\n FINDINGS: Endotracheal tube and nasogastric tube remain in standard position.\n Cardiac silhouette is upper limits of normal in size with left ventricular\n configuration, and the aorta remains tortuous. Persistent bibasilar\n opacities, likely due to atelectasis although co-existing pneumonia is also\n possible. Moderate left pleural effusion is unchanged. Known right pleural\n effusion is seen to better detail on recent CTA of the chest of one day\n earlier.\n\n\n"
}
] |
10,687 | 130,363 | The patient was reviewed by the cardiothoracic surgeons and agreed to undergo urgent coronary artery bypass grafting on the following morning. On the the patient was brought to the Operating Room. Please see the Operating Room report for full details. In summary, the patient underwent coronary artery bypass grafting times four with a left internal mammary coronary artery to the left anterior descending coronary artery, saphenous vein graft to the diagonal, saphenous vein graft to obtuse marginal, saphenous vein graft to the posterior descending coronary artery. She tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. The patient did well in the immediate postoperative period. Her sedation was reversed. She was weaned from the ventilator and successfully extubated. On postoperative day one she remained hemodynamically stable. Her chest tubes were removed and she was transferred from the Cardiothoracic Intensive Care Unit to 2 Far 6 for continuing postoperative care and cardiac rehabilitation. Over the next couple of days with the assistance of the nursing staff and the physical therapist the patient's activity level was gradually increased. She remained hemodynamically stable. On postoperative day four she was noted to have an episode of rapid atrial fibrillation with a heart rate into the 140s. At that time she was treated with intravenous Lopressor and intravenous Amiodarone. With that she had a stable blood pressure of 120 to 130. Following the administration of Amiodarone and Lopressor her heart rate returned to a sinus rhythm in the 80s with the blood pressure remaining 120/70. She was started on a regular regimen of Amiodarone and Lopressor and remained in sinus rhythm since that time. On postoperative day six it was decided that the patient was stable and ready to be transferred to rehabilitation for further postoperative care and additional cardiac rehabilitation and enhancement of her exercise capacity. At the time of transfer the patient's physical examination was vital signs temperature 98.9. Heart rate 69. Blood pressure 140/70. Respiratory rate 18. O2 sat 94% on room air. Laboratory data, white blood cell count 9, hematocrit 26, platelets 179, sodium 135, potassium 4.2, chloride 98, CO2 26, BUN 26, creatinine 1.2, glucose 126. Weight preoperatively is 65 kilograms and at discharge it is 68.5 kilograms. Physical examination, neurological is a nonfocal examination. She moves all extremities and is conversant. Breath sounds mild bibasilar crackles. Heart sounds regular rate and rhythm. S1 and S2. No murmur noted. Abdomen is soft, nontender, nondistended. Normoactive bowel sounds. Extremities are warm and well perfuse with trace bilateral lower extremity edema. Her sternal incision is stable. The incision is open to air clean and dry with staples. The right saphenous vein graft incision site is open to air also clean and dry with Steri-Strips. | Hemodynamically, NTG weaned to off. C/DB AFTER MUCH PERSISTANCE. EZ TUBE.NEURO: ARRIVED SEDATED. ETT SHOWED INF ISCHEMIA. Findings suggesting minimal bibasilar atelectasis. DRAINAGE OOZY UPON ARRIVAL (COAGS OFF)- STABLE NOW. STABLE OR COURSE, ONLY REQUIRING NEO AND PROPOFOL. PACER IN A DEMAND.RESP: LUNGS CLEAR. PT CURRENTLY ON OFM- STABLE.GI: ABD SOFT, NONTENDER. Lungs are CTA but diminished. DISTAL PULSES PALPABLE BILAT. BP STABLE. REQUIRED LG AMTS FLUID FOR LOW FILLING PRESSURES.RESP: LS CTA, DIMIN AT LLL. CO/CI STABLE. CA REPLACED X1. SR NO VEA NOTED, VSS. IMPRESSION: 1. CTX3 INTACT WITH SM AIR LEAK PRESENT. BS ABS. REC'D 4U PRBC'S INTRA-OP. PT ALERT AND ORIENTED. IN AM. OG TUBE D/C'D WITH MINIMAL DRNG.GU: FOLEY INTACT FOR CL YEL URINE IN ADEQUATE AMTS. CRI- MEDS ADJUSTED ACCORDINGLY.HEME: INR 2.2, PTT 68. PT GIVEN PROTAMINE 50MGX1, 4U FFP, 1U PLT. Shift NotePT is neurologically intact, MAE to command. SLIGHTLY CONFUSED TO PLACE AT TIMES, EASILY REORIENTED.ASSESSMENT: DOING WELL, HCT 27 AFTER BLOOD.PLAN: CONTWEAN NTG AS TOLERATED.WEAN O2 AS TOLERATED. FOLLOWS COMMANDS.CV: PT DENIES CP, PALP, SOB. NEO FOR SHORT TIME INITIALLY. PROPOFOL WEANED TO OFF WITHOUT DIFFICULTY. Sinus rhythmLeft axis deviation - possible left anterior fascicular blockQRS changes V3/V4 - probably due to LVH but consider anterior infarctLateral T wave changes are nonspecificSince previous tracing of, , no significant change CHEST, PORTABLE: The patient is s/p median sternotomy/CABG. NOW REQUIRING NTG FOR BP CONTROL. BPT: 100", XCT: 63". PROB: S/P CABGCV: CONT ON NTG FOR BP CONTROL. LYTES REPLETED. EPICARDIAL WIRES INTACT- 2A/2V- SENSE AND CAPTURE APPROPRIATELY. REFFERED FOR CABG.ALLG: SULFA ZITHROMAX CIPRO-> PRURITISPMHX: HTN NIDDM CAD NQWMI () ANGINA BLADDER CA () TX WITH CHEMO, RECURRED . ? REPEAT HCT (AFTER PRODUCTS) 23, TX WITH 1U PRBC'S. NO BM THIS SHIFT. 2. RARE FUSION BEAT SEEN, BUT NO FURTHER ECTOPY. RT MASTECTOMY DIVERTICULITIS GERD: CABGX4: LIMA->LAD, SVG->OM, DIAG, PDA. The cardiac silhouette does appear mildly enlarged. PT INTUBATED, THEN WEANED TO EXTUBATE AT 1730. See flowsheet for details. ANSWERS QUESTIONS APPROPRIATELY. There are minimal streaky areas of increased density in both lung bases, left greater than right, which may reflect scattered areas of subsegmental atelectasis. TELE: NSR/ST HR 80-100'S. SATS 94-96% ON 70% FM, 80'S ON 5L/NP.GU: UOP ADEQUATE.GI: BOWEL SOUNDS ABSENT.NEURO: MAE. No definite pleural effusion. Pt encouraged to cough and deep breathe. REFERRED TO FOR CARDIAC CATH WHICH SHOWED SEVERE CAD, MILD DIASTOLIC DYSFXN WITH EF~59%, AND AORTIC HTN. COMPARISON: None. MOVING ALL EXTREMITIES. No definite mediastinal hilar mass is seen. DIFFICULT TO GET PT TO C/DB, PT REFUSES MOST OF TIME. A catheter projecting over the left hemiabdomen is presumably a urinary stent. CSRU ADMISSION NOTE:79YO FEMALE ADMITTED TO OSH WITH LEFT ARM PAIN RELIEVED BY NTG. Surgical clips are noted along the lateral aspect of the right chest wall. There is no overt CHF or airspace infiltrate. No evidence of pneumothorax. There is no evidence of pneumothorax. WILL MONITOR LABS AND TX FOR HGB<9.ID: ON RENAL DOSE VANCO.PAIN: PT MED WITH MSO4 FOR PAIN WITH ADEQUATE CONTROL.SOC: FAMILY IN TO SEE PT, UPDATED ON PLAN.PLAN: MONITOR LABS. | 5 | [
{
"category": "Radiology",
"chartdate": "2178-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 762916,
"text": " 4:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest and mediastinal tube pull\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with s/p CABG\n REASON FOR THIS EXAMINATION:\n s/p chest and mediastinal tube pull\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Tubes removed following CABG.\n\n COMPARISON: None.\n\n CHEST, PORTABLE: The patient is s/p median sternotomy/CABG. The cardiac\n silhouette does appear mildly enlarged. No definite mediastinal hilar mass is\n seen. There is no overt CHF or airspace infiltrate. There are minimal streaky\n areas of increased density in both lung bases, left greater than right, which\n may reflect scattered areas of subsegmental atelectasis. No definite pleural\n effusion.\n\n Surgical clips are noted along the lateral aspect of the right chest wall.\n There is no evidence of pneumothorax. A catheter projecting over the left\n hemiabdomen is presumably a urinary stent.\n\n IMPRESSION: 1. No evidence of pneumothorax.\n 2. Findings suggesting minimal bibasilar atelectasis.\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2178-07-02 00:00:00.000",
"description": "Report",
"row_id": 176476,
"text": "Sinus rhythm\nLeft axis deviation - possible left anterior fascicular block\nQRS changes V3/V4 - probably due to LVH but consider anterior infarct\nLateral T wave changes are nonspecific\nSince previous tracing of, , no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-02 00:00:00.000",
"description": "Report",
"row_id": 1403499,
"text": "CSRU ADMISSION NOTE:\n\n79YO FEMALE ADMITTED TO OSH WITH LEFT ARM PAIN RELIEVED BY NTG. ETT SHOWED INF ISCHEMIA. REFERRED TO FOR CARDIAC CATH WHICH SHOWED SEVERE CAD, MILD DIASTOLIC DYSFXN WITH EF~59%, AND AORTIC HTN. REFFERED FOR CABG.\n\nALLG: SULFA\n ZITHROMAX\n CIPRO-> PRURITIS\n\nPMHX: HTN\n NIDDM\n CAD\n NQWMI ()\n ANGINA\n BLADDER CA () TX WITH CHEMO, RECURRED .\n RT MASTECTOMY\n DIVERTICULITIS\n GERD\n\n\n: CABGX4: LIMA->LAD, SVG->OM, DIAG, PDA. BPT: 100\", XCT: 63\". REC'D 4U PRBC'S INTRA-OP. STABLE OR COURSE, ONLY REQUIRING NEO AND PROPOFOL. EZ TUBE.\n\nNEURO: ARRIVED SEDATED. PROPOFOL WEANED TO OFF WITHOUT DIFFICULTY. PT ALERT AND ORIENTED. ANSWERS QUESTIONS APPROPRIATELY. MOVING ALL EXTREMITIES. FOLLOWS COMMANDS.\n\nCV: PT DENIES CP, PALP, SOB. TELE: NSR/ST HR 80-100'S. RARE FUSION BEAT SEEN, BUT NO FURTHER ECTOPY. LYTES REPLETED. BP STABLE. NEO FOR SHORT TIME INITIALLY. NOW REQUIRING NTG FOR BP CONTROL. DISTAL PULSES PALPABLE BILAT. EPICARDIAL WIRES INTACT- 2A/2V- SENSE AND CAPTURE APPROPRIATELY. CO/CI STABLE. REQUIRED LG AMTS FLUID FOR LOW FILLING PRESSURES.\n\nRESP: LS CTA, DIMIN AT LLL. PT INTUBATED, THEN WEANED TO EXTUBATE AT 1730. CTX3 INTACT WITH SM AIR LEAK PRESENT. DRAINAGE OOZY UPON ARRIVAL (COAGS OFF)- STABLE NOW. PT CURRENTLY ON OFM- STABLE.\n\nGI: ABD SOFT, NONTENDER. BS ABS. NO BM THIS SHIFT. OG TUBE D/C'D WITH MINIMAL DRNG.\n\nGU: FOLEY INTACT FOR CL YEL URINE IN ADEQUATE AMTS. CRI- MEDS ADJUSTED ACCORDINGLY.\n\nHEME: INR 2.2, PTT 68. PT GIVEN PROTAMINE 50MGX1, 4U FFP, 1U PLT. REPEAT HCT (AFTER PRODUCTS) 23, TX WITH 1U PRBC'S. WILL MONITOR LABS AND TX FOR HGB<9.\n\nID: ON RENAL DOSE VANCO.\n\nPAIN: PT MED WITH MSO4 FOR PAIN WITH ADEQUATE CONTROL.\n\nSOC: FAMILY IN TO SEE PT, UPDATED ON PLAN.\n\nPLAN: MONITOR LABS. ? IN AM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-02 00:00:00.000",
"description": "Report",
"row_id": 1403500,
"text": "PROB: S/P CABG\n\nCV: CONT ON NTG FOR BP CONTROL. SR NO VEA NOTED, VSS. CA REPLACED X1. PACER IN A DEMAND.\n\nRESP: LUNGS CLEAR. DIFFICULT TO GET PT TO C/DB, PT REFUSES MOST OF TIME. C/DB AFTER MUCH PERSISTANCE. SATS 94-96% ON 70% FM, 80'S ON 5L/NP.\n\nGU: UOP ADEQUATE.\n\nGI: BOWEL SOUNDS ABSENT.\n\nNEURO: MAE. SLIGHTLY CONFUSED TO PLACE AT TIMES, EASILY REORIENTED.\n\nASSESSMENT: DOING WELL, HCT 27 AFTER BLOOD.\n\nPLAN: CONT\nWEAN NTG AS TOLERATED.\nWEAN O2 AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-07-03 00:00:00.000",
"description": "Report",
"row_id": 1403501,
"text": "Shift Note\nPT is neurologically intact, MAE to command. Hemodynamically, NTG weaned to off. Lungs are CTA but diminished. Pt encouraged to cough and deep breathe. See flowsheet for details.\n"
}
] |
27,315 | 193,769 | 59 y/o male admitted following liver resection. On POD 1 the patient was found to be hypotensive with SBP of 86. Fluid boluses, 1 unit of RBC's and 500cc albumin given without improvement so patient was transferred to the SICU for further management. Urine output approx 20cc/hr and oxygenation decreased requiring O2. He was found to be hypovolemic and was fluid resuscitated and was transferred back to the regular surgical floor within 24 hours. Chest x ray revealed increased bilateral, right greater than left pleural effusions with vascular re-distribution suggesting fluid overload. There was volume loss in both lower lobes. He was diuresed and chest PT was performed. There was no lower extremity edema. O2 was discontinued. Repeat chest xray on revealed an improvement in the bilateral pleural effusions. . JP drain output was noted to increase on POD 5 and it was continued to be monitored. He required one dose of albumin on POD 6 after continued high JP output and decreasing urine output. The JP was removed on POD 7 without complications. . Abdomen was noted to be mildly distended on POD 6 and dulcolax suppositories were given with results. He required an enema on POD 8. The abdominal incision staples were removed and steri strips applied prior to discharge. He was stable for discharge home on POD 8 with pain well-controlled, ambulating well, and tolerating regular diet. He will follow-up with Dr. in clinic. | right hepatic lobect MEDICAL CONDITION: Exp. Since the previous tracing of atrial ectopy is present. IMPRESSION: Bilateral pleural effusions and bibasilar atelectasis, right greater than left, are unchanged. PORTABLE UPRIGHT CHEST: Tip of right central venous catheter terminates in the lower SVC. The right internal jugular line tip projects over distal SVC. A drain overlies the right upper quadrant abdomen. right hepatic lobectomy, cholecystectomy REASON FOR THIS EXAMINATION: Exp. In segment VI/VII, there is a large solid mass corresponding to the known hepatoma visualized on preoperative imaging. Ventricular ectopy with a ventricular couplet. Sinus rhythm with atrial and ventricular premature beat. Bibasilar opacities persist, consistent with bilateral pleural effusions and bibasilar atelectasis. Drain overlies the right upper quadrant of the abdomen. CONCLUSION: Large solid right lobe liver mass as described corresponding to the known hepatoma. IMPRESSION: Improvement of bilateral pleural effusions. Early precordialQRS transition, probable normal variant. The cardiomediastinal silhouette is within normal limits. Mild interstitial edema is present as well as a questionable small right pleural effusion. Dr notified. Ok to advance to liqiuds per transplant fellow. Compared to the prior tracing ventricular ectopyis more frequent and the atrial ectopy is no longer present.TRACING #1 Heart is upper limits of normal in size. IMPRESSION: CHF. There is gradual decrease in right pleural effusion with currently small amount of pleural fluid demonstrated, accompanied by relaxation atelectasis. Right internal jugular vascular catheter terminates within the lower superior vena cava with no pneumothorax. ADMISSION NOTED: 59 YO TRANSFERRED FROM 10- S/P LIVER RESECTION ON FOR HEPATOCELLULAR CA. There is volume loss in both lower lobes, drain overlies the right-sided abdomen. Sinus rhythm. There are no obvious satellite nodules, and there is full patency of the main right posterior portal vein in the vicinity of the tumor and the hepatic veins as well. Tmax 99.2. Lap., segmental liver resection, ? Lap., segmental liver resection, ? Lap., segmental liver resection, ? HR 60'S NSR. Moderate gaseous distention of the stomach is unchanged. 5:06 AM CHEST (PORTABLE AP) Clip # Reason: eval improvement in CHF Admitting Diagnosis: HEPATOCELLULAR CARCINOMA/SDA MEDICAL CONDITION: 59M w/ HCV, cirrhosis s/p resection mass in segment with CHF on previous CXR. PA and lateral upright chest radiograph was reviewed and compared to and 24, . +pp. The stomach is moderately distended. PT MEDICATED JUST PRIOR TO TRANSFER AND CURRENTLY IS RESTING COMFORTABLYCV: AFEBRILE. PT GIVEN 500CC NS AND PT IS TO BE TRANFUSED WITH 2 UNITS FFPRESP: BS CLEAR BUT SLIGHTLY DIMINSHED IN BASES. Sinus rhythm with frequent ventricular ectopy. TRANSFUSED WITH 1 UNIT PC AND 500CC ALBUMIN GIVEN. BP stable, 100-110/60's. Abd soflty distended, hypoactive bowel sounds, no flatus. K 3.8, Mag 1.8. These findings are more severe on the right compared to the left and are grossly unchanged. Foley with adequate urine output. PT TRANSFERRED TO SICU FOR FURTHER FLUID RESUSITATION.NEURO: ALERT, ORIENTED X3, FOLLOWING COMMANDS. High-resolution scans of the liver were performed demonstrating a completely nodular coarse architecture. Skin intact, llq dsg with drainage, reinforced. SBP 86-96. Condition updateSee Careview for details:Alert, oriented x 3. The small left pleural effusion is noted, also decreased in size. FINDINGS: Compared to the prior film there has been increase in bilateral, right greater than left pleural effusions with vascular re-distribution suggesting fluid overload. REFERENCE EXAM: . Per Dr (transplant HO) repleate with 20 meq kcl and 4 grams mag sulfate. REASON FOR THIS EXAMINATION: eval improvement in CHF FINAL REPORT HISTORY: 59-year-old male with hep C, cirrhosis, status post resection in segment . COMPARISON: . right hepatic lobectomy, cholecystectomy FINAL REPORT INTRAOPERATIVE ULTRASOUND OF THE LIVER CLINICAL INDICATION: Chronic hepatitis C with known liver mass in segment VI/VII seen on preoperative CT and biopsy-proven hepatoma. There is anearly transition which is non-specific. JP with dark serosang output. PT HYPOTENSIVE THIS AM TO SBP 86= INITALLY GIVEN 500CC NS WITH NO CHANGE, BOLUS REPEATED FOR SBP 60. Plan to cont to monitor hemodynamics and fluid status. INDICATION: Line placement. There is an early transitionwhich is non-specific. This measures approximately 7.3 x 6.0 cm. Transfer to floor today. Compared to the prior tracingthere is no significant change.TRACING #2 8:25 AM CHEST (PA & LAT) Clip # Reason: eval progression of pleural effusions Admitting Diagnosis: HEPATOCELLULAR CARCINOMA/SDA MEDICAL CONDITION: 59 M w/ HCV, cirrhosis s/p resection mass in segment with bilateral pleural effusions REASON FOR THIS EXAMINATION: eval progression of pleural effusions FINAL REPORT REASON FOR EXAMINATION: Followup of pleural effusion in a patient after hepatic surgery. C/O incsional pain, morphine 2 mg prn with good effect. | 10 | [
{
"category": "Radiology",
"chartdate": "2168-12-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 992300,
"text": " 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval improvement in CHF\n Admitting Diagnosis: HEPATOCELLULAR CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59M w/ HCV, cirrhosis s/p resection mass in segment with CHF on previous\n CXR.\n REASON FOR THIS EXAMINATION:\n eval improvement in CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 59-year-old male with hep C, cirrhosis, status post resection in\n segment .\n\n COMPARISON: .\n\n PORTABLE UPRIGHT CHEST: Tip of right central venous catheter terminates in\n the lower SVC. A drain overlies the right upper quadrant abdomen. Bibasilar\n opacities persist, consistent with bilateral pleural effusions and bibasilar\n atelectasis. These findings are more severe on the right compared to the left\n and are grossly unchanged. Moderate gaseous distention of the stomach is\n unchanged.\n\n IMPRESSION: Bilateral pleural effusions and bibasilar atelectasis, right\n greater than left, are unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-12-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 992217,
"text": " 7:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pulmon status\n Admitting Diagnosis: HEPATOCELLULAR CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with cirrhosis, hypoxic\n REASON FOR THIS EXAMINATION:\n pulmon status\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Cirrhosis, hypoxemia.\n\n REFERENCE EXAM: .\n\n FINDINGS: Compared to the prior film there has been increase in bilateral,\n right greater than left pleural effusions with vascular re-distribution\n suggesting fluid overload. There is volume loss in both lower lobes, drain\n overlies the right-sided abdomen. The stomach is moderately distended.\n\n IMPRESSION: CHF. An underlying infectious infiltrate cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-12-23 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 992082,
"text": " 9:50 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval cvl/ptx\n Admitting Diagnosis: HEPATOCELLULAR CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man sp cvl/liver resection\n REASON FOR THIS EXAMINATION:\n eval cvl/ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n No prior radiographs for comparison.\n\n INDICATION: Line placement.\n\n Right internal jugular vascular catheter terminates within the lower superior\n vena cava with no pneumothorax. Heart is upper limits of normal in size.\n Mild interstitial edema is present as well as a questionable small right\n pleural effusion. Drain overlies the right upper quadrant of the abdomen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-12-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 992548,
"text": " 8:25 AM\n CHEST (PA & LAT) Clip # \n Reason: eval progression of pleural effusions\n Admitting Diagnosis: HEPATOCELLULAR CARCINOMA/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 M w/ HCV, cirrhosis s/p resection mass in segment with bilateral pleural\n effusions\n REASON FOR THIS EXAMINATION:\n eval progression of pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of pleural effusion in a patient after\n hepatic surgery.\n\n PA and lateral upright chest radiograph was reviewed and compared to and 24, .\n\n There is gradual decrease in right pleural effusion with currently small\n amount of pleural fluid demonstrated, accompanied by relaxation atelectasis.\n The small left pleural effusion is noted, also decreased in size. The upper\n lungs are unremarkable. The cardiomediastinal silhouette is within normal\n limits. The right internal jugular line tip projects over distal SVC.\n\n IMPRESSION: Improvement of bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2168-12-23 00:00:00.000",
"description": "US INTRA-OP 30 MINS",
"row_id": 991940,
"text": " 4:07 PM\n US INTRA-OP 30 MINS Clip # \n Reason: Exp. Lap., segmental liver resection, ? right hepatic lobect\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Exp. Lap., segmental liver resection, ? right hepatic lobectomy,\n cholecystectomy\n REASON FOR THIS EXAMINATION:\n Exp. Lap., segmental liver resection, ? right hepatic lobectomy,\n cholecystectomy\n ______________________________________________________________________________\n FINAL REPORT\n INTRAOPERATIVE ULTRASOUND OF THE LIVER\n\n CLINICAL INDICATION: Chronic hepatitis C with known liver mass in segment\n VI/VII seen on preoperative CT and biopsy-proven hepatoma.\n\n High-resolution scans of the liver were performed demonstrating a completely\n nodular coarse architecture. In the left lobe as well as the right, there\n were several less than 5 mm hypoechoic nodules scattered throughout but none\n of these showed increased vascularity and most likely representative of\n regenerative or dysplastic nodules. In segment VI/VII, there is a large solid\n mass corresponding to the known hepatoma visualized on preoperative imaging.\n This measures approximately 7.3 x 6.0 cm. There are no obvious satellite\n nodules, and there is full patency of the main right posterior portal vein in\n the vicinity of the tumor and the hepatic veins as well. No intraluminal\n growth is seen in the major portal or hepatic venous trunks. No other masses\n are seen elsewhere in the liver.\n\n CONCLUSION: Large solid right lobe liver mass as described corresponding to\n the known hepatoma. Multiple tiny less than 5 mm non-vascular nodules\n scattered elsewhere in the liver most likely representing dysplastic nodules,\n but these require continued surveillance on followup imaging.\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-24 00:00:00.000",
"description": "Report",
"row_id": 1619745,
"text": "ADMISSION NOTE\nD: 59 YO TRANSFERRED FROM 10- S/P LIVER RESECTION ON FOR HEPATOCELLULAR CA. PT HYPOTENSIVE THIS AM TO SBP 86= INITALLY GIVEN 500CC NS WITH NO CHANGE, BOLUS REPEATED FOR SBP 60. TRANSFUSED WITH 1 UNIT PC AND 500CC ALBUMIN GIVEN. PT TRANSFERRED TO SICU FOR FURTHER FLUID RESUSITATION.\nNEURO: ALERT, ORIENTED X3, FOLLOWING COMMANDS. PT MEDICATED JUST PRIOR TO TRANSFER AND CURRENTLY IS RESTING COMFORTABLY\nCV: AFEBRILE. HR 60'S NSR. SBP 86-96. PT GIVEN 500CC NS AND PT IS TO BE TRANFUSED WITH 2 UNITS FFP\nRESP: BS CLEAR BUT SLIGHTLY DIMINSHED IN BASES. ROOM AIR SAT 92%- PLACED ON NC AT 3 LITERS\nGI: ABD SOFT, + BS, TAKING ICE CHIPS\nGU: URINE OUTPUT 20CC\nA/P: CONTINUE TO MONITOR HEMODYNAMICS, START PRESSORS IF MAP<60, ENCOURAGE PULM TOILET, MEDICATE FOR PAIN AS NEEDED, MONITOR URINE CLOSELY\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2168-12-25 00:00:00.000",
"description": "Report",
"row_id": 1619746,
"text": "Condition update\nSee Careview for details:\n\nAlert, oriented x 3. No neuro deficits. C/O incsional pain, morphine 2 mg prn with good effect. Tmax 99.2. Sr with freq pvc's this eve then occasionally in bigemeny. Dr notified. K 3.8, Mag 1.8. Per Dr (transplant HO) repleate with 20 meq kcl and 4 grams mag sulfate. BP stable, 100-110/60's. +pp. cvp 11-13. Lungs clear but diminished, on 3 liters nc increased to 6 liters d/t sat down to 93% when asleep. No sob. Abd soflty distended, hypoactive bowel sounds, no flatus. Taking ice chips and sips h2o. Ok to advance to liqiuds per transplant fellow. Foley with adequate urine output. Skin intact, llq dsg with drainage, reinforced. JP with dark serosang output. Plan to cont to monitor hemodynamics and fluid status. Transfer to floor today. Provide support to patient and family.\n"
},
{
"category": "ECG",
"chartdate": "2168-12-26 00:00:00.000",
"description": "Report",
"row_id": 269276,
"text": "Sinus rhythm. Ventricular ectopy with a ventricular couplet. There is an\nearly transition which is non-specific. Compared to the prior tracing\nthere is no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2168-12-25 00:00:00.000",
"description": "Report",
"row_id": 269277,
"text": "Sinus rhythm with frequent ventricular ectopy. There is an early transition\nwhich is non-specific. Compared to the prior tracing ventricular ectopy\nis more frequent and the atrial ectopy is no longer present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2168-12-20 00:00:00.000",
"description": "Report",
"row_id": 269278,
"text": "Sinus rhythm with atrial and ventricular premature beat. Early precordial\nQRS transition, probable normal variant. Since the previous tracing of \natrial ectopy is present.\n\n"
}
] |
96,848 | 193,525 | Patient is a 89 y/o M with a PMH of CVA in with residual disordered breathing, DM type 2 presenting with four days of intermittent anterior chest discomfort and new hypoxia, work up for PE negative, TTE with new wall motion abnormality concerning for ischmia now s/o cardiac cath with 3VD, DES to RCA . #. Chest Pain/WMA - The pt presents with hx of anterior chest discomfort occuring at rest for several days, similar to previous episodes which occurred during exercise. Symptoms concerning for unstable angina given pain at rest. ECG with new RBBB and ST depressions throughout precordium. TTE EF 60%, basal segments of the inferior and posterior wall are akinetic, and the midventricular segments are hypokinetic, RV cavity is dilated with borderline normal free wall function, 3+MR, moderate pulmonary artery systolic hypertension. Given concern for unstable angina, pt had cardiac catheterization and was found to have 3VD and had DES to RCA. He will need to continue on ASA 325 and Plavix 75 daily. He shoudl also continue on lisinopril 2.5 mg daily. Pt had subsequent episodes of chest pain that were likely r/t cough, pleuritic in nature and with flat CK's. #. Hypoxia - Pt has history of disordered breathing following stroke, has been off CPAP, also has evidence of progression of emphysema and ILD on Chest CT. Workup negative for PE. Pulmonary was consulted who recommended working up ILD with labs which were borderlinie for RF, positive and negative SPEP. They also suggested diuresis given GGO on CT can be representative of pulmonary edema. However, since pt did not clinically appear wet he was not diuresed. He was continued on Flovent 220 and Spiriva. He should continue supplemental oxygen to maintain sats >93%. He will follow up with Pulmonary ( ) as outpatient for PFT's and further workup. . #. Hx of CVA - Pt has resulting complex disordered breathing - pt has refused further treatment with CPAP or home O2 as outpatient. Aggrexox transitioned to plavix given now has stent. . #. HTN - Well controlled in house. Continued lisinopril, metoprolol . #. Type 2 diabetes - hold metformin while in house, insulin SS started, should resume metformin on transfer. . #. Nausea/Diarrhea/Hiccups: Pt had diarrhea, nausea, hiccups and vomiting on consistent with norovirus. He was continued on zofran, reglan, maalox prn for symptomatic management and symptoms improved by time of discharge. He is now 72 hours post start of norovirus symptoms and is considered cleared without need for further precautions. Note that robitussin with codeine works well for cough and hiccups. . #. Hypothyroidism - Continued synthroid . #. Code: Full . Contacts: Son | K 3.7, Mg 2.3, ck 69(trending down), troponin 0.12(0.13). # Pump previous echo from demonstrates mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Trop 0.04, CK neg. Response: Creat 1.1(down from 1.3). Cardiac cath today. Rec: -diuresis as you are able as GGO on CT are likely edema -f/u with Dr. /Dr. Pulses dop. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. Denies prior dyspnea. Denies prior dyspnea. Denies prior dyspnea. Denies prior dyspnea. Denies prior dyspnea. Hypothyroidism - continue synthroid . Hypothyroidism - continue synthroid . Hypothyroidism - continue synthroid . Hypothyroidism - continue synthroid . Hypothyroidism - continue synthroid . Hypothyroidism - continue synthroid . Hypothyroidism - continue synthroid . Hypothyroidism - continue synthroid . Dispo: ICU . Dispo: ICU . Dispo: ICU . Dispo: ICU . Dispo: ICU . Dispo: ICU . Dispo: ICU . In the ED, initial vitals were T: 98.0 HR: 88 BP: 140/85 RR: 18 O2Sat: 94% 4L NC. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. ECG with new RBBB and ST depressions throughout precordium. # Pump previous echo from demonstrates mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. # Pump previous echo from demonstrates mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. # Pump previous echo from demonstrates mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. # Pump previous echo from demonstrates mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. pneumonitis, ILD. pneumonitis, ILD. pneumonitis, ILD. pneumonitis, ILD. PPx: PPI, subQ heparin, bowel regimen . PPx: PPI, subQ heparin, bowel regimen . PPx: PPI, subQ heparin, bowel regimen . PPx: PPI, subQ heparin, bowel regimen . CAD - ECG with new RBBB and ST depressions throughout precordium. CAD - ECG with new RBBB and ST depressions throughout precordium. CAD - ECG with new RBBB and ST depressions throughout precordium. CAD - ECG with new RBBB and ST depressions throughout precordium. Also recommended ongoing diuresis . Also recommended ongoing diuresis . Also recommended ongoing diuresis . Also recommended ongoing diuresis . Hypothyroidism - continue synthroid . Hypothyroidism - continue synthroid . Hypothyroidism - continue synthroid . The right ventricular free wall ishypertrophied. # Pump previous echo from demonstrates mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. # Pump previous echo from demonstrates mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. # Pump previous echo from demonstrates mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Moderate mitralannular calcification. Trop 0.04, CK neg. Trop 0.04, CK neg. The right ventricular cavity is dilated with borderline normalfree wall function. Good uo, + hematuria. Good uo, + hematuria. Moderate [2+] tricuspidregurgitation is seen. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. HTN - continue lisinopril . HTN - continue lisinopril . HTN - continue lisinopril . Hypothyroidism - continue synthroid . Hypothyroidism - continue synthroid . Hypothyroidism - continue synthroid . Issues: (1) I think hypoxia is chronic. PE bibasal fine expiratory crackles, JVP NE, HS normal. Sinus rhythmIntermittent right bundle branch blockST-T changes are nonspecificSince previous tracing of , intermittent right bundle branch blockpresent Denies prior dyspnea. Normal ascending aorta diameter. Reproduced by chest palpation. Reproduced by chest palpation. Therefore, OK to continue heparin and obliged to r/o PE. (3) D-dimers >. Sinus rhythm and frequent atrial ectopy. Focal calcifications inascending aorta.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). ECG with new RBBB and ST depressions throughout precordium. Also, previous echo showed preserved EF. Left anterior fascicular block.Non-specific inferior ST-T wave changes. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. Sinus rhythm with atrial premature complexesRight bundle branch blockSince previous tracing of the same date, atrial premature complexes noted | 60 | [
{
"category": "Physician ",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 444120,
"text": "Chief Complaint: Chest Pain\n HPI:\n The pt is a 89y/o M with a PMH of CVA in with residual disordered\n breathing, DM type 2 presenting with four days of intermittent anterior\n chest discomfort and hypoxia. The pt reports pain worse with feelings\n of anxiety, has previously had similar pain while walking on a\n treadmill. Denies prior dyspnea. Denied N/V, No cough. States he works\n out daily by lifting weights, aerobic activity limited by fatigue. He\n has noted increased fatigue over the past several months. He has been\n off CPAP and nocturnal O2 for complex disordered sleep. Pain is\n unchanged with changes in position of deep breath.\n .\n In the ED, initial vitals were T: 98.0 HR: 88 BP: 140/85 RR: 18 O2Sat:\n 94% 4L NC. Patient received Morphine 2mg X3, NTG SL X2, morphine 4mg\n X1, ASA 325mg, Lasix 40mg IV and heparin gtt was started. D-Dimer 2494\n with initial negative CE. ECG demonstreated new RBBB. He was planned to\n be admitted to geriatric service for hydration prior to CTA but then\n developed recurrent chest pain with associated ECG changes.\n Following NTG and morphine, sat decreased to 82% and he was placed on a\n NRB and is now admitted to the CCU for further management. Cardiac\n enzymes negative X2. Vitals prior to transfer : 83 124/79 22 95 % NRB\n .\n On arrival to the CCU, the patient was resting comfortably, denies\n current dyspnea or pain, sating 90% on 5LNC.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Aggrenox 25 mg-200 mg Cap 1 \n Levothyroxine 25 mcg Tablet daily\n Lisinopril 2.5 mg Tablet daily\n Metformin 500 mg Tablet daily\n OMEPRAZOLE 20 mg Capsule, daily\n Multivitamin 1 capulse daily\n Vit C-Vit E-Copper-ZnOx-Lutein 226-200-5 mg-unit-mg Capsule\n 1 Capsule(s) by mouth twice a day\n Past medical history:\n Family history:\n Social History:\n CVA in presenting with left hemiparesis with brain MRI\n demonstrating distal right MCA stroke with evolution of right\n cerebellar infarct with resulting complex disordered breathing\n Colon ca s/p resection\n Osteoarthritis\n GERD\n HTN\n Drug-induced hepatitis\n Macular degeneration\n Nephrolithiasis\n Allergic rhinitis\n Type 2 diabetes\n Tonsillectomy/adenoidectomy\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Widowed, lives alone. He is retired. He previously worked in\n sales. He has not smoked in 40 years, prior to which he smoked \n packs per day for 20 years.\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 80 (80 - 93) bpm\n BP: 111/68(77) {111/68(77) - 133/82(93)} mmHg\n RR: 18 (16 - 24) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 207 mL\n PO:\n 30 mL\n TF:\n IVF:\n 177 mL\n Blood products:\n Total out:\n 0 mL\n 1,840 mL\n Urine:\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -1,633 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.46/37/60//2\n Physical Examination\n VS - BP 133/82, HR 90, 88% 5L NC\n Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with flat JVP\n CV: RRR, normal S1, S2. II/IV systolic murmur at apex\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Dry crackles throughout\n Abd: Soft, NT/ND. No HSM or tenderness. Abd aorta not enlarged by\n palpation.\n Ext: No c/c/e.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n .\n Pulses:\n Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ DP 2+ PT 1+\n Labs / Radiology\n 135 K/uL\n 14.2 g/dL\n 40.2 %\n 9.1 K/uL\n [image002.jpg]\n \n 2:33 A2/26/ 06:00 AM\n \n 10:20 P2/26/ 06:01 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.1\n Hct\n 40.2\n Plt\n 135\n TC02\n 27\n Other labs: PT / PTT / INR:16.3/150.0/1.5, CK / CKMB / Troponin-T:CK 45\n Trop 0.04, Lactic Acid:1.1 mmol/L\n Fluid analysis / Other labs: proBNP: 2194\n EKG demonstrated NSR rate 95bpm, LAD, RBBB with ST depression\n V2-V6, I, <1mm STE AVR with new RBBB and ST changes compared with prior\n dated .\n 2D-ECHOCARDIOGRAM performed on demonstrated: mild symmetric left\n ventricular hypertrophy with normal cavity size and regional/global\n systolic function (LVEF>55%). Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) are mildly\n thickened but aortic stenosis is not present. No aortic regurgitation\n is seen. The mitral valve leaflets are mildly thickened. There is no\n mitral valve prolapse. Mild to moderate (+) mitral regurgitation is\n seen. There is borderline pulmonary artery systolic hypertension. There\n is no pericardial effusion.\n IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved\n global and regional biventricular systolic function. Mild-moderate\n mitral regurgitation.\n Assessment and Plan\n Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia\n .\n #. Chest Pain - The pt presents with hx of anterior chest discomfort\n occuring at rest for several days, similar to previous episodes which\n occurred during exercise. ECG with new RBBB and ST depressions\n throughout precordium. Symptoms are concerning for cardiac vs pulmonary\n etiology. Cardiac enzymes negative X2, D-dimer elevated. TIMI score 3\n for age, RF and ST changes giving a 13% risk at 14 days of: all-cause\n mortality, new or recurrent MI, or severe recurrent ischemia requiring\n urgent revascularization. However given concurrent hypoxia, elevated\n D-dimer, and new RBBB also concern for PE.\n - Continue IV heparin\n - Continue Aggrenox\n - Continue lisinopril 2.5 mg daily\n - Trend CE - negative X2\n - Pt currently does not want to pursue cardiac catheterization, would\n consider stress testing following rule out of PE, improvement of\n hypoxia\n - Will start pre-contrast hydration for consideration of CTA this am\n .\n #. Hypoxia - The patient with hypoxia requiring NRB, currently weaned\n to 5L NC, no clear evidence of volume overload on exam. Pt has history\n of disordered breathing following stroke, has been off CPAP, also\n history of tobacco use, likely has underlying lung disease. Concern for\n PE as described above\n - Continue O2 NC to maintain sat >88%\n - Discuss risk/benefit of CTA to rule out PE, if no CTA would pursue\n non-contrast Chest CT\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - continue aggrenox\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO pending additional CE, then will start cardiac diet\n .\n #. Access: PIV\n .\n #. PPx: PPI, heparin gtt\n .\n #. Code: Full\n .\n #. Dispo: ICU\n .\n .\n ICU Care\n Nutrition:\n Comments: Cardiac diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: 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 Addendum at time of Rounds: Given Aa Gradient, elevated d-dimer, and\n flat CKs, very low troponin after having pain for days, will pursue CTA\n this morning, and attempt to look at coronary arteries at the same time\n in the CT scanner. CT scan will also allow for a look at the chest for\n any fibrotic or intrinsic interstitial lung disease. Pending CTA, will\n have to decide further risk stratification vs. catheterization. Will\n switch from aggrenox to plavix.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:04 ------\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444222,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia.\n .\n Chest pain\n Assessment:\n Skin warm & dry- no chest pain- good U/O- T max 100.1 Po- cardiac\n enzymes (-) this am.\n Action:\n Echo done- serial enzymes drawn- heparin gtt @ 1050u/hr- PTT pending-\n Plavix 300mg load given.\n Response:\n Trop trending up this afternoon- echo shows Inferior/Posterior L\n ventricular contractile dysfunction as well as R ventricular\n dysfunction.\n Plan:\n Repeat labs @ - follow temps & pan culture if temp > 100.5 Po- NPO\n after 12am ? cardiac cath tomorrow.\n Hypoxemia\n Assessment:\n SpO2\ns on 5L NC 88-93%- diuresed well from lasix given @ 0300 in ED.\n Action:\n CT of chest done.\n Response:\n (-) for PE- (-) 1600cc since 12am- BUN 22 Crea 1.3\n Plan:\n Monitor resp status- Hx sleep apnea -> refuses BiPAP.\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444104,
"text": "Hypoxemia\n Assessment:\n Arrived from in NAD, able to converse easily with staff, lay flat\n on stretcher for transfer, sats 87-89% on 5L n/c. Lungs with fine\n bibasilar rales, rr 18-22\n Action:\n ABG obtained by CCU team, Cardiology fellow in to assess again. Resp.\n status monitored closely, started pre-hydration IVF at 0600 for CT scan\n as ordered, IV Heparin as below\n Response:\n ABG 7.46/37/60/2/27, diuresising well to IV Lasix, tolerated IVF at\n present\n Plan:\n Plan for CT scan to assess pulmonary status, R/O PE, pre-hydration IVF\n as ordered, muco-mist as ordered\n Chest pain\n Assessment:\n Painfree on arrival to CCU, Hemodynamically stable, initial CPK/Trop.\n neg\n Action:\n Maintained on IV Heparin at 1450units/hour, PTT and am labs sent at\n 0600\n Response:\n painfree, ruling out at present\n Plan:\n Cont to monitor hemodynamics, assess for CP, next set of CPKs/Trop.\n due at 1100, comfort and emotional support to Pt. and family\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 444111,
"text": "Chief Complaint: Chest Pain\n HPI:\n The pt is a 89y/o M with a PMH of CVA in with residual disordered\n breathing, DM type 2 presenting with four days of intermittent anterior\n chest discomfort and hypoxia. The pt reports pain worse with feelings\n of anxiety, has previously had similar pain while walking on a\n treadmill. Denies prior dyspnea. Denied N/V, No cough. States he works\n out daily by lifting weights, aerobic activity limited by fatigue. He\n has noted increased fatigue over the past several months. He has been\n off CPAP and nocturnal O2 for complex disordered sleep. Pain is\n unchanged with changes in position of deep breath.\n .\n In the ED, initial vitals were T: 98.0 HR: 88 BP: 140/85 RR: 18 O2Sat:\n 94% 4L NC. Patient received Morphine 2mg X3, NTG SL X2, morphine 4mg\n X1, ASA 325mg, Lasix 40mg IV and heparin gtt was started. D-Dimer 2494\n with initial negative CE. ECG demonstreated new RBBB. He was planned to\n be admitted to geriatric service for hydration prior to CTA but then\n developed recurrent chest pain with associated ECG changes.\n Following NTG and morphine, sat decreased to 82% and he was placed on a\n NRB and is now admitted to the CCU for further management. Cardiac\n enzymes negative X2. Vitals prior to transfer : 83 124/79 22 95 % NRB\n .\n On arrival to the CCU, the patient was resting comfortably, denies\n current dyspnea or pain, sating 90% on 5LNC.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Aggrenox 25 mg-200 mg Cap 1 \n Levothyroxine 25 mcg Tablet daily\n Lisinopril 2.5 mg Tablet daily\n Metformin 500 mg Tablet daily\n OMEPRAZOLE 20 mg Capsule, daily\n Multivitamin 1 capulse daily\n Vit C-Vit E-Copper-ZnOx-Lutein 226-200-5 mg-unit-mg Capsule\n 1 Capsule(s) by mouth twice a day\n Past medical history:\n Family history:\n Social History:\n CVA in presenting with left hemiparesis with brain MRI\n demonstrating distal right MCA stroke with evolution of right\n cerebellar infarct with resulting complex disordered breathing\n Colon ca s/p resection\n Osteoarthritis\n GERD\n HTN\n Drug-induced hepatitis\n Macular degeneration\n Nephrolithiasis\n Allergic rhinitis\n Type 2 diabetes\n Tonsillectomy/adenoidectomy\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Widowed, lives alone. He is retired. He previously worked in\n sales. He has not smoked in 40 years, prior to which he smoked \n packs per day for 20 years.\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 80 (80 - 93) bpm\n BP: 111/68(77) {111/68(77) - 133/82(93)} mmHg\n RR: 18 (16 - 24) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 207 mL\n PO:\n 30 mL\n TF:\n IVF:\n 177 mL\n Blood products:\n Total out:\n 0 mL\n 1,840 mL\n Urine:\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -1,633 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.46/37/60//2\n Physical Examination\n VS - BP 133/82, HR 90, 88% 5L NC\n Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with flat JVP\n CV: RRR, normal S1, S2. II/IV systolic murmur at apex\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Dry crackles throughout\n Abd: Soft, NT/ND. No HSM or tenderness. Abd aorta not enlarged by\n palpation.\n Ext: No c/c/e.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n .\n Pulses:\n Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ DP 2+ PT 1+\n Labs / Radiology\n 135 K/uL\n 14.2 g/dL\n 40.2 %\n 9.1 K/uL\n [image002.jpg]\n \n 2:33 A2/26/ 06:00 AM\n \n 10:20 P2/26/ 06:01 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.1\n Hct\n 40.2\n Plt\n 135\n TC02\n 27\n Other labs: PT / PTT / INR:16.3/150.0/1.5, CK / CKMB / Troponin-T:CK 45\n Trop 0.04, Lactic Acid:1.1 mmol/L\n Fluid analysis / Other labs: proBNP: 2194\n EKG demonstrated NSR rate 95bpm, LAD, RBBB with ST depression\n V2-V6, I, <1mm STE AVR with new RBBB and ST changes compared with prior\n dated .\n 2D-ECHOCARDIOGRAM performed on demonstrated: mild symmetric left\n ventricular hypertrophy with normal cavity size and regional/global\n systolic function (LVEF>55%). Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) are mildly\n thickened but aortic stenosis is not present. No aortic regurgitation\n is seen. The mitral valve leaflets are mildly thickened. There is no\n mitral valve prolapse. Mild to moderate (+) mitral regurgitation is\n seen. There is borderline pulmonary artery systolic hypertension. There\n is no pericardial effusion.\n IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved\n global and regional biventricular systolic function. Mild-moderate\n mitral regurgitation.\n Assessment and Plan\n Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia\n .\n #. Chest Pain - The pt presents with hx of anterior chest discomfort\n occuring at rest for several days, similar to previous episodes which\n occurred during exercise. ECG with new RBBB and ST depressions\n throughout precordium. Symptoms are concerning for cardiac vs pulmonary\n etiology. Cardiac enzymes negative X2, D-dimer elevated. TIMI score 3\n for age, RF and ST changes giving a 13% risk at 14 days of: all-cause\n mortality, new or recurrent MI, or severe recurrent ischemia requiring\n urgent revascularization. However given concurrent hypoxia, elevated\n D-dimer, and new RBBB also concern for PE.\n - Continue IV heparin\n - Continue Aggrenox\n - Continue lisinopril 2.5 mg daily\n - Trend CE - negative X2\n - Pt currently does not want to pursue cardiac catheterization, would\n consider stress testing following rule out of PE, improvement of\n hypoxia\n - Will start pre-contrast hydration for consideration of CTA this am\n .\n #. Hypoxia - The patient with hypoxia requiring NRB, currently weaned\n to 5L NC, no clear evidence of volume overload on exam. Pt has history\n of disordered breathing following stroke, has been off CPAP, also\n history of tobacco use, likely has underlying lung disease. Concern for\n PE as described above\n - Continue O2 NC to maintain sat >88%\n - Discuss risk/benefit of CTA to rule out PE, if no CTA would pursue\n non-contrast Chest CT\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - continue aggrenox\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO pending additional CE, then will start cardiac diet\n .\n #. Access: PIV\n .\n #. PPx: PPI, heparin gtt\n .\n #. Code: Full\n .\n #. Dispo: ICU\n .\n .\n ICU Care\n Nutrition:\n Comments: Cardiac diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin gtt)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444264,
"text": "89 yr. old functionally independent male, without known CAD, but with\n DM, h/o R MCA and R cerebellar CVA in , presenting with 3 days of\n intermittent atypical sounding CP while at rest, culminating in a 1hr\n episode yesterday at 5pm. Background of intermittent pain for months.\n Pain not related to exertion (exercises 4x/week in gym without\n symptoms), but brought on by emotional stress. Reproduced by chest\n palpation. EKG showed new RBBB compared to , but subsequently\n developed more CP associated with dynamic ST depressions V1-4. Trop\n 0.04, CK neg. Also noted to be hypoxic 86% on 4L, switched to NRB->\n 93%. Transferred to CCU for further w/u. Chest CT (-) PE.\n Hypoxemia\n Assessment:\n O2 sat 89-93% on 5L NP. RR 20-28. BS clear with crackles 1/3 up\n bilaterally. Denies c/o sob. U/O 40-120 cc/hr. (-)1.6L\n Action:\n No further lasix at this point(dye load with CT & will get dye with\n cath). D5W + bicarb iv completed. Receiving mucomyst x4 doses.\n Response:\n Creat 1.1(down from 1.3).\n Plan:\n Cont. to monitor creat closely. ?? lasix after cath.\n Chest pain\n Assessment:\n HR 70-80\ns SR with frequent PAC\ns. BP 98-124/52-66. Heparin gtt\n infusing at 750u/hr. PTT 53.9. Denies c/o CP/SOB. K 3.7, Mg 2.3, ck\n 69(trending down), troponin 0.12(0.13).\n Action:\n Bilateral LE US (-) DVT. Received KCL 40meq po x1 for low K. Repeat\n PTT, lytes with AM labs.\n Response:\n Hemodynamically stable while awaiting cath.\n Plan:\n NPO for?? Cardiac cath today. Monitor PTT. Replete lytes as indicated.\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444425,
"text": "HPI:\n The pt is a 89y/o M with a PMH of CVA in with residual disordered\n breathing, DM type 2 presenting with four days of intermittent anterior\n chest discomfort and hypoxia. The pt reports pain worse with feelings\n of anxiety, has previously had similar pain while walking on a\n treadmill. Denies prior dyspnea. Denied N/V, No cough. States he works\n out daily by lifting weights, aerobic activity limited by fatigue. He\n has noted increased fatigue over the past several months. He has been\n off CPAP and nocturnal O2 for complex disordered sleep. Pain is\n unchanged with changes in position of deep breath.\n .\n In the ED, initial vitals were T: 98.0 HR: 88 BP: 140/85 RR: 18 O2Sat:\n 94% 4L NC. Patient received Morphine 2mg X3, NTG SL X2, morphine 4mg\n X1, ASA 325mg, Lasix 40mg IV and heparin gtt was started. D-Dimer 2494\n with initial negative CE. ECG demonstreated new RBBB. He was planned to\n be admitted to geriatric service for hydration prior to CTA but then\n developed recurrent chest pain with associated ECG changes.\n Following NTG and morphine, sat decreased to 82% and he was placed on a\n NRB and is now admitted to the CCU for further management. Cardiac\n enzymes negative X2. Vitals prior to transfer : 83 124/79 22 95 % NRB\n .\n On arrival to the CCU, the patient was resting comfortably, denies\n current dyspnea or pain, sating 90% on 5LNC.\n Hypoxemia\n Assessment:\n On 5 L NP, bs+ all lobes, clear, crackles to bases, chest CT to\n r/o PE, PE r/o, emphesema & pulmonary fibrosis noted on chest CT, no\n c/o SOB since admission, no resp distress noted\n Action:\n Continue o2 @ 5 L NP, npo for cath lab today\n Response:\n Sat 91-94 on 5 L NP, no c/o CP or SOB, no resp distress noted\n Plan:\n Wean o2 as tolerated, continue to monitor resp status, may need home\n o2, further workup of pulmonary status\n Chest pain\n Assessment:\n No c/o CP or SOB since admission to ccu, new RBBB & st depression\n throughout precordium, troponin trending down\n Action:\n On heparin gtt @ 750u/hr, npo for cath lab, iv fluids up @ 75/hr, to\n get ivf with bicarb on call to lab\n Response:\n No cp or sob, vss\n Plan:\n Cath lab today, post cardiac cath care\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 444423,
"text": "HPI:\n The pt is a 89y/o M with a PMH of CVA in with residual disordered\n breathing, DM type 2 presenting with four days of intermittent anterior\n chest discomfort and hypoxia. The pt reports pain worse with feelings\n of anxiety, has previously had similar pain while walking on a\n treadmill. Denies prior dyspnea. Denied N/V, No cough. States he works\n out daily by lifting weights, aerobic activity limited by fatigue. He\n has noted increased fatigue over the past several months. He has been\n off CPAP and nocturnal O2 for complex disordered sleep. Pain is\n unchanged with changes in position of deep breath.\n .\n In the ED, initial vitals were T: 98.0 HR: 88 BP: 140/85 RR: 18 O2Sat:\n 94% 4L NC. Patient received Morphine 2mg X3, NTG SL X2, morphine 4mg\n X1, ASA 325mg, Lasix 40mg IV and heparin gtt was started. D-Dimer 2494\n with initial negative CE. ECG demonstreated new RBBB. He was planned to\n be admitted to geriatric service for hydration prior to CTA but then\n developed recurrent chest pain with associated ECG changes.\n Following NTG and morphine, sat decreased to 82% and he was placed on a\n NRB and is now admitted to the CCU for further management. Cardiac\n enzymes negative X2. Vitals prior to transfer : 83 124/79 22 95 % NRB\n .\n On arrival to the CCU, the patient was resting comfortably, denies\n current dyspnea or pain, sating 90% on 5LNC.\n Hypoxemia\n Assessment:\n On 5 L NP, bs+ all lobes, clear, crackles to bases, chest CT to\n r/o PE, PE r/o, emphesema & pulmonary fibrosis noted on chest CT, no\n c/o SOB since admission, no resp distress noted\n Action:\n Continue o2 @ 5 L NP, npo for cath lab today\n Response:\n Sat 91-94 on 5 L NP, no c/o CP or SOB, no resp distress noted\n Plan:\n Wean o2 as tolerated, continue to monitor resp status, may need home\n o2, further workup of pulmonary status\n Chest pain\n Assessment:\n No c/o CP or SOB since admission to ccu, new RBBB & st depression\n throughout precordium, troponin trending down\n Action:\n On heparin gtt @ 750u/hr, npo for cath lab, iv fluids up @ 75/hr, to\n get ivf with bicarb on call to lab\n Response:\n No cp or sob, vss\n Plan:\n Cath lab today, post cardiac cath care\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444498,
"text": "TITLE: CCU Resident Admission Note\n Chief Complaint: chest pain\n 24 Hour Events:\n Cardiac catherization : cath demonstrated right dominant, LMCA no\n significant disease, LAD diffuse proximal calcification, mid up to 60%,\n LCX total occlusion at OM1 take off and then long subtotal occlusion of\n OM1 appears chronic, RCA diffuse 90% proximal and 80% distal, heavily\n calcified - final dxg 3 vessel CAD, successful DES to RCA\n - post cath recs: aspirin 325 mg PO daily x 6 months and then may\n decrease to 81 mg PO daily, plavix 75 mg PO daily for at least one year\n - post cath check: small bruising around cath site, doppleralbe pulses\n bilaterally, stable vital signs\n - will need pulmonary appointment as outpatient\n - start beta today, restart lisinopril after cath\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98\n HR: 84 (63 - 84) bpm\n BP: 115/57(71) {99/48(65) - 134/70(84)} mmHg\n RR: 24 (11 - 25) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,733 mL\n 1,270 mL\n PO:\n 480 mL\n TF:\n IVF:\n 1,253 mL\n 1,270 mL\n Blood products:\n Total out:\n 1,720 mL\n 660 mL\n Urine:\n 1,510 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 13 mL\n 610 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 88%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished),\n good DP/PT pulses by doppler\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, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 144 K/uL\n 12.8 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 103 mEq/L\n 139 mEq/L\n 37.2 %\n 7.1 K/uL\n [image002.jpg]\n 06:00 AM\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n 01:19 AM\n WBC\n 9.1\n 7.1\n Hct\n 40.2\n 37.2\n Plt\n 135\n 140\n 144\n Cr\n 1.3\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n TCO2\n 27\n Glucose\n 139\n 179\n 161\n \n Other labs: PT / PTT / INR:15.9/63.8/1.4, CK / CKMB /\n Troponin-T:51/9/0.11, Lactic Acid:1.1 mmol/L, Ca++:8.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 89 y/o M with a PMH of CVA in with residual disordered breathing,\n DM type 2 presenting with four days of intermittent anterior chest\n discomfort and new hypoxia, work up for PE negative, TTE with new wall\n motion abnormality concerning for ischmia now s/p cardiac catherization\n with stent placement to RCA\n .\n #. Chest Pain/WMA - The pt presents with hx of anterior chest\n discomfort occuring at rest for several days, similar to previous\n episodes which occurred during exercise. ECG with new RBBB and ST\n depressions throughout precordium. TTE EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension. No further episodes of chest pain since admission.\n Patient s/p DES to RCA.\n - off IV heparin\n - Continue Plavix, aspirin, beta blocker\n .\n # Pump\n previous echo from demonstrates mild symmetric left\n ventricular hypertrophy with preserved global and regional\n biventricular systolic function. Mild-moderate mitral regurgitation.\n - consider repeat echo this admission\n - cont aspirin, statin, beta blocker\n #. Hypoxia - Pt has history of disordered breathing following stroke,\n has been off CPAP, also has evidence of progression of emphysema and\n ILD on Chest CT. Workup negative for PE\n - Continue O2 NC to maintain sat >88%\n - Pt will need evaluation by Pulmonary as outpatient, eval for home O2\n post-postentional revascularization\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - aggrexox transitioned to plavix given concern for ACS\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO for cath\n .\n #. Access: PIV\n .\n #. PPx: PPI, subQ heparin, bowel regimen\n .\n #. Code: Full\n .\n #. Dispo: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444501,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, TTE with new wall motion abnormality concerning for ischmia\n .\n #. Chest Pain/WMA - The pt presents with hx of anterior chest\n discomfort occuring at rest for several days, similar to previous\n episodes which occurred during exercise. ECG with new RBBB and ST\n depressions throughout precordium. TTE EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension. No further episodes of chest pain since admission\n Denies chest pain. Hr 70-80\ns with frequent pac\ns/pvc\ns. SBP\n 120-130\ns/70\ns. Completed bicarb drip. !/2 NS infusing. Right groin\n with transparent dsg with small amount of bld drainage. Pulses dop.\n Slept with 12.5 mg of benadryl for sleep. Small sot hematoma to right\n groin site. Anticipate call out to floor.\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444412,
"text": "Chief Complaint:\n 24 Hour Events:\n - ECHO (summary): dilated, EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension\n - CT shows: 1) diffuse bronchial wall thickening. Wall in main\n pulmonary bronchus measures up to 4 mm. Suggestive of bronchitis.\n 2) progression of emphysema.\n 3) slight progression of interstitial lung disease.\n 4) Large hiatal hernia.\n - Bilateral LENIs checked to r/o DVT-> negative\n - CE trending up, but now peaked (Trop <0.01->0.04-> 1.13->0.12->0.11),\n CK 44->45->109->69->58\n - Plavix increased to total 300mg dose x 1\n - Started on ASA 325, held ACEI\n - Repleted K\n - Discussed cath with pt and son, agree to proceed in am\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:08 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: 37.6\nC (99.6\n HR: 69 (69 - 90) bpm\n BP: 83/52(59) {83/50(59) - 131/84(95)} mmHg\n RR: 23 (14 - 28) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,155 mL\n 286 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 1,555 mL\n 46 mL\n Blood products:\n Total out:\n 3,710 mL\n 350 mL\n Urine:\n 2,710 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,555 mL\n -64 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///28/\n Physical Examination\n Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with flat JVP\n CV: RRR, normal S1, S2. II/IV systolic murmur at apex\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Dry crackles throughout\n Abd: Soft, NT/ND. No HSM or tenderness. Abd aorta not enlarged by\n palpation.\n Ext: No c/c/e.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 140 K/uL\n 12.8 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 103 mEq/L\n 139 mEq/L\n 37.2 %\n 7.1 K/uL\n [image002.jpg]\n 06:00 AM\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n WBC\n 9.1\n 7.1\n Hct\n 40.2\n 37.2\n Plt\n 135\n 140\n Cr\n 1.3\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n TCO2\n 27\n Glucose\n 139\n 179\n 161\n \n Other labs: PT / PTT / INR:15.9/63.8/1.4, CK / CKMB /\n Troponin-T:58/9/0.11, Lactic Acid:1.1 mmol/L, Ca++:8.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, TTE with new wall motion abnormality concerning for ischmia\n .\n #. Chest Pain/WMA - The pt presents with hx of anterior chest\n discomfort occuring at rest for several days, similar to previous\n episodes which occurred during exercise. ECG with new RBBB and ST\n depressions throughout precordium. TTE EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension. No further episodes of chest pain since admission\n - Continue IV heparin\n - Continue Plavix\n - Continue lisinopril 2.5 mg daily\n - Pt agreeable to cardiac cath today for further evaluation for CAD\n .\n #. Hypoxia - Pt has history of disordered breathing following stroke,\n has been off CPAP, also has evidence of progression of emphysema and\n ILD on Chest CT. Workup negative for PE\n - Continue O2 NC to maintain sat >88%\n - Pt will need evaluation by Pulmonary as outpatient, eval for home O2\n post-postentional revascularization\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - aggrexox transitioned to plavix given concern for ACS\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO for cath\n .\n #. Access: PIV\n .\n #. PPx: PPI, heparin gtt\n .\n #. Code: Full\n .\n #. Dispo: ICU\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full\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, agree with above\n Physical Examination\n nothing to add, agree with above\n Medical Decision Making\n nothing to add, agree with above\n Total time spent on patient care: 50 minutes.\n ------ Protected Section Addendum Entered By: on:\n 18:36 ------\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444330,
"text": "Chief Complaint:\n 24 Hour Events:\n - ECHO (summary): dilated, EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension\n - CT shows: 1) diffuse bronchial wall thickening. Wall in main\n pulmonary bronchus measures up to 4 mm. Suggestive of bronchitis.\n 2) progression of emphysema.\n 3) slight progression of interstitial lung disease.\n 4) Large hiatal hernia.\n - Bilateral LENIs checked to r/o DVT-> negative\n - CE trending up, but now peaked (Trop <0.01->0.04-> 1.13->0.12->0.11),\n CK 44->45->109->69->58\n - Plavix increased to total 300mg dose x 1\n - Started on ASA 325, held ACEI\n - Repleted K\n - Discussed cath with pt and son, agree to proceed in am\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:08 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: 37.6\nC (99.6\n HR: 69 (69 - 90) bpm\n BP: 83/52(59) {83/50(59) - 131/84(95)} mmHg\n RR: 23 (14 - 28) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,155 mL\n 286 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 1,555 mL\n 46 mL\n Blood products:\n Total out:\n 3,710 mL\n 350 mL\n Urine:\n 2,710 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,555 mL\n -64 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///28/\n Physical Examination\n Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with flat JVP\n CV: RRR, normal S1, S2. II/IV systolic murmur at apex\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Dry crackles throughout\n Abd: Soft, NT/ND. No HSM or tenderness. Abd aorta not enlarged by\n palpation.\n Ext: No c/c/e.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 140 K/uL\n 12.8 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 103 mEq/L\n 139 mEq/L\n 37.2 %\n 7.1 K/uL\n [image002.jpg]\n 06:00 AM\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n WBC\n 9.1\n 7.1\n Hct\n 40.2\n 37.2\n Plt\n 135\n 140\n Cr\n 1.3\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n TCO2\n 27\n Glucose\n 139\n 179\n 161\n \n Other labs: PT / PTT / INR:15.9/63.8/1.4, CK / CKMB /\n Troponin-T:58/9/0.11, Lactic Acid:1.1 mmol/L, Ca++:8.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia\n .\n #. Chest Pain - The pt presents with hx of anterior chest discomfort\n occuring at rest for several days, similar to previous episodes which\n occurred during exercise. ECG with new RBBB and ST depressions\n throughout precordium. Symptoms are concerning for cardiac vs pulmonary\n etiology. Cardiac enzymes negative X2, D-dimer elevated. TIMI score 3\n for age, RF and ST changes giving a 13% risk at 14 days of: all-cause\n mortality, new or recurrent MI, or severe recurrent ischemia requiring\n urgent revascularization. However given concurrent hypoxia, elevated\n D-dimer, and new RBBB also concern for PE.\n - Continue IV heparin\n - Continue Aggrenox\n - Continue lisinopril 2.5 mg daily\n - Trend CE - negative X2\n - Pt currently does not want to pursue cardiac catheterization, would\n consider stress testing following rule out of PE, improvement of\n hypoxia\n - Will start pre-contrast hydration for consideration of CTA this am\n .\n #. Hypoxia - The patient with hypoxia requiring NRB, currently weaned\n to 5L NC, no clear evidence of volume overload on exam. Pt has history\n of disordered breathing following stroke, has been off CPAP, also\n history of tobacco use, likely has underlying lung disease. Concern for\n PE as described above\n - Continue O2 NC to maintain sat >88%\n - Discuss risk/benefit of CTA to rule out PE, if no CTA would pursue\n non-contrast Chest CT\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - aggrexox transitioned to plavix given concern for ACS\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO for cath\n .\n #. Access: PIV\n .\n #. PPx: PPI, heparin gtt\n .\n #. Code: Full\n .\n #. Dispo: ICU\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444331,
"text": "Chief Complaint:\n 24 Hour Events:\n - ECHO (summary): dilated, EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension\n - CT shows: 1) diffuse bronchial wall thickening. Wall in main\n pulmonary bronchus measures up to 4 mm. Suggestive of bronchitis.\n 2) progression of emphysema.\n 3) slight progression of interstitial lung disease.\n 4) Large hiatal hernia.\n - Bilateral LENIs checked to r/o DVT-> negative\n - CE trending up, but now peaked (Trop <0.01->0.04-> 1.13->0.12->0.11),\n CK 44->45->109->69->58\n - Plavix increased to total 300mg dose x 1\n - Started on ASA 325, held ACEI\n - Repleted K\n - Discussed cath with pt and son, agree to proceed in am\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:08 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: 37.6\nC (99.6\n HR: 69 (69 - 90) bpm\n BP: 83/52(59) {83/50(59) - 131/84(95)} mmHg\n RR: 23 (14 - 28) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,155 mL\n 286 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 1,555 mL\n 46 mL\n Blood products:\n Total out:\n 3,710 mL\n 350 mL\n Urine:\n 2,710 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,555 mL\n -64 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///28/\n Physical Examination\n Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with flat JVP\n CV: RRR, normal S1, S2. II/IV systolic murmur at apex\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Dry crackles throughout\n Abd: Soft, NT/ND. No HSM or tenderness. Abd aorta not enlarged by\n palpation.\n Ext: No c/c/e.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 140 K/uL\n 12.8 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 103 mEq/L\n 139 mEq/L\n 37.2 %\n 7.1 K/uL\n [image002.jpg]\n 06:00 AM\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n WBC\n 9.1\n 7.1\n Hct\n 40.2\n 37.2\n Plt\n 135\n 140\n Cr\n 1.3\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n TCO2\n 27\n Glucose\n 139\n 179\n 161\n \n Other labs: PT / PTT / INR:15.9/63.8/1.4, CK / CKMB /\n Troponin-T:58/9/0.11, Lactic Acid:1.1 mmol/L, Ca++:8.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, TTE with new wall motion abnormality concerning for ischmia\n .\n #. Chest Pain - The pt presents with hx of anterior chest discomfort\n occuring at rest for several days, similar to previous episodes which\n occurred during exercise. ECG with new RBBB and ST depressions\n throughout precordium. Symptoms are concerning for cardiac vs pulmonary\n etiology. Cardiac enzymes negative X2, D-dimer elevated. TIMI score 3\n for age, RF and ST changes giving a 13% risk at 14 days of: all-cause\n mortality, new or recurrent MI, or severe recurrent ischemia requiring\n urgent revascularization. However given concurrent hypoxia, elevated\n D-dimer, and new RBBB also concern for PE.\n - Continue IV heparin\n - Continue Aggrenox\n - Continue lisinopril 2.5 mg daily\n - Trend CE - negative X2\n - Pt currently does not want to pursue cardiac catheterization, would\n consider stress testing following rule out of PE, improvement of\n hypoxia\n - Will start pre-contrast hydration for consideration of CTA this am\n .\n #. Hypoxia - The patient with hypoxia requiring NRB, currently weaned\n to 5L NC, no clear evidence of volume overload on exam. Pt has history\n of disordered breathing following stroke, has been off CPAP, also\n history of tobacco use, likely has underlying lung disease. Concern for\n PE as described above\n - Continue O2 NC to maintain sat >88%\n - Discuss risk/benefit of CTA to rule out PE, if no CTA would pursue\n non-contrast Chest CT\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - aggrexox transitioned to plavix given concern for ACS\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO for cath\n .\n #. Access: PIV\n .\n #. PPx: PPI, heparin gtt\n .\n #. Code: Full\n .\n #. Dispo: ICU\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444333,
"text": "Chief Complaint:\n 24 Hour Events:\n - ECHO (summary): dilated, EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension\n - CT shows: 1) diffuse bronchial wall thickening. Wall in main\n pulmonary bronchus measures up to 4 mm. Suggestive of bronchitis.\n 2) progression of emphysema.\n 3) slight progression of interstitial lung disease.\n 4) Large hiatal hernia.\n - Bilateral LENIs checked to r/o DVT-> negative\n - CE trending up, but now peaked (Trop <0.01->0.04-> 1.13->0.12->0.11),\n CK 44->45->109->69->58\n - Plavix increased to total 300mg dose x 1\n - Started on ASA 325, held ACEI\n - Repleted K\n - Discussed cath with pt and son, agree to proceed in am\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:08 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: 37.6\nC (99.6\n HR: 69 (69 - 90) bpm\n BP: 83/52(59) {83/50(59) - 131/84(95)} mmHg\n RR: 23 (14 - 28) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,155 mL\n 286 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 1,555 mL\n 46 mL\n Blood products:\n Total out:\n 3,710 mL\n 350 mL\n Urine:\n 2,710 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,555 mL\n -64 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///28/\n Physical Examination\n Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with flat JVP\n CV: RRR, normal S1, S2. II/IV systolic murmur at apex\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Dry crackles throughout\n Abd: Soft, NT/ND. No HSM or tenderness. Abd aorta not enlarged by\n palpation.\n Ext: No c/c/e.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 140 K/uL\n 12.8 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 103 mEq/L\n 139 mEq/L\n 37.2 %\n 7.1 K/uL\n [image002.jpg]\n 06:00 AM\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n WBC\n 9.1\n 7.1\n Hct\n 40.2\n 37.2\n Plt\n 135\n 140\n Cr\n 1.3\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n TCO2\n 27\n Glucose\n 139\n 179\n 161\n \n Other labs: PT / PTT / INR:15.9/63.8/1.4, CK / CKMB /\n Troponin-T:58/9/0.11, Lactic Acid:1.1 mmol/L, Ca++:8.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, TTE with new wall motion abnormality concerning for ischmia\n .\n #. Chest Pain/WMA - The pt presents with hx of anterior chest\n discomfort occuring at rest for several days, similar to previous\n episodes which occurred during exercise. ECG with new RBBB and ST\n depressions throughout precordium. TTE EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension. No further episodes of chest pain since admission\n - Continue IV heparin\n - Continue Plavix\n - Continue lisinopril 2.5 mg daily\n - Pt agreeable to cardiac cath today for further evaluation for CAD\n .\n #. Hypoxia - Pt has history of disordered breathing following stroke,\n has been off CPAP, also has evidence of progression of emphysema and\n ILD on Chest CT. Workup negative for PE\n - Continue O2 NC to maintain sat >88%\n - Pt will need evaluation by Pulmonary as outpatient, eval for home O2\n post-postentional revascularization\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - aggrexox transitioned to plavix given concern for ACS\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO for cath\n .\n #. Access: PIV\n .\n #. PPx: PPI, heparin gtt\n .\n #. Code: Full\n .\n #. Dispo: ICU\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT: heparin gtt\n Stress ulcer: PPI\n VAP: NA\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 444408,
"text": "Chief Complaint: Chest Pain\n HPI:\n The pt is a 89y/o M with a PMH of CVA in with residual disordered\n breathing, DM type 2 presenting with four days of intermittent anterior\n chest discomfort and hypoxia. The pt reports pain worse with feelings\n of anxiety, has previously had similar pain while walking on a\n treadmill. Denies prior dyspnea. Denied N/V, No cough. States he works\n out daily by lifting weights, aerobic activity limited by fatigue. He\n has noted increased fatigue over the past several months. He has been\n off CPAP and nocturnal O2 for complex disordered sleep. Pain is\n unchanged with changes in position of deep breath.\n .\n In the ED, initial vitals were T: 98.0 HR: 88 BP: 140/85 RR: 18 O2Sat:\n 94% 4L NC. Patient received Morphine 2mg X3, NTG SL X2, morphine 4mg\n X1, ASA 325mg, Lasix 40mg IV and heparin gtt was started. D-Dimer 2494\n with initial negative CE. ECG demonstreated new RBBB. He was planned to\n be admitted to geriatric service for hydration prior to CTA but then\n developed recurrent chest pain with associated ECG changes.\n Following NTG and morphine, sat decreased to 82% and he was placed on a\n NRB and is now admitted to the CCU for further management. Cardiac\n enzymes negative X2. Vitals prior to transfer : 83 124/79 22 95 % NRB\n .\n On arrival to the CCU, the patient was resting comfortably, denies\n current dyspnea or pain, sating 90% on 5LNC.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Aggrenox 25 mg-200 mg Cap 1 \n Levothyroxine 25 mcg Tablet daily\n Lisinopril 2.5 mg Tablet daily\n Metformin 500 mg Tablet daily\n OMEPRAZOLE 20 mg Capsule, daily\n Multivitamin 1 capulse daily\n Vit C-Vit E-Copper-ZnOx-Lutein 226-200-5 mg-unit-mg Capsule\n 1 Capsule(s) by mouth twice a day\n Past medical history:\n Family history:\n Social History:\n CVA in presenting with left hemiparesis with brain MRI\n demonstrating distal right MCA stroke with evolution of right\n cerebellar infarct with resulting complex disordered breathing\n Colon ca s/p resection\n Osteoarthritis\n GERD\n HTN\n Drug-induced hepatitis\n Macular degeneration\n Nephrolithiasis\n Allergic rhinitis\n Type 2 diabetes\n Tonsillectomy/adenoidectomy\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Widowed, lives alone. He is retired. He previously worked in\n sales. He has not smoked in 40 years, prior to which he smoked \n packs per day for 20 years.\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 80 (80 - 93) bpm\n BP: 111/68(77) {111/68(77) - 133/82(93)} mmHg\n RR: 18 (16 - 24) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 207 mL\n PO:\n 30 mL\n TF:\n IVF:\n 177 mL\n Blood products:\n Total out:\n 0 mL\n 1,840 mL\n Urine:\n 840 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -1,633 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.46/37/60//2\n Physical Examination\n VS - BP 133/82, HR 90, 88% 5L NC\n Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with flat JVP\n CV: RRR, normal S1, S2. II/IV systolic murmur at apex\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Dry crackles throughout\n Abd: Soft, NT/ND. No HSM or tenderness. Abd aorta not enlarged by\n palpation.\n Ext: No c/c/e.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n .\n Pulses:\n Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ DP 2+ PT 1+\n Labs / Radiology\n 135 K/uL\n 14.2 g/dL\n 40.2 %\n 9.1 K/uL\n [image002.jpg]\n \n 2:33 A2/26/ 06:00 AM\n \n 10:20 P2/26/ 06:01 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.1\n Hct\n 40.2\n Plt\n 135\n TC02\n 27\n Other labs: PT / PTT / INR:16.3/150.0/1.5, CK / CKMB / Troponin-T:CK 45\n Trop 0.04, Lactic Acid:1.1 mmol/L\n Fluid analysis / Other labs: proBNP: 2194\n EKG demonstrated NSR rate 95bpm, LAD, RBBB with ST depression\n V2-V6, I, <1mm STE AVR with new RBBB and ST changes compared with prior\n dated .\n 2D-ECHOCARDIOGRAM performed on demonstrated: mild symmetric left\n ventricular hypertrophy with normal cavity size and regional/global\n systolic function (LVEF>55%). Right ventricular chamber size and free\n wall motion are normal. The aortic valve leaflets (3) are mildly\n thickened but aortic stenosis is not present. No aortic regurgitation\n is seen. The mitral valve leaflets are mildly thickened. There is no\n mitral valve prolapse. Mild to moderate (+) mitral regurgitation is\n seen. There is borderline pulmonary artery systolic hypertension. There\n is no pericardial effusion.\n IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved\n global and regional biventricular systolic function. Mild-moderate\n mitral regurgitation.\n Assessment and Plan\n Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia\n .\n #. Chest Pain - The pt presents with hx of anterior chest discomfort\n occuring at rest for several days, similar to previous episodes which\n occurred during exercise. ECG with new RBBB and ST depressions\n throughout precordium. Symptoms are concerning for cardiac vs pulmonary\n etiology. Cardiac enzymes negative X2, D-dimer elevated. TIMI score 3\n for age, RF and ST changes giving a 13% risk at 14 days of: all-cause\n mortality, new or recurrent MI, or severe recurrent ischemia requiring\n urgent revascularization. However given concurrent hypoxia, elevated\n D-dimer, and new RBBB also concern for PE.\n - Continue IV heparin\n - Continue Aggrenox\n - Continue lisinopril 2.5 mg daily\n - Trend CE - negative X2\n - Pt currently does not want to pursue cardiac catheterization, would\n consider stress testing following rule out of PE, improvement of\n hypoxia\n - Will start pre-contrast hydration for consideration of CTA this am\n .\n #. Hypoxia - The patient with hypoxia requiring NRB, currently weaned\n to 5L NC, no clear evidence of volume overload on exam. Pt has history\n of disordered breathing following stroke, has been off CPAP, also\n history of tobacco use, likely has underlying lung disease. Concern for\n PE as described above\n - Continue O2 NC to maintain sat >88%\n - Discuss risk/benefit of CTA to rule out PE, if no CTA would pursue\n non-contrast Chest CT\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - continue aggrenox\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO pending additional CE, then will start cardiac diet\n .\n #. Access: PIV\n .\n #. PPx: PPI, heparin gtt\n .\n #. Code: Full\n .\n #. Dispo: ICU\n .\n .\n ICU Care\n Nutrition:\n Comments: Cardiac diet\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: 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 Addendum at time of Rounds: Given Aa Gradient, elevated d-dimer, and\n flat CKs, very low troponin after having pain for days, will pursue CTA\n this morning, and attempt to look at coronary arteries at the same time\n in the CT scanner. CT scan will also allow for a look at the chest for\n any fibrotic or intrinsic interstitial lung disease. Pending CTA, will\n have to decide further risk stratification vs. catheterization. Will\n switch from aggrenox to plavix.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:04 ------\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, agree with above\n Physical Examination\n nothing to add, agree with above\n Medical Decision Making\n nothing to add, agree with above\n Total time spent on patient care: 50 minutes.\n Additional comments:\n visit on \n ------ Protected Section Addendum Entered By: on:\n 18:34 ------\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444589,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, However CT showed what is likely pulm fibrosis and emphysema\n previously undiagnosed. Echo Cardiogram showed new wall motion\n abnormality concerning for ischemia\n Chest Pain - The pt presents with hx of anterior chest discomfort\n occuring at rest for several days, similar to previous episodes which\n occurred during exercise. ECG with new RBBB and ST depressions\n throughout precordium. TTE EF 60%, basal segments of the inferior and\n posterior wall are akinetic, and the midventricular segments are\n hypokinetic, RV cavity is dilated with borderline normal free wall\n function, 3+MR, moderate pulmonary artery systolic hypertension. No\n further episodes of chest pain since admission Taken to cath lab Friday\n and 3 stents to RCA, which is thought to be culprit lesion. Did well\n post procedure minx closure with old blood on dressing eccymotic at\n that area but unchanged, good pedal pulses and PT by Doppler.\n PT Denies chest pain.\n PT did C/O indigestion this afternoon Saturday 12 lead done, nothing\n new, Tums without relief so Maalox/lidocaine/benadryl solution was\n given, with good effect. pt takes prilosec at home and received his\n dose today in the Am. . Pt also had two BM today one was normal second\n slightly Quiac positive and Appeared light brown diarrhea, team\n updated. Later pt vomited bile x 3 episodes and feels sick. Pt thought\n to have ? of and is on contact precautions, Afebrile today putting\n out good amount of urine intermittently pink tinged, Dr aware.\n Cv wise Hr 70-80\ns with frequent pac\ns/pvc\ns. SBP 120-130\ns/70\n Completed bicarb drip. !/2 NS given post cath . Right groin with\n transparent dsg , has one last dose acetylcystine due tonight. He has\n faint crackles at his bases but otherwise clear. Team has consulted\n Pulm doctors as pt high o2 requirements 5 Liters and DOE with\n exertion, likely from a pulmonary source.\n Physical therapy is consulted pt lives alone did get OOB with\n supervision, appears weak or deconditioned but does weight\n Bear and is getting SS insulin 2-4 units .\n Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n Hypoxemia\n Assessment:\n Lung faint crackles at bases requires 5LNC sats 89-93 on 5L\n Action:\n Spiriva inhaler started, pt ruled out for PE, pulm MD consulted.\n Response:\n PT had some DOE getting OOB to Commode x 2, otherwise no complaints\n SATs 90-92\n Plan:\n Consult pulmonary and Physical therapy, spiriva.\n"
},
{
"category": "Consult",
"chartdate": "2146-03-06 00:00:00.000",
"description": "Physician Consult Progress Note",
"row_id": 444670,
"text": "Consult requested by: Dr. \n Chief Complaint: hypoxia, ILD\n 24 Hour Events:\n History obtained from Medical records\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 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 04:16 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: 37\nC (98.6\n HR: 76 (62 - 83) bpm\n BP: 109/59(71) {97/38(60) - 139/105(109)} mmHg\n RR: 22 (12 - 26) insp/min\n SpO2: 91%\n Heart rhythm:: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n 490 mL\n PO:\n 540 mL\n 240 mL\n TF:\n IVF:\n 1,510 mL\n 250 mL\n Blood products:\n Total out:\n 2,680 mL\n 618 mL\n Urine:\n 1,630 mL\n 618 mL\n NG:\n 350 mL\n Stool:\n 700 mL\n Drains:\n Balance:\n -630 mL\n -128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\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 157 K/uL\n 12.7 g/dL\n 118 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 21 mg/dL\n 102 mEq/L\n 140 mEq/L\n 36.3 %\n 7.5 K/uL\n [image002.jpg]\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n 01:19 AM\n 06:43 AM\n 12:00 PM\n 02:42 PM\n 06:57 AM\n WBC\n 7.1\n 11.4\n 7.5\n Hct\n 37.2\n 39.9\n 36.3\n Plt\n 140\n 144\n 146\n 157\n Cr\n 1.1\n 1.1\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n 0.12\n 0.10\n 0.12\n Glucose\n 179\n 161\n 207\n 185\n 113\n 130\n \n Other labs: PT / PTT / INR:15.0/27.5/1.3, CK / CKMB /\n Troponin-T:33/9/0.12, Differential-Neuts:85.4 %, Lymph:6.6 %, Mono:7.3\n %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n HYPOXEMIA\n CHEST PAIN\n"
},
{
"category": "Consult",
"chartdate": "2146-03-06 00:00:00.000",
"description": "Physician Consult Progress Note",
"row_id": 444672,
"text": "Consult requested by: Dr. \n Chief Complaint: hypoxia, ILD\n 24 Hour Events:\n So far RF just slightly elevated, , scleroderma tests pending.\n Denies SOB/cough. On 4L NC. Was about 500 cc neg yesterday. Still\n having GI upset/diarrhea.\n History obtained from Medical records\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 06:00 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: still epigastric pain and belching with diarrhea\n Flowsheet Data as of 04:16 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: 37\nC (98.6\n HR: 76 (62 - 83) bpm\n BP: 109/59(71) {97/38(60) - 139/105(109)} mmHg\n RR: 22 (12 - 26) insp/min\n SpO2: 91%\n Heart rhythm:: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n 490 mL\n PO:\n 540 mL\n 240 mL\n TF:\n IVF:\n 1,510 mL\n 250 mL\n Blood products:\n Total out:\n 2,680 mL\n 618 mL\n Urine:\n 1,630 mL\n 618 mL\n NG:\n 350 mL\n Stool:\n 700 mL\n Drains:\n Balance:\n -630 mL\n -128 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula 4L\n SpO2: 91%\n ABG: ///27/\n Physical Examination\n Gen: NAD A+OX3\n HEENT: mmm\n CV: RRR 3/6 sys m\n Pulm bibasilar crackles\n Abd: slight epigastric TTP, no rebound +BS\n Ext: no clubbing, no edema\n Skin: no rash\n Neurologic: A+OX3\n Labs / Radiology\n 157 K/uL\n 12.7 g/dL\n 118 mg/dL\n 1.1 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 21 mg/dL\n 102 mEq/L\n 140 mEq/L\n 36.3 %\n 7.5 K/uL\n [image002.jpg]\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n 01:19 AM\n 06:43 AM\n 12:00 PM\n 02:42 PM\n 06:57 AM\n WBC\n 7.1\n 11.4\n 7.5\n Hct\n 37.2\n 39.9\n 36.3\n Plt\n 140\n 144\n 146\n 157\n Cr\n 1.1\n 1.1\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n 0.12\n 0.10\n 0.12\n Glucose\n 179\n 161\n 207\n 185\n 113\n 130\n \n Other labs: PT / PTT / INR:15.0/27.5/1.3, CK / CKMB /\n Troponin-T:33/9/0.12, Differential-Neuts:85.4 %, Lymph:6.6 %, Mono:7.3\n %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Ca++:9.0 mg/dL, Mg++:2.0 mg/dL,\n PO4:3.5 mg/dL\n Assessment and Plan\n HYPOXEMIA\n CHEST PAIN\n 89 y/o m here with angina s/p cath showing 3VD s/p RCA DES, found to\n have progressive ILD, with superimposed GGO on CT. Checking\n rheumatologic studies.\n Rec:\n -diuresis as you are able as GGO on CT are likely edema\n -f/u with Dr. /Dr. in pulm clinic\n -discharge on flovent 220 mcg 1 puff and spireva\n -make sure he has received influenza/pneumovax prior to d/c\n -may need home O2 if O2 requirement persists after diuresis\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-06 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 444677,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, However CT showed what is Pulm Fibrosis and Emphysema\n previously undiagnosed. Echo Cardiogram showed new wall motion\n abnormality concerning for ischemia\n Chest Pain - The pt presents with hx of anterior chest discomfort\n occurring at rest for several days, similar to previous episodes which\n occurred during exercise. ECG with new RBBB and ST depressions\n throughout precordium. TTE EF 60%, basal segments of the inferior and\n posterior wall are akinetic, and the midventricular segments are\n hypokinetic, RV cavity is dilated with borderline normal free wall\n function, 3+MR, moderate pulmonary artery systolic hypertension. No\n further episodes of chest pain since admission Taken to cath lab Friday\n and 3 stents to RCA, which is thought to be culprit lesion. Did well\n post procedure minx closure with old blood on dressing eccymotic at\n that area but unchanged, good pedal pulses and PT by Doppler.\n PT Denies chest pain since cardiac cath.\n PT did C/O indigestion this afternoon Saturday 12 lead done, nothing\n new, Tums without relief so Maalox/lidocaine/benadryl solution was\n given, with good effect. pt takes prilosec at home and received his\n dose today in the Am. . Pt also had two BM today one was normal second\n slightly Quiac positive and Appeared light brown diarrhea, team Later\n pt vomited bile x 3 episodes and feels sick. Pt thought to have Noro\n Virus/gastroenteritis, last BM 0300 AM and although was slightly quiac\n pos it was not or bloody appearing, PT is on contact\n precautions, Afebrile today putting out good amount of urine yesterday\n as well as a lot of stool and emesis. PT coughed up blood to\n intermittently pink tinged, team aware and PULMONARY is consulted.\n PT has had some hemoptosis not sure if it is from O2, Has high o2\n requirement of 5LNC and goal sat is above 88. Pt ranges from 88-93 %\n Cv wise Hr 70-80\ns with frequent pac\ns/pvc\ns. SBP 120-130\ns/70\n Down to 97/60 while sleeping and agfter lopressor dose, team aware.\n Completed bicarb drip. !/2 NS given post cath ( cath was Friday) .\n Right groin with transparent dsg , old blood and somewhat eccymotic\n but stable no heamatoma. He has faint crackles at his bases but\n otherwise clear. Team has consulted Pulm doctors as pt high o2\n requirements 5 Liters and DOE with exertion, likely from a pulmonary\n source.\n Physical therapy is consulted pt lives alone did get OOB with\n supervision, appears deconditioned but does weight\n Bear and is getting SSInsulin now that he is able to tolerate PO\n liquids and light solid foods. Tolerated two meals but gets\n indigestion, Maalox with lidocaine and benadryl works well for him last\n dose 1700- today.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Full code\n Height:\n Admission weight:\n 80 kg\n Daily weight:\n Allergies/Reactions:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Precautions: Contact\n PMH: Diabetes - Oral \n CV-PMH: Angina, CVA, Hypertension\n Additional history: Colon Cancer- \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:118\n D:62\n Temperature:\n 98.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 74 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 89% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 24h total in:\n 490 mL\n 24h total out:\n 683 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 06:57 AM\n Potassium:\n 4.3 mEq/L\n 06:57 AM\n Chloride:\n 102 mEq/L\n 06:57 AM\n CO2:\n 27 mEq/L\n 06:57 AM\n BUN:\n 21 mg/dL\n 06:57 AM\n Creatinine:\n 1.1 mg/dL\n 06:57 AM\n Glucose:\n 118 mg/dL\n 06:57 AM\n Hematocrit:\n 36.3 %\n 06:57 AM\n Finger Stick Glucose:\n 185\n 12:00 PM\n Valuables / Signature\n Patient valuables: see below\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry: pt has cell phone and silver steel looking watch, also his\n inhalers and benadryl lidocaine Maalox liquid.\n Transferred from: \n Transferred to: 3\n Date & time of Transfer: at 1715\n Hypoxemia\n Assessment:\n Lung faint crackles at bases requires 5LNC sats 89-93 on 5L\n Action:\n Spiriva inhaler started, fluticasone inhaler, pt ruled out for PE,\n Pulm MD consulted. Has PULM fibrosis by CT scan and both are new\n diagnosis for this pt. Blood work sent and pulm following\n Response:\n PT had some DOE getting OOB to Commode x 2, otherwise no complaints\n SATs 88-93\n Plan:\n Consult pulmonary and Physical therapy, spiriva. Goal keep o2 sats\n greater than 88\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-06 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 444674,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, However CT showed what is Pulm Fibrosis and Emphysema\n previously undiagnosed. Echo Cardiogram showed new wall motion\n abnormality concerning for ischemia\n Chest Pain - The pt presents with hx of anterior chest discomfort\n occurring at rest for several days, similar to previous episodes which\n occurred during exercise. ECG with new RBBB and ST depressions\n throughout precordium. TTE EF 60%, basal segments of the inferior and\n posterior wall are akinetic, and the midventricular segments are\n hypokinetic, RV cavity is dilated with borderline normal free wall\n function, 3+MR, moderate pulmonary artery systolic hypertension. No\n further episodes of chest pain since admission Taken to cath lab Friday\n and 3 stents to RCA, which is thought to be culprit lesion. Did well\n post procedure minx closure with old blood on dressing eccymotic at\n that area but unchanged, good pedal pulses and PT by Doppler.\n PT Denies chest pain since cardiac cath.\n PT did C/O indigestion this afternoon Saturday 12 lead done, nothing\n new, Tums without relief so Maalox/lidocaine/benadryl solution was\n given, with good effect. pt takes prilosec at home and received his\n dose today in the Am. . Pt also had two BM today one was normal second\n slightly Quiac positive and Appeared light brown diarrhea, team Later\n pt vomited bile x 3 episodes and feels sick. Pt thought to have Noro\n Virus/gastroenteritis, last BM 0300 AM and although was slightly quiac\n pos it was not or bloody appearing, PT is on contact\n precautions, Afebrile today putting out good amount of urine yesterday\n as well as a lot of stool and emesis. PT coughed up blood to\n intermittently pink tinged, team aware and PULMONARY is consulted.\n PT has had some hemoptosis not sure if it is from O2, Has high o2\n requirement of 5LNC and goal sat is above 88. Pt ranges from 88-93 %\n Cv wise Hr 70-80\ns with frequent pac\ns/pvc\ns. SBP 120-130\ns/70\n Down to 97/60 while sleeping and agfter lopressor dose, team aware.\n Completed bicarb drip. !/2 NS given post cath ( cath was Friday) .\n Right groin with transparent dsg , old blood and somewhat eccymotic\n but stable no heamatoma. He has faint crackles at his bases but\n otherwise clear. Team has consulted Pulm doctors as pt high o2\n requirements 5 Liters and DOE with exertion, likely from a pulmonary\n source.\n Physical therapy is consulted pt lives alone did get OOB with\n supervision, appears deconditioned but does weight\n Bear and is getting SSInsulin now that he is able to tolerate PO\n liquids and light solid foods. .\n Hypoxemia\n Assessment:\n Lung faint crackles at bases requires 5LNC sats 89-93 on 5L\n Action:\n Spiriva inhaler started, fluticasone inhaler, pt ruled out for PE,\n Pulm MD consulted. Has PULM fibrosis by CT scan and both are new\n diagnosis for this pt. Blood work sent and pulm following\n Response:\n PT had some DOE getting OOB to Commode x 2, otherwise no complaints\n SATs 88-93\n Plan:\n Consult pulmonary and Physical therapy, spiriva. Goal keep o2 sats\n greater than 88\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444172,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia.\n .\n Chest pain\n Assessment:\n Skin warm & dry- no chest pain- good U/O- T max 100.1 Po- cardiac\n enzymes (-) this am.\n Action:\n Echo done- serial enzymes drawn- heparin gtt @ 1050u/hr- PTT pending-\n Plavix 300mg load given.\n Response:\n Trop trending up this afternoon- echo shows Inferior/Posterior L\n ventricular contractile dysfunction as well as R ventricular\n dysfunction.\n Plan:\n Repeat labs @ - follow temps & pan culture if temp > 100.5 Po- NPO\n after 12am ? cardiac cath tomorrow.\n Hypoxemia\n Assessment:\n SpO2\ns on 5L NC 88-93%- diuresed well from lasix given @ 0300 in ED.\n Action:\n CT of chest done.\n Response:\n (-) for PE- (-) 1600cc since 12am- BUN 22 Crea 1.3\n Plan:\n Monitor resp status- Hx sleep apnea -> refuses BiPAP\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444173,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia.\n .\n Chest pain\n Assessment:\n Skin warm & dry- no chest pain- good U/O- T max 100.1 Po- cardiac\n enzymes (-) this am.\n Action:\n Echo done- serial enzymes drawn- heparin gtt @ 1050u/hr- PTT pending-\n Plavix 300mg load given.\n Response:\n Trop trending up this afternoon- echo shows Inferior/Posterior L\n ventricular contractile dysfunction as well as R ventricular\n dysfunction.\n Plan:\n Repeat labs @ - follow temps & pan culture if temp > 100.5 Po- NPO\n after 12am ? cardiac cath tomorrow.\n Hypoxemia\n Assessment:\n SpO2\ns on 5L NC 88-93%- diuresed well from lasix given @ 0300 in ED.\n Action:\n CT of chest done.\n Response:\n (-) for PE- (-) 1600cc since 12am- BUN 22 Crea 1.3\n Plan:\n Monitor resp status- Hx sleep apnea -> refuses BiPAP.\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444280,
"text": "Chief Complaint:\n 24 Hour Events:\n - ECHO (summary): dilated, EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension\n - CT shows: 1) diffuse bronchial wall thickening. Wall in main\n pulmonary bronchus measures up to 4 mm. Suggestive of bronchitis.\n 2) progression of emphysema.\n 3) slight progression of interstitial lung disease.\n 4) Large hiatal hernia.\n - Bilateral LENIs checked to r/o DVT-> negative\n - CE trending up, but now peaked (Trop <0.01->0.04-> 1.13->0.12->0.11),\n CK 44->45->109->69->58\n - Plavix increased to total 300mg dose x 1\n - Started on ASA 325, held ACEI\n - Repleted K\n - Discussed cath with pt and son, agree to proceed in am\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:08 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: 37.6\nC (99.6\n HR: 69 (69 - 90) bpm\n BP: 83/52(59) {83/50(59) - 131/84(95)} mmHg\n RR: 23 (14 - 28) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,155 mL\n 286 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 1,555 mL\n 46 mL\n Blood products:\n Total out:\n 3,710 mL\n 350 mL\n Urine:\n 2,710 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,555 mL\n -64 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 140 K/uL\n 12.8 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 103 mEq/L\n 139 mEq/L\n 37.2 %\n 7.1 K/uL\n [image002.jpg]\n 06:00 AM\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n WBC\n 9.1\n 7.1\n Hct\n 40.2\n 37.2\n Plt\n 135\n 140\n Cr\n 1.3\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n TCO2\n 27\n Glucose\n 139\n 179\n 161\n \n Other labs: PT / PTT / INR:15.9/63.8/1.4, CK / CKMB /\n Troponin-T:58/9/0.11, Lactic Acid:1.1 mmol/L, Ca++:8.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n HYPOXEMIA\n CHEST PAIN\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444281,
"text": "Chief Complaint:\n 24 Hour Events:\n - ECHO (summary): dilated, EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension\n - CT shows: 1) diffuse bronchial wall thickening. Wall in main\n pulmonary bronchus measures up to 4 mm. Suggestive of bronchitis.\n 2) progression of emphysema.\n 3) slight progression of interstitial lung disease.\n 4) Large hiatal hernia.\n - Bilateral LENIs checked to r/o DVT-> negative\n - CE trending up, but now peaked (Trop <0.01->0.04-> 1.13->0.12->0.11),\n CK 44->45->109->69->58\n - Plavix increased to total 300mg dose x 1\n - Started on ASA 325, held ACEI\n - Repleted K\n - Discussed cath with pt and son, agree to proceed in am\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:08 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: 37.6\nC (99.6\n HR: 69 (69 - 90) bpm\n BP: 83/52(59) {83/50(59) - 131/84(95)} mmHg\n RR: 23 (14 - 28) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,155 mL\n 286 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 1,555 mL\n 46 mL\n Blood products:\n Total out:\n 3,710 mL\n 350 mL\n Urine:\n 2,710 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,555 mL\n -64 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///28/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 140 K/uL\n 12.8 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 103 mEq/L\n 139 mEq/L\n 37.2 %\n 7.1 K/uL\n [image002.jpg]\n 06:00 AM\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n WBC\n 9.1\n 7.1\n Hct\n 40.2\n 37.2\n Plt\n 135\n 140\n Cr\n 1.3\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n TCO2\n 27\n Glucose\n 139\n 179\n 161\n \n Other labs: PT / PTT / INR:15.9/63.8/1.4, CK / CKMB /\n Troponin-T:58/9/0.11, Lactic Acid:1.1 mmol/L, Ca++:8.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia\n .\n #. Chest Pain - The pt presents with hx of anterior chest discomfort\n occuring at rest for several days, similar to previous episodes which\n occurred during exercise. ECG with new RBBB and ST depressions\n throughout precordium. Symptoms are concerning for cardiac vs pulmonary\n etiology. Cardiac enzymes negative X2, D-dimer elevated. TIMI score 3\n for age, RF and ST changes giving a 13% risk at 14 days of: all-cause\n mortality, new or recurrent MI, or severe recurrent ischemia requiring\n urgent revascularization. However given concurrent hypoxia, elevated\n D-dimer, and new RBBB also concern for PE.\n - Continue IV heparin\n - Continue Aggrenox\n - Continue lisinopril 2.5 mg daily\n - Trend CE - negative X2\n - Pt currently does not want to pursue cardiac catheterization, would\n consider stress testing following rule out of PE, improvement of\n hypoxia\n - Will start pre-contrast hydration for consideration of CTA this am\n .\n #. Hypoxia - The patient with hypoxia requiring NRB, currently weaned\n to 5L NC, no clear evidence of volume overload on exam. Pt has history\n of disordered breathing following stroke, has been off CPAP, also\n history of tobacco use, likely has underlying lung disease. Concern for\n PE as described above\n - Continue O2 NC to maintain sat >88%\n - Discuss risk/benefit of CTA to rule out PE, if no CTA would pursue\n non-contrast Chest CT\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - continue aggrenox\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO pending additional CE, then will start cardiac diet\n .\n #. Access: PIV\n .\n #. PPx: PPI, heparin gtt\n .\n #. Code: Full\n .\n #. Dispo: ICU\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444283,
"text": "Chief Complaint:\n 24 Hour Events:\n - ECHO (summary): dilated, EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension\n - CT shows: 1) diffuse bronchial wall thickening. Wall in main\n pulmonary bronchus measures up to 4 mm. Suggestive of bronchitis.\n 2) progression of emphysema.\n 3) slight progression of interstitial lung disease.\n 4) Large hiatal hernia.\n - Bilateral LENIs checked to r/o DVT-> negative\n - CE trending up, but now peaked (Trop <0.01->0.04-> 1.13->0.12->0.11),\n CK 44->45->109->69->58\n - Plavix increased to total 300mg dose x 1\n - Started on ASA 325, held ACEI\n - Repleted K\n - Discussed cath with pt and son, agree to proceed in am\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 750 units/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:08 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: 37.6\nC (99.6\n HR: 69 (69 - 90) bpm\n BP: 83/52(59) {83/50(59) - 131/84(95)} mmHg\n RR: 23 (14 - 28) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,155 mL\n 286 mL\n PO:\n 600 mL\n 240 mL\n TF:\n IVF:\n 1,555 mL\n 46 mL\n Blood products:\n Total out:\n 3,710 mL\n 350 mL\n Urine:\n 2,710 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,555 mL\n -64 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 91%\n ABG: ///28/\n Physical Examination\n Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect appropriate.\n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no\n pallor or cyanosis of the oral mucosa. No xanthalesma.\n Neck: Supple with flat JVP\n CV: RRR, normal S1, S2. II/IV systolic murmur at apex\n Chest: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. Dry crackles throughout\n Abd: Soft, NT/ND. No HSM or tenderness. Abd aorta not enlarged by\n palpation.\n Ext: No c/c/e.\n Skin: No stasis dermatitis, ulcers, scars, or xanthomas.\n Labs / Radiology\n 140 K/uL\n 12.8 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 17 mg/dL\n 103 mEq/L\n 139 mEq/L\n 37.2 %\n 7.1 K/uL\n [image002.jpg]\n 06:00 AM\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n WBC\n 9.1\n 7.1\n Hct\n 40.2\n 37.2\n Plt\n 135\n 140\n Cr\n 1.3\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n TCO2\n 27\n Glucose\n 139\n 179\n 161\n \n Other labs: PT / PTT / INR:15.9/63.8/1.4, CK / CKMB /\n Troponin-T:58/9/0.11, Lactic Acid:1.1 mmol/L, Ca++:8.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia\n .\n #. Chest Pain - The pt presents with hx of anterior chest discomfort\n occuring at rest for several days, similar to previous episodes which\n occurred during exercise. ECG with new RBBB and ST depressions\n throughout precordium. Symptoms are concerning for cardiac vs pulmonary\n etiology. Cardiac enzymes negative X2, D-dimer elevated. TIMI score 3\n for age, RF and ST changes giving a 13% risk at 14 days of: all-cause\n mortality, new or recurrent MI, or severe recurrent ischemia requiring\n urgent revascularization. However given concurrent hypoxia, elevated\n D-dimer, and new RBBB also concern for PE.\n - Continue IV heparin\n - Continue Aggrenox\n - Continue lisinopril 2.5 mg daily\n - Trend CE - negative X2\n - Pt currently does not want to pursue cardiac catheterization, would\n consider stress testing following rule out of PE, improvement of\n hypoxia\n - Will start pre-contrast hydration for consideration of CTA this am\n .\n #. Hypoxia - The patient with hypoxia requiring NRB, currently weaned\n to 5L NC, no clear evidence of volume overload on exam. Pt has history\n of disordered breathing following stroke, has been off CPAP, also\n history of tobacco use, likely has underlying lung disease. Concern for\n PE as described above\n - Continue O2 NC to maintain sat >88%\n - Discuss risk/benefit of CTA to rule out PE, if no CTA would pursue\n non-contrast Chest CT\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - continue aggrenox\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO pending additional CE, then will start cardiac diet\n .\n #. Access: PIV\n .\n #. PPx: PPI, heparin gtt\n .\n #. Code: Full\n .\n #. Dispo: ICU\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444165,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia.\n .\n Chest pain\n Assessment:\n Skin warm & dry- no chest pain- good U/O- T max 100.1 Po- cardiac\n enzymes (-) this am.\n Action:\n Echo done- CT of chest done- serial enzymes drawn- heparin gtt @\n 1050u/hr- PTT pending- Plavix 300mg load given.\n Response:\n Trop trending up this afternoon- echo shows Inferior/Posterior L\n ventricular contractile dysfunction as well as R ventricular\n dysfunction- CT (-) PE\n Plan:\n Repeat labs @ - follow temps & pan culture if temp > 100.5 Po- NPO\n after 12am ? cardiac cath tomorrow.\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444170,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia.\n .\n Chest pain\n Assessment:\n Skin warm & dry- no chest pain- good U/O- T max 100.1 Po- cardiac\n enzymes (-) this am.\n Action:\n Echo done- serial enzymes drawn- heparin gtt @ 1050u/hr- PTT pending-\n Plavix 300mg load given.\n Response:\n Trop trending up this afternoon- echo shows Inferior/Posterior L\n ventricular contractile dysfunction as well as R ventricular\n dysfunction.\n Plan:\n Repeat labs @ - follow temps & pan culture if temp > 100.5 Po- NPO\n after 12am ? cardiac cath tomorrow.\n Hypoxemia\n Assessment:\n SpO2\ns on 5L NC 88-93%- diuresed well from lasix given @ 0300 in ED.\n Action:\n CT of chest done.\n Response:\n (-) for PE- (-)\n Plan:\n Monitor resp status- Hx sleep apnea -> refuses BiPAP\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444171,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia.\n .\n Chest pain\n Assessment:\n Skin warm & dry- no chest pain- good U/O- T max 100.1 Po- cardiac\n enzymes (-) this am.\n Action:\n Echo done- serial enzymes drawn- heparin gtt @ 1050u/hr- PTT pending-\n Plavix 300mg load given.\n Response:\n Trop trending up this afternoon- echo shows Inferior/Posterior L\n ventricular contractile dysfunction as well as R ventricular\n dysfunction.\n Plan:\n Repeat labs @ - follow temps & pan culture if temp > 100.5 Po- NPO\n after 12am ? cardiac cath tomorrow.\n Hypoxemia\n Assessment:\n SpO2\ns on 5L NC 88-93%- diuresed well from lasix given @ 0300 in ED.\n Action:\n CT of chest done.\n Response:\n (-) for PE- (-) 1600cc since 12am-\n Plan:\n Monitor resp status- Hx sleep apnea -> refuses BiPAP\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 444548,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, TTE with new wall motion abnormality concerning for ischmia\n .\n #. Chest Pain/WMA - The pt presents with hx of anterior chest\n discomfort occuring at rest for several days, similar to previous\n episodes which occurred during exercise. ECG with new RBBB and ST\n depressions throughout precordium. TTE EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension. No further episodes of chest pain since admission\n Denies chest pain. Hr 70-80\ns with frequent pac\ns/pvc\ns. SBP\n 120-130\ns/70\ns. Completed bicarb drip. !/2 NS infusing. Right groin\n with transparent dsg with small amount of bld drainage. Pulses dop.\n Slept with 12.5 mg of benadryl for sleep. Small sot hematoma to right\n groin site. Anticipate call out to floor.\n Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, TTE with new wall motion abnormality concerning for ischmia\n .\n #. Chest Pain/WMA - The pt presents with hx of anterior chest\n discomfort occuring at rest for several days, similar to previous\n episodes which occurred during exercise. ECG with new RBBB and ST\n depressions throughout precordium. TTE EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension. No further episodes of chest pain since admission\n Chest pain\n Assessment:\n Returned from cath lab at 1900 post stent placement to rca, Angioseal\n intact, ecchymotic soft right fem site. Good uo, + hematuria. Sr with\n pvc\ns. denied cp\n Action:\n Vs and checks as per orders, small amount of sanguinous drainage at\n 2300, dopp pp. receiving bicarb gtt as well as Mucomyst. Labs to be\n drawn at 0100.\n Response:\n Stable post cath, hematuria\n Plan:\n Monitor comfort, hr and rythym, sbp, pp, right fem site, i+O,\n ns at\n 100ml/hr post bicarb gtt, labs. As per orders. If continues stable ?\n transfer in am\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 444550,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, However CT showed what is likely pulm fibrosis and emphasema\n previously undiagnosed. Echo Cardiogram showed new wall motion\n abnormality concerning for ischemia\n Chest Pain/WMA - The pt presents with hx of anterior chest discomfort\n occuring at rest for several days, similar to previous episodes which\n occurred during exercise. ECG with new RBBB and ST depressions\n throughout precordium. TTE EF 60%, basal segments of the inferior and\n posterior wall are akinetic, and the midventricular segments are\n hypokinetic, RV cavity is dilated with borderline normal free wall\n function, 3+MR, moderate pulmonary artery systolic hypertension. No\n further episodes of chest pain since admission Taken to cath lab Friday\n and 3 stents to RCA, which is thought to be culprit lesion. Did well\n post procedure minx closure with old blood on dressing eccymotic at\n that area but unchanged, good pedal pulses and PT by Doppler.\n PT Denies chest pain. Post he did Co indigestion this afternoon\n Saturday 12 lead done tums without relief so Maalox was given, pt takes\n prilosec at home. Pt also had two BM today one was normal second\n slightly Qiac positive and Appeared ltt brouwn diarrhea, spec sent team\n updated.\n Cv wise Hr 70-80\ns with frequent pac\ns/pvc\ns. SBP 120-130\ns/70\n Completed bicarb drip. !/2 NS . Right groin with transparent dsg , has\n one last dose acetyl cystine. He has faint crackles at his bases but\n otherwise clear. Team has consulted Pulm doctors as pt high o2\n requirements 5 Liters and DOE with exertion, likely from a pulmonary\n source.\n Physical therapy is consulted pt lives alone did get OOB with\n supervision, appears weak or deconditioned but does weight\n Bere.\n Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n Hypoxemia\n Assessment:\n Lung faint crackles at bases requires 5LNC sats 89-93 on 5L\n Action:\n Siriva started, pt ruled out for PE pulm MD consulted.\n Response:\n PT had some DOE getting OOB to Commode x 2, otherwise no complaints\n SATs 90-92\n Plan:\n Consult pulmonary nad Physical therapy, spiriva.\n Chest pain\n Assessment:\n NO CP today had indigestion and Diarrhea tx with maalocx and tums\n Action:\n No cp today 12 lead done at mnoon no changes\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n CHEST PAIN\n Code status:\n Height:\n Admission weight:\n 80 kg\n Daily weight:\n Allergies/Reactions:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Precautions:\n PMH: Diabetes - Oral \n CV-PMH: Angina, CVA, Hypertension\n Additional history: Colon Cancer- \n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:130\n D:64\n Temperature:\n 98.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 27 insp/min\n Heart Rate:\n 78 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 91% %\n O2 flow:\n 5 L/min\n FiO2 set:\n 24h total in:\n 1,750 mL\n 24h total out:\n 910 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 06:43 AM\n Potassium:\n 4.0 mEq/L\n 06:43 AM\n Chloride:\n 99 mEq/L\n 06:43 AM\n CO2:\n 29 mEq/L\n 06:43 AM\n BUN:\n 14 mg/dL\n 06:43 AM\n Creatinine:\n 1.1 mg/dL\n 06:43 AM\n Glucose:\n 236\n 12:00 PM\n Hematocrit:\n 39.9 %\n 06:43 AM\n Finger Stick Glucose:\n 205\n 09:00 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 Response:\n Pt says pain is unlike his CP just stomache upset\n Plan:\n monitor\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444626,
"text": "TITLE: CCU Progress Note\n Chief Complaint:\n 24 Hour Events:\n - guiac positive stool today, sent for c. diff (stool is not grossly\n bloody)\n - had sour taste in mouth/upset stomach wrote for tums PRN\n - Ultimately developed nausea, vomiting, and diarrhea consistent with\n gastroenteritis\n - Did well on Zofran + IVF\n - Increased metoprolol 25mg PO BID\n - Pulm C/Sed for concerning chest CTA for ? pneumonitis, ILD.\n Recommended Check BNP, ESR, , Anti SCL-70, Anti centromere Ab, RF,\n HIV Ab (assoc w LIP), hepatitis serologies (assoc w LIP),\n immunoglobulin levels, SPEP, and UPEP. All sent except HIV. Also\n recommended ongoing diuresis\n - Improved throughout the evening\n - Likely call out to in the AM\n - Being screened for short term rehab\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 10:00 AM\n Heparin Sodium (Prophylaxis) - 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 07:27 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: 36.3\nC (97.4\n HR: 69 (65 - 88) bpm\n BP: 100/49(62) {98/38(60) - 139/105(109)} mmHg\n RR: 19 (12 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,510 mL\n Blood products:\n Total out:\n 2,680 mL\n 270 mL\n Urine:\n 1,630 mL\n 270 mL\n NG:\n 350 mL\n Stool:\n 700 mL\n Drains:\n Balance:\n -630 mL\n -270 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished),\n good DP/PT pulses by doppler\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, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 146 K/uL\n 13.6 g/dL\n 156 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 14 mg/dL\n 99 mEq/L\n 136 mEq/L\n 39.9 %\n 11.4 K/uL\n [image002.jpg]\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n 01:19 AM\n 06:43 AM\n 12:00 PM\n 02:42 PM\n WBC\n 7.1\n 11.4\n Hct\n 37.2\n 39.9\n Plt\n 140\n 144\n 146\n Cr\n 1.1\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n 0.12\n 0.10\n TCO2\n 27\n Glucose\n 179\n 161\n 207\n 185\n 113\n 130\n 236\n 156\n Other labs: PT / PTT / INR:15.9/32.7/1.4, CK / CKMB /\n Troponin-T:45/9/0.10, Differential-Neuts:85.4 %, Lymph:6.6 %, Mono:7.3\n %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Ca++:8.9 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n 89 y/o M with a PMH of CVA in with residual disordered breathing,\n DM type 2 presenting with four days of intermittent anterior chest\n discomfort and new hypoxia, work up for PE negative, TTE with new wall\n motion abnormality concerning for ischmia now s/p cardiac catherization\n with stent placement to RCA. Now seems to have developed\n gastroenteritis, likely viral\n .\n #. CAD - ECG with new RBBB and ST depressions throughout precordium.\n TTE EF 60%, basal segments of the inferior and posterior wall are\n akinetic, and the midventricular segments are hypokinetic, RV cavity is\n dilated with borderline normal free wall function, 3+MR, moderate\n pulmonary artery systolic hypertension. No further episodes of chest\n pain since admission. Patient s/p DES to RCA.\n - off IV heparin\n - Continue Plavix, aspirin, beta blocker\n .\n # Pump\n previous echo from demonstrates mild symmetric left\n ventricular hypertrophy with preserved global and regional\n biventricular systolic function. Mild-moderate mitral regurgitation.\n - cont aspirin, statin, beta blocker\n - restarted Lisinopril. Uptitrate as tolerated\n #. Hypoxia - Pt has history of disordered breathing following stroke,\n has been off CPAP, also has evidence of progression of emphysema and\n ILD on Chest CT. Workup negative for PE\n - Continue O2 NC to maintain sat >88%\n - Consult pulmonary for further evaluation/treatment of hypoxia.\n Recommended extensive workup for UIP/ILD and related disordered.\n Requested labs pending including BNP, ESR, , Anti SCL-70, Anti\n centromere Ab, RF, hepatitis serologies, immunoglobulin levels, SPEP,\n and UPEP. Also recommended ongoing diuresis\n .\n # Nausea, vomiting, and diarrhea: Pt developed acute N/V/D this\n admission consistent with a viral gastroenteritis.\n - Already improving after <24hrs\n - Continue IVF and PRN zofran\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - aggrexox transitioned to plavix given concern for ACS\n .\n #. HTN - continue lisinopril, metoprolol as above\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO for cath\n .\n #. Access: PIV\n .\n #. PPx: PPI, subQ heparin, bowel regimen\n .\n #. Code: Full\n .\n #. Dispo: Call out to medical floor, PT consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444158,
"text": "Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444160,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia.\n .\n Chest pain\n Assessment:\n Skin warm & dry- no chest pain- good U/O.\n Action:\n Echo done- CT of chest done- serial enzymes drawn.\n Response:\n Trop trending up- CT (-) PE-\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444162,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia.\n .\n Chest pain\n Assessment:\n Skin warm & dry- no chest pain- good U/O.\n Action:\n Echo done- CT of chest done- serial enzymes drawn- heparin\n Response:\n Trop trending up- CT (-) PE-\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444640,
"text": "TITLE: CCU Progress Note\n Chief Complaint:\n 24 Hour Events:\n - guiac positive stool today, sent for c. diff (stool is not grossly\n bloody)\n - had sour taste in mouth/upset stomach wrote for tums PRN\n - Ultimately developed nausea, vomiting, and diarrhea consistent with\n gastroenteritis\n - Did well on Zofran + IVF\n - Increased metoprolol 25mg PO BID\n - Pulm C/Sed for concerning chest CTA for ? pneumonitis, ILD.\n Recommended Check BNP, ESR, , Anti SCL-70, Anti centromere Ab, RF,\n HIV Ab (assoc w LIP), hepatitis serologies (assoc w LIP),\n immunoglobulin levels, SPEP, and UPEP. All sent except HIV. Also\n recommended ongoing diuresis\n - Improved throughout the evening\n - Likely call out to in the AM\n - Being screened for short term rehab\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 10:00 AM\n Heparin Sodium (Prophylaxis) - 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 07:27 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: 36.3\nC (97.4\n HR: 69 (65 - 88) bpm\n BP: 100/49(62) {98/38(60) - 139/105(109)} mmHg\n RR: 19 (12 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,510 mL\n Blood products:\n Total out:\n 2,680 mL\n 270 mL\n Urine:\n 1,630 mL\n 270 mL\n NG:\n 350 mL\n Stool:\n 700 mL\n Drains:\n Balance:\n -630 mL\n -270 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished),\n good DP/PT pulses by doppler\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, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 146 K/uL\n 13.6 g/dL\n 156 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 14 mg/dL\n 99 mEq/L\n 136 mEq/L\n 39.9 %\n 11.4 K/uL\n [image002.jpg]\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n 01:19 AM\n 06:43 AM\n 12:00 PM\n 02:42 PM\n WBC\n 7.1\n 11.4\n Hct\n 37.2\n 39.9\n Plt\n 140\n 144\n 146\n Cr\n 1.1\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n 0.12\n 0.10\n TCO2\n 27\n Glucose\n 179\n 161\n 207\n 185\n 113\n 130\n 236\n 156\n Other labs: PT / PTT / INR:15.9/32.7/1.4, CK / CKMB /\n Troponin-T:45/9/0.10, Differential-Neuts:85.4 %, Lymph:6.6 %, Mono:7.3\n %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Ca++:8.9 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n 89 y/o M with a PMH of CVA in with residual disordered breathing,\n DM type 2 presenting with four days of intermittent anterior chest\n discomfort and new hypoxia, work up for PE negative, TTE with new wall\n motion abnormality concerning for ischmia now s/p cardiac catherization\n with stent placement to RCA. Now seems to have developed\n gastroenteritis, likely viral\n .\n #. CAD - ECG with new RBBB and ST depressions throughout precordium.\n TTE EF 60%, basal segments of the inferior and posterior wall are\n akinetic, and the midventricular segments are hypokinetic, RV cavity is\n dilated with borderline normal free wall function, 3+MR, moderate\n pulmonary artery systolic hypertension. No further episodes of chest\n pain since admission. Patient s/p DES to RCA.\n - off IV heparin\n - Continue Plavix, aspirin, beta blocker\n .\n # Pump\n previous echo from demonstrates mild symmetric left\n ventricular hypertrophy with preserved global and regional\n biventricular systolic function. Mild-moderate mitral regurgitation.\n - cont aspirin, statin, beta blocker\n - restarted Lisinopril. Uptitrate as tolerated\n #. Hypoxia - Pt has history of disordered breathing following stroke,\n has been off CPAP, also has evidence of progression of emphysema and\n ILD on Chest CT. Workup negative for PE\n - Continue O2 NC to maintain sat >88%\n - Appreciate Pulmonary consult recommendations\n concern for UIP/ILD\n and related disordered. Requested labs pending including BNP, ESR, ,\n Anti SCL-70, Anti centromere Ab, RF, hepatitis serologies,\n immunoglobulin levels, SPEP, and UPEP. Also recommended ongoing\n diuresis\n .\n # Nausea, vomiting, and diarrhea: Pt developed acute N/V/D this\n admission consistent with a viral gastroenteritis.\n - Already improving after <24hrs\n - Continue IVF and PRN zofran\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - aggrexox transitioned to plavix given concern for ACS\n .\n #. HTN - continue lisinopril, metoprolol as above\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN\n cardiac diet\n .\n #. Access: PIV\n .\n #. PPx: PPI, subQ heparin, bowel regimen\n .\n #. Code: Full\n .\n #. Dispo: Call out to medical floor, PT consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: Call out to medical floor\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444641,
"text": "TITLE: CCU Progress Note\n Chief Complaint:\n 24 Hour Events:\n - guiac positive stool today, sent for c. diff (stool is not grossly\n bloody)\n - had sour taste in mouth/upset stomach wrote for tums PRN\n - Ultimately developed nausea, vomiting, and diarrhea consistent with\n gastroenteritis\n - Did well on Zofran + IVF\n - Increased metoprolol 25mg PO BID\n - Pulm C/Sed for concerning chest CTA for ? pneumonitis, ILD.\n Recommended Check BNP, ESR, , Anti SCL-70, Anti centromere Ab, RF,\n HIV Ab (assoc w LIP), hepatitis serologies (assoc w LIP),\n immunoglobulin levels, SPEP, and UPEP. All sent except HIV. Also\n recommended ongoing diuresis\n - Improved throughout the evening\n - Likely call out to in the AM\n - Being screened for short term rehab\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 10:00 AM\n Heparin Sodium (Prophylaxis) - 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 07:27 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: 36.3\nC (97.4\n HR: 69 (65 - 88) bpm\n BP: 100/49(62) {98/38(60) - 139/105(109)} mmHg\n RR: 19 (12 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,510 mL\n Blood products:\n Total out:\n 2,680 mL\n 270 mL\n Urine:\n 1,630 mL\n 270 mL\n NG:\n 350 mL\n Stool:\n 700 mL\n Drains:\n Balance:\n -630 mL\n -270 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished),\n good DP/PT pulses by doppler\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, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 146 K/uL\n 13.6 g/dL\n 156 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 14 mg/dL\n 99 mEq/L\n 136 mEq/L\n 39.9 %\n 11.4 K/uL\n [image002.jpg]\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n 01:19 AM\n 06:43 AM\n 12:00 PM\n 02:42 PM\n WBC\n 7.1\n 11.4\n Hct\n 37.2\n 39.9\n Plt\n 140\n 144\n 146\n Cr\n 1.1\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n 0.12\n 0.10\n TCO2\n 27\n Glucose\n 179\n 161\n 207\n 185\n 113\n 130\n 236\n 156\n Other labs: PT / PTT / INR:15.9/32.7/1.4, CK / CKMB /\n Troponin-T:45/9/0.10, Differential-Neuts:85.4 %, Lymph:6.6 %, Mono:7.3\n %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Ca++:8.9 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n 89 y/o M with a PMH of CVA in with residual disordered breathing,\n DM type 2 presenting with four days of intermittent anterior chest\n discomfort and new hypoxia, work up for PE negative, TTE with new wall\n motion abnormality concerning for ischmia now s/p cardiac catherization\n with stent placement to RCA. Now seems to have developed\n gastroenteritis, likely viral\n .\n #. CAD - ECG with new RBBB and ST depressions throughout precordium.\n TTE EF 60%, basal segments of the inferior and posterior wall are\n akinetic, and the midventricular segments are hypokinetic, RV cavity is\n dilated with borderline normal free wall function, 3+MR, moderate\n pulmonary artery systolic hypertension. No further episodes of chest\n pain since admission. Patient s/p DES to RCA.\n - off IV heparin\n - Continue Plavix, aspirin, beta blocker\n .\n # Pump\n previous echo from demonstrates mild symmetric left\n ventricular hypertrophy with preserved global and regional\n biventricular systolic function. Mild-moderate mitral regurgitation.\n - cont aspirin, statin, beta blocker\n - restarted Lisinopril. Uptitrate as tolerated\n #. Hypoxia - Pt has history of disordered breathing following stroke,\n has been off CPAP, also has evidence of progression of emphysema and\n ILD on Chest CT. Workup negative for PE\n - Continue O2 NC to maintain sat >88%\n - Will trial diuresis with lasix bolus\n - Appreciate Pulmonary consult recommendations\n concern for UIP/ILD\n and related disordered. Requested labs pending including BNP, ESR, ,\n Anti SCL-70, Anti centromere Ab, RF, hepatitis serologies,\n immunoglobulin levels, SPEP, and UPEP. Also recommended ongoing\n diuresis\n .\n # Nausea, vomiting, and diarrhea: Pt developed acute N/V/D this\n admission consistent with a viral gastroenteritis.\n - Already improving after <24hrs\n - Continue IVF and PRN zofran\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - aggrexox transitioned to plavix given concern for ACS\n .\n #. HTN - continue lisinopril, metoprolol as above\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN\n cardiac diet\n .\n #. Access: PIV\n .\n #. PPx: PPI, subQ heparin, bowel regimen\n .\n #. Code: Full\n .\n #. Dispo: Call out to medical floor, PT consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: Call out to medical floor\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-06 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444642,
"text": "TITLE: CCU Progress Note\n Chief Complaint:\n 24 Hour Events:\n - guiac positive stool today, sent for c. diff (stool is not grossly\n bloody)\n - had sour taste in mouth/upset stomach wrote for tums PRN\n - Ultimately developed nausea, vomiting, and diarrhea consistent with\n gastroenteritis\n - Did well on Zofran + IVF\n - Increased metoprolol 25mg PO BID\n - Pulm C/Sed for concerning chest CTA for ? pneumonitis, ILD.\n Recommended Check BNP, ESR, , Anti SCL-70, Anti centromere Ab, RF,\n HIV Ab (assoc w LIP), hepatitis serologies (assoc w LIP),\n immunoglobulin levels, SPEP, and UPEP. All sent except HIV. Also\n recommended ongoing diuresis\n - Improved throughout the evening\n - Likely call out to in the AM\n - Being screened for short term rehab\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Omeprazole (Prilosec) - 10:00 AM\n Heparin Sodium (Prophylaxis) - 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 07:27 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: 36.3\nC (97.4\n HR: 69 (65 - 88) bpm\n BP: 100/49(62) {98/38(60) - 139/105(109)} mmHg\n RR: 19 (12 - 29) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,050 mL\n PO:\n 540 mL\n TF:\n IVF:\n 1,510 mL\n Blood products:\n Total out:\n 2,680 mL\n 270 mL\n Urine:\n 1,630 mL\n 270 mL\n NG:\n 350 mL\n Stool:\n 700 mL\n Drains:\n Balance:\n -630 mL\n -270 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished),\n good DP/PT pulses by doppler\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, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 146 K/uL\n 13.6 g/dL\n 156 mg/dL\n 1.1 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 14 mg/dL\n 99 mEq/L\n 136 mEq/L\n 39.9 %\n 11.4 K/uL\n [image002.jpg]\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n 01:19 AM\n 06:43 AM\n 12:00 PM\n 02:42 PM\n WBC\n 7.1\n 11.4\n Hct\n 37.2\n 39.9\n Plt\n 140\n 144\n 146\n Cr\n 1.1\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n 0.12\n 0.10\n TCO2\n 27\n Glucose\n 179\n 161\n 207\n 185\n 113\n 130\n 236\n 156\n Other labs: PT / PTT / INR:15.9/32.7/1.4, CK / CKMB /\n Troponin-T:45/9/0.10, Differential-Neuts:85.4 %, Lymph:6.6 %, Mono:7.3\n %, Eos:0.6 %, Lactic Acid:1.1 mmol/L, Ca++:8.9 mg/dL, Mg++:1.9 mg/dL,\n PO4:2.9 mg/dL\n Assessment and Plan\n 89 y/o M with a PMH of CVA in with residual disordered breathing,\n DM type 2 presenting with four days of intermittent anterior chest\n discomfort and new hypoxia, work up for PE negative, TTE with new wall\n motion abnormality concerning for ischmia now s/p cardiac catherization\n with stent placement to RCA. Now seems to have developed\n gastroenteritis, likely viral\n .\n #. CAD - ECG with new RBBB and ST depressions throughout precordium.\n TTE EF 60%, basal segments of the inferior and posterior wall are\n akinetic, and the midventricular segments are hypokinetic, RV cavity is\n dilated with borderline normal free wall function, 3+MR, moderate\n pulmonary artery systolic hypertension. No further episodes of chest\n pain since admission. Patient s/p DES to RCA.\n - off IV heparin\n - Continue Plavix, aspirin, beta blocker\n .\n # Pump\n previous echo from demonstrates mild symmetric left\n ventricular hypertrophy with preserved global and regional\n biventricular systolic function. Mild-moderate mitral regurgitation.\n - cont aspirin, statin, beta blocker\n - restarted Lisinopril. Uptitrate as tolerated\n #. Hypoxia - Pt has history of disordered breathing following stroke,\n has been off CPAP, also has evidence of progression of emphysema and\n ILD on Chest CT. Workup negative for PE\n - Continue O2 NC to maintain sat >88%\n - Will trial diuresis with lasix bolus\n - Appreciate Pulmonary consult recommendations\n concern for UIP/ILD\n and related disordered. Requested labs pending including BNP, ESR, ,\n Anti SCL-70, Anti centromere Ab, RF, hepatitis serologies,\n immunoglobulin levels, SPEP, and UPEP. Also recommended ongoing\n diuresis\n .\n # Nausea, vomiting, and diarrhea: Pt developed acute N/V/D this\n admission consistent with a viral gastroenteritis.\n - Already improving after <24hrs\n - Continue IVF and PRN zofran\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - aggrexox transitioned to plavix given concern for ACS\n .\n #. HTN - continue lisinopril, metoprolol as above\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN\n cardiac diet\n .\n #. Access: PIV\n .\n #. PPx: PPI, subQ heparin, bowel regimen\n .\n #. Code: Full\n .\n #. Dispo: Call out to medical floor, PT consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: Call out to medical floor\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, agree with above\n Physical Examination\n nothing to add, agree with above\n Medical Decision Making\n nothing to add, agree with above\n Total time spent on patient care: 40 minutes.\n ------ Protected Section Addendum Entered By: on:\n 10:23 ------\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-06 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 444644,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, However CT showed what is Pulm Fibrosis and Emphysema\n previously undiagnosed. Echo Cardiogram showed new wall motion\n abnormality concerning for ischemia\n Chest Pain - The pt presents with hx of anterior chest discomfort\n occurring at rest for several days, similar to previous episodes which\n occurred during exercise. ECG with new RBBB and ST depressions\n throughout precordium. TTE EF 60%, basal segments of the inferior and\n posterior wall are akinetic, and the midventricular segments are\n hypokinetic, RV cavity is dilated with borderline normal free wall\n function, 3+MR, moderate pulmonary artery systolic hypertension. No\n further episodes of chest pain since admission Taken to cath lab Friday\n and 3 stents to RCA, which is thought to be culprit lesion. Did well\n post procedure minx closure with old blood on dressing eccymotic at\n that area but unchanged, good pedal pulses and PT by Doppler.\n PT Denies chest pain since cardiac cath.\n PT did C/O indigestion this afternoon Saturday 12 lead done, nothing\n new, Tums without relief so Maalox/lidocaine/benadryl solution was\n given, with good effect. pt takes prilosec at home and received his\n dose today in the Am. . Pt also had two BM today one was normal second\n slightly Quiac positive and Appeared light brown diarrhea, team Later\n pt vomited bile x 3 episodes and feels sick. Pt thought to have Noro\n Virus/gastroenteritis, last BM 0300 AM and although was slightly quiac\n pos it was not or bloody appearing, PT is on contact\n precautions, Afebrile today putting out good amount of urine yesterday\n as well as a lot of stool and emesis. PT coughed up blood to\n intermittently pink tinged, team aware and PULMONARY is consulted.\n PT has had some hemoptosis not sure if it is from O2, Has high o2\n requirement of 5LNC and goal sat is above 88. Pt ranges from 88-93 %\n Cv wise Hr 70-80\ns with frequent pac\ns/pvc\ns. SBP 120-130\ns/70\n Down to 97/60 while sleeping and agfter lopressor dose, team aware.\n Completed bicarb drip. !/2 NS given post cath ( cath was Friday) .\n Right groin with transparent dsg , old blood and somewhat eccymotic\n but stable no heamatoma. He has faint crackles at his bases but\n otherwise clear. Team has consulted Pulm doctors as pt high o2\n requirements 5 Liters and DOE with exertion, likely from a pulmonary\n source.\n Physical therapy is consulted pt lives alone did get OOB with\n supervision, appears deconditioned but does weight\n Bear and is getting SSInsulin now that he is able to tolerate PO\n liquids and light solid foods. .\n Hypoxemia\n Assessment:\n Lung faint crackles at bases requires 5LNC sats 89-93 on 5L\n Action:\n Spiriva inhaler started, fluticasone inhaler, pt ruled out for PE,\n Pulm MD consulted. Has PULM fibrosis by CT scan and both are new\n diagnosis for this pt. Blood work sent and pulm following\n Response:\n PT had some DOE getting OOB to Commode x 2, otherwise no complaints\n SATs 88-93\n Plan:\n Consult pulmonary and Physical therapy, spiriva. Goal keep o2 sats\n greater than 88\n Pt is also on contact precautions for gastroenteritis/Noro virus, Good\n hand washing gown and gloves mask if pt actively\n Vomiting. Last episode of Diarrhea and or vomiting was at 0300 on\n \n"
},
{
"category": "Nursing",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 444547,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, TTE with new wall motion abnormality concerning for ischmia\n .\n #. Chest Pain/WMA - The pt presents with hx of anterior chest\n discomfort occuring at rest for several days, similar to previous\n episodes which occurred during exercise. ECG with new RBBB and ST\n depressions throughout precordium. TTE EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension. No further episodes of chest pain since admission\n Denies chest pain. Hr 70-80\ns with frequent pac\ns/pvc\ns. SBP\n 120-130\ns/70\ns. Completed bicarb drip. !/2 NS infusing. Right groin\n with transparent dsg with small amount of bld drainage. Pulses dop.\n Slept with 12.5 mg of benadryl for sleep. Small sot hematoma to right\n groin site. Anticipate call out to floor.\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444616,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, TTE with new wall motion abnormality concerning for ischmia\n .\n #. Chest Pain/WMA - The pt presents with hx of anterior chest\n discomfort occuring at rest for several days, similar to previous\n episodes which occurred during exercise. ECG with new RBBB and ST\n depressions throughout precordium. TTE EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension.\n Pt. underwent stent placement x3 to RCA on \n ? norovirus as pt experiencing nausea, vomiting and diarrhea.\n Chest pain\n Assessment:\n s/p stent to rca lesion. Right groin with small ooze, area soft, no\n hematoma. Doppler pedal pulses. Foot warm to touch. Denies c/o chest\n discomfort.\n Action:\n Assess right groin, monitor i/o,\n Response:\n No hematoma,\n Plan:\n Follow cath site, i/o lytes. Transfer to floor when bed available\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 444382,
"text": "HPI:\n The pt is a 89y/o M with a PMH of CVA in with residual disordered\n breathing, DM type 2 presenting with four days of intermittent anterior\n chest discomfort and hypoxia. The pt reports pain worse with feelings\n of anxiety, has previously had similar pain while walking on a\n treadmill. Denies prior dyspnea. Denied N/V, No cough. States he works\n out daily by lifting weights, aerobic activity limited by fatigue. He\n has noted increased fatigue over the past several months. He has been\n off CPAP and nocturnal O2 for complex disordered sleep. Pain is\n unchanged with changes in position of deep breath.\n .\n In the ED, initial vitals were T: 98.0 HR: 88 BP: 140/85 RR: 18 O2Sat:\n 94% 4L NC. Patient received Morphine 2mg X3, NTG SL X2, morphine 4mg\n X1, ASA 325mg, Lasix 40mg IV and heparin gtt was started. D-Dimer 2494\n with initial negative CE. ECG demonstreated new RBBB. He was planned to\n be admitted to geriatric service for hydration prior to CTA but then\n developed recurrent chest pain with associated ECG changes.\n Following NTG and morphine, sat decreased to 82% and he was placed on a\n NRB and is now admitted to the CCU for further management. Cardiac\n enzymes negative X2. Vitals prior to transfer : 83 124/79 22 95 % NRB\n .\n On arrival to the CCU, the patient was resting comfortably, denies\n current dyspnea or pain, sating 90% on 5LNC.\n Hypoxemia\n Assessment:\n On 5 L NP, bs+ all lobes, clear, crackles to bases, chest CT to\n r/o PE, PE r/o, emphesema & pulmonary fibrosis noted on chest CT, no\n c/o SOB since admission, no resp distress noted\n Action:\n Continue o2 @ 5 L NP, npo for cath lab today\n Response:\n Sat 91-94 on 5 L NP, no c/o CP or SOB, no resp distress noted\n Plan:\n Wean o2 as tolerated, continue to monitor resp status, may need home\n o2, further workup of pulmonary status\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 444380,
"text": "HPI:\n The pt is a 89y/o M with a PMH of CVA in with residual disordered\n breathing, DM type 2 presenting with four days of intermittent anterior\n chest discomfort and hypoxia. The pt reports pain worse with feelings\n of anxiety, has previously had similar pain while walking on a\n treadmill. Denies prior dyspnea. Denied N/V, No cough. States he works\n out daily by lifting weights, aerobic activity limited by fatigue. He\n has noted increased fatigue over the past several months. He has been\n off CPAP and nocturnal O2 for complex disordered sleep. Pain is\n unchanged with changes in position of deep breath.\n .\n In the ED, initial vitals were T: 98.0 HR: 88 BP: 140/85 RR: 18 O2Sat:\n 94% 4L NC. Patient received Morphine 2mg X3, NTG SL X2, morphine 4mg\n X1, ASA 325mg, Lasix 40mg IV and heparin gtt was started. D-Dimer 2494\n with initial negative CE. ECG demonstreated new RBBB. He was planned to\n be admitted to geriatric service for hydration prior to CTA but then\n developed recurrent chest pain with associated ECG changes.\n Following NTG and morphine, sat decreased to 82% and he was placed on a\n NRB and is now admitted to the CCU for further management. Cardiac\n enzymes negative X2. Vitals prior to transfer : 83 124/79 22 95 % NRB\n .\n On arrival to the CCU, the patient was resting comfortably, denies\n current dyspnea or pain, sating 90% on 5LNC.\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444442,
"text": "Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444443,
"text": "Chest pain\n Assessment:\n Returned from cath lab at 1900 post stent placement to rca, Angioseal\n intact, ecchymotic soft right fem site. Good uo, + hematuria. Sr with\n pvc\ns. denied cp\n Action:\n Vs and checks as per orders, small amount of sanguinous drainage at\n 2300, dopp pp. receiving bicarb gtt as well as Mucomyst. Labs to be\n drawn at 0100.\n Response:\n Stable post cath, hematuria\n Plan:\n Monitor comfort, hr and rythym, sbp, pp, right fem site, i+O,\n ns at\n 100ml/hr post bicarb gtt, labs. As per orders. If continues stable ?\n transfer in am\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444444,
"text": "Patient is a 89 y/o M with a PMH of CVA in with residual\n disordered breathing, DM type 2 presenting with four days of\n intermittent anterior chest discomfort and new hypoxia, work up for PE\n negative, TTE with new wall motion abnormality concerning for ischmia\n .\n #. Chest Pain/WMA - The pt presents with hx of anterior chest\n discomfort occuring at rest for several days, similar to previous\n episodes which occurred during exercise. ECG with new RBBB and ST\n depressions throughout precordium. TTE EF 60%, basal segments of the\n inferior and posterior wall are akinetic, and the midventricular\n segments are hypokinetic, RV cavity is dilated with borderline normal\n free wall function, 3+MR, moderate pulmonary artery systolic\n hypertension. No further episodes of chest pain since admission\n Chest pain\n Assessment:\n Returned from cath lab at 1900 post stent placement to rca, Angioseal\n intact, ecchymotic soft right fem site. Good uo, + hematuria. Sr with\n pvc\ns. denied cp\n Action:\n Vs and checks as per orders, small amount of sanguinous drainage at\n 2300, dopp pp. receiving bicarb gtt as well as Mucomyst. Labs to be\n drawn at 0100.\n Response:\n Stable post cath, hematuria\n Plan:\n Monitor comfort, hr and rythym, sbp, pp, right fem site, i+O,\n ns at\n 100ml/hr post bicarb gtt, labs. As per orders. If continues stable ?\n transfer in am\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444522,
"text": "TITLE: CCU Resident Admission Note\n Chief Complaint: chest pain\n 24 Hour Events:\n Cardiac catherization : cath demonstrated right dominant, LMCA no\n significant disease, LAD diffuse proximal calcification, mid up to 60%,\n LCX total occlusion at OM1 take off and then long subtotal occlusion of\n OM1 appears chronic, RCA diffuse 90% proximal and 80% distal, heavily\n calcified - final dxg 3 vessel CAD, successful DES to RCA\n - post cath recs: aspirin 325 mg PO daily x 6 months and then may\n decrease to 81 mg PO daily, plavix 75 mg PO daily for at least one year\n - post cath check: small bruising around cath site, doppleralbe pulses\n bilaterally, stable vital signs\n - will need pulmonary appointment as outpatient\n - start beta today, restart lisinopril after cath\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98\n HR: 84 (63 - 84) bpm\n BP: 115/57(71) {99/48(65) - 134/70(84)} mmHg\n RR: 24 (11 - 25) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,733 mL\n 1,270 mL\n PO:\n 480 mL\n TF:\n IVF:\n 1,253 mL\n 1,270 mL\n Blood products:\n Total out:\n 1,720 mL\n 660 mL\n Urine:\n 1,510 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 13 mL\n 610 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 88%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished),\n good DP/PT pulses by doppler\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, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 144 K/uL\n 12.8 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 103 mEq/L\n 139 mEq/L\n 37.2 %\n 7.1 K/uL\n [image002.jpg]\n 06:00 AM\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n 01:19 AM\n WBC\n 9.1\n 7.1\n Hct\n 40.2\n 37.2\n Plt\n 135\n 140\n 144\n Cr\n 1.3\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n TCO2\n 27\n Glucose\n 139\n 179\n 161\n \n Other labs: PT / PTT / INR:15.9/63.8/1.4, CK / CKMB /\n Troponin-T:51/9/0.11, Lactic Acid:1.1 mmol/L, Ca++:8.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 89 y/o M with a PMH of CVA in with residual disordered breathing,\n DM type 2 presenting with four days of intermittent anterior chest\n discomfort and new hypoxia, work up for PE negative, TTE with new wall\n motion abnormality concerning for ischmia now s/p cardiac catherization\n with stent placement to RCA\n .\n #. CAD - ECG with new RBBB and ST depressions throughout precordium.\n TTE EF 60%, basal segments of the inferior and posterior wall are\n akinetic, and the midventricular segments are hypokinetic, RV cavity is\n dilated with borderline normal free wall function, 3+MR, moderate\n pulmonary artery systolic hypertension. No further episodes of chest\n pain since admission. Patient s/p DES to RCA.\n - off IV heparin\n - Continue Plavix, aspirin, beta blocker\n .\n # Pump\n previous echo from demonstrates mild symmetric left\n ventricular hypertrophy with preserved global and regional\n biventricular systolic function. Mild-moderate mitral regurgitation.\n - cont aspirin, statin, beta blocker\n - restart Lisinopril this am\n #. Hypoxia - Pt has history of disordered breathing following stroke,\n has been off CPAP, also has evidence of progression of emphysema and\n ILD on Chest CT. Workup negative for PE\n - Continue O2 NC to maintain sat >88%\n - Pt will need evaluation by Pulmonary as outpatient, eval for home O2\n post-postentional revascularization\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - aggrexox transitioned to plavix given concern for ACS\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO for cath\n .\n #. Access: PIV\n .\n #. PPx: PPI, subQ heparin, bowel regimen\n .\n #. Code: Full\n .\n #. Dispo: Call out to medical floor, PT consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: NA\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: Call out to medical floor\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444523,
"text": "TITLE: CCU Resident Admission Note\n Chief Complaint: chest pain\n 24 Hour Events:\n Cardiac catherization : cath demonstrated right dominant, LMCA no\n significant disease, LAD diffuse proximal calcification, mid up to 60%,\n LCX total occlusion at OM1 take off and then long subtotal occlusion of\n OM1 appears chronic, RCA diffuse 90% proximal and 80% distal, heavily\n calcified - final dxg 3 vessel CAD, successful DES to RCA\n - post cath recs: aspirin 325 mg PO daily x 6 months and then may\n decrease to 81 mg PO daily, plavix 75 mg PO daily for at least one year\n - post cath check: small bruising around cath site, doppleralbe pulses\n bilaterally, stable vital signs\n - will need pulmonary appointment as outpatient\n - start beta today, restart lisinopril after cath\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98\n HR: 84 (63 - 84) bpm\n BP: 115/57(71) {99/48(65) - 134/70(84)} mmHg\n RR: 24 (11 - 25) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,733 mL\n 1,270 mL\n PO:\n 480 mL\n TF:\n IVF:\n 1,253 mL\n 1,270 mL\n Blood products:\n Total out:\n 1,720 mL\n 660 mL\n Urine:\n 1,510 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 13 mL\n 610 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 88%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished),\n good DP/PT pulses by doppler\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, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 144 K/uL\n 12.8 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 103 mEq/L\n 139 mEq/L\n 37.2 %\n 7.1 K/uL\n [image002.jpg]\n 06:00 AM\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n 01:19 AM\n WBC\n 9.1\n 7.1\n Hct\n 40.2\n 37.2\n Plt\n 135\n 140\n 144\n Cr\n 1.3\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n TCO2\n 27\n Glucose\n 139\n 179\n 161\n \n Other labs: PT / PTT / INR:15.9/63.8/1.4, CK / CKMB /\n Troponin-T:51/9/0.11, Lactic Acid:1.1 mmol/L, Ca++:8.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 89 y/o M with a PMH of CVA in with residual disordered breathing,\n DM type 2 presenting with four days of intermittent anterior chest\n discomfort and new hypoxia, work up for PE negative, TTE with new wall\n motion abnormality concerning for ischmia now s/p cardiac catherization\n with stent placement to RCA\n .\n #. CAD - ECG with new RBBB and ST depressions throughout precordium.\n TTE EF 60%, basal segments of the inferior and posterior wall are\n akinetic, and the midventricular segments are hypokinetic, RV cavity is\n dilated with borderline normal free wall function, 3+MR, moderate\n pulmonary artery systolic hypertension. No further episodes of chest\n pain since admission. Patient s/p DES to RCA.\n - off IV heparin\n - Continue Plavix, aspirin, beta blocker\n .\n # Pump\n previous echo from demonstrates mild symmetric left\n ventricular hypertrophy with preserved global and regional\n biventricular systolic function. Mild-moderate mitral regurgitation.\n - cont aspirin, statin, beta blocker\n - restart Lisinopril this am\n #. Hypoxia - Pt has history of disordered breathing following stroke,\n has been off CPAP, also has evidence of progression of emphysema and\n ILD on Chest CT. Workup negative for PE\n - Continue O2 NC to maintain sat >88%\n - Consult pulmonary for further evaluation/treatment of hypoxia\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - aggrexox transitioned to plavix given concern for ACS\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO for cath\n .\n #. Access: PIV\n .\n #. PPx: PPI, subQ heparin, bowel regimen\n .\n #. Code: Full\n .\n #. Dispo: Call out to medical floor, PT consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: NA\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: Call out to medical floor\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 444526,
"text": "TITLE: CCU Resident Admission Note\n Chief Complaint: chest pain\n 24 Hour Events:\n Cardiac catherization : cath demonstrated right dominant, LMCA no\n significant disease, LAD diffuse proximal calcification, mid up to 60%,\n LCX total occlusion at OM1 take off and then long subtotal occlusion of\n OM1 appears chronic, RCA diffuse 90% proximal and 80% distal, heavily\n calcified - final dxg 3 vessel CAD, successful DES to RCA\n - post cath recs: aspirin 325 mg PO daily x 6 months and then may\n decrease to 81 mg PO daily, plavix 75 mg PO daily for at least one year\n - post cath check: small bruising around cath site, doppleralbe pulses\n bilaterally, stable vital signs\n - will need pulmonary appointment as outpatient\n - start beta today, restart lisinopril after cath\n Allergies:\n Allopurinol\n Thrombocytopeni\n Cimetidine\n Hepatic toxicit\n Pioglitazone\n Hepatic toxicit\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.7\nC (98\n HR: 84 (63 - 84) bpm\n BP: 115/57(71) {99/48(65) - 134/70(84)} mmHg\n RR: 24 (11 - 25) insp/min\n SpO2: 88%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 1,733 mL\n 1,270 mL\n PO:\n 480 mL\n TF:\n IVF:\n 1,253 mL\n 1,270 mL\n Blood products:\n Total out:\n 1,720 mL\n 660 mL\n Urine:\n 1,510 mL\n 660 mL\n NG:\n Stool:\n Drains:\n Balance:\n 13 mL\n 610 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 88%\n ABG: ////\n Physical Examination\n General Appearance: Well nourished, No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished),\n good DP/PT pulses by doppler\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, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 144 K/uL\n 12.8 g/dL\n 113 mg/dL\n 1.1 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 17 mg/dL\n 103 mEq/L\n 139 mEq/L\n 37.2 %\n 7.1 K/uL\n [image002.jpg]\n 06:00 AM\n 06:01 AM\n 11:33 AM\n 06:00 PM\n 10:00 PM\n 10:20 PM\n 04:35 AM\n 01:19 AM\n WBC\n 9.1\n 7.1\n Hct\n 40.2\n 37.2\n Plt\n 135\n 140\n 144\n Cr\n 1.3\n 1.1\n 1.1\n TropT\n 0.13\n 0.12\n 0.11\n TCO2\n 27\n Glucose\n 139\n 179\n 161\n \n Other labs: PT / PTT / INR:15.9/63.8/1.4, CK / CKMB /\n Troponin-T:51/9/0.11, Lactic Acid:1.1 mmol/L, Ca++:8.8 mg/dL, Mg++:2.2\n mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 89 y/o M with a PMH of CVA in with residual disordered breathing,\n DM type 2 presenting with four days of intermittent anterior chest\n discomfort and new hypoxia, work up for PE negative, TTE with new wall\n motion abnormality concerning for ischmia now s/p cardiac catherization\n with stent placement to RCA\n .\n #. CAD - ECG with new RBBB and ST depressions throughout precordium.\n TTE EF 60%, basal segments of the inferior and posterior wall are\n akinetic, and the midventricular segments are hypokinetic, RV cavity is\n dilated with borderline normal free wall function, 3+MR, moderate\n pulmonary artery systolic hypertension. No further episodes of chest\n pain since admission. Patient s/p DES to RCA.\n - off IV heparin\n - Continue Plavix, aspirin, beta blocker\n .\n # Pump\n previous echo from demonstrates mild symmetric left\n ventricular hypertrophy with preserved global and regional\n biventricular systolic function. Mild-moderate mitral regurgitation.\n - cont aspirin, statin, beta blocker\n - restart Lisinopril this am\n #. Hypoxia - Pt has history of disordered breathing following stroke,\n has been off CPAP, also has evidence of progression of emphysema and\n ILD on Chest CT. Workup negative for PE\n - Continue O2 NC to maintain sat >88%\n - Consult pulmonary for further evaluation/treatment of hypoxia\n .\n #. Hx of CVA - resulting complex disordered breathing - pt has refused\n further treatment with CPAP or home O2 as outpatient\n - aggrexox transitioned to plavix given concern for ACS\n .\n #. HTN - continue lisinopril\n .\n #. Type 2 diabetes - hold metformin while in house, start insulin SS\n .\n #. Hypothyroidism - continue synthroid\n .\n #. FEN - NPO for cath\n .\n #. Access: PIV\n .\n #. PPx: PPI, subQ heparin, bowel regimen\n .\n #. Code: Full\n .\n #. Dispo: Call out to medical floor, PT consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 05:03 AM\n 20 Gauge - 05:04 AM\n Prophylaxis:\n DVT: heparin SC\n Stress ulcer: NA\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full\n Disposition: Call out to medical floor\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, agree with above\n Physical Examination\n Nothing to add, agree with above\n Medical Decision Making\n Nothing to add, agree with above\n ------ Protected Section Addendum Entered By: on:\n 10:05 ------\n"
},
{
"category": "Physician ",
"chartdate": "2146-03-03 00:00:00.000",
"description": "CARDIOLOGY FELLOW NOTE",
"row_id": 444081,
"text": "TITLE:\n CARDIOLOGY FELLOW NOTE\n Please refer to CCU resident note for full H&P.\n 89 yo functionally independent male, without known CAD, but with DM,\n h/o R MCA and R cerebellar CVA in , presenting with 3 days of\n intermittent atypical sounding CP while at rest, culminating in a 1hr\n episode yesterday at 5pm. Background of intermittent pain for months.\n Pain not related to exertion (exercises 4x/week in gym without\n symptoms), but brought on by emotional stress. Reproduced by chest\n palpation. EKG showed new RBBB compared to , but subsequently\n developed more CP associated with dynamic ST depressions V1-4. Trop\n 0.04, CK neg. Also noted to be hypoxic 86% on 4L, switched to NRB\n 93%. Because of hypoxia (can't go to floor), and EKG changes with pain\n (therefore cardiac ICU, not MICU), sent to CCU.\n PE bibasal fine expiratory crackles, JVP NE, HS normal.\n Issues:\n (1) I think hypoxia is chronic. Pt says his\nO2 levels have always been\n low\n. CXR shows bibasilar interstitial changes new compared to ,\n but appears to be more fibrotic than failure. Pt denies SOB and DOES\n NOT APPEAR in respiratory distress, therefore, likely chronic.\n (2) Unlikely to be failure because of above. Also, previous echo\n showed preserved EF. However, ED's already given IV lasix 20, with\n UO 1000. Despite this, pt is clinically unchanged after lasix\n (persistent crackles) - again supporting chronic interstitial lung\n changes rather than CHF. need rpt echo.\n (3) D-dimers >. Low pretest prob for PE, but cannot ignore ,\n even despite CKD (Cr 1.4). Therefore, OK to continue heparin and\n obliged to r/o PE. V/q will not be helpful, because of abn CXR.\n Therefore, should get CTA to r/o PE but also add some HR slices to\n examine lung parenchyma. To protect kidneys, can give back some IVF (as\n failure less likely) and mucormyst.\n (4) Dynamic EKG changes with CP. Although pain sounds more\n musculoskeletal (reproduced by palpation), pt has RFs (exsmoker, DM)\n and had associated EKG changes, so ischemic pain still a possibility.\n If w/u neg for PE, willl prob need a stress test as inpatient prior to\n d/c. For now, will not tx as classic ACS although has gotten ASA 325\n and on hep gtt.\n"
},
{
"category": "Nursing",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 444232,
"text": "89 yr. old functionally independent male, without known CAD, but with\n DM, h/o R MCA and R cerebellar CVA in , presenting with 3 days of\n intermittent atypical sounding CP while at rest, culminating in a 1hr\n episode yesterday at 5pm. Background of intermittent pain for months.\n Pain not related to exertion (exercises 4x/week in gym without\n symptoms), but brought on by emotional stress. Reproduced by chest\n palpation. EKG showed new RBBB compared to , but subsequently\n developed more CP associated with dynamic ST depressions V1-4. Trop\n 0.04, CK neg. Also noted to be hypoxic 86% on 4L, switched to NRB->\n 93%.\n Hypoxemia\n Assessment:\n Action:\n Response:\n Plan:\n Chest pain\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Echo",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Report",
"row_id": 101815,
"text": "PATIENT/TEST INFORMATION:\nIndication: Abnormal ECG. Chest pain\nHeight: (in) 70\nWeight (lb): 172\nBSA (m2): 1.96 m2\nBP (mm Hg): 117/67\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 10:51\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. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%). No resting LVOT gradient. No VSD.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- akinetic; mid inferior - hypo; basal inferolateral - akinetic; mid\ninferolateral - hypo;\n\nRIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. Borderline normal RV\nsystolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Moderate to severe (3+) MR. LV inflow pattern c/w\nrestrictive filling abnormality, with elevated LA pressure.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic\ntricuspid valve supporting structures. No TS. Moderate [2+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PS. Mild\nPR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular ejection fraction\nis normal (LVEF 60%). However, the basal segments of the inferior and\nposterior wall are akinetic, and the midventricular segments are hypokinetic.\nThere is no ventricular septal defect. The right ventricular free wall is\nhypertrophied. The right ventricular cavity is dilated with borderline normal\nfree wall function. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral\nregurgitation is seen. The left ventricular inflow pattern suggests a\nrestrictive filling abnormality, with elevated left atrial pressure. The\ntricuspid valve leaflets are mildly thickened. The supporting structures of\nthe tricuspid valve are thickened/fibrotic. Moderate [2+] tricuspid\nregurgitation is seen. There is moderate pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nCompared with the findings of the prior study (images unavailable for review)\nof , inferior posterior left ventricular contractile\ndysfunction as well as right ventricular dysfunction are now present. The\nmitral and tricuspid regurgitation and pulmonary artery pressure are\nsignificantly increased.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-07 00:00:00.000",
"description": "Report",
"row_id": 296903,
"text": "Sinus rhythm. Premature atrial contractions. Right bundle-branch block.\nLeft anterior fascicular block. Non-specific ST-T wave changes. Compared to\nthe previous tracing of premature atrial contractions are new.\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Report",
"row_id": 296904,
"text": "Sinus rhythm. The previously mentioned multiple abnormalities recorded\non persist without diagnostic interim change.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-05 00:00:00.000",
"description": "Report",
"row_id": 296905,
"text": "Sinus rhythm and frequent atrial ectopy. Right bundle-branch block. Compared\nto the previous tracing of no diagnostic interim change.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Report",
"row_id": 296906,
"text": "Sinus rhythm. Right bundle-branch block. Left anterior fascicular block.\nNon-specific inferior ST-T wave changes. Early precordial R wave transition.\nCompared to the previous tracing of no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-04 00:00:00.000",
"description": "Report",
"row_id": 296907,
"text": "Sinus rhythm. Right bundle-branch block. Left anterior fascicular block.\nBorderline low limb lead voltage. Compared to the previous tracing of \natrial ectopy is not recorded. Otherwise, no diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Report",
"row_id": 296908,
"text": "Sinus rhythm with PAC(s)\nRight bundle branch block\nInferior T wave changes are nonspecific\nSince previous tracing of the same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Report",
"row_id": 296909,
"text": "Sinus rhythm with atrial premature complexes\nRight bundle branch block\nSince previous tracing of the same date, atrial premature complexes noted\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Report",
"row_id": 296910,
"text": "Sinus rhythm\nRight bundle branch block\nT wave changes are nonspecific\nSince previous tracing of the same date, ST segment depression noted\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-03 00:00:00.000",
"description": "Report",
"row_id": 297143,
"text": "Sinus rhythm\nLeft axis deviation\nRBBB with left anterior fascicular block\nST-T changes suggest myocardial injury/ischemia\nSince previous tracing of , ST-T wave changes now present\n\n"
},
{
"category": "ECG",
"chartdate": "2146-03-02 00:00:00.000",
"description": "Report",
"row_id": 297144,
"text": "Sinus rhythm\nIntermittent right bundle branch block\nST-T changes are nonspecific\nSince previous tracing of , intermittent right bundle branch block\npresent\n\n"
}
] |
7,275 | 103,990 | Pt admitted on with bleeding AV fistula, taken to the OR. Aneursym of fistula ligated and resected. Pt given 3U PRBC during the operation. Pt on GET secondary to SOB at the onset of MAC. Pt unable to be extubated after the case, transferred to the MICU intubated. Pt then extubated overnight, tolerated well. Pt transferred to the floor. Pt with tunneled dialysis cath placed on . Pt continued to improve. Pt tolerated diet well, pain controlled. Pt D/C'd with VNA for dressing changes on . | IVF changed to heplock as pt is probably fluid overloaded at this point.Resp - BS cl bilat. A&Ox3, approp, answering questions approp, FC, MAE.REsp-Simv, Propofol weaned 1450 s/p Quenten cath placemnt for HD. pressure 180 on arrival, propafol/MS given with good result of sys 130-150. lead depression unchanged from prev. AV fistula site serous on dressing. Dsg changed by MICU nursing for ser/sang saturation. ESRD.Neuro - Pleasant A&O X4. BS clear Upper and lower.CV-stable, HR 60's sR, BP 130-150/60-80. Scleral edema bil. arrives from OR at0345 transfered to ICU bed post op AV fistula repair.NEURO: sedated from OR, propafol in use lightly as plan to extubate pt. EKG. Plan is to wean to extubate this am after patient is fully awake. Placed on ventilatory support, SIMV, Vt-600; rr-16; FIO2- 40%; 5 cm PEEP; 5 cm PSV. distal pulse wnl, skin warm cms intact.CV: sys. NSICU team informed of dsg change.Quetin cath placed R subclavian via IR w/o complication.Pt to have HD Thurs 9/9 per Renal Team. ESRD pt. Plan dialysis today. Pt acknowledges that he does have sleep apnea. Pt changed to CPAP 5/5, then 5/0 w/ good spont breathing.Pt awoke, good cuff leak, able to raise head w/o assist. sedation. pt anuric by history no foley.ACCESS: 2 PIV in left arm functional.SKIN: drsg with serous drainage. ABG rresults on the initial settings determined a mild respiratory alkalemia with good oxygenation. ORal secretions Breath sounds clear to bases diminished bil at bases.GI/GU: BT not present. Nsg Progress Note 1900-0700CV - Pt hemodynamically stable. movementwhen propafol off or min. NPN 0345-0730Pt. spont. Propofol d/c @1500, pt awoke to follow commands, safely extubated. Very appropriate and cooperative.A/PPt stable s/p surgical repair of R arm fistula/shunt requiring intubation.Successfully extubated.R arm sig for moderate s/s drainage on dsg, afebrile.HD planned for . Right arm fistula dsg was changed x2 for sm to mod amt bloody drainage. All very pleasant and asking appropriate questions.Pt will be transferred to the floor today. Incision in 3 parts, 2 parts sutured, 1 open w/ NS guaze packing, then DSD, Kurlex. Sinus rhythmLeft atrial abnormalityLeft ventricular hypertrophy with ST-T abnormalitiesProlonged Q-Tc intervalBorderline left axis deviationST-T wave changes are diffuse - considerin part metabolic/drug effectSince previous tracing of , atrial ectopy not seen and ST-T wave changesless prominent min ET. saline soaks to eyes. pp intact. Occasionally gets grumpy but was very cooperative for most of the night.Renal - pt has quentin cath to right and will be getting HD at some point today. MD visited with son.Contact precautions for MRSA of prev shunt.PLAN: MD . Tums and protonix tried with no decrease of discomfort. Sinus rhythmAtrial premature complexesProlonged Q-Tc intervalLeft atrial abnormalityLeft axis deviation - left anterior fascicular blockLeft ventricular hypertrophy with ST-T wave abnormalitiesST-T wave abnormalities are diffuse - consider in part metabolic/drug effectand/or ischemiaSince previous tracing of , further ST-T wave changes present Called this afternoon p line placement and extubaiton. anuric no foley. Body temp slowly warming up to normal temp. Extubation w/o complication, placed on .40 facetent w/ sat 99-100. Informed of status and plan. other wise intact.SOCIAL: Son to see pt. Only needs O2 via nasal cannula when deeply asleep. Attempted mult different ways to decrease the nausea. MS 4 mgm given with good result. Strong prod cough. this am. Total intake for day ~4L including 3L+ in OR, 1000cc in MICU.REnal- Afebrile-R arm fistula s/p surgical repair. MAE. OR. He brought up one mod dk bld tinged amount of phlegm.GI - C/O nausea all night. Zofran IV given with no changes. 3 aneyrsms on A-V fistula-presented s/p large internal bleed @ fistula requiring surgical repair overnight .Neuro-Initally sedated on propofol while intubated. Respiratory Care:55 YOmale patient received in MICU-B S/P a-v repair. Able to sit on edge of bed and stand with min assist. PERL at 4 cm. MgSO4 2 grams given this am.No urine output. Maalox cocktail given with no relief.EKG done to rule out cardiac element.GU - No foley - no urine output. MICU Nursing Progress Note 7a-7p55y/o male w/ RF, HTN, Hep C, sz disorder, s/p 2 kidney transplants, now on HD M-W-F for failed 2nd tx kidney. appears supportive and appropriate. RR rate decreased to 14. T 94.5 blankets to warm effective.RESP: intubated on arrival, 50% to 40% with 100% sats, PS 5 TV 600 peep 5. abgs wnl. Patient still too sedated to place on CPAP or perform RSBI. Transplant has also seen pt.Social-Family visiting this am prior to extubation. no orders recieved. | 6 | [
{
"category": "Nursing/other",
"chartdate": "2134-10-20 00:00:00.000",
"description": "Report",
"row_id": 1359592,
"text": "MICU Nursing Progress Note 7a-7p\n55y/o male w/ RF, HTN, Hep C, sz disorder, s/p 2 kidney transplants, now on HD M-W-F for failed 2nd tx kidney. 3 aneyrsms on A-V fistula-presented s/p large internal bleed @ fistula requiring surgical repair overnight .\nNeuro-\nInitally sedated on propofol while intubated. Propofol d/c @1500, pt awoke to follow commands, safely extubated. A&Ox3, approp, answering questions approp, FC, MAE.\nREsp-\nSimv, Propofol weaned 1450 s/p Quenten cath placemnt for HD. Pt changed to CPAP 5/5, then 5/0 w/ good spont breathing.Pt awoke, good cuff leak, able to raise head w/o assist. Extubation w/o complication, placed on .40 facetent w/ sat 99-100. BS clear Upper and lower.\nCV-\nstable, HR 60's sR, BP 130-150/60-80. MgSO4 2 grams given this am.\nNo urine output. Total intake for day ~4L including 3L+ in OR, 1000cc in MICU.\nREnal-\n Afebrile-R arm fistula s/p surgical repair. Dsg changed by MICU nursing for ser/sang saturation. Incision in 3 parts, 2 parts sutured, 1 open w/ NS guaze packing, then DSD, Kurlex. NSICU team informed of dsg change.\nQuetin cath placed R subclavian via IR w/o complication.\nPt to have HD Thurs 9/9 per Renal Team. Transplant has also seen pt.\nSocial-\nFamily visiting this am prior to extubation. Called this afternoon p line placement and extubaiton. Informed of status and plan. Very appropriate and cooperative.\nA/P\nPt stable s/p surgical repair of R arm fistula/shunt requiring intubation.\nSuccessfully extubated.\nR arm sig for moderate s/s drainage on dsg, afebrile.\nHD planned for .\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-21 00:00:00.000",
"description": "Report",
"row_id": 1359593,
"text": "Nsg Progress Note 1900-0700\n\nCV - Pt hemodynamically stable. Body temp slowly warming up to normal temp. IVF changed to heplock as pt is probably fluid overloaded at this point.\n\nResp - BS cl bilat. Only needs O2 via nasal cannula when deeply asleep. Pt acknowledges that he does have sleep apnea. Strong prod cough. He brought up one mod dk bld tinged amount of phlegm.\n\nGI - C/O nausea all night. Attempted mult different ways to decrease the nausea. Zofran IV given with no changes. Tums and protonix tried with no decrease of discomfort. Maalox cocktail given with no relief.\nEKG done to rule out cardiac element.\n\nGU - No foley - no urine output. ESRD.\n\nNeuro - Pleasant A&O X4. Able to sit on edge of bed and stand with min assist. Occasionally gets grumpy but was very cooperative for most of the night.\n\nRenal - pt has quentin cath to right and will be getting HD at some point today. Right arm fistula dsg was changed x2 for sm to mod amt bloody drainage. Right hand is warm with good sensation and movement.\n\nSocial - Pt had many visitors on last night. All very pleasant and asking appropriate questions.\n\nPt will be transferred to the floor today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-20 00:00:00.000",
"description": "Report",
"row_id": 1359590,
"text": "Respiratory Care:\n55 YOmale patient received in MICU-B S/P a-v repair. Placed on ventilatory support, SIMV, Vt-600; rr-16; FIO2- 40%; 5 cm PEEP; 5 cm PSV. Plan is to wean to extubate this am after patient is fully awake. ABG rresults on the initial settings determined a mild respiratory alkalemia with good oxygenation. RR rate decreased to 14. Patient still too sedated to place on CPAP or perform RSBI.\n"
},
{
"category": "Nursing/other",
"chartdate": "2134-10-20 00:00:00.000",
"description": "Report",
"row_id": 1359591,
"text": "NPN 0345-0730\nPt. arrives from OR at0345 transfered to ICU bed post op AV fistula repair.\n\nNEURO: sedated from OR, propafol in use lightly as plan to extubate pt. this am. ESRD pt. MS 4 mgm given with good result. Scleral edema bil. saline soaks to eyes. PERL at 4 cm. spont. movementwhen propafol off or min. sedation. MAE. pp intact. AV fistula site serous on dressing. distal pulse wnl, skin warm cms intact.\n\nCV: sys. pressure 180 on arrival, propafol/MS given with good result of sys 130-150. lead depression unchanged from prev. OR. EKG. anuric no foley. T 94.5 blankets to warm effective.\n\nRESP: intubated on arrival, 50% to 40% with 100% sats, PS 5 TV 600 peep 5. abgs wnl. min ET. ORal secretions Breath sounds clear to bases diminished bil at bases.\n\nGI/GU: BT not present. pt anuric by history no foley.\n\nACCESS: 2 PIV in left arm functional.\n\nSKIN: drsg with serous drainage. other wise intact.\n\nSOCIAL: Son to see pt. appears supportive and appropriate. MD visited with son.\n\nContact precautions for MRSA of prev shunt.\n\nPLAN: MD . Plan dialysis today. no orders recieved.\n"
},
{
"category": "ECG",
"chartdate": "2134-10-19 00:00:00.000",
"description": "Report",
"row_id": 246329,
"text": "Sinus rhythm\nAtrial premature complexes\nProlonged Q-Tc interval\nLeft atrial abnormality\nLeft axis deviation - left anterior fascicular block\nLeft ventricular hypertrophy with ST-T wave abnormalities\nST-T wave abnormalities are diffuse - consider in part metabolic/drug effect\nand/or ischemia\nSince previous tracing of , further ST-T wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2134-10-21 00:00:00.000",
"description": "Report",
"row_id": 246328,
"text": "Sinus rhythm\nLeft atrial abnormality\nLeft ventricular hypertrophy with ST-T abnormalities\nProlonged Q-Tc interval\nBorderline left axis deviation\nST-T wave changes are diffuse - considerin part metabolic/drug effect\nSince previous tracing of , atrial ectopy not seen and ST-T wave changes\nless prominent\n\n"
}
] |
55,523 | 109,446 | The patient was admitted the ICU on for close neurological observation. He was prepped for surgery. On he was taken to the operating room and underwent a left cranectomy with drainage of the hygroma with drain left in. This was performed without complication. Post operatively the patient did well and was transferred to the surgical ICU for monitoring. Repeat head CT was stable with persistent 6-mm rightward shift. on the patient's exam was significantly improved from the day of presentation with return of upper right extremity strength, improved word finding ability and only minimal right nasolabial fold flattening. He was draining minimal amounts of serosanguinous fluid and drain was removed. Repeat CT head was done in the afternoon for fluctuating neurologica exam. Pneumocephalus and persisten SDH was noted. On he was doing well with only mild right pronator drift. On he began to have episodes of dysarthria and RUE weakness that would last about 15 minutes with clear episodes of improvement. Neurology was called and EEG was in place. There was no clear seizures on report. He had a repeat CT head on that showed increased posterior expansion of the subdural hematoma but stable midline shift. continued to follow and make recommendations for his diabetes management. On the patient had an MRI/MRA which showed no infarct and no vascular abnormalities. Echocardiogram was also done and was normal and carotid ultrasounds showed less than 40% stenosis bilaterally. That evening the patient was noted to be more confused with increasingly frequency episodes of aphasia and right arm weakness. Urinalysis and blood cultures were sent to check for underlying infection and continuous EEG was resumed on . The patient also had a repeat CT with reconstructions that showed a persistent L SDH measuring 2.5cm in maximal thickness with 9mm of MLS. On he remained stable and on EEG was stopped as he was not noted to have any seizure activity. His Antieplileptic regimen was changed to Keppra only as well. On his right arm was noted to be decreased in strength with proximal weakness of and distal weakness of 3. Ct head was obtained that showed slight increase in the size of the SDH with slight increase in mass effect and edema. In the evening of the patient's strength improved to however he continued to be dysphasic. Family meeting was held to discuss the option of a third surgery to evacuate the hematoma and the family and patient decided to defer surgery for now in the setting of his improved strength. On patient's exam again worsened, he was having difficulty speaking and was unable to move to his right arm. He was taken to the operating room and underwent a extended left frontal/temporal craniotomy for subdural hematoma evacuation. Post operatively he was transferred to the ICU intubaed. He had a head CT immediately after which showed much improvement in the midline shift. On The patient remained intubated overnight due to concerns that he was slow to awake. He was extubated successfully POD #1. His subdural drain was removed. His exam revealed improved right arm strength and facial droop but continued aphasia. Later in the day the patient became tachycardic to the 120s. His cardiac enzymes were negative but he had some ST changes concerning for demand ischemia. on He had lower extremity ultrasounds which was negative for DVTs. As no clear cause for sinus tachycardia could be found, it was thought that is was most likely due to hydralazine that was being given for blood pressure control. This was discontinued and he was started on metoprolol. He started working with physical and speech therapy. On Another repeat CT head was obtained which showed no changes. On , patient remained stable, more conversant and with good strength. He was OOB with assistance and PT was consulted. On the patient was tranfered to the floor and continued to improve with regards to his aphasia. The patient was discharged the following day in good condition. | Small left temporoparietal subgaleal hematoma is unchanged. There is persistent partial effacement of the left lateral ventricle, with 8-mm rightward shift, unchanged from prior CT from . FINDINGS: PA and lateral images of the chest are essentially unchanged from . Changes from a craniotomy on the right temporal region including a right frontal burr hole and the left frontal/parietal craniotomy are unchanged. FINAL REPORT COMPARISON: CT head without contrast . COMPARISON: Multiple non-enhanced head CTs, most recently from . Unchanged borderline size of the cardiac silhouette. Old right frontal craniotomy defect is unchanged, without right-sided subdural collection. IMPRESSION: No change from the most recent post-surgical CT. Normal interatrial septum. Small temporal subgaleal hematoma is unchanged. COMPARISON: CT head without contrast . COMPARISON: CT head without contrast . The mitral valve leaflets are mildly thickened.There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Normal PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: No PS.PERICARDIUM: No pericardial effusion.Conclusions:The left atrium is normal in size. IMPRESSION: Unchanged chest radiograph since prior imaging. TECHNIQUE: Non-contrast head CT. There are again seen low lung volumes and bibasilar opacities which are unchanged. No VSD.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Mildly dilated ascending aorta. Ventricles are similar in size without evidence of hydrocephalus. Mild mass effect including 2- mm rightward shift of the normally midline structures is unchanged. Craniectomy changes and subgaleal hematoma are stable. Cardiomediastinal silhouette is unchanged. Pneumocephalus is stable. There are stable post-surgical changes with a left frontal and subdural pneumocephalus and subdural fluid along the left cerebral hemisphere, unchanged from the most recent post-surgical CT from at 20:40 p.m. The ventricles are similar in size, without evidence of hydrocephalus. There is unchanged shift of normally midline structures by 6 mm to the right. There is unchanged mild midline shift to the right by about 7 mm. Scattered foci of T2/FLAIR subcortical white matter hyperintensity are nonspecific. The aorta is tortuous, unchanged. FINDINGS: There is no acute intracranial hemorrhage. stable left subdural collection. Change in mental status.Height: (in) 68Weight (lb): 140BSA (m2): 1.76 m2BP (mm Hg): 137/68HR (bpm): 72Status: InpatientDate/Time: at 15:48Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. There is no high density within the left frontal component of the recently drained fluid collection. COMPARISON: Multiple prior studies with only CT head without contrast ranging from to . Mild [1+]TR. Mild mass effect and 5-mm rightward shift of midline structures are unchanged. Persistent 8-mm rightward shift of normally midline structures, approximately stable from previous exam. Similar appearance of moderate-sized left subdural collection, with hemorrhagic component. There isno ventricular septal defect. No acute infarction. There are prominent cortical vessels superficially located throughout the left hemisphere, without definite evidence of leptomeningeal enhancement. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Otherwise, the radiograph is unchanged. COMPARISON: Multiple non-enhanced head CTs, most recently from . COMPARISON: Non-enhanced CT of the head from . Old right frontal craniotomy defect is again noted. Resolution of sinus tachycardia and sinus rhythm has now been restored. There is asymmetric dilation of the right lateral ventricle which is unchanged from previous exam. Mass effect on the lateral ventricle is seen with approximately 11 mm of rightward shift of midline structures, stable from previous exam. IMPRESSION: Large left-sided subdural hematoma appears stable from previous exam with stable mass effect and rightward shift of midline structures. Right bundle branch block.Precordial T wave abnormalities. The following velocities measurements were obtained: RIGHT: Proximal ICA is 61/13 cm/sec, mid ICA 51/9 cm/sec, distal ICA 66/19 cm/sec, CCA 82/19 cm/sec, ECA 69 cm/sec, vertebral artery 48 cm/sec, right ICA/CCA ratio is 0.80. Post left frontal craniotomy changes are again noted with pneumocephalus. FINDINGS: Post-surgical changes related to left frontal craniotomy are noted. FINDINGS: Post-surgical changes related to left frontal craniotomy are noted. Surgical drain has been removed in the interim. The ST segment depression has nowresolved. Mild heterogeneous plaque is seen in the proximal ICAs bilaterally. LEFT: Proximal ICA 64/16 cm/sec, mid ICA 47/15 cm/sec, distal ICA 45/14 cm/sec, CCA 108/24 cm/sec, ECA 61 cm/sec, vertebral artery 59 cm/sec, left ICA/CCA ratio 0.59. FINDINGS: The large left hemispheric subdural hematoma is again seen and appears stable in size. Persistent 6 mm rightward shift of normally midline structures, stable from previous exam. There is persistent 6 mm rightward shift of the normal midline structures, unchanged from previous. FINDINGS: Grayscale, color and Doppler images were obtained of bilateral common femoral, femoral, popliteal and tibial veins. IMPRESSION: Post-surgical changes related to left frontal craniotomy as described above. There are downsloping ST segments diffuselyraising a question of ischemia. The patient is status post left frontal craniotomy. Post-surgical changes related to left frontal craniotomy are again noted with pneumocephalus as well as hyperdense material suggestive of post-surgical material (2:21). DLP: 1025.72 mGy-cm. REASON FOR THIS EXAMINATION: PLEASE DO SAGITTAL AND CORONAL REFORMATS No contraindications for IV contrast FINAL REPORT INDICATION: Evaluation of patient with history of left subdural hematoma status post left frontal craniotomy for interval change. Downsloping ST segmentdepression persists.TRACING #2 Post-surgical changes related to left craniotomy with interval removal of drain and slight decrease in size of bilateral subdural collections. DLP: 936.52 mGy-cm. Sinus tachycardia, rate 114. Imaged paranasal sinuses and mastoid air cells are well aerated. Imaged paranasal sinuses and mastoid air cells are well aerated. COMPARISON: Multiple CT head studies dating back to . BILATERAL CAROTID ULTRASOUND: Grayscale and color Doppler son was performed of the right and left ICA, ECA, CCA and vertebral arteries. | 25 | [
{
"category": "Echo",
"chartdate": "2150-07-10 00:00:00.000",
"description": "Report",
"row_id": 105328,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Change in mental status.\nHeight: (in) 68\nWeight (lb): 140\nBSA (m2): 1.76 m2\nBP (mm Hg): 137/68\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 15:48\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: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated ascending aorta. No 2D or Doppler evidence of distal\narch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MS. Mild (1+)\nMR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild [1+]\nTR. Normal PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\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. There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and regional/global systolic function (LVEF>55%). There is\nno ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The ascending aorta is mildly dilated. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. Trace\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. The estimated pulmonary artery\nsystolic pressure is normal. There is no pericardial effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1249458,
"text": " 3:41 PM\n CHEST (PA & LAT) Clip # \n Reason: ? PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 80M with worsening weakness\n REASON FOR THIS EXAMINATION:\n ? PNA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 80-year-old man with worsening weakness, question\n pneumonia.\n\n COMPARISON: .\n\n AP AND LATERAL VIEWS OF THE CHEST: There are again low lung volumes causing\n bibasilar atelectasis and crowding of the pulmonary vasculature. No focal\n opacities concerning for infectious process are present. No pleural effusion\n or pneumothorax is noted. Aorta is tortous, unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1249442,
"text": " 1:49 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? ICH ? mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 80M with worsening aphasia and dysarthria as well as arm numbness\n REASON FOR THIS EXAMINATION:\n ? ICH ? mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SVMc FRI 2:10 PM\n little changed from the CT 2 days prior with no ICH. midline shit up to 6 mm\n again, stable. stable left subdural collection. craniotomy changes. decreasing\n pneumocephalus.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old male with worsening aphasia and dysarthria as well as\n right arm numbness. Additional history was obtained from the OMR showing this\n patient recently had a craniotomy.\n\n TECHNIQUE: Non-contrast head CT.\n\n COMPARISON: Multiple head CTs, the latest from as well as most\n remote exam from .\n\n FINDINGS: Again noted are bilateral subdural collections, left greater than\n right. There is no overall change from the prior exam in the size or density\n of these collections. There is unchanged shift of normally midline structures\n by 6 mm to the right. Changes from a craniotomy on the right temporal region\n including a right frontal burr hole and the left frontal/parietal craniotomy\n are unchanged. Pneumocephalus has regressed since prior exam as expected.\n Visualized paranasal sinuses and mastoid air cells are well aerated. There is\n no evidence of acute hemorrhage or vascular territorial infarct.\n\n IMPRESSION: No change since prior study .\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-18 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1251155,
"text": " 3:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval interval progression\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with s/p left crani x 3\n REASON FOR THIS EXAMINATION:\n eval interval progression\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RJab SAT 6:02 PM\n No significant change from yesterday. No new hemorrhage or mass effect.\n Hyperdense material in left subdural collection is new from , but stable\n since yesterday and probably post surgical change. Stable 5mm rightward shift\n of midline structures.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with status post left craniectomy x 3. Evaluate\n interval progression.\n\n COMPARISONS: CT head from .\n\n TECHNIQUE: MDCT axial images were obtained through the brain without the\n administration of intravenous contrast material. Coronal and sagittal\n reformats were completed.\n\n FINDINGS: Since the prior exam from , there has been no\n significant change. The patient is status post left frontal craniectomy with\n evacuation of subdural collection. New high density within the left frontal\n component of the recently drained fluid collection seen, which is new since\n , but stable since . There is no evidence of new hemorrhage\n and this is likely due to post-surgical change. Pneumocephalus is stable.\n Mild mass effect including 2- mm rightward shift of the normally midline\n structures is unchanged. The basilar cisterns are normal. Ventricles are\n similar in size without evidence of hydrocephalus. Small temporal subgaleal\n hematoma is unchanged. Imaged portions of the paranasal sinuses, mastoid air\n cells and middle ear cavities are clear.\n\n IMPRESSION: No change since . No new hemorrhage. Stable mass\n effect with 2 mm rightward shift of midline structures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-14 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1250654,
"text": " 2:16 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: HEAD BLEED\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with crani scheduled for \n REASON FOR THIS EXAMINATION:\n pre-op cxr plase perform today\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old male requiring preoperative assessment prior to\n craniotomy.\n\n COMPARISON: Comparison is made with chest radiographs from and\n .\n\n FINDINGS: PA and lateral images of the chest are essentially unchanged from\n . There are again seen low lung volumes and bibasilar opacities which\n are unchanged. There is no evidence of new infiltrate or consolidation.\n Cardiomediastinal silhouette is unchanged. Visualized osseous structures are\n unremarkable.\n\n IMPRESSION: Unchanged chest radiograph since prior imaging. No evidence for\n acute pulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-09 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1250070,
"text": " 9:39 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o mass effect bleed\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with intermittent dysarthria, known L SDH s/p evac\n REASON FOR THIS EXAMINATION:\n r/o mass effect bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 12:29 PM\n Study limited by streak artifact from overlying EEG leads. Previously seen\n left subdural hematoma now has more posterior extention, unclear if due to\n redistribution. Consider continued followup.\n \n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n INDICATION: 80-year-old man with intermittent dysarthria, known left subdural\n hematoma status post evacuation, rule out mass effect, bleed.\n\n TECHNIQUE: Continuous axial MDCT images were obtained through the brain\n without administration of IV contrast. Reformatted coronal and sagittal\n images were acquired.\n\n DLP: 1153.93 mGy-cm.\n\n COMPARISON: Multiple non-enhanced head CTs, most recently from .\n\n FINDINGS: The study is limited by streak artifact from overlying EEG leads.\n The previously seen left subdural hematoma now has more posterior extension,\n unclear if this is due to redistribution. The locules of air are smaller\n compared to previous study. The left subdural hematoma measures 2.6 cm in\n greatest dimension from the inner table. There is approximately 8-mm midline\n shift. Post-surgical changes related to the left frontal craniotomy are again\n noted.\n\n IMPRESSION:\n 1. Study limited by streak artifact from overlying EEG leads. The previously\n seen left subdural hematoma now has more posterior extension, unclear if this\n is due to redistribution. Would consider continued followup.\n 2. Persistent 8-mm rightward shift of normally midline structures,\n approximately stable from previous exam.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-10 00:00:00.000",
"description": "MR HEAD W & W/O CONTRAST",
"row_id": 1250158,
"text": " 12:02 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n -59 DISTINCT PROCEDURAL SERVICE; MRA NECK W&W/O CONTRAST\n Reason: rule out TIA/stroke/vascular cause of transient symptoms\n Admitting Diagnosis: HEAD BLEED\n Contrast: MULTIHANCE Amt: 15\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with transient facial weakness and aphasia\n REASON FOR THIS EXAMINATION:\n rule out TIA/stroke/vascular cause of transient symptoms\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old man, with transient facial weakness and dysphagia; rule\n out TIA, stroke or vascular cause of transient symptoms.\n\n COMPARISON: Multiple prior studies with only CT head without contrast ranging\n from to .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through\n the brain before and after administration of IV gadolinium contrast.\n Non-enhanced 3D time-of-flight images were acquired per standard MRA brain\n protocol. Post-contrast coronal 3D-VIBE images from the aortic arch to the\n skull base were obtained per MRA neck protocol.\n\n FINDINGS:\n\n MRI BRAIN WITH AND WITHOUT CONTRAST: The patient is recently status post\n right craniotomy, with small pockets of susceptibility artifact representing\n small residual postoperative pneumocephalus. There is a mild-to-moderate\n subdural collection along the left hemispheric convexity, predominately\n T2-isointense but with small area of T2/FLAIR hyperintensity representing\n small hemorrhagic component. Old right frontal craniotomy defect is\n unchanged, without right-sided subdural collection. There is persistent\n partial effacement of the left lateral ventricle, with 8-mm rightward shift,\n unchanged from prior CT from .\n\n There is no abnormal restricted diffusion to suggest acute infarction.\n Scattered foci of T2/FLAIR subcortical white matter hyperintensity are\n nonspecific. The -white matter differentiation is grossly preserved.\n\n In the post-contrast images, there is moderate left-sided dural enhancement,\n with possible component of transudation of contrast into the subjacent\n prominent CSF space. There are prominent cortical vessels superficially\n located throughout the left hemisphere, without definite evidence of\n leptomeningeal enhancement. The overall findings are within the expected\n realm of perioperative appearance.\n\n There is no suspicious mass-like focal enhancement.\n\n MRA BRAIN: There is a tortuous left supraclinoid ICA. The A1 segment of the\n right ACA is also tortuous. There is mildly irregular luminal narrowing at\n (Over)\n\n 12:02 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n -59 DISTINCT PROCEDURAL SERVICE; MRA NECK W&W/O CONTRAST\n Reason: rule out TIA/stroke/vascular cause of transient symptoms\n Admitting Diagnosis: HEAD BLEED\n Contrast: MULTIHANCE Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the distal right vertebral artery (V4 segment), likely secondary to\n atherosclerotic disease. There is no flow-limiting stenosis, aneurysm larger\n than 3 mm or arteriovenous malformation.\n\n MRA NECK: Allowing for mild patient motion, major cervical vessels are\n patent, without flow-limiting stenosis. There is a normal three-vessel aortic\n arch. There is no significant atherosclerotic disease.\n\n IMPRESSION:\n\n 1. No acute infarction.\n\n 2. Similar appearance of moderate-sized left subdural collection, with\n hemorrhagic component. Extensive left-sided pachymeningeal enhancement with\n appearance of transudation of contrast to the subjacent CSF space.\n\n 3. Post-surgical changes, including small post-operative pneumocephalus\n account for the described MR abnormality. Prominent left-sided cortical\n vessels. No definite leptomeningeal or mass-like enhancement.\n\n 4. Tortuous intracranial vessels, as described, but no aneurysm larger than 3\n mm, arteriovenous malformation or flow-limiting stenosis. Normal cervical\n vessels.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-15 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1250836,
"text": " 7:42 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ?line placement\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p subclav placement\n REASON FOR THIS EXAMINATION:\n ?line placement\n ______________________________________________________________________________\n WET READ: 1:18 AM\n Left subclavian line ends in mid SVC. No pneumothorax. ETT tip 4.5 cm above\n carina.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post subclavian line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has been\n intubated. The tip of the endotracheal tube projects 3.5 cm above the carina.\n The course of the left subclavian line is unremarkable, the tip projects over\n the mid SVC. Otherwise, the radiograph is unchanged. There is no evidence of\n complications such as pneumothorax. The lung volumes remain low with\n bilateral areas of atelectasis but no evidence of acute lung disease.\n Unchanged borderline size of the cardiac silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-15 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1250839,
"text": " 8:08 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate for post operative changes. please perform by at 8p\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p third left sided crani for sdh evacuation\n REASON FOR THIS EXAMINATION:\n evaluate for post operative changes. please perform by at 8pm or when patient\n stable.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 2:16 AM\n Status post evacuation of left hemispheric subdural hematoma, with minimum\n residual left subdural fluid. Significant improvement in the mass effect on\n the left hemisphere and rightward shift of midline structures.\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: CT head without contrast .\n\n TECHNIQUE: Multidetector CT imaging of the head was obtained without\n intravenous contrast. Sagittal and coronal reformations were performed.\n\n FINDINGS: The patient is status post left frontal craniotomy with evacuation\n of a previously seen large left hemispheric subdural hematoma. There is a\n very small left hemispheric subdural collection with some residual high\n density hemorrhage. There has seen near-complete resolution of the mass\n effect on the left cerebral hemisphere. Very minimal rightward shift of\n midline structures persists, now 3 mm, previously 11 mm. The basal cisterns\n are normal. No new intracranial hemorrhage is detected. Small amount of\n pneumocephalus is noted. Partial opacification of bilateral ethmoid sinuses\n are noted. The imaged portions of the mastoid air cells are clear.\n\n IMPRESSION: Status post evacuation of left hemispheric subdural hematoma,\n with minimum residual left subdural fluid. Significant improvement in the\n mass effect on the left hemisphere and rightward shift of midline structures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1251087,
"text": " 5:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for new collection or acute changes from pre\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with subdural seroma s/p evacuation and drain removal with\n altered mental status with speech difficulty\n REASON FOR THIS EXAMINATION:\n please evaluate for new collection or acute changes from previous CT given\n clinical findings\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: FRI 7:21 PM\n No significant interval change in the residual left hemispheric subdural\n collection, mild mass effect and 5-mm rightward shift of midline structures.\n\n No new intracranial hemorrhage\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with subdural collection, status post evacuation\n and drain removal, now with altered mental status with speech difficulty.\n\n COMPARISON: CT head without contrast .\n\n TECHNIQUE: Multidetector axial CT images of the head were obtained without\n intravenous contrast.\n\n FINDINGS: The patient is status post left frontal craniotomy with evacuation\n of left hemispheric subdural collection. There is no high density within the\n left frontal component of the recently drained fluid collection. Although this\n is compatible with post surgical change, it appears slightly increased since\n the study of . The -white matter differentiation is preserved.\n\n\n There is interval decrease in the pneumocephalus. Mild mass effect on the\n left hemispheric sulci and a 5-mm rightward shift of midline structures have\n not significantly changed. The basal cisterns are normal. The ventricles\n are similar in size, without evidence of hydrocephalus. Small left\n temporoparietal subgaleal hematoma is unchanged. The imaged portion of the\n paranasal sinuses and mastoid air cells are clear.\n\n IMPRESSION:\n Slight increase in high density material, presumably hemorrhage, in the\n residual left hemispheric subdural collection. Mild mass effect and 5-mm\n rightward shift of midline structures are unchanged.\n\n\n (Over)\n\n 5:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for new collection or acute changes from pre\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1250853,
"text": " 3:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed, ?reaccumulation\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man s/p craniectomy and subdural evacuation, now failing to wake up\n REASON FOR THIS EXAMINATION:\n eval for bleed, ?reaccumulation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:08 AM\n No change from the most recent CT (post-op :40). No new intracranial\n hemorrhage or reaccumulation.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man after craniectomy for subdural evacuation, please\n re-assess.\n\n TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal\n reformats were acquired.\n\n COMPARISON: CT from at 20:40 and from at\n 12:10.\n\n FINDINGS:\n There is no acute intracranial hemorrhage. There are stable post-surgical\n changes with a left frontal and subdural pneumocephalus and subdural fluid\n along the left cerebral hemisphere, unchanged from the most recent\n post-surgical CT from at 20:40 p.m. There is unchanged mild\n midline shift to the right by about 7 mm. There is no intracranial herniation\n with patent basilar cisterns. There is no hydrocephalus. Craniectomy changes\n and subgaleal hematoma are stable. The paranasal sinuses and mastoid air cells\n are clear.\n\n IMPRESSION: No change from the most recent post-surgical CT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1250282,
"text": " 6:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 80 year old man with MS changes but no change in CT/MRI Brai\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with MS changes but no change in CT/MRI Brain. R/O chest\n abnormality/infection\n REASON FOR THIS EXAMINATION:\n 80 year old man with MS changes but no change in CT/MRI Brain. R/O chest\n abnormality/infection\n ______________________________________________________________________________\n WET READ: JEKh FRI 8:46 PM\n low lung volumes w/ basal atelectasis but no lobar consolidation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Mental status changes. Question chest abnormality.\n\n REFERENCE EXAMINATION: .\n\n FINDINGS: Again seen is bibasilar atelectasis. A small infectious infiltrate\n at either base cannot be totally excluded; however, the overall appearance is\n similar to that from one week prior. The upper lungs are clear. The aorta is\n tortuous, unchanged. There continues to be mild cardiomegaly.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1250680,
"text": " 6:01 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: pre-operative NCHCT for planning- scheduled for a right \n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with left chronic subdural hematoma\n REASON FOR THIS EXAMINATION:\n pre-operative NCHCT for planning- scheduled for a right crani please\n perform by 1800 on \n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc WED 1:14 AM\n Large left-sided subdural hematoma slightly larger since . Mild\n increase in the mass effect and rightward shift of midline structures.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with chronic left subdural hematoma, preoperative\n evaluation.\n\n COMPARISON: CT head without contrast .\n\n TECHNIQUE: Multidetector CT imaging of the head was obtained without\n intravenous contrast.\n\n FINDINGS: A large left hemispheric subdural hematoma now maximally measures\n 28 mm, and is larger since the prior study of 24 mm. There is mass effect on\n the left cerebral hemisphere with effacement of the sulci. Mass effect on the\n left lateral ventricle is seen, with approximately 11 mm rightward shift of\n midline structures, previously 9 mm. There is asymmetric dilatation of the\n right lateral ventricle. There is no new intracranial hemorrhage or edema.\n There has been interval decrease in the pneumocephalus. The patient is status\n post left frontal craniotomy. The basal cisterns are normal.\n\n The imaged portion of the mastoid air cells, middle ear cavities and paranasal\n sinuses are clear.\n\n IMPRESSION: Large left-sided subdural hematoma slightly larger since .\n Mild increase in the mass effect and rightward shift of midline structures.\n\n The findings were discussed with Dr. at 8:00 P.M immediately after\n discovery.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-15 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1250757,
"text": " 10:35 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute hemorrhage\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with Left SDH and worsening lethargy, right sided weakness,\n pupil asymmetry\n REASON FOR THIS EXAMINATION:\n eval for acute hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with left subdural hematoma and worsening\n lethargy, right-sided weakness, pupil asymmetry. Evaluate for acute\n hemorrhage.\n\n TECHNIQUE: Contiguous axial MDCT images were obtained through the brain\n without administration of IV contrast.\n\n DLP: 936.52 mGy-cm.\n\n COMPARISON: Multiple non-enhanced head CTs, most recently from .\n\n FINDINGS: The large left hemispheric subdural hematoma is again seen and\n appears stable in size. It now maximally measures 28 mm from the inner table.\n There is mass effect on the left cerebral hemisphere with effacement of the\n sulci. Mass effect on the lateral ventricle is seen with approximately 11 mm\n of rightward shift of midline structures, stable from previous exam. There is\n asymmetric dilation of the right lateral ventricle which is unchanged from\n previous exam. There is no new intracranial hemorrhage or edema. The patient\n is status post left frontal craniotomy. The basal cisterns are normal. The\n imaged portion of the mastoid air cells, middle ear cavities and paranasal\n sinuses are clear.\n\n IMPRESSION: Large left-sided subdural hematoma appears stable from previous\n exam with stable mass effect and rightward shift of midline structures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-05 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1249596,
"text": " 8:55 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o re-accumulation\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man POD1 s/p L crani for SDH\n REASON FOR THIS EXAMINATION:\n r/o re-accumulation\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient status post left craniotomy on . Assess for\n interval change.\n\n COMPARISON: Multiple CT head studies dating back to .\n\n TECHNIQUE: MDCT-acquired contiguous images through the head were obtained\n without intravenous contrast at 5-mm slice thickness.\n\n FINDINGS:\n\n Post-surgical changes related to left frontal craniotomy are noted. Surgical\n drain is in place. Several locules of gas in the resection bed are likely\n post-surgical. There is no change in bilateral subdural collections since\n exam. Left-sided collection measures 2.5 cm in maximum diameter at\n the level of the vertex. No new focus of intracranial hemorrhage is\n identified. There is persistent 6 mm rightward shift of the normal midline\n structures. There is no territorial infarction. Basal cisterns are patent.\n Imaged paranasal sinuses and mastoid air cells are well aerated. Sphenoid\n sinus septation inserts on the right carotid groove.\n\n IMPRESSION:\n\n Post-surgical changes related to left frontal craniotomy as described above.\n In comparison to exam, there is no significant change in bilateral\n subdural collections.\n Persistent 6-mm rightward shift of normally midline structures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-10 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 1250223,
"text": " 11:05 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: r/o cause of TIAs\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with ? TIAs, episodic mental status changes\n REASON FOR THIS EXAMINATION:\n r/o cause of TIAs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80-year-old man with history of possible TIAs and episodic mental\n status changes, evaluate for carotid artery stenosis.\n\n COMPARISON: None.\n\n BILATERAL CAROTID ULTRASOUND: Grayscale and color Doppler son was\n performed of the right and left ICA, ECA, CCA and vertebral arteries.\n Antegrade flow is seen within the vertebral arteries bilaterally. Mild\n heterogeneous plaque is seen in the proximal ICAs bilaterally. The following\n velocities measurements were obtained:\n\n RIGHT: Proximal ICA is 61/13 cm/sec, mid ICA 51/9 cm/sec, distal ICA 66/19\n cm/sec, CCA 82/19 cm/sec, ECA 69 cm/sec, vertebral artery 48 cm/sec, right\n ICA/CCA ratio is 0.80.\n\n LEFT: Proximal ICA 64/16 cm/sec, mid ICA 47/15 cm/sec, distal ICA 45/14\n cm/sec, CCA 108/24 cm/sec, ECA 61 cm/sec, vertebral artery 59 cm/sec, left\n ICA/CCA ratio 0.59.\n\n IMPRESSION: Findings consistent with less than 40% stenosis bilaterally.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-11 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1250317,
"text": " 9:34 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: PLEASE DO SAGITTAL AND CORONAL REFORMATS\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with L frontal SDH.\n REASON FOR THIS EXAMINATION:\n PLEASE DO SAGITTAL AND CORONAL REFORMATS\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation of patient with history of left subdural hematoma\n status post left frontal craniotomy for interval change.\n\n COMPARISON: Multiple prior head CTs with the most recent from \n as well as MRI and MRA brain from .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n intravenous contrast. Multiplanar reformatted images were prepared and\n reviewed.\n\n FINDINGS: Again visualized is a left subdural hematoma measuring\n approximately 25 mm in maximal width from the inner table of the skull\n compared to 26 mm previously with continued mass effect on the adjacent sulci,\n greatest at the left frontal lobe, as well as continued rightward shift of\n normally midline structures by 9 mm compared to 8 mm previously (2:14). There\n is no evidence of new hemorrhage. Post-surgical changes related to left\n frontal craniotomy are again noted with pneumocephalus as well as hyperdense\n material suggestive of post-surgical material (2:21). Old right frontal\n craniotomy defect is again noted. The visualized mastoid air cells and\n paranasal sinuses are clear.\n\n IMPRESSION: Persistent left subdural hematoma measuring up to 25 mm in\n maximal dimension in the inner table of skull with mass effect on the adjacent\n sulci, greatest at the left frontal lobe, as well as persistent rightward\n shift of normally midline structures by 9mm, compared to 8 mm previously.\n Post left frontal craniotomy changes are again noted with pneumocephalus.\n Continued followup is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-17 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1251060,
"text": " 1:20 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: r/o DVT\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with tachycardia\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 80-year-old man with tachycardia evaluate for DVT.\n\n COMPARISON: No previous exam for comparison.\n\n FINDINGS: Grayscale, color and Doppler images were obtained of bilateral\n common femoral, femoral, popliteal and tibial veins. Normal flow, compression\n and augmentation is seen in all of the vessels.\n\n IMPRESSION: No evidence of deep vein thrombosis in either leg.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2150-07-06 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1249728,
"text": " 4:18 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: follow up subdural hamatoma s/p drainage\n Admitting Diagnosis: HEAD BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old man with chronic SDH s/p left crani and drainage\n REASON FOR THIS EXAMINATION:\n follow up subdural hamatoma s/p drainage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST\n\n INDICATION: 80-year-old man with chronic subdural hematoma status post left\n craniotomy and drainage, follow up subdural hematoma status post drainage.\n\n COMPARISON: Non-enhanced CT of the head from .\n\n TECHNIQUE: Continuous axial MDCT images were obtained through the brain\n without administration of IV contrast.\n\n DLP: 1025.72 mGy-cm.\n\n FINDINGS: Post-surgical changes related to left frontal craniotomy are noted.\n Surgical drain has been removed in the interim. Several locules of gas in the\n resection bed are likely post-surgical. There is mild decrease in the\n bilateral subdural collections since exam. Left-sided\n collection measures 2.3 cm in maximum diameter at the level of the vertex. No\n new focus of intracranial hemorrhage is identified. There is persistent 6 mm\n rightward shift of the normal midline structures, unchanged from previous.\n There is no territorial infarction. Basal cisterns are patent. Imaged\n paranasal sinuses and mastoid air cells are well aerated.\n\n IMPRESSION:\n 1. Post-surgical changes related to left craniotomy with interval removal of\n drain and slight decrease in size of bilateral subdural collections.\n\n 2. Persistent 6 mm rightward shift of normally midline structures, stable\n from previous exam.\n\n"
},
{
"category": "ECG",
"chartdate": "2150-07-17 00:00:00.000",
"description": "Report",
"row_id": 307127,
"text": "Resolution of sinus tachycardia and sinus rhythm has now been restored. Right\nbundle-branch block remains present. The ST segment depression has now\nresolved. The tracing appears somewhat improved.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2150-07-16 00:00:00.000",
"description": "Report",
"row_id": 307128,
"text": "Sinus tachycardia. Right bundle-branch block. Downsloping ST segment\ndepression persists.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2150-07-16 00:00:00.000",
"description": "Report",
"row_id": 307129,
"text": "Sinus tachycardia, rate 114. There are downsloping ST segments diffusely\nraising a question of ischemia. Clinical correlation is suggested. Right\nbundle-branch block is also present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2150-07-14 00:00:00.000",
"description": "Report",
"row_id": 307130,
"text": "Baseline artifact. Sinus rhythm. Leftward axis. Right bundle branch block.\nPrecordial T wave abnormalities. Since the previous tracing of the rate\nis slower. ST-T wave changes cannot be compared because of the present\nbaseline artifact. However, precordial T wave abnormalities may now be more\nprominent. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2150-07-04 00:00:00.000",
"description": "Report",
"row_id": 307131,
"text": "Sinus rhythm. Right bundle-branch block. No major change from previous\ntracing.\n\n"
},
{
"category": "ECG",
"chartdate": "2150-07-01 00:00:00.000",
"description": "Report",
"row_id": 307132,
"text": "Sinus rhythm. Right bundle-branch block. Compared to the previous tracing\nof the rate has increased. Otherwise, no diagnostic interim change.\n\n"
}
] |
23,358 | 168,282 | 1. Respiratory status - The infant required nasopharyngeal continuous positive airway pressure until approximately eleven hours of age. The chest x-ray was consistent with retained fetal lung fluid. The capillary blood gas was pH 7.33, pCO2 53. The infant weaned to room air at twelve hours of age and remained there for the remainder of the NICU stay with comfortable respirations and no episodes of apnea, bradycardia or desaturations. 2. Cardiovascular - The infant remained normotensive throughout the NICU stay, had a normal S1 and S2 heart sound and no murmur and no cardiovascular issues. 3. Fluid, electrolyte and nutrition status - After discontinuing CPAP, the infant began breast feeding with supplemental formula. He was breast feeding well and maintaining euglycemia at the time of transfer. The electrolytes at 24 hours of age were sodium 144, potassium 3.9, chloride 104, bicarbonate 19. 4. Hematologic status - The hematocrit at the time of admission was 59.1 and the platelets were 208,000. 5. Infectious disease - The infant was started on Ampicillin and Gentamicin at the time of admission for sepsis risk factors. At the time of transfer, the infant continues on those medications through a heparin intravenous lock and blood cultures remain negative to date at the time of transfer. The infant is being transferred to the Newborn Nursery for continuing care. The primary pediatrician will be Dr. , , , , telephone number . | DSTIX STABLE 53/97. Sepsis O: Pt. Transfer to NN when resp stable. Respiratory O: Pt. Wt 2715 BW. P: Continue w/IVAB. Cor nl s1s2 w/o murmurs. CBC/Cult(-) to date. LSclear/=. P: Continue tomonitor respiratory status. A: pt. A: Pt. On amp/gent. Neonatology Attending NoteDay 1NP CPAP RA. PIV PLACED. Remains on D10W at 60/k/d via PIV. Respiratory TherapyReceived on cpap this AM. CBG: 7.33/39/53/21/-4. is stable on RA. PT STARTED ON AMP AND GENT. Pt. Last (c) gas 7.33/39. Respiratory CareSee attending admit note for hx and further details. TF 60 D10 w. d/s 66. Nursing NICU Note#1. Delivery today by SVD after prenatal rx with abx. CBC AND CX SENT, NEG TO DATE. FEN O: Pt. Breathingcomforatbly in RA. CONT ON RA CPAP, LS ARE CLEAR, SLIGHTLY DIMINISHED. Plan to D/C IVF after thiscurrent feed. Momupdated by Dr. as well. Growth/Developemnt O: Pt. Well perfused and saturated in RA. He has mildSC retractions. Monitor for s/s ofintolerance.#3. Temp stable under warmer. Continue amp/gent for a probable 48 hr course. Sxn x1 for lg amt secretions as per flowsheet. PT ARRIVED GRUNTING, MILD FLARING AND RTXN'S. NPN 0700-15301 Resp2 FEN3 Sepsis4 G&D5 Social1. Dsticks 63-66,afebrile, VSS-see flowsheet. Most likely etiology is RFLF. P:Continue w/ current feeding plan. HR 130-160s. Neuro non-focal and age appropriate. Cont on amp and gent for 48hr R/O. is on a warmer, swaddled x1w/ hat, temps stable. Cont to monitor dsticks and tolerance offeed.3. Testes desc bilaterally. NPO. Mean BP 48. PT NPO, D10W AT 60/KG. Cont to promote G&D.5. Under radiant warmer.Plan:1. Dsticks 66, 63. Temps stable. Tolerated well. He is voiding/ stoolingmeconium. RR 30-60, no desats.Dr. CAP GAS SENT PH 7.33, C02 39. Maternal prenatal screens notable for HbSag-, RPRNR,RI, GBS +, A+ ab- status. Cont to assess and support as needed.2. continues on IV Amp/Gent for 48hr R/O.He is alert and active w/ cares. Try off CPAP.2. BS clear, but diminished. Wean IVF as enteral feedings improve.4. D/C'd cpap at 1000to RA. Abdomen benign. No abx unless CBC abnormal or sx persist. 3.0 NPT placed without difficulty. PT OBSERVED FOR A WHILE SATING 100% ON RA, CXR OBTAINED,PLACED ON CPAP 6. Apgars 9,9. Parents aware of status and plan. Abdsoft, round, +BS, no loops. If tolerates off CPAP begin enteral feedings.3. Respiratory status improved on CPAP, will cont to follow closely. remains on RA w/ sats >95%. Lungs clear and equal, mild SC retractions, andintermittent grunting noted at times. Lungs clear. P:Continue to support and educate. The cardiac silhouette is at the upper limits of normal in size. Monitor for any increase workof breathing.#2. aware of intermittent grunting. RR 30's-40's. grunting off CPAP3.5 hoursHEENT: AFSF, palate intactChest: CTA BCV: RRR, no murmurABD: Soft, NT, no massesExts: CR< 3 secPt off CPAP, but has had some occ. Fontanelle soft/flat. Hips normal.A- Well appearing 36 week infant with resolving resp distress during transitional period. Cont tosupport and update parents.REVISIONS TO PATHWAY: 1 Resp; added Start date: 2 FEN; added Start date: 3 Sepsis; added Start date: 4 G&D; added Start date: 5 Social; added Start date: going to breast Q 4hrs w/ supplemental PO bottlefeeds. Will feed and continue to observe for resp. Plan to transfer infant toNBN tonight. There is a moderate ground glass appearance of the lung parenchyma in keeping with RDS. Low but finite risk of sepsis.P Admit NICU Clinical and non-invasive monitoring of resp status CBC diff BC. tolerating current nutritional plan. Received infant on NP CPAP 6, 21%. Nl voidinga nd stooling. Infant nursedwell for the first time. was on TF 60cc/kg of IV D10W, D/C'd @1500. A: Potential for sepsis. RR30-50s. Infant resting wellthroughout day, awake and active with cares. Skin w/o lesions. FINDINGS: A supine film of the chest demonstrates visceral situs solitus and a left aortic arch. Transferred to the Newborn Nursery. Infant ablt to nursewell with good latch and intermittent suckling for 10mins at1400. A: AGA P:Continue to provide environment appropriate for growth anddevelopment.#5. NPN Transfer NoteInfant pink in room air. Did well in DR continued mild GFR prompted transfer to NICU.On exam pink active non-dysmorphic infant. NURSING ADMIT NOTE PT ADMITTED TO NICU FROM L&D FOR RESP DISTRESS. Monitor for s/s of sepsis.#4. Transfer Note has been off CPAP since 0900 hrs this am, in room air, no distress, breath sounds clear/=.PO feeding well, breast/bottle.Maintaining serum glucoses off IV dextrose.Color mildly jaundiced.Will transfer to Newborn Nursery. grunting, but looks comfortable. Blood cultures neg to date.Cont to monitor for s/sx of infection.4. Parents verbalizedunderstanding of update without further questions. Voiding and X1 large mec stool. distress Abdomen is soft, pink, +BS, no loops/spits.Abdominal girth is 26.5cm. No distress. Taken off to RA at 10AM. He is alert and active w/ cares,sleeps well between. A: Mother very and involved. Monitor for increased respiratory distress. Parents in to visit and updated on plan of care. No increase work of breathing noted. These findings may also be due to TTN. MOM AND DAD TO VISIT PT, UPDATED AT BEDSIDE. NICU Fellow Exam NoteGEN: Well developed male with occ. Mom spoke with Dr. prior to transfer. Genitalia nl male. Spoke with mother at 2300 regarding transfer. No other abnormality is noted. Parents O: Mother in to visit throughout the shift.She was updated at bedside on pt's current status and dailyplan of care. To complete 48 hour course antibiotics.In house pediatric coverage through Newborn Service. Baby placed on NPCPAP 6, 21% due to persistant grunting. No murmur. NeonatologyPatient is 2.71 kg product of 36 week gestation born to 26 yo G3P1 woman with a pregnancy notable for maternal anti-cardiolipin ab rxed with Baby ASA. | 11 | [
{
"category": "Nursing/other",
"chartdate": "2171-02-21 00:00:00.000",
"description": "Report",
"row_id": 1994164,
"text": "Neonatology\nPatient is 2.71 kg product of 36 week gestation born to 26 yo G3P1 woman with a pregnancy notable for maternal anti-cardiolipin ab rxed with Baby ASA. Maternal prenatal screens notable for HbSag-, RPRNR,RI, GBS +, A+ ab- status. Delivery today by SVD after prenatal rx with abx. Apgars 9,9. Did well in DR continued mild GFR prompted transfer to NICU.\n\nOn exam pink active non-dysmorphic infant. Well perfused and saturated in RA. Skin w/o lesions. Cor nl s1s2 w/o murmurs. Lungs clear. No distress. Abdomen benign. Genitalia nl male. Testes desc bilaterally. Neuro non-focal and age appropriate. Hips normal.\n\nA- Well appearing 36 week infant with resolving resp distress during transitional period. Most likely etiology is RFLF. Low but finite risk of sepsis.\n\nP Admit NICU\n Clinical and non-invasive monitoring of resp status\n CBC diff BC. No abx unless CBC abnormal or sx persist.\n Transfer to NN when resp stable.\n Parents aware of status and plan.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-02-22 00:00:00.000",
"description": "Report",
"row_id": 1994171,
"text": "Nursing NICU Note\n\n\n#1. Respiratory O: Pt. remains on RA w/ sats >95%. LS\nclear/=. No increase work of breathing noted. He has mild\nSC retractions. A: pt. is stable on RA. P: Continue to\nmonitor respiratory status. Monitor for any increase work\nof breathing.\n\n#2. FEN O: Pt. was on TF 60cc/kg of IV D10W, D/C'd @\n1500. Pt. going to breast Q 4hrs w/ supplemental PO bottle\nfeeds. Abdomen is soft, pink, +BS, no loops/spits.\nAbdominal girth is 26.5cm. He is voiding/ stooling\nmeconium. A: Pt. tolerating current nutritional plan. P:\nContinue w/ current feeding plan. Monitor for s/s of\nintolerance.\n\n#3. Sepsis O: Pt. continues on IV Amp/Gent for 48hr R/O.\nHe is alert and active w/ cares. Temps stable. CBC/Cult\n(-) to date. A: Potential for sepsis. P: Continue w/\nIVAB. Monitor for s/s of sepsis.\n\n#4. Growth/Developemnt O: Pt. is on a warmer, swaddled x1\nw/ hat, temps stable. He is alert and active w/ cares,\nsleeps well between. Fontanelle soft/flat. A: AGA P:\nContinue to provide environment appropriate for growth and\ndevelopment.\n\n#5. Parents O: Mother in to visit throughout the shift.\nShe was updated at bedside on pt's current status and daily\nplan of care. A: Mother very and involved. P:\nContinue to support and educate. Plan to transfer infant to\nNBN tonight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-02-22 00:00:00.000",
"description": "Report",
"row_id": 1994172,
"text": "Transfer Note\n has been off CPAP since 0900 hrs this am, in room air, no distress, breath sounds clear/=.\nPO feeding well, breast/bottle.\nMaintaining serum glucoses off IV dextrose.\nColor mildly jaundiced.\nWill transfer to Newborn Nursery. To complete 48 hour course antibiotics.\nIn house pediatric coverage through Newborn Service.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-02-23 00:00:00.000",
"description": "Report",
"row_id": 1994173,
"text": "NPN Transfer Note\nInfant pink in room air. Transferred to the Newborn Nursery. Spoke with mother at 2300 regarding transfer. Mom spoke with Dr. prior to transfer.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-02-22 00:00:00.000",
"description": "Report",
"row_id": 1994165,
"text": "NURSING ADMIT NOTE\n PT ADMITTED TO NICU FROM L&D FOR RESP DISTRESS. PT ARRIVED GRUNTING, MILD FLARING AND RTXN'S. PT OBSERVED FOR A WHILE SATING 100% ON RA, CXR OBTAINED,PLACED ON CPAP 6. CONT ON RA CPAP, LS ARE CLEAR, SLIGHTLY DIMINISHED. CAP GAS SENT PH 7.33, C02 39.\n CBC AND CX SENT, NEG TO DATE. PT STARTED ON AMP AND GENT. PIV PLACED. PT NPO, D10W AT 60/KG. DSTIX STABLE 53/97. MOM AND DAD TO VISIT PT, UPDATED AT BEDSIDE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-02-22 00:00:00.000",
"description": "Report",
"row_id": 1994166,
"text": "Respiratory Care\nSee attending admit note for hx and further details. Baby placed on NPCPAP 6, 21% due to persistant grunting. Sxn x1 for lg amt secretions as per flowsheet. 3.0 NPT placed without difficulty. BS clear, but diminished. RR 30's-40's. CBG: 7.33/39/53/21/-4. Respiratory status improved on CPAP, will cont to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-02-22 00:00:00.000",
"description": "Report",
"row_id": 1994167,
"text": "Neonatology Attending Note\nDay 1\n\nNP CPAP RA. RR30-50s. Last (c) gas 7.33/39. HR 130-160s. No murmur. Mean BP 48. Wt 2715 BW. NPO. TF 60 D10 w. d/s 66. Nl voidinga nd stooling. On amp/gent. Under radiant warmer.\n\nPlan:\n1. Try off CPAP.\n2. If tolerates off CPAP begin enteral feedings.\n3. Wean IVF as enteral feedings improve.\n4. Continue amp/gent for a probable 48 hr course.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-02-22 00:00:00.000",
"description": "Report",
"row_id": 1994168,
"text": "Respiratory Therapy\nReceived on cpap this AM. Taken off to RA at 10AM. Tolerated well. Monitor for increased respiratory distress.\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-02-22 00:00:00.000",
"description": "Report",
"row_id": 1994169,
"text": "NICU Fellow Exam Note\nGEN: Well developed male with occ. grunting off CPAP3.5 hours\nHEENT: AFSF, palate intact\nChest: CTA B\nCV: RRR, no murmur\nABD: Soft, NT, no masses\nExts: CR< 3 sec\n\n\nPt off CPAP, but has had some occ. grunting, but looks comfortable. Will feed and continue to observe for resp. distress\n"
},
{
"category": "Nursing/other",
"chartdate": "2171-02-22 00:00:00.000",
"description": "Report",
"row_id": 1994170,
"text": "NPN 0700-1530\n\n1 Resp\n2 FEN\n3 Sepsis\n4 G&D\n5 Social\n\n1. Received infant on NP CPAP 6, 21%. D/C'd cpap at 1000\nto RA. Lungs clear and equal, mild SC retractions, and\nintermittent grunting noted at times. RR 30-60, no desats.\nDr. aware of intermittent grunting. Breathing\ncomforatbly in RA. Cont to assess and support as needed.\n\n2. Remains on D10W at 60/k/d via PIV. Infant ablt to nurse\nwell with good latch and intermittent suckling for 10mins at\n1400. Dsticks 66, 63. Voiding and X1 large mec stool. Abd\nsoft, round, +BS, no loops. Plan to D/C IVF after this\ncurrent feed. Cont to monitor dsticks and tolerance of\nfeed.\n\n3. Cont on amp and gent for 48hr R/O. Dsticks 63-66,\nafebrile, VSS-see flowsheet. Blood cultures neg to date.\nCont to monitor for s/sx of infection.\n\n4. Temp stable under warmer. Infant resting well\nthroughout day, awake and active with cares. Infant nursed\nwell for the first time. No pacifier and bottles per\nparents. Cont to promote G&D.\n\n5. Parents in to visit and updated on plan of care. Mom\nupdated by Dr. as well. Parents verbalized\nunderstanding of update without further questions. Cont to\nsupport and update parents.\n\nREVISIONS TO PATHWAY:\n\n 1 Resp; added\n Start date: \n 2 FEN; added\n Start date: \n 3 Sepsis; added\n Start date: \n 4 G&D; added\n Start date: \n 5 Social; added\n Start date: \n\n"
},
{
"category": "Radiology",
"chartdate": "2171-02-21 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 752704,
"text": " 8:42 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate lungs and heart\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with grunting, 35 weeks gestation\n REASON FOR THIS EXAMINATION:\n evaluate lungs and heart\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infant with grunting, born at 35 weeks gestational age.\n\n FINDINGS: A supine film of the chest demonstrates visceral situs solitus and\n a left aortic arch. The cardiac silhouette is at the upper limits of normal in\n size. There is a moderate ground glass appearance of the lung parenchyma in\n keeping with RDS. No other abnormality is noted. These findings may also be\n due to TTN.\n\n"
}
] |
46,672 | 112,899 | 57 yo Male with history of poorly controlled DM, transferred from for managment of DKA, pancreatitis and EtOH withdrawal #DKA- came in with gap of 18, glucose of 230s. Patient endorse medication non-compliance. While in the ICU, patient was treated with fluid and electrolyte resuscitation and subcutaneous insulin, with good response. Diabetes Center was consulted. His insulin drip was stopped on . He was called out to the medicine floor where he remained quite stable. He was seen by PT on whose recommendation he was dc-ed to rehab. # Acute pancreatitis- Nausea and abdominal pain were present on admission, as well as a lipase to 1098 at 1251 at . He was treated conservatively with NPO diet, pain control with tylenol. A CT abdomen showed uncomplicated pancreatitis, without pseudocyst, necrosis, or fluid collection. Pt improved quickly and was toelrating regular diet, with pain controlled on tylenol at dc to rehab. # Alcohol withdrawal- Patient reports his last drink was on friday morning before admission. Patient reports that he drinks hard alcoholic drinks daily. He denies any withdrawal symptoms in the past, however while in the ICU he required more than 100mg of PRN Diazepam on a CIWA scale. He was treated with Diazepam and breakthrough lorazepam per CIWA protocol, and given thiamine and multivitamin supplementation. A social work consult was placed regarding his substance abuse, as well. He did not score on CIWA after transfer to floor. | There is again note of colonic diverticulosis without evidence of diverticulitis. diverticulosis without evidence of diverticulitis. Diverticulosis without evidence of diverticulitis. Diverticulosis without evidence of diverticulitis. The pancreatic parenchyma itself is not well evaluated on this non-contrast examination. There is diverticulosis, however, no evidence of diverticulitis. Within the limits of this non-contrast examination, no obvious splenic artery aneurysm is seen. Left atrialabnormality. Non-specific ST segment changes. No concerning osseous lesion is seen. The bladder and distal ureters appear grossly unremarkable. No pneumothorax. hepatic steatosis. Hepatic steatosis. Hepatic steatosis. The gallbladder, adrenal glands and right kidney appear grossly unremarkable. No organized pseudocyst formation. History of diverticulitis. COMPARISON: None available. No comparison studies. Intravenous contrast was not administered secondary to renal dysfunction. No pericardial effusion is seen. Sinus tachycardia. No lymphadenopathy is identified. No pelvic free air or lymphadenopathy is seen. No evidence of pulmonary edema. There is a 1 mm non-obstructing left renal stone. No acute bone abnormality appreciated. No pancreatic pseudocyst is identified. Oral contrast was not administered secondary to nausea and vomiting. No evidence of organized fluid collection. Evaluation for evidence of diverticulitis. 12:27 AM CT ABD & PELVIS W/O CONTRAST Clip # Reason: eval for diverticulitis, intraabdominal abscess. No previous tracing availablefor comparison. Additionally, there is a small amount of free fluid which appears to originate from this region and tracks inferiorly along the left paracolic gutter. IMPRESSION: Lung volumes are low and there are patchy bibasilar opacities which may reflect patchy lower lobe atelectasis, although aspiration or pneumonia cannot be entirely excluded. TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was obtained without the administration of oral or intravenous contrast. (Over) 12:27 AM CT ABD & PELVIS W/O CONTRAST Clip # Reason: eval for diverticulitis, intraabdominal abscess. No abdominal free air or evidence of abscess formation is seen. FINDINGS: The included portions of the lung bases demonstrate bilateral dependent atelectatic changes. limited study due to no IV contrast (poor Cr) no PO (n/v/d) CONTRAINDICATIONS for IV CONTRAST: WET READ: OXZa SUN 10:51 AM 1. RSR' pattern in lead V1 (normal variant). together, these are suggestive of pancreatitis. A single portable AP upright chest film at 1011 is submitted. The spleen is within normal limits. Peripancreatic fluid and fat stranding suggestive of pancreatitis. Peripancreatic fluid and fat stranding suggestive of pancreatitis. limited stu FINAL REPORT (Cont) There is fatty deposition within the liver with area of lower density along the gallbladder fossa which is incompletely evaluated but could represent further focal fatty deposition. the pancreatic parenchyma itself is not well evaluated without contrast but there may be some heterogeneity of the panc tail. consolidation? IMPRESSION: 1. WET READ VERSION #1 WET READ VERSION #2 OXZa SUN 2:06 AM there is inflammatory fat stranding which appears centered around the pancreatic tail; also free (simple) fluid appears to track from this region towards the left paracolic gutter. There is a remote right rib fracture. There are notable coronary calcifications within the visualized coronary arteries. Within the pelvis, distal loops of large bowel and rectum are normal in size and caliber. Coronal and sagittal reformations were prepared. There are dense calcifications of the vas deferens. 3. 3. FINAL REPORT INDICATION: History of diabetic ketoacidosis with significant abdominal pain. Within the abdomen, there is fat stranding which appears to be centered predominantly about the pancreas, possibly localizing to the pancreatic body. Loops of small and large bowel are normal in size and caliber. Clinical correlation is advised. 2. 2. Please note that comparison to old films can be helpful to detect subtle interval change. limited stu MEDICAL CONDITION: History: 57M with dka, significant abdominal pain starting prior to DKA per history REASON FOR THIS EXAMINATION: eval for diverticulitis, intraabdominal abscess. Comparison is made to selected images from the abdominal and pelvic CT performed on . 9:42 AM CHEST (PORTABLE AP) Clip # Reason: EDEMA CONSOLIDATION Admitting Diagnosis: DIABETIC KETOACIDOSIS MEDICAL CONDITION: 57 year old man with pancreatitis and crackles on exam REASON FOR THIS EXAMINATION: edema? | 3 | [
{
"category": "Radiology",
"chartdate": "2190-09-05 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1248878,
"text": " 12:27 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for diverticulitis, intraabdominal abscess. limited stu\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 57M with dka, significant abdominal pain starting prior to DKA per\n history\n REASON FOR THIS EXAMINATION:\n eval for diverticulitis, intraabdominal abscess. limited study due to no IV\n contrast (poor Cr) no PO (n/v/d)\n CONTRAINDICATIONS for IV CONTRAST:\n\n ______________________________________________________________________________\n WET READ: OXZa SUN 10:51 AM\n 1. Peripancreatic fluid and fat stranding suggestive of pancreatitis. No\n organized pseudocyst formation.\n 2. Hepatic steatosis.\n 3. Diverticulosis without evidence of diverticulitis.\n WET READ VERSION #1\n WET READ VERSION #2 OXZa SUN 2:06 AM\n there is inflammatory fat stranding which appears centered around the\n pancreatic tail; also free (simple) fluid appears to track from this region\n towards the left paracolic gutter. the pancreatic parenchyma itself is not\n well evaluated without contrast but there may be some heterogeneity of the\n panc tail. together, these are suggestive of pancreatitis. hepatic steatosis.\n diverticulosis without evidence of diverticulitis.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of diabetic ketoacidosis with significant abdominal pain.\n History of diverticulitis. Evaluation for evidence of diverticulitis.\n\n TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was\n obtained without the administration of oral or intravenous contrast.\n Intravenous contrast was not administered secondary to renal dysfunction.\n Oral contrast was not administered secondary to nausea and vomiting. Coronal\n and sagittal reformations were prepared.\n\n COMPARISON: None available.\n\n FINDINGS: The included portions of the lung bases demonstrate bilateral\n dependent atelectatic changes. There are notable coronary calcifications\n within the visualized coronary arteries. No pericardial effusion is seen.\n\n Within the abdomen, there is fat stranding which appears to be centered\n predominantly about the pancreas, possibly localizing to the pancreatic body.\n Additionally, there is a small amount of free fluid which appears to originate\n from this region and tracks inferiorly along the left paracolic gutter. The\n pancreatic parenchyma itself is not well evaluated on this non-contrast\n examination. No abdominal free air or evidence of abscess formation is seen.\n No pancreatic pseudocyst is identified. Within the limits of this\n non-contrast examination, no obvious splenic artery aneurysm is seen.\n\n (Over)\n\n 12:27 AM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: eval for diverticulitis, intraabdominal abscess. limited stu\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is fatty deposition within the liver with area of lower density along\n the gallbladder fossa which is incompletely evaluated but could represent\n further focal fatty deposition. The spleen is within normal limits. The\n gallbladder, adrenal glands and right kidney appear grossly unremarkable.\n There is a 1 mm non-obstructing left renal stone. Loops of small and large\n bowel are normal in size and caliber. There is diverticulosis, however, no\n evidence of diverticulitis. No lymphadenopathy is identified.\n\n Within the pelvis, distal loops of large bowel and rectum are normal in size\n and caliber. There is again note of colonic diverticulosis without evidence\n of diverticulitis. The bladder and distal ureters appear grossly\n unremarkable. There are dense calcifications of the vas deferens. No pelvic\n free air or lymphadenopathy is seen.\n\n No concerning osseous lesion is seen. There is a remote right rib fracture.\n\n IMPRESSION:\n 1. Peripancreatic fluid and fat stranding suggestive of pancreatitis. No\n evidence of organized fluid collection.\n 2. Hepatic steatosis.\n 3. Diverticulosis without evidence of diverticulitis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2190-09-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1248896,
"text": " 9:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: EDEMA CONSOLIDATION\n Admitting Diagnosis: DIABETIC KETOACIDOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old man with pancreatitis and crackles on exam\n REASON FOR THIS EXAMINATION:\n edema? consolidation?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST FILM AT 10:11 A.M.\n\n CLINICAL INDICATION: 57-year-old with pancreatitis and crackles on exam,\n question edema, question consolidation.\n\n No comparison studies. Please note that comparison to old films can be\n helpful to detect subtle interval change. Comparison is made to selected\n images from the abdominal and pelvic CT performed on .\n\n A single portable AP upright chest film at 1011 is submitted.\n\n IMPRESSION:\n\n Lung volumes are low and there are patchy bibasilar opacities which may\n reflect patchy lower lobe atelectasis, although aspiration or pneumonia cannot\n be entirely excluded. Clinical correlation is advised. No pneumothorax. No\n evidence of pulmonary edema. No acute bone abnormality appreciated.\n\n"
},
{
"category": "ECG",
"chartdate": "2190-09-05 00:00:00.000",
"description": "Report",
"row_id": 304676,
"text": "Sinus tachycardia. RSR' pattern in lead V1 (normal variant). Left atrial\nabnormality. Non-specific ST segment changes. No previous tracing available\nfor comparison.\n\n\n"
}
] |
48,417 | 173,453 | ID: 62F with history of CVA with right-sided deficit, presenting today somnolence and frequent falls, now with acute respiratory failure. | Paradoxic septalmotion consistent with conduction abnormality/ventricular pacing.AORTA: Normal aortic diameter at the sinus level.AORTIC VALVE: ?# aortic valve leaflets. Normal left ventricular cavity size withregional systolic dysfunction suggestive of CAD (proximal RCA distributiongiven RV enlargement). The RA pressure could not be estimated.LEFT VENTRICLE: Moderate symmetric LVH. Trivial mitral regurgitation is seen. Mild pulm edema + small effusions R>L. Mild PA systolic hypertension.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. There is moderate symmetric left ventricular hypertrophy. Shortness of breath.Height: (in) 62Weight (lb): 116BSA (m2): 1.52 m2BP (mm Hg): 142/60HR (bpm): 110Status: InpatientDate/Time: at 06:00Test: Portable TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Suboptimal technicalquality, a focal LV wall motion abnormality cannot be fully excluded.Moderately depressed LVEF.RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Moderate[2+] tricuspid regurgitation is seen. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Normal PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Bilateral pleural effusions are redemonstrated. The right ventricular cavity is moderately dilated with moderateglobal free wall hypokinesis. Bilateral small pleural effusions. Mild regional LVsystolic dysfunction.LV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior- hypo; mid inferior - hypo; basal inferolateral - akinetic; mid inferolateral- akinetic;RIGHT VENTRICLE: Moderately dilated RV cavity. There is mild pulmonary artery systolichypertension. Mild-moderate mitral regurgitation. The mitral valve leaflets are mildlythickened. Moderate-to-severe atherosclerotic calcification and non-calcified plaque (3:34) is seen within the thoracic aorta, without aneurysmal dilation. Cardiomediastinal silhouette is within normal limits. Mild to moderate (+) mitral regurgitation is seen. Resting tachycardia(HR>100bpm).Conclusions:The left atrium is normal in size. Left ventricular function. Small bilateral simple pleural effusions are present. Moderate concentric LVH with a small LVcavity size and moderately depressed global LV function. Trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Suboptimal image quality - patient unable tocooperate. Pulmonary arteryhypertension.Compared with the prior study (images reviewed) of the findings arenew and suggestive of interim ischemia (proximal RCA distribution). Moderate global RV free wallhypokinesis.AORTIC VALVE: Normal aortic valve leaflets (?#).MITRAL VALVE: Normal mitral valve leaflets. No contraindications for IV contrast FINAL REPORT PORTABLE CHEST: . Mild to moderate (+) MR.TRICUSPID VALVE: Moderate [2+] TR. Left internal jugular line tip is at the level of mid SVC. FINDINGS: There is a large left frontal region of encephalomalacia consistent with prior infarction. Altogether, the findings are suggestive of moderate pulmonary edema. Hypertension. There is no pericardial effusion.IMPRESSION: Suboptimal image quality. There is no pericardial effusion.IMPRESSION: Suboptimal image quality. The estimated pulmonaryartery systolic pressure is normal. There is consequent ex vacuo dilatation of the frontal and body of the left lateral ventricle. A few scattered mediastinal lymph nodes are seen, do not meet CT criteria for significant adenopathy. Stable encephalomalacia in the left frontoparietal region secondary to prior infarct. Most likely focal calcification and much less likely stable foci of hemorrhage. A focus of hyperdensity within the area of encephalomalacia (2C:51, 50) is unchanged compared to prior examination and may represent focal calcification and less likely a focus of stable hemorrhage. Compared to the previous tracingof , the rhythm appears to be sinus, although artifact is present andventricular premature contractions are seen. Focus of hyperdensity at the site of encephalomalacia, most likely represents an area of calcification and less likely stable hemorrhage. Probable left ventricular hypertrophy. The ST-T wave changes haveimproved. Poor R waveprogression, cannot exclude prior anteroseptal myocardial infarction.ST-T wave changes in the early precordial leads may be due to anteriorischemia. Non-specificanterolateral ST-T wave changes which may be due to ischemia. Precordial T waves are less prominent.Early precordial leads now have prominent T wave inversions. COMPARISON: Non-contrast head CT from . NON-CONTRAST HEAD CT: There is stable encephalomalacia within the left frontoparietal region secondary to patient's prior infarct. Marked Q-T interval prolongation and slowing ofthe rate as compared to prior tracing of . Q-T interval does not appearprolonged on the current tracing. Delayed precordial R wave transition. Cannot exclude prior inferiorwall myocardial infarction, age indeterminate. Compared totracing #1 the QRS duration is narrow without intraventricular conductiondelay and anterolateral ST segment changes are more prominent.TRACING #2 Ectopic atrial bradycardia. AnteroseptalT wave inversions are no longer present.TRACING #1 Since the previoustracing of the rate is slower. Compared to the previoustracing of a left bundle-branch block is now present. Probable sinus rhythm, although P waves are difficult to discern givenextensive artifact. The patient is now status post PEA arrest. Ex vacuo dilatation of the left lateral ventricle appears unchanged. The tracing is marred by baseline artifact. Sinus tachycardia. Sinus tachycardia. Sinus tachycardia. Followup and clinical correlation aresuggested.TRACING #1 Sinus rhythm with ventricular premature contractions. Sinus rhythm. Unchanged size of the cardiac silhouette. Baseline artifact. Clinicalcorrelation is suggested. Late R wave progression. Right IJ line tip is in the SVC. Calcifications of the vertebral and carotid arteries are noted. T wave inversionin leads V1-V4 consistent with active anterior ischemic process. Assess for hemorrhage. There is nowleft bundle-branch block. There is low limblead voltage. Left internal jugular line ends in the mid SVC and nasogastric tube loops in the stomach and passes out of view. ProminentQRS voltage. Lung volumes have decreased, potentially reflecting decreased ventilatory pressures. The cardiac and mediastinal silhouettes are normal. Low QRS voltage in the limb leads. Besides the area of infarct, -white matter differentiation is preserved. IMPRESSION: 1. FINDINGS: As compared to the previous radiograph, the monitoring and support devices are in unchanged position. Patient also on anticoagulation due to lower extremity ischemia. Clinical correlation is suggested. Left bundle-branch block. The visualized paranasal sinuses and mastoid air cells are well aerated. There continues to be pulmonary vascular redistribution and patchy areas of alveolar infiltrate most marked in the right lower lobe along with Kerley B lines compatible with CHF. | 22 | [
{
"category": "Echo",
"chartdate": "2139-05-03 00:00:00.000",
"description": "Report",
"row_id": 104658,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. S/p PEA arrest.\nHeight: (in) 66\nWeight (lb): 112\nBSA (m2): 1.56 m2\nBP (mm Hg): 172/63\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 14:55\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo; basal inferolateral - akinetic; mid inferolateral\n- akinetic;\n\nRIGHT VENTRICLE: Moderately dilated RV cavity. Moderate global RV free wall\nhypokinesis.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#).\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Moderate [2+] TR. Mild PA systolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator. Suboptimal image quality - patient unable to\ncooperate. Echocardiographic results were reviewed by telephone with the MD\ncaring for the patient.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with near akinesis of the inferolateral wall, moderate hypokinesis\nof the inferior wall and mild hypokinesis of the remaining segments (LVEF =\n35-40 %). The right ventricular cavity is moderately dilated with moderate\nglobal free wall hypokinesis. The aortic valve leaflets (?#) appear\nstructurally normal with good leaflet excursion. The mitral leaflets are\ngrossly normal. Mild to moderate (+) mitral regurgitation is seen. Moderate\n[2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with\nregional systolic dysfunction suggestive of CAD (proximal RCA distribution\ngiven RV enlargement). Mild-moderate mitral regurgitation. Pulmonary artery\nhypertension.\nCompared with the prior study (images reviewed) of the findings are\nnew and suggestive of interim ischemia (proximal RCA distribution).\n\n\n"
},
{
"category": "Echo",
"chartdate": "2139-04-30 00:00:00.000",
"description": "Report",
"row_id": 104659,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Hypertension. Left ventricular function. Shortness of breath.\nHeight: (in) 62\nWeight (lb): 116\nBSA (m2): 1.52 m2\nBP (mm Hg): 142/60\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 06:00\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler. The IVC was not visualized. The RA pressure could not be estimated.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Small LV cavity. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded.\nModerately depressed LVEF.\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.\n\nAORTIC VALVE: ?# aortic valve leaflets. No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR.\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. Resting tachycardia\n(HR>100bpm).\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. There is moderate symmetric left ventricular hypertrophy. The\nleft ventricular cavity is unusually small. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\nleft ventricular systolic function is moderately depressed (LVEF= 35-40 %).\nRight ventricular chamber size and free wall motion are normal. The number of\naortic valve leaflets cannot be determined. There is no aortic valve stenosis.\nNo aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Trivial mitral regurgitation is seen. The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Moderate concentric LVH with a small LV\ncavity size and moderately depressed global LV function. The inferolateral\nwall appears more hypokinetic than other segments.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-04-29 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1241719,
"text": " 7:21 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? pna , ICH , FX.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62F with HX OF CVA. falls, ? pna\n REASON FOR THIS EXAMINATION:\n ? pna , ICH , FX.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg WED 8:53 PM\n neg acute\n prior left mca infarct\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old female with history of CVA and falls. Question ICH.\n\n COMPARISON: None.\n\n TECHNIQUE: Axial CT images were acquired of the head without contrast and\n reformatted into coronal and sagittal planes.\n\n FINDINGS: There is a large left frontal region of encephalomalacia consistent\n with prior infarction. There is consequent ex vacuo dilatation of the frontal\n and body of the left lateral ventricle. There is no acute intracranial\n hemorrhage or extra-axial collection. Elsewhere, matter/white matter\n differentiation is preserved. The visualized portions of the paranasal\n sinuses, and mastoid air cells are clear. There is no osseous abnormality.\n\n IMPRESSION:\n No acute intracranial process. There is a large region of left frontal\n encephalomalacia consistent with history of prior infarction, with associated\n ex vacuo dilatation of the ventricles.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-04-29 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 1241720,
"text": " 7:22 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: ? pna , ICH , FX.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62F with HX OF CVA. falls, ? pna\n REASON FOR THIS EXAMINATION:\n ? pna , ICH , FX.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg WED 8:56 PM\n no fx or malalignment\n large posterior osteophyte at C5-6 results in moderate spinal canal narrowing,\n if there is clinical concern for cord injury, please note that MRI is more\n sensitive for this.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old female with history of stroke and fall, question\n fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Helical CT images were acquired of the cervical spine without\n contrast and reformatted into coronal and sagittal planes.\n\n FINDINGS: There is normal spinal alignment. The prevertebral soft tissues\n are normal in appearance. There is no fracture. There is a large posterior\n osteophyte which projects at C5-C6, resulting in moderate narrowing of the\n spinal canal. There is multilevel mild neural foraminal narrowing, the result\n of uncovertebral joint hypertrophy. The thyroid and visualized lung apices\n are normal. The visualized soft tissues of the neck are notable for dense\n calcification at the bilateral carotid bifurcation.\n\n IMPRESSION: No fracture or malalignment of the cervical spine. There is a\n large posterior osteophyte, at C5-6, which results in moderate canal\n narrowing. If there is concern for cord injury, please note that MRI is more\n sensitive for this.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-04-30 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1241756,
"text": " 5:27 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n Admitting Diagnosis: FALL;CONFUSION\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with h/o stroke, new oxygen requirement requiring NRB\n REASON FOR THIS EXAMINATION:\n eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:56 AM\n COPD with severe emphysema and diffuse bronchial wall thickening, worst in RLL\n with probable aspiration.\n Mild pulm edema + small effusions R>L.\n Severe atherosclerosis.\n No PE.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with history of stroke, now with new oxygen\n requirement.\n\n COMPARISON: Chest radiograph done earlier today at 4:20 a.m.\n\n TECHNIQUE: Multidetector CT imaging of the chest was obtained prior to and\n after the uneventful intravenous administration of 100 cc of Omnipaque\n intravenous contrast. Sagittal, coronal and oblique reformations were\n performed.\n\n FINDINGS: The pulmonary arteries are well opacified to subsegmental levels,\n without pulmonary emboli. The heart is normal. Moderate-to-severe\n atherosclerotic calcification and non-calcified plaque (3:34) is seen within\n the thoracic aorta, without aneurysmal dilation. he heart size is normal.\n Extensive coronary arterial calcification is seen. There is no pericardial\n effusion. A few scattered mediastinal lymph nodes are seen, do not meet CT\n criteria for significant adenopathy.\n\n Bilateral upper lobe predominant severe centrilobular emphysema is seen. There\n is mild pulmonary vascular congestion without overt edema. Moderate bronchial\n wall thickening is seen throughout both lungs, worse in the right lower lobe.\n Mild dependent atelectasis is seen in both lower lobes. Small bilateral\n simple pleural effusions are present.\n\n A hypodense nodule measuring 1.5 cm is seen in the left thyroid lobe(2:1).\n\n This study is not tailored for subdiaphragmatic assessment, within this\n limitation the imaged upper abdomen is unremarkable, except to note extensive\n atherosclerotic calcification in the imaged upper abdominal aorta, and at the\n origins of the renal arteries and SMA.\n\n BONES AND SOFT TISSUES: Healing rib fractures are seen in the right lateral\n (Over)\n\n 5:27 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: eval for PE\n Admitting Diagnosis: FALL;CONFUSION\n Contrast: OMNIPAQUE Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 5, 6 and 7th ribs. No bone lesions suspicious for infection or malignancy are\n detected.\n\n IMPRESSION:\n 1. No pulmonary embolism or thoracic aortic pathology.\n 2. Moderate centrilobular emphysema and diffuse airways inflammation, worse\n in the right lower lobe. Bilateral small pleural effusions.\n 3. Extensive atherosclerotic disease of the thoracic and upper abdominal\n aorta.\n 4. 1.5 cm left thyroid lobe nodule, a thyroid ultrasound can be performed for\n further evaluation of the same.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1242137,
"text": " 9:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ett, other acute process\n Admitting Diagnosis: FALL;CONFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with s/p arrest, intubated\n REASON FOR THIS EXAMINATION:\n ett, other acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Status post arrest, intubated.\n\n FINDINGS: The ET tube is 2.6 cm above the carina. NG tube tip is off the\n film, at least in the stomach. There continues to be pulmonary vascular\n re-distribution and some patchy areas of alveolar infiltrate most marked in\n the right lower lobe. Kerley B lines are present. The overall impression is\n that of CHF which is slightly increased in the interval. An underlying\n infectious infiltrate in the right lower lobe cannot be excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-04-29 00:00:00.000",
"description": "R FOREARM (AP & LAT) RIGHT",
"row_id": 1241712,
"text": " 6:31 PM\n FOREARM (AP & LAT) RIGHT; HAND, AP & LAT. VIEWS RIGHT Clip # \n Reason: ?? fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62F with fall onto right side.\n REASON FOR THIS EXAMINATION:\n ?? fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old female with fall on right side.\n\n No prior examinations for comparison.\n\n RIGHT FOREARM, THREE VIEWS; RIGHT HAND, THREE VIEWS: Severe flexion\n contractures limit complete evaluation. The bones are diffusely\n demineralized, with severe degenerative changes. No acute fractures are\n identified.\n\n IMPRESSION: Limited exam, without evidence of fractures.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-04-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1241752,
"text": " 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema\n Admitting Diagnosis: FALL;CONFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with new O2 requirement\n REASON FOR THIS EXAMINATION:\n eval for pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: New oxygen requirement, evaluation for pulmonary edema.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is a slight increase\n in diameter of the cardiac silhouette, an increase in diameter of the\n pulmonary vessels and mild increase in interstitial markings. Altogether, the\n findings are suggestive of moderate pulmonary edema. At the time of\n observation and dictation, 9:11 a.m., the referring physician, . ,\n covered by Dr. , was paged for notification.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-04-29 00:00:00.000",
"description": "CHEST (SINGLE VIEW)",
"row_id": 1241711,
"text": " 6:31 PM\n CHEST (SINGLE VIEW) Clip # \n Reason: ? pna , ICH , FX.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62F with HX OF CVA. falls, ? pna\n REASON FOR THIS EXAMINATION:\n ? pna , ICH , FX.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST: .\n\n HISTORY: 62-year-old female with history of CVA and fall. Question\n pneumonia.\n\n FINDINGS: Two portable views of the chest. No prior. There are diffuse\n increased interstitial markings in the lungs, suggestive of underlying chronic\n lung disease. There is no focal consolidation or large effusion.\n Cardiomediastinal silhouette is within normal limits. The bones are diffusely\n osteopenic. No visualized displaced fracture seen. Calcifications in the\n neck on the right suggestive of carotid artery calcifications.\n\n IMPRESSION: No definite acute cardiopulmonary process. Increased\n interstitial markings suggestive of underlying chronic lung disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1242780,
"text": " 3:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess ET tube placement, interval change.\n Admitting Diagnosis: FALL;CONFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman intubated.\n REASON FOR THIS EXAMINATION:\n Assess ET tube placement, interval change.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST ON \n\n HISTORY: Intubated patient, check ET tube.\n\n IMPRESSION: AP chest compared to , 6:00 p.m.:\n\n Moderate pulmonary edema has progressed substantially accompanied by\n increasing small bilateral pleural effusions. Heart size normal. Tip of the\n endotracheal tube is no less than 2 cm from the carina. Left internal jugular\n line ends in the SVC and a nasogastric tube is looped in the stomach and\n passes out of view. No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1242570,
"text": " 3:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube was pulled back. Would like to assess for placement.\n Admitting Diagnosis: FALL;CONFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman intubated.\n REASON FOR THIS EXAMINATION:\n ET tube was pulled back. Would like to assess for placement.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: ET tube adjustment.\n\n COMPARISON: obtained at 03:56 a.m.\n\n Note is made that the original dictation was lost and the study was brought to\n our review today, on .\n\n The ET tube tip is 3.3 cm above the carina. Left internal jugular line tip is\n at the level of mid SVC. NG tube tip is in the stomach. Heart size and\n mediastinum are stable. Bilateral pleural effusions are redemonstrated.\n There is interval decrease in pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-03 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1242144,
"text": " 10:35 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please eval line placement\n Admitting Diagnosis: FALL;CONFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with cardiac arrest, intubated, now s/p L IJ CVL\n REASON FOR THIS EXAMINATION:\n please eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Cardiac arrest, intubated with new left IJ central line.\n\n FINDINGS: The ET tube is 3 cm above the carina. Right IJ line tip is in the\n SVC. NG tube tip is in the stomach. The cardiac and mediastinal silhouettes\n are normal. There continues to be pulmonary vascular redistribution and\n patchy areas of alveolar infiltrate most marked in the right lower lobe along\n with Kerley B lines compatible with CHF. Compared to the study from earlier\n the same day, the amount of CHF is similar. There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1242468,
"text": " 3:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: FALL;CONFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with aresst, cooling\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 3:56 AM, \n\n HISTORY: 62-year-old woman after a cardiopulmonary arrest.\n\n IMPRESSION: AP chest compared to through :\n\n Moderately severe pulmonary edema has not changed appreciably since ,\n but moderate bilateral pleural effusions are larger, and lower lung volumes\n probably account for an increase in the apparent caliber of the heart, though\n still within normal limits. Large lung volumes earlier in this\n hospitalization attest to emphysema.\n\n Tip of the endotracheal tube is no less than 1 cm from the carina, but it\n should be withdrawn 3 cm for appropriate positioning. Left internal jugular\n line ends in the mid SVC and nasogastric tube loops in the stomach and passes\n out of view. ICU was telephoned at 11:01, 1 minute following discovery of\n pertinent findings, which I discussed with Dr. at 11:04.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 1242162,
"text": " 4:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for new CVA, ICH\n Admitting Diagnosis: FALL;CONFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman h/o CVA, now s/p PEA arrest, now minimally responsive\n REASON FOR THIS EXAMINATION:\n assess for new CVA, ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GMSj SUN 4:50 PM\n -Stable left fronto-parietal encephalomalacia\n -Punctate hyperdensities in area of encephalomalacia appear stable. Most\n likely focal calcification and much less likely stable foci of hemorrhage.\n -No new intra- or extra-axial hemorrhage\n -No midline shift\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 62-year-old female with history of recent CVA. Patient also on\n anticoagulation due to lower extremity ischemia. The patient is now status\n post PEA arrest. Assess for hemorrhage.\n\n COMPARISON: Non-contrast head CT from .\n\n TECHNIQUE: 64 MDCT axial images of the brain were obtained without\n intravenous contrast.\n\n NON-CONTRAST HEAD CT: There is stable encephalomalacia within the left\n frontoparietal region secondary to patient's prior infarct. Ex vacuo\n dilatation of the left lateral ventricle appears unchanged. A focus of\n hyperdensity within the area of encephalomalacia (2C:51, 50) is unchanged\n compared to prior examination and may represent focal calcification and less\n likely a focus of stable hemorrhage. No new intra- or extra-axial hemorrhage\n is identified. There is no shift of the usually midline structures.\n Suprasellar and basilar cisterns are widely patent. Besides the area of\n infarct, -white matter differentiation is preserved. There is no scalp\n hematoma or acute skull fracture. The visualized paranasal sinuses and\n mastoid air cells are well aerated. Calcifications of the vertebral and\n carotid arteries are noted.\n\n IMPRESSION:\n 1. Stable encephalomalacia in the left frontoparietal region secondary to\n prior infarct.\n 2. Focus of hyperdensity at the site of encephalomalacia, most likely\n represents an area of calcification and less likely stable hemorrhage.\n 3. No new intra- or extra-axial hemorrhage. No midline shift or evidence of\n herniation.\n (Over)\n\n 4:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for new CVA, ICH\n Admitting Diagnosis: FALL;CONFUSION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2139-05-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1242328,
"text": " 3:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FALL;CONFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with PEA arrest, intubated\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Cardiac arrest, intubation, evaluation for interval change.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. Lung volumes have decreased, potentially\n reflecting decreased ventilatory pressures. As a consequence, the\n pre-existing parenchymal opacities have increased, notably at the lung bases\n and in the retrocardiac lung areas. There is no evidence of larger pleural\n effusions. Unchanged size of the cardiac silhouette. No pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2139-04-30 00:00:00.000",
"description": "Report",
"row_id": 306192,
"text": "Baseline artifact. Sinus rhythm. Late R wave progression. Prominent\nQRS voltage. Probable left ventricular hypertrophy. Since the previous\ntracing of the rate is slower. Precordial T waves are less prominent.\nEarly precordial leads now have prominent T wave inversions. Clinical\ncorrelation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-05-05 00:00:00.000",
"description": "Report",
"row_id": 306188,
"text": "Sinus rhythm with ventricular premature contractions. Poor R wave\nprogression, cannot exclude prior anteroseptal myocardial infarction.\nST-T wave changes in the early precordial leads may be due to anterior\nischemia. Clinical correlation is suggested. Compared to the previous tracing\nof , the rhythm appears to be sinus, although artifact is present and\nventricular premature contractions are seen. Q-T interval does not appear\nprolonged on the current tracing. The heart rate is increased.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2139-05-04 00:00:00.000",
"description": "Report",
"row_id": 306189,
"text": "Ectopic atrial bradycardia. Marked Q-T interval prolongation and slowing of\nthe rate as compared to prior tracing of . The ST-T wave changes have\nimproved. Followup and clinical correlation are suggested. There is low limb\nlead voltage.\n\n"
},
{
"category": "ECG",
"chartdate": "2139-05-03 00:00:00.000",
"description": "Report",
"row_id": 306190,
"text": "Sinus tachycardia. Low QRS voltage in the limb leads. Non-specific\nanterolateral ST-T wave changes which may be due to ischemia. Compared to\ntracing #1 the QRS duration is narrow without intraventricular conduction\ndelay and anterolateral ST segment changes are more prominent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2139-05-01 00:00:00.000",
"description": "Report",
"row_id": 306191,
"text": "Probable sinus rhythm, although P waves are difficult to discern given\nextensive artifact. Left bundle-branch block. Cannot exclude prior inferior\nwall myocardial infarction, age indeterminate. Compared to the previous\ntracing of a left bundle-branch block is now present. Anteroseptal\nT wave inversions are no longer present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2139-04-30 00:00:00.000",
"description": "Report",
"row_id": 306352,
"text": "Sinus tachycardia. The tracing is marred by baseline artifact. There is now\nleft bundle-branch block. Followup and clinical correlation are suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2139-04-29 00:00:00.000",
"description": "Report",
"row_id": 306353,
"text": "Sinus tachycardia. Delayed precordial R wave transition. T wave inversion\nin leads V1-V4 consistent with active anterior ischemic process. No previous\ntracing available for comparison. Followup and clinical correlation are\nsuggested.\nTRACING #1\n\n"
}
] |
27,543 | 113,974 | She had previously been hospitalized in early with long history of splenomegaly with undefined non-malignant hematologic abnormality, followed closely by Hematology/Oncology for this. After much discussion with patient, family and her providers the decision was made for therapeutic splenectomy. She underwent successful splenic artery embolization on in order to reduce the operative risk of splenectomy and on she underwent splenectomy. She was eventually discharged to home with services. She returned with a smoldering wound infection and illness, and then began to pour gastric juice out of the wound. She was brought back to the operating room for exploration of her wound and repair of gastric perforation. Postoperatively she remained sedated and vented in the Surgical ICU. TPN was started. She was eventually weaned and extubated and was later transferred to the regular nursing unit. A VAC dressing to her abdomen was later applied; the JP drains which were placed intraoperatively have remained in place because of continued high output. A regular diet was started and she is tolerating this without difficulty. She was trialed on Octreotide; this was eventually discontinued. IV antibiotics will need to continue for an additional 2 days and then discontinue; follow up with Dr. in 1 week. She underwent LUE ultrasound for swelling noted in her left arm that was noted several days after central line removal; it did reveal a thrombus in the cephalic vein. She was maintained on tid Heparin. A right PICC line was placed eventually for continued IV antibiotics. Because of her deconditioned status she was evaluated by Physical and Occupational therapy and it was recommended that she go to an acute rehab following hospitalization. | The contents of the ventricular are hypodense with respect to the myocardium suggestive of anemia. The myocardial septum is conspicuous on this non-contrast scan indicating anemia. CONCLUSION: The main finding is a decrease in the amount of left pleural effusion and the position of the chest tube is indicated. CT OF THE ABDOMEN: There is a large left pleural effusion and small right pleural effusion, both measuring simple fluid density, with significant associated collapse of the left lower lobe. INDICATION: Left chest tube removal. IMPRESSION: AP chest compared to : Left subclavian line has been withdrawn to the mid SVC. Sigmoid diverticulosis is noted. FINDINGS: Grayscale, color, and Doppler son of bilateral common femoral, superficial femoral, popliteal, and tibial veins were performed. Left IJ, axillary, basilic veins patent. Evidence of anemia. Several partially opacified loops of small bowel are seen in the left upper quadrant (series 3, image 23). IMPRESSION: Thrombosis of the left cephalic vein, likely acute. Severe left lower lobe atelectasis persists. Side port of a left pleural drain remains extrathoracic. Left lower lobe retrocardiac opacity which may be focal consolidation and/or effusion. The intraabdominal drains are again noted. Since the previous study, there is opacification in the left retrocardiac region, which may represent consolidation and/or effusion in the left lower lobe. Large amount of previously noted intra-abdominal gas has resolved. COMPARISON: Abdomen CT, . There is a small collection of high-density contrast ( likely residual from the upper GI performed on the same day ), with significant adjacent streak artifact (series 2, image 19), in the dependent portion of the gastric cardia. Left chest tube is in place with the tip about the mid thoracic level and when compared to the examination of , there is marked decrease in pleural effusion and if any is present, it is very small quantity. Incidentally noted in the right groin is an approximately 3 x 6 cm cystic area with several thin septations within it, consistent with a fluid collection. The left subclavian line was inserted in the meantime interval with its tip projecting 3 cm below the cavoatrial junction in the right atrium. Bilateral small pleural effusions most likely present. The NG tube tip is in the proximal stomach. FINAL REPORT INDICATION: Status post repair of gastrocutaneous fistula with question of persistent fistula. Superiorly, the collection abuts the left tip of the liver as well as what is presumed to be a small bowel loop. Bilateral pleural effusions. CHF FINAL REPORT INDICATION: Status post splenectomy with wound dehiscence. IMPRESSION: While there is no definitive evidence of enterocutaneous fistula, question of a small contained leakage is raised near the mid portion of the greater curvature of the stomach. Abdomen softly distended.continues on TPN. Trace aortic regurgitation is seen (clip ). Abd soft/lge with w->D dressing packed in am with serosang drg. Compared to the previous tracing of atrial fibrillation is nowseen. Spec sent from Right JP for amylase. neo gtt weaned to off. MAE with generalized weakness.BP stable 90's/50's. jp's ddraining sero sang drainage. Respiratory care:Pt. Plan to extubate this am as tolerates. Left CT draining serous drainage. +hypoactive BS. ?endocarditis.Height: (in) 66Weight (lb): 200BSA (m2): 2.00 m2BP (mm Hg): 111/66HR (bpm): 79Status: InpatientDate/Time: at 14:10Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). The mitral valveappears structurally normal with trivial mitral regurgitation. Lungs are clear and diminished in the bases and chest tube in place put to water seal this am. Compared to prior tracing of ventricularectopy is no longer present. Cough weak d/t splinting abd incision. Primary team aware, to be flushed by MD only.Abdominal incision with stay sutures covered with Wet to dry dsg. Left pleural effusion.Conclusions:The left atrium is mildly dilated. npo ngt to lcws. Sinus rhythm with ventricular premature beats. NGT to sxn with min clear output. Medicated with dilaudid 1mg ivp with some effect. debridement of pancreas, expl lap, repair of gastric perforation and insertion of chest tube.neuro: sedated and on propofol gtt at 30mcg/kg/min. IN ED, SHE WAS NOTED TO BE MILDY HYPOTENSIVE W/ A WBC OF 20 K. FULLY CX'D AND ANTI'B'S BEGUN. Compared with tracing of ventricular premature beatsare new. Right ventricular function. Condition UpdateD: see carevue flowsheet for specifics Patient afebrile, Hemodynamically stable today. ngt to lcws and draining pink ddrainage. pt resp status stable. vap mouth care done as per protocol. abd dsg intact with visable serosang drainage noted via transparent dsg. propofol gtt. Given 1 mg Dilaudid IVP with good effect (). chest tube to suction. Sinus rhythm. There is nomitral valve prolapse. Theaortic valve leaflets (3) are mildly thickened but aortic stenosis is notpresent. Diffuse non-specific ST-T waveabnormalities. wbc 19.9 --23.5. lactated ringer at 150cc/hr. Trace AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: Suboptimal image quality - poor apical views. NPN (NOC): PLEASE SEE FHP AND FLOWSHEET FOR DETAILS OF PMHX, HPI AND ASSESSMENT. O2 weaned down to 4L NC. dsg changed for large amt of drainage.cardiac: remains in nsr hct 31.2. k 4.3 neo gtt added upon arrival due to bp dropping to the 80's. Abd incision open with stay sutures packed with W->D guauze this am, tissue red/beefy. Nsg Progress NotePt remains Afebrile. when hand untied, pt will attempt to touch et tube. Bp remained stable.LS clear at apices, diminished at bases. ABD WOUND DSG REPACKED X 1 FOR LG AMT OF THICK BROWN DRNG (SPEC SENT IN ED.) Extremities edematous. | 23 | [
{
"category": "Radiology",
"chartdate": "2187-11-08 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 982221,
"text": " 5:09 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for possible leakplease give oral contrast & infuse con\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 y/o female s/p open splenectomy with copious drainage from abdominal wound\n\n REASON FOR THIS EXAMINATION:\n eval for possible leakplease give oral contrast & infuse contrast into the 2\n abdominal drains\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS WITHOUT CONTRAST:\n\n CLINICAL HISTORY: 70-year-old female status post open splenectomy and gastric\n surgery and partial pancreatectomy (approximately a week ago).\n\n TECHNIQUE: MDCT acquired axial images were obtained through the abdomen and\n pelvis following administration of oral contrast only. Intravenous contrast\n was not administered due to lack of IV access.\n\n Coronal and sagittal reformatted images were also obtained.\n\n COMPARISON: .\n\n Limited images through the lung bases demonstrate moderate bilateral pleural\n effusions with associated airspace disease. The right pleural effusion has\n increased in size since the prior study. The contents of the ventricular\n are hypodense with respect to the myocardium suggestive of anemia.\n\n The unenhanced morphology of the liver is unremarkable. There is no\n intrahepatic or extrahepatic biliary dilatation. The patient is status post\n cholecystectomy. There is extensive streaking in the peripancreatic region\n and the omentum consistent with recent postoperative state. Surgical staples\n are seen in the body of the pancreas.\n\n A very small 2.8 x 1.5 cm fluid collection seen in the midline just deep to\n the anterior abdominal wall musculature (series 2, image 38). This is also\n likely postoperative in nature. Two surgical drains are identified. The\n right-sided surgical drain is seen with its tip in the region of the\n pancreatic tail. The left-sided drain is seen high with its tip in the left\n upper quadrant.\n\n The stomach is partially opacified with contrast. There is a small collection\n of high-density contrast ( likely residual from the upper GI performed on the\n same day ), with significant adjacent streak artifact (series 2, image 19), in\n the dependent portion of the gastric cardia. It cannot be ascertained whether\n this contrast is within or outside the gastric lumen. Several partially\n opacified loops of small bowel are seen in the left upper quadrant (series 3,\n image 23). It is also not clear whether the contrast is within or outside the\n bowel lumen.\n (Over)\n\n 5:09 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for possible leakplease give oral contrast & infuse con\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n The colon is partially opacified with contrast and is grossly unremarkable.\n There is no evidence of free air, pneumatosis or bowel obstruction.\n\n There is diffuse anasarca. There has been interval improvement in previously\n noted ascites. Large amount of previously noted intra-abdominal gas has\n resolved.\n\n CT OF THE PELVIS: There is a small amount of fluid in the pelvis. A Foley\n catheter is present in the urinary bladder. There is a right groin hematoma\n that measures approximately 3.7 x 5.7 x 9.1 cm which is stable in appearance\n when compared with the prior study from .\n\n There is a 2.2 x 2.0 cm fluid collection just deep to the abdominal wall\n muscles at the level of the iliac bones (series 2, image 73) which is\n unchanged since the prior study.\n\n BONE WINDOWS: T12 compression fracture is again noted. No suspicious lytic\n or sclerotic lesions are identified. There are multilevel degenerative\n changes in the lumbar spine.\n\n These findings were discussed with Dr. on and .\n\n IMPRESSION:\n\n 1. Bilateral pleural effusions. The right pleural effusion has increased in\n size since the prior study.\n\n 2. Overall, marked improvement in previously seen amount of gas and fluid in\n the upper abdomen, now with expected post-surgical changes. Streak artifact\n from the residual high- density barium in the stomach and proximal small bowel\n makes it difficult to determine whether the oral contrast is within or\n immediately adjacent to the bowel lumen.\n\n 3. No frank contrast extravasation and no free intraperitoenal air is seen.\n\n 4. Stable right groin hematoma.\n\n\n\n\n\n\n\n\n (Over)\n\n 5:09 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: eval for possible leakplease give oral contrast & infuse con\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-11-10 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 982425,
"text": " 9:59 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: SWELLING ? DVT\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with LUE swelling x 1d, hx of L subclavian Catheter removed\n about 5d ago\n REASON FOR THIS EXAMINATION:\n ?dvt\n ______________________________________________________________________________\n WET READ: AKSb SAT 10:45 AM\n Thrombosis of left cephalic vein.\n\n Left IJ, axillary, basilic veins patent.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old female with left upper extremity swelling and history\n of left subclavian catheter removed five days ago. Evaluate for DVT.\n\n No prior examinations.\n\n LEFT UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler examination of\n the left internal jugular vein, axillary vein, basilic vein and cephalic veins\n were performed. The left cephalic vein is distended, non-compressible, with\n hypoechoic intraluminal thrombus, and no flow. The left internal jugular\n vein, axillary vein, and basilic veins demonstrate normal compressibility,\n augmentability and respiratory variation and flow.\n\n IMPRESSION: Thrombosis of the left cephalic vein, likely acute.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-11-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 981231,
"text": " 12:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: check chest tube position\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p splenectomy. p/w wound dehisc, also with b/ \n\n REASON FOR THIS EXAMINATION:\n check chest tube position\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable supine film of the chest on at 01:01 hours.\n\n There appears to be a tube and a drain seen beneath the abdomen with tip of\n the tube in the left upper quadrant. An airway is in place in good position\n the tip approximately 3 cm above the tracheal bifurcation. Nasogastric tube\n extends well into the fundus of the stomach. This could be advanced further\n if thought clinically desirable. Left chest tube is in place with the tip\n about the mid thoracic level and when compared to the examination of , there is marked decrease in pleural effusion and if any is present, it\n is very small quantity. There does appear to be a small amount of left lower\n lobe atelectasis. There is no evidence of pulmonary edema or definite acute\n pulmonary inflammatory disease.\n\n CONCLUSION: The main finding is a decrease in the amount of left pleural\n effusion and the position of the chest tube is indicated.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-11-08 00:00:00.000",
"description": "UGI SGL CONTRAST W/ KUB",
"row_id": 982168,
"text": " 10:44 AM\n UGI SGL CONTRAST W/ KUB Clip # \n Reason: Pt has NG tube in place. Please assess stomach for leak.\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ? gastrocutaneous fistula s/p repair of gastrocutaneous\n fistula 6 days ago, still with some drainage of through wound and JP drains.\n REASON FOR THIS EXAMINATION:\n Pt has NG tube in place. Please assess stomach for leak.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post repair of gastrocutaneous fistula with question of\n persistent fistula.\n\n COMPARISON: Multiple priors, the most recent CT abdomen dated .\n\n FINDINGS: Initial scout image demonstrates retained oral contrast in the\n colon. Surgical clips and drains project over the mid and left upper abdomen.\n\n Oral Conray and thin barium were administered under fluoroscopic surveillance.\n Prompt filling of the stomach and proximal small bowel is demonstrated. Near\n the mid point of the greater curvature of the stomach, there is a\n focus of contrast opacification which extends approximately 12 mm beyond the\n expected confines of the stomach contour. At no point does it extend further\n than this and it is therefore felt unlikely to represent an enterocutaneous\n fistula, perhaps instead representing a small contained leak. No other foci of\n leak are observed. There is no evidence of obstruction of the stomach or\n proximal small bowel.\n\n IMPRESSION: While there is no definitive evidence of enterocutaneous fistula,\n question of a small contained leakage is raised near the mid portion of the\n greater curvature of the stomach.\n\n Findings discussed with Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-10-31 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 981183,
"text": " 3:13 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evaluate for enteric leakPlease use PO & IV contrast\n Admitting Diagnosis: WOUND INFECTION\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 y/o female s/p open splenectomy with copious drainage from abdominal wound\n REASON FOR THIS EXAMINATION:\n evaluate for enteric leakPlease use PO & IV contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old female, status post open splenectomy with copious\n drainage from abdominal wound. Please evaluate for enteric leak.\n\n COMPARISON: CT of the abdomen, .\n\n TECHNIQUE: Multidetector helical scanning of the abdomen and pelvis was\n performed following the administration of oral contrast. Coronal and sagittal\n reformats were displayed.\n\n CT OF THE ABDOMEN: There is a large left pleural effusion and small right\n pleural effusion, both measuring simple fluid density, with significant\n associated collapse of the left lower lobe. There is no pericardial effusion.\n The myocardial septum is conspicuous on this non-contrast scan indicating\n anemia.\n\n Within the abdomen, there is an ill-defined but large collection of air and\n fluid lateral and inferior to the gastric body. A small amount of oral\n contrast material layers within the posterior aspect of this collection and\n appears to be extravasating from a rent in the posterior aspect of the\n stomach. Fluid and air tracks to the anterior subcutaneous tissues, and there\n is an open abdominal wound. Superiorly, the collection abuts the left tip of\n the liver as well as what is presumed to be a small bowel loop. The inferior\n aspect of the collection is indistinguishable from the tail of the pancreas,\n and the degree of pancreatic involvement cannot be elucidated. The colon is\n separate from the collection, located more inferiorly.\n\n The spleen and gallbladder have been removed. The liver, adrenal glands, and\n kidneys are normal on this non-contrast scan. There is a mild amount of\n stranding extending into the more inferior mesentery. Oral contrast passes\n through to the distal colon with no evidence of obstruction or wall\n thickening.\n\n CT OF THE PELVIS: There is simple fluid layering within the pelvis. Sigmoid\n diverticulosis is noted. A small well-defined fluid collection in the low mid\n anterior pelvis has decreased in size from 3 x 2.8 cm to 1.9 x 1.8 cm.\n\n Moderate anasarca is seen, particularly in the left flank.\n\n No suspicious lytic or sclerotic lesions.\n\n (Over)\n\n 3:13 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evaluate for enteric leakPlease use PO & IV contrast\n Admitting Diagnosis: WOUND INFECTION\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Large ill-defined collection of fluid and air in the left upper quadrant\n with oral contrast pooling within it, all likely related to perforation of the\n posterior stomach.\n 2. The collection is indistinguishable from the pancreatic tail and the\n degree of pancreatic involvement cannot be elucidated on this non-contrast\n scan.\n 3. Fluid and air tracking to the anterior abdominal wall with an open\n abdominal wound.\n 4. Decreased size of small 2 cm intra-abdominal fluid collection in the low\n mid pelvis.\n 5. Large left and small right pleural effusions with significant collapse of\n the left lower lobe.\n 6. Evidence of anemia.\n\n Findings were discussed with Dr. and Dr. immediately\n after completion of the exam.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-11-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 981345,
"text": " 4:03 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval LEFt SC position\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p splenectomy. p/w wound dehisc, also with b/ \n\n REASON FOR THIS EXAMINATION:\n eval LEFt SC position\n ______________________________________________________________________________\n WET READ: 7:37 PM\n left subclavian line tip now overlying proximal to mid svc.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:04 P.M. \n\n HISTORY: Splenectomy and wound dehiscence. Evaluate subclavian line\n placement.\n\n IMPRESSION: AP chest compared to :\n\n Left subclavian line has been withdrawn to the mid SVC. Side port of a left\n pleural drain remains extrathoracic. No appreciable pneumothorax or pleural\n fluid collection on the left. Severe left lower lobe atelectasis persists.\n Right lung clear. Nasogastric tube would need to be advanced 6 cm to move all\n the side ports into the stomach. Upper quadrant drains cannot be localized on\n this view alone.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-11-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 982036,
"text": " 1:03 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 55cm R basilic PICC placed; please determine tip location.\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p splenectomy. p/w wound dehisc, also with b/ \n\n REASON FOR THIS EXAMINATION:\n 55cm R basilic PICC placed; please determine tip location.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, _____ LINE PLACEMENT\n\n COMPARISON: , chest portable.\n\n HISTORY: 70-year-old female, status post PICC line placement.\n\n FINDINGS: The left central line is in the upper SVC and may be advanced\n further into correct position. The right central line is in the right atrium.\n The NG tube extends below the diaphragm, however, its tip is not well\n visualized and may be in the proximal stomach. Since the previous study,\n there is opacification in the left retrocardiac region, which may represent\n consolidation and/or effusion in the left lower lobe. There are persistent\n low lung volumes. There is no evidence of pneumothorax. The pulmonary\n vasculature is unremarkable. Two surgical drains are seen in the upper\n abdomen.\n\n IMPRESSION:\n 1. Abnormal positioning of central lines as described above.\n 2. Left lower lobe retrocardiac opacity which may be focal consolidation\n and/or effusion.\n\n These findings were discussed with Dr. _____ at approximately 3:30 p.m.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-11-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 981322,
"text": " 1:34 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval line placement\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p splenectomy. p/w wound dehisc, also with b/ \n REASON FOR THIS EXAMINATION:\n eval line placement\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of line placement.\n\n The left subclavian line was inserted in the meantime interval with its tip\n projecting 3 cm below the cavoatrial junction in the right atrium. The ET\n tube tip is 3 cm above the carina. The NG tube is proximal with its tip in\n the cavoatrial junction and sidehole in the distal esophagus, advancement of\n at least 20 cm cm is recommended.\n\n The left chest tube is in unchanged location. There is worsening of the left\n lower lobe atelectasis. Small left pleural effusion cannot be excluded.\n\n Findings were discussed with Dr. the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-11-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 982108,
"text": " 10:02 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: re-eval R PICC position\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p splenectomy.\n REASON FOR THIS EXAMINATION:\n re-eval R PICC position\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after splenectomy.\n\n PORTABLE AP CHEST RADIOGRAPH COMPARED TO .\n\n The NG tube tip is in the proximal stomach. The left subclavian line tip is\n at the junction of the brachiocephalic vein and SVC. The right PICC line tip\n is in the medial end of the right subclavian vein. There is again\n demonstrated bibasilar atelectasis, left worse than right, slightly worse\n compared to the previous study. Bilateral small pleural effusions most likely\n present. The intraabdominal drains are again noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-11-04 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 981669,
"text": " 11:59 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pneumothorax post chest tube removal\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p splenectomy c/b gastrocutaneous fistula, pancreatic\n necrosis, s/p L chest tube removal.\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax post chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Left chest tube removal.\n\n Single AP view of the chest is obtained on at 1226 hours following\n removal of a left-sided pleural tube. There is no evidence of pneumothorax.\n Nasogastric tube is present. Due to the underexposure in the upper abdomen\n the tip cannot be seen. A left-sided subclavian line is present with its tip\n likely directed against the lateral wall of the proximal SVC. This should be\n re-positioned. Increased retrocardiac density of the left base consistent\n with atelectasis/airspace disease. No large pleural effusions are present.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-10-30 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 981016,
"text": " 3:04 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: ? DVT/LE SWELLING\n Admitting Diagnosis: WOUND INFECTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with B/L LE edema & SOB\n REASON FOR THIS EXAMINATION:\n ?DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old female with bilateral lower extremity edema and\n shortness of breath.\n\n COMPARISON: Abdomen CT, .\n\n FINDINGS: Grayscale, color, and Doppler son of bilateral common\n femoral, superficial femoral, popliteal, and tibial veins were performed.\n There is normal flow, compression, and augmentation identified in all of the\n blood vessels. There is no evidence of DVT.\n\n Incidentally noted in the right groin is an approximately 3 x 6 cm cystic area\n with several thin septations within it, consistent with a fluid collection.\n\n IMPRESSION: No DVT in the right or left leg. Incidentally noted is a 6-cm\n fluid collection in the right groin.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-10-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 980758,
"text": " 3:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval cardiopulm disease, ? CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman s/p splenectomy. p/w wound dehisc, also with b/ \n REASON FOR THIS EXAMINATION:\n eval cardiopulm disease, ? CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post splenectomy with wound dehiscence.\n\n COMPARISON: CXR .\n\n PORTABLE UPRIGHT CHEST: There has been increase in size of a large left\n layering pleural effusion associated with compressive atelectasis. The right\n lung remains clear. Cardiomediastinal silhouette demonstrates no significant\n interval change though evaluation is limited due to the large effusion. A\n right internal jugular line has been removed and there is no evidence of\n pneumothorax.\n\n IMPRESSION: Increase in size of a large layering left pleural effusion and\n associated atelectasis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-10-29 00:00:00.000",
"description": "Report",
"row_id": 1622632,
"text": "NPN (NOC): PLEASE SEE FHP AND FLOWSHEET FOR DETAILS OF PMHX, HPI AND ASSESSMENT. BRIEFLY, PT IS A 70 Y/O WOMAN WHO WAS RECENTLY DISCHARGED FOLLOWING A SPLENECTOMY. WHILE AT HOME, HER WOUND BEGAN TO DEHISCE AND DRAIN THICK BROWN DRAINAGE. CAME INTO ED LAST NIGHT W/ LOW GRADE FEVER. IN ED, SHE WAS NOTED TO BE MILDY HYPOTENSIVE W/ A WBC OF 20 K. FULLY CX'D AND ANTI'B'S BEGUN. SHE WAS BEGUN ON IVF AND ADM TO SICU FOR FURTHER MONITORING. SINCE ADM TO SICU, SHE HAS BEEN AFEBRILE AND HEMODYNAMICALLY STABLE. FSBS'S AS HIGH AS 300. INSULIN DRIP BEGUN, BUT IS NOW OFF BECAUSE FSBS DROPPED AS LOW AS 62. IT IS NOW 138 (IN TARGET RANGE OF 100-150.) ABD WOUND DSG REPACKED X 1 FOR LG AMT OF THICK BROWN DRNG (SPEC SENT IN ED.) SHE ALSO HAS BLISTERS ON LE'S WHICH LOOK LIKE WERE AN ALLERGIC RXN TO PNEUMO BOOTS ON RECENT ADM. A LG BLISTER HAS BROKEN ON HER RLE AND I HAVE CHANGED THE TELFA PAD, KLING AND CHUX X 3 OVERNOC FOR LG AMTS OF SEROUS FLUID. PNEUMO BOOTS NOT ON FOR THIS REASON. SHE IS ON MINIHEP. ALSO, SHE IS A VERY DIFFICULT STICK AND WE HAD TO RESORT TO AN ART STICK TO GET AM LABS, PT/PTT NOT DONE AS WE WERE UNABLE TO GET ENOUGH BLOOD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-01 00:00:00.000",
"description": "Report",
"row_id": 1622633,
"text": "Respiratory Care:\nPt is a 70 yo F, s/p splenectomy few weeks ago at . Presented with abdominal pain to ED on . To OR for exp lap--gastric perforation, necrotizing pancreatitis. Now on PSv 10 /5 peep 50%. Morning RSBI = 81. Plan to extubate this am as tolerates.\n"
},
{
"category": "Echo",
"chartdate": "2187-10-29 00:00:00.000",
"description": "Report",
"row_id": 65251,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function. ?endocarditis.\nHeight: (in) 66\nWeight (lb): 200\nBSA (m2): 2.00 m2\nBP (mm Hg): 111/66\nHR (bpm): 79\nStatus: Inpatient\nDate/Time: at 14:10\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and 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\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. Suboptimal\nimage quality - poor subcostal views. Left pleural effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and systolic function (LVEF>55%). Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. Right ventricular chamber size and free wall motion are normal. The\naortic valve leaflets (3) are mildly thickened but aortic stenosis is not\npresent. Trace aortic regurgitation is seen (clip ). The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. There is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nand regional biventricular systolic function. Trace aortic regurgitation with\nmild aortic valve sclerosis.\n\nCompared with the prior study (images reviewed) of , trace aortic\nregurgitation is now identified (but the same orientation in which AR is seen\non the current study was not obtained with the prior study and thus this may\nnot reflect a true change).\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-02 00:00:00.000",
"description": "Report",
"row_id": 1622637,
"text": "Nsg Progress Note\nPt remains Afebrile. WBC pending. Very pleasant and cooperative. Reports increased pain with movement/turning (). Given 1 mg Dilaudid IVP with good effect (). MAE with generalized weakness.\nBP stable 90's/50's. Goal MAP >60. Remains in Afib. HR 80's-90's. Tachy at times. Given Lopressor 5mg. Bp remained stable.\nLS clear at apices, diminished at bases. Left CT draining serous drainage. Site intact. No crepitus.\nNGT to LCWS draining small amts clear to bilious drainage. Primary team aware, to be flushed by MD only.\nAbdominal incision with stay sutures covered with Wet to dry dsg. +hypoactive BS. Abdomen softly distended.\ncontinues on TPN. Insulin gtt for glycemic control.\n+PP difficult to palpate. Extremities edematous. Abrasions both legs draining moderate amts serous fluid-covered with adaptic and softsorb.\n\nPlan: monitor for worsening infection, MAP>60, Dilaudid for pain, Chest tube drainage, insulin gtt, labs. Continue provide support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-02 00:00:00.000",
"description": "Report",
"row_id": 1622638,
"text": "Condition Update\nD: see carevue flowsheet for specifics\n Patient afebrile, Hemodynamically stable today. HR in afib rate 90-110 with no ectopy. SBP 90-100. Fluids decreased today so IVF and TPN total 75cchr will continue to see if urine output remains adequate. HCT stable WBC remains elevated.\n Lungs are clear and diminished in the bases and chest tube in place put to water seal this am. Continues to drain serous fluid. Sats 97-100% on RA.\n Abd incision open with stay sutures packed with W->D guauze this am, tissue red/beefy. JP's with some bilious/purulent drg but less noted today. NGT to sxn with min clear output. Octreotide started today d/t elevated amylase in Right JP (to decrease release of pancreatic enzymes).\n Pt turned and repostioned but complaining of pain only at chest tube site on left. Medicated with dilaudid 1mg ivp with some effect.\n Husband/son in to visit and updated by RN.\n Insulin gtt titrated off and started coverage with SSI as well as adding insulin to TPN. Closely monitoring bloodsugars and range 120-170.\n Pt is a/oX3\nPLAN:\n Pt called out to floor CC6 no tele\n Closely monitor Bloodsugars\n w-D dressing to ABD incision\n LE with DSD to open blistered area (no venodynes)\n Notify H.O. with any changes\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-01 00:00:00.000",
"description": "Report",
"row_id": 1622634,
"text": "FOCUS ADMISSION note\ndata: admitted to the sicu from the or. debridement of pancreas, expl lap, repair of gastric perforation and insertion of chest tube.\n\nneuro: sedated and on propofol gtt at 30mcg/kg/min. opens eyees to voice and nods to questions. when hand untied, pt will attempt to touch et tube. moves extremties on the bed. pupils react equally.\n\nresp: remains intubated and suctioned for small amt of white sputum. vap mouth care done as per protocol. breath sounds clear in the upper bases but diminished in the lower bases. on cpap with 10 ips. chest tube patent and draining straw colored drainage. no air leaks noted. dsg changed for large amt of drainage.\n\n\ncardiac: remains in nsr hct 31.2. k 4.3 neo gtt added upon arrival due to bp dropping to the 80's. 1000cc lactated ringer bolus iv given bp up to the 90-120's. neo gtt weaned to off. aline placed via left radial area.\n\ngu: foley patent and draining amber colored urine.\n\ngI abd soft with absent bowel sounds. abd dsg intact with visable serosang drainage noted via transparent dsg. jp's ddraining sero sang drainage. ngt to lcws and draining pink ddrainage.\n\n action: labs as ordered. wbc 19.9 --23.5. lactated ringer at 150cc/hr. propofol gtt. npo ngt to lcws. chest tube to suction. on iv fluconazole, cipro and flagyl. family updated by dr \n\nresponse: monitor closelly.\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-01 00:00:00.000",
"description": "Report",
"row_id": 1622635,
"text": "Respiratory care:\nPt. Extubated to a 50% cool neb. At extubation she brady'd down to 40\"s but spontaniously recovered a few seconds later. Pre-extubation she was Sx'd for small amount of loose yellow secretions, that cleared the lungs. Sat = 99%; RR = 25; BP = 92/47. vocating well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-11-01 00:00:00.000",
"description": "Report",
"row_id": 1622636,
"text": "Condition Update\nD: See carevue flowsheet for specifics\n Patient afebrile WBC elevated on AM labs. HR in afib with rate 90-115 most of the day. ABP for the most part 90-100 with drops into the 80's which coincided with drops in urine these episodes treated with fluid bolluses. After 3L of LR BP now maintaining around 100 systolically. Due to need for aggressive fluid ressucitation and TPN CVL placed while patient still intubated. Placement of CVL checked with CXR which showed line needed to be pulled back 3cm, line pulled back, pt extubated and CXR done again and placement was confirmed. Due to amt of of fluid given over the day urine lytes sent this eve.\n pt resp status stable. O2 weaned down to 4L NC. Left chest tube with serous fluid out small leak noted but no leakage from around site after dressing changed this am. Lungs clear and dim in bases. Cough weak d/t splinting abd incision.\n Abd soft/lge with w->D dressing packed in am with serosang drg. JP's patent and stripped frequently. Right JP with sanginous/bloody output and Left with more sanginous output. Both with some puss like sediment. Spec sent from Right JP for amylase.\n Pt is a/oX3 and denying pain until this eve when c/o some back pain in near left shoulder blade. Lots of grimacing noted when repositioning. Dilaudid .5mg iv given.\n TPN started for nutrition this eve along with insulin gtt d/t elevated bloodsugars.\n Pt's daughter (contact person) in and updated by RN throughout the day. Pt's huband also in to visit.\nPLAN:\n F/U with urine lytes\n Map>60\n Dilaudid for pain\n Insulin gtt for bloodsugar control\n Notify H.O. with any changes\n"
},
{
"category": "ECG",
"chartdate": "2187-11-02 00:00:00.000",
"description": "Report",
"row_id": 130355,
"text": "Baseline artifact. Atrial fibrillation with an average ventricular response\nabout 95 per minute. Relatively low voltage diffusely. Non-specific ST-T wave\nchanges. Compared to the previous tracing of atrial fibrillation is now\nseen. Clinical correlation is suggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2187-10-30 00:00:00.000",
"description": "Report",
"row_id": 130356,
"text": "Sinus rhythm. Intraventricular conduction delay. Diffuse non-specific\nT wave abnormalities. Compared to prior tracing of ventricular\nectopy is no longer present. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2187-10-29 00:00:00.000",
"description": "Report",
"row_id": 130357,
"text": "Sinus rhythm with ventricular premature beats. Diffuse non-specific ST-T wave\nabnormalities. Compared with tracing of ventricular premature beats\nare new.\n\n"
}
] |
11,189 | 171,562 | As mentioned in the HPI, Mr. was transferred from OSH for coronary surgical revascularization. Given recent myocardial infarction and severe three vessel disease, intravenous Heparin was initiated. He otherwise remained stable on medical therapy and underwent further evaluation. Routine chest x-ray was notable for a tortuous and calcified for which a chest CT scan was obtained. There was calcification at the left side of the arch and the posterior proximal arch was only slightly dilated. There was no evidence of dissection. The CT scan also revealed a 3.1 cm spiculated mass in the right middle lobe, concerning for lung carcinoma. Given this finding, the Thoracic service was consulted. Head MR imaging found no evidence of metastatic disease. Spirometry showed normal lung volumes and PET imaging revealed focal abnormal uptake of FDG in a right middle lobe mass with a maximal SUV measured at 8.3. There was no FDG-avid or enlarged mediastinal or hilar nodes. Given the above, clinical findings were consistent with non-small cell lung carcinoma, stage T2N0. Coronary revascularization surgery was recommended followed by elective right middle lobectomy in weeks. All findings and recommendations were discussed with the patient. Further preoperative workup included abdominal ultrasound for elevated LFT's. Ultrasound was notable for multiple small mobile gallstones. There was no evidence of gallbladder wall thickening or edema and the common duct was not distended. The pancreatic head and body were unremarkable and there were no focal liver lesions. His preoperative AST/ALT/amylase/lipase peaked to /108 respectively. Bilirubins and alk phos remained within normal limits. Hepatology consult obtained. Right middle lobe mass also evaluated by Dr. of thoracic surgery and he will need lobectomy in weeks after CABG. Cardiology consult also done and he remained on a heparin drip prior to surgery. Underwent CABG x4 with Dr. on and was transferred to the CSRU in stable condition on neo and propofol drips. Extubated in the early morning, transfused one unit PRBCs, and chest tubes removed. Beta blockade started and transferred to the floor to on POD #2 to begin increasing his activity level.ACE inhibitor also titrated.Short bursts of AFib treated with amiodarone on POD #4 and pacing wires removed. Cleared for discharge to home with VNA on POD #5. | Will wean vent as pt awakens more.GI/GU: Abd soft, -BS. Mild (1+) aortic regurgitation is seen. Denies pain at present time.CV: Epicardial wires as noted above. Monitor resp. There are simple atheroma in the descendingthoracic . Wean vent as pt tolerates. Sternal dsg w/ small amt of serosang., small amt of crepitus noted to top part of dsg area, NP aware. Mild [1+] TR.PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Mild (1+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. ace wrap to rle cdi. Mildly thickened aortic valveleaflets. Pt reversed and waking up. See carevue for ABGs and vent changes. Resp. : Normal aortic root diameter. Bright, cooperative and following commands, but when asleep becomes apneic.CVS: afebrile, hr sinus 70's, SBP now > 100 off neo. CVL site very , NP aware, changed dsg, cdi at present. Left groin site , NP aware, dsg changed SR 70-80s. Mildlydilated descending . +OGT placement, draining clear secretions. Resting regionalwall motion abnormalities include hypokinesis of apex and apical segments.Right ventricular chamber size and free wall motion are normal. Care NotePt received from OR s/p CABG x4. Perrla. The descendingthoracic is mildly dilated. Lungs clear throughout, sats 100.GI: abd soft, bs hypo. Normal ascending diameter. Orally intubated, weaning vent as pt tolerates. Otherparameters as pre-bypass. Plan is to wean to PSV and extubate once more consistantly awake. Placed on vent with SIMV settings as charted on resp flowsheet. To CSRU on neo and propofol. No MR.TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Pulses present x 4 ext. To CSRU SR 70s, a wires do not work despite changing polarities, v wires w/ inappropriate random spiking.Neuro: Received pt sedated on propofol, able to wean propofol after reversals given once pt warmed to >36 as per protocol. On neo gtt as high as 1.75mcg, see carevue. PATIENT/TEST INFORMATION:Indication: cabgStatus: InpatientDate/Time: at 09:46Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.LV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior- normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal- normal; basal inferoseptal - normal; mid inferoseptal - normal; basalinferior - normal; mid inferior - normal; basal inferolateral - normal; midinferolateral - normal; basal anterolateral - normal; mid anterolateral -normal; anterior apex - hypo; septal apex - hypo; inferior apex - hypo;lateral apex - hypo; apex - hypo;RIGHT VENTRICLE: Normal RV chamber size and free wall motion. On IMV 12, 0.4, overbreathing when awake. Themitral valve leaflets are mildly thickened. No mitral regurgitation is seen.The tricuspid valve leaflets are mildly thickened. Nursing Progress NoteNeuro: alert, remains ett unable to speak. Speaking, A & O x3. restraints off, pupils 2 mm brisk equal reactive. +palpable pulses. Simple atheroma in descending .AORTIC VALVE: Three aortic valve leaflets. Rare PVC noted. status. Sinus bradycardiaAnteroseptal T wave changesSince previous tracing, no significant change The aortic valveleaflets are mildly thickened. SBP 90-120. Sinus bradycardia. Follows commands. Nursing Progress Note:CV- Tele: SR no ectopy- HR 90's this am- lopressor 12.5mg given @ 10am- HR now 66-78- R radial A line ABP 97-120/51-62- MAPs 65-81- NIBP correlating MAPs 62-73- CVP 8- 13- Hct this am 25- lactic acid 3.2- 1u PRBC's ordered & given- repeat Hct 28.6- lactic acid 2.8- 2nd u PRBC's ordered & infused without incident- repeat Hct 30.9- lactic acid 2.7- K 4.9- ionized Ca 1.24- A & V wires sense but do not capture appropriately- pacer box off- A sensitivity .5 V sensitivity 2.5Resp- In O2 3L via NC- last ABG 7.33-39-81-(-)4- 21-96%- lung sounds diminished @ bases- SpO2 97-100%- CT tubes D/C'd- dsg intact- C&DB encouraged- using IS.Neuro- A&O X3- moving all extremities- pleasant & cooperative- follows command- PERLGI- abd soft with hypoactive bowel sounds- denies passing flatus- taking Po liquid fairly well & without incident- glucose range 118- 151- insulin given as per sliding scale.GU- foley draining clear amber colored urine in small amts- U/O trending down this afternoon- 500cc fluid bolus given @ 1600 with some effect- Pt due lasix @ 1800, however would hold if U/O improves due to improving metabolic acidosis.Comfort- medicated with dilaudid 4mg Po X2 today with effect- OOB to chair without difficulty.Plan: monitor hemodynamics- increase activity & diet as tolerated- IS q1hr while awake- medicate for comfort- follow U/O- ? transfer to 2 once metabolic acidosis resolves. Biphasic to inverted T waves in leads I, aVL and VI-V5 withslight ST segment depression in lead V6. CVP 6-9. ogt pos placement verified by air bolus.GU: Foleyc ath draining clear yellow uringe.Endo: Insulin gtt off, sc given.Pain: morphine 1 mg ivp x 1, denies at this time.Plan: Continue to wean vent as tolerated to extubate. There is no pericardialeffusion.Post-CPB: Preserved biventricular systolic fxn. I certifyI was present in compliance with HCFA regulations. CVP 5-8. Pain control. A wires pace the diaphragm.Resp: remains intubated, not requiring sedation. RIJ multilumen patent x 3 ports. Manage blood sugars, pain control.See carevue flowsheet and mars for further details and values. MAE. No previous tracing available for comparison.Followup and clinical correlation are suggested. Neuro: A&O X3, initiates conversation, well spoken, MAE's well, pain X1, medicated with dilaudid po with good resultsCardiac: SR with occasional PAC, replaced mag X1, epi pacer offResp: O2 via NC @ 2LPM, SPO2 > 92%, LS clear, denies SOBGI: + BS, no BM, no flatus, tolerating liwuids and solids wellGU: foley to gravity draining@ 20cc clear yellow urine, 500cc bolus NS with minimal resultsEndo: SSRI per protocolPaln: transfer to 2 today, monitor labs and vitals and treat as indicated and as ordered The patient was under generalanesthesia throughout the procedure.Conclusions:Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage.Left ventricular wall thicknesses and cavity size are normal. | 10 | [
{
"category": "Echo",
"chartdate": "2185-10-25 00:00:00.000",
"description": "Report",
"row_id": 82710,
"text": "PATIENT/TEST INFORMATION:\nIndication: cabg\nStatus: Inpatient\nDate/Time: at 09:46\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal anterior\n- normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal\n- normal; basal inferoseptal - normal; mid inferoseptal - normal; basal\ninferior - normal; mid inferior - normal; basal inferolateral - normal; mid\ninferolateral - normal; basal anterolateral - normal; mid anterolateral -\nnormal; anterior apex - hypo; septal apex - hypo; inferior apex - hypo;\nlateral apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\n: Normal aortic root diameter. Normal ascending diameter. Mildly\ndilated descending . Simple atheroma in descending .\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR.\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. 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:\nPre-CPB: No spontaneous echo contrast is seen in the left atrial appendage.\nLeft ventricular wall thicknesses and cavity size are normal. Resting regional\nwall motion abnormalities include hypokinesis of apex and apical segments.\nRight ventricular chamber size and free wall motion are normal. The descending\nthoracic is mildly dilated. There are simple atheroma in the descending\nthoracic . There are three aortic valve leaflets. The aortic valve\nleaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. No mitral regurgitation is seen.\nThe tricuspid valve leaflets are mildly thickened. There is no pericardial\neffusion.\nPost-CPB: Preserved biventricular systolic fxn. No MR. . Other\nparameters as pre-bypass.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2185-10-25 00:00:00.000",
"description": "Report",
"row_id": 197471,
"text": "Sinus rhythm\nAnterolateral ST-T changes are nonspecific\nLow QRS voltages in limb leads\nEarly R wave progression\nSince previous tracing, heart rate increased, T wave inversion in leads V2-V3\nnot seen\n\n"
},
{
"category": "ECG",
"chartdate": "2185-10-24 00:00:00.000",
"description": "Report",
"row_id": 197472,
"text": "Sinus bradycardia\nAnteroseptal T wave changes\nSince previous tracing, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2185-10-17 00:00:00.000",
"description": "Report",
"row_id": 197473,
"text": "Sinus bradycardia. Biphasic to inverted T waves in leads I, aVL and VI-V5 with\nslight ST segment depression in lead V6. These findings may represent an active\nanterolateral ischemic process. No previous tracing available for comparison.\nFollowup and clinical correlation are suggested.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-10-25 00:00:00.000",
"description": "Report",
"row_id": 1409592,
"text": "Admission\nPt is a 70 year old male admitted to CSRU s/p cabgx4, see admission history sheet for details. Uneventful intra-op. To CSRU on neo and propofol. To CSRU SR 70s, a wires do not work despite changing polarities, v wires w/ inappropriate random spiking.\n\nNeuro: Received pt sedated on propofol, able to wean propofol after reversals given once pt warmed to >36 as per protocol. Perrla. MAE. Follows commands. Denies pain at present time.\n\nCV: Epicardial wires as noted above. CVL site very , NP aware, changed dsg, cdi at present. Left groin site , NP aware, dsg changed SR 70-80s. Rare PVC noted. SBP 90-120. On neo gtt as high as 1.75mcg, see carevue. Sternal dsg w/ small amt of serosang., small amt of crepitus noted to top part of dsg area, NP aware. CVP 5-8. +palpable pulses. NP aware of HCT,NA, and all labs, no new orders at present time.\n\nResp: LS clear. Orally intubated, weaning vent as pt tolerates. On SIMV rate 8 at present, pt breathing over vent 12-14, PS 5, Peep 5, FiO2 50%. Sats >97%. See carevue for ABGs and vent changes. Pt too sleepy at this time for CPAP 5/5, w/ periods of apnea. Will wean vent as pt awakens more.\n\nGI/GU: Abd soft, -BS. +OGT placement, draining clear secretions. Foley draining adequate amts of clear yellow urine.\n\nEndo: Insulin gtt started for FS 140s, see carevue for details.\n\nPlan: Monitor hemodynamics. Monitor resp. status. Pain control. Wean vent as pt tolerates. Follow labs and treat as appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-10-25 00:00:00.000",
"description": "Report",
"row_id": 1409593,
"text": "Resp. Care Note\nPt received from OR s/p CABG x4. Placed on vent with SIMV settings as charted on resp flowsheet. Pt reversed and waking up. Plan is to wean to PSV and extubate once more consistantly awake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-10-26 00:00:00.000",
"description": "Report",
"row_id": 1409594,
"text": "Nursing Progress Note\nAddendum: Extubated without incident at 0530 to 50 % face tent. Speaking, A & O x3. Tol ice chips, off all gtts. Using cough pillow and taught to use IS, able to raise to 300 x10 on first attempt. Plan to transfer to floor today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-10-26 00:00:00.000",
"description": "Report",
"row_id": 1409595,
"text": "Nursing Progress Note\nNeuro: alert, remains ett unable to speak. restraints off, pupils 2 mm brisk equal reactive. Bright, cooperative and following commands, but when asleep becomes apneic.\n\nCVS: afebrile, hr sinus 70's, SBP now > 100 off neo. CVP 6-9. RIJ multilumen patent x 3 ports. ace wrap to rle cdi. Pulses present x 4 ext. Hands and feet cool with good capillary refill, A and V wires both senes but do not capture appropriately. A wires pace the diaphragm.\n\nResp: remains intubated, not requiring sedation. Failing Cpap trials having periods of apnea. On IMV 12, 0.4, overbreathing when awake. Lungs clear throughout, sats 100.\n\nGI: abd soft, bs hypo. ogt pos placement verified by air bolus.\n\nGU: Foleyc ath draining clear yellow uringe.\n\nEndo: Insulin gtt off, sc given.\n\nPain: morphine 1 mg ivp x 1, denies at this time.\n\nPlan: Continue to wean vent as tolerated to extubate. Manage blood sugars, pain control.\n\nSee carevue flowsheet and mars for further details and values.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-10-26 00:00:00.000",
"description": "Report",
"row_id": 1409596,
"text": "Nursing Progress Note:\n\nCV- Tele: SR no ectopy- HR 90's this am- lopressor 12.5mg given @ 10am- HR now 66-78- R radial A line ABP 97-120/51-62- MAPs 65-81- NIBP correlating MAPs 62-73- CVP 8- 13- Hct this am 25- lactic acid 3.2- 1u PRBC's ordered & given- repeat Hct 28.6- lactic acid 2.8- 2nd u PRBC's ordered & infused without incident- repeat Hct 30.9- lactic acid 2.7- K 4.9- ionized Ca 1.24- A & V wires sense but do not capture appropriately- pacer box off- A sensitivity .5 V sensitivity 2.5\n\nResp- In O2 3L via NC- last ABG 7.33-39-81-(-)4- 21-96%- lung sounds diminished @ bases- SpO2 97-100%- CT tubes D/C'd- dsg intact- C&DB encouraged- using IS.\n\nNeuro- A&O X3- moving all extremities- pleasant & cooperative- follows command- PERL\n\nGI- abd soft with hypoactive bowel sounds- denies passing flatus- taking Po liquid fairly well & without incident- glucose range 118- 151- insulin given as per sliding scale.\n\nGU- foley draining clear amber colored urine in small amts- U/O trending down this afternoon- 500cc fluid bolus given @ 1600 with some effect- Pt due lasix @ 1800, however would hold if U/O improves due to improving metabolic acidosis.\n\nComfort- medicated with dilaudid 4mg Po X2 today with effect- OOB to chair without difficulty.\n\nPlan: monitor hemodynamics- increase activity & diet as tolerated- IS q1hr while awake- medicate for comfort- follow U/O- ? transfer to 2 once metabolic acidosis resolves.\n"
},
{
"category": "Nursing/other",
"chartdate": "2185-10-27 00:00:00.000",
"description": "Report",
"row_id": 1409597,
"text": "Neuro: A&O X3, initiates conversation, well spoken, MAE's well, pain X1, medicated with dilaudid po with good results\nCardiac: SR with occasional PAC, replaced mag X1, epi pacer off\nResp: O2 via NC @ 2LPM, SPO2 > 92%, LS clear, denies SOB\nGI: + BS, no BM, no flatus, tolerating liwuids and solids well\nGU: foley to gravity draining@ 20cc clear yellow urine, 500cc bolus NS with minimal results\nEndo: SSRI per protocol\nPaln: transfer to 2 today, monitor labs and vitals and treat as indicated and as ordered\n"
}
] |
30,846 | 129,568 | # BRBPR: Upon admission, she was hemodynamically stable with no evidence of tachycardia or hypotension with hct within baseline. Etiology was initially suspected to be a lower GI source, especially given her history of bleeding hemorrhoids and known diverticuli. She was on Plavix and ASA on admission for an intra-vertebral artery stent placed in . Initial treament included placing 2 large bore PIVs and hemodynamic monitoring. She was transfused 3u PRBC total for a falling Hct. On , she was transferred to the MICU for closer monitoring. Given active bleeding, Plavix and ASA were held and Neurology was consulted. Neurology confirmed that she could remain off of the Plavix indefinitely, but that she should restart ASA when hemodynamically stable. Per GI consult, she had a colonoscopy on which revealed continued bleeding to the ileum without an obvious lesion. Thus an EGD was performed on which did not reveal an upper GI source of bleeding. A dudenal polyp was found and was sent for biopsy. She was restarted on diovan. On discharge, her hct remained stable. She was continued on ASA. . # s/p CVA: She is s/p CVA in s/p intra-arterial TPA with stent placed in R vertebral artery. She has residual R eyelid ptosis and double vision with no new or worsened deficits. Neurology was consulted on admission given need to hold anti-platelt therapy. They confirmed that Plavix could be discontinued given the nature of her stent, but that aspirin should be restarted once she was hemodynamically stable. She was restarted on ASA on discharge. . # HTN: Her outpt regimen of Diovan was restarted on discharge. . # Asthma: She was continued outpatient albuterol and advair. . # Hyperlipidemia: She was continued on her outpatient regimen of atorvastatin. . | PROTONIX D/C'ED.RENAL: VOIDING. Sinus rhythmNormal ECGSince previous tracing of , sinus tachycardia absent C/o head ache, refused tylenol, MD aware. patient denies pain.Resp: On room air, o2 sats 95-100, Bilateral lung sounds clear.Cv: NSR, SBP 100-130. transfused 2 unit PRBC overnight. SATS97% ON RA.GI: REMAINS NPO. Respiuratory Care:Pt on PRN nebs but has not recieved any from RT..BS's are essentislly clear. Prep started on at 0330 am and not able to drink so far even after with encouragement.neuro: Alert, oriented x3, following commands and able to use bed side commode. Denie ant other pain.Resp: On room air, O2 sats 95-98. 1 unit PRBC given for hct 27.3. IS UPSET ABOUT BEING HERE.COAGS: INR 1.1.ENDOC: K+ 3.9. IVF'S CONT. REMAINS OFF PLAVIX AND ASA. MICU NPN 0100-1900Review carevue for additional dataEvents: Transfused 2units PRBCs, prep for scope this AM, patient is unhappy for drinking GOlytely, able to drink only ?500ml.neuro: Alert, oriented x3, pleasant, following commands and MAE. FURTHER Q4HRS HCTS D/C'ED. NSR without ectopy, SBP 100-130's. NURSING NOTES 7AM-19PMRESP: BS'S CLEAR. Sinus rhythmNormal ECGSince previous tracing of , no significant change Am labs awaitting.Gi/Gu: NPO, abd soft, Bs present, continues to have 4 melenotic/bright rd blood stool.Patient was started on Golytely bowel prep for colonoscopy from yesterday 0300 and not able drink completely and MD aware. Voiding adequate amount of clear yellow urine.skin: INtactAccess: PIV x2Plan: ? MICU NPN 1900-0700Review carevue for all addtional dataEvents: HCT down to 27.3 from 32.1, transfused 1 unit PRBC. patient voiding along with stool.Skin: IntactSocial: Patient needs social work consult for her insurance coverage.Plan: Monitor HCt Q 4hrly Colonoscopy this Am after bowel prep, needs to encourage to drink golytely. H/O CVA in , was on ASA and plavix, able to use bed side commode. for colonoscopy today Encourage to drink golytely Monitor HCT/ for gi bleed Routine support and care. NEURO CONSULT INTO SEE PT. REFUSING NGT. AT 125CC/HR.CV: HEMODYNAMICALLY STABLE.NEURO: ALERT AND ORIENTATED. SIPPING AT GO-LYTELY-UP TO COMMODE FOR MAROON LIQUID WITH SMALL AMTS OF STOOL. Bilateral lung sounds clear.Cv: Haemodynamically stable. NA 142.HEM: POST HCT 32.9-REPEAT AT NOON 32.1. STATES SHE NORMALLY IS FATIGUED. STILL UNABLE TO DO COLONOSCOPY. PT. NS 125ml/hr oflow. Patient waitting for colonoscopy, but very upset to drink golytely. EXPLAINED THAT MRS WOULD BE ABLE TO GET FREE CARE ALONG WITH HER INSURANCE TO HELP PAY FOR HER HOSPITALIZATION.PLAN: PROBABLE COLONOSCOPY TOMORROW, BUT AM AWAITING GI FOR UPDATE RE: HER PROCEDURE. afebrile.Gi/Gu; NPO,abd soft, BS present BM x3 bright red blood. SLEPT IN SHORT NAPS. NEXT HCT AT 20PM.SOCIAL: SOCIAL WORKER CAME TO SEE PT, BUT SHE WAS SLEEPING. | 6 | [
{
"category": "Nursing/other",
"chartdate": "2186-01-24 00:00:00.000",
"description": "Report",
"row_id": 1658169,
"text": "MICU NPN 0100-1900\nReview carevue for additional data\n\nEvents: Transfused 2units PRBCs, prep for scope this AM, patient is unhappy for drinking GOlytely, able to drink only ?500ml.\n\nneuro: Alert, oriented x3, pleasant, following commands and MAE. H/O CVA in , was on ASA and plavix, able to use bed side commode. patient denies pain.\n\nResp: On room air, o2 sats 95-100, Bilateral lung sounds clear.\n\nCv: NSR, SBP 100-130. transfused 2 unit PRBC overnight. afebrile.\nGi/Gu; NPO,abd soft, BS present BM x3 bright red blood. patient voiding along with stool.\n\nSkin: Intact\nSocial: Patient needs social work consult for her insurance coverage.\n\nPlan: Monitor HCt Q 4hrly\n Colonoscopy this Am after bowel prep, needs to encourage to drink golytely. Social work consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-24 00:00:00.000",
"description": "Report",
"row_id": 1658170,
"text": "Respiuratory Care:\nPt on PRN nebs but has not recieved any from RT..BS's are essentislly clear.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-24 00:00:00.000",
"description": "Report",
"row_id": 1658171,
"text": "NURSING NOTES 7AM-19PM\nRESP: BS'S CLEAR. SATS97% ON RA.\nGI: REMAINS NPO. SIPPING AT GO-LYTELY-UP TO COMMODE FOR MAROON LIQUID WITH SMALL AMTS OF STOOL. STILL UNABLE TO DO COLONOSCOPY. REFUSING NGT. PROTONIX D/C'ED.\nRENAL: VOIDING. IVF'S CONT. AT 125CC/HR.\nCV: HEMODYNAMICALLY STABLE.\nNEURO: ALERT AND ORIENTATED. STATES SHE NORMALLY IS FATIGUED. SLEPT IN SHORT NAPS. NEURO CONSULT INTO SEE PT. REMAINS OFF PLAVIX AND ASA. PT. IS UPSET ABOUT BEING HERE.\nCOAGS: INR 1.1.\nENDOC: K+ 3.9. NA 142.\nHEM: POST HCT 32.9-REPEAT AT NOON 32.1. FURTHER Q4HRS HCTS D/C'ED. NEXT HCT AT 20PM.\nSOCIAL: SOCIAL WORKER CAME TO SEE PT, BUT SHE WAS SLEEPING. EXPLAINED THAT MRS WOULD BE ABLE TO GET FREE CARE ALONG WITH HER INSURANCE TO HELP PAY FOR HER HOSPITALIZATION.\nPLAN: PROBABLE COLONOSCOPY TOMORROW, BUT AM AWAITING GI FOR UPDATE RE: HER PROCEDURE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-01-25 00:00:00.000",
"description": "Report",
"row_id": 1658172,
"text": "MICU NPN 1900-0700\nReview carevue for all addtional data\n\nEvents: HCT down to 27.3 from 32.1, transfused 1 unit PRBC. Patient waitting for colonoscopy, but very upset to drink golytely. Prep started on at 0330 am and not able to drink so far even after with encouragement.\n\nneuro: Alert, oriented x3, following commands and able to use bed side commode. C/o head ache, refused tylenol, MD aware. Denie ant other pain.\n\nResp: On room air, O2 sats 95-98. Bilateral lung sounds clear.\nCv: Haemodynamically stable. NSR without ectopy, SBP 100-130's. NS 125ml/hr oflow. 1 unit PRBC given for hct 27.3. Am labs awaitting.\n\nGi/Gu: NPO, abd soft, Bs present, continues to have 4 melenotic/bright rd blood stool.Patient was started on Golytely bowel prep for colonoscopy from yesterday 0300 and not able drink completely and MD aware. Voiding adequate amount of clear yellow urine.\n\nskin: INtact\nAccess: PIV x2\n\nPlan: ? for colonoscopy today\n Encourage to drink golytely\n Monitor HCT/ for gi bleed\n Routine support and care.\n\n"
},
{
"category": "ECG",
"chartdate": "2186-01-24 00:00:00.000",
"description": "Report",
"row_id": 312180,
"text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2186-01-23 00:00:00.000",
"description": "Report",
"row_id": 312181,
"text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , sinus tachycardia absent\n\n"
}
] |
31,692 | 116,133 | SIRS/Sepsis: Patient met SIRS criteria based on tachycardia and bandemia of 29%. Most likely cause is PNA given underlying severe sarcoidosis, other consideration is infected midline which has been in place for unclear duration of time. Vancomycin IV was started to cover for possible line infection. Meropenem was started to provide coverage for resistant pseudomonas seen on recent sputum culture. Patient's urinalysis was unremarkable. Urine cultures were obtained. PICC line was discontinued on arrival to ICU. Patient had central line placed in ED. IVF fluids were administered to maintain CVP 8-10. With progressive hypoxia patient became hypotensive requiring norepinephrine and phenylephrine to maintain MAP > 65 on his second day of admission. Additional fluid boluses had no effect on hypotension and tachycardia. Pressors were discontinued only after the family made the decision to make him CMO. | The right IJ catheter appears to have been pulled back to the upper to mid portion of the SVC. Mild (1+) aortic regurgitation is seen. Mild (1+) aortic regurgitation is seen. CXR c BLL fibrotic changes and BUL cysts, minimal change from prior. Noted to have agonal respirations. Noted to have agonal respirations. Noted to have agonal respirations. Right IJ catheter is terminating at the cavoatrial junction. There is a trivial/physiologic pericardial effusion. There is a trivial/physiologic pericardial effusion. Remainder of PMH/HPI/ROS as above, NKDA. A nasointestinal tube terminates in the distal esophagus and can be advanced. He had grade 2 fibrosis on . He had grade 2 fibrosis on . Compared with the prior study (images reviewed) of , right ventricular systolic function now appears depressed. Compared with the prior study (images reviewed) of , right ventricular systolic function now appears depressed. A right internal jugular catheter terminates at the cavoatrial junction. Status post mandible fracture . Status post mandible fracture . Diffuse prominence of interstitial markings persists, consistent with the patient's known sarcoidosis. Healing left distal clavicle fracture. Healing left distal clavicle fracture. Sarcoidosis. Sarcoidosis. Right ventricular systolic function appears depressed. Right ventricular systolic function appears depressed. Foley catheter and multilumen catheter retained. Foley catheter and multilumen catheter retained. Patient started deteriorating, made as comfortable as possible. Patient started deteriorating, made as comfortable as possible. Patient started deteriorating, made as comfortable as possible. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. Blood gases done, progresssivly getting worse, initially 7.21/85/87, then trending down to 7.14/88/50 with max vent settings. Blood gases done, progresssivly getting worse, initially 7.21/85/87, then trending down to 7.14/88/50 with max vent settings. Blood gases done, progresssivly getting worse, initially 7.21/85/87, then trending down to 7.14/88/50 with max vent settings. Significant pulmonic regurgitation is seen. Significant pulmonic regurgitation is seen. Intubated in ED, currently critically ill on A/C vent and with borderline BP. Resolution of right upper lobe pneumonia. Resolution of right upper lobe pneumonia. Sinus tachycardia. RIJ placed in ED, rx steroids, abx and xfered to . Last rites performed. Last rites performed. Last rites performed. There is moderate pulmonary artery systolic hypertension. There is moderate pulmonary artery systolic hypertension. Pt made a DNR. Pt made a DNR. Pt made a DNR. Started on comfort measures. Started on comfort measures. Started on comfort measures. The ascending aorta is mildly dilated. The ascending aorta is mildly dilated. Upon arrival to ICU, BP trending down to mid 80 Action: Propofol decreased to 40mcg/hr, fluid bolus of 2 liters given , A line inserted in L arm Response: Responsive to fluid boluses, Bp currently in 120s systolic with a MAP of 92 Plan: Monitor VSS closely, bolus as tolerated, titrate propofol as tolerated. Respiratory failure, acute (not ARDS/) Assessment: Remains intubated, sedation changed from propofo gttl -> versed/fentanyl gtts overnight. Respiratory failure, acute (not ARDS/) Assessment: Remains intubated, sedation changed from propofo gttl -> versed/fentanyl gtts overnight. #Type 2 DM likely component chronic steroids -continue NPH/HISS ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 04:00 PM Arterial Line - 07:30 PM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR / DNI Disposition: #Type 2 DM steroids likely contributing to hyperglycemia -continue NPH/HISS ICU Care Nutrition: TF Glycemic Control: RISS Lines: Multi Lumen - 04:00 PM Arterial Line - 07:30 PM Prophylaxis: DVT: SQH Stress ulcer: PPI Code status: DNR / DNI Disposition: ICU -empiric and aggressive pna treatment, difficult to interpret change in CXR given very abnl baseline Continue vanco and meropenem, taper per cx data in next 48 hrs consider double psuedo coverage, touch base with ID service given his resistent organisms in past check legionella antigen and add atypoical coverage empirically continue empiric PCP coverage and send DFA - consider bronchoscopy to obtain sputum sample, though has # 7 ET tube # mechanical ventillation -- wean FIO2 as tolerated for Sat >90 -once stable would get CTA scan to further evaluate for degree of airway disease -albuterol/atrovent MDI # PE remaijhns in ddx--given bandemia and temps lower suspicion, will check lenis and when stable, get cta # bandemia--presumed pulm infection, cover as above #End stage sarcodiosis - has severe sarcoid at baseline on high dose steroids. 55 yo M with PMH of end stage sarcodiosis, Hep C, admitted with fever, tachypnea, and hypoxia intubated in ED concern for increased work of breathing and hypoxia. 55 yo M with PMH of end stage sarcodiosis, Hep C, admitted with fever, tachypnea, and hypoxia intubated in ED concern for increased work of breathing and hypoxia. 55 yo M with PMH of end stage sarcodiosis, Hep C, admitted with fever, tachypnea, and hypoxia intubated in ED concern for increased work of breathing and hypoxia. -vancomycin IV to cover for possible line infection -meropenam given recent h/o resistant pseudomonas on recent sputum cx -ua unremarkable, f/u urine culture -d/c midline, send tip for culture -BP had been stable until propofol started, will d/c propofol and -IVF for CVP 8-10, will start levophed if MAP still < 65 despite CVP at goal . | 35 | [
{
"category": "Physician ",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 331019,
"text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 04:00 PM\n L brachial\n MULTI LUMEN - START 04:00 PM\n inserted in ED\n INVASIVE VENTILATION - START 04:15 PM\n PICC LINE - STOP 07:30 PM\n L brachial\n ARTERIAL LINE - START 07:30 PM\n URINE CULTURE - At 09:27 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:07 PM\n Bactrim (SMX/TMP) - 01:00 AM\n Meropenem - 06:02 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 7 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:06 PM\n Midazolam (Versed) - 11:17 PM\n Fentanyl - 11:17 PM\n Heparin Sodium (Prophylaxis) - 12:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 124 (94 - 124) bpm\n BP: 122/84(99) {38/-12(91) - 149/85(352)} mmHg\n RR: 24 (14 - 28) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 88 kg (admission): 88 kg\n Height: 67 Inch\n CVP: 11 (6 - 14)mmHg\n Total In:\n 2,538 mL\n 846 mL\n PO:\n TF:\n 20 mL\n IVF:\n 2,538 mL\n 827 mL\n Blood products:\n Total out:\n 790 mL\n 635 mL\n Urine:\n 790 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,748 mL\n 211 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 14 cmH2O\n RR (Set): 0\n RR (Spontaneous): 20\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 30 cmH2O\n SpO2: 90%\n ABG: 7.28/68/77/28/2\n Ve: 12.1 L/min\n PaO2 / FiO2: 77\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 246 K/uL\n 11.4 g/dL\n 134 mg/dL\n 0.3 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 135 mEq/L\n 34.7 %\n 15.4 K/uL\n [image002.jpg]\n 03:14 PM\n 07:03 PM\n 08:52 PM\n 02:16 AM\n 03:33 AM\n 04:57 AM\n WBC\n 8.9\n 15.4\n Hct\n 30.6\n 34.7\n Plt\n 216\n 246\n Cr\n 0.3\n 0.3\n TropT\n <0.01\n <0.01\n TCO2\n 36\n 34\n 34\n 33\n Glucose\n 89\n 134\n Other labs: PT / PTT / INR:13.9/27.5/1.2, CK / CKMB /\n Troponin-T:25/4/<0.01, ALT / AST:101/73, Alk Phos / T Bili:261/1.2,\n Lactic Acid:2.0 mmol/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 55 yo M with PMH of end stage sarcodiosis admitted with fever,\n tachypnea, and hypoxia intubated in ED concern for increased work\n of breathing and hypoxia.\n .\n #SIRS/Sepsis - meets criteria based on tachycardia and bandemia of 29%\n on diff,most likely due to PNA given underlying severe sarcoidosis,\n other consideration is infected midline which has been in place for\n unclear duration of time. UA unremarkable and unlikely the source but\n will f/u.\n -vancomycin IV to cover for possible line infection\n -meropenam given recent h/o resistant pseudomonas on recent sputum cx\n -ua unremarkable, f/u urine culture\n -d/c midline, send tip for culture\n -BP had been stable until propofol started, will d/c propofol and\n -IVF for CVP 8-10, will start levophed if MAP still < 65 despite CVP at\n goal\n .\n #Hypoxemic respiratory failure - in setting of report of fever\n concerning for superimposed PNA on severe pulmonary fibrosis end\n stage sarcoid. No clear infiltrate on CXR although difficult to\n interpret in the setting of already severe pulmonary fibrosis.\n -treat for possible PNA given high susceptibility given underlying\n pulmonary abnormalities\n -vanc/meropenam for now for broad coverage given recent h/o multidrug\n resistant pseudomonas (resistant to zosyn and cefepime)\n -send sputum culture\n -f/u blood cultures\n -continue mechanical ventillation, wean FIO2 as tolerated for Sat >90\n -consider bronchoscopy to obtain sputum sample\n -consider CT scan to further evaluate for degree of airway disease\n -albuterol/atrovent MDI\n .\n #End stage sarcodiosis - has severe sarcoid at baseline on high dose\n steroids.\n -continue high dose steroids for now with solumedrol 60mg IV Q6\n -continue PCP prophylaxis /bactrim\n -consider bronch/CT scan as discussed above\n -continue mechanical ventillation\n -continue azathioprine\n .\n #H/O severe anxiety - on multiple agents at baseline for severe anxiety\n including ativan, risperdal, mirtazapine, haldol.\n -Will hold for now while sedated for mechanical ventillation\n -resume once getting close to weaning\n .\n #Chronic pain/spinal stenosis - on chronic ms contin/percocet, will\n hold for now and sedate with fentanyl/midazolam while intubated.\n .\n #Type 2 DM\n likely component chronic steroids\n -continue NPH/HISS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 07:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1023277,
"text": " 5:40 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate ETT position and NGT position\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with end stage pulmonary sarcoidosis admitted with fever,\n hypoxia concerning for PNA s/p intubation and NG tube placement\n REASON FOR THIS EXAMINATION:\n evaluate ETT position and NGT position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: End-stage sarcoidosis with fever, for nasogastric tube placement.\n\n FINDINGS: In comparison with earlier study of this date, the nasogastric tube\n extends to the upper stomach. The side hole remains within the distal\n esophagus. Diffuse prominence of interstitial markings persists, consistent\n with the patient's known sarcoidosis. Given this appearance, the possibility\n of supervening pneumonia would be very difficult to detect and must be\n considered on clinical grounds.\n\n The other tubes remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1023308,
"text": " 3:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate ETT position\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with end stage sarcoid, s/p intubation for resp failure, ETT\n advanced 3cm please re-eval position\n REASON FOR THIS EXAMINATION:\n evaluate ETT position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old man with end-stage sarcoid, status post intubation\n for respiratory failure, ETT advanced 3 cm, please evaluate for position.\n\n COMPARISON: .\n\n PORTABLE AP SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: Limited radiograph due to\n underpenetration and motion blurring.\n\n ET tube is in standard location, terminating 6 cm above the carina. Bilateral\n airspace opacities predominantly involving the lower lobes are unchanged.\n Heart size is mildly enlarged, partly due to technique related factors,\n unchanged. There is no overt CHF. There is no pneumothorax or pleural\n effusion. Right IJ catheter is terminating at the cavoatrial junction. NG\n tube, however, is not clearly visualized beyond the lower esophagus, further\n advancement by at least 15 cm is recommended.\n\n IMPRESSION: Limited due to blurring, consider repeat radiograph.\n 1. ET tube in standard location.\n 2. NG tube terminating in the lower esophagus. Further advancement by \n cm is recommended.\n 3. Bilateral airspace opacities predominantly in the right mid and left mid\n and lower lungs could reflect multifocal pneumonia, unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1023349,
"text": " 11:28 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluate ETT position, for pneumothorax, OG tube position\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with end stage sarcoid, PNA increasing hypoxia on maximal vent\n support, worsening hypotension\n REASON FOR THIS EXAMINATION:\n evaluate ETT position, for pneumothorax, OG tube position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sarcoid with increasing hypoxia.\n\n FINDINGS: In comparison with the study of , there is little change in the\n appearance of the heart and lungs. Diffuse bilateral pulmonary opacifications\n are again consistent with sarcoidosis, though the possibility of supervening\n pneumonia cannot be excluded.\n\n The right IJ catheter appears to have been pulled back to the upper to mid\n portion of the SVC. Other leads remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1023304,
"text": " 11:28 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Gastric Tube Placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with\n REASON FOR THIS EXAMINATION:\n Gastric Tube Placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Gastric tube placement.\n\n FINDINGS: In comparison with the earlier study, the nasogastric tube has been\n advanced into at least the lower body of the stomach with the side hole also\n within this structure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1023228,
"text": " 11:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ET tube\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with sarcoid and fever and resp distress\n REASON FOR THIS EXAMINATION:\n assess ET tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old male with sarcoid and fever, evaluate for position of\n ET tube.\n\n COMPARISON: \n\n AP UPRIGHT CHEST: Extensive pulmonary fibrosis and emphysema are unchanged.\n There is no evidence of effusion or pneumothorax. The endotracheal tube tip\n terminates 4.5 cm above the carina. A right internal jugular catheter\n terminates at the cavoatrial junction. A nasointestinal tube terminates in\n the distal esophagus and can be advanced.\n\n IMPRESSION: Satisfactory placement of a endotracheal tube with nasointestinal\n tube which lies approximately 6-7 cm above the gastroespophageal junction, and\n can be advanced. There is no evidence of acute cardiopulmonary changes.\n\n"
},
{
"category": "ECG",
"chartdate": "2186-07-01 00:00:00.000",
"description": "Report",
"row_id": 195165,
"text": "Sinus tachycardia. Technically limited study. Baseline artifact. Left\natrial abnormality. Non-specific ST-T wave changes are more prominent as\ncompared with previous tracing of . In addition, the rate has\nincreased. Otherwise, no diagnostic interim change.\n\n"
},
{
"category": "Nursing",
"chartdate": "2186-07-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330977,
"text": "55 year old man, with a h/o end stage sarcoidosis , DM, Hep C,\n spinal stonosis, presented to ED with SOB, rebreather mask a/o but\n sats not improving, maintaining in 80\ns, intubated in ED, Temp in ED\n 99.4, Hemodynamically stable.\n"
},
{
"category": "Nursing",
"chartdate": "2186-07-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330978,
"text": "55 year old man, with a h/o end stage sarcoidosis , DM, Hep C,\n spinal stonosis, presented to ED with SOB, rebreather mask a/o but\n sats not improving, maintaining in 80\ns, intubated in ED, Temp in ED\n 99.4, Hemodynamically stable.\n Pneumonia, aspiration\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2186-07-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330979,
"text": "55 year old man, with a h/o end stage sarcoidosis , DM, Hep C,\n spinal stonosis, presented to ED with SOB, rebreather mask a/o but\n sats not improving, maintaining in 80\ns, intubated in ED, Temp in ED\n 99.4, Hemodynamically stable.\n Pneumonia, aspiration\n Assessment:\n Pt on vent settings CMV/500/20/10 peep , Fio2 70%, Temp 96.7 oral.,\n Spo2 around 88-89%, LS diminished, lactate 1.8, WBC 13.2, HCT 32.1\n Action:\n Fio2 increased to 100%\n Response:\n Antibiotics given in ED, Cefapime, Levofloxacin and Vancomycin\n Plan:\n Continue with antibiotics, monitor VSS closely, follow up on blood\n cultures\n Hypotension (not Shock)\n Assessment:\n On arrival to ICU BP maintaining around 100s systolic, on Propofol\n 50mcg/hr from ED. Upon arrival to ICU, BP trending down to mid 80\n Action:\n Propofol decreased to 40mcg/hr, fluid bolus of 2 liters given , A\n line inserted in L arm\n Response:\n Responsive to fluid boluses, Bp currently in 120\ns systolic with a MAP\n of 92\n Plan:\n Monitor VSS closely, bolus as tolerated, titrate propofol as\n tolerated.\n NPO\n Has third spacing in R arm, dressing on.\n"
},
{
"category": "Nursing",
"chartdate": "2186-07-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330980,
"text": "55 year old man, with a h/o end stage sarcoidosis , DM, Hep C,\n spinal stonosis, presented to ED with SOB, rebreather mask a/o but\n sats not improving, maintaining in 80\ns, intubated in ED, Temp in ED\n 99.4, Hemodynamically stable.\n Pneumonia, aspiration\n Assessment:\n Pt on vent settings CMV/500/20/10 peep , Fio2 70%, Temp 96.7 oral.,\n Spo2 around 88-89%, LS diminished, lactate 1.8, WBC 13.2, HCT 32.1\n Action:\n Fio2 increased to 100%\n Response:\n Antibiotics given in ED, Cefapime, Levofloxacin and Vancomycin\n Plan:\n Continue with antibiotics, monitor VSS closely, follow up on blood\n cultures\n Hypotension (not Shock)\n Assessment:\n On arrival to ICU BP maintaining around 100s systolic, on Propofol\n 50mcg/hr from ED. Upon arrival to ICU, BP trending down to mid 80\n Action:\n Propofol decreased to 40mcg/hr, fluid bolus of 2 liters given , A\n line inserted in L arm\n Response:\n Responsive to fluid boluses, Bp currently in 120\ns systolic with a MAP\n of 92\n Plan:\n Monitor VSS closely, bolus as tolerated, titrate propofol as\n tolerated.\n NPO\n Has third spacing in R arm, dressing on.\n"
},
{
"category": "Physician ",
"chartdate": "2186-07-01 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 330981,
"text": "Chief Complaint: dyspnea, worsening hypoxia\n HPI:\n Mr. is a 55 yo M with end-stage sarcoid on 3LNC at\n baseline, transferred from Radius with shortness of breath, tachypnea,\n hypoxia and fevers. According to reports from Radius has has been\n hypoxic for several days with O2 sats 91-92% on 100% NRB with\n desaturation to 86% with minimal exertion, patient refusing to come to\n hospital.\n .\n In the ED T99.2 BP 145/84 RR 20-30 HR 92-140 96% on 100%NRB. He was\n noted to be significantly hypoxic and tachypnic and was intubated due\n to concern for increasing work of breathing. He was given 2.5LNS,\n levofloxacin 750mg IV, cefepime 2g IV x1, decadron 10mg IV x1 and\n versed 2mg IV x1.\n Patient admitted from: Transfer from other hospital, Radius\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Medications on Arrival:\n -Albuterol Sulfate 2.5 mg/3 mL neb q4 hours and q7 hours prn\n -Atrovent Nebs Q4Hours and Q 7 hours prn\n -Solu-medrol 60mg IV Q6hrs\n -Novalog sliding scale QACHS\n -mucomyst 10% 3ML INH QID\n -Clonazepam 1 mg PO TID prn\n -NPH insulin (unclear dosing had been on 12QAM and 6QPM during last\n admit)\n -Nexium 40mg daily\n -dulcolax 10mg pr qday prn\n -colace 100mg po bid\n -milk of magnesia 30ML daily\n -MS Contin 45mg \n -percocet 1-2 tabs TID prn\n -zocor 20mg daily\n -heparin SQ 5000mg TID\n -Azathioprine 150 mg PO DAILY\n -cymbalta 90mg po daily\n -ASA 325mg daily\n -Sennakot 1 \n -Bactrim DS 1 tab QMWF\n -trazodone 25mg qhs prn\n -vitamin b1 100mg daily\n -risperdal 1mg \n -haldol 1mg po BID prn\n -lactulose 30mg po tid prn\n -saline nasal spray 2 sprays each nostril QID\n -Mirtazapine 15 mg PO HS\n -roxanol 10mg po q3hrs prn\n -fleet enema pr daily prn\n -MTV daily\n -primaxin IV 250mg Q6 hours\n Past medical history:\n Family history:\n Social History:\n Past Medical History:\n 1. Hepatitis C, diagnosed as part of the lung transplant workup\n at the . He is followed by Dr. in GI. He\n is hepatitis B core surface antibody positive and surface\n antigen negative. In addition, he has hepatitis C antibody plus type\n 2b with a viral load in , of 5.5 million. He had grade 2\n fibrosis on . He is not thought to be a candidate\n currently for interferon treatment given his sarcoidosis.\n 2. Sarcoidosis. He is followed by Dr. . The patient has\n been obtaining PFTs from Dr. , and he is currently on\n azathioprine and prednisone with prophylaxis Bactrim.\n 3. Sleep apnea.\n 4. Erectile dysfunction.\n 5. Emotional lability and anxiety.\n 6. Status post mandible fracture .\n 7. Status post multiple rib and clavicle fractures\n 8. Spinal stenosis: diagnosed on MRI and is followed by Dr. \n . The diagnosis was established as part of a workup for\n progressive lower leg weakness, which led to multiple falls and\n currently an inability to ambulate.\n 9. Shingles in on the right side of the face with\n residual neuropathic pain.\n NC\n Occupation: on disability\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: has been living at radius hospital since recent discharge in\n \n Review of systems:\n Flowsheet Data as of 07:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 100 (100 - 115) bpm\n BP: 130/78(95) {38/-12(95) - 130/78(352)} mmHg\n RR: 24 (14 - 28) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 88 kg (admission): 88 kg\n CVP: 8 (6 - 8)mmHg\n Total In:\n 2,113 mL\n PO:\n TF:\n IVF:\n 2,113 mL\n Blood products:\n Total out:\n 0 mL\n 30 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,083 mL\n Respiratory\n Ventilator mode: CMV\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 29 cmH2O\n SpO2: 99%\n ABG: 7.34/64/106//6\n Ve: 11.6 L/min\n PaO2 / FiO2: 106\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A7/19/ 03:14 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 36\n Fluid analysis / Other labs: Labs in ED:\n Na 142 K4.7 Cl 102 HCO 33 BUN 29 creat 0.5 Gluc 93\n CK 29 MB - Trop <0.01\n AST 100 ALT 102 AP 317\n WBC 13.2 HCT 32.1 PLT 307 29% bands\n UA: leuk neg, mod blood, nitr neg, granular casts, hyaline\n casts\n Imaging: CXR: (prelim dictation) extensive pulm fibrosis and\n emphysema unchanged, no effusion, no PTX, ETT terminates 4.5cm above\n carina, RIJ at cavo-atrial junction, OG tube in esophagus. Otherwise\n no acute cardiopulmonary changes.\n .\n CTA chest:\n 1. Small PE of segmental/subsegmental right upper lobe branch. This was\n communicated by Dr. with Dr. by\n telephone in the AM on .\n 2. New minimally displaced fracture of the lateral right ninth rib.\n Multiple additional bilateral healing rib fractures.\n 3. Healing left distal clavicle fracture.\n 3. Resolution of right upper lobe pneumonia.\n 4. Chronic severe pulmonary fibrosis in the setting of sarcoidosis.\n .\n ECHO:\n The left atrium is normal in size. Left ventricular wall thicknesses\n are normal. The left ventricular cavity size is normal. Overall left\n ventricular systolic function is normal (LVEF>55%). The right\n ventricular cavity is dilated. Right ventricular systolic function\n appears depressed. There is abnormal septal motion/position consistent\n with right ventricular pressure/volume overload. The ascending aorta is\n mildly dilated. The aortic valve leaflets (3) are mildly thickened.\n There is no aortic valve stenosis. Mild (1+) aortic regurgitation is\n seen. The mitral valve appears structurally normal with trivial mitral\n regurgitation. There is moderate pulmonary artery systolic\n hypertension. Significant pulmonic regurgitation is seen. There is a\n trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , right\n ventricular systolic function now appears depressed.\n Microbiology: Blood Cx: pending\n ECG: EKG:sinus tachycardia at 125bpm, normal axis, normal\n intervals, poor baseline, no apparent ST segment or T wave changes.\n Compared with sinus tachycardia is new otherwise no clear\n change.\n Assessment and Plan\n Mr. is a 55 yo M with PMH of end stage sarcodiosis\n admitted with fever, tachypnea, and hypoxia intubated in ED concern\n for increased work of breathing and hypoxia.\n .\n #SIRS/Sepsis - meets criteria based on tachycardia and bandemia of 29%\n on diff,most likely due to PNA given underlying severe sarcoidosis,\n other consideration is infected midline which has been in place for\n unclear duration of time. UA unremarkable and unlikely the source but\n will f/u.\n -vancomycin IV to cover for possible line infection\n -meropenam given recent h/o resistant pseudomonas on recent sputum cx\n -ua unremarkable, f/u urine culture\n -d/c midline, send tip for culture\n -BP had been stable until propofol started, will d/c propofol and\n -IVF for CVP 8-10, will start levophed if MAP still < 65 despite CVP at\n goal\n .\n #Hypoxemic respiratory failure - in setting of report of fever\n concerning for superimposed PNA on severe pulmonary fibrosis end\n stage sarcoid. No clear infiltrate on CXR although difficult to\n interpret in the setting of already severe pulmonary fibrosis.\n -treat for possible PNA given high susceptibility given underlying\n pulmonary abnormalities\n -vanc/meropenam for now for broad coverage given recent h/o multidrug\n resistant pseudomonas (resistant to zosyn and cefepime)\n -send sputum culture\n -f/u blood cultures\n -continue mechanical ventillation, wean FIO2 as tolerated for Sat >90\n -consider bronchoscopy to obtain sputum sample\n -consider CT scan to further evaluate for degree of airway disease\n -albuterol/atrovent MDI\n .\n #End stage sarcodiosis - has severe sarcoid at baseline on high dose\n steroids.\n -continue high dose steroids for now with solumedrol 60mg IV Q6\n -continue PCP prophylaxis /bactrim\n -consider bronch/CT scan as discussed above\n -continue mechanical ventillation\n -continue azathioprine\n .\n #H/O severe anxiety - on multiple agents at baseline for severe anxiety\n including ativan, risperdal, mirtazapine, haldol.\n -Will hold for now while sedated for mechanical ventillation\n -resume once getting close to weaning\n .\n #Chronic pain/spinal stenosis - on chronic ms contin/percocet, will\n hold for now and sedate with fentanyl/midazolam while intubated.\n .\n #Type 2 DM\n likely component chronic steroids\n -continue NPH/HISS\n ICU Care\n Nutrition:\n Glycemic Control: NPH / HISS\n Lines: -\n Multi Lumen - 04:00 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: Comments: daughter is HCP H:\n c: \n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Physician ",
"chartdate": "2186-07-01 00:00:00.000",
"description": "Attending Admission Note",
"row_id": 330982,
"text": "Chief Complaint: dyspnea, worsening hypoxia\n HPI:\n Mr. is a 55 yo M with end-stage sarcoid on 3LNC at\n baseline, transferred from Radius with shortness of breath, tachypnea,\n hypoxia and fevers. According to reports from Radius has has been\n hypoxic for several days with O2 sats 91-92% on 100% NRB with\n desaturation to 86% with minimal exertion, patient refusing to come to\n hospital.\n .\n In the ED T99.2 BP 145/84 RR 20-30 HR 92-140 96% on 100%NRB. He was\n noted to be significantly hypoxic and tachypnic and was intubated due\n to concern for increasing work of breathing. He was given 2.5LNS,\n levofloxacin 750mg IV, cefepime 2g IV x1, decadron 10mg IV x1 and\n versed 2mg IV x1.\n Patient admitted from: Transfer from other hospital, Radius\n History obtained from Medical records\n Patient unable to provide history: Sedated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Medications on Arrival:\n -Albuterol Sulfate 2.5 mg/3 mL neb q4 hours and q7 hours prn\n -Atrovent Nebs Q4Hours and Q 7 hours prn\n -Solu-medrol 60mg IV Q6hrs\n -Novalog sliding scale QACHS\n -mucomyst 10% 3ML INH QID\n -Clonazepam 1 mg PO TID prn\n -NPH insulin (unclear dosing had been on 12QAM and 6QPM during last\n admit)\n -Nexium 40mg daily\n -dulcolax 10mg pr qday prn\n -colace 100mg po bid\n -milk of magnesia 30ML daily\n -MS Contin 45mg \n -percocet 1-2 tabs TID prn\n -zocor 20mg daily\n -heparin SQ 5000mg TID\n -Azathioprine 150 mg PO DAILY\n -cymbalta 90mg po daily\n -ASA 325mg daily\n -Sennakot 1 \n -Bactrim DS 1 tab QMWF\n -trazodone 25mg qhs prn\n -vitamin b1 100mg daily\n -risperdal 1mg \n -haldol 1mg po BID prn\n -lactulose 30mg po tid prn\n -saline nasal spray 2 sprays each nostril QID\n -Mirtazapine 15 mg PO HS\n -roxanol 10mg po q3hrs prn\n -fleet enema pr daily prn\n -MTV daily\n -primaxin IV 250mg Q6 hours\n Past medical history:\n Family history:\n Social History:\n Past Medical History:\n 1. Hepatitis C, diagnosed as part of the lung transplant workup\n at the . He is followed by Dr. in GI. He\n is hepatitis B core surface antibody positive and surface\n antigen negative. In addition, he has hepatitis C antibody plus type\n 2b with a viral load in , of 5.5 million. He had grade 2\n fibrosis on . He is not thought to be a candidate\n currently for interferon treatment given his sarcoidosis.\n 2. Sarcoidosis. He is followed by Dr. . The patient has\n been obtaining PFTs from Dr. , and he is currently on\n azathioprine and prednisone with prophylaxis Bactrim.\n 3. Sleep apnea.\n 4. Erectile dysfunction.\n 5. Emotional lability and anxiety.\n 6. Status post mandible fracture .\n 7. Status post multiple rib and clavicle fractures\n 8. Spinal stenosis: diagnosed on MRI and is followed by Dr. \n . The diagnosis was established as part of a workup for\n progressive lower leg weakness, which led to multiple falls and\n currently an inability to ambulate.\n 9. Shingles in on the right side of the face with\n residual neuropathic pain.\n NC\n Occupation: on disability\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other: has been living at radius hospital since recent discharge in\n \n Review of systems:\n Flowsheet Data as of 07:51 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 100 (100 - 115) bpm\n BP: 130/78(95) {38/-12(95) - 130/78(352)} mmHg\n RR: 24 (14 - 28) insp/min\n SpO2: 99%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 88 kg (admission): 88 kg\n CVP: 8 (6 - 8)mmHg\n Total In:\n 2,113 mL\n PO:\n TF:\n IVF:\n 2,113 mL\n Blood products:\n Total out:\n 0 mL\n 30 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,083 mL\n Respiratory\n Ventilator mode: CMV\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 20\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 29 cmH2O\n SpO2: 99%\n ABG: 7.34/64/106//6\n Ve: 11.6 L/min\n PaO2 / FiO2: 106\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n \n 2:33 A7/19/ 03:14 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 36\n Fluid analysis / Other labs: Labs in ED:\n Na 142 K4.7 Cl 102 HCO 33 BUN 29 creat 0.5 Gluc 93\n CK 29 MB - Trop <0.01\n AST 100 ALT 102 AP 317\n WBC 13.2 HCT 32.1 PLT 307 29% bands\n UA: leuk neg, mod blood, nitr neg, granular casts, hyaline\n casts\n Imaging: CXR: (prelim dictation) extensive pulm fibrosis and\n emphysema unchanged, no effusion, no PTX, ETT terminates 4.5cm above\n carina, RIJ at cavo-atrial junction, OG tube in esophagus. Otherwise\n no acute cardiopulmonary changes.\n .\n CTA chest:\n 1. Small PE of segmental/subsegmental right upper lobe branch. This was\n communicated by Dr. with Dr. by\n telephone in the AM on .\n 2. New minimally displaced fracture of the lateral right ninth rib.\n Multiple additional bilateral healing rib fractures.\n 3. Healing left distal clavicle fracture.\n 3. Resolution of right upper lobe pneumonia.\n 4. Chronic severe pulmonary fibrosis in the setting of sarcoidosis.\n .\n ECHO:\n The left atrium is normal in size. Left ventricular wall thicknesses\n are normal. The left ventricular cavity size is normal. Overall left\n ventricular systolic function is normal (LVEF>55%). The right\n ventricular cavity is dilated. Right ventricular systolic function\n appears depressed. There is abnormal septal motion/position consistent\n with right ventricular pressure/volume overload. The ascending aorta is\n mildly dilated. The aortic valve leaflets (3) are mildly thickened.\n There is no aortic valve stenosis. Mild (1+) aortic regurgitation is\n seen. The mitral valve appears structurally normal with trivial mitral\n regurgitation. There is moderate pulmonary artery systolic\n hypertension. Significant pulmonic regurgitation is seen. There is a\n trivial/physiologic pericardial effusion.\n Compared with the prior study (images reviewed) of , right\n ventricular systolic function now appears depressed.\n Microbiology: Blood Cx: pending\n ECG: EKG:sinus tachycardia at 125bpm, normal axis, normal\n intervals, poor baseline, no apparent ST segment or T wave changes.\n Compared with sinus tachycardia is new otherwise no clear\n change.\n Assessment and Plan\n Mr. is a 55 yo M with PMH of end stage sarcodiosis\n admitted with fever, tachypnea, and hypoxia intubated in ED concern\n for increased work of breathing and hypoxia.\n .\n #SIRS/Sepsis - meets criteria based on tachycardia and bandemia of 29%\n on diff,most likely due to PNA given underlying severe sarcoidosis,\n other consideration is infected midline which has been in place for\n unclear duration of time. UA unremarkable and unlikely the source but\n will f/u.\n -vancomycin IV to cover for possible line infection\n -meropenam given recent h/o resistant pseudomonas on recent sputum cx\n -ua unremarkable, f/u urine culture\n -d/c midline, send tip for culture\n -BP had been stable until propofol started, will d/c propofol and\n -IVF for CVP 8-10, will start levophed if MAP still < 65 despite CVP at\n goal\n .\n #Hypoxemic respiratory failure - in setting of report of fever\n concerning for superimposed PNA on severe pulmonary fibrosis end\n stage sarcoid. No clear infiltrate on CXR although difficult to\n interpret in the setting of already severe pulmonary fibrosis.\n -treat for possible PNA given high susceptibility given underlying\n pulmonary abnormalities\n -vanc/meropenam for now for broad coverage given recent h/o multidrug\n resistant pseudomonas (resistant to zosyn and cefepime)\n -send sputum culture\n -f/u blood cultures\n -continue mechanical ventillation, wean FIO2 as tolerated for Sat >90\n -consider bronchoscopy to obtain sputum sample\n -consider CT scan to further evaluate for degree of airway disease\n -albuterol/atrovent MDI\n .\n #End stage sarcodiosis - has severe sarcoid at baseline on high dose\n steroids.\n -continue high dose steroids for now with solumedrol 60mg IV Q6\n -continue PCP prophylaxis /bactrim\n -consider bronch/CT scan as discussed above\n -continue mechanical ventillation\n -continue azathioprine\n .\n #H/O severe anxiety - on multiple agents at baseline for severe anxiety\n including ativan, risperdal, mirtazapine, haldol.\n -Will hold for now while sedated for mechanical ventillation\n -resume once getting close to weaning\n .\n #Chronic pain/spinal stenosis - on chronic ms contin/percocet, will\n hold for now and sedate with fentanyl/midazolam while intubated.\n .\n #Type 2 DM\n likely component chronic steroids\n -continue NPH/HISS\n ICU Care\n Nutrition:\n Glycemic Control: NPH / HISS\n Lines: -\n Multi Lumen - 04:00 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: Comments: daughter is HCP H:\n c: \n Code status: Full code\n Disposition: ICU\n ------ Protected Section ------\n MICU ATTENDING ADMISSION NOTE\n Case reviewed, pt examined and primary data reviewed with Dr. ,\n whose note reflects my thoughts. Briefly, patient is a 53M with\n advanced sarcoidosis c/b end stage fibrosis and severe PHTN, HCV,\n osteopenia, recent abd wall hematoma, zoster c/b neuropathic pain\n admitted with progressive respiratory failure from rehab. Intubated in\n ED, currently critically ill on A/C vent and with borderline BP. RIJ\n placed in ED, rx steroids, abx and xfered to . Remainder of\n PMH/HPI/ROS as above, NKDA.\n On exam, asynchronous with vent, VS 97.6 90/60 115 24 99% on VAC 500 x\n 20 PEEP 10\n 7.34 / 64 / 106\n PERRL, distant coarse BS B with wheeze. RRR +PA tap, diffuse abd\n purpura non-tender, 2+ edema\n Labs with WBC 13K c 29% bands, HCO3 33, Cr 0.5. CXR c BLL fibrotic\n changes and BUL cysts, minimal change from prior. ETT high, CVL in good\n position.\n A/P\n 53M end stage sarcoidosis now with likely sepsis from pneumonia\n and respiratory failure.\n - Will change to PSV for better synchrony and sedate with fent /\n midaz.\n - Advance ETT 2cm, cover with and vanco\n - Will send sputum and bronch if able to tolerate lower FiO2 to\n speciate PSA and r/o PCP\n treat with IV steroids since he has been on them and still\n appears wheezy\n - Check Legionella Ag and beta-glucan, hold azathioprine, continue\n bactrim TIW for now\n - Pan culture and consider CT though this is unlikely to change\n treatment at this point\n - D/c PICC now and continue vanco, consider LENIs for ?DVT in AM\n - Start TFs\n - Pneumoboots\n - CVL, MICU, Full, d/w family\n - Above d/w team in detail, patient is critically ill, total time 60\n min\n ------ Protected Section Addendum Entered By: , MD\n on: 20:34 ------\n"
},
{
"category": "General",
"chartdate": "2186-07-02 00:00:00.000",
"description": "ICU Event Note",
"row_id": 331094,
"text": "At beginning of shift, pt on PS , 500x 18 peep 10 , Fio2 100%. Noted to\n have agonal respirations. On Fentanyl infusion at 150mcg/hr and Versed\n at 7mg/hr. Pt bloused with Versed and Fentanyl infusions stepped up to\n 300mcg/hr and Versed at 10mg/hr. Blood gases done, progresssivly\n getting worse, initially 7.21/85/87, then trending down to 7.14/88/50\n with max vent settings. Pt tried on Pressure controlled ventilation\n and APRV, but failed. Put on prone position so as to improve O2 sats,\n with no effect. Daughter in to visit, aware of curremt status. Pt made\n a DNR.\n Pt started dropping his pressures, requiring Neo and then Levo. Fluid\n challenge given for hypotension and tachycardia with no effect. Family\n in to visit and updated regarding status. Family meeting conducted.\n They are in acceptance of pts deteriorating state and at this point\n does not want any resuscitative measures. Started on comfort measures.\n Patient started deteriorating, made as comfortable as possible. Family\n at bedside. Priest in to visit. Last rites performed.\n Pt had no heart or lung sounds, absent radial and carotid pulses, no\n corneal reflex. Pronounced dead at 1648. Family at bedside.\n 1845, body transported. Foley catheter and multilumen catheter\n retained.\n"
},
{
"category": "General",
"chartdate": "2186-07-02 00:00:00.000",
"description": "ICU Event Note",
"row_id": 331095,
"text": "At beginning of shift, pt on PS , 500x 18 peep 10 , Fio2 100%. Noted to\n have agonal respirations. On Fentanyl infusion at 150mcg/hr and Versed\n at 7mg/hr. Pt bloused with Versed and Fentanyl infusions stepped up to\n 300mcg/hr and Versed at 10mg/hr. Blood gases done, progresssivly\n getting worse, initially 7.21/85/87, then trending down to 7.14/88/50\n with max vent settings. Pt tried on Pressure controlled ventilation\n and APRV, but failed. Put on prone position so as to improve O2 sats,\n with no effect. Daughter in to visit, aware of curremt status. Pt made\n a DNR.\n Pt started dropping his pressures, requiring Neo and then Levo. Fluid\n challenge given for hypotension and tachycardia with no effect. Family\n in to visit and updated regarding status. Family meeting conducted.\n They are in acceptance of pts deteriorating state and at this point\n does not want any resuscitative measures. Started on comfort measures.\n Patient started deteriorating, made as comfortable as possible. Family\n at bedside. Priest in to visit. Last rites performed.\n Pt had no heart or lung sounds, absent radial and carotid pulses, no\n corneal reflex. Pronounced dead at 1648. Family at bedside.\n 1845, body transported. Foley catheter and multilumen catheter\n retained.\n"
},
{
"category": "General",
"chartdate": "2186-07-02 00:00:00.000",
"description": "ICU Event Note",
"row_id": 331092,
"text": "At beginning of shift, pt on PS , 500x 18 peep 10 , Fio2 100%. Noted to\n have agonal respirations. On Fentanyl infusion at 150mcg/hr and Versed\n at 7mg/hr. Pt bloused with Versed and Fentanyl infusions stepped up to\n 300mcg/hr and Versed at 10mg/hr. Blood gases done, progresssivly\n getting worse, initially 7.21/85/87, then trending down to 7.14/88/50\n with max vent settings. Pt tried on Pressure controlled ventilation\n and APRV, but failed. Put on prone position so as to improve O2 sats,\n with no effect. Daughter in to visit, aware of curremt status. Pt made\n a DNR.\n Pt started dropping his pressures, requiring Neo and then Levo. Fluid\n challenge given for hypotension and tachycardia with no effect. Family\n in to visit and updated regarding status. Family meeting conducted.\n They are in acceptance of pts deteriorating state and at this point\n does not want any resuscitative measures. Started on comfort measures.\n Patient started deteriorating, made as comfortable as possible. Family\n at bedside. Priest in to visit. Last rites performed.\n"
},
{
"category": "Respiratory ",
"chartdate": "2186-07-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 330969,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: ED\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\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: Gasping efforts; Comments: pt\n dysynchronous on vent, has frequent gasping efforts, desats on FiO2\n less than 100%. PEEP is at +10.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\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 Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n To ICU from ED\n 1600\n transported from ED to MICU-East w/out incident\n"
},
{
"category": "General",
"chartdate": "2186-07-02 00:00:00.000",
"description": "ICU Event Note",
"row_id": 331089,
"text": "At beginning of shift, pt on PS , 500\n"
},
{
"category": "General",
"chartdate": "2186-07-02 00:00:00.000",
"description": "ICU Event Note",
"row_id": 331090,
"text": "At beginning of shift, pt on PS , 500x 18 peep 10 , Fio2 100%. Noted to\n have agonal respirations. On Fentanyl infusion at 150mcg/hr and Versed\n at 7mg/hr. Pt bloused with Versed and Fentanyl infusions stepped up to\n 300mcg/hr and Versed at 10mg/hr. Blood gases done\n"
},
{
"category": "General",
"chartdate": "2186-07-02 00:00:00.000",
"description": "ICU Event Note",
"row_id": 331081,
"text": "Clinician: Resident\n Pt was declared CMO by HCP. non-comfort medications were\n discontinued. Pt became asystolic on telemetry monitoring. Pt had no\n radial or carotid pulses. Pt was then extubated. On exam pt had no\n audible lung or heart sounds. Pt did not respond to painful stimuli\n and had no corneal reflex. Pt was pronounced dead at 16:48. Family\n was notified.\n Total time spent: 30 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 331075,
"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: Unknown\n Procedure location: ED\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Gasping efforts, High flow\n demand; Comments: Pt initially on PSV, attempted mulitple modes of\n ventilation including A/C, PCV, APRV but pt quickly desaturated and\n became increasingly dysynchronous w/ the ventilator. Pt given a\n paralytic and changed to PCV w/ no improvement in oxygenation.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Trigger work assessment: Frequent failed trigger efforts\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments: pt taking gasping breaths out of synch w/ vent which improved\n w/ paralytic.\n Plan\n Next 24-48 hours: Comfort measures only\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Prone position (1300)\n Comments: pt proned w/out incident for ~10 mins...no improvement in\n oxygenation.\n"
},
{
"category": "Physician ",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 331049,
"text": "Chief Complaint: Hypoxic resp failure\n 24 Hour Events:\n L radial A-line placed, d/c\nd L brachial midline\n Has had persistently poor oxygenation and ventilation, with escalating\n FiO2 and pressure support; changed to PSV 18/10/100% - on these\n settings, O2sat 86-96%, Vt 550-700, RR 19-22, 7.21/87/85/28\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:07 PM\n Bactrim (SMX/TMP) - 01:00 AM\n Meropenem - 06:02 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 7 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:06 PM\n Midazolam (Versed) - 11:17 PM\n Fentanyl - 11:17 PM\n Heparin Sodium (Prophylaxis) - 12:07 AM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt sedated\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 124 (94 - 124) bpm\n BP: 122/84(99) {38/-12(91) - 149/85(352)} mmHg\n RR: 24 (14 - 28) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 88 kg (admission): 88 kg\n Height: 67 Inch\n CVP: 11 (6 - 14)mmHg\n Total In:\n 2,538 mL\n 846 mL\n PO:\n TF:\n 20 mL\n IVF:\n 2,538 mL\n 827 mL\n Blood products:\n Total out:\n 790 mL\n 635 mL\n Urine:\n 790 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,748 mL\n 211 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 14 cmH2O\n RR (Set): 0\n RR (Spontaneous): 20\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 30 cmH2O\n SpO2: 90%\n ABG: 7.28/68/77/28/2\n Ve: 12.1 L/min\n PaO2 / FiO2: 77\n Physical Examination\n GEN: intubated, sedated\n CV: distant heart sounds\n PULM: coarse BS bilat, scattered wheeze\n ABD: soft distended, NT +BS multiple discrete areas of purpura,\n ecchymosis\n EXT: warm, dry, doppler +DP pulses: 2+ putting edema\n Labs / Radiology\n 246 K/uL\n 11.4 g/dL\n 134 mg/dL\n 0.3 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 135 mEq/L\n 34.7 %\n 15.4 K/uL\n [image002.jpg]\n 79% bands\n 03:14 PM\n 07:03 PM\n 08:52 PM\n 02:16 AM\n 03:33 AM\n 04:57 AM\n WBC\n 8.9\n 15.4\n Hct\n 30.6\n 34.7\n Plt\n 216\n 246\n Cr\n 0.3\n 0.3\n TropT\n <0.01\n <0.01\n TCO2\n 36\n 34\n 34\n 33\n Glucose\n 89\n 134\n Other labs: PT / PTT / INR:13.9/27.5/1.2, CK / CKMB /\n Troponin-T:25/4/<0.01, ALT / AST:101/73, Alk Phos / T Bili:261/1.2,\n Lactic Acid:2.0 mmol/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 55 y/o M with end-stage pulm sarcoid admitted with hypoxic respiratory\n failure in the setting of pneumonial sepsis.\n .\n #Hypoxic resp failure\n PNA on top of severe underlying fibrotic\n lung disease; requiring maximal support with suboptimal oxygenation and\n ventilation\n -Cont. full support, appears most comfortable on PSV; if requires more\n sedation, may consider PC or APRV\n -Uptitrate PEEP, downtitrate FiO2 to maintain PaO2 > 60, O2sat > 90%\n -will likely not tolerate bronchoscopy at this time\n -CTA to r/o PE when more stable (has h/o small PE)\n .\n #Sepsis\n Has not required pressors, had single episode of\n fluid-response HoTN w/ propofol bolus; suspect resistant nosocomial\n pathogen, has grown MDR pseudomonas (meropenem-) in the past; also\n consider PCP as has been chronically steroid-dependent; line infection\n midline also a possibility\n -IVF bolus to maintain CVP ~, will tolerate higher CVP as has high\n RV pressures pulm HTN\n -MAP > 65, start neo if HoTN + tachy\n -/tobra for double cov\ng pseudomonas; add azithro for atypicals\n -bactrim IV for empiric cov\ng PCP; B-glucan pending\n -vancomycin IV to cover for possible line infection\n -f/u blood, urine, sputum, tip Cx\n .\n #Sarcoid\n O2, steroid-dependent at b/l\n - solumedrol 60mg IV Q6\n clarify outpatient regimen\n - empiric tx for PCP with IV Bactrim\n - hold azathioprine in the setting of infection\n .\n #Sedation\n HoTN with propofol, and will likely remain on vent; changed\n to fentanyl/versed gtt\n .\n #Type 2 DM\n steroids likely contributing to hyperglycemia\n -continue NPH/HISS\n ICU Care\n Nutrition: TF\n Glycemic Control: RISS\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 07:30 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: PPI\n Code status: DNR / DNI\n Disposition: ICU\n"
},
{
"category": "Nutrition",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 331051,
"text": "Subjective\n Intubated.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 183 cm\n 88 kg\n 26.3\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 80.7 kg\n 109\n Diagnosis: PNA\n PMH : end stage sarcoidosis, COPD, NC baseline, Hep.C, spinal stenosis,\n sleep apnea, fx bone mandible , delirium, erectile dysfxn,\n shingles, smoker, DM.\n Food allergies and intolerances: none noted.\n Pertinent medications: solumedrol, Abx, heparin, azithromycin, HISS,\n midazolam, fentanyl.\n Labs:\n Value\n Date\n Glucose\n 134 mg/dL\n 04:57 AM\n Glucose Finger Stick\n 129\n 06:00 AM\n BUN\n 17 mg/dL\n 04:57 AM\n Creatinine\n 0.3 mg/dL\n 04:57 AM\n Sodium\n 135 mEq/L\n 04:57 AM\n Potassium\n 4.8 mEq/L\n 04:57 AM\n Chloride\n 100 mEq/L\n 04:57 AM\n TCO2\n 28 mEq/L\n 04:57 AM\n PO2 (arterial)\n 86. mm Hg\n 08:15 AM\n PCO2 (arterial)\n 85. mm Hg\n 08:15 AM\n pH (arterial)\n 7.21 units\n 08:15 AM\n CO2 (Calc) arterial\n 36 mEq/L\n 08:15 AM\n Albumin\n 2.6 g/dL\n 04:57 AM\n Calcium non-ionized\n 8.8 mg/dL\n 04:57 AM\n Phosphorus\n 3.0 mg/dL\n 04:57 AM\n Magnesium\n 1.9 mg/dL\n 04:57 AM\n ALT\n 101 IU/L\n 04:57 AM\n Alkaline Phosphate\n 261 IU/L\n 04:57 AM\n AST\n 73 IU/L\n 04:57 AM\n Total Bilirubin\n 1.2 mg/dL\n 04:57 AM\n WBC\n 15.4 K/uL\n 04:57 AM\n Hgb\n 11.4 g/dL\n 04:57 AM\n Hematocrit\n 34.7 %\n 04:57 AM\n Current diet order / nutrition support: NPO. TF Nutren Pulmonary at\n 40mL/hr w/ 50mL Q4hrs of free water flushes.\n GI: Abdomen distended, soft, +BS.\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, Low protein stores,\n Intubated & needs nutrition support\n Estimated Nutritional Needs\n Calories: 2200 - 2640 (BEE x or / 25 - 30 cal/kg)\n Protein: 106 - 132 (1.2 - 1.5 g/kg)\n Fluid: per team.\n Specifics:\n 55 YO Male with severe end stage sarcoidosis & hx of DM. On high dose\n steroids for sarcoid. Currently intubated d/t respiratory failure.\n Consulted for TF recs. Current order provides inadequate\n kcals/proteins; recommend increase TF goal rate to 65mL/hr of FS Nutren\n Pulmonary, providing ~2340kcals & 106g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Increase goal rate of TF Nutren Pulmonary to 65mL/hr; start TF\n once access is obtained at 10mL/hr, advance by 10-15mL Q 4-6hrs or as\n tolerated to goal\n 2. Check residuals Q4hrs & hold x1hr if >150mL\n 3. Multivitamin / Mineral supplement: via TF\n 4. Check chemistry 10 panel daily; replete lytes PRN\n 5. continue to monitor BG & adjust insulin PRN\n"
},
{
"category": "Physician ",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 331053,
"text": "Chief Complaint: Hypoxic resp failure\n 24 Hour Events:\n L radial A-line placed, d/c\nd L brachial midline\n Has had persistently poor oxygenation and ventilation, with escalating\n FiO2 and pressure support; changed to PSV 18/10/100% - on these\n settings, O2sat 86-96%, Vt 550-700, RR 19-22, 7.21/87/85/28\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:07 PM\n Bactrim (SMX/TMP) - 01:00 AM\n Meropenem - 06:02 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 7 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:06 PM\n Midazolam (Versed) - 11:17 PM\n Fentanyl - 11:17 PM\n Heparin Sodium (Prophylaxis) - 12:07 AM\n Other medications:\n Changes to medical and family history: n/a\n Review of systems is unchanged from admission except as noted below\n Review of systems: Pt sedated\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 124 (94 - 124) bpm\n BP: 122/84(99) {38/-12(91) - 149/85(352)} mmHg\n RR: 24 (14 - 28) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 88 kg (admission): 88 kg\n Height: 67 Inch\n CVP: 11 (6 - 14)mmHg\n Total In:\n 2,538 mL\n 846 mL\n PO:\n TF:\n 20 mL\n IVF:\n 2,538 mL\n 827 mL\n Blood products:\n Total out:\n 790 mL\n 635 mL\n Urine:\n 790 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,748 mL\n 211 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 14 cmH2O\n RR (Set): 0\n RR (Spontaneous): 20\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 30 cmH2O\n SpO2: 90%\n ABG: 7.28/68/77/28/2\n Ve: 12.1 L/min\n PaO2 / FiO2: 77\n Physical Examination\n GEN: intubated, sedated\n CV: distant heart sounds\n PULM: coarse BS bilat, scattered wheeze\n ABD: soft distended, NT +BS multiple discrete areas of purpura,\n ecchymosis\n EXT: warm, dry, doppler +DP pulses: 2+ putting edema\n Labs / Radiology\n 246 K/uL\n 11.4 g/dL\n 134 mg/dL\n 0.3 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 135 mEq/L\n 34.7 %\n 15.4 K/uL\n [image002.jpg]\n 79% bands\n 03:14 PM\n 07:03 PM\n 08:52 PM\n 02:16 AM\n 03:33 AM\n 04:57 AM\n WBC\n 8.9\n 15.4\n Hct\n 30.6\n 34.7\n Plt\n 216\n 246\n Cr\n 0.3\n 0.3\n TropT\n <0.01\n <0.01\n TCO2\n 36\n 34\n 34\n 33\n Glucose\n 89\n 134\n Other labs: PT / PTT / INR:13.9/27.5/1.2, CK / CKMB /\n Troponin-T:25/4/<0.01, ALT / AST:101/73, Alk Phos / T Bili:261/1.2,\n Lactic Acid:2.0 mmol/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 55 y/o M with end-stage pulm sarcoid admitted with hypoxic respiratory\n failure in the setting of pneumonial sepsis.\n .\n #Hypoxic resp failure\n PNA on top of severe underlying fibrotic\n lung disease; requiring maximal support with suboptimal oxygenation and\n ventilation\n -Cont. full support, appears most comfortable on PSV; if requires more\n sedation, may consider PC or APRV\n -Uptitrate PEEP, downtitrate FiO2 to maintain PaO2 > 60, O2sat > 90%\n -will likely not tolerate bronchoscopy at this time\n -CTA to r/o PE when more stable (has h/o small PE)\n .\n #Sepsis\n Has not required pressors, had single episode of\n fluid-response HoTN w/ propofol bolus; suspect resistant nosocomial\n pathogen, has grown MDR pseudomonas (meropenem-) in the past; also\n consider PCP as has been chronically steroid-dependent; line infection\n midline also a possibility\n -IVF bolus to maintain CVP ~, will tolerate higher CVP as has high\n RV pressures pulm HTN\n -MAP > 65, start neo if HoTN + tachy\n -/tobra for double cov\ng pseudomonas; add azithro for atypicals\n -bactrim IV for empiric cov\ng PCP; B-glucan pending\n -vancomycin IV to cover for possible line infection\n -f/u blood, urine, sputum, tip Cx\n .\n #Sarcoid\n O2, steroid-dependent at b/l\n - solumedrol 60mg IV Q6\n clarify outpatient regimen\n - empiric tx for PCP with IV Bactrim\n - hold azathioprine in the setting of infection\n .\n #Sedation\n HoTN with propofol, and will likely remain on vent; changed\n to fentanyl/versed gtt\n .\n #Type 2 DM\n steroids likely contributing to hyperglycemia\n -continue NPH/HISS\n ICU Care\n Nutrition: TF\n Glycemic Control: RISS\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 07:30 PM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: PPI\n Code status: DNR / DNI\n Disposition: ICU\n ------ Protected Section ------\n Correction: Patient is currently a full code, pending further\n discussion with his daughter/HCP.\n ------ Protected Section Addendum Entered By: , MD\n on: 12:02 ------\n"
},
{
"category": "Physician ",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 331063,
"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: 53M with advanced sarcoidosis c/b end stage fibrosis and severe\n PHTN, HCV, osteopenia, recent abd wall hematoma, zoster c/b neuropathic\n pain admitted with progressive respiratory failure from rehab.\n Intubated in ED, currently critically ill on PSV and with borderline\n BP. RIJ placed in ED, rx steroids, abx and xfered to .\n 24 Hour Events:\n PICC LINE - START 04:00 PM--> d/c'd on arrival to MICU\n L brachial\n MULTI LUMEN - START 04:00 PM\n inserted in ED\n INVASIVE VENTILATION - START 04:15 PM\n PICC LINE - STOP 07:30 PM\n L brachial\n ARTERIAL LINE - START 07:30 PM\n URINE CULTURE - At 09:27 PM\n levoflox/cefepime in ED --> broadened to /vanco in \n empiric PCP Bactrim IV,\n pan cx'd\n decadron given in ED, continued solumedrol 60 Q 6 in ICU\n hypotensive after propofol l--> fluid responsive, changed propofol to\n versed\n never required pressor support overnight\n Oxygenation remained difficult -> 70% FIO2 on arrival with O2 sats in\n 80's --> seemed to better tolerate PSV , FIO2 increased to 100%\n sats in 90's, 7.21/87/85\n History obtained from Medical records, ho\n Patient unable to provide history: Sedated, intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:07 PM\n Bactrim (SMX/TMP) - 01:00 AM\n Meropenem - 06:02 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 7 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:06 PM\n Midazolam (Versed) - 11:17 PM\n Fentanyl - 11:17 PM\n Heparin Sodium (Prophylaxis) - 12:07 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 09:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 124 (94 - 124) bpm\n BP: 122/84(99) {38/-12(91) - 149/85(352)} mmHg\n RR: 24 (14 - 28) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 88 kg (admission): 88 kg\n Height: 67 Inch\n CVP: 11 (6 - 14)mmHg\n Total In:\n 2,538 mL\n 889 mL\n PO:\n TF:\n 20 mL\n IVF:\n 2,538 mL\n 870 mL\n Blood products:\n Total out:\n 790 mL\n 635 mL\n Urine:\n 790 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,748 mL\n 254 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 672 (672 - 672) mL\n PS : 18 cmH2O\n RR (Set): 0\n RR (Spontaneous): 20\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 30 cmH2O\n SpO2: 96%\n ABG: 7.21/85./86./28/2\n Ve: 12.8 L/min\n PaO2 / FiO2: 87\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, dysnchronous\n breathing\n Eyes / Conjunctiva: PERRL, Conjunctiva pale, Sclera edema\n Head, Ears, Nose, Throat: Endotracheal tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), tachy, RV heave\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 scant wheeze : , Diminished: bases, Rhonchorous: )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)\n Distended, Obese\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting\n Skin: Warm, achymosis ove abd from sq hep, No(t) Rash: , No(t)\n Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Non -purposeful,\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 11.4 g/dL\n 246 K/uL\n 134 mg/dL\n 0.3 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 135 mEq/L\n 34.7 %\n 15.4 K/uL\n [image002.jpg]\n 03:14 PM\n 07:03 PM\n 08:52 PM\n 02:16 AM\n 03:33 AM\n 04:57 AM\n 08:15 AM\n WBC\n 8.9\n 15.4\n Hct\n 30.6\n 34.7\n Plt\n 216\n 246\n Cr\n 0.3\n 0.3\n TropT\n <0.01\n <0.01\n TCO2\n 36\n 34\n 34\n 33\n 36\n Glucose\n 89\n 134\n Other labs: PT / PTT / INR:13.9/27.5/1.2, CK / CKMB /\n Troponin-T:25/4/<0.01, ALT / AST:101/73, Alk Phos / T Bili:261/1.2,\n Differential-Neuts:18.0 %, Band:79.0 %, Lymph:0.0 %, Mono:0.0 %,\n Eos:0.0 %, Lactic Acid:2.0 mmol/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.0 mg/dL\n Imaging: cxr--b/l basilar predominant patchy ASD, possibly slightly\n increased at L mid zone c/t prior film from . ET ok, NGT high\n reviewed prior CT scan\n Microbiology: blood, urine, sputum\n Assessment and Plan\n 53M end stage sarcoidosis now with respiratory and sepsis most likely\n pna.\n MAIN ISSUES INCLUDE:\n #SIRS/Sepsis\n - continue empiric antibx\n vanco and meropenem\n double PSA coverage (add Tobra), touch base with ID service given\n his h/o resistant organisms in past\n check legionella antigen and add atypical coverage\n continue empiric PCP coverage and send DFA\n -f/u cx data, send DFA for PCP\n maintain cvp's 8-10 range, though with known bad RV CVP may be\n difficult to interpret and likely needs high filling pressure\n - Bolus IVF then pressor as needed for MAPS > 60\n --trend lactate and check SVO2\n #Hypoxemic respiratory failure - concerning for superimposed PNA on\n severe pulmonary fibrosis end stage sarcoid. No clear infiltrate\n on CXR although difficult to interpret in the setting of already severe\n pulmonary fibrosis.\n - empiric and aggressive pna treatment as above\n - consider bronchoscopy, at this time too unstable to tolerate, has # 7\n ET tube, and will not change management\n -- mdis, steroids\n -- PE remains in ddx--given bandemia and temps lower suspicion, will\n check lenis and when stable CTA\n # mechanical ventilation\n -- wean FIO2 as tolerated for Sat >90, hesitant to increase PEEP much\n more as risk of PNX given multiple blebs\n --continue PSV, could trial APRV\n #End stage sarcodiosis\n - continue high dose steroids for now--solumedrol 60mg IV Q6, clarify\n his prior dosing\n - hold azothioprine in setting of acute infection\n - empiric PCP treatment, though he was on prophy\n #Goals of care\ncontinue family meetings and regular updates\n Respiratory status is very tenuous\n consider palliative care c/s/SW consult\n #Severe anxiety - on multiple agents at baseline for severe anxiety\n including ativan, risperdal, mirtazapine, haldol.\n -Hold while on mechanical vent\n -high tolerance for pain and anxiety meds\n #Chronic pain\non high dose chronic meds at home, high tolerance\n sedate with fentanyl/midazolam\n Remainder per resident\ns note. Plan of care discussed in detai.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale, Comments: NPH\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 07:30 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: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 331064,
"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: 53M with advanced sarcoidosis c/b end stage fibrosis and severe\n PHTN, HCV, osteopenia, recent abd wall hematoma, zoster c/b neuropathic\n pain admitted with progressive respiratory failure from rehab.\n Intubated in ED, currently critically ill on PSV and with borderline\n BP. RIJ placed in ED, rx steroids, abx and xfered to .\n 24 Hour Events:\n PICC LINE - START 04:00 PM--> d/c'd on arrival to MICU\n L brachial\n MULTI LUMEN - START 04:00 PM\n inserted in ED\n INVASIVE VENTILATION - START 04:15 PM\n PICC LINE - STOP 07:30 PM\n L brachial\n ARTERIAL LINE - START 07:30 PM\n URINE CULTURE - At 09:27 PM\n levoflox/cefepime in ED --> broadened to /vanco in \n empiric PCP Bactrim IV,\n pan cx'd\n decadron given in ED, continued solumedrol 60 Q 6 in ICU\n hypotensive after propofol l--> fluid responsive, changed propofol to\n versed\n never required pressor support overnight\n Oxygenation remained difficult -> 70% FIO2 on arrival with O2 sats in\n 80's --> seemed to better tolerate PSV , FIO2 increased to 100%\n sats in 90's, 7.21/87/85\n History obtained from Medical records, ho\n Patient unable to provide history: Sedated, intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:07 PM\n Bactrim (SMX/TMP) - 01:00 AM\n Meropenem - 06:02 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 7 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:06 PM\n Midazolam (Versed) - 11:17 PM\n Fentanyl - 11:17 PM\n Heparin Sodium (Prophylaxis) - 12:07 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 09:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 124 (94 - 124) bpm\n BP: 122/84(99) {38/-12(91) - 149/85(352)} mmHg\n RR: 24 (14 - 28) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 88 kg (admission): 88 kg\n Height: 67 Inch\n CVP: 11 (6 - 14)mmHg\n Total In:\n 2,538 mL\n 889 mL\n PO:\n TF:\n 20 mL\n IVF:\n 2,538 mL\n 870 mL\n Blood products:\n Total out:\n 790 mL\n 635 mL\n Urine:\n 790 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,748 mL\n 254 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 672 (672 - 672) mL\n PS : 18 cmH2O\n RR (Set): 0\n RR (Spontaneous): 20\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 30 cmH2O\n SpO2: 96%\n ABG: 7.21/85./86./28/2\n Ve: 12.8 L/min\n PaO2 / FiO2: 87\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese, dysnchronous\n breathing\n Eyes / Conjunctiva: PERRL, Conjunctiva pale, Sclera edema\n Head, Ears, Nose, Throat: Endotracheal tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), tachy, RV heave\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 scant wheeze : , Diminished: bases, Rhonchorous: )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)\n Distended, Obese\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting\n Skin: Warm, achymosis ove abd from sq hep, No(t) Rash: , No(t)\n Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Non -purposeful,\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 11.4 g/dL\n 246 K/uL\n 134 mg/dL\n 0.3 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 135 mEq/L\n 34.7 %\n 15.4 K/uL\n [image002.jpg]\n 03:14 PM\n 07:03 PM\n 08:52 PM\n 02:16 AM\n 03:33 AM\n 04:57 AM\n 08:15 AM\n WBC\n 8.9\n 15.4\n Hct\n 30.6\n 34.7\n Plt\n 216\n 246\n Cr\n 0.3\n 0.3\n TropT\n <0.01\n <0.01\n TCO2\n 36\n 34\n 34\n 33\n 36\n Glucose\n 89\n 134\n Other labs: PT / PTT / INR:13.9/27.5/1.2, CK / CKMB /\n Troponin-T:25/4/<0.01, ALT / AST:101/73, Alk Phos / T Bili:261/1.2,\n Differential-Neuts:18.0 %, Band:79.0 %, Lymph:0.0 %, Mono:0.0 %,\n Eos:0.0 %, Lactic Acid:2.0 mmol/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.0 mg/dL\n Imaging: cxr--b/l basilar predominant patchy ASD, possibly slightly\n increased at L mid zone c/t prior film from . ET ok, NGT high\n reviewed prior CT scan\n Microbiology: blood, urine, sputum\n Assessment and Plan\n 53M end stage sarcoidosis now with respiratory and sepsis most likely\n pna.\n MAIN ISSUES INCLUDE:\n #SIRS/Sepsis\n - continue empiric antibx\n vanco and meropenem\n double PSA coverage (add Tobra), touch base with ID service given\n his h/o resistant organisms in past\n check legionella antigen and add atypical coverage\n continue empiric PCP coverage and send DFA\n -f/u cx data, send DFA for PCP\n maintain cvp's 8-10 range, though with known bad RV CVP may be\n difficult to interpret and likely needs high filling pressure\n - Bolus IVF then pressor as needed for MAPS > 60\n --trend lactate and check SVO2\n #Hypoxemic respiratory failure - concerning for superimposed PNA on\n severe pulmonary fibrosis end stage sarcoid. No clear infiltrate\n on CXR although difficult to interpret in the setting of already severe\n pulmonary fibrosis.\n - empiric and aggressive pna treatment as above\n - consider bronchoscopy, at this time too unstable to tolerate, has # 7\n ET tube, and will not change management\n -- mdis, steroids\n -- PE remains in ddx--given bandemia and temps lower suspicion, will\n check lenis and when stable CTA\n # mechanical ventilation\n -- wean FIO2 as tolerated for Sat >90, hesitant to increase PEEP much\n more as risk of PNX given multiple blebs\n --continue PSV, could trial APRV\n #End stage sarcodiosis\n - continue high dose steroids for now--solumedrol 60mg IV Q6, clarify\n his prior dosing\n - hold azothioprine in setting of acute infection\n - empiric PCP treatment, though he was on prophy\n #Goals of care\ncontinue family meetings and regular updates\n Respiratory status is very tenuous\n consider palliative care c/s/SW consult\n #Severe anxiety - on multiple agents at baseline for severe anxiety\n including ativan, risperdal, mirtazapine, haldol.\n -Hold while on mechanical vent\n -high tolerance for pain and anxiety meds\n #Chronic pain\non high dose chronic meds at home, high tolerance\n sedate with fentanyl/midazolam\n Remainder per resident\ns note. Plan of care discussed in detai.\n ICU Care\n Nutrition:\n Comments: NPO\n Glycemic Control: Regular insulin sliding scale, Comments: NPH\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 07:30 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: 60 minutes\n Patient is critically ill\n ------ Protected Section ------\n During rounds pt with progressive decline in status.\n Developed worsening oxygenation and hypotension.\n Exam unchanged. Remains tachy in 120\ns. CXR ordered\nno pnx. No\n change in PIPS.\n APRV and PCV trialed but failed both with significantly worse\n hypoxia.\n Replaced on PSV but sats remain in low to mid 80% range. Trialed\n gently increasing PEEP to 12 with no change and then decreasing, as\n concern for PFO/shunt\nwithout effect.\n IVF bloused with minimal improvement in BP (80\ns) though MAPS > 60.\n Family updated about worsening status. Understand gravity of condition\n and poor prognosis given underlying sever lung ds.\n Code status changed to DNR and other family called in.\n Will try paralytic and change to ACV. Proning and iNO as may be\n substantial component of hypoxic vasoconstriction.\n Neo started.\n Additional 40 minutes of crit care time spent.\n ------ Protected Section Addendum Entered By: , MD\n on: 13:24 ------\n"
},
{
"category": "Physician ",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 331020,
"text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 04:00 PM\n L brachial\n MULTI LUMEN - START 04:00 PM\n inserted in ED\n INVASIVE VENTILATION - START 04:15 PM\n PICC LINE - STOP 07:30 PM\n L brachial\n ARTERIAL LINE - START 07:30 PM\n URINE CULTURE - At 09:27 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:07 PM\n Bactrim (SMX/TMP) - 01:00 AM\n Meropenem - 06:02 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 7 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:06 PM\n Midazolam (Versed) - 11:17 PM\n Fentanyl - 11:17 PM\n Heparin Sodium (Prophylaxis) - 12:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 124 (94 - 124) bpm\n BP: 122/84(99) {38/-12(91) - 149/85(352)} mmHg\n RR: 24 (14 - 28) insp/min\n SpO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 88 kg (admission): 88 kg\n Height: 67 Inch\n CVP: 11 (6 - 14)mmHg\n Total In:\n 2,538 mL\n 846 mL\n PO:\n TF:\n 20 mL\n IVF:\n 2,538 mL\n 827 mL\n Blood products:\n Total out:\n 790 mL\n 635 mL\n Urine:\n 790 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,748 mL\n 211 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n PS : 14 cmH2O\n RR (Set): 0\n RR (Spontaneous): 20\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 30 cmH2O\n SpO2: 90%\n ABG: 7.28/68/77/28/2\n Ve: 12.1 L/min\n PaO2 / FiO2: 77\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 246 K/uL\n 11.4 g/dL\n 134 mg/dL\n 0.3 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 135 mEq/L\n 34.7 %\n 15.4 K/uL\n [image002.jpg]\n 03:14 PM\n 07:03 PM\n 08:52 PM\n 02:16 AM\n 03:33 AM\n 04:57 AM\n WBC\n 8.9\n 15.4\n Hct\n 30.6\n 34.7\n Plt\n 216\n 246\n Cr\n 0.3\n 0.3\n TropT\n <0.01\n <0.01\n TCO2\n 36\n 34\n 34\n 33\n Glucose\n 89\n 134\n Other labs: PT / PTT / INR:13.9/27.5/1.2, CK / CKMB /\n Troponin-T:25/4/<0.01, ALT / AST:101/73, Alk Phos / T Bili:261/1.2,\n Lactic Acid:2.0 mmol/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n 55 yo M with PMH of end stage sarcodiosis admitted with fever,\n tachypnea, and hypoxia intubated in ED concern for increased work\n of breathing and hypoxia.\n .\n #SIRS/Sepsis - meets criteria based on tachycardia and bandemia of 29%\n on diff,most likely due to PNA given underlying severe sarcoidosis,\n other consideration is infected midline which has been in place for\n unclear duration of time. UA unremarkable and unlikely the source but\n will f/u.\n -vancomycin IV to cover for possible line infection\n -meropenam given recent h/o resistant pseudomonas on recent sputum cx\n -ua unremarkable, f/u urine culture\n -d/c midline, send tip for culture\n -BP had been stable until propofol started, will d/c propofol and\n -IVF for CVP 8-10, will start levophed if MAP still < 65 despite CVP at\n goal\n .\n #Hypoxemic respiratory failure - in setting of report of fever\n concerning for superimposed PNA on severe pulmonary fibrosis end\n stage sarcoid. No clear infiltrate on CXR although difficult to\n interpret in the setting of already severe pulmonary fibrosis.\n -treat for possible PNA given high susceptibility given underlying\n pulmonary abnormalities\n -vanc/meropenam for now for broad coverage given recent h/o multidrug\n resistant pseudomonas (resistant to zosyn and cefepime)\n -send sputum culture\n -f/u blood cultures\n -continue mechanical ventillation, wean FIO2 as tolerated for Sat >90\n -consider bronchoscopy to obtain sputum sample\n -consider CT scan to further evaluate for degree of airway disease\n -albuterol/atrovent MDI\n .\n #End stage sarcodiosis - has severe sarcoid at baseline on high dose\n steroids.\n -continue high dose steroids for now with solumedrol 60mg IV Q6\n -continue PCP prophylaxis /bactrim\n -consider bronch/CT scan as discussed above\n -continue mechanical ventillation\n -continue azathioprine\n .\n #H/O severe anxiety - on multiple agents at baseline for severe anxiety\n including ativan, risperdal, mirtazapine, haldol.\n -Will hold for now while sedated for mechanical ventillation\n -resume once getting close to weaning\n .\n #Chronic pain/spinal stenosis - on chronic ms contin/percocet, will\n hold for now and sedate with fentanyl/midazolam while intubated.\n .\n #Type 2 DM\n likely component chronic steroids\n -continue NPH/HISS\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 07:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 331035,
"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 55 yo M with end stage sarcoid\n 24 Hour Events:\n PICC LINE - START 04:00 PM--> d/c'd on arrival to MICU\n L brachial\n MULTI LUMEN - START 04:00 PM\n inserted in ED\n INVASIVE VENTILATION - START 04:15 PM\n PICC LINE - STOP 07:30 PM\n L brachial\n ARTERIAL LINE - START 07:30 PM\n URINE CULTURE - At 09:27 PM\n levoflox/cefepime in ED --> broadened to /vanco in , empiric\n PCP Bactrim IV, pan cx'd\n decadron given in ED, continued solumedrol 60 Q 6 in ICU\n hypotensive after propofol--> fluid responsive, changed propofol to\n versed\n never required pressor support\n Oxygenation remained difficult--> 70% FIO2 on arrival with O2 sats in\n 80's --> seemed to better tolerate PSV, FIO2\n increased to 100%, stas in 90's, 7.21/87/85\n History obtained from Medical records, ho\n Patient unable to provide history: Sedated, intubated\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:07 PM\n Bactrim (SMX/TMP) - 01:00 AM\n Meropenem - 06:02 AM\n Infusions:\n Fentanyl - 150 mcg/hour\n Midazolam (Versed) - 7 mg/hour\n Other ICU medications:\n Pantoprazole (Protonix) - 09:06 PM\n Midazolam (Versed) - 11:17 PM\n Fentanyl - 11:17 PM\n Heparin Sodium (Prophylaxis) - 12:07 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 09:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 37.4\nC (99.3\n HR: 124 (94 - 124) bpm\n BP: 122/84(99) {38/-12(91) - 149/85(352)} mmHg\n RR: 24 (14 - 28) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 88 kg (admission): 88 kg\n Height: 67 Inch\n CVP: 11 (6 - 14)mmHg\n Total In:\n 2,538 mL\n 889 mL\n PO:\n TF:\n 20 mL\n IVF:\n 2,538 mL\n 870 mL\n Blood products:\n Total out:\n 790 mL\n 635 mL\n Urine:\n 790 mL\n 635 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,748 mL\n 254 mL\n Respiratory support\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 672 (672 - 672) mL\n PS : 18 cmH2O\n RR (Set): 0\n RR (Spontaneous): 20\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 30 cmH2O\n SpO2: 96%\n ABG: 7.21/85./86./28/2\n Ve: 12.8 L/min\n PaO2 / FiO2: 87\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Eyes / Conjunctiva: PERRL, Conjunctiva pale, Sclera edema\n Head, Ears, Nose, Throat: Endotracheal tube\n Lymphatic: Cervical WNL, Supraclavicular WNL\n Cardiovascular: (S1: Normal), (S2: Normal), tachy\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 , Diminished: bases, Rhonchorous: )\n Abdominal: Soft, No(t) Non-tender, Bowel sounds present, No(t)\n Distended, Obese\n Extremities: Right: 2+, Left: 2+, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting\n Skin: Warm, achymosis ove abd from sq hep, No(t) Rash: , No(t)\n Jaundice\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, No(t) Oriented (to): , Movement: Non -purposeful,\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 11.4 g/dL\n 246 K/uL\n 134 mg/dL\n 0.3 mg/dL\n 28 mEq/L\n 4.8 mEq/L\n 17 mg/dL\n 100 mEq/L\n 135 mEq/L\n 34.7 %\n 15.4 K/uL\n [image002.jpg]\n 03:14 PM\n 07:03 PM\n 08:52 PM\n 02:16 AM\n 03:33 AM\n 04:57 AM\n 08:15 AM\n WBC\n 8.9\n 15.4\n Hct\n 30.6\n 34.7\n Plt\n 216\n 246\n Cr\n 0.3\n 0.3\n TropT\n <0.01\n <0.01\n TCO2\n 36\n 34\n 34\n 33\n 36\n Glucose\n 89\n 134\n Other labs: PT / PTT / INR:13.9/27.5/1.2, CK / CKMB /\n Troponin-T:25/4/<0.01, ALT / AST:101/73, Alk Phos / T Bili:261/1.2,\n Differential-Neuts:18.0 %, Band:79.0 %, Lymph:0.0 %, Mono:0.0 %,\n Eos:0.0 %, Lactic Acid:2.0 mmol/L, Ca++:8.8 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.0 mg/dL\n Imaging: cxr--b/l basilar predominant patchy ASD, possibly slightly\n increased at L mid zone c/t prior film from . ET ok, NGT high\n reviewed prior CT scan\n Microbiology: blood, urine, sputum\n Assessment and Plan\n 55 yo M with end-stage sarcoid admitted with hypoxic/hypercarbic resp\n failure, sepsis with profound bandemia, persistent tachycardia\n #SIRS/Sepsis - meets criteria based on tachycardia and bandemia of 29%\n on diff,most likely due to PNA given underlying severe sarcoidosis,\n other consideration is infected midline which has been in place for\n unclear duration of time. UA unremarkable and unlikely the source but\n will f/u.\n --empiric antibx\n - continue vanco and meropenem, taper per cx data in next 48 hrs\n -- consider double psuedo coverage (Tobra), touch base with ID service\n given his resistent organisms in past\n -- check legionella antigen and add atypoical coverage empirically\n -- continue empiric PCP coverage and send DFA\n -ua unremarkable, f/u urine culture\n -d/c midline, send tip for culture\n -BP had been stable until propofol started, will d/c propofol and\n fluid bolus, maintain cvp's 8-10 range, though with known bad RV CVP\n may be difficult to interpret\n #Hypoxemic respiratory failure - in setting of report of fever\n concerning for superimposed PNA on severe pulmonary fibrosis end\n stage sarcoid. No clear infiltrate on CXR although difficult to\n interpret in the setting of already severe pulmonary fibrosis.\n -empiric and aggressive pna treatment, difficult to interpret change in\n CXR given very abnl baseline\n Continue vanco and meropenem, taper per cx data in next 48 hrs\n consider double psuedo coverage, touch base with ID service\n given his resistent organisms in past\n check legionella antigen and add atypoical coverage empirically\n continue empiric PCP coverage and send DFA\n - consider bronchoscopy to obtain sputum sample, though has # 7 ET tube\n # mechanical ventillation\n -- wean FIO2 as tolerated for Sat >90\n -once stable would get CTA scan to further evaluate for degree of\n airway disease\n -albuterol/atrovent MDI\n # PE remaijhns in ddx--given bandemia and temps lower suspicion, will\n check lenis and when stable, get cta\n # bandemia--presumed pulm infection, cover as above\n #End stage sarcodiosis - has severe sarcoid at baseline on high dose\n steroids.\n - continue high dose steroids for now with solumedrol 60mg IV Q6,\n clarify his prior dosing\n - hold azothioprine\n - empiric PCP treatment\n bronch/CT scan as discussed above\n -continue mechanical ventillation--would try aprv or PC as these modes\n may help with v/q mismatch, opxygenation and ventialtion\n would wean fio2 as tolerated as currently pao2 is high80's on peepm 10\n #H/O severe anxiety - on multiple agents at baseline for severe anxiety\n including ativan, risperdal, mirtazapine, haldol.\n -Will hold for now while sedated for mechanical ventillation\n -resume once getting close to weaning\n -high tolerance for pain and anxiety meds\n #Chronic pain/spinal stenosis - on chronic ms contin/percocet, will\n hold for now and sedate with fentanyl/midazolam while intubated.\n # code status--consider palliativer care c/s tomororw, continue family\n discussion\n #Type 2 DM\n likely component chronic steroids\n -continue NPH/HISS\n ICU Care\n Nutrition:\n Comments: NPO--start TFs\n Glycemic Control: Regular insulin sliding scale, Comments: NPH\n Lines:\n Multi Lumen - 04:00 PM\n Arterial Line - 07:30 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: 60 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 331002,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n :\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Pleural friction\n LUL Lung Sounds: Bronchial\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Frequent desaturation episodes,\n Gasping efforts; Comments: breathing pattern appears agonal\n Assessment of breathing comfort: No response (sleeping / sedated)\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 with labile O2 sats requiring 90% + FIO2. Breathing appears agonal\n on cpap/psv . Had been initially on assist/control but totally\n dysynchronous. ABGs with marginal oxygenation and worsening resp\n acidosis.\n ------ Protected Section------\n This note not written by , written by \n RRT\n ------ Protected Section Error Entered By: , RRT\n on: 05:48 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 331004,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Pleural friction\n LUL Lung Sounds: Bronchial\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Gasping efforts; Comments:\n breathing appears agonal\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 with worsening abgs/O2 sats, agonal breathing pattern. Multiple vent\n changes made throught shift with no change.\n"
},
{
"category": "Respiratory ",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 330999,
"text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 25 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7mm\n :\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Pleural friction\n LUL Lung Sounds: Bronchial\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: / None\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Frequent desaturation episodes,\n Gasping efforts; Comments: breathing pattern appears agonal\n Assessment of breathing comfort: No response (sleeping / sedated)\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 with labile O2 sats requiring 90% + FIO2. Breathing appears agonal\n on cpap/psv . Had been initially on assist/control but totally\n dysynchronous. ABGs with marginal oxygenation and worsening resp\n acidosis.\n"
},
{
"category": "Nursing",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330990,
"text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, sedated on versed/fentanyl gtts.\n Placed on PSV from CMV r/t vent dysynchony, appeared more comfortable\n on PSV.\n Increasingly hypoxic overnight w/ high Fi02/PEEP.\n Increasingly hypercarbic overnight despite adequate MV 10-12 L./Min.\n 02 sats 87-92, RR 15-17, breathing appearing increasingly labored and\n agonal throughout shift.\n Latest ABG 7.28/68/77 w/ Fi02 = 90%\n Hemodynamically stable.\n Action:\n FIO2 increased to 100%, PEEP adjusted per medical team (see\n flowsheet).\n Pts daughter (HCP) called and updated my housestaff, code status\n changed to DNR.\n CXR done overnight.\n Suctioned for scant secretions.\n MDI\ns as ordered by RRT\n On vancomycin/meropenem/bactrim.\n Response:\n 02 sats 90-91% on PSV 14/10, FIO2 1.0\n Cont adequate RR 15-18, MV 10-12 L/min.\n Conts agonal breathing pattern.\n Plan:\n Continue vent support to maintain adequate oxygenation.\n Plan per medical team to attempt to decrease PEEP and increase PS to\n support oxygenation.\n Cont to update pts daughter in any changes in condition.\n"
},
{
"category": "Nursing",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330991,
"text": "55 yo M with PMH of end stage sarcodiosis, Hep C, admitted with fever,\n tachypnea, and hypoxia intubated in ED concern for increased work\n of breathing and hypoxia.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, sedated on versed/fentanyl gtts.\n Placed on PSV from CMV r/t vent dysynchony, appeared more comfortable\n on PSV.\n Increasingly hypoxic overnight w/ high Fi02/PEEP.\n Increasingly hypercarbic overnight despite adequate MV 10-12 L./Min.\n 02 sats 87-92, RR 15-17, breathing appearing increasingly labored and\n agonal throughout shift.\n Latest ABG 7.28/68/77 w/ Fi02 = 90%\n Hemodynamically stable.\n Action:\n FIO2 increased to 100%, PEEP adjusted per medical team (see\n flowsheet).\n Pts daughter (HCP) called and updated my housestaff, code status\n changed to DNR.\n CXR done overnight.\n Suctioned for scant secretions.\n MDI\ns as ordered by RRT\n On vancomycin/meropenem/bactrim.\n Response:\n 02 sats 90-91% on PSV 14/10, FIO2 1.0\n Cont adequate RR 15-18, MV 10-12 L/min.\n Conts agonal breathing pattern.\n Plan:\n Continue vent support to maintain adequate oxygenation.\n Plan per medical team to attempt to decrease PEEP and increase PS to\n support oxygenation.\n Cont to update pts daughter in any changes in condition.\n"
},
{
"category": "Nursing",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330992,
"text": "55 yo M with PMH of end stage sarcodiosis, Hep C, admitted with fever,\n tachypnea, and hypoxia intubated in ED concern for increased work\n of breathing and hypoxia.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, sedation changed from propofo gttl ->\n versed/fentanyl gtts overnight.\n Placed on PSV from CMV r/t vent dysynchony, appeared more comfortable\n on PSV.\n Increasingly hypoxic overnight w/ high Fi02/PEEP.\n Increasingly hypercarbic overnight despite adequate MV 10-12 L./Min.\n 02 sats 87-92, RR 15-17, breathing appearing increasingly labored and\n agonal throughout shift.\n Latest ABG 7.28/68/77 w/ Fi02 = 90%\n Hemodynamically stable.\n Action:\n FIO2 increased to 100%, PEEP adjusted per medical team (see\n flowsheet).\n Pts daughter (HCP) called and updated my housestaff, code status\n changed to DNR.\n CXR done overnight.\n Suctioned for scant secretions.\n MDI\ns as ordered by RRT\n On vancomycin/meropenem/bactrim.\n Response:\n 02 sats 90-91% on PSV 14/10, FIO2 1.0\n Cont adequate RR 15-18, MV 10-12 L/min.\n Conts agonal breathing pattern.\n Plan:\n Continue vent support to maintain adequate oxygenation.\n Plan per medical team to attempt to decrease PEEP and increase PS to\n support oxygenation.\n Cont to update pts daughter in any changes in condition.\n LENI\ns ordered for today r/t prior hx of PE.\n Edema, peripheral\n Assessment:\n Pt has significant weeping edema from old IV insertion site in r arm.\n Action:\n Softsorb dressing changed overnight.\n Response:\n Site continues to weep serious fluid.\n Plan:\n Cont to monitor site and change dressing as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2186-07-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 330996,
"text": "55 yo M with PMH of end stage sarcodiosis, Hep C, admitted with fever,\n tachypnea, and hypoxia intubated in ED concern for increased work\n of breathing and hypoxia.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated, sedation changed from propofo gttl ->\n versed/fentanyl gtts overnight.\n Placed on PSV from CMV r/t vent dysynchony, appeared more comfortable\n on PSV.\n Increasingly hypoxic overnight w/ high Fi02/PEEP.\n Increasingly hypercarbic overnight despite adequate MV 10-12 L./Min.\n 02 sats 87-92, RR 15-17, breathing appearing increasingly labored and\n agonal throughout shift.\n Latest ABG 7.28/68/77 w/ Fi02 = 90%\n Hemodynamically stable.\n Action:\n FIO2 increased to 100%, PEEP adjusted per medical team (see\n flowsheet).\n Pts daughter (HCP) called and updated my housestaff, code status\n changed to DNR.\n CXR done overnight.\n Suctioned for scant secretions.\n MDI\ns as ordered by RRT\n On vancomycin/meropenem/bactrim.\n Response:\n 02 sats 90-91% on PSV 14/10, FIO2 1.0\n Cont adequate RR 15-18, MV 10-12 L/min.\n Conts agonal breathing pattern.\n Plan:\n Continue vent support to maintain adequate oxygenation.\n Plan per medical team to attempt to decrease PEEP and increase PS to\n support oxygenation.\n Cont to update pts daughter in any changes in condition.\n LENI\ns ordered for today r/t prior hx of PE.\n Edema, peripheral\n Assessment:\n Pt has significant weeping edema from old IV insertion site in r arm.\n Action:\n Softsorb dressing changed overnight.\n Response:\n Site continues to weep serious fluid.\n Plan:\n Cont to monitor site and change dressing as needed.\n ------ Protected Section ------\n Called pts daughter () @ 0530 to confirm her understading of\n severity of pts illness and to see if she was planning on visiting pt.\n She stated she was attempting to contact other family members and will\n be in to visit as soon as possible.\n ------ Protected Section Addendum Entered By: , RN\n on: 05:31 ------\n"
}
] |
13,478 | 191,185 | The patient was admitted to the Blue Medicine service under the care of Dr.. She was made NPO and started on IVF for resuscitation. Blood was typed and crossed in preparation for surgery. Appropriate consent was obtained. She did well during the procedure. A central venous line was placed prior to surgery and after the evacuation she was initially transferred to the ICU. Her pain was treated with dilaudid and po pain meds. She was transferred to the floor on POD#2. On the floor, the patient's diet was advanced and she was ordered for a PT consult. She underwent periods of confusion during this time, requiring restraints on POD#6. Her nutritional status was a primary focus during her post-op recovery. Her diet was advanced, but she did not eat independently and required continued intravenous fluids and encouragement and feeding from nursing staff. By the time of discharge, she was tolerating po with assistance in feeding from nursing staff. She was passing gas and having regular bowel movements. She was incontinent and required placement of a foley catheter in order to keep track of her ins/outs. Her peripheral IV was discontinued prior to discharge. | low grade temps.gi- abd distended slightly more firm than this am, dr made aware. to be unknown this a.m. but Lactate down to 1.3, ABG this a.m. 7.33, 43, 103. There is a 6.1 x 3.2 cm low density fluid collection along the anterior right hemipelvis in the region of previously evident hematoma. The right IJ line has been removed and an NG tube is in place, terminating within the stomach. There has been interval removal of an NG tube. MAE but weak, deconditioned.CV: HR low 100's-130's ST w/o ectopy. u/o qs to foley catheter.id- low grade temps to 100.6 po. tachycardic o/n to 130's but HR down to low 100's this a.m., likely hypovolemic intraoperatively- CVP went from 2 to 9 o/n during fluid resuscitation. midline incision has DSD to area with signs of scant serous drainage on underside of drsng. Lungs are clear upper lobes, diminished @ bases.Heme/lytes/micro: Hct down to 32 this a.m. Platelets dropped o/n- etiology unknown. There has been interval placement of a right IJ central venous catheter with its tip terminating in the mid SVC. 1:44 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: assess for abcess, please give oral and iv contrast. Minimal atelectasis at the right lung base. tolerating w/sbp 120-150's, rising to 160's sys w/activity/discomfort. Focal, nonmobile fluid collection in the anterior right hemipelvis in the region of the previously evident hematoma. (Over) 1:44 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: assess for abcess, please give oral and iv contrast. BS are hypoactive. bp stable 95-130's, tolerating lopressor well. Pelvic loops of bowel are within normal limits. nursing note: 7a-7pneuro- pt easily arousable, pleasantly confused, oriented to self only. There is right sided hydronephrosis and hydroureter. HR 100 sinus tach. cpt done.cv- hr this am up to 130's sr. started on iv lopressor with good effect, now changed to po. also c/o of severe abd. PLEASE Admitting Diagnosis: ABDOMINAL PAIN Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) IMPRESSION: 1. Sinus tachycardiaLeft axis deviationPossible anterior infarct - age undeterminedPossible left ventricular hypertrophySince previous tracing of , anterior changes are new There is a moderate sized right pleural effusion. Minimal linear atelectatic changes are seen at the right lung base. Cholelithasis without cholecystitis. There is retained contrast in the rectosigmoid. Had an exploratory lap and evacuation of hematoma. for hypocalcemia. 3) Bilateral patchy pulmonary parenchymal opacities are suggestive of pneumonic consolidation. Minimal amount of patchy atelectasis is seen at the right lung base. Please refer to above notation and carevue for details on lyte repletion. Lactate also rising @ this time- max o/n was 3.6. 7a-7pneuro: alert, follows commands, oriented x 2, moving all extremitiescv: hr st(108-119), HO aware, no ectopy, sbp stable(104-146)resp: on 3 l np, bs + all lobes & clear, diminished to bases, encouraged to deep breath & cough, non-productive cough, rr 16-18, sat 97-100, pt pulls O2 off @ times, desat to 90 on R.A., abg this PM on 3 l np good, no acidosis notedgi: npo, no stool, nausea or vomitinggu: foley patent, clear yellow urine, good uoother: abd dsg D&I, may change dsg after 24 hrs, iv fliuds decreased & changed to d51/2 with 20 kcl, bs covered with rssi, pm hct & lactic acid stableplan: continue to monitor in icu overnoc, tx to floor in am if stable Note is made of tiny bilateral low attenuation foci within the kidneys which likely represent cysts. Cannot entirely exclude the possibility of abscess. fall risk.resp- ls clear but diminished. Moderate sized bilateral pleural effusions. There are symmetric nephrograms bilaterally. Labs repeated and are pnd. line which was d/c'd following placement of R IJ. pain management changed to po's. T-max this shift 98.7. no c/o sobgi/gu- abd soft/distened +bs, dressing intact to abdomen, sm old blood under dressing, surgery will be in this am to change, then may change after that time. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There are patchy opacities at the lung bases bilaterally, new since the previous examination of . K+ this a.m. WNL. patient remains dnr/dni Sinus tachycardiaLeft axis deviationLeft anterior fascicular blockDelayed R wave progression suggests possible old anteroseptal myocardialinfarctionLow QRS voltages in precordial leadsQRS interval 80Since previous tracing of , axis now more leftward + bs pt denies flatus. Small amount of free simple fluid is in the abdomen. CT OF THE ABDOMEN WITH IV CONTRAST: Visualized lung bases demonstrate moderate sized bilateral pleural effusions with associated atelectatic changes. On the left, a fluid-filled structure with layering internal density measures 1.9 x 2.7 cm. with R fem. MSO4 2mg given times two with fair effect.CV: Pt's SBP initially 130-140. CVP ranged from this shift.Resp: O2Sats mid-high 90's on 3L face mask. made aware of possible transfer to surgery floor.dispo- dnr/dni, s/p evacuation of abd muscle hematoma. There is increased patchy opacity at the left lung base with obscuration of the left hemidiaphragm. IMPRESSION: Bilateral pleural effusions, right greater than left. Also arterial gastric bleeder cuaterized. Upright or lateral decubitus film to optimally evaluate for free intraperitoneal gas. midline abd original dsg intact. There is cholelithiasis without evidence of cholecystitis. surgical incision intact.Social: DNR but this is questionable during intraop. Platelet count dropped into 60 range ?etiology.GI: NPO no stool. Her BP is better and she has new a-line which was inserted in OR. | 20 | [
{
"category": "Radiology",
"chartdate": "2117-05-25 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 829781,
"text": " 10:41 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for pneumonia\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with\n REASON FOR THIS EXAMINATION:\n assess for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath.\n\n TWO VIEWS OF THE CHEST: Comparison is made to . The right IJ line\n has been removed and an NG tube is in place, terminating within the stomach.\n There is a moderate sized right pleural effusion. There is a retrocardiac\n density, which could represent atelectasis or an infiltrate. No vascular\n congestion or pneumothorax. There is also probably a small left pleural\n effusion. A right lower lobe infiltrate cannot be excluded.\n\n The cardiac and mediastinal contours are stable.\n\n IMPRESSION: Bilateral pleural effusions, right greater than left. Left lower\n lobe collapse/consolidation, which could represent pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-05-25 00:00:00.000",
"description": "ABDOMEN, SINGLE VIEW",
"row_id": 829782,
"text": " 10:41 AM\n ABDOMEN, SINGLE VIEW Clip # \n Reason: check NG position, and asses distention\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with\n REASON FOR THIS EXAMINATION:\n check NG position, and asses distention\n ______________________________________________________________________________\n FINAL REPORT\n For NG tube placement.\n\n NG tube is in body of stomach. There is retained contrast in the\n rectosigmoid. Lumbar scoliosis convex to the left. There are a few gas-\n filled slightly-dilated loops of small bowel.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-05-26 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 829869,
"text": " 1:44 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: assess for abcess, please give oral and iv contrast. PLEASE\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman s/p ex lap for hematoma (retroperitoneal dissection) on\n , now w/ rising WBC, abd distension, and increasing pain\n REASON FOR THIS EXAMINATION:\n assess for abcess, please give oral and iv contrast. PLEASE PAGE WHEN\n PATIENT ON THE TABLE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: An 82-year-old female status post retroperitoneal dissection\n and hematoma, now with rising white blood cell count and worsening abdominal\n distention.\n\n TECHNIQUE: Contiguous axial images were obtained from the lung bases through\n the symphysis pubis folloing the adminsitration of Optiray, nonionic contrast\n was used due to patient debility.\n\n Multiplanar reformatted images were included.\n\n COMPARISON: .\n\n CT OF THE ABDOMEN WITH IV CONTRAST: Visualized lung bases demonstrate moderate\n sized bilateral pleural effusions with associated atelectatic changes. The\n heart is enlarged. A very small amount of pericardial fluid is present. There\n is a small amount of simple free fluid within the abdomen. The liver, spleen,\n pancreas, kidneys, and adrenal glands appear grossly normal. Note is made of\n tiny bilateral low attenuation foci within the kidneys which likely\n represent cysts. There is cholelithiasis without evidence of cholecystitis.\n The aorta and its major branches are patent. There are a few promininent\n loops of small bowel within the left hemiabdomen but contrast passes freely\n into the colon.\n\n CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder contains a large amount\n of air, secondary to the presence of the Foley catheter. Pelvic loops of\n bowel are within normal limits. There is a 6.1 x 3.2 cm low density fluid\n collection along the anterior right hemipelvis in the region of previously\n evident hematoma. It is unclear whether this represents portion of resolving\n hematoma or a new collection. There is no air within it and no adjacent\n inflammatory changes are identified.\n\n BONE WINDOWS: Diffuse osteopenia and severe degenerative changes of the\n lumbosacral spine are evident.\n\n CT RECONSTRUCTIONS: Multiplanar reformatted images were used to confirm the\n above findings.\n\n (Over)\n\n 1:44 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: assess for abcess, please give oral and iv contrast. PLEASE\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Moderate sized bilateral pleural effusions.\n 2. Cholelithasis without cholecystitis.\n 3. Small amount of free simple fluid is in the abdomen.\n 4. Focal, nonmobile fluid collection in the anterior right hemipelvis in the\n region of the previously evident hematoma. It is unclear whether this\n represents resolving hematoma or a separate collection.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-05-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 829427,
"text": " 1:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p RIJ placement; assess for location and signs of pneumo\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with s/p fall 1 week ago, now w/severe abdominal pain,\n guarding, rebound\n REASON FOR THIS EXAMINATION:\n s/p RIJ placement; assess for location and signs of pneumo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post right IJ central venous line placement, assess position.\n\n PORTABLE SEMI-UPRIGHT FRONTAL RADIOGRAPH. Comparison is made to study done 45\n minutes prior. There has been interval placement of a right IJ central venous\n catheter with its tip terminating in the mid SVC. There is no pneumothorax. No\n other changes compared to the prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-05-21 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 829492,
"text": " 2:35 PM\n PORTABLE ABDOMEN Clip # \n Reason: disproportionate pneumoperitoneum\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with severe abd pain s/p laparotomy\n REASON FOR THIS EXAMINATION:\n disproportionate pneumoperitoneum\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN SINGLE FILM:\n\n HISTORY: Severe abdominal pain following laparotomy.\n\n Distribution of bowel gas is unremarkable with gas and retained contrast\n throughout the colon and no evidence for intestinal obstruction. Upright or\n lateral decubitus film to optimally evaluate for free intraperitoneal gas.\n\n IMPRESSION: No diagnostic abnormality.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-05-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 829496,
"text": " 1:50 PM\n CHEST (PORTABLE AP); REPEAT, (REQUEST BY RADIOLOGIST) Clip # \n Reason: ASSESS FOR PNEUMO\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: 82-year-old with interperitoneal hematoma, assess for\n pneumothorax post-line placement.\n\n PORTABLE SEMIUPRIGHT FRONTAL RADIOGRAPH. Comparison is made to studies of\n earlier the same day.\n\n No pneumothorax is identified. Right IJ line is unchanged in position. There\n has been no change in the appearance of left pleural effusion and left lower\n lobe atelectasis/consolidation. No other interval changes in the 10 hour\n period from the most recent prior study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-05-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 829426,
"text": " 12:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumo s/p L subclavian attempt without success; about t\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with s/p fall 1 week ago, now w/severe abdominal pain,\n guarding, rebound\n REASON FOR THIS EXAMINATION:\n r/o pneumo s/p L subclavian attempt without success; about to attempt different\n site\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82 y/o with intraperitoneal hematoma, failed central venous line\n placement, assess for pneumothorax.\n\n PORTABLE SEMI-UPRIGHT FRONTAL RADIOGRAPH. Comparison is made to 1 day prior.\n\n There has been interval removal of an NG tube. There is increased patchy\n opacity at the left lung base with obscuration of the left hemidiaphragm.\n Minimal linear atelectatic changes are seen at the right lung base. Pulmonary\n vasculature is normal. There is no pneumothorax. Cardiac and mediastinal\n contours are unchanged.\n\n IMPRESSION: No pneumothorax. Increased collapse/consolidation at the left lung\n base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-05-20 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 829336,
"text": " 5:17 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: 82 year old woman with severe ABD pain, rebound and guarding\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with severe ABD pain, rebound and guarding\n REASON FOR THIS EXAMINATION:\n 82 year old woman with severe ABD pain, rebound and guarding\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 6:02 AM\n Large fluid collection within the pelvis with density suggestive of hematoma,\n with additional layering hematomas within the rectus muscles bilaterally.\n This large collection, probably a hematoma, causes right urinary outflow tract\n obstruction.\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Severe abdominal pain, rebound and guarding.\n\n COMPARISON: .\n\n TECHNIQUE: Contiguous helically acquired axial images were acquired from the\n lung bases to the pubic symphysis following the administration of 150 cc of\n intravenous Optiray.\n\n CONTRAST: Oral and intravenous nonionic contrast were administered due to the\n rapid rate of bolus injection required for this examination.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There are patchy opacities at\n the lung bases bilaterally, new since the previous examination of \n . The heart and pericardium appear unremarkable. The liver, gallbladder,\n pancreas, spleen, and adrenal glands appear unremarkable. There are symmetric\n nephrograms bilaterally. There is right sided hydronephrosis and hydroureter.\n The large and small bowel loops are normal in caliber, and there is no\n abnormal bowel wall thickening. Within the upper pole of the right kidney, a\n rounded hypodense structure is seen measuring 1 cm in diameter. Additional\n hypodense lesions are seen within the upper pole and interpolar regions of the\n left kidney. The aorta is normal in caliber throughout. There is dense fluid\n of approximately 37 Hounsfield Units layering adjacent to the right lobe of\n the liver and the right lower quadrant of the abdomen. There are bilateral\n fluid collections within the rectus sheath, expanding the rectus sheath, and\n containing layering internal density. On the left, a fluid-filled structure\n with layering internal density measures 1.9 x 2.7 cm. A very large fluid\n collection with layering internal density is seen extending into the pelvis.\n This measures 8.4 x 14.7 cm. This is 20 Hounsfield Units at its least dense,\n and measures approximately 60 Hounsfield Units within the denser portion\n dependently within the collection.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: A large fluid collection with\n layering density occupyies most of the pelvis. The urinary bladder is\n compressed to the left of the pelvis and contains a Foley catheter and\n (Over)\n\n 5:17 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: 82 year old woman with severe ABD pain, rebound and guarding\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n contrast. The uterus and adnexae are not visualized. The rectum and sigmoid\n colon appear unremarkable. Additional dense fluid is seen within the pelvis\n posterior to this large collection. There is a suggestion of a fat plane\n between the rectum and this large collection of fluid.\n\n BONE WINDOWS: Bone windows demonstrate no evidence of suspicious lytic or\n sclerotic osseous lesions. There is extensive degenerative change of the\n thoracic and lumbosacral spine.\n\n IMPRESSION:\n\n 1) Large fluid collection within the pelvis and right lower quadrant of the\n abdomen, with internal density suggestive of layering blood products. There\n are additional similar collections within the rectus sheath bilaterally,\n raising the possibility of large rectus sheath hematoma with extension to the\n extraperitoneal soft tissues. Cannot entirely exclude the possibility of\n abscess. Additional dense fluid adjacent to the right lobe of the liver\n suggests the possibility of intraperitoneal extension.\n 2) Right sided hydronephrosis and hydroureter, likely resulting from\n compressive effect of the large pelvic fluid collection.\n 3) Bilateral patchy pulmonary parenchymal opacities are suggestive of\n pneumonic consolidation.\n 4) Bilateral hypodense lesions within the kidneys are consistent in\n appearance with cysts, although several are too small to accurately\n characterize.\n\n These results were discussed with the clinical provider at the time of\n interpretation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-05-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 829333,
"text": " 8:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P FALL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with s/p fall 1 week ago, now w/severe abdominal pain,\n guarding, rebound\n REASON FOR THIS EXAMINATION:\n r/o perf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82 y/o post fall with abdominal pain, assess for free air.\n\n PORTABLE SEMI-UPRIGHT FRONTAL RADIOGRAPH. Comparison .\n\n Cardiac and mediastinal contours are stable. The lungs are clear with no focal\n consolidations or effusions. Minimal amount of patchy atelectasis is seen at\n the right lung base. Pulmonary vasculature is normal, and there is no\n pneumothorax. The osseous structures are unremarkable other than a mild\n scoliosis of the thoracic spine. No free air is seen under the diaphragm. An\n NG tube is seen terminating within the fundus of the stomach. Contrast is seen\n being excreted from the right kidney.\n\n IMPRESSION: No free air. Minimal atelectasis at the right lung base.\n\n"
},
{
"category": "ECG",
"chartdate": "2117-05-27 00:00:00.000",
"description": "Report",
"row_id": 157409,
"text": "Sinus tachycardia\nLeft axis deviation\nPossible anterior infarct - age undetermined\nPossible left ventricular hypertrophy\nSince previous tracing of , anterior changes are new\n\n"
},
{
"category": "ECG",
"chartdate": "2117-05-20 00:00:00.000",
"description": "Report",
"row_id": 157621,
"text": "Sinus tachycardia\nLeft axis deviation\nLeft anterior fascicular block\nDelayed R wave progression suggests possible old anteroseptal myocardial\ninfarction\nLow QRS voltages in precordial leads\nQRS interval 80\nSince previous tracing of , axis now more leftward\n\n"
},
{
"category": "ECG",
"chartdate": "2117-05-20 00:00:00.000",
"description": "Report",
"row_id": 157622,
"text": "Sinus rhythm.\nPossible anterior infarct - age undetermined\nTechnically difficult study in leads V4-V6 - shows artifact\nSince previous tracing of , artifact seen in leads V4-V6 - Suggest\nrepeat tracing\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-05-22 00:00:00.000",
"description": "Report",
"row_id": 1437614,
"text": "nursing note: 7a-7p\nneuro- pt easily arousable, pleasantly confused, oriented to self only. follows commands. grimaces with pain, but unable to describe and rate on scale. pain management changed to po's. tylenol with codeine with some relief. oob to chair with assist of two. fall risk.\n\nresp- ls clear but diminished. sats on 3l n/c >95%. rr 10-20. encouraged to cough and deep breath. incentive spirometry instructions given and encouraged however pt unable to perform despite repeated attempts. cpt done.\n\ncv- hr this am up to 130's sr. started on iv lopressor with good effect, now changed to po. bp stable 95-130's, tolerating lopressor well. phos of 1.5 repleted with 30mmol of kphos today. low grade temps.\n\ngi- abd distended slightly more firm than this am, dr made aware. tolerated clear liquids well however needs encouragement to take. midline abd original dsg intact. + bs pt denies flatus. no bm. on colace.\n\ngu- foley patent for yellow urine.\n\naccess- r radial aline d/c'd. quad lumen central line in rij intact.\n\nsocial- daughter called for update. made aware of possible transfer to surgery floor.\n\ndispo- dnr/dni, s/p evacuation of abd muscle hematoma. hemodynamically stable, needs pain to be followed as pt will not ask for meds. encourage cdb and oob.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-05-21 00:00:00.000",
"description": "Report",
"row_id": 1437611,
"text": "7a-7p\nneuro: alert, follows commands, oriented x 2, moving all extremities\n\ncv: hr st(108-119), HO aware, no ectopy, sbp stable(104-146)\n\nresp: on 3 l np, bs + all lobes & clear, diminished to bases, encouraged to deep breath & cough, non-productive cough, rr 16-18, sat 97-100, pt pulls O2 off @ times, desat to 90 on R.A., abg this PM on 3 l np good, no acidosis noted\n\ngi: npo, no stool, nausea or vomiting\n\ngu: foley patent, clear yellow urine, good uo\n\nother: abd dsg D&I, may change dsg after 24 hrs, iv fliuds decreased & changed to d51/2 with 20 kcl, bs covered with rssi, pm hct & lactic acid stable\n\nplan: continue to monitor in icu overnoc, tx to floor in am if stable\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-05-22 00:00:00.000",
"description": "Report",
"row_id": 1437612,
"text": "micu npn 1900-0700\nplease refer to carevue flowsheet for all objective data\n\nneuro- alert+oriented x1-2 o/n. hx of dementia. mae. medicated w/2 mg morphine prn for abdominal discomfort, unable to quantify or specify pain, sometimes described as \"all over\".\n\ncv- at change of shift a line was clotted off, dr in to put new one in w/o difficulty. good waveform. +csm. patient continues to be tachycardic 1teens-130, at times to mid 130's.. sicu resident, dr reiterating that we will continue to watch w/o intervention at this time. tolerating w/sbp 120-150's, rising to 160's sys w/activity/discomfort. continues on d5 .45 ns w/20 kcl @70cc/hr. R groin stick w/slight oozing noted this am, new dressing applied, no hematoma present.\n\nresp- received on 6+liters n/c, sats 100%. down to 3-4l sats 97-98%, does desat to 89% if pulls off o2, which she has only done once through the night. l/s clear/dim at the bases. no c/o sob\n\ngi/gu- abd soft/distened +bs, dressing intact to abdomen, sm old blood under dressing, surgery will be in this am to change, then may change after that time. remains npo per sicu team. following blood sugars qid. no insulin needed o/n. u/o qs to foley catheter.\n\nid- low grade temps to 100.6 po. not on abx. wbc 12.1 today\n\nsocial- no contact from family. patient remains dnr/dni\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-05-22 00:00:00.000",
"description": "Report",
"row_id": 1437613,
"text": "micu npn 1900-0700\nk this am 4.0, repleted w/20 meq kcl iv\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-05-20 00:00:00.000",
"description": "Report",
"row_id": 1437607,
"text": "MICU NPN/\nPt admitted to MICU this AM and was alert and oriented times three. Calm and cooperative but continued to c/o abdominal pain. Repeat hct was 25 so pt is being transfused with 2 more units PRBC's and ICU team say pt may go to the OR for exploration and evacuation of hematoma. Her BP has been boarderline accepatable running 82-100/50. HR 100 sinus tach. UO 30cc/hr clear yellow urine. She has two more units PRBC's on hold in blood bank after these two infuse. Will continue to follow closely until pt goes to the OR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-05-20 00:00:00.000",
"description": "Report",
"row_id": 1437608,
"text": "Brief post-op note Nursing:\nPt returned fromt he OR at 6PM. Had an exploratory lap and evacuation of hematoma. Also arterial gastric bleeder cuaterized. Pt's EBL was 1600cc's (This was the size of the hematoma) and post OR hct was 23. Pt transfused with one more unit PRBC's upon leaving the OR and will get two more here this eve. Post transfusion hct is ordered for later this evening.\n\nPt has midline abdominal dressing which is dry and intact. She has c/o abdominal pain and can get MSO4 for this. She is alert but sleepy. Her BP is better and she has new a-line which was inserted in OR. She was cold and required bear hugger for an hour or so. Foley still in place draining clear yellow urine. Her daughter has been in to see pt as well as talk to MD for update.\n\nK+ was 3.5 post-op and repleted with 40meq. Ionized calcium was .91 and pt repleted with 2gms IV.\n\nWe will follow closely for vital signs/pain/wound assessment and treat as needed. Also pt needs to be encouraged to cough and deep breath as she was intubated for the procedure. Now she is on 5L face mask with RR 12-18. O2 sats are difficult to obtain and are currently 97%.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-05-20 00:00:00.000",
"description": "Report",
"row_id": 1437609,
"text": "MICU NPN 6PM-11PM:\nNeuro: Pt sleepy but easily arousable and alert, oriented to place and name. C/o abdominal pain but refused pain meds initially. Late in the shift began to have increased abdominal pain with ?tense abdomen. MSO4 2mg given times two with fair effect.\n\nCV: Pt's SBP initially 130-140. With increased pain her BP has gone up into the 160 range at times. HR 90-110. SR-st. Labs drawn at 9:30PM looking contaminated with K>6.0. Labs repeated and are pnd. She has developed metabolic acidosis by ABG and has been ordered to get two amps bicarb.\n\nResp: Pt is on 3L face mask with good sats. Sat difficult to obtain at times due to poor circulation. Lungs are clear and RR 14-20 non-labored. Pt's ABG showing metabolic acidosis and pt ordered to get two amps bicarb.\n\nHeme: Pt was transfused with total of 6 units PRBC's today with hct up to 37 this evening. Platelet count dropped into 60 range ?etiology.\n\nGI: NPO no stool. Faint hypoactive bowel sounds heard this evening.\n\nGU: UO is excellent via foley. Bladder pressure is 18 at 11PM.\n\nSocial: Pt is DNR/DNI uon arrival to MICU today. Daughter is spokesperson. Cell number is in pt's room.\n\nID: Afebrile.\n\nSkin: Pt with small staining on her midline abdominal dressing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-05-21 00:00:00.000",
"description": "Report",
"row_id": 1437610,
"text": "MICU-B, NPN:\nPt. receiving LR bolus from previous shift when received @ 23:00. Had just finished receiving X1 amp NaHCO3 for new onset metabolic acidosis from unknown origin. Lactate also rising @ this time- max o/n was 3.6. Pt. received total 6U PRBC's yesterday and total 2500cc LR boluses o/n. Please refer to Carevue for exact trand in ABG's. Pt. also becoming hyperkalemic with K+ as high as 6.4 @ 22:00. EKG did not show signs of changes d/t elevated K+. Pushed another amp. NaHCO3 and amp. Dextrose along with 10U R insulin. K+ this a.m. WNL. Received total 6mg MgSo4 for hypomagnesemia and total 4g Ca gluc. for hypocalcemia. Origin of metabolic acidosis cont. to be unknown this a.m. but Lactate down to 1.3, ABG this a.m. 7.33, 43, 103. Pt. tachycardic o/n to 130's but HR down to low 100's this a.m., likely hypovolemic intraoperatively- CVP went from 2 to 9 o/n during fluid resuscitation. Received pt. with R fem. line which was d/c'd following placement of R IJ. Bladder pressure last p.m. 18. Pt. also c/o of severe abd. pain, was very guarded @ start of shift. Received total 5mg MsO4 over 3.5 hour period for pain- was very slow to respond. Finally able to sleep @ 2:00. Team attempted to place L SVC but were unsuccessful @ 24:30- CXR done to r/o pneumo. following this attempt. No signs of pneumo. and no signs of CHF @ this time.\n\nNeuro: Alert, lethargic this a.m. but opens eyes when spoken to/follows commands. Oriented to person but confused @ times about why she is here. MAE but weak, deconditioned.\n\nCV: HR low 100's-130's ST w/o ectopy. SBP 110's-150's. Easily palpable peripherals. Does have sig. hx CHF- continuously transducing CVP. CVP ranged from this shift.\n\nResp: O2Sats mid-high 90's on 3L face mask. Lungs are clear upper lobes, diminished @ bases.\n\nHeme/lytes/micro: Hct down to 32 this a.m. Platelets dropped o/n- etiology unknown. Please refer to above notation and carevue for details on lyte repletion. T-max this shift 98.7. No antbx coverage @ this time.\n\nGI: NPO ABd. soft, slightly distended, and mildly tender to palpation. midline incision has DSD to area with signs of scant serous drainage on underside of drsng. BS are hypoactive. No BM this shift.\n\nGU: Foley to gravity draining clear yellow urine.\n\nDerm: Midline abd. surgical incision intact.\n\nSocial: DNR but this is questionable during intraop. period. No family contact o/n.\n"
}
] |
26,187 | 157,319 | As stated previously the patient was admitted to the medical service. He was ruled out for an myocardial infarction and he was diuresed with intravenous Lasix, started on an increasing beta blocker dose and on an ACE inhibitor as well. On hospital day #4 the patient was noted to have an elevated white blood cell count to 19,000. On hospital day #6 he was noted to have sternal drainage which was new during the course of this hospitalization. Also on hospital day #6 the patient was seen by the Plastic Surgery Service. He was brought to the Operating Room where he underwent sternal wound exploration and superficial debridement as well as rewiring of his sternum. J-vac dressing was placed at that time with the anticipation that the patient would have a flap closure in the near future. Blood cultures drawn at the time of the initial increase in the white blood cell count were positive for gram positive cocci and urinalysis at that time revealed Pseudomonas and Gram negative rods. The patient was started on Cipro for his urinary tract infection and Vancomycin and gentamicin for his sternal wound infection. Further identification showed that he had Methicillin-resistant Staphylococcus aureus in his superficial sternum. The patient did well in the immediate postoperative period. His back dressing remained in place. He remained hemodynamically stable, however, on postoperative day #3 from his sternal debridement he began to complain of abdominal distention and pain. Gastrointestinal consult was placed and he had an abdominal computerized axial tomography scan which was negative except that it showed a large amount of stool throughout his colon. On postoperative day #5 the patient had a PICC line placed for continuing requirements of intravenous antibiotics. Over the next two weeks the patient remained hospitalized receiving his intravenous antibiotics. He remained hemodynamically stable, however, he continued to complain of abdominal distention, occasionally associated with nausea and vomiting. His KUB continued to show large amounts of stool throughout the gastrointestinal tract. He was initially treated conservatively by being kept NPO and his diet slowly advanced to clear liquids, full liquids and soft solids and then treated more aggressively with stool softeners, suppositories and enemas. Gastrointestinal complaints persisted, however, to a lesser degree and on , the patient was returned to the Operating Room with Plastic Surgery Service at which time he underwent sternal wound closure with bilateral pectoral flaps. Please see the operation report for full details. The patient again did well in the immediate postoperative period, however, he continued to complain of abdominal pain, bloating and cramping. He was maintained on a regime of Pericolace, Metamucil and an occasional enema. Wound cultures from his flap closure showed Albicans and a urine culture also was positive for Albicans at that time, . He was started on Fluconazole. Over the next week the patient did well. From a wound standpoint his flap closure appeared to be healing well. From an infectious disease standpoint he was afebrile with a normal white blood cell count. Hemodynamically he remained stable. From a respiratory standpoint he remained slightly short of breath with activity. From a gastrointestinal standpoint he continued to complain of abdominal pain, however, no nausea or vomiting were noted and he continued to have regular bowel movements. On , the patient continued to progress. With the assistance of case management plans were tentatively begun for discharge to home with for his intravenous antibiotic care. Monday, the week of , the patient was noted to have mental status changes. Initially he was described as being sleepy and somewhat disoriented. Later on in the morning he was found by the nursing staff to be unresponsive and twitching. Vital signs at that time were stable. A blood gas done at that time showed his PH to be 7.28 with a pO2 of 59 and pCO2 of 70. His electrolytes at that time were normal. His blood sugar at that time was 141. The patient was transferred to the Cardiothoracic Intensive Care Unit for closer monitoring. Head computerized tomography scan done at that time was negative. Over the next several hours, the patient's condition improved. He became responsive and alert, oriented at times and remained hemodynamically stable. Neurology Service was consulted at that time and felt that it was a metabolic toxic syndrome. Over the next few days the patient's status continued to improve. His neurological status continued to improve and on , the patient was transferred from the Cardiothoracic Service to the Medical Service for continuing medical management of his multiple health problems. At the time of transfer the patient's laboratory data revealed white count of 13.4, hematocrit 31.7, sodium 141, potassium 4.5, chloride 104, carbon dioxide 31, BUN 16, creatinine 0.9, glucose 269, magnesium 1.8, ammonia 66. | Tardive dyskinesia, ?from heparin. Resp CarePt. Pt rec'd diamox Iv a/o, please follow up with effect.CPNCP. requested simethicone (was taking this preop). to restart Coumadin. Follow vanco levels. ?coumadin. Resp CareFollowing pt. On vanco, flucon. Pt initally htn, diaphoretic and SOB. +peripheral edema.ABG 162/72/7.25/37 pt rec'd CPT... ABG 146/68/7.30/35 following nebs ..262/66/7.33/36. coumadin. Renal; UO 40/hr despite lasix 40 pngt this am. Heme: Hct 31.7. Vanco levels sent today. gent levels sent this am. for RTC neb txs. Pt noted to have slightly garbled speech and mucosal droop.Following commands.CV: Pt V paced with underlying Afib since admission whom was receving coumadin po. HAVING LG. ?TF. lopressor, asa, amiodarone, lasix and kcl. cpt and i/s done. ID: Afebrile. +bowel sounds. FS QID. C.0. Lactulose tid. last abg: 7.36/57/107/33/4. TO RECEIVE LACTALOSE BUT GOLYTELY PLACED ON HOLD. SHIFT UPDATE.PT. Rx lactulose and go-lytely. INTUBATION. 1L, CONT. Pt was discharged from to rehab s/p CABG on . Pt with history of CVA ? PT. PT. PT. (Continued)ftly distended. On aspirin. Endo: sliding scale. Endo: sliding scale. Palpale pulses. id consult pend.ms: a+o x3. +BS. Obtunded at times, with PCO2 70s and pH 7.2s, NH4 >100. Monitor pulm status d/t subjective c/o SOB. Cont's on lactulose. the same.Pt. Monitor fluid status given low u/o and c/o SOB. Pt developed SOB, decreased u/o and midsternal CP(taking percocet po as outpatient). bp 95-130/50 via r rad aline. ?fluid status. Pt is . follow sats/abg. CABG site c/d/i until when purlent drainage was noted on exam. Cont to monitor ABG. Resp: Now on 2LNP with RR 23. Heme: 1UPC for hct 26. ? INR 1.7. mso4 gtt dc'd. AVP w perm pacer w adeq bp's. abd soft, +bs. CX DRAWN FROM PICC LINE. RR a-line. Aspiration precautions. 3piv lines.DISPO: FUll CodeSOCIAL: Pt with attentive and supportive family at bedside atc.A: s/p sternal dedridement with marginal resp status s/p extubation.P: Q 1hr ABG's. BS diminished, faint rales at bases. Responding to golytely/lactulose.P: Continue bowel clean-out. Pt maintaining NPO status. vss.p: cont pulm toilet. Hct 31 this am. Meds given per ngt. AFTERNOON BS 64, TREATED WITH OJ AND BOOST.ASSESSMENT: DENIES PAINMORE ALERT. dehydration.Follow uop's closely notify ho if no ^ after fld bolus.Adv diet per orders as tol. Resp acidosis/met alkalosis persists. FS 153 and 180. cortis in place in rij.pt rec'd 2amps ca gluc for ica 1.19.chest dsg intact. Abd so SBP 200's s/p extubation.R IJ swan in place with PAD's 23-28. Na 141, NACl tablets to be dcd. MD aware. cr stable at 0.7, bun 25.id: afeb. Diamox X 24 hrs. JP still in. cont on vanco, gent and cipro. ID:Temp up to 97.8. BUN/Cr 16/.9. abg notes improving hypercarbia. DB & coughing, coughed sm to mod brb x1 -> ho notified. NH4 103. History of anemia rec'd 1u PRBC's in OR for HCt of 24 repeat 28.4. NP-ordered of Lantus dose (7 units) to be given. heparin resumed with 3000u bolus and gtt at 700u/hr. There is mildpulmonary artery systolic hypertension.PERICARDIUM: There is a small pericardial effusion.Conclusions:1. There is diastasis of the sternum. The sigmoid colon is relatively decompressed. Pericardial effusion.Status: InpatientDate/Time: at 16:19Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. Respiratory Care:Albuterol/Atrovent nebs given q4hr. IMPRESSION: 1) Bilateral small pleural effusions with bibasilar consolidation. Rightventricular systolic function appears depressed.AORTA: The aortic root is normal in diameter.AORTIC VALVE: A bioprosthetic aortic valve prosthesis is present.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. Mild (1+) mitralregurgitation is seen.TRICUSPID VALVE: Moderate [2+] tricuspid regurgitation is seen. PATIENT/TEST INFORMATION:Indication: ?Pericardial effusion. There is a moderate pericardial effusion. STERNAL INCISION C & D,SUTURES INTACT.LOWER MID STERNAL JP->SELF SUCTION W MODERATE SERO-SANG. There is mild symmetric left ventricular hypertrophy. CT OF THE PELVIS WITH IV CONTRAST: There is a small amount of pelvic free fluid. ABG's cont to improve 138/58/7.35/33.GI: Abd softly distended. Pericardial effusion with area of soft tissue attenuation in the superior mediastinum. Chest pain.BP (mm Hg): 159/86HR (bpm): 67Status: InpatientDate/Time: at 21:30Test: Portable TTE(Focused views)Doppler: No DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. There is a small amount of perihepatic fluid consistent with ascites. There is mild pulmonaryartery systolic hypertension.7. Bilateral pleural effusions and bibasilar consolidations. The right ventricular cavity is mildly dilated.4.There is trivial to small pericardial effusion with fibrin/thrombus depositson the surface of the heart. Compared to the previous tracingof atrial fibrillation has replaced A-V sequential pacing and theremay be inappropriate sensing function of the ventricular lead. myoclonic extremity jerking appears to be less when awake.neuro consulted,see note. Right ventricularsystolic function appears depressed.4. Clinical correlation issuggested. Again seen are bilateral small pleural effusions left greater than right. There is a small pericardial effusion. 2) Small pericardial effusion and a small amount of ascites. There is a small pericardial effusion with fibrin/thrombus deposit on thesurface of the heart.8. There is consolidation at the bases bilaterally as well as small pleural effusions, left greater than right -- findings which have been noted since the exam. Overall left ventricular systolic functionis severely depressed.RIGHT VENTRICLE: The right ventricular cavity is moderately dilated. Acatheter or pacing wire is seen in the right atrium and/or right ventricle.LEFT VENTRICLE: The left ventricular cavity size is normal.RIGHT VENTRICLE: The right ventricular cavity is mildly dilated.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:1. These likely represent cysts. CT CHEST WITH CONTRAST: There are bilateral pleural effusions with associated dependent consolidation. Compared to the previoustracing of A-V sequential pacing with capture has replaced sinusrhythm.TRACING #1 Acatheter or pacing wire is seen in the right atrium and/or right ventricle.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. There is soft tissue attenuation in the area of the great vessels and superior mediastinum which is nonspecific. | 31 | [
{
"category": "Nursing/other",
"chartdate": "2119-11-16 00:00:00.000",
"description": "Report",
"row_id": 1603761,
"text": "NEURO: PATIENT APPEARS TO BE ORIENTED X 3, SPEAKS ONLY SPANISH WITH DAUGHTER AS INTERPRETER. DOES CONTINUE TO HAVE TONGUE THRUSTING MOVEMENTS, DAUGHTER STATES THAT HE ONLY DOES THIS WHEN HE IS ON HEPARIN.\nCV: AV PACED WITH PERMANENT PACER.\nGI: TAKING AND TOLERATING PO'S\nGU: URINE OUTPUT ^ AFTER PO LASIX.\nSKIN: INTACT\nENDO: HAVE SWITCHED SLIDING SCALE TO REGULAR INSULIN, NOT HUMULOG, GLUCOSES IN THE 200 RANGE, IN.\nOOB TO CHAIR WITH 2 PERSON ASSIST, FAMILY IN.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-16 00:00:00.000",
"description": "Report",
"row_id": 1603762,
"text": "OLDEST DAUGHTER IN TO VISIT HER FATHER, HE LIVES WITH HER, SHE REPORTED TO ME THAT HER DAD HAS BEEN SSING THING ALL DAY, BOXES IN THE ROOM, GIRAFFES AND OTHER THINGS, HE ALSO DID NOT KNOW WHO SHE WAS BUT WHEN SHE TOLD HIM HE THEN ASKED APPROPRIATE QUESTIONS, \"WHERE IS YOUR DAUGHTER\" ETC.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-17 00:00:00.000",
"description": "Report",
"row_id": 1603763,
"text": "PATIENT WITH UNEVENTFUL NIGHT , BS TREATED WITH INSULIN SC. SLEEPING MOST OF THE NIGHT. WHEN HE AWAKENS APPROPRIATE TO PERSON, PLACE BUT AT TIMES SEES PEOPLE THAT ARE NOT THERE. QUESTION PLAN OOB TO CHAIR, CONTINUE TO CONTROL BS, MONITOR NEURO STATUS.CONTINUE EVALUATE GI STATUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-17 00:00:00.000",
"description": "Report",
"row_id": 1603764,
"text": "CSRU Transfer Note\nS/O: 65 yo Guatamalen male well-known to you.\n HPI: adm for lethargy\n AVR (tissue) and CABG X1\n : DDD pacer\n : Home with VNA\n : Readmit for CHF and sternal drg\n : Flap. Remained in hospital for IV vanco.\n : Mental status changes, transfer to CSRU. Obtunded at times, with PCO2 70s and pH 7.2s, NH4 >100. Found to have dilated bowel filled with stool. Rx lactulose and go-lytely. Mental status and abgs have improved through week.\n Allergies: NKDA\n PMH: CAD, AS, GI Bleed , PAF, fatigue, RLL mass, spinal stenosis, R eye injury, CVA, IDDM, HTN, stopped smoking X 35yrs.\n Social: Lives with very supportive family, who stay with pt 24 hrs in hospital. Pt is .\n ROS: Neuro: A+OX2-3, with some visual hallucinations noted by pt. No sedation entire CSRU stay. Shaky. Tardive dyskinesia, ?from heparin.\n CV: AV paced at 70, BP 1145/75, on zestril. lopressor, asa, amiodarone, lasix and kcl.\n Resp: Now on 2LNP with RR 23. Clear. Last abg : 74 55 7.34.Dry cough.\n Renal: UO 20-40/hr. BUN/Cr 16/.9. K 4.5 (20 kcl po), Mg 1.8(2 gms IV). Na 141, NACl tablets to be dcd.\n Heme: Hct 31.7. On heparin (AFib) until 11 am , now dcd. Last PTT on 500u was 41.8. INR 1.7. On aspirin.\n ID: Afebrile. On vanco and fluconazole (chest). WBC 13.4 (11 ). Vanco levels sent today.\n GI: Now eating diet well. C/O mild abd pain and gas. Had large loose stools during go=lytely. Last bm Wed night.\n Endo: sliding scale. 1/2 dose lantus given last pm, glucoses today 250-300.\n Skin: Sutures out of flap. JP still in.\n Lines: PICC left arm .\n Rehab: Transfers to chair with 1-2 assist.\nA: Unexplained toxic/metabolic state except for constipation, now greatly improved.\nP: Cont to observe carefully. Check pending NH4 level. Follow vanco levels. Transfer to medicine. Cont to advance activity, arrange for eventual discharge home.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-10-19 00:00:00.000",
"description": "Report",
"row_id": 1603743,
"text": "Resp Care\nPt. waking up became agitated, bucking vent. Alert able to lift head from pillow, leak test + extubated onto 50% cool aerosol mask. Spo2 100%, RR20-25, ABP increased slighty most likely due to agitation, other VS esst. the same.Pt. tolerating well no distress @ this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-15 00:00:00.000",
"description": "Report",
"row_id": 1603758,
"text": "CSRU NPN\n\nNeuro: Calm and cooperative. Per daughter (translating), pt oriented much of time with occasional episode of confusion/\"delerium\". Slept on and off during night.\n\nCV: Hemodynamically stable. Skin warm, dry. Hct 31 this am. Noted short episodes of a fib this morning, otherwise AV paced.\n\nResp: Pt w/ c/o SOB. BS diminished, faint rales at bases. RR in high teens, unlabored. O2 sats 97% or greater on 2lNP. ABG this am essentially unchanged, PaO2 slightly lower. MD aware. ? CXR today.\n\nGI/GU: Last BM at approx 2200 last evening. Cont's on lactulose. MD aware of u/o in 20's. No treatment at this time. ? to start TF's today.\n\nEndo: Glucose 73 at 2200. NP-ordered of Lantus dose (7 units) to be given. Glucose 50 this am-MD aware and ordered amp of D50. Pt arousable to voice at this time, slightly confused.\n\nSkin: Scrotum slightly pink, skin intact. Chest incision OTA, no dng. JP site clean. JP draining small amts serousang fluid.\n\nComfort: Pt c/o headache. Given Motrin w/ some improvement.\n\nSocial: Daughter slept in room during noc.\n\nA/P Hemodynamically stable. ? to restart Coumadin. Monitor pulm status d/t subjective c/o SOB. Cont to monitor ABG. ? tube feedings to start today. Monitor glucose closely. Monitor fluid status given low u/o and c/o SOB. Cont to monitor neuro status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-15 00:00:00.000",
"description": "Report",
"row_id": 1603759,
"text": "PROB: S/P FLAP\n\nCV: SR, VSS.\n\nRESP: LUNGS DIMINISHED THROUGHOUT. O2 SATS ADEQUATE. ABG'S IMPROVED.\n\nGI: ABLE TO EAT AFTER ABD US. US DONE, UNIMPRESSIVE. NGT REMOVED AFTER PT DEMONSTRATED HOW WELL HE TOLERATES PO.PT DRINKING BOOST, EATING , APPLESAUCE.\n\nGU: LASIX WITH GOOD RESPONSE. K 2.9 GIVEN 40 KCL IV AND 40 KCL PO.\n\nNEURO: MORE AWAKE TODAY. MORE RESPONSE AND ALERT.\n\nSOCIAL: FAMILY IN MOST OF DAY.\n\nENDO: BS LOW TREATED WITH 1 AMP D50. AFTERNOON BS 64, TREATED WITH OJ AND BOOST.\n\nASSESSMENT: DENIES PAIN\nMORE ALERT. DOING BETER\n\nPLAN: CONT\nHEPARIN STARTED WITHOUT BOLUS, RECHECK PTT 10PM.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-16 00:00:00.000",
"description": "Report",
"row_id": 1603760,
"text": "End of shift note\nO: Pt remains in icu for close observation mental status, abg's & lytes.Pt relatively uneventful noc. Awake,alert,oriented per daughter as interpreter. Mae equal and strong.Vss. AVP w perm pacer w adeq bp's. Sternal flap cl and intact no drng, Bilat brth snds very distant bilat w few crackles bibasilarly. DB & coughing, coughed sm to mod brb x1 -> ho notified. Pt remains on heparin gtt remains on 500 u/hr no change for now in view of hemoptysis.\nResp status: o2 sats on rm air 90% ^ to 97% on 2 lnp.Tol full liqs in small amts. Endo: glucoses labile throughout the day. Pm insulin given as ordered. ? review ss insulin in view of wide range of bl glucoses throughout the day yest and ? po intake today.\nGu status: qs to scant amber urine, cloudy at times.Dr notified and 500 cc ns fld bolus given for same w slt change in uop's.\n\nA/P: Hemodynamically stable w low uop > Copious amts liq stool by report.? dehydration.Follow uop's closely notify ho if no ^ after fld bolus.Adv diet per orders as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-10-19 00:00:00.000",
"description": "Report",
"row_id": 1603744,
"text": "Resp Care\nFollowing pt. for RTC neb txs. Adm. 2.5 mg/5cc atrovent via MN w/ mask.BS:decreased t/o with -basilar crackles, no wheezes noted. RR 18-24, Sp02 100% on 70% cool aerosol,subjectively breathing improved slightly with tx, little change noted by auscultation. Resp will follow with nebs until pts. status improves.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-10-19 00:00:00.000",
"description": "Report",
"row_id": 1603745,
"text": "CCU Nursing Admission Note 7p-7a:\n\n Mr is a 65 y/o primarily spanish speaking male with an extensive past medical history for CAD, HTN, s/p CABG .. during this admission pt had DDD pacer placed and ruled out for an MI.\nAddition hx as follows; NIDDM, PAF, CHF EF<20%, s/p CVA yrs ago, RLL mass diagnosed last admission GERD and GIB.\n Pt was discharged from to rehab s/p CABG on . Pt developed SOB, decreased u/o and midsternal CP(taking percocet po as outpatient). Pt was transfered to ER for further eval.\n Over the coarse of this admission pt rec'd lasix 40mg IV bid for CHF with response. Pt cont to c/o midsternal chest discomfort pt r/o for PE. CABG site c/d/i until when purlent drainage was noted on exam. Pt afebrile elevated WBC and with + blood cultures 2/4 bottles +cocci in pairs and clusters. Pt started on gent and vanco IV for endocarditis. Pt also with GNR in urine receiving cipro po prior to OR. CT evaluated wound and rec a sternal debridement. Pt went to OR pm tolerated procedure well and arrived to ICU at appox 8:15pm.\n\nCurrent Review of Systems:\n\nNeuro: Pt initially on propofol gtt prior to extubation. Pt alert and oriented per daughter translating. Pt moving all extremities spontaneously. Pt with history of CVA ? deficits. Pt noted to have slightly garbled speech and mucosal droop.\nFollowing commands.\n\nCV: Pt V paced with underlying Afib since admission whom was receving coumadin po. INR reversed yesterday with 4u FFP. HR 67-91. Pt denies CP. Palpale pulses. History of anemia rec'd 1u PRBC's in OR for HCt of 24 repeat 28.4. No further transfusions ordered at this time.\n Sternal wound attached to vac draining sang fluid, team aware. BRB is expected post op per team. Plan to vac off and closure on Friday per CT notes.\n SBP 114-150 at rest. SBP 200's s/p extubation.\nR IJ swan in place with PAD's 23-28. Unable to wedge swan, Res. aware. CVP 16-18. C.0. 5.9(7.3) CI 3.58(4.42) SVR 908(942).\nCardiac regimen on hold during this acute period.\nK+ 3.7 repleted with 40meq KCL. Ca 1.01 pt rec'd 2 grams of ca gluconate.\n\nPULM: Pt weaned and extubated within an hour. Pt initally htn, diaphoretic and SOB. RR 20's Sats 100% on 3L NC and 50% face tent. Pt started on morphine gtt at 1mg/hr with excellant results. Pt appeared more comfortable and verbalized to daughter that he felt ok.\nLS diminshed on RLL where Mass is located overwise coarse. Pt with weak non productive cough. Small shallow breaths requiring encouragement to deep breath. +peripheral edema.\nABG 162/72/7.25/37 pt rec'd CPT... ABG 146/68/7.30/35 following nebs ..262/66/7.33/36. Res ordered Q1hr ABG's no further interventions at this time due to appropriate trend per Res.\n Pt to rec diamox w/a from pharmacy for metabolic alkalosis. Pt appears comfortable now resting. IS in room, pt's daughter understands how to operate it.\n\nGI: Pt with hx of GERD in protonix po. Pt rec'd last dose 10/24 on the floor. Abd so\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-10-19 00:00:00.000",
"description": "Report",
"row_id": 1603746,
"text": "(Continued)\nftly distended. +BS. No stool this shift. Pt maintaining NPO status. Per chart pt on thickened nectar diet do to history of CVA.\n\nGU: foley cath patent with marginal u/o BUN 26 Creat 0.6\nUrine yellow and clear.\n-330 LOS +93cc since mn.\n\nENDO: Pt is a NIDDM per chart. FS 153 and 180. Reg insulin SS ordered.\n\nSKIN: Sternal wound c/d/i. L upper thigh graft site with steri strips area is red. Pt w.o compliants regarding L upper thigh.\n\nID: afebrile\n\nPSYCH: Pt rec'd a pysch consult for c/o hallucinations and decreased appetite. Team conts to follow.\n\nLINES: R IJ swan. RR a-line. 3piv lines.\n\nDISPO: FUll Code\n\nSOCIAL: Pt with attentive and supportive family at bedside atc.\n\nA: s/p sternal dedridement with marginal resp status s/p extubation.\n\nP: Q 1hr ABG's. Monitor drainage in vac container. Replete electrolytes prn. Aspiration precautions. FS QID. Follow swan numbers.\nProvide support to patient and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-10-19 00:00:00.000",
"description": "Report",
"row_id": 1603747,
"text": "Addendum to Nursing Progress Note:\n\nPt's u/o decreasing over last couple of hours from >60 now 30cc/hr. Pt rec'd diamox Iv a/o, please follow up with effect.\nCPNCP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-10-19 00:00:00.000",
"description": "Report",
"row_id": 1603748,
"text": "ccu nurisng progress note\ns: my stomach (when asked if he has pain)\no: pls see carevue flowsheet for complete vs/data/events\ncv: hr 70s v paced. bp 95-130/50 via r rad aline. resumed amiodarone, lopressor scheduled for this eve. heparin resumed with 3000u bolus and gtt at 700u/hr. ptt due at 5:30pm.\npa line dc'd. cortis in place in rij.\npt rec'd 2amps ca gluc for ica 1.19.\nchest dsg intact. drg is serosang, 75cc form this am (total 200cc since or).\n\nresp: no acute distress. abg notes improving hypercarbia. o2 weaned to nc at 4l. rr 14-18, nonlabored. sats >97%. bs dim at bases, scatt coarse. nonprod cough. cpt and i/s done. last abg: 7.36/57/107/33/4. started on diamox for metabolic alkalosis.\n\ngi: started po intake. abd soft, +bs. no n/v. taking liquids and soft solids. no stool. c/o gas pains after taking meds this pm. requested simethicone (was taking this preop). team informed but will hold off for now. bs 120-150. not req ss.\n\ngu: uop 30cc/hr. no maintenance fluids. i/o balance 500+from mn. cr stable at 0.7, bun 25.\n\nid: afeb. bld culture sent off aline, needs a peripheral one as well. cont on vanco, gent and cipro. need vanco peak and trough this eve. gent levels sent this am. id consult pend.\n\nms: a+o x3. cooperative. assisting with position changes. oob to ch with 2 assists. weak on r side.\nc/o some back and chest pain this am. responded best to position changes. mso4 gtt dc'd. ordered for prn mso4 sq, percocet prn but pt denies need this afternoon.\n\na: improving ventilation. vss.\np: cont pulm toilet. follow sats/abg. plan for or tomorrow to close chest.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-14 00:00:00.000",
"description": "Report",
"row_id": 1603755,
"text": "SHIFT UPDATE.\nPT. HAVING LG. AMT'S OF LOOSE LIQUID STOOL, APPROX. 1L, CONT. TO RECEIVE LACTALOSE BUT GOLYTELY PLACED ON HOLD. PT. OOB TO COMMODE WITH MAX ASSIST X2, VERY UNSTEADY ON FEET. PT. BECOMING INCREASING MORE SOMMULENT TO STIMULI, DAUGHTER ATTEMPTING TO KEEP PT. AWAKE AND HAVE PT. TALKING. AM ABG SHOWING RISING PCO2 UPTO 71 FROM 61 EARLIER IN EVE, PAO2 ACCEPTABLE AND ABLE TO DECREASE FIO2 TO 4L NP. PT. HAVING NO MORE EPISODES OF RAISING SPUTUM. WILL PLAN ON RECHECKING ABG AT 0645AM AND IF PCO2 CONT. TO BE ELEVATED WILL ? INTUBATION. . CX DRAWN FROM PICC LINE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-14 00:00:00.000",
"description": "Report",
"row_id": 1603756,
"text": "CSRU Progress Note\nS/O: Neuro: Sleepy at times, but oriented X3.\n CV: AVPaced 70, stable BP. Meds given per ngt.\n Resp: RR 16, coughed up lg plug of yellow sputum. SAO2 100% on 2lnp. Resp acidosis/met alkalosis persists. Diamox X 24 hrs.\n Renal; UO 40/hr despite lasix 40 pngt this am.\n Heme: 1UPC for hct 26. ? coumadin.\n ID:Temp up to 97.8. On vanco, flucon.\n GI: 4 liters of golytely still infusing. Lactulose tid. LARGE loose stool after lactulose. +bowel sounds. NH4 103.\n Endo: sliding scale.\n Skin: Chest wound intact.\n Family: Present at all times.\n Rehab: Shaky on feet. 2+transfer to chair.\nA: ?reason for metabolic issues. Responding to golytely/lactulose.\nP: Continue bowel clean-out. Explore metabolic issues. ?TF. ?coumadin. Watch abgs and encourage pulm toilet. ?fluid status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-14 00:00:00.000",
"description": "Report",
"row_id": 1603757,
"text": "PROB: CONFUSION AND LETHARGY\n\nCV: CHEST INCISION HEALING, CLEAN AND DRY. JP DRESSING SITE CLEAN, DRAINING MINIMAL AMOUNT S/S DRAINAGE.\n\nRESP: O2 SATS ADEQUATE.\n\nGI: GOLYTELY FINISHED AT 18:00, NG TUBE CLAMPED. PT HAD MULTIPLE RESULTS FROM CONT GOLYTELY INFUSION. BOWEL SOUNDS PRESENT.\n\nGU: UOP MARGINAL.\n\nNEURO: PT SPEAKS SPANISH, DAUGHTER STATES HE'S STILL CONFUSED AT TIMES. PT DOES NOT ANSWER QUESTIONS APPROPRIATELY SOME OF THE TIME. PT VERY WEAK GETTING IN AND OUT OF BED. PT NEEDS 2 PERSON ASSIST. PT STILL HAVING MUSCLE TWITCHING OF ARMS AND LEGS.\n\nSOCIAL: FAMILY IN WITH PT. PT RESPONDING AND FOLLOWING COMMANDS MOST OF THE TIME.\n\nASSESSMENT: STILL SLIGHTLY CONFUSED.\n\nPLAN: CONT\nMONITOR NEURO STATUS.\nMONITOR WBC\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-10-20 00:00:00.000",
"description": "Report",
"row_id": 1603749,
"text": "Respiratory Care:\n\nAlbuterol/Atrovent nebs given q4hr. Tolerated well with mask. HR 70 with RR 16-20. Bs clear bilaterally. Non productive cough. O2 2-3lpm nasal prongs with adequate O2 sats. No further changes made. Will continue to follow q4hr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-10-20 00:00:00.000",
"description": "Report",
"row_id": 1603750,
"text": "Nursing Progress Note 7p-7a:\n\nNeuro: Per pt's daughter translating, pt is alert and oriented x 3. Pt moving all extremities spontaneously. Turning side to side with minimal assistance. Pt OOB to chair with two assist pt is unable to stand independently. Tolerated chair well.\n\nPain/Insomnia: Pt awake all night and unable to get comfortable. Pt rec'd mso4 x 2 SC for chest incisional pain and vioxx for muscle aches. Medications did have desired effect but only for a short period of time. Pt had previosly been on neurotin po. Res aware and ordered benadryl 25mg IV pt slept for possibly 1/2 hr following benadryl administration.\n\nCV: V paced at 70. Denies CP. SBP 94-133. Lopressor po dose held last pm for SBP <100. HCT this am 26.5. Await am electrolyte results.\nPalpable pulses. Sternal debridement site conts to be attached to vaccum. Site is draining small amt of sang drainage, 155cc this shift.\nPt scheduled for OR today to close site.\nPTT 45.8 hep gtt increased to 800u/hr goal PTT mid 50's per Res. PTT this am 42.2. await orders from team.\n\nPULM: LS diminished bibasilary. Sats 99% on 2-3L NC. Pt receiving nebs by RT. Pt with occasional non productive cough. Pt requires HOB >30 degrees. No c/p SOB. RR 18-20. Cont on diamox po for metabolic alkalosis. ABG's cont to improve 138/58/7.35/33.\n\nGI: Abd softly distended. +BS. Pt taking pills with custard. Aspiration precautions maintained. NPO since mn for OR today. No stool this shift.\n\nGU: Foley cath patent draining yellow urine. u/o adequate. -149 since mn -410 LOS.\nAwait renal lab.\n\nSKIN: L inner thigh with steri strips area pink and w/o drainage. Heels red.\n\nID: Afebrile. WBC 7.2. Pt conts on triple abx for presumed endocarditis. Vanco peak and trough sent.\n\nENDO: Fs 258-305. Pt covered with reg insulin ss.\n\nLINES: RIJ cortis with small bend in catheter, flushing w/o incidence. Clean dressing placed.\n\nDISPO: Full Code\n\nSOCIAL: Daughter at bedside overnight.\n\nA: Improving metabolic alkalosis. PTT subtherapeutic. Hyperglycemia/NPO.\n+incisional pain and muscle aches.\n\nP: Provide support. NPO for OR today. Follow ABG's. Check FS.\nAwait Am labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-10-20 00:00:00.000",
"description": "Report",
"row_id": 1603751,
"text": "Addendum to Nursing Progress Note:\n\nHep gtt d/c'd at 7am per team due to INR of 2.2. CPNCP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-13 00:00:00.000",
"description": "Report",
"row_id": 1603752,
"text": "ADMITTED FROM F6 W MENTAL STATUS CHANGES. SOMNULENT & ONLY RESPONSIVE TO STIMULI ON ARRIVAL BUT OVER 2 HRS WAKING & CONVERSANT IN SPANISH W FAMILY.+ GAG & COUGH ELICITED.MAE X 4 BUT NOT TO COMMAND.WRIST RESTRAINTS APPLIED FOR CONTINUED ATTEMPTS TO REMOVE FACE MASK,NGT. PL NGT PLACED FOR MED ADMINISTRATION.ASPIRATION PRECAUTIONS MAINTAINED. A LINE PLACED FOR BG MONITORING.RANDOM EXTREMITY TWITCHING NOTED THAT SEEMS MORE PRONOUNCED OVER THE PAST FEW DAYS. LABS PER FLOW SHEET. REPLETING NACL AS ORDERED,CA++ & LFT'S WNL FOR NOW. LASIX CHANGED TO DIAMOX FOR MET. ALK.FOLEY INSERTED FOR CLEAR URINE,C & S SENT. STERNAL INCISION C & D,SUTURES INTACT.LOWER MID STERNAL JP->SELF SUCTION W MODERATE SERO-SANG. DNG.CONT. TO MONITOR MENTAL & METABOLIC CHANGES. SEE FLOW SHEET.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-13 00:00:00.000",
"description": "Report",
"row_id": 1603753,
"text": "more alert per family. conversing in spanish & able to follow simple commands.states he's hungry per daughter. myoclonic extremity jerking appears to be less when awake.neuro consulted,see note. feel ms status changes prob. metabolic,hypercarbic in nature.diamox started x 24 hrs for severe met. alk. still picking @ lines,removing face mask & pulling @ gastric tube. soft wrist restraints applied.severe constipation reported by n.p. lactulose continues & nu-lytely started via ngt. remains npo for now.plan to monitor elytes,neuro status,pulm. toilet.see flow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-11-14 00:00:00.000",
"description": "Report",
"row_id": 1603754,
"text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: SPANISH SPEAKING ONLY, DAUGHTER IN AND STATES THAT PT. IS MUCH MORE APPROPRIATE BUT OCCASSIONALLY MAKING STATEMENTS THAT ARE INAPPROPRIATE. 1 FAMILY MEMBER TO STAY IN ROOM WITH PT. SOFT WRIST RESTRAINTS ON, PT. AT TIMES PULLING O2 MASK OFF. MAE TO STIMULI, SLIGHT TWITCHES NOTED ON LOWER EXTREMITIES, L>R. L PUPIL REACTIVE, R PUPIL IRRIG. IN SHAPE & SIZE, ? IF PT. HAS GLAUCOMA OR EYE SURGERY.\nCARDIAC: CONT. TO BE AV-PACED WITH INTERNAL PACER APPROPRIATELY. L ANTICUB PICC LINE INTACT, L RAD ALINE WITH GOOD WAVE FORM. VSS, + PULSES BILT.\nRESP: CONT. ON 40% OFM WITH SAT'S >95%, BS DIMINISHED SLIGHTLY IN R BASE. COUGHING AND RAISING LG. AMT'S OF (OLD) BLOODY SECREATIONS, NO . NOTED IN SPUTUM. WILL CHECK ABG IN AM.\nGI/GU: HOURLY URINES CONT. TO BE >25CC OF CLEAR YELLOW. + BS , PT. RECEIVING 4L OF GOLYTELY VIA FEEDING PUMP @ 250CC/HR, + PLACEMENT OF NGT CHECKED. ABD IS SOFT AND NON-DISTENDED. NO STOOL AT THIS TIME. BS TREATED WITH S.S. INSULIN.\nSKIN: INTACT, VENODYNE BOOTS REMAINS ON, BUTTUCKS SLIGHTLY REDDENED, TURNED Q2/HR.\nPLAN: CONT. WITH AGGRESSIVE BOWEL REGIME, MONITOR BS AND TREAT WITH S.S. INSULIN. FAMILY FOR INTERPURTATION.\n"
},
{
"category": "Echo",
"chartdate": "2119-10-12 00:00:00.000",
"description": "Report",
"row_id": 69242,
"text": "PATIENT/TEST INFORMATION:\nIndication: ?Pericardial effusion. ?Tamponade. Chest pain.\nBP (mm Hg): 159/86\nHR (bpm): 67\nStatus: Inpatient\nDate/Time: at 21:30\nTest: Portable TTE(Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: The left ventricular cavity size is normal.\n\nRIGHT VENTRICLE: The right ventricular cavity is mildly dilated.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. A technically difficult study.\n2. The left ventricular cavity size is normal.\n3. The right ventricular cavity is mildly dilated.\n4.There is trivial to small pericardial effusion with fibrin/thrombus deposits\non the surface of the heart.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2119-10-13 00:00:00.000",
"description": "Report",
"row_id": 69510,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion.\nStatus: Inpatient\nDate/Time: at 16:19\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 mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis severely depressed.\n\nRIGHT VENTRICLE: The right ventricular cavity is moderately dilated. Right\nventricular systolic function appears depressed.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: A bioprosthetic aortic valve prosthesis is present.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n\nTRICUSPID VALVE: Moderate [2+] tricuspid regurgitation is seen. There is mild\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is a small pericardial effusion.\n\nConclusions:\n1. The left atrium is mildly dilated.\n2. There is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is difficult\nto assess but is proabably moderately to possiblyseverely depressed. An exact\nLV ejection fractio could not be determined.\n3. The right ventricular cavity is moderately dilated. Right ventricular\nsystolic function appears depressed.\n4. A bioprosthetic aortic valve prosthesis is present.\n5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen.\n6. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary\nartery systolic hypertension.\n7. There is a small pericardial effusion with fibrin/thrombus deposit on the\nsurface of the heart.\n8. No comparison could be made to the study of due to the quality of\nthe study. In comparison to the report of , there appears to a decrease\nin LV and possible RV function.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2119-10-12 00:00:00.000",
"description": "Report",
"row_id": 156864,
"text": "Atrial fibrillation with a rapid ventricular response. Ventricular ectopy.\nThere are two ventricular pacing spikes which may be present secondary to\ninappropriate sensing of the ventricular lead. Clinical correlation is\nsuggested. Inferolateral ST-T wave changes. Compared to the previous tracing\nof atrial fibrillation has replaced A-V sequential pacing and there\nmay be inappropriate sensing function of the ventricular lead. Clinical\ncorrelation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2119-10-12 00:00:00.000",
"description": "Report",
"row_id": 156865,
"text": "A-V sequential pacing. Appropriate pacemaker function. Compared to the previous\ntracing of A-V sequential pacing with capture has replaced sinus\nrhythm.\nTRACING #1\n\n\n"
},
{
"category": "ECG",
"chartdate": "2119-10-14 00:00:00.000",
"description": "Report",
"row_id": 156863,
"text": "Undetermined rhythm\n - demand A-V sequential pacing\n Extensive T wave changes may be related to electronic pacemaker\nSince last ECG, A-V pacing again present\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-10-21 00:00:00.000",
"description": "CT PELVIS W/CONTRAST",
"row_id": 745365,
"text": " 9:49 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: GI bleed, r/o ischemic colitis.\n Field of view: 40 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with s/p CABG and s/p sternal wound debridement\n REASON FOR THIS EXAMINATION:\n GI bleed, r/o ischemic colitis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG with sternal wound debridement with GI bleed.\n\n COMPARISON: .\n\n TECHNIQUE: CT of the abdomen and pelvis with IV contrast per CTE protocol.\n 150 cc Optiray was administered. Optiray was selected secondary to cardiac\n history.\n\n Multiplanar reconstructions were performed.\n\n FINDINGS: CT of the abdomen with IV contrast. The lung bases are visualized.\n Again seen are bilateral small pleural effusions left greater than right.\n There are areas of consolidation at the lung bases bilaterally which partly\n may represent atelectasis, however, the extent of consolidation is slightly\n larger than just with atelectasis, and consequently bibasilar pneumonia should\n be considered. There is a small pericardial effusion. The heart is large.\n\n There is a small amount of perihepatic fluid consistent with ascites. The\n liver, spleen, adrenal glands, and pancreas are unremarkable. There is high\n density in the dependent portion of a non-dilated gallbladder consistent with\n gallstones. Additionally, there is a 9.5 x 12.9 mm retrocrural lymph node on\n the right. The kidneys are symmetric in size. There are multiple punctate\n areas of hypodensity within the kidneys bilaterally with the largest at the\n upper pole of the right kidney measuring 12.6 x 10.2 mm. These likely\n represent cysts. There are scattered retroperitoneal lymph nodes, none of\n which meet pathologic criteria. There is no free intraperitoneal air. Oral\n contrast has been administered and is seen within small bowel and colon. The\n appendix is unremarkable. The sigmoid colon is relatively decompressed. No\n definite obstruction is seen. There is no evidence of focal bowel wall\n thickening or pneumatosis.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is a small amount of pelvic free\n fluid. A Foley catheter is present within the urinary bladder.\n\n BONE WINDOWS: There are no suspicious osseous lesions.\n\n MULTIPLANAR RECONSTRUCTIONS: There is no evidence of bowel obstruction.\n\n IMPRESSION:\n\n 1) Bilateral small pleural effusions with bibasilar consolidation. This may\n (Over)\n\n 9:49 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT RECONSTRUCTION; CT 150CC NONIONIC CONTRAST\n Reason: GI bleed, r/o ischemic colitis.\n Field of view: 40 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n represent bibasilar pneumonia.\n\n 2) Small pericardial effusion and a small amount of ascites.\n\n 3) Bilateral hypodense lesions within the kidneys that likely represent cysts.\n\n 4) Cholelithiasis without evidence of cholecystitis.\n\n 5) There is no evidence of bowel wall thickening. Please note that there is\n additionally subcutaneous edema consistent with anasarca.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-10-12 00:00:00.000",
"description": "CT 150CC NONIONIC CONTRAST",
"row_id": 744841,
"text": " 7:52 PM\n CHEST CTA WITH CONTRAST; CT 150CC NONIONIC CONTRAST Clip # \n Reason: r/o PE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man s/p AVR, CABG last week, now with dyspnea and pleuritic CP,\n ruled out for dissection or obvious anatomical defect by ECHO and CXR.\n REASON FOR THIS EXAMINATION:\n r/o PE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 64 year old man status post AVR and CABG last week, now with dyspnea\n and pleuritic chest pain.\n\n TECHNIQUE: Contiguous helical images of the thorax were obtained after the\n administration of 100 cc of intravenous Optiray. Optiray was used per the\n fast bolus of the CTA protocol.\n\n Technical error relating to poor cardiac output resulted in adequate contrast\n bolus timing for evaluation of pulmonary embolus.\n\n COMPARISON: \n\n CT THORAX WITH IV CONTRAST: As above, the study is inadequate for assessment\n of pulmonary embolus. There is a moderate pericardial effusion. Fluid tracks\n up around the great vessels and into the superior mediastinum. The majority\n of the fluid is of low density. However, in the mediastinal fluid there are a\n few small areas of moderate density fluid. This likely relates to blood\n products. A few small foci of air are seen as well. There is no obvious\n source of active hemorrhage. The heart demonstrates multichamber cardiac\n enlargement. Metallic artifact from pacing wires and AVR is present. There are\n several sub-cm lymph nodes within the mediastinum which could relate to the\n prior surgery.\n\n Evaluation of the lung parenchyma reveals bilateral pleural effusions and\n fluid in the fissures. There is consolidation/atelectasis in the left lower\n lobe. Again seen in the left apex is a parenchymal nodule with both solid and\n ground glass components, not significantlt changed since .\n Bone windows demonstrate degenerative change throughout the thoracic spine.\n\n IMPRESSION:\n\n 1) Suboptimal study secondary to apparent low cardiac output. Presence of\n pulmonary embolus cannot be evaluated.\n\n 2) Large pericardial effusion with fluid tracking into the superior\n mediastinum. Fluid has characteristics suggesting blood of varying age.\n Although this could be post operative, small active hemorrhage or infection\n cannot be excluded in this patient with chest pain. Correlate with\n echocardiogram and clinical evaluation.\n\n 4) Multichamber cardiac enlargement and pleural effusions consistent with\n (Over)\n\n 7:52 PM\n CHEST CTA WITH CONTRAST; CT 150CC NONIONIC CONTRAST Clip # \n Reason: r/o PE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n congestive failure. Correlate clinically.\n\n 5)Left apical nodule, suspicious for broncoalveolar cell carcinoma, not\n changed since .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-10-12 00:00:00.000",
"description": "CT 150CC NONIONIC CONTRAST",
"row_id": 744848,
"text": " 11:26 PM\n CHEST CTA WITH CONTRAST; CT 150CC NONIONIC CONTRAST Clip # \n Reason: r/o PE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man s/p AVR, CABG last week, now with dyspnea and pleuritic CP,\n ruled out for dissection or obvious anatomical defect by ECHO and CXR.\n REASON FOR THIS EXAMINATION:\n r/o PE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pleuritic chest pain and dyspnea, one week status post CABG and\n aortic valve replacement. Previous chest CT was done with suboptimal bolus\n timing.\n\n TECHNIQUE: Following administration of 150 cc Optiray for indication of rapid\n bolus CTA, CT of the chest was performed with multiplanar reconstructions per\n CT pulmonary angiography protocol.\n\n CT CHEST WITH CONTRAST: The pulmonary vessels opacify normally without\n endoluminal filling defects to suggest the presence of pulmonary emboli. The\n patient is status post median sternotomy, aortic valve replacement and CABG.\n There is a moderate amount of fluid surrounding the heart, ranging in\n Hounsfield units from six to 50, representing blood of differing ages. There\n are small foci of air within the fluid collection. Although this may be seen\n one week status post cardiac surgery, in the presence of chest pain and\n symptoms of infection, an infected hematoma must be considered. There is\n consolidation at the bases bilaterally as well as small pleural effusions,\n left greater than right -- findings which have been noted since the \n exam. Again noted is the ground glass density at the left upper lobe measuring\n 1.7 cm, not significantly changed in the interval, though clinically\n concerning for lung neoplasm.\n\n RECONSTRUCTIONS: There is appropriate opacification of the pulmonary vessels\n without evidence of pulmonary emboli.\n\n IMPRESSION: No evidence of pulmonary emboli. No interval change since exam\n four hours previously. If the patient exhibits symptoms of infection, then an\n infected mediastinal hematoma should be considered.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-11-24 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 747492,
"text": " 11:34 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: r/o diverticulitis, abscess\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with s/p CABG and s/p sternal wound debridement. Now with\n increasing white count and daily drenching sweats. Also with abdominal pain.\n Seeking source of suspected infection.\n intern, \n REASON FOR THIS EXAMINATION:\n r/o diverticulitis, abscess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65 YEAR OLD STATUS POST CABG WITH STERNAL WOUND DEBRIDEMENT, NOW\n WITH INCREASING WHITE COUNT AND DAILY DRENCHING SWEATS. ALSO HAS ABDOMINAL\n PAIN, RULE OUT DIVERTICULITIS, ABSCESS.\n\n TECHNIQUE: Helically acquired axial images were obtained from the thoracic\n inlet to the femoral heads after administration of intravenous contrast.\n\n CONTRAST: 150 cc of Optiray was administered secondary to language barrier.\n\n COMPARISONS: Chest CTA dated and CT abdomen/pelvis dated\n .\n\n CT CHEST WITH CONTRAST:\n\n There are bilateral pleural effusions with associated dependent consolidation.\n This is not significantly changed from the prior examination. A left apical\n nodule which measures 18 x 17 mm is redemonstrated and is not significantly\n changed. Multi-chamber cardiac enlargement is redemonstrated. There is a\n moderately sized pericardial effusion. There is soft tissue attenuation in\n the area of the great vessels and superior mediastinum which is nonspecific.\n No air within this area is identified which would suggest infection. There is\n diastasis of the sternum.\n\n CT ABDOMEN WITH CONTRAST:\n\n The liver, gallbladder, spleen, pancreas, adrenals, and kidneys are normal. No\n free air, free fluid, or lymphadenopathy is identified in the abdomen. The\n opacified loops of small and large bowel are unremarkable.\n\n CT PELVIS WITH CONTRAST:\n\n The distal ureters, bladder, sigmoid, and rectum are unremarkable. There is\n no free fluid or adenopathy.\n\n Bone windows demonstrate diastasis of the sternum as described above. There\n are marked degenerative changes of the right hip joint with osteophytosis,\n sclerosis, and impaction of the femoral neck. This is consistent with an old\n fracture with narrowing of the joint space.\n (Over)\n\n 11:34 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: r/o diverticulitis, abscess\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n\n 1. No evidence for abscess within the mediastinum or abdomen.\n\n 2. No evidence for diverticulitis.\n\n 3. Pericardial effusion with area of soft tissue attenuation in the superior\n mediastinum.\n\n 4. Bilateral pleural effusions and bibasilar consolidations.\n\n 5. Left apical nodule which is not significantly changed since .\n\n 6. Evidence for remote fracture of the right hip with degenerative changes.\n\n\n\n"
}
] |
79,224 | 131,806 | 32F h/o asthma and intubations consistent with severe asthma exacerbation. ASTHMA was initially admitted to the MICU where she was started on solumedrol 80mg IV q8hrs and transitioned to oral prednisone 50mg daily for 5 days total. Albuterol/Ipratropium nebs q6hr prn were continued. Advair substituted for symbicort while in house. Was also treated with Azithromycin for 5 days for presumed bacterial Bronchitis based on purulent sputum. She was noted have atypical respiratory exam with nearly absent breath sounds, but appeared in no respiratory distress. Wheezes were not audible. On multiple occassions patient reported concern that she was not being treated appropriately (due to transition from IV steroids to oral) and tried to leave AMA. She also stated on numerous occassions that she "wished she was inutabed" thinking she would feel better if that had been the case. She maintained that she asked the team not to intubate her. Patient was suspected of breath holding and this was confirmed by placing stethoscope on chest for prolonged periods, patient would cough and in the process large volume air movement could be appreciated X 1 then no breath sounds again for 30 seconds to one minute. This process would repeat. Patient was continued on oral steroids/azithromycin 5 day course which was completed while patient was hospitalized. She was continued on prn nebulizers which were prescribed for patient comfort. On day of discharge patient was cooperative with exam, she had good airmovement with clear breath sounds, no wheezes. She reported her breathing was much improved. Patient described pleuritic chest pain which was found not to be cardiac in origin or related to PE as negative CTA. She was treated symptomatically. She continued to report intermittent chest tightness which resolved by day of discharge. . UNRESPONSIVENESS Her hospitalization was notable for three episodes of sudden unresponsiveness with chest discomfort/tightness prior to all. Pt denies any history of episodes like these previously, says they are different from prior syncopal drop attacks she has had previously. First episode was noted in the ED on arrival, no breath sounds were noted, HR 160, Hemodynamically stable, O2 sats in the 90s to 100%. Symptoms improved suddenly with NIV. Subsequent episode in ICU was observed, possibly thought to be secondary to low cardiac output in vagal state, and initiation of CLS feature as described below. She was tachycardic and hemodynamically stable, no air movement noted on exam, no drop in O2 sats throughout the episodes. Episodes resolve suddenly with no postdrome. During third episode which occured several hours after transfer to the floor. Began suddenly after episode of "chest tightness", patient was unresponsive to sternal rub and multiple ABG attempts. Patient had slight resistance to eye opening, eyes were roaming, at one point eyes made contact but patient did not respond to voice or commands. Eyes remained roaming as head was turned side to side. Arms had reduced tone, but patient protected her face when arm was dropped over her head. Vitals remained normal. ABG was notable for 7.38/92/42/26 on room air. Episode resolved suddenly in minutes with no postictal state, no self urination or tongue biting. Patient was at baseline mental status, alert and oriented immediately after the event reporting nausea and dry heaving. There was no emesis. Neurology was consulted who found her episode to be highly unsuggestive of a seizure episode or related to patient reported history of reversible cerebral vasoconstriction syndrome. Possibility of vasovagal syncope related to migraine headaches was raised, though this would require no further intervention. There is also concern for non-organic causes of her symptoms. Patient, herself, demonstrated less concern for her unresponsive episodes than her asthma symptoms. Patient is to follow up with a new neurology attending at , Dr. . She was previously seen at , but decided to change neurologists when somatisization was raised as a cause of her symtpoms. TACHYCARDIA Also during her hospitalization, patient had intermittent tachycardia as high as 140-160s. Tachycardia was more significant when patient was describing respiratory distress, and came down to 70's to 80s when calm. Patient had one unusual episode thought to be vagal episode during which patient was noted to be unresponsive and tachycardiac. HR was in 140s, EKG showed that she was apaced. Electrophysiology was consulted realized pacer was triggered by low cardiac output states like vasovagal episodes. This CLS feature of the pace maker was turned off and this was communicated to her electrophysiologist. Despite this she continued to have intermittent tachycardia which continued through subsequent episodes of unresponiveness as well as when she was in her baseline state. Tachycardia was not noted when patient was calm or sleeping. . The summary of the EP report is as follows "Summary (normal / abnormal device function): Stable lead parameters, without evidence of over/undersensing or inappropriately tracking. Her CLS function appears to be activating during rest in the absence of vagal episodes, prompting atrial pacing to 130 bpm while in bed. To avoid confusion and inappropriate pacing during this hospitalization, this feature was turned off (programmed to DDD). She should follow-up with her cardiologist soon after discharge so that this feature can be addressed and optimized. She notes that she has also had an episode since implantation where she was not adequately treated by the device and lost consciousness, indicating that the device needed to be optimized prior to this encounter." Outpatient cardiologist, Dr. of was notified and felt her symptoms seemed unlikely to be cardiogenic, no intervention needs to be made to CLS function. Routine follow up is appropriate. | No pulmonary embolus is detected to the subsegmental levels. No pulmonary embolus detected to the subsegmental levels. OSSEOUS STRUCTURES: There is no acute fracture. No consolidations or pleural effusions. No effusion or pneumothorax is detected. IMPRESSION: No acute intrathoracic process. There is no pericardial effusion. No concerning blastic or lytic lesions are identified. There is no pneumothorax, focal consolidation, or pleural effusion. No consolidation or effusions. No dissection. No dissection. Otherwise, normal tracing.Compared to the previous tracing of this date ventricular pacing is no longerseen.TRACING #2 The thoracic aorta is normal in caliber. There is no dissection. Compared to the previoustracing of paced rhythm is present and further comparison cannot bemade.TRACING #1 The main pulmonary arteries are normal in caliber. FRONTAL CHEST RADIOGRAPH: The heart size is normal. REASON FOR THIS EXAMINATION: r/o PE No contraindications for IV contrast WET READ: LLTc FRI 1:15 AM No PE detected to the subsegmental levels. No comparison studies available. Hilar and mediastinal contours are within normal limits. This tracing is uninterpretable due to baseline artifact in leads V1-V3.No previous tracing available for comparison.TRACING #1 (Over) 12:05 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o PE Admitting Diagnosis: SHORTNESS OF BREATH Field of view: 36 FINAL REPORT (Cont) FINAL REPORT INDICATION: Shortness of breath. A left-sided pacemaker generator projects leads into the right atrium and ventricle. The heart size is top normal. Sinus tachycardia with resistant baseline artifact. TECHNIQUE: MDCT-acquired 5-mm axial images of the chest were obtained following the uneventful administration of 100 cc of Omnipaque intravenous contrast. COMPARISON: Chest radiograph available from . UPPER ABDOMEN: Included views of the liver, stomach, and spleen are normal. IMPRESSION: 1. The tracing showsinferolateral ST segment abnormalities.TRACING #2 CHEST CT WITH IV CONTRAST: Crowding of the bronchopulmonary structures at the lung bases is likely secondary to There is mild dependent atelectasis bilaterally. Pacemaker wires project into the right atrium and ventricle. The rhythm appears to be predominantly atrial paced at a rate of around130 beats per minute with periods of A-V pacing. 12:05 AM CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # Reason: r/o PE Admitting Diagnosis: SHORTNESS OF BREATH Field of view: 36 MEDICAL CONDITION: 32 year old woman with SOB, PLEURITIC Cp, hx of DVT, PE. Bronchovascular crowding at the lung bases likely due to underinflation of the lungs. 2. . Atrial paced rhythm at 104 beats per minute. Coronal and sagittal reformations were performed at 5-mm slice thickness. 9:37 PM CHEST (PORTABLE AP) Clip # Reason: eval for PTX MEDICAL CONDITION: 32 year old woman with asthma and resp distress REASON FOR THIS EXAMINATION: eval for PTX FINAL REPORT INDICATION: Asthma and respiratory distress. | 6 | [
{
"category": "Radiology",
"chartdate": "2162-02-12 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1221752,
"text": " 12:05 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: SHORTNESS OF BREATH\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with SOB, PLEURITIC Cp, hx of DVT, PE.\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: LLTc FRI 1:15 AM\n No PE detected to the subsegmental levels. No dissection. Bronchovascular\n crowding at the lung bases likely due to underinflation of the lungs. No\n consolidation or effusions.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath.\n\n COMPARISON: Chest radiograph available from .\n\n TECHNIQUE: MDCT-acquired 5-mm axial images of the chest were obtained\n following the uneventful administration of 100 cc of Omnipaque intravenous\n contrast. Coronal and sagittal reformations were performed at 5-mm slice\n thickness. Additional right and left reconstructions were also obtained for\n further evaluation of the pulmonary vessels.\n\n CHEST CT WITH IV CONTRAST:\n Crowding of the bronchopulmonary structures at the lung bases is likely\n secondary to There is mild dependent atelectasis bilaterally. No effusion\n or pneumothorax is detected.\n\n The heart size is top normal. Pacemaker wires project into the right atrium\n and ventricle. There is no pericardial effusion.\n\n The thoracic aorta is normal in caliber. There is no dissection. The main\n pulmonary arteries are normal in caliber. No pulmonary embolus is detected to\n the subsegmental levels.\n\n OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or\n lytic lesions are identified.\n\n UPPER ABDOMEN: Included views of the liver, stomach, and spleen are normal.\n\n IMPRESSION:\n 1. No pulmonary embolus detected to the subsegmental levels. No dissection.\n 2. . No consolidations or pleural effusions.\n (Over)\n\n 12:05 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: r/o PE\n Admitting Diagnosis: SHORTNESS OF BREATH\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-02-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1221744,
"text": " 9:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with asthma and resp distress\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Asthma and respiratory distress.\n\n No comparison studies available.\n\n FRONTAL CHEST RADIOGRAPH: The heart size is normal. A left-sided pacemaker\n generator projects leads into the right atrium and ventricle. Hilar and\n mediastinal contours are within normal limits. There is no pneumothorax,\n focal consolidation, or pleural effusion.\n\n IMPRESSION: No acute intrathoracic process.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2162-02-13 00:00:00.000",
"description": "Report",
"row_id": 247526,
"text": "Atrial paced rhythm at 104 beats per minute. Otherwise, normal tracing.\nCompared to the previous tracing of this date ventricular pacing is no longer\nseen.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2162-02-13 00:00:00.000",
"description": "Report",
"row_id": 247527,
"text": "The rhythm appears to be predominantly atrial paced at a rate of around\n130 beats per minute with periods of A-V pacing. Compared to the previous\ntracing of paced rhythm is present and further comparison cannot be\nmade.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2162-02-11 00:00:00.000",
"description": "Report",
"row_id": 247528,
"text": "Sinus tachycardia with resistant baseline artifact. The tracing shows\ninferolateral ST segment abnormalities.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2162-02-11 00:00:00.000",
"description": "Report",
"row_id": 247529,
"text": "This tracing is uninterpretable due to baseline artifact in leads V1-V3.\nNo previous tracing available for comparison.\nTRACING #1\n\n"
}
] |
11,024 | 130,703 | Respiratory: was intubated in the delivery room on admission to the newborn intensive care unit, received surfactant for a total of 2 doses. She is currently on conventional ventilation 17/5 with a rate of 26 and about 25 to 30% O2. Her most recently arterial blood gas had a pH of 726, PCO2 49, PO2 69, bicarb 23, base deficit of 5. She was started on caffeine citrate for management of apnea and bradycardia prematura. She is currently receiving 7 mg per kilogram per day, 3.6 mg IV every 24 given at 4:00 in the afternoon. | Lytes 140/5.2/108/18. sx'd for sm. NGT in place. Check lytes this am. Indocin completed . TF at 120- PN and lipids. Hct 28.3 this am. Had CBG 7.24/60. Echo to beobtained in am. Dstick 72. Respiratory Care NoteCBG clotted. Receiving Indocin. Venous gas at 1800 7.21/50/27/21/-9.Settings kept at 18/5 X 24. Murmurpersists despite indocin. levels sent today. VBG drawn: 7.21/50/27/21/-9. Murmur audible. BS clear with suctioning. Indomethacin started- has received two does. Nsg Note continued.Gas repeated by cap.7.24/60/27/27/-3. Bili to be sent in am. Sxn for lg cldy secretions from ETT. VBG: 7.20/58/29/24/-6. + murmur. Anticipated continued indomethacin course. NPO due to indocinP. NPN#1Sepsis Day . Plan to check bili this am. P-Cont toassess cv needs.#5O/A-Corrected age 24 4/7 weeks. Corrected age of 25 4/7weeks. Nested insheepskin on radiant warmer. Pt. D/S=72+104.Lytes=140/5.2/108/18.#4 CV-Continues to have M. HR=150-160.B/P W/M's in the40's.Plan for echo today s/p INDO.PRBC's x2. Lytes 147/5.1/115/16. Transfusion consent signed. PN and lipids currently hung at 110cc/kg.D12.5W hung at 30cc/kg vis UVL. Venous blood gas 7.17/61. AG 16.5 to 17.Hypoactive BS,soft loops.NG open to air. Cont with course of Indocin.#5DevTemp sl warm. began shift on SIMV 18/5 R 24. Abd appears full. Following lytes. Perfusion gd with briskcapillary refill. BP stable with meansabove 35. Npostatus continues.A-Fen needs wnl this shift. Plan to transfuse today. Able to wean vent settings earlier today. Cont to monitor resp status closely.#3FENWt 600g down 19g. RR 60-70's stable on current vent settings cont to follow. Respiratory Care NotePt. Min O2 requirement.Settings weaned after survanta.P. andcalibrated. #1Sepsisbaby cont on ampi and . being transferred to TCH. Consent signed and in chart. Infantvoiding well. Xray with picc crossing midline, pulled back 1cm and secured. A- Appears to havePDA ? PRBC transfusion ordered. VBG 7.28/48. PN started on DOL 0 via DUVC. Informed consent signed and inchart. Settings have been weaned. servo weaned. Labs noted and PN adjusted accordingly. CONSENT FOR TRANSFER TO TCH OBTAINED. I have placed EIP & VNA options in record. Monitor apnea and brady.#3FENBW .619. A-Sepsis needs wnl thisshift. and MD in to assess. Respiratory CarePt currently on SIMV. Indocin to be given. NURSING ADDENDUM#6 REPOGAL TUBE PLACED AT 0200 TO LOW CONTINUOUS SX. Starter PN D5, D10W. Monitor resp status. #1 SepsisBlood cultures pending. Lytes 142/4.9/111/16. NeonatologyRemains stable. Adequate Dstick.P. informed.P. A-Resp needs wnl this shift with resp status stablevented. PN to advance as per protocol and tolerance. Plan to check lytes and bili at 0400.#4CVInitially UA line tracing a dampened pattern. CLINDIMYIN GIVEN AS ORDERED. Baby cont to receive Ampand GentP. Appropriate to add Fe and Vit E supps when feeds reach initial goal. Flushed by MD. Small reddened area in L axilla.Aquaphor applied as ordered.P. Left foot notedto be edematous and MD notified. Mild IC/SC retractions. A- Bili needs wnl thisshift. Last ABG was at 0015 7.33/44.A. Check with team relevels. With sterile technique right antecubital cannulated with introducer and PICC advanced to premeasured distance of 10cm and secure. CXR done for ETT placement. Intermittent murmur including noted this am. Last bili11.7/0.6. Total b.o. ic/sc retrx's. Pwp. Oncaffeine. Continues on amp/. Tolerating wean thusfar. Pt is currently on SIMV with settings of 18/5, rate of 26 (weaned for an ABG of 7.38/41/44/25/0). Initial rectal temp was 93.9. current wt 573gms (-2). NPN 0700-1. Currently pt. A;tolerated vent wean. Sx'd for old bldy tinged/cldysecretions q4-6hrs.Continue to monitor resp status.3. began shift on SIMV 18/5 R 22. PnD12.5 andI/L infusing via DLUV. Pt has IC/SC retractions. Pt. Pt. Pt. Pt. P; cont respsupport as needed.#3. REmains under neoblue mini phototherapy with eye shieldson. TF 140cc/k/d D12.5PN and IL via DLUVC. UAC in place. AddendumLytes at 12h of life 142/4.9/111/16. On SIMV 18/5 X22. Bili 3.5/0.2. Initial D-stick=62. More stabilized this am. Remains under high intensity neoblue. TF at 140 cc/k/d of PN 12.5. Respiratory CarePt born this shift, intubated in the D.R. cbg@~1530= 7.28/44, above changes made on the vent.On Caffinegiven as ordered. HR 170's-190's. Remains NPO. D'stix 97.Triglycerides 73 today.A; NPO, maintained d'stix. NPNOte#1.On Amp+ given as ordered.Alert, active with care. TF 140cc/k/d, NPO. is on 16/5 R 26. 0.22-0.28. sx;d for mod. 7 HyperbiliREVISIONS TO PATHWAY: 7 Hyperbili; added Start date: Plan to wean as tolerated. A;AGA P; cont dev support.#6. Soft murmur overnight, notified. Temp 99.1-99.4ax, servo set temp weaned. Will dc and recheck in am.On day of abx. On Tf=140cc/kg/day, PN D8.5 with lipids infuaing atdouble lumen UVC. CBGdrawn & rate weaned. Respiratory CarePt cont on SIMV. #1SepsisBaby cont on amp and . Also will need repeatlevels#2RespBaby remains intubated on same settings of 18/5 with rate32. Adequate dstick.P. Check lytes and bilithis am.#4CVMurmur persists. Settings weaned to 18/5 x26. New intraperitoneal free air. This asymmetry is thought to be within normal limits. Lytes, BUN & creatininepnd. O2 inc forcares. O2 sat labileP. TPN D 8.5 infuding viaprim an sec via UVC. LP and PICC consent obtained. P: Cont toassess. On ampicillin and gentamicn- day . She then experienced PPROM on , and was begun on amp/erythro. #4 O: Baby received Indocin. Contto have ic/sc retractions. BP stable. Baby remains NPO. Endotracheal tube is 1 cm above the carina. NGT in place & vented to air. Cont to monitor closely.#3FENWt 563g down 7. Fio2 .23-.26. bs clear, rr 50's. UVC withdrawn 1 cm to 6.5 cm; repeat X-ray shows tip in low RA. Lytes 137/3.9/103/21. CBG 7.30/48. Bowel sounds heard.A. Breath sounds equal & clear with mildIC/SC retractions. O2sat labile. A: Stable on vent. Plan to recheck bili this am. Today, given prolonged ROM, cerclage was removed. A: Audible murmur. Not placed in isolette because willneed PIC line placed as well as LP. Will cont to wean vent as tolerated. The UAC tip has been pulled back and is now at T7. Umbilical venous line has been withdrawn to the inferior vena cava. SUPINE AND LEFT LATERAL DECUBITUS ABDOMEN Again noted is a large amount of free intraperitoneal air, which may be somewhat greater than on the earlier study. | 66 | [
{
"category": "Nursing/other",
"chartdate": "2165-09-11 00:00:00.000",
"description": "Report",
"row_id": 1834307,
"text": "Nsg Note continued.\nGas repeated by cap.7.24/60/27/27/-3. Settings increased to\n18/5 with rate 22. FIO2 has been 25-32. FIO2 more labile\ntonight than last night. No spells. Baby was loaded\npreviosly in the day with caffeine. No spells tonight.\nA. Sl increase in FIO2. Required increase in pressures.\nP. Cont to monitor resp status closely.\n#3FEN\nWt 600g down 19g. Baby remains NPO. TF at 120 cc/kg/ TPN D5\ninfusing at 70cc/kg or 1.8cc/hr. D12.5 infusing at 50cc/kg\nor 1.3cc/hr. via UVC. Abd appears full. Feed tube inserted\nand position checked with a stehoscope. Air removed. Baby\nalso had .4cc pale green asp. AG 15.5. Bowel sounds\nhypoactive to not audible. Dstick 72. Void, but no stool\never so far.\nA. NPO due to indocin\nP. Cont to monitor dstick. Check lytes this am. NPO while\nreceiving indocin.\n#4CV\nHR 160-170's, Pink sl less ruddy. BP means in mid 30's.\nMurmur stiil heard after one dose of indocin. Blood out\n4.6cc total.\nP. Monitor murmur. Check CBC this am. Cont to monitor blood\nout. Cont with course of Indocin.\n#5Dev\nTemp sl warm. Temp probe slides off freq due to aquaphor.\nMouth care done. baby nested on sheepskin with boundaries.\nAwake and alert with cares.\nP. Will check HUS on thursday.\n#6Parent\nParents and grandparents here at 2130. Parents back at 0230.\nParents updated.\n#7Bili\nBaby remains under neo blue phototherapy with mask.\nP. Plan to check bili this am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-11 00:00:00.000",
"description": "Report",
"row_id": 1834308,
"text": "RESPIRATORY CARE NOTE\nBaby received intubated on vent settings 16/5 Rate 22 FiO2 28-34%. Cap gas 7.24/60/27/27/-3 pressures increased to 18/5. Suctioned ETT for sm amt of white secretions. Breath sounds are coarse. Rpt cap gas 7.26/45/26/21/-7 no vent changes made. Baby is on caffeine. RR 60-70's stable on current vent settings cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-11 00:00:00.000",
"description": "Report",
"row_id": 1834309,
"text": "Addendum\nBlood out 5.6cc. Hct 28.3 this am. Murmur persists. Urine out put 2.4cc/kg/hr. Indocin given at 0630\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-11 00:00:00.000",
"description": "Report",
"row_id": 1834310,
"text": "Neonatology Attending\n\nDay 2 (PMA 25 wks)\n\nRemains on simv with settings- 18/5, x22, 0.28-0.34. Had CBG 7.24/60. Pressure subsequently increased. Started on caffeine. Repeat CBG 7.25/55. Murmur heard yesterday. Indomethacin started- has received two does. HR 150-160s. BP mean 30. Hct 28 with 10% blood out. Plts 274k. Weight 600 gms (-19). TF at 120- PN and lipids. Double lumen UV. Blood glucose 72, 75. No stool passed. Lytes 147/5.1/115/16. Bilirubin 2.3/0.3 under phototherapy. NGT in place. On ampicillin and gentamicin. Blood culture no growth. Stable temperature on open warmer. Family up to date.\n\nCritially ill and stable on current respiratory support. Treating PDA. Hope to see decreasing ventilatory requirement. Plan to transfuse today. Following lytes. Plan 7 day course of antibiotics given extreme prematurity, PROM, and degree of illness.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-11 00:00:00.000",
"description": "Report",
"row_id": 1834311,
"text": "Neonatology NP Note\nPE\nnested on radiant warmer\nAFOF, sagital sutures slightly over riding\nmild subcostal/intercostal retractions on IMv, lungs clear/=\nl/Vl SEM at LSB, pink and well perfused\nabdomen very full but soft, nontender and without loops, hypoactive bowel sounds\nUVC in place, very slight erythema around umbilical cord\nmild edema of left foot, pulses good\nage appropriate tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-11 00:00:00.000",
"description": "Report",
"row_id": 1834315,
"text": "NPN continued\n\n\n#4C/V O-HR 150-160. Murmur audible. BP stable with means\nabove 35. Color pink. Indocin completed . Echo to be\nobtained in am. Transfusion consent signed. A-Probable PDA\nneeds transfusion for blood out P- Transfuse this PM as\nordered.\n#5Dev. O-Temps stable on servo warmer. Infant opening eyes\nwith cares. Sleeping between cares. A- Day 2 for this 25\n1/7week infant AGA P-Head U/S to be done in am.\n#6Family obtained consent for transfusion/LP/ PIC.\nUpdated Mom in her room. Mom up to NICU at 1700 and updated\nby this RN. Mom Appears to understand plan of care\nP- Update and support as needed. Family meeting to be\nplanned.\n#7 Bili No change. Bili to be sent in am.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-12 00:00:00.000",
"description": "Report",
"row_id": 1834316,
"text": "Respiratory Care Note\nPt. began shift on SIMV 18/5 R 24. Cap gas poor increased rate to 28 and pt. was given bicarb. Current cap gas is 7.23/54/39/-5. BS decreased. Pt. sx'd for sm. cloudy. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-11 00:00:00.000",
"description": "Report",
"row_id": 1834312,
"text": "Respiratory Care Note\nBaby Girl was received vented on SIMV 22, 18/5, FiO2 .26-.30 this shift. VBG: 7.20/58/29/24/-6. Increased RR to 24. Plan CBG today. BS clear with suctioning. Suctioned for mod white secretions. On caffeine. No bradys thus far this shift. + murmur. Receiving Indocin.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-11 00:00:00.000",
"description": "Report",
"row_id": 1834313,
"text": "Respiratory Care Note\nCBG clotted. VBG drawn: 7.21/50/27/21/-9. No further changes made.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-11 00:00:00.000",
"description": "Report",
"row_id": 1834314,
"text": "NPN\n\n\n#1Sepsis Day . levels sent today. LP consent\nsigned.Blood culutre neg. to date.\n#2Resp received infant on settings of 18/5 X 22. Rate\nincreased to 24 at 1400 for venous gas 7.20/58. Repeat cap\ngas at 1700 clotted. Venous gas at 1800 7.21/50/27/21/-9.\nSettings kept at 18/5 X 24. O2 need 28-32%. RR 40-60. Breath\nsounds coarse but improve after suctioning. Occassional\ndesats to 80's responding to slight increase in FIO2. Murmur\npersists despite indocin. A-Immature lungs/PDA contributing\nto acidosis P- Check cap gas this pm. Transfuse for blood\nout this PM.\n#3F/N O-Infant remains NPO with total fluids increased this\nam to 140cc/kg. PN and lipids currently hung at 110cc/kg.\nD12.5W hung at 30cc/kg vis UVL. D-sticks today 106/83.\nVoiding well. No stool passed. Abdomen very full with\nhypoactive bowel sounds. Girth 16.5cm. Stomach decompressed\nduring the day per NG with only air aspirated. Soft bowel\nloops palpable. Lytes sent at 1300 139/4/108/22. A- Adequate\nhydration blood sugar stable P- Check lytes this PM per\nteam.Check lytes and bili in am.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-12 00:00:00.000",
"description": "Report",
"row_id": 1834319,
"text": "Nrsg Progress Note-0700-1900\n\n\n#1OA-Rem on ampi and with dose increased for due\nto levels. Alert with gd tone. Temp stable on radiant\nwarmer.A-No overt sepsis needs. P-Cont to assess sepsis\nneeds.\n#2O/A-Orally intubated with 2.5 ett at 7 cm mark of upper\nlip with simv 18/5 rate 32 with increaqsed rate due to\nvenous gas of 7.17,61,42. Repeat cap gas 7.23,56,36.Sx'd for\nmod white via ett and clear orally. Aeration improved after\nsx'ing. Rem on caffeine. A-Resp needs wnl this shift. P-Cont\nto assess resp needs.\n#3O/A-Tf 140 cc's/kg with double lumen uvc line infusing\nwell. D stix 85 at 0930. No stool. Vding q diaper change.\nAbd soft yet distended with faint bs in all 4 quads. Npo\nstatus continues.A-Fen needs wnl this shift. P-Cont to\nassess fen needs.\n#4O/A-Rem alert and active with cares with stressors related\nto repositioning and procedures. Desat to 85 with hus with\nquick recovery and 02 increased. Corrected age of 25 4/7\nweeks. A-G&d needs wnl this shift.P-Cont to assess g&d\nneeds.\n#4O/A-Murmur audible with ap 130-150's with plans for eccho\ntoday. Pulses non bounding with quiet precordium noted.\nBlood out 0.4 cc's thus far. Perfusion gd with brisk\ncapillary refill. A-Cv needs wnl this shift. P-Cont to\nassess cv needs.\n#5O/A-Corrected age 24 4/7 weeks. Alert and active with\ncares looking around. Moving all extrem equally. Nested in\nsheepskin on radiant warmer. A-G&d needs wnl this shift.\nP-Cont to assess g&d needs.\n#6O/A-Mom and dad have not visited as of this writing. Mom\nwas not feeling well last evening. A-Parenting needs will be\nassessed with visit or call. P-Cont to assess parenting\nneeds.\n#7O/A-Rem on neo blue phototherapy with palsn for repeat\nbili tomorrow. Rem with bili masks in place with removal\nwith cares. A-Bili needs wnl this shift. P-Cont to assess\nbili needs.\nPlans for report at 1900.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-12 00:00:00.000",
"description": "Report",
"row_id": 1834320,
"text": "Neonatology NP Note\nPE\nnested on radiant warmer\nAFOF, suturesa approximated\nmild subcostal/intercostal retractions on IMV, lungs clear/=\nl/Vl SEm at LUSB, pink and well perfused, quiet precordium, femoral pulses full, liver edge at RCM\nabdomen soft, nontender and nondistended, absent bowel sounds\nUVC secured in place\nage appropriate tone and reflexes\ndecreased edema in left foot since yesterday\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-12 00:00:00.000",
"description": "Report",
"row_id": 1834321,
"text": "Respiratory Care\nPt received on SIMV, rate of 28, pressures of 18/5, with the fio2 26 to 32%. Pt vent rate increased from 28 to 32 based on VGB of 7.17 with a PCO2 of 61. The repeat blood gas was capillary and improved. Plan is to follow blood gases and ajust vent settings per results.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-13 00:00:00.000",
"description": "Report",
"row_id": 1834322,
"text": "Respiratory Care\nBaby continues on 18/5, R 32 with 02 req 21-26% this shift. BS coarse- clear. Sxn for lg cldy secretions from ETT. RR 30's-50's with IC/SCR. CBG: 7.29/51/60/26/-2; no changes made @ this time. Rec'd first dose of 2nd course of Indocin tonight. No spells recorded as of this writing. Will cont to follow closely, support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-12 00:00:00.000",
"description": "Report",
"row_id": 1834317,
"text": "NPN\n\n\n#1 Sepsis- Remains on Amp+ .\n#2 Resp- Remains on vent 28-32%,18/5, Rate increased and\nneut givenx1 after CBG=7.19/58/37/23/-7.F/U\nCBG=7.23/54/39/24/-5.No other vent changes made.BS coarse\nand clear after sxn q 4-5 hrs for sm to mod amts.RR=\n40-60.Mild retractions.\n#3 F/N- Abd softly distended. AG 16.5 to 17.Hypoactive BS,\nsoft loops.NG open to air. No asps.Voiding in adeq amts. No\nstool.Wt down 30gms.Tf= 140cc/kg/day of TPN(D6),IL,+\nD12.5.See flowsheet. D/S=72+104.Lytes=140/5.2/108/18.\n#4 CV-Continues to have M. HR=150-160.B/P W/M's in the\n40's.Plan for echo today s/p INDO.PRBC's x2. See\nflowsheet.Pale to now pink.\n#5 Dev- Alert+ active w/cares. Temp stable on servo warmer\nnested in sheepskin w/h20 pillow.\n#6 Parents-Mom and Dad here to visit x1.Updated.\n#7 Bili- Remains under double phototx w/eye shields on. Bili\nbthos AM=2.3/2/.3\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-12 00:00:00.000",
"description": "Report",
"row_id": 1834318,
"text": "Neonatology Attending\n\nDay 3 PMA 25 wks\n\nRemains on simv with settings- x32, 18/5, 0.26-0.32. Venous blood gas 7.17/61. Rate subsequently increased. Murmur persists. HR 150-160s. BP mean 44. Pink. Transfused overnight with PRBCs for Hct 28. Weight 570 gms (-30). TF at 140 cc/kg/d with PN and lipids (and Dextrose solution). Lytes 140/5.2/108/18. NPO. Full, soft abdomen. Stable girth. Blood glucose 85. No stool passed. Stable temperature on warmer. HUS normal. On ampicillin and gentamicin (0.9/4.2).\n\nIncreasing ventilatory requirement with persisting murmur. Cardiology consultation (echo) requested. Anticipated continued indomethacin course. Advancing parenteral nutrition. Starting vitamin A. Metabolically fine. Adjusting antibiotics.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-16 00:00:00.000",
"description": "Report",
"row_id": 1834343,
"text": "Neonatology\nAs above, noted to have abdominal free air on xray done for line placement. No pneumo seen. No evidence of pneumotosis seen. ? isolated perforation. HAs remained clinically very stable during entire dayu including currently. Able to wean vent settings earlier today. CV has been stable. Well perfused and active. has been placed.\nAntibiotic coverage to be increased to include clindamycin.\nCBC diff BC, lytes and gas to be checked.\n\nPedi at CH consulted.\n\nHave spoken with father by phone at his home. Have described current status, potential diagnoses inlc NEC, isolated perforation and potential interventions including bedside drain placemnet or laparotomy. They understand that latter would require transfer to CH.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-10 00:00:00.000",
"description": "Report",
"row_id": 1834303,
"text": "Neonatology\nExam: active premature infant, on SIMV. Skin warm and dry. Fontanelles soft and flat. Chest coarse, well-aerated. Cardiac RRR, + 2/6 systolic murmur. Abdomen soft, quiet but present BS. Femoral pulses and pedal pulses 2+. Left foot mildly edematous; pink, brisk cap refill, toes very mildly dusky.\n\nOf note, infant's UAC had to be removed last night secondary to decreased perfusion of feet. Color improved following removal of line.\n\nExam suggests presence of PDA.\n\nWill continue to monitor appearance of left foot. If remains stable, will initiate indocin treatment this afternoon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-16 00:00:00.000",
"description": "Report",
"row_id": 1834344,
"text": "Neonatology\nRemains stable. Blood gas in good range. Lytes normal. CBC shows Hct of 27 with platelets 262. PRBC transfusion ordered. Has been seen by surgical team from CH. They are planning laparotomy for exploration with direct visualization of bowel. Transfer to CH to be arranged.\n\nSPoke with parents by phone again this morning. Spoke with mother and father and again discussed status, diagnostic possibilities and oeprtaive plan. Also discussed potential for worsenign of condition including possibility of mortality.\n\nParents appear to understand and have no questions at this time. They provided consent for transfer to me.\n\nThey spoke on the phone with Dr from surgery. They will plan to visit patient at CH after surgery is completed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-16 00:00:00.000",
"description": "Report",
"row_id": 1834345,
"text": "NURSING TRANSFER NOTE\n\nRECEIVED INFANT ORALLY INTUBATED ON UNCHANGED VENT SETTINGS. NO A&B'S OR DESATS NOTED TONIGHT. FI02 23-30% WITH CL&= BS AND MINIMAL WORK OF BREATHING. SX'D FOR MOD SECRETIONS Q4HRS. SOFT MURMER AUDIBLE, COLOR PINK AND WELL PERFUSED. BP STABLE. HR 140-160'S. LUMBAR PUNCTURE SUCCESSFULLY DONE AT 2400. REMAINS ON AMP/ IV. PICC LINE PLACED IN RIGHT ARM AND PLACEMENT VERIFIED BY XRAY. NOTED ABNORMAL ABD FINDINGS ON XRAY (PLEASE REFER TO ABOVE NEONATOLOGY AND NOTES). CLINDIMYIN GIVEN AS ORDERED. SURGICAL CONSULT REQUESTED AND OBTAINED. PARENTS CALLED, CBC, BLOOD CULTURES AND ABG OBTAINED. LYTES & BILI ALSO DRAWN. TRANSFUSED WITH 12CC PRBC (20CC/KG) STARTING AT 0430. CONSENT FOR TRANSFER TO TCH OBTAINED. PRESENTLY TOTAL FLUIDS AT 140CC/KG/D OF PN12.5%, IL AND D12.5/LYTES. D-STICK 169. REMAINS NPO, ABD SOFT, PINK WITH 17.5-18CM ABD GIRTH AND HYPOACTIVE BS. URINE OUTPUT 3CC/KG/HR, NO STOOL SINCE BIRTH. TRANSFERED TO TCH VIA AMBULANCE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-16 00:00:00.000",
"description": "Report",
"row_id": 1834346,
"text": "Respiratory Care Note\nPt. continues on SIMV 17/5 R 26 and 23-35% FIO2. BS clear. Pt. sx'd for mod.cloudy bld-tinged secretions. Abg overnight 7.26/49/69/23/-5. Pt. evaluated by Surgery from TCH. Pt. being transferred to TCH.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-16 00:00:00.000",
"description": "Report",
"row_id": 1834347,
"text": "NURSING ADDENDUM\n#6 REPOGAL TUBE PLACED AT 0200 TO LOW CONTINUOUS SX. NO DRAINAGE AT THIS TIME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-10 00:00:00.000",
"description": "Report",
"row_id": 1834300,
"text": "Neonatology\nDOL #1, 25 wks.\n\nBorn yesterday evening.\n\nCVR: Currently on SIMV 18/5 x 20, FiO2 25%. S/P surfactant x 2 doses. VBG 7.28/48. Hemodynamically stable, no need for volume or pressor support overnight. No murmur noted.\n\nFEN: Wt 619. TF increased from 100 to 120 cc/kg/day this am. Lytes 142/4.9/111/16. Starter PN D5, D10W. Dstik 92. Voiding (1.2 cc/kg/hr). Abdomen soft, no stool.\n\nGI: Bili 3.5/0.2, started phototherapy.\n\nACCESS: UVC remains in place. UAC removed overnight secondary to duskiness of feet.\n\nHEME: Hct 35.6. Blood out 3.2 mL.\n\nID: Continues on amp/gent. Initial WBC 6.1 with 28N/0B.\n\nIMP: 1 day old 25 wk infant with RDS, hyperbilirubinemia. At risk for sepsis given prematurity. Hemodynamically stable. Mildly anemic on initial CBC.\n\nPLANS:\n- Continue SIMV, wean as able.\n- Start caffeine in anticipation of possible trial of CPAP soon.\n- Monitor hemodynamics, at risk for PDA.\n- Continue TF 120, periodic monitoring of lytes and bili.\n- Continue phototherapy.\n- NPO today, consider trophic feeds tomorrow if stable.\n- Check type and coombs.\n- Continue amp/gent, anticipate 48 hour course if remains stable and cultures negative.\n- Plan HUS at day 3 of age (thursday).\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-10 00:00:00.000",
"description": "Report",
"row_id": 1834301,
"text": "Case Management Note\nChart has been reviewed and events noted. I have placed EIP & VNA options in record. Neighborhood Health Plan will be doing daily on-site reviews of clinical status. I will be following for any d'c planning needs along w/team & family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-10 00:00:00.000",
"description": "Report",
"row_id": 1834304,
"text": "NPN\n\n\n#1Sepsis No change. Remains on antibiotics. CBC to be\nchecked in am.\n#2Resp O- Infant had vent settings weaned to 16/5 X 20. O2\nneed 23-30% with sats above 90. RR 30-40's. Venous gas at\n1530 7.23/55/35/24/-6. Rate increased to 22 at this time.\nCaffeine bolus given at 1500. Indocin to be given. Murmur\naudible. A-Probable PDA /minimal O2 need. P- Wean vent as\ntolerated.\n#3F/N O- Infant remains NPO with total fluids at 120cc/kg.\nInfant has soft abdomen with hypoactive bowel sounds. Blue\nhue noted on abdomen. Girth 16.5cm No stool passed. Infant\nvoiding well. Lytes and bili sent at 1530. D-stick 115.\nA-Adequate hydration at present time P- Check labs.\n#4C/V O- HR 140-160. Murmur audible at 1300. Left foot noted\nto be edematous and MD notified. Perfusion to left leg/foot\ngood with good pulses. Toes to left foot slightly\n dusky/?bruising. Blood out over 4cc's. A- Appears to have\nPDA ? cause edema to left foot.(sat probes not on legs for\nover 3 hours) P- Treat with Indocin per team. Follow\n edema/perfusion. Check CBC in am.\n#5Dev. No change. H/U this week per team.\n#6Family Mom and Dad in to visit and updated at bedside\nby this RN. Family asking appropriate questions and aware UA\nline discontinued. A- Loving family/ coping with NICU\nadmission P- Update and support as needed.\n#7Bili No change. Bili sent at 1530.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-10 00:00:00.000",
"description": "Report",
"row_id": 1834305,
"text": "Respiratory Care\nPt currently on SIMV. Settings 16/5 x22. FJio2 .25-.28. bs clear, rr 50's. vbg on rate 20 7.23/55. Started 1st course indocin for PDA. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-11 00:00:00.000",
"description": "Report",
"row_id": 1834306,
"text": "#\n1Sepsis\nbaby cont on ampi and . Blood cultures still pending.\nArea of pinkness noted at riight side of UV line. \ninformed.\nP. Cont to monitor site. Await results of blood cultures.\n#2Resp\nLungs clear with suctioning. Mild IC/SC retractions. RR\n50-70's. Baby received on settings of 16/5 with rate 22.\nGas obtained from UV line.7.18/63/43/25/-5\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-15 00:00:00.000",
"description": "Report",
"row_id": 1834340,
"text": "Nrsg Progress Note-0700-1500\n\n\n#1O/A-Day of ampi and with no plans for lp as of\nthis writing. Lp attempt x2 not tolerated by patient\novernight. Tone wnl this shift. A-Sepsis needs wnl this\nshift. P-Cont to assess sepsis needs.\n#2O/A-Received oralyy intubated with 2.5 ett with taping at\n7 upper lip. Imv with 17/5 rate 30 weaned to 26 at 0900.\nInfant's recent cbg of 7.26,57,40, 27. Color pink with gd\naeration noted. Sx'd for moderate cloudy via ett and clear\norally. A-Resp needs wnl this shift with resp status stable\nvented. P-Cont to assess resp needs.\n#3O/A-Tf remain 140 cc's/kg with double lumen uvc line\ninfusing d12.5 pn and il. D stix 129-148. Abd soft with non\ndistention. Ag 17 cms. Vding 2.8 cc's/kg/hr. A-Fen needs wnl\nthis shift. P-Cont to assess fen needs.\n#4O/A-Rem with interm murmur with soft murmur haerd at 1400.\nColor pink with perfusion gd and capillary refill brisk.\nBlood out 5.7 cc's total. A-Fen needs wnl this shift. P-Cont\nto assess fen needs.\n#5O/A-Mom and dad have not phoned as of this writing with no\nindication of visiting plan for today. A-Unable to assess\nparenting needs with no contact this shift. A-Parenting\nneeds unable to assess. P-Cont to assess parenting needs.\n#7O/A-Received on neo blue photo with photo dc'd at 1000\ntoday. Plans for rebound with lytes in am also. Alert moving\naround with cares. Eyes opened. A- Bili needs wnl this\nshift. P-Cont to assess bili needs.\nPlans for report at 1500.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-15 00:00:00.000",
"description": "Report",
"row_id": 1834341,
"text": "Neonatology - Progress Note\n\nInfant is active with good tone. AFOF. She is pink, well perfused, grade II/VI murmur auscultated this AM. She remains on low vent settings with fio2 21-25%. Breath sounds clear and equal. She remains Npo. IV fluids infusing via DLUVC @ 140cc/kg/day. Abd soft, active bowel sounds, voiding and stooling. Stable temp in heated isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-16 00:00:00.000",
"description": "Report",
"row_id": 1834342,
"text": "Neonatal NP-Procedure: lumbar puncture\n\nIndication: R/O meningitis\n\nTime out observed. Consent signed and in chart. Infant positioned and prep'd for procedure. #24 guage LP needle used to cannulate L4-L5 intraspace with blood tinged CSF. Collected 1.5 cm fluid and sent to lab for analysis. Infant tolerated procedure well.\n\nProcedure: PICC line placement\nIndication: long term IV nutritional needs.\n\nTime out observed. Informed consent signed and inchart. Infant positioned and Right arm prep'd for procedure. With sterile technique right antecubital cannulated with introducer and PICC advanced to premeasured distance of 10cm and secure. Xray with picc crossing midline, pulled back 1cm and secured. Repeat film with tip in SVC.\n\nOf note, noted ? free abd air on film. Awaiting decub. Dr. aware.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-10 00:00:00.000",
"description": "Report",
"row_id": 1834302,
"text": "Clinical Nutrition\nO:\n25 wk gestational age BG, AGA, now on DOL 1.\nBirth wt: 619 g (~10th to 25th %Ile)\nHC: 21.5 cm (extrapolates to ~10th to 25th %Ile)\nLN: 30 cm (extrapolates to ~10th to 25th %Ile)\nLabs noted\nNutrition: 120 cc/kg/day TF. NPO. PN started on DOL 0 via DUVC. D10 also infusing via other port of DUVC. Plan to change PN to ~70 cc/kg/day tonight, w/ remaining ~50 cc/kg/day of fluids as D12.5 w/ lytes via DUVC. Projected intake for next 24hrs from PN ~20 kcal/kg/day, ~2 g pro/kg/day; no lipids yet. GIR from PN + IVF ~6.8 mg/kg/min.\nGI: Abdomen benign; hypoactive bowel sounds. No stool yet.\n\nA/Goals:\nTolerating PN + IVF with good BS control so far; monitoring dstix. Remains NPO at this time; may start trophic feeds tomorrow if hemodynamically stable. Labs noted and PN adjusted accordingly. Initial goal for PN is ~90 to 110 kcal/kg/day, ~3 to 3.5 g pro/kg/day and ~3 g fat/kg/day. PN to advance as per protocol and tolerance. When able to start enteral feeds, initial goal is ~150 cc/kg/day PE/BM 24, providing ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day. Expect PN to taper as feeds advance towards initial goal. Further increases in feeds as per growth and tolerance. Appropriate to add Fe and Vit E supps when feeds reach initial goal. Growth goals after initial diuresis are ~15 to 20 g/kg/day for wt gain, ~0.5 to 1 cm/wk for HC gain,and ~1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-10 00:00:00.000",
"description": "Report",
"row_id": 1834296,
"text": "#1 Sepsis\nBlood cultures pending. CBC benign. Baby cont to receive Amp\nand Gent\nP. Monitor urine output while on gent. Check with team re\nlevels. Await results of blood cultures.\n#2Resp\nBaby remains orally intubate. Baby received second dose of\n about 2230. Settings have been weaned. Current\nsettings are 18/5 with rate 20 . FIO2 requirement has been\n21-26%. RR 50-60's with IC/SC retractions. Rare drift to\n80's but generally in low 90's for sat. No true spells.\nSuctioned for oral secretions. Last ABG was at 0015 7.33/\n44.\nA. Min O2 requirement.Settings weaned after survanta.\nP. Monitor resp status. Monitor apnea and brady.\n#3FEN\nBW .619. Baby NPO. TF were at 110 but decreased to 100cc/kg\nonce UA line pulled. Double lumen UVC infusing with starter\nTPN D5 at 50cc/kg and D10W with .5u hep/cc at 50 cc/kg.\nDstick last check was 69. Baby voiding. AG 15.5 soft flat.\nBowel sounds not audible. No stool as yet.\nA. Adequate Dstick.\nP. Plan to check lytes and bili at 0400.\n#4CV\nInitially UA line tracing a dampened pattern. Difficult to\nobtain BP from tracing. Flushed by MD. and\ncalibrated. At , tracing improved but feet quite\npale. informed. L worse than R foot. Heel warmer placed\non R foot with improve,ment. Then heel warmer placed on L\nfoot also with improvement. Later toe on L foot appeared\ndark. and MD in to assess. Observed with some\nimprovement but did not completely resolve. UAC removed by\n. BP means had been higher on cuff than UA. Means have\nbeen in 30's by cuff. HR 170-190's but now more 160-170.\nBlood out 2.4cc total. Once UA line removed toes improved\nin color. Murmur not heard so far.\nA. Stable BP. UA line needed to be pulled to circulation\nissues.\nP. Cont to monitor BP HR and blood out. Monitor for signs of\nmurmur.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-10 00:00:00.000",
"description": "Report",
"row_id": 1834297,
"text": "#5Development\nTemp stable on servo control. servo weaned. Nested on\nsheepskin with tent. Active and alert with cares. Quiet\nbetween cares. Skin intact. Small reddened area in L axilla.\nAquaphor applied as ordered.\nP. Cont to monitor.\n#6Parent\nDad in x 2. Dad updated on baby's condition as well as NICU\nroutine.\n#7Bili\nBaby ruddy. to check a bili at 0400.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-10 00:00:00.000",
"description": "Report",
"row_id": 1834298,
"text": "Respiratory Care Note\nPt. began shift on 18/5 R 26. Pt. received a second dose of Survanta @2230. Pt. has weaned throughout the night and is currently on 18/5 R 20. Last gas was 7.28/48/40/24/-4. FIO2 has been 22-30%. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-10 00:00:00.000",
"description": "Report",
"row_id": 1834299,
"text": "Addendum\nLytes at 12h of life 142/4.9/111/16. Bili 3.5/0.2. Phototherapy started with mask. TF increased to 120cc/kg\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-15 00:00:00.000",
"description": "Report",
"row_id": 1834336,
"text": "NPN 1900-0700\n\n\n1. Continues on amp/. LP attempt unsuccessful. \nlvls: pre-1.3, post-7.9.\nCOntinue to administer antibx as ordered and monitor for s/s\nsepsis.\n\n2. Continues on vent settings 18/5 rate 22. fiO2 mainly 21%\novernight. Increased briefly to 50% following LP (infant\nhad recvd fent for procedure). rr30-60's, rides vent\noccasionally. ic/sc retrx's. Sx'd for old bldy tinged/cldy\nsecretions q4-6hrs.\nContinue to monitor resp status.\n\n3. current wt 573gms (-2). TF 140cc/k/d, NPO. PnD12.5 and\nI/L infusing via DLUV. DS 129. belly full soft, no loops,\nag 17.5cm. No stool, u/o 2.4cc/k/hr.\nContinue to monitor I+O.\n\n4. Soft murmur overnight, notified. S/P 2x indo\ncourses. hr140-160's. Pwp. Total b.o. 5cc.\nContinue to monitor cv status.\n\n5. Temp 99.1-99.4ax, servo set temp weaned. Nested on\nsheepskin w/water pillow, and tent. Alert/active at cares,\nsleeps well b/w. Given fentanyl prior to LP for pain\nrelief. AFSF.\nContinue to support needs.\n\n6. Parents in visiting and given update.\nContinue to support and update parents regularly.\n\n7. Remains under high intensity neoblue. Last bili\n11.7/0.6. Bili to be checked mon am after phtx stopped.\nContinue to monitor bili status.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-15 00:00:00.000",
"description": "Report",
"row_id": 1834337,
"text": "Respiratory Care Note\nPt. began shift on SIMV 18/5 R 22. FIO2 has been 21-25%. BS coarse. Pt.'s rate increased to 26 after given Fentanyl due to desats. Pt. desat more when rate decreased. Pt.'s chest bounding. Currently pt. is on 16/5 R 26. Pt. sx;d for mod. cloudy secretions. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-15 00:00:00.000",
"description": "Report",
"row_id": 1834338,
"text": "Neonatology\nMOderate variability in vent settiungs noted last night. More stabilized this am. Low fio2. CBG this this am in good range allowing wening of rate this am. Intermittent murmur including noted this am. WIll ask cardiology for echocardiogram with potential need for ligation if continued PDA is seen.\n\nWt 573 down 2. TF at 140 cc/k/d of PN 12.5. Remains NPO. Abdomen benign. WIll hold on feeds while evaluating for PDA. Lytes to be checked in am.\n\nDOuble photorx. Bili 1-2 range yesterday. Will dc and recheck in am.\n\nOn day of abx. LP attempted unsuccesfully last night. Will hold on repeat attempts for today given impact on CV status last night.\n\nContinue to monitor resp status and titrate support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-15 00:00:00.000",
"description": "Report",
"row_id": 1834339,
"text": "Respiratory Therapy\nWeaned today to SIMV 17/5-26 from rate of 30. 0.22-0.28. RR 30-70. LS coarse. Large cloudy secretions. CBG on current 7.26/57. Occ rides vent settings. Plan to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-09 00:00:00.000",
"description": "Report",
"row_id": 1834292,
"text": "Respiratory Care\nPt born this shift, intubated in the D.R. with 2.5 ett placed at the 6.5cm mark. Pt given 2.5cc for 1st dose of surfactant, tolerated. Pt weaned down on vent settings and remains on rate of 28, pressures of 20/5 with the fio2 weaning down to 24%. Plan is to follow blood gases, wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-09 00:00:00.000",
"description": "Report",
"row_id": 1834293,
"text": "Admission Note\nPt admitted to NICU from L&D at 1630. Attending MD note for maternal history and delivery room course. Pt is currently on SIMV with settings of 18/5, rate of 26 (weaned for an ABG of 7.38/41/44/25/0). FiO2 is currently at 21%. Pt received one dose of Surfactant. CXR done for ETT placement. Pt has IC/SC retractions. No spells or desats. No murmur noted. HR 170's-190's. BP cuff means are 31-55. UAC in place. Pt is pink, well perfused. CBC sent, see lab data for details. Blood cultures sent and are pending. Ampicillin and Gentamicin started. Birthweight is 619 grams. TF=110cc/kg/d. Pt has UAC which is running 1/2NS with 1/2 unit of Heparin per cc at 0.8cc/hr. DUVC primary port has D5 Starter PN with 1/2 unit of Heparin per cc at 1.2cc/hr and secondary port has D10W with 1/2unit of Heparin per cc at 0.8cc/hr. Initial D-stick=62. D-stick prior to start of IVF was 42. Pt voided in DR, no stool yet. Lytes/bili to be drawn at 12 hours of life. Initial rectal temp was 93.9. Subsequent temps after warming lights and warm water bags placed on pt were 98.6-98.8. Pt is nested on sheepskin. Alert/active, settles well. Erythromycin and Vitamin K given. Mom in to visit in transition from L&D to Postpartum floor, updated by this RN and MD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-10 00:00:00.000",
"description": "Report",
"row_id": 1834294,
"text": "1 Infant with Potential Sepsis\n2 Alt in Resp due to Prematurity\n3 Alt in Fluid and Nutrition\n4 Alt in Cardiovascular\n5 Alt in Development\n6 Alt in Parenting\n\nREVISIONS TO PATHWAY:\n\n 1 Infant with Potential Sepsis; added\n Start date: \n 2 Alt in Resp due to Prematurity; added\n Start date: \n 3 Alt in Fluid and Nutrition; added\n Start date: \n 4 Alt in Cardiovascular; added\n Start date: \n 5 Alt in Development; added\n Start date: \n 6 Alt in Parenting; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-10 00:00:00.000",
"description": "Report",
"row_id": 1834295,
"text": "7 Hyperbili\n\nREVISIONS TO PATHWAY:\n\n 7 Hyperbili; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-13 00:00:00.000",
"description": "Report",
"row_id": 1834327,
"text": "NPNOte\n\n\n#1.On Amp+ given as ordered.Alert, active with care. A;\nasymptomatic P; cont antibiotics as ordered.\n\n#2. Remains orally intubated, 18/5, rate26/mt,fio2 21-26%,\nBBS clear, equal, mild subcostal/intercostal retractiosn\npresent, no spells noted, o2 requirement increased with care\nand handling. Occassional desats to high 80's QSR. cbg\n@~1530= 7.28/44, above changes made on the vent.On Caffine\ngiven as ordered. A;tolerated vent wean. P; cont resp\nsupport as needed.\n\n#3. On Tf=140cc/kg/day, PN D8.5 with lipids infuaing at\ndouble lumen UVC. UVC site without redness.BS+, soft loops\nnoted while in supine position.NGT in place, no aspirate,\nkept open to air, team aware of results of lytes. D'stix 97.\nTriglycerides 73 today.A; NPO, maintained d'stix. P; cont\ncurrent nutritional plan,BUN, creat, lytes, bili in am.\n\n#4.Soft murmur heard, pink, well perfused. Bp means 34.\nA;hemodynamically stable. P; cont to monitor.\n\n#5. Alert,active with care, temp stable on a warmer bed,\nmae,nested, MAE. A;AGA P; cont dev support.\n\n#6. Parents visited, family meeting held, parents, social\nworker and present.A; P; cont\nupdate and support.\n\n#7. MIldly jaundiced, under neoblue light double. A;mildly\njaundiced.P; cont phototheraphy, bili in am with lytes, BUn,\nCreat.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-13 00:00:00.000",
"description": "Report",
"row_id": 1834328,
"text": "Neonatology NP Note\nnetsed in isolette\nAFOF, sutures approximated\nmild subcostal/intercostal retractions on IMv, lungs clear/=\nl/Vl SEM at LSB, pink and well perfused, quiet precordium, pulses full\nabdomen soft, nontender and nondistended, hypoactve bowel sounds, transient soft loops\nUVC in place\nage appropriate tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-14 00:00:00.000",
"description": "Report",
"row_id": 1834329,
"text": "RESPIRATORY CARE NOTE\nBaby received intubated on vent settings 18/5 Rate 26 FiO2 21%. Suctioned ETT for sm-mod amt of white secretions. Breath sounds are clear. Cap gas 7.29/43/33/22/-6 rate decreased to 24. Baby is on caffeine. Stable on current vent settings cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-14 00:00:00.000",
"description": "Report",
"row_id": 1834331,
"text": "NOTE: THIS IS NEONATOLOGY ATTENDING NOTE ( \"T CURRENTLY HAVE ACCESS TO MY CAREVUE LOGIN--WORKING ON IT).\n\nDOL #5\n35 6/7 weeks PMA\n18 /5 x 24 27% FiO2\nlast dose of indomethacin was at 10pm last night.\ncurrently on amp and to complete 7 day course\nHR=150-160's, BP mean=44\nLytes: 132/4.2/99/19/29/0.9\nbili=1.7/0.7\nTF=140cc/kg/d, NPO, Double lumen UVC\nwt=619g\n\nPE: well appearing, active, AFOF, normal S1S2, no murmur, breath sounds clear, abdomen soft,nontender, nondistended. ext warm, well perfused. tone aga.\n\n\nImp/Plan: premie with RDS, resolving PDA, indirect hyperbilirubinemia, possible sepsis, remains critical but stable.\n--d/c phototherapy Sunday am and check bili on Monday\n--will attempt LP today, continue amp and to complete 7 day course if LP results normal\n--monitor for murmur--if signs of PDA, will consider obtaining echo on Sunday.\n--check lytes, BUN, bili on Monday\n--continue rest of present management\n\n\n (NOT RIVERS WROTE ABOVE NOTE)\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-14 00:00:00.000",
"description": "Report",
"row_id": 1834332,
"text": "I wrote and agree with above--my password is now working!\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-14 00:00:00.000",
"description": "Report",
"row_id": 1834333,
"text": "Respiratory Care\nPt received on SIMV, rate of 24, pressures of 18/5 with the fio2 21%. Pt's resp rates 30's to 60's, on caffine. Pt weaned down on vent rate from 24 to 22. Plans is to follow on PPV, check bld gas, wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-14 00:00:00.000",
"description": "Report",
"row_id": 1834334,
"text": "NPN 0700-\n\n\n1. Remains on amp and . levels pending. Blood\ncultures negative to date. No apparent s/sx of sepsis.\nContinue to treat for 7days per team.\n\n2. On SIMV 18/5 X22. FiO2 21% all day. Weaned rate from\n24 at 1100 and VBG at 1745= 7.25/51. Lungs clear. RR\n22-40's with mild IC and SC retractions. Sxn for small old\nblood tinged secretions and then cloudy this afternoon. On\ncaffeine. No A&B/desats thus far. Tolerating wean thus\nfar. Continue to monitor for A&B/desats and support as\nneeded.\n\n3. TF 140cc/k/d D12.5PN and IL via DLUVC. NPO. Abdomen\nsoft, pink, no loops. Faint, hypoactive BS. 12hr urine\noutput= 2.8cc/k/hr. NO stool yet. Continue to monitor FEN\nclosely.\n\n4. No murmur audible. HR 150-160's. BP 54/23 MAP 37.\nColor is pink, brisk cap refills, 2+PP. No apparent s/sx of\nPDA. Continue to monitor for s/sx of PDA.\n\n5. Temp stable nested under warmer. Infant on sheepskin\nwith water pillow. Alert and active with cares. MAE.\nCares clustered. Continue to promote development.\n\n6. Mom called and updated on plan of care. Continue to\nsupport, update, and educate parents.\n\n7. REmains under neoblue mini phototherapy with eye shields\non. Color is pink, ruddy. No stool yet and NPO. Cont.\nwith phototherapy as per team.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-15 00:00:00.000",
"description": "Report",
"row_id": 1834335,
"text": "Neonatology NP Note\nLP attempt-no success, only blood obtained\nFentanyl given for pain management\nConsent in chart\nInfant tolerated procedure well. no complications\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-14 00:00:00.000",
"description": "Report",
"row_id": 1834330,
"text": "Nursing progress note\n\n\n#1 O: Blood cultures neg to date. Remains on antibiotics. A:\nStable. P: Cont to assess.\n#2 O: Remains oraly intubated in 21% O2, 18/5, X's 24. CBG\ndrawn & rate weaned. Breath sounds equal & clear with mild\nIC/SC retractions. Suctioned X's 2 for sm wh ETT & OP.\nRemains on caffeine. No A's, B's or desats. O2 inc for\ncares. A: Stable on vent. P: Cont to assess.\n#3 O: Wgt up 12gms. Remains NPO. Total fluids are 140cc/k/d.\nPN & IL infusing thru DUV. DS 110. Lytes, BUN & creatinine\npnd. Abd is soft & full with occasional soft transient\nloops. NGT in place & vented to air. Voiding with diaper\nchanges. No stool. A: receiving fluid as ordered. P: Cont to\nassess.\n #4 O: Baby received Indocin. Murmur is still audible. BP\nmeans > 35. A: Audible murmur. P: Cont to assess.\n#5 O: Remains on servo warmer with stable temp. Alert with\ncares, Nested in sheepskin with H2O pillow\n#6 O: Mom phoned for update. Mom stated that she planned to\nvisit But did not come. A: Involved parent. P: support. #7\nO: Remains under neo blue phohotherapy with eye patches on.\nBili pdg. A: Jaundiced. P: Cont to assess.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-09 00:00:00.000",
"description": "Report",
"row_id": 1834289,
"text": "Admission Note\nNeonatology Admit H&P\n\nBaby Girl is a newborn 25 wk infant admitted to the NICU with respiratory distress and prematurity.\n\nShe was born at 4:10pm this afternoon as the 619 gram product of a 25 wk gestation to a 28 y.o. G6 P2-3 mother with . Prenatal labs included BT B+/Ab-, HBsAg-, RPR NR, RI, and GBS unknown. Prior maternal history notable for previous delivery at 25 wks; that infant hospitalized in NICU, now 4 years old and doing well. This pregnancy complicated by cervical shortening treated with cerclage, and admission on for bedrest. She was given course of betamethasone, complete . She then experienced PPROM on , and was begun on amp/erythro. Today, given prolonged ROM, cerclage was removed. Following removal, persistent fetal tachycardia was noted, with concerns for chorioamnionitis, and mother was taken for c-section. Infant was in breech position. No fever was noted.\n\nAt delivery, infant emerged with moderate tone and respiratory effort. She was dried and warmed, with initial HR approx 100. PPV was begun, with rapid increase in HR to approx 150, and gradual improvement in color. She was intubated at approx 6-7 mins of life secondary to persistent respiratory distress. Apgars were , and she was brought to NICU.\n\nPhysical Exam:\nWt 619 gm (10-25%) HC 21.5 cm (10%) L 30 cm (10%)\nVS: T 93.9 --> 98.8 HR 170s RR 40s BP 58/34 (43)\nO2sats 90% on 40% FiO2, on SIMV\nGen: small premature infant, active on warmer\nSkin: warm, pink, no significant bruising, no rash\nHEENT: fontanelles full but soft, sutures not split, non-dysmorphic, palate intact, ears/nares normal\nNeck: supple, no lesions\nChest: coarse, moderately aerated, + retractions with spontaneous breaths\nCardiac: RRR, mildly tachycardic, no m/g\nAbdomen: soft, no HSM, 3VC, quiet BS, no mass\nGU: normal female, anus patent\nExt: hips without notable dislocation, back normal\nNeuro: active with exam, tone and activity grossly normal\n\nDstik: 62\n\nIMP: Newborn 25 extremely premature infant, delivered to mother with history of cervical shortening and cerclage placement and currently with prolonged PPROM and concerns for chorioamnionitis. Moderate respiratory distress, secondary to hyaline membrane disease. Hemodynamically stable. At risk for sepsis given degree of prematurity and circumstances of perinatal course.\n\nPLANS:\n- Continue SIMV, adjust as needed.\n- Administer surfactant, anticipate needing 2nd dose as well.\n- UAC/UVC for monitoring.\n- Continues blood pressure monitoring, at risk for hypotension.\n- Vigilence for PDA.\n- NPO, maintenance IVF.\n- Periodic monitoring of electrolytes, dstiks, and bilirubin.\n- Send CBC with diff, blood cx.\n- Begin amp/gent pending clinical course and culture results.\n- Periodic monitoring of blood counts, will need transfusions.\n- Plan HUS at day 3 of life.\n\nPMD: Dr. , St.\nMother updated at bedside.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-09 00:00:00.000",
"description": "Report",
"row_id": 1834290,
"text": "Fellow Procedure Note\nUAC/UVC Line Placement:\n\nThe patient was prepped and draped in sterile fashion. Umbilical cord was cleaned w/betadine, tied and cut. Questionable presence of 3 umbilical arteries and one vein. A single lumen 3.5 UAC was placed at 13 cm. Good blood return and easily flushed.\n\nA 3.5 DL UVC was then placed at 8cm with good blood return, easily flushed. Less than 1cc of fluid was administered.\n\nPatient tolerated the procedure well. No arrhythmia was seen on the monitor. X-ray is pending.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-09 00:00:00.000",
"description": "Report",
"row_id": 1834291,
"text": "Fellow Procedure Note\nAddendum:\n\nX-ray revealed UAC high in aorta (approx T2), UVC high in RA. UAC withdrawn 2 cm to 11; repeat X-ray shows tip at T6. Withdrawn additional 0.5 cm to 10.5 cm. UVC withdrawn 1 cm to 6.5 cm; repeat X-ray shows tip in low RA. Withdrawn additional 0.5 cm to 6 cm.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-13 00:00:00.000",
"description": "Report",
"row_id": 1834323,
"text": "#1Sepsis\nBaby cont on amp and . Today will be day4/7.\nP. Will need an LP at some point. Also will need repeat\nlevels\n#2Resp\nBaby remains intubated on same settings of 18/5 with rate\n32. FIO2 has been between 22-36, mosstly at high 20's. O2\nsat labile. Lungs coarse but clear with suctioning. Baby has\nbeen suctioned x 3 so far tonight for mod to large cloudy to\nwhite secretions. No true spells only drifts in sat\ngenerally to mid 80's but did go as low as 79 rarely. Cont\nto have ic/sc retractions. RR 30-50's, noted to be riding\nthe vent at times. Cap gas at 2300 was 7.29/51\nA. O2 sat labile\nP. Cont to monitor closely.\n#3FEN\nWt 563g down 7. Baby remains NPO. TPN D 8.5 infuding via\nprim an sec via UVC. Lipids infusing at .2cc/hr. Dstick at\n2300 was 87. Voiding but baby has never stooled. Abd\ndistended at 2100. Bowel sounds heard. Pink but bluish\nundertone. Also sl loopy. Feed tube at 12cm marking. feed\ntube advanced to 14. Position checked and approx 4cc air\nremoved. Baby seen by . Abd has remained round but soft.\nFeed tube vented. AG 16cm. Bowel sounds heard.\nA. Adequate dstick.\nP. Cont to monitor abd exam closely. Check lytes and bili\nthis am.\n#4CV\nMurmur persists. Echo shows PDA remains open. Second course\non INdocin started at 2145. BP stable. HR 150-160. Pink well\nperfused.\nP. Cont to monitor.\n#5Dev\nBaby remains on warmer. Not placed in isolette because will\nneed PIC line placed as well as LP. Remains nested on\nsheepskin with boundaries on servo under tent. Temp sl warm.\nServo control decreased. Awake and alert with cares. Calm.\nCares done every 6 to allow baby as much rest and as little\nstress as possible.\n#6Parent\nno contact tonight. It was reported that Mom is on triple\nantibiotics.\n#7Bili\nBaby remains under neo blue phototherapy with mask on.\nP. Plan to recheck bili this am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-13 00:00:00.000",
"description": "Report",
"row_id": 1834324,
"text": "Respiratory Care Addendum\nCBG @ 0445: 7.30/48/28/25/-3; rate decreased to 30 from 32. Will cont to wean vent as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-13 00:00:00.000",
"description": "Report",
"row_id": 1834325,
"text": "Neonatology Attending\n\nDay 4 PMA 25 wks\n\nRemains on 18/5, x30, 0.22-0.28. CBG 7.30/48. Now on caffeine. No bradycardia. HR 140-160. Started on second indomethacin course yesterday. Echo yesterday showed persistent PDA. Soft murmur heard this morning. Weight 563 gms (-7). NPO. PN 8.5 and lipids via double lumen UVC. Benign abdomen. Blood glucose 87, 81. No stool passed. Lytes 137/3.9/103/21. LP and PICC consent obtained. On ampicillin and gentamicn- day . Mother started on antibiotics.\n\nImproved respiratory status. Receiving treatment for persistent PDA. Monitoring cardio-respiratory status closely. Will need re-echo if murmur persists. Metabolically doing well. Family meeting at 1200 today. Mother up to date.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2165-09-13 00:00:00.000",
"description": "Report",
"row_id": 1834326,
"text": "Respiratory Care\nPt cont on SIMV. Settings weaned to 18/5 x26. Fio2 .23-.26. bs clear, rr 50's. On caffeine. No spells. Plan to support as needed. Will follow.\n"
},
{
"category": "Echo",
"chartdate": "2165-09-12 00:00:00.000",
"description": "Report",
"row_id": 79592,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease.\nStatus: Inpatient\nDate/Time: at 14:30\nTest: Portable TTE (Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-09-16 00:00:00.000",
"description": "P BABYGRAM ABD WITH DECUB (74020) PORT",
"row_id": 878168,
"text": " 1:50 AM\n BABYGRAM ABD WITH DECUB () PORT Clip # \n Reason: r/o free air\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, ? free air\n REASON FOR THIS EXAMINATION:\n r/o free air\n ______________________________________________________________________________\n FINAL REPORT\n SUPINE AND LEFT LATERAL DECUBITUS FILMS ON \n\n CLINICAL HISTORY: Premature infant with question of free air.\n\n FINDINGS: Supine and left lateral decubitus films of the abdomen demonstrate\n the presence of a large amount of free air within the peritoneal cavity. There\n is mild gaseous distention of bowel loops.\n\n IMPRESSION: Large amount of free intraperitoneal air.\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-09-16 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 878166,
"text": " 1:24 AM\n BABYGRAM (CHEST ONLY) PORT; -76 BY SAME PHYSICIAN # \n Reason: picc line position\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with adjusted picc line\n REASON FOR THIS EXAMINATION:\n picc line position\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM, 1:33 P.M., \n\n Endotracheal tube is 1.5 cm above the carina. PICC line has been withdrawn\n but remains near the left brachiocephalic vein. Umbilical venous catheter is\n unchanged position. Diminished lung volumes are seen. Right upper lobe\n collapse is somewhat less apparent. Increasing gaseous intestinal distention\n is again noted with diffuse intraperitoneal air.\n\n SUPINE AND LEFT LATERAL DECUBITUS ABDOMEN\n\n Again noted is a large amount of free intraperitoneal air, which may be\n somewhat greater than on the earlier study. Umbilical venous line is\n unchanged. No definite pneumatosis intestinalis is apparent.\n\n IMPRESSION: Increasing pneumoperitoneum.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-09-16 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 878163,
"text": " 12:51 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: picc line position, , '\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with newly placed picc line\n REASON FOR THIS EXAMINATION:\n picc line position\n\n '\n ______________________________________________________________________________\n FINAL REPORT\n CHEST.\n\n Endotracheal tube is 1 cm above the carina. Umbilical venous line has been\n withdrawn to the inferior vena cava. There is now extensive free\n intraperitoneal air and mild-to-moderate gaseous intestinal distention is\n apparent. No definite intramural air or intrahepatic portal air seen. The\n lung volumes are diminished with diffuse air-space disease with focal\n atelectasis in the right upper lobe. The atelectasis is more apparent that on\n the prior study of . A right-sided PICC line crosses the midline to\n terminate in the left subclavian vein.\n\n IMPRESSION:\n 1. New intraperitoneal free air.\n 2. Right PICC line in left subclavian vein.\n 3. Umbilical vein catheter now within the inferior vena cava.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-09-09 00:00:00.000",
"description": "BABYGRAM CHEST & ABD (TOGETHER ONE FILM)",
"row_id": 877461,
"text": " 5:41 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) Clip # \n Reason: babygram to check ETT, UAC and UVC line placement, 25 week G\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with\n REASON FOR THIS EXAMINATION:\n babygram to check ETT, UAC and UVC line placement\n 25 week GA DOL 0\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Assess line placement in a 25-week gestational age infant.\n\n FINDINGS: A supine radiograph of the chest and abdomen demonstrates the\n presence of an endotracheal tube with its tip in satisfactory position below\n the thoracic inlet and above the carina. There is an umbilical arterial\n catheter with its tip high, at the level of T2-3. There is an umbilical\n venous catheter with its tip high in the right atrium. Lung volumes are low\n with moderate bilateral ground-glass opacification of the lung parenchyma.\n There is mild gaseous distention of left-sided bowel loops. No other\n abnormality is noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-09-09 00:00:00.000",
"description": "BABYGRAM CHEST & ABD (TOGETHER ONE FILM)",
"row_id": 877465,
"text": " 6:09 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM); -76 BY SAME PHYSICIAN # \n Reason: UAC and UVC placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity, umbilical lines pulled back\n REASON FOR THIS EXAMINATION:\n UAC and UVC placement\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM ON .\n\n CLINICAL HISTORY: Assess line placement.\n\n FINDINGS: A supine radiograph of the chest and abdomen is compared to the\n prior babygram dated , at 17:54 hours. The endotracheal tube\n tip is low, at the level of the carina. The UAC tip has been pulled back and\n is now at T7. The UVC has also been pulled back slightly and is in the right\n atrium. There has been a mild improvement in bilateral lung aeration. There\n is a persistent mild-to-moderate ground-glass appearance of the lung\n parenchyma. The abdominal bowel gas pattern demonstrates minimal gaseous\n distention of left-sided bowel loops without evidence of pneumatosis or free\n air. Several nondilated right-sided abdominal bowel loops are also\n identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2165-09-12 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 877770,
"text": " 7:43 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANT ASSESS FOR IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 25 weeks, 3 days old\n REASON FOR THIS EXAMINATION:\n R/O IVH\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Infant born at 25 weeks. Now three days old.\n\n FINDINGS: There is some asymmetry of the lateral ventricles, left being\n slightly larger than the right. This asymmetry is thought to be within normal\n limits. No intracranial hemorrhage or extraaxial collections. No structural\n abnormalities are identified. White matter is normal.\n\n IMPRESSION: Normal head ultrasound for gestation age.\n\n\n"
}
] |
53,014 | 163,168 | 38 year old female with ALL s/p cord blood transplant complicated by multi-organ GVHD admitted directly to the ICU for recurrent fever and increased pulmonary infiltrates on CXR. | and moderate pericardial effusion, now with acute hypoxia. UNILATERAL LEFT LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler son of the left common femoral, left superficial femoral and left popliteal veins showed normal compressibility, flow and augmentation. Bilateral pulmonary opacities are again noted. COMPARISON: Multiple chest radiographs, the latest from . Bilateral pulmonary opacifications are again seen. Diffuse bilateral pulmonary opacifications persist. Diffuse bilateral pulmonary opacifications persist. Bilateral moderate-sized pleural effusions and a small amount of ascites is present. A right-sided PICC line terminates in the mid SVC appropriately. ONE VIEW OF THE CHEST: The lungs are well expanded and show interval worsening of bilateral confluent opacities with relative sparing of the apices. FINDINGS: In comparison with the study of earlier in this date, the monitoring and support devices remain in place, except for an apparent Swan-Ganz catheter that is no longer present. Moderate-sized bilateral pleural effusions and a small amount of ascites. Moderate-sized bilateral pleural effusions and a small amount of ascites. The previously described bilateral confluenting parenchymal densities remain. Redemonstration of FNH in the right hepatic lobe. Redemonstration of FNH in the right hepatic lobe. IMPRESSION: Bilateral confluent opacities have mildly progressed since the radiograph from but appear essentially unchanged from the CT of the chest from two days ago. FINDINGS: AP single view of the chest has been obtained with patient in supine position. Right subclavian catheter tip is at the carina. FINDINGS: AP single view of the chest has been obtained with patient in upright position. FINDINGS: In comparison with the study of , there is persistent diffuse bilateral pulmonary opacifications that appear to have worsened in the interim. Limited evaluation of the main portal vein demonstrates reversal of flow, which could be secondary to the cardiac tamponade or tricuspid regurgitation. Again seen is an ill-defined hyperechoic lesion in segment VI of the liver measuring 3.7 x 3.2 x 3.0 cm, consistent with known FNH. CHEST The tip of the endotracheal tube lies 4.6 cm from the carinal angle. FINDINGS: In comparison with the earlier study of this date, the distal tip of the esophageal balloon is in the mid thoracic esophagus, approximately 3 cm below the carina. REASON FOR THIS EXAMINATION: confirm ETT position FINAL REPORT TYPE OF EXAMINATION: Chest, AP portable single view. Reversed flow in the main portal vein, could be secondary to cardiac tamponade or tricuspid regurgitation. Reversed flow in the main portal vein, could be secondary to cardiac tamponade or tricuspid regurgitation. Extensive bilateral pulmonary opacities are unchanged since . Cardiomegaly related to known pericardial effusion is unchanged. FINAL REPORT CLINICAL HISTORY: Orogastric tube placed, check position. Previously described right-sided PICC line and NG tube are unchanged. Effusion circumferential.No echocardiographic signs of tamponade.Conclusions:There is mild symmetric left ventricular hypertrophy. Indeterminate PA systolicpressure.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. Normal main PA. No Doppler evidence for PDAPERICARDIUM: Small to moderate pericardial effusion. Echocardiographic signs of tamponade may be absent in the presence ofelevated right sided pressures.IMPRESSION: Moderate ?partially loculated pericardial effusion withoutdefinite evidence for tamponade physiology. There is mildsymmetric left ventricular hypertrophy. with normal free wall contractility.There is a very small residual pericardial effusion. Mild PAsystolic hypertension.PERICARDIUM: Moderate pericardial effusion. The right ventricular free wall ishypertrophied. Low normal LVEF.RIGHT VENTRICLE: RV hypertrophy. There is mild symmetric left ventricularhypertrophy. There are noechocardiographic signs of tamponade.Compared with the prior study (images reviewed) of , the pericardialeffusion has mostly resolved and tamponade is no longer seen. There is mild pulmonary artery systolic hypertension.There is a moderate sized pericardial effusion most prominent (1.7cm)inferolateral and lateral to the left ventricle and around the right atriaum(1.8cm) with minimal anterior to the right ventricle and around the leftventriuclar apex. Borderline normal RVsystolic function.AORTA: Normal diameter of aorta at the sinus, ascending and arch levels.AORTIC VALVE: Normal aortic valve leaflets (3). No MS.TRICUSPID VALVE: Normal tricuspid valve leaflets. There is nomitral valve prolapse. There is nomitral valve prolapse. Borderline normal RVsystolic function.AORTIC VALVE: Normal aortic valve leaflets (3). PATIENT/TEST INFORMATION:Indication: Pericardial effusionHeight: (in) 69Weight (lb): 135BSA (m2): 1.75 m2BP (mm Hg): 89/68HR (bpm): 101Status: InpatientDate/Time: at 15:10Test: Portable TTE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Mild symmetric LVH. Left ventricular function.Height: (in) 64Weight (lb): 135BSA (m2): 1.66 m2BP (mm Hg): 110/67HR (bpm): 97Status: InpatientDate/Time: at 14:58Test: TTE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA and RA cavity sizes.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTIC VALVE: Normal aortic valve leaflets (3). There is moderate pulmonary artery systolic hypertension. Extensive diffuse bilateral lung opacities are unchanged. PATIENT/TEST INFORMATION:Indication: Evaluate for tamponadeHeight: (in) 64Weight (lb): 135BSA (m2): 1.66 m2BP (mm Hg): 116/72HR (bpm): 110Status: InpatientDate/Time: at 13:56Test: Portable TTE (Complete)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT VENTRICLE: Mild symmetric LVH. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.TRICUSPID VALVE: Normal tricuspid valve leaflets. Low density cardiac contents suggests anemia. The mitral valveappears structurally normal with trivial mitral regurgitation. The mitral valveappears structurally normal with trivial mitral regurgitation. No AR.TRICUSPID VALVE: Normal tricuspid valve leaflets. There is a moderatesized pericardial effusion. The left ventricular cavity isunusually small. Right ventricular function.Height: (in) 64Weight (lb): 135BSA (m2): 1.66 m2BP (mm Hg): 112/72HR (bpm): 72Status: InpatientDate/Time: at 10:39Test: TTE (Focused views)Doppler: Limited Doppler and no color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Overall normal LVEF (>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.PERICARDIUM: Moderate pericardial effusion. Mild [1+] TR. Mild [1+] TR. | 26 | [
{
"category": "Radiology",
"chartdate": "2174-08-22 00:00:00.000",
"description": "O CHEST (SINGLE VIEW) IN O.R.",
"row_id": 1198890,
"text": " 4:20 PM\n CHEST (SINGLE VIEW) IN O.R.; -77 BY DIFFERENT PHYSICIAN # \n CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.\n Reason: PASACENTESIS, FLOURO GUIDED\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Paracentesis.\n\n FINDINGS: The images are just being presented. Nasogastric tube is in place\n extending well into the stomach. The other catheter is presumably the\n paracentesis catheter which has its tip just to the right of the T10 vertebral\n body. Further information can be gathered from the procedure report.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1199070,
"text": " 4:01 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: confirm ETT position\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38F with ALL s/p transplant c/b GVHD skin and heart recently admitted with GVHD\n of myocardium now with respiratory failure.\n REASON FOR THIS EXAMINATION:\n confirm ETT position\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest, AP portable single view.\n\n INDICATION: 38-year-old female patient with acute lymphatic leukemia, status\n post transplant, recently admitted with GVHD of myocardium, now with\n respiratory failure, confirm ETT position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. Analysis is performed in direct comparison with the next\n preceding similar examination obtained 12 hours earlier during the same day.\n The patient remains intubated, the ETT terminating in the trachea in unchanged\n position. Previously described right-sided PICC line and NG tube are\n unchanged. The previously described bilateral confluenting parenchymal\n densities remain. Differential diagnosis exists between confluenting\n inflammatory changes or pulmonary edema. The amount of bilateral pleural\n effusions has increased further, in particular on the right side where it now\n measures up to 3 cm in width along the lateral chest wall and covering the\n apical area. No pneumothorax is seen.\n\n IMPRESSION: Progression of bilateral pulmonary densities and pleural effusion\n in patient with graft-versus-host disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198701,
"text": " 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: int change\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with ett. resp failure\n REASON FOR THIS EXAMINATION:\n int change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory failure.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Diffuse bilateral pulmonary opacifications persist.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198783,
"text": " 5:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval volume status, interval change\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with AML and GVHD on high dose steroids, now with CMV\n pneumonitis and aspergillus pneumonia s/p intubation and initiation of CRRT.\n REASON FOR THIS EXAMINATION:\n eval volume status, interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 38-year-old woman with AML and graft-versus-host disease on\n high-dose steroids, now with CMV pneumonitis and aspergillosis pneumonia\n status post intubation and initiation of CRRT. Evaluate volume status and\n interval change.\n\n COMPARISON: Multiple chest radiographs, the latest from and a\n CT of the chest from .\n\n ONE VIEW OF THE CHEST:\n\n The lungs are well expanded and show essentially unchanged multifocal airspace\n opacities compared to recent priors. The cardiac silhouette is enlarged, but\n small compared to . The mediastinal silhouette and hilar contours\n are normal. There is a moderate right and a small left pleural effusion,\n unchanged. An ET tube terminates 4.2 cm above the carina. A NG tube\n terminates with its tip passing out of view below the diaphragm. The\n esophageal balloon is noted with its tip in the mid esophagus 3 cm below the\n carina.\n\n IMPRESSION:\n\n Unchanged bilateral airspace opacities are worsened compared to .\n The cardiac silhouette is smaller, which could represent a change in the\n pericardial effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198670,
"text": " 5:58 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval placement of esophageal balloon\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with ALL, GVHD and new vent dependence w/recent balloon\n placement\n REASON FOR THIS EXAMINATION:\n eval placement of esophageal balloon\n ______________________________________________________________________________\n WET READ: MXAk SAT 8:54 PM\n Et tube at 4.7 cm from carinal. Esophageal baloon with tip in mid esophagus.\n Bilateral patchy opacities appear slightly less confluent. Otherwise stable in\n comparison to prior. Ashkan at 20:53 on .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Esophageal balloon placement.\n\n FINDINGS: In comparison with the earlier study of this date, the distal tip\n of the esophageal balloon is in the mid thoracic esophagus, approximately 3 cm\n below the carina. Endotracheal tube tip lies approximately 4.7 cm above the\n carina. Right subclavian catheter tip is at the carina.\n\n Bilateral pulmonary opacifications are again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-19 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1198573,
"text": " 5:39 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OGT PLACEMENT CHECK\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with tube replacement\n REASON FOR THIS EXAMINATION:\n eval int change\n ______________________________________________________________________________\n WET READ: ENYa FRI 9:55 PM\n ETT terminates 4.5 cm above the carina. Interval increase left basilar\n opacity, likely increased L pleural effusion. Otherwise unchanged extensive\n bilateral hazy opacities. NGT in stomach. PICC tip at cavoatrial junction.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Orogastric tube placed, check position.\n\n The tip of the orogastric tube lies in the region of the antrum. The position\n of the various other lines and tubes is unchanged. Extensive bilateral\n pulmonary opacities are unchanged since .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198903,
"text": " 6:23 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Any increased evolution of infiltrates?\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with dropping oxygen sats despite maximal vent support.\n REASON FOR THIS EXAMINATION:\n Any increased evolution of infiltrates?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dropping oxygen, to assess for evolution of infiltrates.\n\n FINDINGS: In comparison with the study of earlier in this date, the\n monitoring and support devices remain in place, except for an apparent\n Swan-Ganz catheter that is no longer present. Diffuse bilateral pulmonary\n opacifications persist.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-23 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1199006,
"text": " 10:49 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please evaluate for cholecystitis or pancreatitis\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38F with ALL s/p transplant c/b GVHD skin and heart recently admitted with GVHD\n of myocardium now with respiratory failure and rising liver enzymes.\n REASON FOR THIS EXAMINATION:\n please evaluate for cholecystitis or pancreatitis\n ______________________________________________________________________________\n WET READ: KKgc TUE 4:38 PM\n 1. No evidence of acute cholecystitis, as clinically queried.\n 2. Reversed flow in the main portal vein, could be secondary to cardiac\n tamponade or tricuspid regurgitation.\n 3. Redemonstration of FNH in the right hepatic lobe.\n 4. Moderate-sized bilateral pleural effusions and a small amount of ascites.\n\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old female with ALL, status post stem cell transplant\n complicated by GVHD of the skin and heart, recently admitted with respiratory\n failure and raising liver enzymes.\n\n COMPARISON: Multiple prior liver ultrasounds, with the recent study from\n and an MRI of the abdomen, .\n\n FINDINGS: The liver is normal in echotexture. Again seen is an ill-defined\n hyperechoic lesion in segment VI of the liver measuring 3.7 x 3.2 x 3.0 cm,\n consistent with known FNH. No new hepatic lesions are identified. There is\n no intra- or extra-hepatic biliary dilatation. The common bile duct is normal\n measuring 2 mm. The gallbladder is mildly distended, but no gallstones are\n identified. There is significant interval improvement in the gallbladder wall\n thickening compared to the prior study. The spleen is normal measuring 8.9\n cm. The head and body of the pancreas are normal, but the pancreatic tail is\n obscured by overlying bowel gas. Bilateral moderate-sized pleural effusions\n and a small amount of ascites is present. Limited evaluation of the main\n portal vein demonstrates reversal of flow, which could be secondary to the\n cardiac tamponade or tricuspid regurgitation. A complete Doppler analysis was\n not performed at this time.\n\n IMPRESSION:\n 1. No evidence of acute cholecystitis, as clinically queried.\n 2. Reversed flow in the main portal vein, could be secondary to cardiac\n tamponade or tricuspid regurgitation.\n 3. Redemonstration of FNH in the right hepatic lobe.\n 4. Moderate-sized bilateral pleural effusions and a small amount of ascites.\n The above findings were discussed with Dr. at 12:20 p.m. on .\n\n\n (Over)\n\n 10:49 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: please evaluate for cholecystitis or pancreatitis\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198941,
"text": " 2:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: volume overload\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with worsening acidosis.\n REASON FOR THIS EXAMINATION:\n volume overload\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Worsening acidosis with volume overload.\n\n FINDINGS: In comparison with the study of , there is persistent diffuse\n bilateral pulmonary opacifications that appear to have worsened in the\n interim. Monitoring and support devices remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198614,
"text": " 5:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ett placement, interval change\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with ALL and CMV pneumonitis s/p intubation\n REASON FOR THIS EXAMINATION:\n ett placement, interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: ALL, pneumonia, status post intubation.\n\n CHEST\n\n The tip of the endotracheal tube lies 4.6 cm from the carinal angle. This is\n unchanged since the prior chest x-ray. The position of the right PICC line is\n also unchanged. Allowing for differences in penetration there has been little\n other change since the prior chest x-ray. Bilateral pulmonary opacities are\n again noted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-18 00:00:00.000",
"description": "LP UNILAT LOWER EXT VEINS LEFT PORT",
"row_id": 1198385,
"text": " 1:11 PM\n UNILAT LOWER EXT VEINS LEFT PORT Clip # \n Reason: eval for dvt\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with asymmetric leg swelling and new hypoxia\n REASON FOR THIS EXAMINATION:\n eval for dvt\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 2:43 PM\n No evidence of DVT, edema in the left calf.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old woman with asymmetric leg swelling.\n\n COMPARISON: None.\n\n UNILATERAL LEFT LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler\n son of the left common femoral, left superficial femoral and left\n popliteal veins showed normal compressibility, flow and augmentation. Normal\n flow was noted within the left calf veins. There is edema in the left calf.\n\n IMPRESSION: No evidence of DVT, edema in the left calf.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1197421,
"text": " 4:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman s/p an allo cord transplant for ALL, discharged yesterday,\n here today with fever of 101.2\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 38-year-old female patient status post allogenic cord transplant\n for acute lymphatic leukemia. Discharged yesterday, here today with fever of\n 101. Evaluate for pneumonia.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n upright position. Comparison is made with the next preceding PA and lateral\n chest examination of . The heart size has increased further in\n size. There is no typical configurational abnormality. The rather general\n increase of the heart shadow is suggestive of pericardial effusion.\n Previously described right-sided PICC line remains in unchanged position.\n Pulmonary vascular congestive pattern has not changed significantly; however,\n the previously described patchy and partially confluenting parenchymal\n densities persist and apparently have progressed further. They are most\n marked in the mid lung field on the right side and the lateral upper lobe area\n on the left. Lateral pleural sinuses are partially concealed by the described\n parenchymal densities. Conclusive evidence of pleural effusion is not\n present, and major pleural effusion is unlikely as it did not exist on the\n lateral view on the preceding chest examination.\n\n Progression of bilateral pulmonary infiltrates in this patient on stem cell\n transplant therapy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198342,
"text": " 8:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute process?\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with known pneumonitis (CMV?) and moderate pericardial\n effusion, now with acute hypoxia.\n REASON FOR THIS EXAMINATION:\n acute process?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old woman with known pneumonitis and moderate pericardial\n effusion, now with acute hypoxia.\n\n COMPARISON: Multiple chest radiographs, the latest from .\n\n ONE VIEW OF THE CHEST:\n\n The lungs are well expanded and show interval worsening of bilateral confluent\n opacities with relative sparing of the apices. The cardiac silhouette is\n enlarged. The mediastinal silhouette is normal. The left hilar contours are\n prominent. No pleural effusion or pneumothorax is present. A right-sided\n PICC line terminates in the mid SVC appropriately.\n\n IMPRESSION:\n\n Bilateral confluent opacities have mildly progressed since the radiograph from\n but appear essentially unchanged from the CT of the chest from\n two days ago. These could represent sequelae of pneumonia, drug reaction, or\n stem cell transplantation as previously described. Cardiomegaly related to\n known pericardial effusion is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198466,
"text": " 5:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with AML s/p transplant c/b GVHD of the heart/lungs now with\n CMV pneumonitis and worsening hypoxia.\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: Intubated patient with AML, GVHD and CMV pneumonitis.\n\n Comparison is made with multiple prior studies including CT from and\n chest x-ray from the day before.\n\n Cardiomegaly is stable. Extensive diffuse bilateral lung opacities are\n unchanged. The differential diagnoses is broad and include viral pneumonia,\n ARDS and drug reaction. There is no evident pneumothorax or large pleural\n effusion. Right PICC tip is in the right atrium, can be withdrawn\n approximately 2.5 cm for more optimal position.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-18 00:00:00.000",
"description": "LP UNILAT LOWER EXT VEINS LEFT PORT",
"row_id": 1198386,
"text": ", OMED 1:11 PM\n UNILAT LOWER EXT VEINS LEFT PORT Clip # \n Reason: eval for dvt\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with asymmetric leg swelling and new hypoxia\n REASON FOR THIS EXAMINATION:\n eval for dvt\n ______________________________________________________________________________\n PFI REPORT\n No evidence of DVT, edema in the left calf.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198493,
"text": " 8:52 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: EVAL FOR ETT AND NG TUBE PLACEMENT, ARDS\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with history of AML s/p SCT with GVHD of the heart and lungs\n on steroids now with CMV pneumonitis and hypoxemia s/p intubation.\n REASON FOR THIS EXAMINATION:\n eval for ETT placement, ARDS\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess NG tube and ET tube.\n\n ET tube tip is at the takeoff of the right main bronchus. NG tube tip is out\n of view below the diaphragm. Right PICC tip is in the lower SVC. There are\n no other interval changes from 4 hours before.\n\n Findings were discussed with Dr. at 9:30 a.m. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1198503,
"text": " 10:08 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: assess ET tube placement\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with ALL sp BMT w GVHD worsening O2 sats requiring\n intubation, pulled ET tube back after last CXR.\n REASON FOR THIS EXAMINATION:\n assess ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old woman with ALL status post BMT with graft-versus-host\n disease, worsening O2 requirement, intubation pulled ET tube back after last\n chest x-ray. Assess ET tube placement.\n\n COMPARISON: Multiple chest radiographs, latest from at 9:00\n a.m.\n\n ONE VIEW OF THE CHEST:\n\n An ET tube has been pulled back by 3 cm. The remaining of this examination is\n unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-08-16 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 1198081,
"text": " 11:22 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Worsening viral process?\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old woman with suspected cardiac GVHD and moderate pericardial effusion\n with recent parainfluenza, CMV grew from BAL . Fevers, hypoxia and SOB with\n ambulation.\n REASON FOR THIS EXAMINATION:\n Worsening viral process?\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT, .\n\n HISTORY: 38-year-old woman with suspected cardiac graft-versus-host disease\n and moderate pericardial effusion, recent parainfluenza. CMV grew from a\n lavage on . Fever, hypoxia and shortness of breath with ambulation.\n Suspect a worsening viral infection.\n\n TECHNIQUE: Multidetector helical scanning of the chest was performed without\n intravenous contrast reconstructed as contiguous 5- and 1.25-mm thick\n axial and 5-mm thick coronal and parasagittal imaging compared to chest CT\n scans since , most recently , read in conjunction\n with chest radiographs since , most recently .\n\n FINDINGS:\n\n The findings on the chest CT mirror those on conventional radiographs showing\n progressive increase in extent and radiodensity of widespread peribronchial\n ground glass and consolidative opacification. There is no cavitation. Large\n non-hemorrhagic pericardial effusion has increased, absent any radiographic\n findings of cardiac tamponade. Progressive enlargement of the main pulmonary\n artery from 33 to 37 mm suggests increasing pulmonary vascular resistance.\n Small nonhemorrhagic layering right pleural effusion is new. There is no\n anasarca or ascites in the upper abdomen. Moderate-to-severe cardiomegaly has\n progressed. Low density cardiac contents suggests anemia.\n\n IMPRESSION:\n 1. Progressive pulmonary abnormality most likely viral infection; drug\n reaction, for example acute amiodarone toxicity, is a second possibility, and\n pulmonary hemorrhage the third, though one would expect hemoptysis given the\n progression. Worsening pericardial effusion is a finding that can be seen\n with either viral infection or drug toxicity. It should be noted that the\n current radiographic lung findings can develop up to two weeks after\n autologous stem cell transplantation as part of engraftment syndrome, but I do\n not know whether that fits this patient's clinical history.\n (Over)\n\n 11:22 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: Worsening viral process?\n Admitting Diagnosis: FEVERS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Echo",
"chartdate": "2174-08-15 00:00:00.000",
"description": "Report",
"row_id": 94470,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pericardial effusion. Right ventricular function.\nHeight: (in) 64\nWeight (lb): 135\nBSA (m2): 1.66 m2\nBP (mm Hg): 112/72\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 10:39\nTest: TTE (Focused views)\nDoppler: Limited Doppler and no color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. There is a moderate\nsized pericardial effusion. The effusion appears circumferential. There are no\nechocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , no major change.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2174-08-23 00:00:00.000",
"description": "Report",
"row_id": 95025,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion\nHeight: (in) 69\nWeight (lb): 135\nBSA (m2): 1.75 m2\nBP (mm Hg): 89/68\nHR (bpm): 101\nStatus: Inpatient\nDate/Time: at 15:10\nTest: Portable TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Low normal LVEF.\n\nRIGHT VENTRICLE: RV hypertrophy. RV function depressed.\n\nConclusions:\nThe left atrium appears extrinsically compressed (mildly) posteriorly,\npossibly by a consolidated posterior pericardial effusion. There is mild\nsymmetric left ventricular hypertrophy. The left ventricular cavity is\nunusually small. Overall left ventricular systolic function is low normal\n(LVEF 50%). The right ventricular free wall is hypertrophied. with depressed\nfree wall contractility. The epicardial surface of the right ventricle as well\nas atria appears to be encased in a layer of echodense material (epicardial\nfat vs consolidated effusive material). No evidence of cardiac tamponade seen.\n\nCompared with the findings of the prior study (images reviewed) of , the findings are similar.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2174-08-22 00:00:00.000",
"description": "Report",
"row_id": 95026,
"text": "PATIENT/TEST INFORMATION:\nIndication: Focused views during echo guided pericardiocentesis at patient bedside. Tap yielded approximately 380cc fluid.\nHeight: (in) 64\nWeight (lb): 135\nBSA (m2): 1.66 m2\nBP (mm Hg): 111/70\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 14:00\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and no color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nPERICARDIUM: Very small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nConclusions:\nFollowing 380 ml of pericardial fluid drainage: Overall left ventricular\nsystolic function is normal (LVEF>55%). with normal free wall contractility.\nThere is a very small residual pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nCompared with the prior study (images reviewed) of , the pericardial\neffusion has mostly resolved and tamponade is no longer seen.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2174-08-22 00:00:00.000",
"description": "Report",
"row_id": 95000,
"text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 64\nWeight (lb): 135\nBSA (m2): 1.66 m2\nBP (mm Hg): 98/66\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 11:16\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: Mild symmetric LVH. Small LV cavity. Overall normal LVEF\n(>55%).\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo;\n\nRIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. Borderline normal RV\nsystolic function.\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\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No TS. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPERICARDIUM: Large pericardial effusion. RV diastolic collapse, c/w impaired\nfillling/tamponade physiology.\n\nGENERAL COMMENTS: Suboptimal image quality - ventilator. Echocardiographic\nresults were reviewed by telephone with the houseofficer caring for the\npatient.\n\nConclusions:\nThe left atrium is elongated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is unusually small. Inferior\nhypokinesis is suggested on some images. Overall left ventricular systolic\nfunction is preserved (LVEF>55%). The right ventricular free wall is\nhypertrophied. Right ventricular chamber size is normal. with borderline\nnormal free wall function. The diameters of aorta at the sinus, ascending and\narch levels are normal. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic stenosis or aortic\nregurgitation. There is moderate pulmonary artery systolic hypertension. There\nis a large pericardial effusion. There is right ventricular diastolic\ncompression, consistent with impaired fillling/tamponade physiology (clip ).\n\nCompared with the prior study (images reviewed) of /201, the pericardial\neffusion has increased and there is now echo evidence of tamponade (RV\ncompression).\n\n\n"
},
{
"category": "Echo",
"chartdate": "2174-08-18 00:00:00.000",
"description": "Report",
"row_id": 95001,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for tamponade\nHeight: (in) 64\nWeight (lb): 135\nBSA (m2): 1.66 m2\nBP (mm Hg): 116/72\nHR (bpm): 110\nStatus: Inpatient\nDate/Time: at 13:56\nTest: Portable TTE (Complete)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. Borderline normal RV\nsystolic function.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures. No MS.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve\nsupporting structures. No TS. Mild [1+] TR. Indeterminate PA systolic\npressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential.\nNo echocardiographic signs of tamponade.\n\nConclusions:\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is normal\n(LVEF 65%). The right ventricular free wall is hypertrophied. Right\nventricular chamber size is normal. with borderline normal free wall function.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. The pulmonary artery systolic pressure could not be\ndetermined. There is a small to moderate sized pericardial effusion. The\neffusion appears circumferential. There are no echocardiographic signs of\ntamponade.\n\nCompared with the findings of the prior study (images reviewed) of , the pericardial effusion is smaller. Left ventricular contractile\nfunction is further improved.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2174-08-12 00:00:00.000",
"description": "Report",
"row_id": 95002,
"text": "PATIENT/TEST INFORMATION:\nIndication: Cardiomegaly on CXR. S/p cord transplant for ALL in . Acute chronic congestive heart failure. Left ventricular function.\nHeight: (in) 64\nWeight (lb): 135\nBSA (m2): 1.66 m2\nBP (mm Hg): 110/67\nHR (bpm): 97\nStatus: Inpatient\nDate/Time: at 14:58\nTest: 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 ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: Moderate pericardial effusion. No RA or RV diastolic collapse.\nEchocardiographic signs of tamponade may be absent in the presence of elevated\nright sided pressures.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\nmitral valve prolapse. There is mild pulmonary artery systolic hypertension.\nThere is a moderate sized pericardial effusion most prominent (1.7cm)\ninferolateral and lateral to the left ventricle and around the right atriaum\n(1.8cm) with minimal anterior to the right ventricle and around the left\nventriuclar apex. No right atrial or right ventricular diastolic collapse is\nseen. Echocardiographic signs of tamponade may be absent in the presence of\nelevated right sided pressures.\n\nIMPRESSION: Moderate ?partially loculated pericardial effusion without\ndefinite evidence for tamponade physiology. Normal biventricular cavity sizes\nwith preserved global and regional biventricular systolic function.\nCompared with the prior study (images reviewed) of , the pericardial\neffusion is larger.\nSerial evaluation is suggested.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2174-08-16 00:00:00.000",
"description": "Report",
"row_id": 270587,
"text": "Baseline artifact. Sinus rhythm. Probable left atrial abnormality. Modest\nST-T wave changes that are non-specific. Poor R wave progression. Possible\nanterior wall myocardial infarction of indeterminate age. Also, most likely\ninferior myocardial infarction of indeterminate age. Compared to the previous\ntracing of loss of R waves in anterior leads is much more prominent.\nLateral ST-T wave abnormalities have improved. Clinical correlation is\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2174-08-20 00:00:00.000",
"description": "Report",
"row_id": 270586,
"text": "Sinus rhythm. Low voltage. Compared to the previous tracing of voltage\nhas decreased.\n\n"
}
] |
76,315 | 119,437 | The patient was taken to the operating room on and again on . His hospital course will be outlined in a system format below: | Diaphoretic, Tachycardic to 130s. Pt tachycardic. Pt tachycardic. pre-op w/ sinus tachy. Pts given Vanco, Levaquin, and Flagyl in ED. Pts given Vanco, Levaquin, and Flagyl in ED. Improved on Dilaudid PCA pump. Fever, unknown origin (FUO, Hyperthermia, Pyrexia) Assessment: Pt remains febrile Tmax 101. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Tylenol given. Albuterol 0.083% Neb Soln 4. Action: Tylenol po and fan applied. Will order PCA dilaudid. Ipratropium Bromide Neb 10. Chief complaint: abd pain PMHx: PMH: recurrent acute pancreatitis PSH: appy, CCY pancreatic pseudocyst drainage (?cyst gastrostomy) ( Hosp) Current medications: 1. Hypertension, benign Assessment: Pt hypertensive this shift, SBP elevated to the 180s. Hypertension, benign Assessment: Pt hypertensive this shift, SBP elevated to the 180s. CXR done. CXR done . Action: Cont with PCA dilaudid. Hct stable post-op and pt self extubated in a.m. Hct stable post-op and pt self extubated in a.m. Hct stable post-op and pt self extubated in a.m. Pt currently afebrile. Pt currently afebrile. Pt been afebrile. Pt been afebrile. Action: PTT drawn, Heparin gtt titrated per sliding scale. Action: PTT drawn, Heparin gtt titrated per sliding scale. Action: PTT drawn, Heparin gtt titrated per sliding scale. Action: PTT drawn, Heparin gtt titrated per sliding scale. Resumed anticoagulation as per Surgery --> monitor PTT 60-80 PLEURAL EFFUSION suspect sympathetic and related to abdominal surgeries. Plan: Continue to monitor MS, if pt becomes acutely delirious will start haldol after baseline EKG obtained. Plan: Continue to monitor MS, if pt becomes acutely delirious will start haldol after baseline EKG obtained. Status post splenectomy and distal pancreatectomy, with a collection in the left upper quadrant with associated adjacent peritoneal enhancement, consistent with inflammatory change. - continue dilaudid for now but consider pain consult as above # Sinus Tachycardia: Likely multifactorial in setting of pain, PE, tachypnea/respiratory distress, and infection. Plan: Continue to monitor MS, if pt becomes acutely delirious will start haldol after baseline EKG obtained. - continue NG tube to intermittent suction - continue cipro/flagyl - appreciate surgery input # Sinus Tachycardia:Likely multifactorial in setting of pain, PE, tachypnea/respiratory distress, and infection. Pleural effusion, acute Assessment: Received pt on 2 LNC. Pleural effusion, acute Assessment: Received pt on 2 LNC. Status post splenectomy and distal pancreatectomy, with a collection in the left upper quadrant with associated adjacent peritoneal enhancement, consistent with inflammatory change. s/p ENTERIC LEAK -- NGT with intermittent suction, antibiotics, await culture results. - continue NG tube to intermittent suction - continue cipro/flagyl - appreciate surgery input # Sinus Tachycardia:Likely multifactorial in setting of pain, PE, tachypnea/respiratory distress, and infection. Extubated post-op, but developed tachypnea. Extubated post-op, but developed tachypnea. Extubated post-op, but developed tachypnea. Extubated post-op, but developed tachypnea. Extubated post-op, but developed tachypnea. Replete iv fluid, optimize pain, treat sepsis/bacteremia. Replete iv fluid, optimize pain, treat sepsis/bacteremia. Replete iv fluid, optimize pain, treat sepsis/bacteremia. Replete iv fluid, optimize pain, treat sepsis/bacteremia. CXR with apparent significant worsening of left pleural effusion --> transferred to MICU service for further evaluation and mangement. Plan: Continue to monitor MS, if pt becomes acutely delirious will start haldol after baseline EKG obtained. Pt tachycardic. Pt tachycardic. Resumed anticoagulation as per Surgery --> monitor PTT 60-80 PLEURAL EFFUSION suspect sympathetic and related to abdominal surgeries. NGT connected to low cont.suction draining bilious. - continue NG tube to intermittent suction - continue cipro/flagyl - appreciate surgery input # Sinus Tachycardia:Likely multifactorial in setting of pain, PE, tachypnea/respiratory distress, and infection. - follow serial Hcts - active type and screen - If Hct drops less than current 23.7, contact surgery immediately for discussion re: transfusion. Tachycardia, Other Assessment: HR 100s-110s in sinus tach. REASON FOR THIS EXAMINATION: confirm placement of pleural drain and r/o worsening effusion or post-op PNA FINAL REPORT PA AND LATERAL CHEST HISTORY: Splenectomy and distal pancreatectomy. - follow serial Hcts - active type and screen - If Hct drops less than current 23.7, contact surgery immediately for discussion re: transfusion. - follow serial Hcts - active type and screen - If Hct drops less than current 23.7, contact surgery immediately for discussion re: transfusion. FINAL REPORT CHEST TWO VIEWS CLINICAL INFORMATION: Pleural effusion. Tiny locules of air are seen within the epicardial fat, likely post-surgical. Within the distal SVC and the left brachiocephalic vein, there are small filling defects consistent with nonocclusive thrombus. CT ABDOMEN WITH IV CONTRAST: There is a small-to-moderate left and trace right pleural effusion. Nonocclusive venous thrombus in the SVC and left brachiocephalic vein at the site of prior central venous catheter. REASON FOR THIS EXAMINATION: eval for change in left pleural effusion or evidence of intra-abdominal abscess or hematoma No contraindications for IV contrast PFI REPORT 1. | 149 | [
{
"category": "Physician ",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 684648,
"text": "Chief Complaint: Sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Overall continues to feel improved.\n Pain management improved now on dilaudid PCA pump.\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Fluconazole - 10:09 PM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 09:21 AM\n Cefipime - 10:21 AM\n Infusions:\n Heparin Sodium - 2,050 units/hour\n Other ICU medications:\n Metoprolol - 12:21 AM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, 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, 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, Tube feeds, Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:59 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: 95 (82 - 104) bpm\n BP: 115/93(98) {115/68(85) - 150/93(104)} mmHg\n RR: 13 (13 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 4,798 mL\n 2,166 mL\n PO:\n TF:\n 166 mL\n 287 mL\n IVF:\n 2,800 mL\n 901 mL\n Blood products:\n Total out:\n 8,245 mL\n 4,145 mL\n Urine:\n 6,785 mL\n 3,950 mL\n NG:\n Stool:\n Drains:\n 480 mL\n 115 mL\n Balance:\n -3,447 mL\n -1,979 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: 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: No(t) Soft, No(t) Non-tender, Bowel sounds present,\n Distended, Tender: , No(t) Obese, Midline surgical incision;\n percutaneous drains on left\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.5 g/dL\n 1124 K/uL\n 129 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 8 mg/dL\n 101 mEq/L\n 135 mEq/L\n 25.1 %\n 13.9 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n 03:00 PM\n 08:20 PM\n 09:00 PM\n 02:56 AM\n 01:25 AM\n 05:45 PM\n 04:53 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n 15.4\n 13.9\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n 25.0\n 23.8\n 25.1\n Plt\n 1\n 1109\n 1173\n 1120\n 1124\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n 0.6\n 0.5\n TCO2\n 27\n Glucose\n 135\n 142\n 115\n 105\n 96\n 129\n Other labs: PT / PTT / INR:14.9/40.6/1.3, ALT / AST:24/33, Alk Phos / T\n Bili:133/0.5, Amylase / Lipase:80/120, Differential-Neuts:70.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:11.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:359 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 39 yomh/o recurrent pancreatitis, recent surgery for splenectomy,\n enteric leak now with post-operative respiratory distress and delerium\n (recurrent).\n RESPIRATORY DISTRESS\n Much improved. Multifactorial. Suspect\n contribution of bacteremia and sepsis, acidosis, left pleural effusion,\n left atalectasis, pulmonary emboli (off anticoagulation), and abdominal\n pain (splinting). Continue treat sepsis, antibiotics, iv fliuds,\n optimize pain management, maintain upright position. Consider left\n thoracentesis if expands.\n TACHYCARDIA\n Improved. Likley reflected respiratory distress, pain,\n hypovolemia, possible pulmonary embolism. Monitor HR, check EKG.\n Replete iv fluid, optimize pain, treat sepsis/bacteremia.\n SEPSIS -- evidence for line-related infection and now suspect\n peritoneal source. For Abd CT imaging to assess for collection.\n Continue Cipro, Cefopime, Vanco, Fluconozole.\n BACTEREMIA\n GPC, possible line related, but concern for enteric\n infection. Remove central lines if possible (use peripheral if\n feasible). Continue Vanco.\n PULMONARY EMBOLI\n left, subsegmental, multiple. Continue\n anticoagulation --> monitor PTT 60-80.\n PLEURAL EFFUSION\n suspect sympathetic and related to abdominal\n surgeries. S/p drainage. Chest tube not draining, and without\n respiratory variation on water seal --> would D/C.\n s/p ENTERIC LEAK -- NGT with intermittent suction, antibiotics, await\n culture results. For Abd CT today.\n PAIN MANAGEMENT\n post-op. Improved on Dilaudid PCA pump.\n s/p SPLENECTOMY -- will need meningococcal and pneumococcal vaccines\n FLUID\n Euvolemic. Monitor I/O, maintain balance.\n THROMBOCYTOSIS\n perhaps reactive. ? reactive. be contributing to\n clotting (pulmonary emboli, clot on PICC line) as value exceeds 1\n million. Monitor. Hematology consult.\n DELERIUM\n recurrent. Possible related to medications and contribution\n of sepsis (toxic-metabolic). Improved this AM.\n NUTRITIONAL SUPPORT -- NPO. Trophic TF. Resume TPN once central\n access established.\n RECURRENT PANCREATITS -- Unclear cause, but consider cystic fibrosis\n given family history. Recheck amylase, lipase and monitor clinical\n exam.\n ICU Care\n Nutrition:\n Replete () - 12:48 PM 30 mL/hour\n TPN w/ Lipids - 06:31 PM 88 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 684378,
"text": "TITLE:\n Chief Complaint: AMS, respiratory distress\n 24 Hour Events:\n MULTI LUMEN - START 10:10 PM\n - CT abdomen/ thorax done: large sequestered fluid collection in\n abdomen, increasing pleural effusion in Left lung -- IR to drain\n tomorrow am\n - Right IJ placed for TPN to start after procedure tomorrow\n - 1st attempt to place3 left IJ but clotted\n - d/c tube feeds tonight at 12am for procedure tomorrow, will advance\n post procedure\n - d/c heparin drip at 1800units/hr at 6 am tomorrow for procedure, will\n restart after drains placed\n - heme consult, said to delay any thrombotic w/u until after rx. course\n with heparin\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 10:30 AM\n Vancomycin - 08:36 PM\n Ciprofloxacin - 08:38 PM\n Cefipime - 10:20 PM\n Fluconazole - 11:30 PM\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Metoprolol - 12:08 PM\n Hydromorphone (Dilaudid) - 03:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 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: 92 (89 - 109) bpm\n BP: 141/71(88) {127/63(83) - 149/90(101)} mmHg\n RR: 19 (19 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 4,403 mL\n 997 mL\n PO:\n TF:\n 194 mL\n IVF:\n 3,558 mL\n 530 mL\n Blood products:\n Total out:\n 3,960 mL\n 1,780 mL\n Urine:\n 3,260 mL\n 1,780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 443 mL\n -783 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n PHYSICAL EXAM\n GENERAL: Lying comfortably in bed, NAD,\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. EOMI. MMM. OP clear. Neck Supple.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP not assessed\n LUNGS: CTAB anteriorly, poor air movement\n ABDOMEN: decreased BS Soft, NT, ND. Well healed surgical incision,\n drains with serous fluid.\n EXTREMITIES: 2+ dorsalis pedis/ posterior tibial pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3.\n Labs / Radiology\n 1120 K/uL\n 7.5 g/dL\n 96 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 7 mg/dL\n 102 mEq/L\n 133 mEq/L\n 25.0 %\n 15.4 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n 03:00 PM\n 08:20 PM\n 09:00 PM\n 02:56 AM\n 01:25 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n 15.4\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n 25.0\n Plt\n 1\n 1109\n 1173\n 1120\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 27\n Glucose\n 135\n 142\n 115\n 105\n 96\n Other labs: PT / PTT / INR:15.3/32.0/1.3, ALT / AST:16/22, Alk Phos / T\n Bili:100/0.7, Amylase / Lipase:111/194, Differential-Neuts:70.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:11.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:359 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n DELIRIUM / CONFUSION\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis s/p splenectomy for\n ruptured spleen who returns to the with fevers and tachycardia in\n the setting of recent enteric leak repair.\n # Fevers and Leukocytosis:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . The line has since been\n removed. Other possible sources for infection include empyema\n (although thoracentesis on did not show evidence of organisms),\n pancreatitis (lipase slightly increasing), or pneumonia.\n - start fluconazole for coverage\n - start cefepime for broad gram negative and anaerobic coverage (has\n penicillin allergy)\n - continue vancomycin and cipro\n - f/u sensitivities , bcx, fungal cx, c. diff\n - will discuss possibility of thoracentesis with surgery if he\n continues to be febrile despite appropriate antibiotics\n - CT abdomen and pelvis with possible IR drainage today.\n # Delirium:\n This may be secondary to his pain medications or could be a\n manifestation of severe infection +/- sepsis. If he is bacteremic or\n fungemic, would also consider the possibility of septic emboli, but not\n at threshold to image head without supportive culture data.\n - pain not well controlled, increase dilaudid to .25 mg IV q 2 hours.\n - haldol prn, per psych recs in chart\nconfirm QTc prior to dosing\n - ABG without hypercarbia\n # Anemia, Hct 30-31 on admission, currently 23.7, concerning for\n possible bleed considering heparin gtt\n one supratherapeutic measure\n on .\n - follow serial Hcts\n - active type and screen\n - If Hct drops less than current 23.7, contact surgery immediately for\n discussion re: transfusion.\n - CT abdomen/pelvis to evaluate for bleed.\n # Tachypnea with respiratory alkalosis:\n Likely related to pain, although he may also have some anxiety from\n being disoriented.\n - improve control, consider pain cosult.\n # Sinus Tachycardia:\n Likely multifactorial in setting of pain, PE, tachypnea/respiratory\n distress, and infection.\n - would avoid beta blocking sinus tachycardia and rather would treat\n underlying causes\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n - note that pt is infected with encapsulated organism\n # Subsegmental PEs:\n - stop heparin gtt per surgery today for CT Abdomen/Pelvis and possible\n IR intervention\n # Elevated platelets:\n be inflammatory reaction, but elevation of platelets is extremely\n pronounced.\n - consult heme\n - monitor\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # Comm: with mom \n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:30 AM 83. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 09:07 PM\n Multi Lumen - 10:10 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": "2159-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 681809,
"text": "39 year old male with history of pancreatitis was admitted to \n Hospital a week ago with fevers and LLQ pain x1wk. Pt was treated with\n levaquin and flagyl but no diagnosis given. Pt frustrated and left AMA.\n Pt decided on pursuing further treatment at . Pt in ED was febrile\n and had an elevated WBC. CT scan of abdomen showed splenic lesion with\n hemorrhagic bleed. Pt transferred to TSICU for further monitoring,\n serial Hcts and IR embolization.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt tmax of 103.3. Diaphoretic, Tachycardic to 130s. Hct stable. WBC\n count elevated.\n Action:\n Blood cultures and urine culture drawn, labs taken. Serial Hcts.\n Tylenol given. Fan and cool cloth in place.\n Response:\n Temp decreased to 100. Pending lab cultures. Pt\ns HR decreased.\n Plan:\n Start possible antbx regimen. Give Tylenol as needed. Pt planned for\n add-on in the OR today for splenectomy.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of pain in left upper quadrant and radiating to back.\n Pt slightly anxious at baseline.\n Action:\n Pt repositioned and on Dilaudid PCA. IVP dilaudid given for\n breakthrough pain and ativan given for anxiety. Emotional support\n provided.\n Response:\n Pt more comfortable with pain regimen.\n Plan:\n Continue with Dilaudid PCA. ? epidural once splenectomy performed.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 681927,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt w/ pmh of acute pancreatits. adm from OSH (pt left ama). To OR today\n for splenectomy possible distal pancreatectomy. VSS. pre-op w/ sinus\n tachy. Sbp stable 140\ns. uop qs.\n Action:\n LR at 100cc/hr\n Use of dilaudid pca for pain management\n NPO\n Oob to ch\n Pre op teaching\n Report to OR RN\n Response:\n Stable pre-op\n Plan:\n Return to TSICU post-op\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 682034,
"text": "TSICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o\n fever/chills; he went 9 days ago to OSH where he was admitted, had an\n elevated lipase and emesis; he was treated there conservatively for\n presumed pancreatitis & given abx; he left AMA & now has come to w/\n LUQ pain, possible splenic rupture vs. abscess seen on CT abd. Has had\n no hypotension in ED.\n Chief complaint:\n abd pain\n PMHx:\n PMH: recurrent acute pancreatitis\n PSH: appy, CCY\n pancreatic pseudocyst drainage (?cyst gastrostomy) ( Hosp)\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5.\n Calcium Gluconate 6. CefazoLIN\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Famotidine 9. Fentanyl\n Citrate 10. Heparin 11. Insulin\n 12. Ipratropium Bromide Neb 13. Magnesium Sulfate 14. Potassium\n Phosphate 15. Propofol 16. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - START 01:07 PM\n OR SENT - At 01:30 PM\n MULTI LUMEN - START 06:30 PM\n INVASIVE VENTILATION - START 07:00 PM\n MULTI LUMEN - STOP 10:45 PM\n MULTI LUMEN - START 10:46 PM\n FEVER - 101.2\nF - 07:00 AM\n : OR for splenectomy and distal pancreatectomy- spleen completely\n ruptured, also with bleeding from splenic vein and sbp in 70s--> got 7\n u prbcs, 2 u ffp, and 4 L crystalloid. Hct stable post-op and pt self\n extubated in a.m.\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Cefazolin - 04:00 AM\n Infusions:\n Fentanyl (Concentrate) - 30 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:43 PM\n Heparin Sodium (Prophylaxis) - 11:36 PM\n Other medications:\n Flowsheet Data as of 06:27 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: 38.4\nC (101.1\n HR: 128 (110 - 129) bpm\n BP: 146/88(101) {139/76(95) - 151/93(156)} mmHg\n RR: 29 (14 - 29) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 117.5 kg (admission): 115 kg\n CVP: 6 (-1 - 8) mmHg\n Total In:\n 8,877 mL\n 838 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,248 mL\n 838 mL\n Blood products:\n 2,549 mL\n Total out:\n 5,085 mL\n 935 mL\n Urine:\n 1,715 mL\n 485 mL\n NG:\n Stool:\n Drains:\n 120 mL\n 450 mL\n Balance:\n 3,792 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 628 (628 - 628) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 31\n PIP: 6 cmH2O\n Plateau: 9 cmH2O\n SPO2: 96%\n ABG: 7.43/44/87./27/3\n Ve: 12.4 L/min\n PaO2 / FiO2: 176\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Tender: mild throughout, no r/g/r\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: No(t) Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 390 K/uL\n 12.0 g/dL\n 143 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 5.2 mEq/L\n 18 mg/dL\n 103 mEq/L\n 137 mEq/L\n 35.9 %\n 28.7 K/uL\n [image002.jpg]\n 02:32 AM\n 02:55 PM\n 04:00 PM\n 05:00 PM\n 05:22 PM\n 07:10 PM\n 07:11 PM\n 10:51 PM\n 02:45 AM\n 02:52 AM\n WBC\n 24.4\n 29.0\n 28.7\n Hct\n 30.8\n 28\n 30\n 33\n 31\n 34.3\n 33.9\n 35.9\n Plt\n 474\n 304\n 390\n Creatinine\n 0.7\n 0.5\n 0.7\n TCO2\n 32\n 27\n 25\n 30\n 30\n Glucose\n 111\n 112\n 124\n 141\n 149\n 171\n 143\n Other labs: PT / PTT / INR:14.0/28.5/1.2, CK / CK-MB / Troponin\n T:272//, ALT / AST:27/67, Alk-Phos / T bili:66/2.8, Amylase /\n Lipase:88/156, Fibrinogen:380 mg/dL, Lactic Acid:3.4 mmol/L,\n Albumin:2.7 g/dL, LDH:855 IU/L, Ca:7.4 mg/dL, Mg:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 39 yo M POD 1 s/p splenectomy and distal\n pancreatectomy, no signs of abscess intra-abd and pt HD stable\n Neurologic: Neuro checks Q: 4 hr\n Cardiovascular: - tachy 20 120s with good urine output and without\n hypotension\n - optimize pain control for tachycardia\n Pulmonary: - no acute issues- self extubated and tolerating well\n -incentive spirometer\n Gastrointestinal / Abdomen: - s/p splenectomy and distal pancreatectomy\n Nutrition: NPO\n Renal: Foley, Adequate UO, -nl Cr\n -monitor U output\n Hematology: Serial Hct, -Hct stable at 36 o/n, increase to Q 6 hcts\n Endocrine: RISS\n Infectious Disease: - cont cefazolin x 3 doses, no acute issues\n - wbc count stable at 28\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: LR\n Consults: General surgery\n Billing Diagnosis: (Shock: Unspecified)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\n Arterial Line - 01:07 PM\n Multi Lumen - 10:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 681806,
"text": "SICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o fever/chills;\n he went 9 days ago to OSH where he was admitted, had an elevated lipase\n and emesis; he was treated there conservatively for presumed\n pancreatitis & given abx; he left AMA & now has come to w/ LUQ pain,\n possible splenic rupture vs. abscess seen on CT abd. Has had no\n hypotension in ED.\n .\n PMHx:\n PMH: recurrent acute pancreatitis\n PSH: appy, CCY\n pancreatic pseudocyst drainage (?cyst gastrostomy) ( Hosp)\n : Viokase with meals ; Vicodin prn\n Current medications:\n 1. 1000 mL LR 2. Acetaminophen 3. Albuterol 0.083% Neb Soln 4. Docusate\n Sodium (Liquid) 5. Famotidine 6. . HYDROmorphone (Dilaudid) 8. Insulin\n 9. Ipratropium Bromide Neb 10. Lorazepam\n 24 Hour Events:\n BLOOD CULTURED - At 03:45 AM\n URINE CULTURE - At 03:45 AM\n FEVER - 103.3\nF - 12:00 AM\n EVENTS:IR embolized splenic artery\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:50 AM\n Famotidine (Pepcid) - 08:05 PM\n Lorazepam (Ativan) - 10:33 PM\n Hydromorphone (Dilaudid) - 10:37 PM\n Other medications:\n Flowsheet Data as of 04:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.6\nC (103.3\n T current: 38.2\nC (100.8\n HR: 123 (102 - 127) bpm\n BP: 133/86(98) {124/62(85) - 169/104(118)} mmHg\n RR: 17 (12 - 44) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 5,875 mL\n 418 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,600 mL\n 418 mL\n Blood products:\n 275 mL\n Total out:\n 4,375 mL\n 580 mL\n Urine:\n 2,475 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,500 mL\n -162 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), Tachycardia\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Groin no hematoma\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\n Labs / Radiology\n 474 K/uL\n 10.1 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 95 mEq/L\n 133 mEq/L\n 30.8 %\n 24.4 K/uL\n [image002.jpg]\n 06:30 AM\n 11:07 AM\n 02:57 PM\n 06:29 PM\n 10:29 PM\n 02:32 AM\n WBC\n 17.9\n 24.4\n Hct\n 29.4\n 28.4\n 30.7\n 30.2\n 30.6\n 30.8\n Plt\n 436\n 474\n Creatinine\n 0.7\n 0.7\n Glucose\n 99\n 111\n Other labs: PT / PTT / INR:14.3/28.2/1.2, CK / CK-MB / Troponin\n T:272//, ALT / AST:27/67, Alk-Phos / T bili:66/2.8, Amylase /\n Lipase:88/156, Fibrinogen:652 mg/dL, Albumin:2.7 g/dL, LDH:855 IU/L,\n Ca:8.0 mg/dL, Mg:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 39 yo male with ac pancreatitis now with possible\n splenic bleed\n NEURO:Pain: Dilaudid PCA; Ativan prn;\n CVS:Stable; tachycardia\n PULM:No issues\n GI: IR embolized splenic artery; For distal pancreatectomy splenectomy\n on ; Talk to team about nasojej tube in oR\n RENAL: Cr WNL, follow UOP\n HEME: Hct 32 ->27; got 1 U PRBCs in ED; Crits stable at 30\n ENDO:RISS - euglycemic\n Infectious Disease: WBC 15 on admit; increased to 24.4\n Lines / Tubes / Drains: foley, PIV\n Fluids: LR @ 100\n Consults: Gen Surgery\n Billing Diagnosis: Other: pancreatitis\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682033,
"text": "39 year old male with history of pancreatitis was admitted to \n Hospital a week ago with fevers and LLQ pain x1wk. Pt was treated with\n levaquin and flagyl but no diagnosis given. Pt frustrated and left AMA.\n Pt decided on pursuing further treatment at . Pt in ED was febrile\n and had an elevated WBC. CT scan of abdomen showed splenic lesion with\n hemorrhagic bleed.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n To OR today for splenectomy and distal pancreatectomy, splenic artery\n was hemorrhaging during surgery and pt was given lots of blood products\n and crystalloid. Pt tachycardic. HCT\ns stable, UOP adequate. Pt\n intubated on CMV post-op. Primary dsg on midline abdominal incision.\n Large JP drain left lateral abdomen draining moderate amts of\n serosanguinous fluid. Pt remains febrile to 100.8\n Action:\n -Serial Hcts\n -Kefzol given x3 doses post-op\n -Multilumen IJ central line placed\n -tylenol given\n Response:\n Pt continues to be tachycardic, Hct\ns remain stable. Febrile, Pt weaned\n to CPAP 5/5 with ABG wnl.\n Plan:\n Plan for extubation in the am. Monitor Hcts.\n ------ Protected Section ------\n Pt self-extubated with restraints in place and sedation on. Pt\n oxygenating well with sats in the mid 90s on nasal cannula at 4L.\n ------ Protected Section Addendum Entered By: , RN\n on: 06:25 ------\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682026,
"text": "39 year old male with history of pancreatitis was admitted to \n Hospital a week ago with fevers and LLQ pain x1wk. Pt was treated with\n levaquin and flagyl but no diagnosis given. Pt frustrated and left AMA.\n Pt decided on pursuing further treatment at . Pt in ED was febrile\n and had an elevated WBC. CT scan of abdomen showed splenic lesion with\n hemorrhagic bleed.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n To OR today for splenectomy and distal pancreatectomy, splenic artery\n was hemorrhaging during surgery and pt was given lots of blood products\n and crystalloid. Pt tachycardic. HCT\ns stable, UOP adequate. Pt\n intubated on CMV post-op. Primary dsg on midline abdominal incision.\n Large JP drain left lateral abdomen draining moderate amts of\n serosanguinous fluid. Pt remains febrile to 100.8\n Action:\n -Serial Hcts\n -Kefzol given x3 doses post-op\n -Multilumen IJ central line placed\n -tylenol given\n Response:\n Pt continues to be tachycardic, Hct\ns remain stable. Febrile, Pt weaned\n to CPAP 5/5 with ABG wnl.\n Plan:\n Plan for extubation in the am. Monitor Hcts.\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 681651,
"text": "TSICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o fever/chills;\n he went 9 days ago to OSH where he was admitted, had an elevated lipase\n and emesis; he was treated there conservatively for presumed\n pancreatitis & given abx; he left AMA & now has come to w/ LUQ pain,\n possible splenic rupture vs. abscess seen on CT abd. Has had no\n hypotension in ED.\n Chief complaint:\n PMHx:\n recurrent acute pancreatitis, s/p ERCP & drainage of biliary sludge;\n s/p appy, s/p open chole; s/p drainage of pancreatic pseudocyst\n Current medications:\n 24 Hour Events:\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:50 AM\n Other medications:\n Flowsheet Data as of 07:37 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: 123 (115 - 123) bpm\n BP: 164/89(110) {162/89(106) - 164/91(110)} mmHg\n RR: 26 (24 - 28) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,275 mL\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n 275 mL\n Total out:\n 0 mL\n 2,140 mL\n Urine:\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (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:\n Neurologic: Neuro checks Q: 4 hr, has morphine for pain\n Cardiovascular: tachy, receiving 1 U PRBCs now, no h/o cardiac disease\n Pulmonary: NC O2, pain control to avoid splinting\n Gastrointestinal / Abdomen: NPO, f/u final CT abd read; IR consulted\n for poss embolization of splenic vessels\n Nutrition: NPO\n Renal: Foley, follow UOP\n Hematology: Serial Hct, Hct q 4 h\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, PIV x2\n Wounds:\n Imaging:\n Fluids: LR\n Consults: General surgery, IR\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 681666,
"text": "TSICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o fever/chills;\n he went 9 days ago to OSH where he was admitted, had an elevated lipase\n and emesis; he was treated there conservatively for presumed\n pancreatitis & given abx; he left AMA & now has come to w/ LUQ pain,\n possible splenic rupture vs. abscess seen on CT abd. Has had no\n hypotension in ED.\n Chief complaint:\n PMHx:\n recurrent acute pancreatitis, s/p ERCP & drainage of biliary sludge;\n s/p appy, s/p open chole; s/p drainage of pancreatic pseudocyst\n Current medications:\n 24 Hour Events:\n admitted\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:50 AM\n Other medications:\n Flowsheet Data as of 07:37 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: 123 (115 - 123) bpm\n BP: 164/89(110) {162/89(106) - 164/91(110)} mmHg\n RR: 26 (24 - 28) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,275 mL\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n 275 mL\n Total out:\n 0 mL\n 2,140 mL\n Urine:\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (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: 39yo with hx of acute gallstone pancreatitis now\n with possible splenic hematoma vs. abscess, going to IR for drain\n today.\n Neurologic: Neuro checks Q: 4 hr, change morphine to dilaudid for pain.\n Will order PCA dilaudid.\n Cardiovascular: tachy, receiving 1 U PRBCs now, no h/o cardiac disease\n Pulmonary: NC O2, pain control to avoid splinting\n Gastrointestinal / Abdomen: NPO, f/u final CT abd read; IR consulted\n for poss embolization of splenic vessels\n Nutrition: NPO\n Renal: Foley, follow UOP. Will give fluids for contrast load today.\n Hematology: anemia. Serial Hct, Hct q 4h.\n Endocrine: euglycemia. RISS\n Infectious Disease: afebrile, leukocytosis elevated, likely\n inflammatory vs. abscess. Will readdress Empiric coverage need.\n Lines / Tubes / Drains: Foley, PIV x2\n Wounds:\n Imaging:\n Fluids: LR@100cc/hr\n Consults: General surgery, IR\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\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: 32mins\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 681640,
"text": "39 year old male with history of pancreatitis was admitted to \n Hospital a week ago with fevers and LLQ pain x1wk. Pt was treated with\n levaquin and flagyl but no diagnosis given. Pt frustrated and left AMA.\n Pt decided on pursuing further treatment at . Pt in ED was febrile\n and had an elevated WBC. CT scan of abdomen showed ?splenic abscess vs.\n hemorrhage. Pt\ns given Vanco, Levaquin, and Flagyl in ED. Blood, Urine\n and Stool cultures collected. Hct dropped from 32.3 to 27.2 and pt was\n transfused with 1 unit PRBC. Pt transferred to TSICU for further\n monitoring, serial Hcts and possible embolization of bleed.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 681642,
"text": "39 year old male with history of pancreatitis was admitted to \n Hospital a week ago with fevers and LLQ pain x1wk. Pt was treated with\n levaquin and flagyl but no diagnosis given. Pt frustrated and left AMA.\n Pt decided on pursuing further treatment at . Pt in ED was febrile\n and had an elevated WBC. CT scan of abdomen showed ?splenic abscess vs.\n hemorrhage. Pt\ns given Vanco, Levaquin, and Flagyl in ED. Blood, Urine\n and Stool cultures collected. Hct dropped from 32.3 to 27.2 and pt was\n transfused with 1 unit PRBC. Pt transferred to TSICU for further\n monitoring, serial Hcts and possible embolization of bleed.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 681758,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt remains febrile Tmax 101.\n Action:\n Tylenol po and fan applied. Blood culture results pending. Vancomycin\n 1000mg given x 1 during IR procedure.\n Response:\n Temp down to 100.6. Blood cultures pending.\n Plan:\n Awaiting blood cultures. Monitor WBC and temp. For OR for removal of\n speen.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues to c/o pain to left abdomen and back. Pt grimacing\n with activity.\n Action:\n Started on PCA of Hydromorphone and given boluses for pain control. Pt\n encouraged to use PCA. Pt repositioned in bed and back rub given.\n Response:\n Pain down to on pain scale.\n Plan:\n Continue with PCA for pain control. Encourage pt and remind pt to use\n PCA. Bolus of hydromorphone given for total of 1.5mg IV.\n ------ Protected Section ------\n PCA increased dose to 0.25/6/2.5. Ativan x 1 given for anxiety. SBP\n remains >165.\n ------ Protected Section Addendum Entered By: , RN\n on: 18:44 ------\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-05 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 682571,
"text": "HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o fever/chills;\n he went 9 days ago to OSH where he was admitted, had an elevated lipase\n and emesis; he was treated there conservatively for presumed\n pancreatitis & given abx; he left AMA & now has come to w/ LUQ pain,\n possible splenic rupture vs. abscess seen on CT abd. Has had no\n hypotension in ED.\n .\n PMHx:\n PMH: recurrent acute pancreatitis\n PSH: appy, CCY\n pancreatic pseudocyst drainage (?cyst gastrostomy) ( Hosp)\n : Viokase with meals\n Vicodin prn\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 103.4\n WBC 25.8 from 29.6\n Action:\n Tylenol 650mg po\n Fan on\n CT torso obtained\n LENI\ns obtained\n Response:\n Per surgical team, patient has pleural effusions and a pulmonary\n embolism\n SPO2 92-96% on room air; >97% on 2L nasal cannula\n Plan:\n Heparin gtt just started; titrate to therapeutic PTT as ordered\n Antibiotics ordered; first dose vancomycin given\n Promote normothermia\n Hemodynamically stable; transfer to floor per surgical & critical care\n teams\n Pain control (acute pain, chronic pain)\n Assessment:\n Complains of diffuse abdominal pain with movement, coughing, deep\n breathing, etc\n Action:\n Dilaudid PCA unchanged 0.25/6/2.5\n Response:\n Pain 0-3/10 at rest.\n Able to use IS >750mL and ambulated >100 feet in the \n Plan:\n Continue PCA while NPO\n Mobilize out of bed to improve GI motility and independence\n Demographics\n Attending MD:\n T.\n Admit diagnosis:\n SPLENIC HEMORRHAGE\n Code status:\n Full code\n Height:\n Admission weight:\n 115 kg\n Daily weight:\n 117.5 kg\n Allergies/Reactions:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Precautions:\n PMH: Pancreatitis\n CV-PMH:\n Additional history: gallbladder and appendix were removed, pancreatic\n pseudocyst\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:144\n D:83\n Temperature:\n 102.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 25 insp/min\n Heart Rate:\n 113 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,245 mL\n 24h total out:\n 1,670 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 04:03 AM\n Potassium:\n 4.6 mEq/L\n 04:03 AM\n Chloride:\n 97 mEq/L\n 04:03 AM\n CO2:\n 28 mEq/L\n 04:03 AM\n BUN:\n 15 mg/dL\n 04:03 AM\n Creatinine:\n 0.6 mg/dL\n 04:03 AM\n Glucose:\n 96 mg/dL\n 04:03 AM\n Hematocrit:\n 29.8 %\n 04:03 AM\n Finger Stick Glucose:\n 116\n 02:00 PM\n Valuables / Signature\n Patient valuables:\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: T/\n Transferred to: East 548D\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 682056,
"text": "TSICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o\n fever/chills; he went 9 days ago to OSH where he was admitted, had an\n elevated lipase and emesis; he was treated there conservatively for\n presumed pancreatitis & given abx; he left AMA & now has come to w/\n LUQ pain, possible splenic rupture vs. abscess seen on CT abd. Has had\n no hypotension in ED.\n Chief complaint:\n abd pain\n PMHx:\n PMH: recurrent acute pancreatitis\n PSH: appy, CCY\n pancreatic pseudocyst drainage (?cyst gastrostomy) ( Hosp)\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5.\n Calcium Gluconate 6. CefazoLIN\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Famotidine 9. Fentanyl\n Citrate 10. Heparin 11. Insulin\n 12. Ipratropium Bromide Neb 13. Magnesium Sulfate 14. Potassium\n Phosphate 15. Propofol 16. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - START 01:07 PM\n OR SENT - At 01:30 PM\n MULTI LUMEN - START 06:30 PM\n INVASIVE VENTILATION - START 07:00 PM\n MULTI LUMEN - STOP 10:45 PM\n MULTI LUMEN - START 10:46 PM\n FEVER - 101.2\nF - 07:00 AM\n : OR for splenectomy and distal pancreatectomy- spleen completely\n ruptured, also with bleeding from splenic vein and sbp in 70s--> got 7\n u prbcs, 2 u ffp, and 4 L crystalloid. Hct stable post-op and pt self\n extubated in a.m.\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Cefazolin - 04:00 AM\n Infusions:\n Fentanyl (Concentrate) - 30 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:43 PM\n Heparin Sodium (Prophylaxis) - 11:36 PM\n Other medications:\n Flowsheet Data as of 06:27 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: 38.4\nC (101.1\n HR: 128 (110 - 129) bpm\n BP: 146/88(101) {139/76(95) - 151/93(156)} mmHg\n RR: 29 (14 - 29) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 117.5 kg (admission): 115 kg\n CVP: 6 (-1 - 8) mmHg\n Total In:\n 8,877 mL\n 838 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,248 mL\n 838 mL\n Blood products:\n 2,549 mL\n Total out:\n 5,085 mL\n 935 mL\n Urine:\n 1,715 mL\n 485 mL\n NG:\n Stool:\n Drains:\n 120 mL\n 450 mL\n Balance:\n 3,792 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 628 (628 - 628) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 31\n PIP: 6 cmH2O\n Plateau: 9 cmH2O\n SPO2: 96%\n ABG: 7.43/44/87./27/3\n Ve: 12.4 L/min\n PaO2 / FiO2: 176\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Tender: mild throughout, no r/g/r\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: No(t) Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 390 K/uL\n 12.0 g/dL\n 143 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 5.2 mEq/L\n 18 mg/dL\n 103 mEq/L\n 137 mEq/L\n 35.9 %\n 28.7 K/uL\n [image002.jpg]\n 02:32 AM\n 02:55 PM\n 04:00 PM\n 05:00 PM\n 05:22 PM\n 07:10 PM\n 07:11 PM\n 10:51 PM\n 02:45 AM\n 02:52 AM\n WBC\n 24.4\n 29.0\n 28.7\n Hct\n 30.8\n 28\n 30\n 33\n 31\n 34.3\n 33.9\n 35.9\n Plt\n 474\n 304\n 390\n Creatinine\n 0.7\n 0.5\n 0.7\n TCO2\n 32\n 27\n 25\n 30\n 30\n Glucose\n 111\n 112\n 124\n 141\n 149\n 171\n 143\n Other labs: PT / PTT / INR:14.0/28.5/1.2, CK / CK-MB / Troponin\n T:272//, ALT / AST:27/67, Alk-Phos / T bili:66/2.8, Amylase /\n Lipase:88/156, Fibrinogen:380 mg/dL, Lactic Acid:3.4 mmol/L,\n Albumin:2.7 g/dL, LDH:855 IU/L, Ca:7.4 mg/dL, Mg:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 39 yo M POD 1 s/p splenectomy and distal\n pancreatectomy, no signs of abscess intra-abd and pt HD stable\n Neurologic: Neuro checks Q: 4 hr\n Cardiovascular: - tachy to 120s with good urine output and without\n hypotension. Likely combo of SIRS response + pain.\n - optimize pain control for tachycardia\n Pulmonary: - no acute issues- self extubated and tolerating well\n -incentive spirometer\n Gastrointestinal / Abdomen: - s/p splenectomy and distal\n pancreatectomy. Keep NPO\n Nutrition: NPO for now.\n Renal: Foley, Adequate UO, -nl Cr\n -monitor U output\n Hematology: Serial Hct, -Hct stable at 36 o/n, increase to Q 6 hcts\n Endocrine: hyperglycemia. Tighten RISS\n Infectious Disease: - leukocytosis likely SIRS response given\n unremarkable intraop findings\n no abscess. cont periop cefazolin x 3\n doses, no acute issues\n - wbc count stable at 28\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: LR\n Consults: General surgery\n Billing Diagnosis: (Shock: Unspecified)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\n Arterial Line - 01:07 PM\n Multi Lumen - 10:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: icu\n Total time spent: 32mins\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 682057,
"text": "TSICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o\n fever/chills; he went 9 days ago to OSH where he was admitted, had an\n elevated lipase and emesis; he was treated there conservatively for\n presumed pancreatitis & given abx; he left AMA & now has come to w/\n LUQ pain, possible splenic rupture vs. abscess seen on CT abd. Has had\n no hypotension in ED.\n Chief complaint:\n abd pain\n PMHx:\n PMH: recurrent acute pancreatitis\n PSH: appy, CCY\n pancreatic pseudocyst drainage (?cyst gastrostomy) ( Hosp)\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5.\n Calcium Gluconate 6. CefazoLIN\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Famotidine 9. Fentanyl\n Citrate 10. Heparin 11. Insulin\n 12. Ipratropium Bromide Neb 13. Magnesium Sulfate 14. Potassium\n Phosphate 15. Propofol 16. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - START 01:07 PM\n OR SENT - At 01:30 PM\n MULTI LUMEN - START 06:30 PM\n INVASIVE VENTILATION - START 07:00 PM\n MULTI LUMEN - STOP 10:45 PM\n MULTI LUMEN - START 10:46 PM\n FEVER - 101.2\nF - 07:00 AM\n : OR for splenectomy and distal pancreatectomy- spleen completely\n ruptured, also with bleeding from splenic vein and sbp in 70s--> got 7\n u prbcs, 2 u ffp, and 4 L crystalloid. Hct stable post-op and pt self\n extubated in a.m.\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Cefazolin - 04:00 AM\n Infusions:\n Fentanyl (Concentrate) - 30 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:43 PM\n Heparin Sodium (Prophylaxis) - 11:36 PM\n Other medications:\n Flowsheet Data as of 06:27 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: 38.4\nC (101.1\n HR: 128 (110 - 129) bpm\n BP: 146/88(101) {139/76(95) - 151/93(156)} mmHg\n RR: 29 (14 - 29) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 117.5 kg (admission): 115 kg\n CVP: 6 (-1 - 8) mmHg\n Total In:\n 8,877 mL\n 838 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,248 mL\n 838 mL\n Blood products:\n 2,549 mL\n Total out:\n 5,085 mL\n 935 mL\n Urine:\n 1,715 mL\n 485 mL\n NG:\n Stool:\n Drains:\n 120 mL\n 450 mL\n Balance:\n 3,792 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 628 (628 - 628) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 31\n PIP: 6 cmH2O\n Plateau: 9 cmH2O\n SPO2: 96%\n ABG: 7.43/44/87./27/3\n Ve: 12.4 L/min\n PaO2 / FiO2: 176\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Tender: mild throughout, no r/g/r\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: No(t) Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 390 K/uL\n 12.0 g/dL\n 143 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 5.2 mEq/L\n 18 mg/dL\n 103 mEq/L\n 137 mEq/L\n 35.9 %\n 28.7 K/uL\n [image002.jpg]\n 02:32 AM\n 02:55 PM\n 04:00 PM\n 05:00 PM\n 05:22 PM\n 07:10 PM\n 07:11 PM\n 10:51 PM\n 02:45 AM\n 02:52 AM\n WBC\n 24.4\n 29.0\n 28.7\n Hct\n 30.8\n 28\n 30\n 33\n 31\n 34.3\n 33.9\n 35.9\n Plt\n 474\n 304\n 390\n Creatinine\n 0.7\n 0.5\n 0.7\n TCO2\n 32\n 27\n 25\n 30\n 30\n Glucose\n 111\n 112\n 124\n 141\n 149\n 171\n 143\n Other labs: PT / PTT / INR:14.0/28.5/1.2, CK / CK-MB / Troponin\n T:272//, ALT / AST:27/67, Alk-Phos / T bili:66/2.8, Amylase /\n Lipase:88/156, Fibrinogen:380 mg/dL, Lactic Acid:3.4 mmol/L,\n Albumin:2.7 g/dL, LDH:855 IU/L, Ca:7.4 mg/dL, Mg:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 39 yo M POD 1 s/p splenectomy and distal\n pancreatectomy, no signs of abscess intra-abd and pt HD stable\n Neurologic: Neuro checks Q: 4 hr\n Cardiovascular: - tachy to 120s with good urine output and without\n hypotension. Likely combo of SIRS response + pain.\n - optimize pain control for tachycardia\n Pulmonary: - no acute issues- self extubated and tolerating well\n -incentive spirometer\n Gastrointestinal / Abdomen: - s/p splenectomy and distal\n pancreatectomy. Keep NPO\n Nutrition: NPO for now.\n Renal: Foley, Adequate UO, -nl Cr\n -monitor U output\n Hematology: Serial Hct, -Hct stable at 36 o/n, increase to Q 6 hcts\n Endocrine: hyperglycemia. Tighten RISS\n Infectious Disease: - leukocytosis likely SIRS response given\n unremarkable intraop findings\n no abscess. cont periop cefazolin x 3\n doses, no acute issues\n - wbc count stable at 28\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: LR\n Consults: General surgery\n Billing Diagnosis: (Shock: Unspecified)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\n Arterial Line - 01:07 PM\n Multi Lumen - 10:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: icu\n Total time spent: 32mins\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 682058,
"text": "TSICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o\n fever/chills; he went 9 days ago to OSH where he was admitted, had an\n elevated lipase and emesis; he was treated there conservatively for\n presumed pancreatitis & given abx; he left AMA & now has come to w/\n LUQ pain, possible splenic rupture vs. abscess seen on CT abd. Has had\n no hypotension in ED.\n Chief complaint:\n abd pain\n PMHx:\n PMH: recurrent acute pancreatitis\n PSH: appy, CCY\n pancreatic pseudocyst drainage (?cyst gastrostomy) ( Hosp)\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5.\n Calcium Gluconate 6. CefazoLIN\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Famotidine 9. Fentanyl\n Citrate 10. Heparin 11. Insulin\n 12. Ipratropium Bromide Neb 13. Magnesium Sulfate 14. Potassium\n Phosphate 15. Propofol 16. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - START 01:07 PM\n OR SENT - At 01:30 PM\n MULTI LUMEN - START 06:30 PM\n INVASIVE VENTILATION - START 07:00 PM\n MULTI LUMEN - STOP 10:45 PM\n MULTI LUMEN - START 10:46 PM\n FEVER - 101.2\nF - 07:00 AM\n : OR for splenectomy and distal pancreatectomy- spleen completely\n ruptured, also with bleeding from splenic vein and sbp in 70s--> got 7\n u prbcs, 2 u ffp, and 4 L crystalloid. Hct stable post-op and pt self\n extubated in a.m.\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Cefazolin - 04:00 AM\n Infusions:\n Fentanyl (Concentrate) - 30 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:43 PM\n Heparin Sodium (Prophylaxis) - 11:36 PM\n Other medications:\n Flowsheet Data as of 06:27 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: 38.4\nC (101.1\n HR: 128 (110 - 129) bpm\n BP: 146/88(101) {139/76(95) - 151/93(156)} mmHg\n RR: 29 (14 - 29) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 117.5 kg (admission): 115 kg\n CVP: 6 (-1 - 8) mmHg\n Total In:\n 8,877 mL\n 838 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,248 mL\n 838 mL\n Blood products:\n 2,549 mL\n Total out:\n 5,085 mL\n 935 mL\n Urine:\n 1,715 mL\n 485 mL\n NG:\n Stool:\n Drains:\n 120 mL\n 450 mL\n Balance:\n 3,792 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 628 (628 - 628) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 31\n PIP: 6 cmH2O\n Plateau: 9 cmH2O\n SPO2: 96%\n ABG: 7.43/44/87./27/3\n Ve: 12.4 L/min\n PaO2 / FiO2: 176\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Tender: mild throughout, no r/g/r\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: No(t) Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 390 K/uL\n 12.0 g/dL\n 143 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 5.2 mEq/L\n 18 mg/dL\n 103 mEq/L\n 137 mEq/L\n 35.9 %\n 28.7 K/uL\n [image002.jpg]\n 02:32 AM\n 02:55 PM\n 04:00 PM\n 05:00 PM\n 05:22 PM\n 07:10 PM\n 07:11 PM\n 10:51 PM\n 02:45 AM\n 02:52 AM\n WBC\n 24.4\n 29.0\n 28.7\n Hct\n 30.8\n 28\n 30\n 33\n 31\n 34.3\n 33.9\n 35.9\n Plt\n 474\n 304\n 390\n Creatinine\n 0.7\n 0.5\n 0.7\n TCO2\n 32\n 27\n 25\n 30\n 30\n Glucose\n 111\n 112\n 124\n 141\n 149\n 171\n 143\n Other labs: PT / PTT / INR:14.0/28.5/1.2, CK / CK-MB / Troponin\n T:272//, ALT / AST:27/67, Alk-Phos / T bili:66/2.8, Amylase /\n Lipase:88/156, Fibrinogen:380 mg/dL, Lactic Acid:3.4 mmol/L,\n Albumin:2.7 g/dL, LDH:855 IU/L, Ca:7.4 mg/dL, Mg:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 39 yo M POD 1 s/p splenectomy and distal\n pancreatectomy, no signs of abscess intra-abd and pt HD stable\n Neurologic: Neuro checks Q: 4 hr\n Cardiovascular: - tachy to 120s with good urine output and without\n hypotension. Likely combo of SIRS response + pain.\n - optimize pain control for tachycardia\n Pulmonary: - no acute issues- self extubated and tolerating well\n -incentive spirometer\n Gastrointestinal / Abdomen: - s/p splenectomy and distal\n pancreatectomy. Keep NPO\n Nutrition: NPO for now.\n Renal: Foley, Adequate UO, -nl Cr\n -monitor U output\n Hematology: Serial Hct, -Hct stable at 36 o/n, increase to Q 6 hcts\n Endocrine: hyperglycemia. Tighten RISS\n Infectious Disease: - leukocytosis likely SIRS response given\n unremarkable intraop findings\n no abscess. cont periop cefazolin x 3\n doses, no acute issues\n - wbc count stable at 28\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: LR\n Consults: General surgery\n Billing Diagnosis: (Shock: Unspecified)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\n Arterial Line - 01:07 PM\n Multi Lumen - 10:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: icu\n Total time spent: 32mins\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682198,
"text": "39 year old male POD #1 for splenectomy and partial pancreactomy.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt alert and oriented. Pt c/o abdominal pain mild to on pain\n scale. Incision to abdomen dry and intact. Pt been afebrile. Hct\n stable. Abdomen soft but distended. Pt NPO, ice chips are ok. Large JP\n drain with moderate serosanguinous fluid.\n Action:\n Pt on PCA hydromorphone 0.25/6/2.5.\n Response:\n Pt has adequate pain coverage.\n Plan:\n Continue with PCA dilaudid. Transfer to floor.\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 682204,
"text": "TSICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o fever/chills;\n he went 9 days ago to OSH where he was admitted, had an elevated lipase\n and emesis; he was treated there conservatively for presumed\n pancreatitis & given abx; he left AMA & now has come to w/ LUQ pain,\n possible splenic rupture vs. abscess seen on CT abd. Has had no\n hypotension in ED\n Chief complaint:\n PMHx:\n recurrent acute pancreatitis\n Current medications:\n Viokase with meals\n 24 Hour Events:\n ARTERIAL LINE - STOP 02:21 AM\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Cefazolin - 11:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:31 PM\n Heparin Sodium (Prophylaxis) - 12:13 AM\n Metoprolol - 03:14 AM\n Other medications:\n Flowsheet Data as of 05:00 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: 37.2\nC (98.9\n HR: 114 (106 - 128) bpm\n BP: 171/86(106) {161/85(104) - 179/91(111)} mmHg\n RR: 23 (18 - 29) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 117.5 kg (admission): 115 kg\n CVP: 4 (0 - 17) mmHg\n Total In:\n 2,682 mL\n 483 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,682 mL\n 483 mL\n Blood products:\n Total out:\n 2,965 mL\n 690 mL\n Urine:\n 2,085 mL\n 650 mL\n NG:\n 150 mL\n Stool:\n Drains:\n 730 mL\n 40 mL\n Balance:\n -283 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: No(t) PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 578 K/uL\n 9.7 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 4.9 mEq/L\n 16 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.7 %\n 29.6 K/uL\n [image002.jpg]\n 05:22 PM\n 07:10 PM\n 07:11 PM\n 10:51 PM\n 02:45 AM\n 02:52 AM\n 11:03 AM\n 11:05 AM\n 05:48 PM\n 01:30 AM\n WBC\n 29.0\n 28.7\n 29.6\n Hct\n 31\n 34.3\n 33.9\n 35.9\n 31.1\n 29.8\n 29.7\n Plt\n \n Creatinine\n 0.5\n 0.7\n 0.7\n 0.6\n TCO2\n 25\n 30\n 30\n Glucose\n 149\n 171\n 143\n 143\n 121\n Other labs: PT / PTT / INR:13.5/26.4/1.2, CK / CK-MB / Troponin\n T:272//, ALT / AST:27/67, Alk-Phos / T bili:66/2.8, Amylase /\n Lipase:88/156, Fibrinogen:380 mg/dL, Lactic Acid:3.4 mmol/L,\n Albumin:2.7 g/dL, LDH:855 IU/L, Ca:7.2 mg/dL, Mg:2.0 mg/dL, PO4:1.8\n mg/dL\n Assessment and Plan\n splenic rupture s/p splenectomy and distal pancreatectomy, no signs of\n abscess intra-abd and pt HD stable\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular:\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal: Foley\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: LR, 100ml/hr\n Consults: General surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\n Multi Lumen - 10:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682199,
"text": "39 year old male POD #1 for splenectomy and partial pancreactomy.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt alert and oriented. Pt c/o abdominal pain mild to on pain\n scale. Incision to abdomen dry and intact. Pt been afebrile. Hct\n stable. Abdomen soft but distended. Pt NPO, ice chips are ok. Large JP\n drain with moderate serosanguinous fluid.\n Action:\n Pt on PCA hydromorphone 0.25/6/2.5.\n Response:\n Pt has adequate pain coverage.\n Plan:\n Continue with PCA dilaudid. Transfer to floor.\n Hypertension, benign\n Assessment:\n Pt hypertensive this shift, SBP elevated to the 180s. Pt has been\n tachycardic throughout stay. 1teens to 120s. Hct stable, UOP adequate,\n afebrile and pain level under control.\n Action:\n Po and IV metoprolol given. Surgery team notified.\n Response:\n Surgery team will discuss situation on rounds, unconcerned at this\n time.\n Plan:\n Discuss on rounds, ?trigger on floor.\n `\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682200,
"text": "39 year old male with history of pancreatitis was admitted to \n Hospital a week ago with fevers and LLQ pain x1wk. Pt was treated with\n levaquin and flagyl but no diagnosis given. Pt frustrated and left AMA.\n Pt decided on pursuing further treatment at . Pt in ED was febrile\n and had an elevated WBC. CT scan of abdomen showed splenic lesion with\n hemorrhagic bleed. Pt transferred to TSICU for further monitoring,\n serial Hcts and IR embolization. Pt had splenectomy and partial\n pancreatectomy on . Pt\ns received lots of blood products and\n crystalloid throughout surgery due to splenic artery hemorrhaging. Pt\n is post-op day #2.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt alert and oriented. Pt c/o abdominal pain mild to on pain\n scale. Incision to abdomen dry and intact. Pt been afebrile. Hct\n stable. Abdomen soft but distended. Pt NPO, ice chips are ok. Large JP\n drain with moderate serosanguinous fluid.\n Action:\n Pt on PCA hydromorphone 0.25/6/2.5.\n Response:\n Pt has adequate pain coverage.\n Plan:\n Continue with PCA dilaudid. Transfer to floor.\n Hypertension, benign\n Assessment:\n Pt hypertensive this shift, SBP elevated to the 180s. Pt has been\n tachycardic throughout stay. 1teens to 120s. Hct stable, UOP adequate,\n afebrile and pain level under control.\n Action:\n Po and IV metoprolol given. Surgery team notified.\n Response:\n Surgery team will discuss situation on rounds, unconcerned at this\n time.\n Plan:\n Discuss on rounds, ?trigger on floor.\n `\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 682275,
"text": "TSICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o fever/chills;\n he went 9 days ago to OSH where he was admitted, had an elevated lipase\n and emesis; he was treated there conservatively for presumed\n pancreatitis & given abx; he left AMA & now has come to w/ LUQ pain,\n possible splenic rupture vs. abscess seen on CT abd. Has had no\n hypotension in ED\n Chief complaint:\n PMHx:\n recurrent acute pancreatitis\n Current medications:\n Viokase with meals\n 24 Hour Events:\n ARTERIAL LINE - STOP 02:21 AM\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Cefazolin - 11:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:31 PM\n Heparin Sodium (Prophylaxis) - 12:13 AM\n Metoprolol - 03:14 AM\n Other medications:\n Flowsheet Data as of 05:00 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: 37.2\nC (98.9\n HR: 114 (106 - 128) bpm\n BP: 171/86(106) {161/85(104) - 179/91(111)} mmHg\n RR: 23 (18 - 29) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 117.5 kg (admission): 115 kg\n CVP: 4 (0 - 17) mmHg\n Total In:\n 2,682 mL\n 483 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,682 mL\n 483 mL\n Blood products:\n Total out:\n 2,965 mL\n 690 mL\n Urine:\n 2,085 mL\n 650 mL\n NG:\n 150 mL\n Stool:\n Drains:\n 730 mL\n 40 mL\n Balance:\n -283 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: No(t) PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 578 K/uL\n 9.7 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 4.9 mEq/L\n 16 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.7 %\n 29.6 K/uL\n [image002.jpg]\n 05:22 PM\n 07:10 PM\n 07:11 PM\n 10:51 PM\n 02:45 AM\n 02:52 AM\n 11:03 AM\n 11:05 AM\n 05:48 PM\n 01:30 AM\n WBC\n 29.0\n 28.7\n 29.6\n Hct\n 31\n 34.3\n 33.9\n 35.9\n 31.1\n 29.8\n 29.7\n Plt\n \n Creatinine\n 0.5\n 0.7\n 0.7\n 0.6\n TCO2\n 25\n 30\n 30\n Glucose\n 149\n 171\n 143\n 143\n 121\n Other labs: PT / PTT / INR:13.5/26.4/1.2, CK / CK-MB / Troponin\n T:272//, ALT / AST:27/67, Alk-Phos / T bili:66/2.8, Amylase /\n Lipase:88/156, Fibrinogen:380 mg/dL, Lactic Acid:3.4 mmol/L,\n Albumin:2.7 g/dL, LDH:855 IU/L, Ca:7.2 mg/dL, Mg:2.0 mg/dL, PO4:1.8\n mg/dL\n Assessment and Plan\n splenic rupture s/p splenectomy and distal pancreatectomy, no signs of\n abscess intra-abd and pt HD stable\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled w/ Dilaudid PCA\n Cardiovascular: stable tachycardia to 120. BP is fine. Will start\n beta blocker.\n Pulmonary: IS\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: Foley\n Hematology: hct stable at 30\n Endocrine: RISS\n Infectious Disease: No Abx\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: LR, 100ml/hr Change to maintenance\n Consults: General surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\n Multi Lumen - 10:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 682472,
"text": "SICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o fever/chills;\n he went 9 days ago to OSH where he was admitted, had an elevated lipase\n and emesis; he was treated there conservatively for presumed\n pancreatitis & given abx; he left AMA & now has come to w/ LUQ pain,\n possible splenic rupture vs. abscess seen on CT abd. Has had no\n hypotension in ED.\n .\n PMHx:\n PMH: recurrent acute pancreatitis\n PSH: appy, CCY\n pancreatic pseudocyst drainage (?cyst gastrostomy) ( Hosp)\n : Viokase with meals\n Vicodin prn\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5.\n Calcium Gluconate 6. Famotidine 7. HYDROmorphone (Dilaudid) 8. Heparin\n 9. Insulin 10. Ipratropium Bromide Neb 11. Magnesium Sulfate 12.\n Metoprolol Tartrate 13. Potassium Phosphate 14. Sodium Chloride 0.9%\n Flush 15. Sodium Phosphate\n 24 Hour Events:\n ARTERIAL LINE - STOP 02:21 AM\n : OR for splenectomy and distal pancreatectomy- spleen completely\n ruptured, also with bleeding from splenic vein and sbp in 70s--> got 7\n u prbcs, 2 u ffp, and 4 L crystalloid. Hct stable post-op and pt self\n extubated in a.m.\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Cefazolin - 11:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:27 PM\n Heparin Sodium (Prophylaxis) - 11:59 PM\n Metoprolol - 11:59 PM\n Other medications:\n Flowsheet Data as of 03:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39\nC (102.2\n T current: 37.8\nC (100\n HR: 108 (93 - 120) bpm\n BP: 156/96(110) {136/48(57) - 179/96(110)} mmHg\n RR: 18 (17 - 35) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 117.5 kg (admission): 115 kg\n Total In:\n 1,696 mL\n 210 mL\n PO:\n 40 mL\n Tube feeding:\n IV Fluid:\n 1,656 mL\n 210 mL\n Blood products:\n Total out:\n 3,035 mL\n 315 mL\n Urine:\n 2,915 mL\n 290 mL\n NG:\n Stool:\n Drains:\n 120 mL\n 25 mL\n Balance:\n -1,339 mL\n -105 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Diminished: L\n base)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 578 K/uL\n 9.7 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 4.9 mEq/L\n 16 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.7 %\n 29.6 K/uL\n [image002.jpg]\n 05:22 PM\n 07:10 PM\n 07:11 PM\n 10:51 PM\n 02:45 AM\n 02:52 AM\n 11:03 AM\n 11:05 AM\n 05:48 PM\n 01:30 AM\n WBC\n 29.0\n 28.7\n 29.6\n Hct\n 31\n 34.3\n 33.9\n 35.9\n 31.1\n 29.8\n 29.7\n Plt\n \n Creatinine\n 0.5\n 0.7\n 0.7\n 0.6\n TCO2\n 25\n 30\n 30\n Glucose\n 149\n 171\n 143\n 143\n 121\n Other labs: PT / PTT / INR:13.5/26.4/1.2, CK / CK-MB / Troponin\n T:272//, ALT / AST:27/67, Alk-Phos / T bili:66/2.8, Amylase /\n Lipase:88/156, Fibrinogen:380 mg/dL, Lactic Acid:3.4 mmol/L,\n Albumin:2.7 g/dL, LDH:855 IU/L, Ca:7.2 mg/dL, Mg:2.0 mg/dL, PO4:1.8\n mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 39 yo M POD 1 s/p splenectomy and distal\n pancreatectomy, no signs of abscess intra-abd and pt HD stable\n Neurologic: Pain controlled, Dilaudid PCA\n Cardiovascular: Beta-blocker, Stable HD. Tachycardic, but febrile.\n Pulmonary: IS, OOB, IS ; CXR L Pleural effusion\n Gastrointestinal / Abdomen: NPO s/p splenectomy and distal\n pancreatectomy; No Feeding tube for now per primary team. F/u primary\n team\ns recs re: starting feeding.\n Renal: Foley, Adequate UO\n Hematology: Stable anemia, mild thrombocytosis, m/p from\n inflammatory/infection process\n Endocrine: RISS with adequate glucose control. Keep < 150\n Infectious Disease: Spiked a temp Pan cultured; FU cultures. As of\n now, no evidence of infection. No Abx for now as no evidence of\n infection except elevated WBC, which is trending down.\n Lines / Tubes / Drains: Foley, PIV, L IJ\n Wounds: Dry dressings\n Fluids: LR, 60ml/hr\n Consults: General surgery\n Billing Diagnosis: Pancreatitis\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines: 18 Gauge - 06:42 AM; Multi Lumen - 10:46\n PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n Communication: ICU consent signed Comments:\n Code status: Full\n Disposition: Transfer to floor\n Total time spent: 20 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-04 00:00:00.000",
"description": "Intensivist Note",
"row_id": 682254,
"text": "TSICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o fever/chills;\n he went 9 days ago to OSH where he was admitted, had an elevated lipase\n and emesis; he was treated there conservatively for presumed\n pancreatitis & given abx; he left AMA & now has come to w/ LUQ pain,\n possible splenic rupture vs. abscess seen on CT abd. Has had no\n hypotension in ED\n Chief complaint:\n PMHx:\n recurrent acute pancreatitis\n Current medications:\n Viokase with meals\n 24 Hour Events:\n ARTERIAL LINE - STOP 02:21 AM\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Cefazolin - 11:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:31 PM\n Heparin Sodium (Prophylaxis) - 12:13 AM\n Metoprolol - 03:14 AM\n Other medications:\n Flowsheet Data as of 05:00 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: 37.2\nC (98.9\n HR: 114 (106 - 128) bpm\n BP: 171/86(106) {161/85(104) - 179/91(111)} mmHg\n RR: 23 (18 - 29) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 117.5 kg (admission): 115 kg\n CVP: 4 (0 - 17) mmHg\n Total In:\n 2,682 mL\n 483 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,682 mL\n 483 mL\n Blood products:\n Total out:\n 2,965 mL\n 690 mL\n Urine:\n 2,085 mL\n 650 mL\n NG:\n 150 mL\n Stool:\n Drains:\n 730 mL\n 40 mL\n Balance:\n -283 mL\n -207 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: No(t) PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 578 K/uL\n 9.7 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 4.9 mEq/L\n 16 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.7 %\n 29.6 K/uL\n [image002.jpg]\n 05:22 PM\n 07:10 PM\n 07:11 PM\n 10:51 PM\n 02:45 AM\n 02:52 AM\n 11:03 AM\n 11:05 AM\n 05:48 PM\n 01:30 AM\n WBC\n 29.0\n 28.7\n 29.6\n Hct\n 31\n 34.3\n 33.9\n 35.9\n 31.1\n 29.8\n 29.7\n Plt\n \n Creatinine\n 0.5\n 0.7\n 0.7\n 0.6\n TCO2\n 25\n 30\n 30\n Glucose\n 149\n 171\n 143\n 143\n 121\n Other labs: PT / PTT / INR:13.5/26.4/1.2, CK / CK-MB / Troponin\n T:272//, ALT / AST:27/67, Alk-Phos / T bili:66/2.8, Amylase /\n Lipase:88/156, Fibrinogen:380 mg/dL, Lactic Acid:3.4 mmol/L,\n Albumin:2.7 g/dL, LDH:855 IU/L, Ca:7.2 mg/dL, Mg:2.0 mg/dL, PO4:1.8\n mg/dL\n Assessment and Plan\n splenic rupture s/p splenectomy and distal pancreatectomy, no signs of\n abscess intra-abd and pt HD stable\n Assessment and Plan:\n Neurologic: Neuro checks Q: 4 hr, Pain controlled w/ Dilaudid PCA\n Cardiovascular: stable tachycardia to 120\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition:\n Renal: Foley\n Hematology: hct stable at 30\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds:\n Imaging:\n Fluids: LR, 100ml/hr\n Consults: General surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\n Multi Lumen - 10:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent:\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682117,
"text": "39 year old male POD #1 for splenectomy and paretial pancreactomy.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt alert and orientated. Pt c/o abdominal pain mild to on pain\n scale. Incision to abdomen dry and intact. Pt been afebrile at this\n time. Abdomen soft but distended. NG pulled out early this AM by\n patient. Pt has been NPO thus far. Primary team aware. Pt to keep N\n Action:\n Pt on PCA hydromorphone 0.25/6/2.5.\n Response:\n Pt has adequate pain coverage.\n Plan:\n Continue with PCA dilaudid. ? transfer to floor.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682118,
"text": "39 year old male POD #1 for splenectomy and paretial pancreactomy.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt alert and orientated. Pt c/o abdominal pain mild to on pain\n scale. Incision to abdomen dry and intact. Pt been afebrile at this\n time. Abdomen soft but distended. NG pulled out early this AM by\n patient. Pt has been NPO thus far. Primary team aware. Pt to keep N\n Action:\n Pt on PCA hydromorphone 0.25/6/2.5.\n Response:\n Pt has adequate pain coverage.\n Plan:\n Continue with PCA dilaudid. ? transfer to floor.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682382,
"text": "39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o fever/chills;\n he went 9 days ago to OSH where he was admitted, had an elevated lipase\n and emesis; he was treated there conservatively for presumed\n pancreatitis & given abx; he left AMA & now has come to w/ LUQ pain,\n possible splenic rupture vs. abscess seen on CT abd. Has had no\n hypotension in ED\n Hypertension, benign\n Assessment:\n Pt. SBP had been up to the 170\ns earlier this shift. He has since\n started on metoprolol 5mg every 6 hrs. Initially, metoprolol is\n effective but is not long acting and SBP is back up to 170 by the end\n of the 6 hr interval, may need every 4 hr doses. HR has been up to 116\n but again, with metoprolol is will drop down to 94-104 with an eventual\n increase when dose effectiveness wears down. Presently HR and BP are 95\n amd 157/87.\n Action:\n Metoprolol as ordered to keep BP and HR in better control.\n Response:\n HR and BP respond well to lopressor 5mg IV but effect is not long\n lasting.\n Plan:\n Cont. to monitor VS closely, cont. metoprolol 5mg every 6 hrs with\n possible need to go to every 4 hrs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain, in his abdomen. He has dilaudid PCA infusing\n and using efficiently. He states he has pain under control with PCA,\n 11.25 mg over this shift. Pt. has a slight moan with every breath,\n although when questioned about pain, he states,\nno, I\nm good\n . Pt.\n had a temp spike earlier this afternoon, he states- that was from\n pain\nDiscussed more probable vs changes due to pain.\n Action:\n Cont with PCA dilaudid.\n Response:\n Pain in control.\n Plan:\n Monitor pain and response with PCA.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682389,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp spiked today, 102.4. Bld cultures x 2, one from left IJ line and\n one peripheral stick, obtained. Urine also sent. Pt. attempting to get\n sputum specimen. CXR done. Tylenol given with gd response. Pt. using\n incentive spirometer, OOB. Fan in rm.\n Action:\n Cultures sent. CXR done . Pulmonary toilet. Tylenol.\n Response:\n Temp responds to actions.\n Plan:\n Cont to monitor temp. Cont pulm toilet and Tylenol as needed.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 684768,
"text": "Bacteremia\n Assessment:\n Tmax 100.1 this a.m. Pigtail drain via LUQ draining slightly turbid\n serosanguinous fluid\n per team this is an improvement. VSS. Pt. with\n minimal complaints today. Abdomen is softly distened.\n Action:\n Pt. continues on Vanco, Cipro, Cefipime, and Fluconazole. Drain care\n done this a.m. Tube feeds increased per order; pt. remains on TPN.\n Response:\n Temp down 99.4 at noontime. Vital signs remain stable. Pt. tolerating\n TF\n Plan:\n Continue present regimen, monitor and treat as indicated. To transfer\n to floor today.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt. with known PE, hemodynamically stable, no complaint of SOB.\n Action:\n PTT drawn, Heparin gtt titrated per sliding scale.\n Response:\n Afternoon PTT is pending.\n Plan:\n Continue to assess PTT and titrate heparin gtt per protocol.\n Pleural effusion, acute\n Assessment:\n LS diminished at bases with bibasilar crackles. Denies SOB. Left PCT\n in place, though no fluctuation or output noted. Sats stable.\n Action:\n Team aware of CT assessment. IS encouraged.\n Response:\n No change in pulmonary assessment.\n Plan:\n Mobilize pt, pulmonary hygiene. ?Plan to d/c CT to be addressed with\n team.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 684769,
"text": "Mr. is a 39yo gentleman with h/o recurrent pancreatitis admitted\n with ruptured spleen who is transferred to the unit in the setting of\n post-op respiratory distress.\n He was initially admitted to an OSH with LUQ pain, rigors, and\n lipase of 1100. He was initially treated for pancreatitis but had\n ongoing bilious emesis and developed fevers to 103. At that time, he\n was transferred to for further care on .\n Upon arrival at , he was found to have a CT scan concerning for\n splenic rupture. He was started on vancomycin, levofloxacin, and\n flagyl and he underwent splenic artery embolization on . He\n underwent splenectomy with distal pancreatectomy on . He was doing\n well post-op until he developed fevers and tachycardia. On , he\n had a CT torso that revealed left subsegmental PEs and a fluid\n collection in the LUQ with drain in place. He was on a heparin gtt.\n His course was complicated by significant left pleural effusion that\n was tapped on , yielding 500cc of serosanguinous fluid, exudative\n by Light's criteria. In addition, psychiatry was contact for\n delirium and recommended haldol as needed. Because of continued fevers\n with increasing abdominal distention, the team pursued a CT abd/pelvis\n that revealed the LUQ fluid pocket now had air consistent with an\n enteric leak. He therefore went back to the OR on for repair of\n his enteric leak.\n Bacteremia\n Assessment:\n Tmax 100.1 this a.m. Pigtail drain via LUQ draining slightly turbid\n serosanguinous fluid\n per team this is an improvement. VSS. Pt. with\n minimal complaints today. Abdomen is softly distened.\n Action:\n Pt. continues on Vanco, Cipro, Cefipime, and Fluconazole. Drain care\n done this a.m. Tube feeds increased per order; pt. remains on TPN.\n Response:\n Temp down 99.4 at noontime. Vital signs remain stable. Pt. tolerating\n TF\n Plan:\n Continue present regimen, monitor and treat as indicated. To transfer\n to floor today.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt. with known PE, hemodynamically stable, no complaint of SOB.\n Action:\n PTT drawn, Heparin gtt titrated per sliding scale.\n Response:\n Afternoon PTT is pending.\n Plan:\n Continue to assess PTT and titrate heparin gtt per protocol.\n Pleural effusion, acute\n Assessment:\n LS diminished at bases with bibasilar crackles. Denies SOB. Left PCT\n in place, though no fluctuation or output noted. Sats stable.\n Action:\n Team aware of CT assessment. IS encouraged.\n Response:\n No change in pulmonary assessment.\n Plan:\n Mobilize pt, pulmonary hygiene. ?Plan to d/c CT to be addressed with\n team.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 684773,
"text": "Mr. is a 39yo gentleman with h/o recurrent pancreatitis admitted\n with ruptured spleen who is transferred to the unit in the setting of\n post-op respiratory distress.\n He was initially admitted to an OSH with LUQ pain, rigors, and\n lipase of 1100. He was initially treated for pancreatitis but had\n ongoing bilious emesis and developed fevers to 103. At that time, he\n was transferred to for further care on .\n Upon arrival at , he was found to have a CT scan concerning for\n splenic rupture. He was started on vancomycin, levofloxacin, and\n flagyl and he underwent splenic artery embolization on . He\n underwent splenectomy with distal pancreatectomy on . He was doing\n well post-op until he developed fevers and tachycardia. On , he\n had a CT torso that revealed left subsegmental PEs and a fluid\n collection in the LUQ with drain in place. He was on a heparin gtt.\n His course was complicated by significant left pleural effusion that\n was tapped on , yielding 500cc of serosanguinous fluid, exudative\n by Light's criteria. In addition, psychiatry was contact for\n delirium and recommended haldol as needed. Because of continued fevers\n with increasing abdominal distention, the team pursued a CT abd/pelvis\n that revealed the LUQ fluid pocket now had air consistent with an\n enteric leak. He therefore went back to the OR on for repair of\n his enteric leak.\n Bacteremia\n Assessment:\n Temp 100 this a.m.101.2. Pigtail drain via LUQ draining slightly\n turbid serosanguinous fluid\n per team this is an improvement. VSS.\n Pt. with minimal complaints today. Abdomen is softly distened.\n Action:\n Pt. continues on Vanco, Cipro, Cefipime, and Fluconazole. Drain care\n done this a.m. Tube feeds increased per order; pt. remains on TPN.\n Response:\n Temp down 99.4 at noontime, but spiked to 101.2 this evening\n surgeon\n and medical team aware. Vital signs remain stable. Pt. tolerating\n TF\n Plan:\n Continue present regimen, monitor and treat as indicated. To transfer\n to floor today.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt. with known PE, hemodynamically stable, no complaint of SOB.\n Action:\n PTT drawn, Heparin gtt titrated per sliding scale.\n Response:\n Afternoon PTT is pending.\n Plan:\n Continue to assess PTT and titrate heparin gtt per protocol.\n Pleural effusion, acute\n Assessment:\n LS diminished at bases with bibasilar crackles. Denies SOB. Left PCT\n in place, though no fluctuation or output noted. Sats stable.\n Action:\n Team aware of CT assessment. IS encouraged.\n Response:\n No change in pulmonary assessment.\n Plan:\n Mobilize pt, pulmonary hygiene. ?Plan to d/c CT to be addressed with\n team.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 684774,
"text": "Mr. is a 39yo gentleman with h/o recurrent pancreatitis admitted\n with ruptured spleen who is transferred to the unit in the setting of\n post-op respiratory distress.\n He was initially admitted to an OSH with LUQ pain, rigors, and\n lipase of 1100. He was initially treated for pancreatitis but had\n ongoing bilious emesis and developed fevers to 103. At that time, he\n was transferred to for further care on .\n Upon arrival at , he was found to have a CT scan concerning for\n splenic rupture. He was started on vancomycin, levofloxacin, and\n flagyl and he underwent splenic artery embolization on . He\n underwent splenectomy with distal pancreatectomy on . He was doing\n well post-op until he developed fevers and tachycardia. On , he\n had a CT torso that revealed left subsegmental PEs and a fluid\n collection in the LUQ with drain in place. He was on a heparin gtt.\n His course was complicated by significant left pleural effusion that\n was tapped on , yielding 500cc of serosanguinous fluid, exudative\n by Light's criteria. In addition, psychiatry was contact for\n delirium and recommended haldol as needed. Because of continued fevers\n with increasing abdominal distention, the team pursued a CT abd/pelvis\n that revealed the LUQ fluid pocket now had air consistent with an\n enteric leak. He therefore went back to the OR on for repair of\n his enteric leak.\n Bacteremia\n Assessment:\n Temp 100 this a.m.101.2. Pigtail drain via LUQ draining slightly\n turbid serosanguinous fluid\n per team this is an improvement. VSS.\n Pt. with minimal complaints today. Abdomen is softly distened.\n Action:\n Pt. continues on Vanco, Cipro, Cefipime, and Fluconazole. Drain care\n done this a.m. Tube feeds increased per order; pt. remains on TPN.\n Response:\n Temp down 99.4 at noontime, but spiked to 101.2 this evening\n surgeon\n and medical team aware. No new treatments or orders at this time.\n Vital signs remain stable. Pt. tolerating TF\n Plan:\n Continue present regimen, monitor and treat as indicated. To transfer\n to floor today.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt. with known PE, hemodynamically stable, no complaint of SOB.\n Action:\n PTT drawn, Heparin gtt titrated per sliding scale.\n Response:\n Afternoon PTT is pending.\n Plan:\n Continue to assess PTT and titrate heparin gtt per protocol.\n Pleural effusion, acute\n Assessment:\n LS diminished at bases with bibasilar crackles. Denies SOB. Left PCT\n in place, though no fluctuation or output noted. Sats stable.\n Action:\n Team aware of CT assessment. IS encouraged.\n Response:\n No change in pulmonary assessment.\n Plan:\n Mobilize pt, pulmonary hygiene. ?Plan to d/c CT to be addressed with\n team.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 684777,
"text": "Mr. is a 39yo gentleman with h/o recurrent pancreatitis admitted\n with ruptured spleen who is transferred to the unit in the setting of\n post-op respiratory distress.\n He was initially admitted to an OSH with LUQ pain, rigors, and\n lipase of 1100. He was initially treated for pancreatitis but had\n ongoing bilious emesis and developed fevers to 103. At that time, he\n was transferred to for further care on .\n Upon arrival at , he was found to have a CT scan concerning for\n splenic rupture. He was started on vancomycin, levofloxacin, and\n flagyl and he underwent splenic artery embolization on . He\n underwent splenectomy with distal pancreatectomy on . He was doing\n well post-op until he developed fevers and tachycardia. On , he\n had a CT torso that revealed left subsegmental PEs and a fluid\n collection in the LUQ with drain in place. He was on a heparin gtt.\n His course was complicated by significant left pleural effusion that\n was tapped on , yielding 500cc of serosanguinous fluid, exudative\n by Light's criteria. In addition, psychiatry was contact for\n delirium and recommended haldol as needed. Because of continued fevers\n with increasing abdominal distention, the team pursued a CT abd/pelvis\n that revealed the LUQ fluid pocket now had air consistent with an\n enteric leak. He therefore went back to the OR on for repair of\n his enteric leak.\n Bacteremia\n Assessment:\n Temp 100 this a.m.101.2. Pigtail drain via LUQ draining slightly\n turbid serosanguinous fluid\n per team this is an improvement. VSS.\n Pt. with minimal complaints today. Abdomen is softly distened.\n Action:\n Pt. continues on Vanco, Cipro, Cefipime, and Fluconazole. Drain care\n done this a.m. Tube feeds increased per order; pt. remains on TPN.\n Response:\n Temp down 99.4 at noontime, but spiked to 101.2 this evening\n surgeon\n and medical team aware. No new treatments or orders at this time.\n Vital signs remain stable. Pt. tolerating TF\n Plan:\n Continue present regimen, monitor and treat as indicated. To transfer\n to floor today.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt. with known PE, hemodynamically stable, no complaint of SOB.\n Action:\n PTT drawn, Heparin gtt titrated per sliding scale.\n Response:\n Afternoon PTT is pending.\n Plan:\n Continue to assess PTT and titrate heparin gtt per protocol.\n Pleural effusion, acute\n Assessment:\n LS diminished at bases with bibasilar crackles. Denies SOB. Left PCT\n in place, though no fluctuation or output noted. Sats stable.\n Action:\n Team aware of CT assessment. IS encouraged.\n Response:\n No change in pulmonary assessment.\n Plan:\n Mobilize pt, pulmonary hygiene. ?Plan to d/c CT to be addressed with\n team.\n Pt currently afebrile. No further changes since assuming care of pt at\n 1900. abx given. Pt currently comfortable and pain free. No\n changes to heparin gtt. Next PTT due to be drawn at 2300. Pt\n hemodynamically stable. Report given to 12 .\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 684778,
"text": "Demographics\n Attending MD:\n T.\n Admit diagnosis:\n SPLENIC HEMORRHAGE\n Code status:\n Full code\n Height:\n 74 Inch\n Admission weight:\n 113.6 kg\n Daily weight:\n 113.6 kg\n Allergies/Reactions:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Precautions:\n PMH: Anemia, Pancreatitis\n CV-PMH:\n Additional history: subsequential PE, confusion, agitation ( called\n code purple few days back ) h/o 22 episodes of acute pancreatitis.\n Surgery / Procedure and date: - distal pancreatectomy and\n splenectomy\n - exp laprotomy ,lysis of adhesions, repair of jejunal\n enterotomy,gastric serosal patch,and J tube placement.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:125\n D:76\n Temperature:\n 97.1\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 3,892 mL\n 24h total out:\n 6,501 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 04:53 AM\n Potassium:\n 4.0 mEq/L\n 04:53 AM\n Chloride:\n 101 mEq/L\n 04:53 AM\n CO2:\n 29 mEq/L\n 04:53 AM\n BUN:\n 8 mg/dL\n 04:53 AM\n Creatinine:\n 0.5 mg/dL\n 04:53 AM\n Glucose:\n 129 mg/dL\n 04:53 AM\n Hematocrit:\n 25.1 %\n 04:53 AM\n Finger Stick Glucose:\n 171\n 06:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4\n Transferred to: 12 \n Date & time of Transfer: 2045 \n Mr. is a 39yo gentleman with h/o recurrent pancreatitis admitted\n with ruptured spleen who is transferred to the unit in the setting of\n post-op respiratory distress.\n He was initially admitted to an OSH with LUQ pain, rigors, and\n lipase of 1100. He was initially treated for pancreatitis but had\n ongoing bilious emesis and developed fevers to 103. At that time, he\n was transferred to for further care on .\n Upon arrival at , he was found to have a CT scan concerning for\n splenic rupture. He was started on vancomycin, levofloxacin, and\n flagyl and he underwent splenic artery embolization on . He\n underwent splenectomy with distal pancreatectomy on . He was doing\n well post-op until he developed fevers and tachycardia. On , he\n had a CT torso that revealed left subsegmental PEs and a fluid\n collection in the LUQ with drain in place. He was on a heparin gtt.\n His course was complicated by significant left pleural effusion that\n was tapped on , yielding 500cc of serosanguinous fluid, exudative\n by Light's criteria. In addition, psychiatry was contact for\n delirium and recommended haldol as needed. Because of continued fevers\n with increasing abdominal distention, the team pursued a CT abd/pelvis\n that revealed the LUQ fluid pocket now had air consistent with an\n enteric leak. He therefore went back to the OR on for repair of\n his enteric leak.\n Bacteremia\n Assessment:\n Temp 100 this a.m.101.2. Pigtail drain via LUQ draining slightly\n turbid serosanguinous fluid\n per team this is an improvement. VSS.\n Pt. with minimal complaints today. Abdomen is softly distened.\n Action:\n Pt. continues on Vanco, Cipro, Cefipime, and Fluconazole. Drain care\n done this a.m. Tube feeds increased per order; pt. remains on TPN.\n Response:\n Temp down 99.4 at noontime, but spiked to 101.2 this evening\n surgeon\n and medical team aware. No new treatments or orders at this time.\n Vital signs remain stable. Pt. tolerating TF\n Plan:\n Continue present regimen, monitor and treat as indicated. To transfer\n to floor today.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt. with known PE, hemodynamically stable, no complaint of SOB.\n Action:\n PTT drawn, Heparin gtt titrated per sliding scale.\n Response:\n Afternoon PTT is pending.\n Plan:\n Continue to assess PTT and titrate heparin gtt per protocol.\n Pleural effusion, acute\n Assessment:\n LS diminished at bases with bibasilar crackles. Denies SOB. Left PCT\n in place, though no fluctuation or output noted. Sats stable.\n Action:\n Team aware of CT assessment. IS encouraged.\n Response:\n No change in pulmonary assessment.\n Plan:\n Mobilize pt, pulmonary hygiene. ?Plan to d/c CT to be addressed with\n team.\n Pt currently afebrile. No further changes since assuming care of pt at\n 1900. abx given. Pt currently comfortable and pain free. No\n changes to heparin gtt. Next PTT due to be drawn at 2300. Pt\n hemodynamically stable. Report given to 12 .\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Intensivist Note",
"row_id": 682102,
"text": "TSICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o\n fever/chills; he went 9 days ago to OSH where he was admitted, had an\n elevated lipase and emesis; he was treated there conservatively for\n presumed pancreatitis & given abx; he left AMA & now has come to w/\n LUQ pain, possible splenic rupture vs. abscess seen on CT abd. Has had\n no hypotension in ED.\n Chief complaint:\n abd pain\n PMHx:\n PMH: recurrent acute pancreatitis\n PSH: appy, CCY\n pancreatic pseudocyst drainage (?cyst gastrostomy) ( Hosp)\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5.\n Calcium Gluconate 6. CefazoLIN\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Famotidine 9. Fentanyl\n Citrate 10. Heparin 11. Insulin\n 12. Ipratropium Bromide Neb 13. Magnesium Sulfate 14. Potassium\n Phosphate 15. Propofol 16. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - START 01:07 PM\n OR SENT - At 01:30 PM\n MULTI LUMEN - START 06:30 PM\n INVASIVE VENTILATION - START 07:00 PM\n MULTI LUMEN - STOP 10:45 PM\n MULTI LUMEN - START 10:46 PM\n FEVER - 101.2\nF - 07:00 AM\n : OR for splenectomy and distal pancreatectomy- spleen completely\n ruptured, also with bleeding from splenic vein and sbp in 70s--> got 7\n u prbcs, 2 u ffp, and 4 L crystalloid. Hct stable post-op and pt self\n extubated in a.m.\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Cefazolin - 04:00 AM\n Infusions:\n Fentanyl (Concentrate) - 30 mcg/hour\n Other ICU medications:\n Famotidine (Pepcid) - 07:43 PM\n Heparin Sodium (Prophylaxis) - 11:36 PM\n Other medications:\n Flowsheet Data as of 06:27 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: 38.4\nC (101.1\n HR: 128 (110 - 129) bpm\n BP: 146/88(101) {139/76(95) - 151/93(156)} mmHg\n RR: 29 (14 - 29) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 117.5 kg (admission): 115 kg\n CVP: 6 (-1 - 8) mmHg\n Total In:\n 8,877 mL\n 838 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,248 mL\n 838 mL\n Blood products:\n 2,549 mL\n Total out:\n 5,085 mL\n 935 mL\n Urine:\n 1,715 mL\n 485 mL\n NG:\n Stool:\n Drains:\n 120 mL\n 450 mL\n Balance:\n 3,792 mL\n -97 mL\n Respiratory support\n O2 Delivery Device: Medium conc mask\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 628 (628 - 628) mL\n PS : 5 cmH2O\n RR (Set): 16\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 31\n PIP: 6 cmH2O\n Plateau: 9 cmH2O\n SPO2: 96%\n ABG: 7.43/44/87./27/3\n Ve: 12.4 L/min\n PaO2 / FiO2: 176\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Tender: mild throughout, no r/g/r\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: No(t) Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 390 K/uL\n 12.0 g/dL\n 143 mg/dL\n 0.7 mg/dL\n 27 mEq/L\n 5.2 mEq/L\n 18 mg/dL\n 103 mEq/L\n 137 mEq/L\n 35.9 %\n 28.7 K/uL\n [image002.jpg]\n 02:32 AM\n 02:55 PM\n 04:00 PM\n 05:00 PM\n 05:22 PM\n 07:10 PM\n 07:11 PM\n 10:51 PM\n 02:45 AM\n 02:52 AM\n WBC\n 24.4\n 29.0\n 28.7\n Hct\n 30.8\n 28\n 30\n 33\n 31\n 34.3\n 33.9\n 35.9\n Plt\n 474\n 304\n 390\n Creatinine\n 0.7\n 0.5\n 0.7\n TCO2\n 32\n 27\n 25\n 30\n 30\n Glucose\n 111\n 112\n 124\n 141\n 149\n 171\n 143\n Other labs: PT / PTT / INR:14.0/28.5/1.2, CK / CK-MB / Troponin\n T:272//, ALT / AST:27/67, Alk-Phos / T bili:66/2.8, Amylase /\n Lipase:88/156, Fibrinogen:380 mg/dL, Lactic Acid:3.4 mmol/L,\n Albumin:2.7 g/dL, LDH:855 IU/L, Ca:7.4 mg/dL, Mg:2.1 mg/dL, PO4:3.5\n mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 39 yo M POD 1 s/p splenectomy and distal\n pancreatectomy, no signs of abscess intra-abd and pt HD stable\n Neurologic: Neuro checks Q: 4 hr\n Cardiovascular: - tachy to 120s with good urine output and without\n hypotension. Likely combo of SIRS response + pain.\n - optimize pain control for tachycardia\n Pulmonary: - no acute issues- self extubated and tolerating well\n -incentive spirometer\n Gastrointestinal / Abdomen: - s/p splenectomy and distal\n pancreatectomy. Keep NPO\n Nutrition: NPO for now.\n Renal: Foley, Adequate UO, -nl Cr\n -monitor U output\n Hematology: Serial Hct, -Hct stable at 36 o/n, increase to Q 6 hcts\n Endocrine: hyperglycemia. Tighten RISS\n Infectious Disease: - leukocytosis likely SIRS response given\n unremarkable intraop findings\n no abscess. cont periop cefazolin x 3\n doses, no acute issues\n - wbc count stable at 28\n Lines / Tubes / Drains: Foley, Dobhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: LR\n Consults: General surgery\n Billing Diagnosis: (Shock: Unspecified)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\n Arterial Line - 01:07 PM\n Multi Lumen - 10:46 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: full\n Disposition: icu\n Total time spent: 32mins\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-05 00:00:00.000",
"description": "Intensivist Note",
"row_id": 682421,
"text": "SICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o fever/chills;\n he went 9 days ago to OSH where he was admitted, had an elevated lipase\n and emesis; he was treated there conservatively for presumed\n pancreatitis & given abx; he left AMA & now has come to w/ LUQ pain,\n possible splenic rupture vs. abscess seen on CT abd. Has had no\n hypotension in ED.\n .\n PMHx:\n PMH: recurrent acute pancreatitis\n PSH: appy, CCY\n pancreatic pseudocyst drainage (?cyst gastrostomy) ( Hosp)\n : Viokase with meals\n Vicodin prn\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Albuterol 0.083% Neb Soln 5.\n Calcium Gluconate 6. Famotidine 7. HYDROmorphone (Dilaudid) 8. Heparin\n 9. Insulin 10. Ipratropium Bromide Neb 11. Magnesium Sulfate 12.\n Metoprolol Tartrate 13. Potassium Phosphate 14. Sodium Chloride 0.9%\n Flush 15. Sodium Phosphate\n 24 Hour Events:\n ARTERIAL LINE - STOP 02:21 AM\n : OR for splenectomy and distal pancreatectomy- spleen completely\n ruptured, also with bleeding from splenic vein and sbp in 70s--> got 7\n u prbcs, 2 u ffp, and 4 L crystalloid. Hct stable post-op and pt self\n extubated in a.m.\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Cefazolin - 11:54 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:27 PM\n Heparin Sodium (Prophylaxis) - 11:59 PM\n Metoprolol - 11:59 PM\n Other medications:\n Flowsheet Data as of 03:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39\nC (102.2\n T current: 37.8\nC (100\n HR: 108 (93 - 120) bpm\n BP: 156/96(110) {136/48(57) - 179/96(110)} mmHg\n RR: 18 (17 - 35) insp/min\n SPO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 117.5 kg (admission): 115 kg\n Total In:\n 1,696 mL\n 210 mL\n PO:\n 40 mL\n Tube feeding:\n IV Fluid:\n 1,656 mL\n 210 mL\n Blood products:\n Total out:\n 3,035 mL\n 315 mL\n Urine:\n 2,915 mL\n 290 mL\n NG:\n Stool:\n Drains:\n 120 mL\n 25 mL\n Balance:\n -1,339 mL\n -105 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 100%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Diminished: L\n base)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 578 K/uL\n 9.7 g/dL\n 121 mg/dL\n 0.6 mg/dL\n 31 mEq/L\n 4.9 mEq/L\n 16 mg/dL\n 103 mEq/L\n 138 mEq/L\n 29.7 %\n 29.6 K/uL\n [image002.jpg]\n 05:22 PM\n 07:10 PM\n 07:11 PM\n 10:51 PM\n 02:45 AM\n 02:52 AM\n 11:03 AM\n 11:05 AM\n 05:48 PM\n 01:30 AM\n WBC\n 29.0\n 28.7\n 29.6\n Hct\n 31\n 34.3\n 33.9\n 35.9\n 31.1\n 29.8\n 29.7\n Plt\n \n Creatinine\n 0.5\n 0.7\n 0.7\n 0.6\n TCO2\n 25\n 30\n 30\n Glucose\n 149\n 171\n 143\n 143\n 121\n Other labs: PT / PTT / INR:13.5/26.4/1.2, CK / CK-MB / Troponin\n T:272//, ALT / AST:27/67, Alk-Phos / T bili:66/2.8, Amylase /\n Lipase:88/156, Fibrinogen:380 mg/dL, Lactic Acid:3.4 mmol/L,\n Albumin:2.7 g/dL, LDH:855 IU/L, Ca:7.2 mg/dL, Mg:2.0 mg/dL, PO4:1.8\n mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: 39 yo M POD 1 s/p splenectomy and distal\n pancreatectomy, no signs of abscess intra-abd and pt HD stable\n Neurologic: Pain controlled, Dilaudid PCA\n Cardiovascular: Beta-blocker, Stable\n Pulmonary: IS, OOB, IS ; CXR L Pleural effusion\n Gastrointestinal / Abdomen: NPO s/p splenectomy and distal\n pancreatectomy; No Feeding tube for now per primary team\n Renal: Foley, Adequate UO\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: Spiked a temp Pan cultured; FU cultures\n Lines / Tubes / Drains: Foley, PIV, L IJ\n Wounds: Dry dressings\n Fluids: LR, 60ml/hr\n Consults: General surgery\n Billing Diagnosis: Pancreatitis\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines: 18 Gauge - 06:42 AM; Multi Lumen - 10:46\n PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n Communication: ICU consent signed Comments:\n Code status: Full\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682499,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt with T max of 103 PO, Pt with blood cultures and urine culture pnd\n from yesterday, sputum spec obtained at 4am, sputum thick greenish\n yellow, breath sounds diminished at bases yet clear in upper lobes.\n Action:\n Pulmonary hygiene encouraged, sputum spec sent for culture, Tylenol and\n cool bath given for fever\n Response:\n Pt remains febrile at this time\n Plan:\n Con\nt with pulmonary hygiene, follow fever and cultures, advance\n activity as tolerated\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt on PCA Dilaudid, pain level 3 at rest, with coughing\n Action:\n Pt encouraged to use PCA\n Response:\n Good relief from PCA\n Plan:\n Con\nt to monitor and assess per care plan\n Hypertension, benign\n Assessment:\n Pt tachycardic w/ HR 100-110 over night and BP from 140-160/80\n Action:\n Dose and frequency of lopressor increased to 7.5mg IVP every four\n hours.\n Response:\n Pt w/ small response to increased dose of lopressor.\n Plan:\n Con\nt to monitor , adjust meds as ordered, control HR by antipyretcs\n and pain med as well.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682109,
"text": "39 year old male POD #1 for splenectomy and paretial pancreactomy.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt alert and orientated. Pt c/o abdominal pain mild to on pain\n scale. Incision to abdomen dry and intact. Pt been afebrile at this\n time. Abdomen soft but distended. NG pulled out early this AM by\n patient. Pt has been NPO thus far. Primary team aware\n Action:\n Pt on PCA hydromorphone 0.25/6/2.5.\n Response:\n Pt has adequate pain coverage.\n Plan:\n Continue with PCA dilaudid. ? transfer to floor.\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 684706,
"text": "Chief Complaint: Sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Overall continues to feel improved.\n Pain management improved now on dilaudid PCA pump.\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Fluconazole - 10:09 PM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 09:21 AM\n Cefipime - 10:21 AM\n Infusions:\n Heparin Sodium - 2,050 units/hour\n Other ICU medications:\n Metoprolol - 12:21 AM\n Pantoprazole (Protonix) - 08:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, 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, 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, Tube feeds, Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Endocrine: Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:59 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: 95 (82 - 104) bpm\n BP: 115/93(98) {115/68(85) - 150/93(104)} mmHg\n RR: 13 (13 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 4,798 mL\n 2,166 mL\n PO:\n TF:\n 166 mL\n 287 mL\n IVF:\n 2,800 mL\n 901 mL\n Blood products:\n Total out:\n 8,245 mL\n 4,145 mL\n Urine:\n 6,785 mL\n 3,950 mL\n NG:\n Stool:\n Drains:\n 480 mL\n 115 mL\n Balance:\n -3,447 mL\n -1,979 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///29/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: 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: No(t) Soft, No(t) Non-tender, Bowel sounds present,\n Distended, Tender: , No(t) Obese, Midline surgical incision;\n percutaneous drains on left\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): , Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.5 g/dL\n 1124 K/uL\n 129 mg/dL\n 0.5 mg/dL\n 29 mEq/L\n 4.0 mEq/L\n 8 mg/dL\n 101 mEq/L\n 135 mEq/L\n 25.1 %\n 13.9 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n 03:00 PM\n 08:20 PM\n 09:00 PM\n 02:56 AM\n 01:25 AM\n 05:45 PM\n 04:53 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n 15.4\n 13.9\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n 25.0\n 23.8\n 25.1\n Plt\n 1\n 1109\n 1173\n 1120\n 1124\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n 0.6\n 0.5\n TCO2\n 27\n Glucose\n 135\n 142\n 115\n 105\n 96\n 129\n Other labs: PT / PTT / INR:14.9/40.6/1.3, ALT / AST:24/33, Alk Phos / T\n Bili:133/0.5, Amylase / Lipase:80/120, Differential-Neuts:70.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:11.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:359 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n 39 yomh/o recurrent pancreatitis, recent surgery for splenectomy,\n enteric leak now with post-operative respiratory distress and delerium\n (recurrent).\n RESPIRATORY DISTRESS\n Much improved. Multifactorial. Suspect\n contribution of bacteremia and sepsis, acidosis, left pleural effusion,\n left atalectasis, pulmonary emboli (off anticoagulation), and abdominal\n pain (splinting). Continue treat sepsis, antibiotics, iv fliuds,\n optimize pain management, maintain upright position. Consider left\n thoracentesis if expands.\n TACHYCARDIA\n Improved. Likley reflected respiratory distress, pain,\n hypovolemia, possible pulmonary embolism. Monitor HR, check EKG.\n Replete iv fluid, optimize pain, treat sepsis/bacteremia.\n SEPSIS -- evidence for line-related infection and now suspect\n peritoneal source. For Abd CT imaging to assess for collection.\n Continue Cipro, Cefopime, Vanco, Fluconozole.\n BACTEREMIA\n GPC, possible line related, but concern for enteric\n infection. Remove central lines if possible (use peripheral if\n feasible). Continue Vanco.\n PULMONARY EMBOLI\n left, subsegmental, multiple. Continue\n anticoagulation --> monitor PTT 60-80.\n PLEURAL EFFUSION\n suspect sympathetic and related to abdominal\n surgeries. S/p drainage. Chest tube not draining, and without\n respiratory variation on water seal --> would D/C.\n s/p ENTERIC LEAK -- NGT with intermittent suction, antibiotics, await\n culture results. For Abd CT today.\n PAIN MANAGEMENT\n post-op. Improved on Dilaudid PCA pump.\n s/p SPLENECTOMY -- will need meningococcal and pneumococcal vaccines\n FLUID\n Euvolemic. Monitor I/O, maintain balance.\n THROMBOCYTOSIS\n perhaps reactive. ? reactive. be contributing to\n clotting (pulmonary emboli, clot on PICC line) as value exceeds 1\n million. Monitor. Hematology consult.\n DELERIUM\n recurrent. Possible related to medications and contribution\n of sepsis (toxic-metabolic). Improved this AM.\n NUTRITIONAL SUPPORT -- NPO. Trophic TF. Resume TPN once central\n access established.\n RECURRENT PANCREATITS -- Unclear cause, but consider cystic fibrosis\n given family history. Recheck amylase, lipase and monitor clinical\n exam.\n ICU Care\n Nutrition:\n Replete () - 12:48 PM 30 mL/hour\n TPN w/ Lipids - 06:31 PM 88 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683793,
"text": "39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, and now transferred to MICU for post-op\n respiratory distress.\n Tachycardia, Other\n Assessment:\n HR 100\ns-110\ns in sinus tach.\n Action:\n Given Lopressor 2.5 mg IV Q 6 hours. Remains on LR at 125 ml/hr.\n Response:\n HR maintained in 100\ns in sinus rythym.pt temp 101.4 blood and urine\n cultures sent\n Plan:\n Continue to monitor and give Lopressor 2.5 mg IV Q 6 hours.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known hx of PE. Started on Heparin gtt on . On 3 L NC.\n Action:\n SCD on. PTT Q6 hr.\n Response:\n ptt@830 55.6 oob to chair without distress. Not increased per team due\n to 5 pt hct drop.\n Plan:\n Continue to monitor PTT and resp status. Next PTT due at 1400\n s/p laperotomy, Pain control (acute pain, chronic pain)\n Assessment:\n S/P laperotomy. Dsd Removed this morning. Abd firm and distended. But\n pt states that abdomen feels less tense than yesterday and that he is\n burping but unsure if he has flatus. Pt on low con\nt wall suction\n via NGT. 2 JP drains present draining serous/serosanguinous fluid. J\n tube clamped. PCA pump with Dilaudid working well for pt.\n Action:\n Monitor for pain.\n Response:\n NGT draining bilious fluid. Pt currently A&O x 3. Pain level 0-4/10\n and Pt. states Pain tolerable. Coughing and expectorating mod amounts\n of thick tan secretions using is 750-x10 oob to chair x2 with 2person\n assist.\n Plan:\n Continue pain management. Monitor incision site and f/u with surgery.\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 683796,
"text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Pain control improved today.\n Overall, states to be much improved.\n Denies dyspnea - states breathing much easier.\n Using incentive spirometer.\n Up in chair.\n Heparin resumed yesterday.\n TPN resumed.\n History obtained from Medical records\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Metronidazole - 01:11 AM\n Vancomycin - 08:07 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:05 PM\n Heparin Sodium - 06:31 PM\n Pantoprazole (Protonix) - 12:00 AM\n Metoprolol - 12:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: Mild\n Pain location: Abd surgical incision\n Flowsheet Data as of 11:39 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: 115 (101 - 125) bpm\n BP: 137/72(88) {120/60(75) - 148/85(98)} mmHg\n RR: 24 (17 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 8 (7 - 23)mmHg\n Total In:\n 7,360 mL\n 2,868 mL\n PO:\n TF:\n IVF:\n 6,405 mL\n 1,920 mL\n Blood products:\n 500 mL\n Total out:\n 1,725 mL\n 985 mL\n Urine:\n 1,435 mL\n 945 mL\n NG:\n 225 mL\n Stool:\n Drains:\n 65 mL\n 40 mL\n Balance:\n 5,635 mL\n 1,883 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///26/\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: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: No(t) Soft, No(t) Non-tender, No(t) Bowel sounds present,\n Distended, No(t) Tender: , No(t) Obese, Firm, but much less tender;\n Midline surgical incision with staples, and 2 JP drains from left\n quadrants.\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): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.9 g/dL\n 994 K/uL\n 142 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.5 %\n 20.7 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n WBC\n 21.9\n 20.7\n Hct\n 31.6\n 25.8\n 26.5\n Plt\n 1058\n 994\n Cr\n 0.7\n 0.6\n Glucose\n 135\n 142\n Other labs: PT / PTT / INR:15.8/55.6/1.4, ALT / AST:21/32, Alk Phos / T\n Bili:52/0.7, Amylase / Lipase:65/110, Differential-Neuts:79.0 %,\n Band:0.0 %, Lymph:16.0 %, Mono:3.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Albumin:2.2 g/dL, LDH:357 IU/L, Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:1.9\n mg/dL\n Assessment and Plan\n 39 yomh/o recurrent pancreatitis, recent surgery for splenectomy,\n enteric leak now with post-operative respiratory distress.\n RESPIRATORY DISTRESS\n Much improved. Multifactorial. Suspect\n contribution of bacteremia and sepsis, acidosis, left pleural effusion,\n left atalectasis, pulmonary emboli (off anticoagulation), and abdominal\n pain. Plan treat sepsis, antibiotics, iv fliuds, optimize pain\n management, maintain upright position. Consider left thoracentesis if\n expands.\n TACHYCARDIA\n likley reflects respiratory distress, pain, hypovolemia,\n possible pulmonary embolism. Monitor HR, check EKG. Replete iv fluid,\n optimize pain, treat sepsis/bacteremia.\n BACTEREMIA\n GPC, possible line related, but concern for enteric\n infection. Remove central lines if possible (use peripheral if\n feasible). Continue Vanco.\n PULMONARY EMBOLI\n left, subsegmental, multiple. Resumed\n anticoagulation as per Surgery --> monitor PTT 60-80\n PLEURAL EFFUSION\n suspect sympathetic and related to abdominal\n surgeries.\n s/p ENTERIC LEAK -- NGT with intermittent suction, antibiotics, await\n culture results.\n PAIN MANAGEMENT\n post-op. PCA pump, optimize dosing.\n s/p SPLENECTOMY -- will need meningococcal and pneumococcal vaccines\n FLIUD\n desire net volume expension.\n THROMBOCYTOSIS\n perhaps reactive. Monitor.\n DELERIUM\n resolved.\n NUTRITIONAL SUPPORT -- NPO. Continue TPN.\n RECURRENT PANCREATITS -- Unclear cause, but consider cystic fibrosis\n given family history. Recheck amylase, lipase and monitor clinical\n exam.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:31 PM 83 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684760,
"text": "Bacteremia\n Assessment:\n Tmax 100.1 this a.m. Pigtail drain via LUQ draining slightly turbid\n serosanguinous fluid\n per team this is an improvement. VSS. Pt. with\n minimal complaints today. Abdomen is softly distened.\n Action:\n Pt. continues on Vanco, Cipro, Cefipime, and Fluconazole. Drain care\n done this a.m. Tube feeds increased per order; pt. remains on TPN.\n Response:\n Temp down 99.4 at noontime. Vital signs remain stable. Pt. tolerating\n TF\n Plan:\n Continue present regimen, monitor and treat as indicated. To transfer\n to floor today.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt. with known PE, hemodynamically stable, no complaint of SOB.\n Action:\n PTT drawn, Heparin gtt titrated per sliding scale.\n Response:\n Afternoon PTT is pending.\n Plan:\n Continue to assess PTT and titrate heparin gtt per protocol.\n Pleural effusion, acute\n Assessment:\n LS diminished at bases with bibasilar crackles. Denies SOB. Left PCT\n in place, though no fluctuation or output noted. Sats stable.\n Action:\n Team aware of CT assessment. IS encouraged.\n Response:\n No change in pulmonary assessment.\n Plan:\n Mobilize pt, pulmonary hygiene. ?Plan to d/c CT to be addressed with\n team.\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: , RN\n on: 18:48 ------\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684763,
"text": "Bacteremia\n Assessment:\n Tmax 100.1 this a.m. Pigtail drain via LUQ draining slightly turbid\n serosanguinous fluid\n per team this is an improvement. VSS. Pt. with\n minimal complaints today. Abdomen is softly distened.\n Action:\n Pt. continues on Vanco, Cipro, Cefipime, and Fluconazole. Drain care\n done this a.m. Tube feeds increased per order; pt. remains on TPN.\n Response:\n Temp down 99.4 at noontime. Vital signs remain stable. Pt. tolerating\n TF\n Plan:\n Continue present regimen, monitor and treat as indicated. To transfer\n to floor today.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt. with known PE, hemodynamically stable, no complaint of SOB.\n Action:\n PTT drawn, Heparin gtt titrated per sliding scale.\n Response:\n Afternoon PTT is pending.\n Plan:\n Continue to assess PTT and titrate heparin gtt per protocol.\n Pleural effusion, acute\n Assessment:\n LS diminished at bases with bibasilar crackles. Denies SOB. Left PCT\n in place, though no fluctuation or output noted. Sats stable.\n Action:\n Team aware of CT assessment. IS encouraged.\n Response:\n No change in pulmonary assessment.\n Plan:\n Mobilize pt, pulmonary hygiene. ?Plan to d/c CT to be addressed with\n team.\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: , RN\n on: 18:48 ------\n Addendum: Pt. did spike temp this evening to 101.2 PO. Attending\n surgeon and micu team aware, no new orders at this time. Tylenol\n given, pt. diaphoretic at present. Pt .has been up in the chair since\n approximately 1650 and tolerating well. Drainage output as noted. All\n findings d/w Dr. .\n ------ Protected Section Addendum Entered By: , RN\n on: 18:50 ------\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684079,
"text": " is a 39yo gentleman, who is readmitted to the ICU in the setting\n of agitation and tachycardia.\n He has a h/o recurrent episodes of pancreatitis and was initially\n admitted in early to an OSH with suspected pancreatitis. When he\n continued to have fevers, he was sent to , where he was found to have\n a ruptured spleen. He initially had a splenic artery embolization \n and then had splenectomy with distal pancreatectomy on .\n Unfortunately, he continued to have fevers and tachycardia post-op. As\n part of his tachycardia work-up, he underwent a CT torso that showed a\n subsegmental PE and a thoracentesis for left pleural\n effusion--exudative but not infected. On , he was taken back to the\n OR when it was discovered that he had a LUQ fluid collection with air\n in it c/w an enteric leak. He then came to the ICU post-op for\n respiratory distress in the setting of significant reaccumulation of\n his pleural effusion. He was bolused IV fluids with improvement in his\n urine output and tachycardia and then sent back to the surgical floor.\n He was continued on his vanc, cipro, and flagyl that he had been\n started upon admission to .On the surgical floor, he was initially\n doing well, but then was noted to become increasingly tachycardic and\n agitated. Although his mother came to visit him, she reports he was\n \"in outer space.\" He then became febrile to 101.8 and the surgery team\n asked that he be brought back to the ICU.\n Delirium / confusion\n Assessment:\n Patient is lethargic, oriented x1, following commands, confused,this\n may be secondary to his pain medications or could be a manifestation of\n severe infection +/- sepsis.\n Action:\n Frequent reorientation , continue to monitor\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Sub segmental PE\ns and patient is on heparin gtt 1800units per hr\n Action:\n PTT monitored and it is within therapeutic range\n Response:\n Plan:\n Continue heparin gtt, monitor for bleeding and PTT Q6hrs\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient was pain free at the beginning of shift and he was sleeping\n Action:\n Later during night, did c/o abdominal pain , sharp and\n hydromorphone 0.25mg iv given with good effect\n Response:\n Pain after pain med\n Plan:\n Pain consult in Am, frequent change of position\n Leukocytosis/fever\n Assessment:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . pancreatitis (lipase\n slightly increasing), or pneumonia. Patient has low grade temp, WBC,\n Action:\n started fluconazole for coverage, fungal blood culture sent,\n cefepime started,\n - continue vancomycin and cipro\n Response:\n Plan:\n Continue antibiotics, F/U culture data, monitor temp curve\n Electrolyte & fluid disorder, other\n Assessment:\n K\n, Mag, PHOs, and calcium, patient was on TPN during day time and\n patient pulled his PICC line and since then off TPN. On TF 10ml/hr, do\n not advance further\n Action:\n Repleted with K phos, ca gluconate and magnesium sulphate\n Response:\n Plan:\n Repeat labs in Am, and replete accordingly\n On contact precaution for c diff, 3^rd sample results pending, flexy\n seal placed,\n TF continued to be 10ml/hr via J tube and not to advance further as per\n surgeons\n Lt side abd wound dressing intact, staple intact, 2 JP drain very\n minimal/no drains\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684069,
"text": " is a 39yo gentleman, who is readmitted to the ICU in the setting\n of agitation and tachycardia.\n He has a h/o recurrent episodes of pancreatitis and was initially\n admitted in early to an OSH with suspected pancreatitis. When he\n continued to have fevers, he was sent to , where he was found to have\n a ruptured spleen. He initially had a splenic artery embolization \n and then had splenectomy with distal pancreatectomy on .\n Unfortunately, he continued to have fevers and tachycardia post-op. As\n part of his tachycardia work-up, he underwent a CT torso that showed a\n subsegmental PE and a thoracentesis for left pleural\n effusion--exudative but not infected. On , he was taken back to the\n OR when it was discovered that he had a LUQ fluid collection with air\n in it c/w an enteric leak. He then came to the ICU post-op for\n respiratory distress in the setting of significant reaccumulation of\n his pleural effusion. He was bolused IV fluids with improvement in his\n urine output and tachycardia and then sent back to the surgical floor.\n He was continued on his vanc, cipro, and flagyl that he had been\n started upon admission to .On the surgical floor, he was initially\n doing well, but then was noted to become increasingly tachycardic and\n agitated. Although his mother came to visit him, she reports he was\n \"in outer space.\" He then became febrile to 101.8 and the surgery team\n asked that he be brought back to the ICU.\n Delirium / confusion\n Assessment:\n Patient is lethargic, oriented x1, following commands, confused,this\n may be secondary to his pain medications or could be a manifestation of\n severe infection +/- sepsis.\n Action:\n Frequent reoriention , continue to monitor\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Leukocytosis/fever\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684071,
"text": " is a 39yo gentleman, who is readmitted to the ICU in the setting\n of agitation and tachycardia.\n He has a h/o recurrent episodes of pancreatitis and was initially\n admitted in early to an OSH with suspected pancreatitis. When he\n continued to have fevers, he was sent to , where he was found to have\n a ruptured spleen. He initially had a splenic artery embolization \n and then had splenectomy with distal pancreatectomy on .\n Unfortunately, he continued to have fevers and tachycardia post-op. As\n part of his tachycardia work-up, he underwent a CT torso that showed a\n subsegmental PE and a thoracentesis for left pleural\n effusion--exudative but not infected. On , he was taken back to the\n OR when it was discovered that he had a LUQ fluid collection with air\n in it c/w an enteric leak. He then came to the ICU post-op for\n respiratory distress in the setting of significant reaccumulation of\n his pleural effusion. He was bolused IV fluids with improvement in his\n urine output and tachycardia and then sent back to the surgical floor.\n He was continued on his vanc, cipro, and flagyl that he had been\n started upon admission to .On the surgical floor, he was initially\n doing well, but then was noted to become increasingly tachycardic and\n agitated. Although his mother came to visit him, she reports he was\n \"in outer space.\" He then became febrile to 101.8 and the surgery team\n asked that he be brought back to the ICU.\n Delirium / confusion\n Assessment:\n Patient is lethargic, oriented x1, following commands, confused,this\n may be secondary to his pain medications or could be a manifestation of\n severe infection +/- sepsis.\n Action:\n Frequent reoriention , continue to monitor\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient was pain free at the beginning of shift and he was sleeping\n Action:\n Later during night, did c/o abdominal pain , sharp and\n hydromorphone 0.25mg iv given with good effect\n Response:\n Pain after pain med\n Plan:\n Pain consult in Am, frequent change of position\n Leukocytosis/fever\n Assessment:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . pancreatitis (lipase\n slightly increasing), or pneumonia. Patient has low grade temp, WBC,\n Action:\n started fluconazole for coverage, fungal blood culture sent,\n cefepime started,\n - continue vancomycin and cipro\n Response:\n Plan:\n Continue antibiotics, F/U culture data, monitor temp curve\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684072,
"text": " is a 39yo gentleman, who is readmitted to the ICU in the setting\n of agitation and tachycardia.\n He has a h/o recurrent episodes of pancreatitis and was initially\n admitted in early to an OSH with suspected pancreatitis. When he\n continued to have fevers, he was sent to , where he was found to have\n a ruptured spleen. He initially had a splenic artery embolization \n and then had splenectomy with distal pancreatectomy on .\n Unfortunately, he continued to have fevers and tachycardia post-op. As\n part of his tachycardia work-up, he underwent a CT torso that showed a\n subsegmental PE and a thoracentesis for left pleural\n effusion--exudative but not infected. On , he was taken back to the\n OR when it was discovered that he had a LUQ fluid collection with air\n in it c/w an enteric leak. He then came to the ICU post-op for\n respiratory distress in the setting of significant reaccumulation of\n his pleural effusion. He was bolused IV fluids with improvement in his\n urine output and tachycardia and then sent back to the surgical floor.\n He was continued on his vanc, cipro, and flagyl that he had been\n started upon admission to .On the surgical floor, he was initially\n doing well, but then was noted to become increasingly tachycardic and\n agitated. Although his mother came to visit him, she reports he was\n \"in outer space.\" He then became febrile to 101.8 and the surgery team\n asked that he be brought back to the ICU.\n Delirium / confusion\n Assessment:\n Patient is lethargic, oriented x1, following commands, confused,this\n may be secondary to his pain medications or could be a manifestation of\n severe infection +/- sepsis.\n Action:\n Frequent reoriention , continue to monitor\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Sub segmental PE\ns and patient is on heparin gtt 1800units per hr\n Action:\n PTT monitored and it is within therapeutic range\n Response:\n Plan:\n Continue heparin gtt, monitor for bleeding and PTT Q6hrs\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient was pain free at the beginning of shift and he was sleeping\n Action:\n Later during night, did c/o abdominal pain , sharp and\n hydromorphone 0.25mg iv given with good effect\n Response:\n Pain after pain med\n Plan:\n Pain consult in Am, frequent change of position\n Leukocytosis/fever\n Assessment:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . pancreatitis (lipase\n slightly increasing), or pneumonia. Patient has low grade temp, WBC,\n Action:\n started fluconazole for coverage, fungal blood culture sent,\n cefepime started,\n - continue vancomycin and cipro\n Response:\n Plan:\n Continue antibiotics, F/U culture data, monitor temp curve\n Sinus Tachy: HR 110-high 120\ns, 1L bolus LR fluid given, patient has\n low grade temp and abdominal pain,continued on IV lopressor 2.5mg.\n Contine to have loose stool, flexy seal place, on contact precaution,\n stool; 3^rd sample for c diff results pending\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 684150,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 09:12 PM\n Blood culture x2 and for fungal\n FEVER - 101.9\nF - 06:25 PM\n No acute events overnight\npt mental state fluctuates in and out of\n delerium\n Started on cefepime and fluconazole, continued vanc and cipro\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 10:30 AM\n Vancomycin - 10:06 PM\n Ciprofloxacin - 10:06 PM\n Cefipime - 10:50 PM\n Fluconazole - 11:00 PM\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 38.4\nC (101.2\n HR: 115 (99 - 121) bpm\n BP: 139/77(87) {131/66(82) - 149/85(99)} mmHg\n RR: 26 (23 - 29) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 1,442 mL\n 1,475 mL\n PO:\n TF:\n 67 mL\n IVF:\n 1,442 mL\n 1,407 mL\n Blood products:\n Total out:\n 300 mL\n 560 mL\n Urine:\n 300 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,142 mL\n 915 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.53/31/61/26/3\n Physical Examination\n Concentrated urine in Foley.\n Lying in bed with eyes closed, minimally responsive to efforts to rouse\n him but able to follow simple commands.\n Pupils small and equal. No scleral icterus.\n Face symmetric. Mucous membranes dry. Tongue midline.\n Neck supple, no adenopathy.\n S1, S2, regular tachycardia.\n Tachypneic with shallow breaths. Has somewhat decreased air movement\n at left base.\n Abd: Surgical dressings in place; JP drains with small amount of\n serosanguinous fluid. +BS. Soft; pt does not react with palpation.\n Neuro: Pt mumbles incoherently when asked questions. Hand grip\n intact b/l. Able to move legs b/l.\n Ext: warm, well perfused. DP +1 b/l. Pneumoboots in place.\n Labs / Radiology\n 1173 K/uL\n 7.5 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 10 mg/dL\n 104 mEq/L\n 136 mEq/L\n 23.7 %\n 19.4 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n 03:00 PM\n 08:20 PM\n 09:00 PM\n 02:56 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n Plt\n 1\n 1109\n 1173\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n TCO2\n 27\n Glucose\n 135\n 142\n 115\n 105\n Other labs: PT / PTT / INR:15.6/70.7/1.4, ALT / AST:18/25, Alk Phos / T\n Bili:101/0.8, Amylase / Lipase:113/228, Differential-Neuts:91.0 %,\n Band:2.0 %, Lymph:4.0 %, Mono:1.0 %, Eos:0.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:391 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n DELIRIUM / CONFUSION\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis s/p splenectomy for\n ruptured spleen who returns to the with fevers and tachycardia in\n the setting of recent enteric leak repair.\n # Fevers and Leukocytosis:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . The line has since been\n removed. Other possible sources for infection include empyema\n (although thoracentesis on did not show evidence of organisms),\n pancreatitis (lipase slightly increasing), or pneumonia.\n - start fluconazole for coverage\n - should grow from blood cultures, but will send fungal blood\n cultures as well\n - start cefepime for broad gram negative and anaerobic coverage (has\n penicillin allergy)\n - continue vancomycin and cipro for now; if he does well clinically,\n would favor stopping cipro and then treating with short course of vanc\n for 5 days after PICC line was pulled ()\n - f/u sensitivities and cultures\n - will discuss possibility of thoracentesis with surgery if he\n continues to be febrile despite appropriate antibiotics\n # Delirium:\n This may be secondary to his pain medications or could be a\n manifestation of severe infection +/- sepsis. If he is bacteremic or\n fungemic, would also consider the possibility of septic emboli, but not\n at threshold to image head without supportive culture data.\n - consider pain consult in AM to help with pain management\n - per prior psych recs, can use haldol if patient becomes agitated\n - if haldol is given, would check QTc\n - no hypercarbia on ABG\n # Anemia, Hct 30-31 on admission, currently 23.7:\n Note that patient has been on a heparin gtt, although he was only\n supratherapeutic on one measure post-op on the 26th.\n - follow serial Hcts\n - active type and screen\n - if pt's Hct is dropping, would have low threshold to obtain CT\n abdomen to evaluate for hematoma\n # Tachypnea with respiratory alkalosis:\n Likely related to pain, although he may also have some anxiety from\n being disoriented.\n - continue dilaudid for now but consider pain consult as above\n # Sinus Tachycardia:\n Likely multifactorial in setting of pain, PE, tachypnea/respiratory\n distress, and infection.\n - would avoid beta blocking sinus tachycardia and rather would treat\n underlying causes\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n - note that pt is infected with encapsulated organism\n # Subsegmental PEs:\n - continue heparin gtt\n # Elevated platelets:\n be inflammatory reaction, but elevation of platelets is extremely\n pronounced.\n - monitor\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # FEN: strict NPO including for meds; LR boluses PRN; restart TPN once\n he has central access\n # PPx: heparin gtt; continue IV PPI started by surgical team\n # Access: PIV x 2; per surgery, will need CVL\n # Comm: with mom \n # Code: confirmed FULL\n # Dispo: to surgical floor once stable\n ICU Care\n Nutrition:\n Replete () - 12:09 AM 10 mL/hour\n Glycemic Control: insulin SS\n Lines:\n 20 Gauge - 09:07 PM\n Prophylaxis:\n DVT: on heparin gtt\n Stress ulcer: pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684065,
"text": " is a 39yo gentleman, who is readmitted to the ICU in the setting\n of agitation and tachycardia.\n He has a h/o recurrent episodes of pancreatitis and was initially\n admitted in early to an OSH with suspected pancreatitis. When he\n continued to have fevers, he was sent to , where he was found to have\n a ruptured spleen. He initially had a splenic artery embolization \n and then had splenectomy with distal pancreatectomy on .\n Unfortunately, he continued to have fevers and tachycardia post-op. As\n part of his tachycardia work-up, he underwent a CT torso that showed a\n subsegmental PE and a thoracentesis for left pleural\n effusion--exudative but not infected. On , he was taken back to the\n OR when it was discovered that he had a LUQ fluid collection with air\n in it c/w an enteric leak. He then came to the ICU post-op for\n respiratory distress in the setting of significant reaccumulation of\n his pleural effusion. He was bolused IV fluids with improvement in his\n urine output and tachycardia and then sent back to the surgical floor.\n He was continued on his vanc, cipro, and flagyl that he had been\n started upon admission to .On the surgical floor, he was initially\n doing well, but then was noted to become increasingly tachycardic and\n agitated. Although his mother came to visit him, she reports he was\n \"in outer space.\" He then became febrile to 101.8 and the surgery team\n asked that he be brought back to the ICU.\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Leukocytosis/fever\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684063,
"text": " is a 39yo gentleman, who is readmitted to the ICU in the setting\n of agitation and tachycardia.\n He has a h/o recurrent episodes of pancreatitis and was initially\n admitted in early to an OSH with suspected pancreatitis. When he\n continued to have fevers, he was sent to , where he was found to have\n a ruptured spleen. He initially had a splenic artery embolization \n and then had splenectomy with distal pancreatectomy on .\n Unfortunately, he continued to have fevers and tachycardia post-op. As\n part of his tachycardia work-up, he underwent a CT torso that showed a\n subsegmental PE and a thoracentesis for left pleural\n effusion--exudative but not infected. On , he was taken back to the\n OR when it was discovered that he had a LUQ fluid collection with air\n in it c/w an enteric leak. He then came to the ICU post-op for\n respiratory distress in the setting of significant reaccumulation of\n his pleural effusion. He was bolused IV fluids with improvement in his\n urine output and tachycardia and then sent back to the surgical floor.\n He was continued on his vanc, cipro, and flagyl that he had been\n started upon admission to .On the surgical floor, he was initially\n doing well, but then was noted to become increasingly tachycardic and\n agitated. Although his mother came to visit him, she reports he was\n \"in outer space.\" He then became febrile to 101.8 and the surgery team\n asked that he be brought back to the ICU.\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Leukocytosis/fever\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 684060,
"text": "TITLE:\n Chief Complaint: tachycardia and fevers\n HPI:\n Mr. is a 39yo gentleman already known to the staff who is\n readmitted to the ICU in the setting of agitation and tachycardia.\n He has a h/o recurrent episodes of pancreatitis and was initially\n admitted in early to an OSH with suspected pancreatitis. When he\n continued to have fevers, he was sent to , where he was found to have\n a ruptured spleen. He initially had a splenic artery embolization \n and then had splenectomy with distal pancreatectomy on .\n Unfortunately, he continued to have fevers and tachycardia post-op. As\n part of his tachycardia work-up, he underwent a CT torso that showed a\n subsegmental PE and a thoracentesis for left pleural\n effusion--exudative but not infected.\n On , he was taken back to the OR when it was discovered that he had\n a LUQ fluid collection with air in it c/w an enteric leak. He then\n came to the ICU post-op for respiratory distress in the setting of\n significant reaccumulation of his pleural effusion. He was bolused IV\n fluids with improvement in his urine output and tachycardia and then\n sent back to the surgical floor. He was continued on his vanc, cipro,\n and flagyl that he had been started upon admission to .\n On the surgical floor, he was initially doing well, but then was noted\n to become increasingly tachycardic and agitated. Although his mother\n came to visit him, she reports he was \"in outer space.\" He then became\n febrile to 101.8 and the surgery team asked that he be brought back to\n the ICU.\n Upon arrival in the ICU, Mr. was speaking gibberish and unable to\n answer questions.\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 10:30 AM\n Vancomycin - 10:06 PM\n Ciprofloxacin - 10:06 PM\n Cefipime - 10:50 PM\n Fluconazole - 11:00 PM\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:15 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Pancreatic pseudocyst formation s/p cyst gastrostomy for drainage\n Following pseudocyst drainage, has had multiple admissions for\n pancreatitis\n \"Erosive gastritis and gastric varices\"\n Fatty liver on imaging, possible non-alcoholic fatty liver disease\n s/p appendectomy\n s/p cholecystectomy\n Positive for cystic fibrosis in some cousins. His dad had brain\n cancer.\n Lives with his mom. he has worked as an accountant. Denies\n smoking or alcohol.\n Review of systems:\n Flowsheet Data as of 01:38 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 38.1\nC (100.5\n HR: 99 (99 - 121) bpm\n BP: 135/77(90) {131/66(82) - 149/85(99)} mmHg\n RR: 28 (23 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 1,442 mL\n 337 mL\n PO:\n TF:\n IVF:\n 1,442 mL\n 337 mL\n Blood products:\n Total out:\n 300 mL\n 100 mL\n Urine:\n 300 mL\n 100 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,142 mL\n 237 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.53/31/61/26/3\n Physical Examination\n 101.9 119 149/84 29 96% RA\n Concentrated urine in Foley.\n Lying in bed with eyes closed, minimally responsive to efforts to rouse\n him but able to follow simple commands.\n Pupils small and equal. No scleral icterus.\n Face symmetric. Mucous membranes dry. Tongue midline.\n Neck supple, no adenopathy.\n S1, S2, regular tachycardia.\n Tachypneic with shallow breaths. Has somewhat decreased air movement\n at left base.\n Abd: Surgical dressings in place; JP drains with small amount of\n serosanguinous fluid. +BS. Soft; pt does not react with palpation.\n Neuro: Pt mumbles incoherently when asked questions. Hand grip\n intact b/l. Able to move legs b/l.\n Ext: warm, well perfused. DP +1 b/l. Pneumoboots in place.\n Labs / Radiology\n 1109 K/uL\n 7.7 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 10 mg/dL\n 26 mEq/L\n 104 mEq/L\n 3.9 mEq/L\n 137 mEq/L\n 23.7 %\n 21.6 K/uL\n [image002.jpg]\n \n 2:33 A6/25/ 03:41 AM\n \n 10:20 P6/26/ 04:04 AM\n \n 1:20 P6/26/ 07:14 AM\n \n 11:50 P6/27/ 03:00 PM\n \n 1:20 A6/27/ 08:20 PM\n \n 7:20 P6/27/ 09:00 PM\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 21.9\n 20.7\n 21.8\n 21.6\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n Plt\n 1\n 1109\n Cr\n 0.7\n 0.6\n 0.5\n TC02\n 27\n Glucose\n 135\n 142\n 115\n Other labs: PT / PTT / INR:16.2/65.6/1.4, ALT / AST:20/30, Alk Phos / T\n Bili:104/0.8, Amylase / Lipase:115/222, Differential-Neuts:91.0 %,\n Band:2.0 %, Lymph:4.0 %, Mono:1.0 %, Eos:0.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:391 IU/L, Ca++:7.4 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.6 mg/dL\n Micro:\n Intrabdominal abscess:\n HAEMOPHILUS SPECIES NOT INFLUENZAE. MODERATE GROWTH.\n ALBICANS. SPARSE GROWTH.\n Peritoneal fluid:\n HAEMOPHILUS SPECIES NOT INFLUENZAE. HEAVY GROWTH.\n ALBICANS. SPARSE GROWTH.\n Pathology:\n I. Spleen and distal pancreas (A - G):\n 1. Fragmented spleen with adhesions, focal infarction, hemorrhage, and\n evidence of previous embolization with associated thrombus.\n 2. Fibroadipose tissue with reactive changes and focal acute and\n chronic inflammation.\n 3. No viable pancreatic tissue seen.\n II. Omentum (H - I):\n Marked reactive changes and focal acute and chronic inflammation.\n Imaging:\n CTA Chest/Abd/Pelvis :\n 1. Small filling defects within subsegmental branches to the left upper\n lobe pulmonary arterial branches, compatible with pulmonary emboli.\n 2. Large left pleural effusion, with associated\n atelectasis/consolidation of the adjacent lung.\n 3. Status post splenectomy and distal pancreatectomy, with a collection\n in the left upper quadrant with associated adjacent peritoneal\n enhancement, consistent with inflammatory change. A drain lies within\n the inferior aspect of the collection.\n 4. Dilated loops of small bowel, could reflect a postoperative ileus.\n 5. Small amount of free fluid in abdomen, with high density fluid in\n the pelvic cul-de-sac, decreased in extent from prior study.\n LE doppler : No evidence of DVT of bilateral lower extremities.\n CT Abd/Pelvis :\n 1. Status post splenectomy and distal pancreatectomy. Collection\n containing air and fluid in the left upper quadrant with adjacent\n peritoneal enhancement is not larger. However, there is apparent\n contiguity of this fluid collection anteriorly with an adjacent loop of\n small bowel. While there is no contrast opacification of the collection\n to confirm, this is consistent with enteric leak. The surgical drain\n remains within the fluid collection.\n 2. Small amount of fluid of intermediate density remains in the pelvis\n but slightly less than that seen three days prior.\n 3. Moderate nonhemorrhagic left pleural effusion is unchanged with\n adjacent atelectasis in the left lower lobe. Few patchy peripheral\n opacities in the visualized right middle and lower lobes appear similar\n to that previously seen and again may represent infectious or\n inflammatory etiology versus atelectasis.\n CXR (MY READ): Left IJ in place. NG tube extends below\n diaphragm. Complete white-out of left lung fields with effusion.\n Assessment and Plan\n 39yo gentleman with h/o recurrent pancreatitis s/p splenectomy for\n ruptured spleen who returns to the with fevers and tachycardia in\n the setting of recent enteric leak repair.\n # Fevers and Leukocytosis:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . The line has since been\n removed. Other possible sources for infection include empyema\n (although thoracentesis on did not show evidence of organisms),\n pancreatitis (lipase slightly increasing), or pneumonia.\n - start fluconazole for coverage\n - should grow from blood cultures, but will send fungal blood\n cultures as well\n - start cefepime for broad gram negative and anaerobic coverage (has\n penicillin allergy)\n - continue vancomycin and cipro for now; if he does well clinically,\n would favor stopping cipro and then treating with short course of vanc\n for 5 days after PICC line was pulled ()\n - f/u sensitivities and cultures\n - will discuss possibility of thoracentesis with surgery if he\n continues to be febrile despite appropriate antibiotics\n # Delirium:\n This may be secondary to his pain medications or could be a\n manifestation of severe infection +/- sepsis. If he is bacteremic or\n fungemic, would also consider the possibility of septic emboli, but not\n at threshold to image head without supportive culture data.\n - consider pain consult in AM to help with pain management\n - per prior psych recs, can use haldol if patient becomes agitated\n - if haldol is given, would check QTc\n - no hypercarbia on ABG\n # Anemia, Hct 30-31 on admission, currently 23.7:\n Note that patient has been on a heparin gtt, although he was only\n supratherapeutic on one measure post-op on the 26th.\n - follow serial Hcts\n - active type and screen\n - if pt's Hct is dropping, would have low threshold to obtain CT\n abdomen to evaluate for hematoma\n # Tachypnea with respiratory alkalosis:\n Likely related to pain, although he may also have some anxiety from\n being disoriented.\n - continue dilaudid for now but consider pain consult as above\n # Sinus Tachycardia:\n Likely multifactorial in setting of pain, PE, tachypnea/respiratory\n distress, and infection.\n - would avoid beta blocking sinus tachycardia and rather would treat\n underlying causes\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n - note that pt is infected with encapsulated organism\n # Subsegmental PEs:\n - continue heparin gtt\n # Elevated platelets:\n be inflammatory reaction, but elevation of platelets is extremely\n pronounced.\n - monitor\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # FEN: strict NPO including for meds; LR boluses PRN; restart TPN once\n he has central access\n # PPx: heparin gtt; continue IV PPI started by surgical team\n # Access: PIV x 2; per surgery, will need CVL\n # Comm: with mom \n # Code: confirmed FULL\n # Dispo: to surgical floor once stable\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684062,
"text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Leukocytosis/fever\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684125,
"text": " is a 39yo gentleman, who is readmitted to the ICU in the setting\n of agitation and tachycardia.\n He has a h/o recurrent episodes of pancreatitis and was initially\n admitted in early to an OSH with suspected pancreatitis. When he\n continued to have fevers, he was sent to , where he was found to have\n a ruptured spleen. He initially had a splenic artery embolization \n and then had splenectomy with distal pancreatectomy on .\n Unfortunately, he continued to have fevers and tachycardia post-op. As\n part of his tachycardia work-up, he underwent a CT torso that showed a\n subsegmental PE and a thoracentesis for left pleural\n effusion--exudative but not infected. On , he was taken back to the\n OR when it was discovered that he had a LUQ fluid collection with air\n in it c/w an enteric leak. He then came to the ICU post-op for\n respiratory distress in the setting of significant reaccumulation of\n his pleural effusion. He was bolused IV fluids with improvement in his\n urine output and tachycardia and then sent back to the surgical floor.\n He was continued on his vanc, cipro, and flagyl that he had been\n started upon admission to .On the surgical floor, he was initially\n doing well, but then was noted to become increasingly tachycardic and\n agitated. Although his mother came to visit him, she reports he was\n \"in outer space.\" He then became febrile to 101.8 and the surgery team\n asked that he be brought back to the ICU.\n Delirium / confusion\n Assessment:\n Patient is lethargic, oriented x1, following commands, confused,this\n may be secondary to his pain medications or could be a manifestation of\n severe infection +/- sepsis.\n Action:\n Frequent reorientation , continue to monitor\n Response:\n More awake and responsive, oriented x2, pain meds x1 with good effect\n Plan:\n Continue monitor Ms and pain consult for better management of pain\n Pulmonary Embolism (PE), Acute\n Assessment:\n Sub segmental PE\ns and patient is on heparin gtt 1800units per hr\n Action:\n PTT monitored and it is within therapeutic range\n Response:\n PTT this Am 70.7, continued 1800units/hr\n Plan:\n Continue heparin gtt, monitor for bleeding and PTT Q6hrs, next due at\n 10am\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient was pain free at the beginning of shift and he was sleeping\n Action:\n Later during night, did c/o abdominal pain , sharp and\n hydromorphone 0.25mg iv given with good effect\n Response:\n Pain after pain med, continue to have pain on his back and\n abdomen, Tylenol given this AM\n Plan:\n Pain consult in Am, frequent change of position and pain meds\n Leukocytosis/fever\n Assessment:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . pancreatitis (lipase\n slightly increasing), or pneumonia. Patient has low grade temp, WBC,\n elevated\n Action:\n started fluconazole for coverage, fungal blood culture sent,\n cefepime started,\n - continue vancomycin and cipro\n Response:\n T max to 101.2, wbc 19.4 this Am\n Plan:\n Continue antibiotics, F/U culture data, monitor temp curve\n Electrolyte & fluid disorder, other\n Assessment:\n K 3.9, Mag 1.9, PHOs 2.6, and ionized Ca 1.05, patient was on TPN\n during day time and patient pulled his PICC line and since then off\n TPN. On TF 10ml/hr, do not advance further\n Action:\n Repleted with K phos, ca gluconate and magnesium sulphate\n Response:\n K phos continuing, is AM K 4.1, Mag 2.2, phos 2.6\n Plan:\n Repeat labs in Am, and replete accordingly\n PIV x2\n On contact precaution for c diff, 3^rd sample results pending, flexy\n seal placed,\n TF continued to be 10ml/hr via J tube and not to advance further as per\n surgeons\n Lt side abd wound dressing intact, staple intact, 2 JP drain very\n minimal/no drains\n Hct stable @ 23.7\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684314,
"text": "Events: Central line placement (RIJ) done, position confirmed after\n x-ray and after x-ray line pulled out and now OK to use\n TPN started\n Heparin gtt off at 6 am for procedure in IR\n Pancreatitis, acute\n Assessment:\n Pt with persistent low grade temp, c/o LLQ abd and back pain, two JP\n drains in place in this area with no drainage, surgical site dressing\n dry and intact and elevated amylase and lypase\n Action:\n Continue antibiotics as ordered, TPN started after CVL placement, NPO\n for procedure in AM\n Response:\n Pt with abd absess per CT, continues with low grade temp, and abd pain,\n No drainage in JP drain\n Plan:\n Continue antibiotics as ordered, continue to follow temp curve, f/u\n culture data, CT guided drain placement tomorrow, continue TPN\n Delirium / confusion\n Assessment:\n Pt A&Ox3, able to follow commands, and co operative with care,able to\n use call light appropriately,\n Action:\n Monitoring\n Response:\n Delirium largely resolved/resolving.\n Plan:\n Continue to monitor MS, if pt becomes acutely delirious will start\n haldol after baseline EKG obtained.\n Pleural effusion, acute\n Assessment:\n Pt on C x-ray with large left sided pleural effusion, effusion was\n tapped micro from which had no growth, pt with limited breath\n sounds on the left, absent in the left lower lobe, denies SOB,\n maintaining sats on 2 L NC\n Action:\n HOB 30-45, continue to monitor\n Response:\n Large left sided pleural effusion for tapping in AM\n Plan:\n Effusion to be tapped in conjunction with CT guided abscess drain\n tomorrow\n Tachycardia, Other\n Assessment:\n HR: 95-115 SR-ST, no ectopy noted, no chest pain, patient with low\n grade temp\n Action:\n Pt receiving Metoprolol as ordered\n Response:\n Ongoing, pt\ns HR since admission low 110s\n Plan:\n Continue Metoprolol as ordered, continue to monitor\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting abd pain at worst at 8/10 in LLQ and occasional back pain\n Action:\n Administering PRN dilaudid as ordered, dose increased to 0.5mg q 2hrs,\n pt provided with cough pillow, encouraged to deep breath\n Response:\n With increased frequency of PRN dilaudid pt with better control of pain\n Plan:\n Continue with PRNs as ordered for now, if unable to control pain with\n current regiment would increase dosing, if continues to have ongoing\n pain issues pt may require pain consult\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684123,
"text": " is a 39yo gentleman, who is readmitted to the ICU in the setting\n of agitation and tachycardia.\n He has a h/o recurrent episodes of pancreatitis and was initially\n admitted in early to an OSH with suspected pancreatitis. When he\n continued to have fevers, he was sent to , where he was found to have\n a ruptured spleen. He initially had a splenic artery embolization \n and then had splenectomy with distal pancreatectomy on .\n Unfortunately, he continued to have fevers and tachycardia post-op. As\n part of his tachycardia work-up, he underwent a CT torso that showed a\n subsegmental PE and a thoracentesis for left pleural\n effusion--exudative but not infected. On , he was taken back to the\n OR when it was discovered that he had a LUQ fluid collection with air\n in it c/w an enteric leak. He then came to the ICU post-op for\n respiratory distress in the setting of significant reaccumulation of\n his pleural effusion. He was bolused IV fluids with improvement in his\n urine output and tachycardia and then sent back to the surgical floor.\n He was continued on his vanc, cipro, and flagyl that he had been\n started upon admission to .On the surgical floor, he was initially\n doing well, but then was noted to become increasingly tachycardic and\n agitated. Although his mother came to visit him, she reports he was\n \"in outer space.\" He then became febrile to 101.8 and the surgery team\n asked that he be brought back to the ICU.\n Delirium / confusion\n Assessment:\n Patient is lethargic, oriented x1, following commands, confused,this\n may be secondary to his pain medications or could be a manifestation of\n severe infection +/- sepsis.\n Action:\n Frequent reorientation , continue to monitor\n Response:\n More awake and responsive, oriented x2, pain meds x1 with good effect\n Plan:\n Continue monitor Ms and pain consult for better management of pain\n Pulmonary Embolism (PE), Acute\n Assessment:\n Sub segmental PE\ns and patient is on heparin gtt 1800units per hr\n Action:\n PTT monitored and it is within therapeutic range\n Response:\n PTT this Am 70.7, continued 1800units/hr\n Plan:\n Continue heparin gtt, monitor for bleeding and PTT Q6hrs, next due at\n 10am\n Pain control (acute pain, chronic pain)\n Assessment:\n Patient was pain free at the beginning of shift and he was sleeping\n Action:\n Later during night, did c/o abdominal pain , sharp and\n hydromorphone 0.25mg iv given with good effect\n Response:\n Pain after pain med, continue to have pain on his back and\n abdomen, Tylenol given this AM\n Plan:\n Pain consult in Am, frequent change of position and pain meds\n Leukocytosis/fever\n Assessment:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . pancreatitis (lipase\n slightly increasing), or pneumonia. Patient has low grade temp, WBC,\n elevated\n Action:\n started fluconazole for coverage, fungal blood culture sent,\n cefepime started,\n - continue vancomycin and cipro\n Response:\n T max to 101.2, wbc 19.4 this Am\n Plan:\n Continue antibiotics, F/U culture data, monitor temp curve\n Electrolyte & fluid disorder, other\n Assessment:\n K\n, Mag, PHOs, and calcium, patient was on TPN during day time and\n patient pulled his PICC line and since then off TPN. On TF 10ml/hr, do\n not advance further\n Action:\n Repleted with K phos, ca gluconate and magnesium sulphate\n Response:\n K phos continuing,\n Plan:\n Repeat labs in Am, and replete accordingly\n On contact precaution for c diff, 3^rd sample results pending, flexy\n seal placed,\n TF continued to be 10ml/hr via J tube and not to advance further as per\n surgeons\n Lt side abd wound dressing intact, staple intact, 2 JP drain very\n minimal/no drains\n Hct stable @ 23.7\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684432,
"text": "Pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known PE, obtained off heparin gtt for procedure\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Pleural effusion, acute\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684305,
"text": "Events: Central line placement(RIJ) done, position confirmed after\n x-ray and after x-ray line pulled out and now OK to use\n TPN started\n Pancreatitis, acute\n Assessment:\n Pt with persistent low grade temp, c/o LLQ abd and back pain, two JP\n drains in place in this area with no drainage, surgical site dressing\n dry and intact and elevated amylase and lypase\n Action:\n Continue antibiotics as ordered, TPN started after CVL placement, NPO\n for procedure in AM\n Response:\n Pt with abd absess per CT, continues with low grade temp, and abd pain,\n No drainage in JP drain\n Plan:\n Continue antibiotics as ordered, continue to follow temp curve, f/u\n culture data, CT guided drain placement tomorrow, continue TPN\n Delirium / confusion\n Assessment:\n Pt A&Ox3, able to follow commands, and co operative with care,able to\n use call light appropriately,\n Action:\n Monitoring\n Response:\n Delirium largely resolved/resolving.\n Plan:\n Continue to monitor MS, if pt becomes acutely delirious will start\n haldol after baseline EKG obtained.\n Pleural effusion, acute\n Assessment:\n Pt on C x-ray with large left sided pleural effusion, effusion was\n tapped micro from which had no growth, pt with limited breath\n sounds on the left, absent in the left lower lobe, denies SOB,\n maintaining sats on 2 L NC\n Action:\n HOB 30-45, continue to monitor\n Response:\n Large left sided pleural effusion for tapping in AM\n Plan:\n Effusion to be tapped in conjunction with CT guided abscess drain\n tomorrow\n Tachycardia, Other\n Assessment:\n HR: 95-115 SR-ST, no ectopy noted, no chest pain, patient with low\n grade temp\n Action:\n Pt receiving Metoprolol as ordered\n Response:\n Ongoing, pt\ns HR since admission low 110s\n Plan:\n Continue Metoprolol as ordered, continue to monitor\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting abd pain at worst at 8/10 in LLQ and occasional back pain\n Action:\n Administering PRN dilaudid as ordered, dose increased to 0.5mg q 2hrs,\n pt provided with cough pillow, encouraged to deep breath\n Response:\n With increased frequency of PRN dilaudid pt with better control of pain\n Plan:\n Continue with PRNs as ordered for now, if unable to control pain with\n current regiment would increase dosing, if continues to have ongoing\n pain issues pt may require pain consult\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 684663,
"text": "TITLE:\n Chief Complaint:\n HPI:\n \n -heparin restarted\n -advance tube feeds 10 ml q 4 hrs to 100/hr\n -PCA restarted\n - recs to transfer to floor \n -no microrganisms seen in pleural fluid or abcess\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Cefipime - 10:00 AM\n Ciprofloxacin - 07:22 PM\n Vancomycin - 08:29 PM\n Fluconazole - 10:09 PM\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 07:47 AM\n Fentanyl - 10:00 AM\n Midazolam (Versed) - 10:00 AM\n Metoprolol - 12:21 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.9\n HR: 99 (82 - 101) bpm\n BP: 133/77(90) {129/68(85) - 150/90(104)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 4,798 mL\n 919 mL\n PO:\n TF:\n 166 mL\n 130 mL\n IVF:\n 2,800 mL\n 248 mL\n Blood products:\n Total out:\n 8,245 mL\n 2,905 mL\n Urine:\n 6,785 mL\n 2,710 mL\n NG:\n Stool:\n Drains:\n 480 mL\n 115 mL\n Balance:\n -3,447 mL\n -1,986 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 1124 K/uL\n 7.5 g/dL\n 129 mg/dL\n 0.5 mg/dL\n 8 mg/dL\n 29 mEq/L\n 101 mEq/L\n 4.0 mEq/L\n 135 mEq/L\n 25.1 %\n 13.9 K/uL\n [image002.jpg]\n \n 2:33 A6/25/ 03:41 AM\n \n 10:20 P6/26/ 04:04 AM\n \n 1:20 P6/26/ 07:14 AM\n \n 11:50 P6/27/ 03:00 PM\n \n 1:20 A6/27/ 08:20 PM\n \n 7:20 P6/27/ 09:00 PM\n 1//11/006\n 1:23 P6/28/ 02:56 AM\n \n 1:20 P6/29/ 01:25 AM\n \n 11:20 P6/29/ 05:45 PM\n \n 4:20 P6/30/ 04:53 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n 15.4\n 13.9\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n 25.0\n 23.8\n 25.1\n Plt\n 1\n 1109\n 1173\n 1120\n 1124\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n 0.6\n 0.5\n TC02\n 27\n Glucose\n 135\n 142\n 115\n 105\n 96\n 129\n Other labs: PT / PTT / INR:14.9/40.6/1.3, ALT / AST:24/33, Alk Phos / T\n Bili:133/0.5, Amylase / Lipase:80/120, Differential-Neuts:70.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:11.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:359 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PANCREATITIS, ACUTE\n THROMBOCYTOSIS (INCLUDING ESSENTIAL THROMBOCYTOSIS, ET)\n ELECTROLYTE & FLUID DISORDER, OTHER\n DELIRIUM / CONFUSION\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis s/p splenectomy for\n ruptured spleen who returns to the with fevers, AMS, tachycardia\n in the setting of recent enteric leak repair.\n # Fevers and Leukocytosis:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . The line has since been\n removed. Other possible sources for infection include empyema\n (although thoracentesis on did not show evidence of organisms),\n pancreatitis (lipase slightly increasing), pneumonia, or abd fluid\n collection. Patient had IR drainage of peroteanal abscess and pleural\n effusion yesterday\n - continue fluconazole for albicans coverage\n - continue cefepime for broad gram negative and anaerobic coverage (has\n penicillin allergy)\n - continue vancomycin and cipro\n - f/u sensitivities , bcx, fungal cx, c. diff\n - IR drainage today of abdominal and pleural fluid collections\n # Delirium:\n This may be secondary to his pain medications or could be a\n manifestation of severe infection +/- sepsis. If he is bacteremic or\n fungemic, would also consider the possibility of septic emboli, but not\n at threshold to image head without supportive culture data.\n - pain not well controlled, restart dilaudid PCA\n - haldol prn, per psych recs in chart\nconfirm QTc prior to dosing\n # Anemia: Stable, however will follow closely given his recent surgery\n and anticoagulation.\n - follow serial Hcts\n - active type and screen\n - If Hct drops less than current 23.7, contact surgery immediately for\n discussion re: transfusion.\n # Tachypnea with respiratory alkalosis: improved since initial ICU\n stay. Likely related to pain, although he may also have some anxiety\n from being disoriented.\n - continue pain control\n # Sinus Tachycardia:\n Likely multifactorial in setting of pain, PE, tachypnea/respiratory\n distress, and infection. Improved since initial infection\n - would avoid beta blocking sinus tachycardia and rather would treat\n underlying causes\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n - note that pt is infected with encapsulated organism\n # Subsegmental PEs:\n - restart heparin drip today\n # Elevated platelets:\n be inflammatory reaction, but elevation of platelets is extremely\n pronounced.\n - consult heme\n - monitor\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # Comm: with mom \n ICU Care\n Nutrition:\n Replete () - 12:48 PM 20 mL/hour\n TPN w/ Lipids - 06:31 PM 83. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 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": "2159-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684295,
"text": "Pancreatitis, acute\n Assessment:\n Pt with persistent low grade temp, c/o LLQ abd and back pain, two JP\n drains in place in this area with no drainage, surgical site dressing\n dry and intact\n Action:\n Receiving antibiotics as ordered, Ct torso done yesterday, NPO for\n procedure in AM\n Response:\n Pt with abd absess per CT, continues with low grade temp though\n trending down\n Plan:\n Continue antibiotics as ordered, continue to follow temp curve, f/u\n culture data, CT guided drain placement tomorrow\n Delirium / confusion\n Assessment:\n Pt A&Ox3, with some confused responses at times, able to follow\n commands, able to use call light appropriately,\n Action:\n Monitoring\n Response:\n Delirium largely resolved/resolving.\n Plan:\n Continue to monitor MS, if pt becomes acutely delirious will start\n haldol after baseline EKG obtained.\n Pleural effusion, acute\n Assessment:\n Pt on Cxray with large left sided pleural effusion, effusion was tapped\n micro from which had no growth, pt with limited breath sounds on\n the left, absent in the left lower lobe, denies SOB, maintaining sats\n on 2 L NC\n Action:\n HOB 30-45, continue to monitor\n Response:\n Large left sided pleural effusion for tapping in AM\n Plan:\n Effusion to be tapped in conjunction with CT guided abscess drain\n tomorrow\n Tachycardia, Other\n Assessment:\n HR: 97-115 SR-ST, no ectopy noted, no chest pain, patient with low\n grade temp\n Action:\n Pt receiving Metoprolol as ordered\n Response:\n Ongoing, pt\ns HR since admission low 110s\n Plan:\n Continue Metoprolol as ordered, continue to monitor\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting abd pain at worst at 8/10 in LLQ\n Action:\n Administering PRN dilaudid as ordered, dose increased to 0.5mg, pt\n provided with cough pillow, encouraged to deep breath\n Response:\n With increased frequency of PRN dilaudid pt with better control of pain\n Plan:\n Continue with PRNs as ordered for now, if unable to control pain with\n current regiment would increase dosing, if continues to have ongoing\n pain issues pt may require pain consult\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 684413,
"text": "Chief Complaint: Sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Much improved overnight. No resp. distress.\n Transferred IR this AM for percutaneous drainage for left\n intraabdominal fluid collection --> removal of >200 ml purulant tan\n colored material.\n Also left chest tube drain placed, with removal of 300 cc\n serosanguinous fluid.\n Tachycardia improved.\n Improved pain control overnight, receiving q2h dilaudid.\n Much increased pain upon return from IR.\n History obtained from Medical records\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Cefipime - 10:20 PM\n Fluconazole - 11:30 PM\n Vancomycin - 07:47 AM\n Ciprofloxacin - 08:42 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 12:08 PM\n Hydromorphone (Dilaudid) - 07:47 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: 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 Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:55 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: 36.6\nC (97.8\n HR: 98 (89 - 109) bpm\n BP: 140/80(94) {127/63(83) - 149/90(101)} mmHg\n RR: 20 (19 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 4,403 mL\n 2,199 mL\n PO:\n TF:\n 194 mL\n IVF:\n 3,558 mL\n 1,342 mL\n Blood products:\n Total out:\n 3,960 mL\n 2,500 mL\n Urine:\n 3,260 mL\n 2,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 443 mL\n -301 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, 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), 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: No(t) Soft, No(t) Non-tender, No(t) Bowel sounds present,\n Distended, Tender: , No(t) Obese, Surgical scar in midline, appears\n intact\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.5 g/dL\n 1120 K/uL\n 96 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 7 mg/dL\n 102 mEq/L\n 133 mEq/L\n 25.0 %\n 15.4 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n 03:00 PM\n 08:20 PM\n 09:00 PM\n 02:56 AM\n 01:25 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n 15.4\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n 25.0\n Plt\n 1\n 1109\n 1173\n 1120\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 27\n Glucose\n 135\n 142\n 115\n 105\n 96\n Other labs: PT / PTT / INR:15.3/32.0/1.3, ALT / AST:16/22, Alk Phos / T\n Bili:100/0.7, Amylase / Lipase:111/194, Differential-Neuts:70.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:11.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:359 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 39 yomh/o recurrent pancreatitis, recent surgery for splenectomy,\n enteric leak now with post-operative respiratory distress and delerium\n (recurrent).\n RESPIRATORY DISTRESS\n Much improved. Multifactorial. Suspect\n contribution of bacteremia and sepsis, acidosis, left pleural effusion,\n left atalectasis, pulmonary emboli (off anticoagulation), and abdominal\n pain (splinting). Plan treat sepsis, antibiotics, iv fliuds, optimize\n pain management, maintain upright position. Consider left\n thoracentesis if expands.\n TACHYCARDIA\n likley reflects respiratory distress, pain, hypovolemia,\n possible pulmonary embolism. Monitor HR, check EKG. Replete iv fluid,\n optimize pain, treat sepsis/bacteremia.\n SEPSIS -- evidence for line-related infection and now suspect\n peritoneal source. For Abd CT imaging to assess for collection.\n Continue Cipro, Cefopime, Vanco, Fluconozole.\n BACTEREMIA\n GPC, possible line related, but concern for enteric\n infection. Remove central lines if possible (use peripheral if\n feasible). Continue Vanco.\n PULMONARY EMBOLI\n left, subsegmental, multiple. Continue\n anticoagulation --> monitor PTT 60-80.\n PLEURAL EFFUSION\n suspect sympathetic and related to abdominal\n surgeries. Doubt empyema, but consider diagnostic thoracentesis.\n Monitor.\n s/p ENTERIC LEAK -- NGT with intermittent suction, antibiotics, await\n culture results. For Abd CT today.\n PAIN MANAGEMENT\n post-op. s/p PCA pump --> need to optimize dosing\n and interval.\n s/p SPLENECTOMY -- will need meningococcal and pneumococcal vaccines\n FLUID\n desire net volume expension.\n THROMBOCYTOSIS\n perhaps reactive. ? reactive. be contributing to\n clotting (pulmonary emboli, clot on PICC line) as value exceeds 1\n million. Monitor. Hematology consult.\n DELERIUM\n recurrent. Possible related to medications and contribution\n of sepsis (toxic-metabolic). Improved this AM.\n NUTRITIONAL SUPPORT -- NPO. Trophic TF. Resume TPN once central\n access established.\n RECURRENT PANCREATITS -- Unclear cause, but consider cystic fibrosis\n given family history. Recheck amylase, lipase and monitor clinical\n exam.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:30 AM 83. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684492,
"text": "Pancreatitis, acute\n Assessment:\n Pt with left sided pain, known hx of frequent pancreatitis, per CT done\n yesterday absess in splenic space, 2 JP drains currently in that space,\n minimal drainage from JP drains, low grade temps\n Action:\n CT guided drain placement, pain addressed as noted below, spec sent for\n culture from CT\n Response:\n CT drain with initial large drainage of about 300, thick grey/yellow\n pussy drainage, pt normo thermic following drain placement\n Plan:\n f/u culture data, continue to monitor drain output, dsg to be changed\n on pigtail site dailly, flush pigtail TID per radiology orders,\n continue to monitor overnight\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting left sided abd pain in upper and lower quadrants, at\n worst at best, described pain as constant and stabbing, pain worse\n with reposition, received on PRN dilaudid regimen 0.5mg q2hr\n Action:\n Pt down to CT for procedure off the floor for about 3 hours, CT RN\n provided sedation for procedure, pt received 100mcg fent from CT RN,\n started on PCA when back on floor, pt able to use PCA appropriately\n Response:\n Pt\ns pain with greater control now on PCA, reporting immense pain peri\n procedure, still not reaching a pain free state though with much\n improvement, pt is reporting pain in left side and lower back at times\n Plan:\n Continue to monitor pain control, encourage pt to use PCA as needed, if\n unable to control pt\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known PE, obtained off heparin gtt for procedure\n Action:\n Heparin restarted after procedure, trending ptt q6hrs\n Response:\n 1800 labs pending\n Plan:\n Ongoing, continue to trend q6hr ptt, next draw 0000\n Pleural effusion, acute\n Assessment:\n Large left sided pleural effusion per Cxray and Ct torso, pt with no\n resp distress or compromise, maintaining sats on 2L NC\n Action:\n CT guided pig tail placed in left chest, draining straw colored\n drainage, spec sent for culture, chest tube attached to pleurovac to\n water seal\n Response:\n Pt has put out about 1000ml from pig tail thus far, out put initially\n steady now slowing, resp status remains the same,\n Plan:\n Continue to monitor chest tube site, continue to monitor out put, f/u\n culture data\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 684372,
"text": "TITLE:\n Chief Complaint: AMS, respiratory distress\n 24 Hour Events:\n MULTI LUMEN - START 10:10 PM\n - CT abdomen/ thorax done: large sequestered fluid collection in\n abdomen, increasing pleural effusion in Left lung -- IR to drain\n tomorrow am\n - Right IJ placed for TPN to start after procedure tomorrow\n - 1st attempt to place3 left IJ but clotted\n - d/c tube feeds tonight at 12am for procedure tomorrow, will advance\n post procedure\n - d/c heparin drip at 1800units/hr at 6 am tomorrow for procedure, will\n restart after drains placed\n - heme consult, said to delay any thrombotic w/u until after rx. course\n with heparin\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 10:30 AM\n Vancomycin - 08:36 PM\n Ciprofloxacin - 08:38 PM\n Cefipime - 10:20 PM\n Fluconazole - 11:30 PM\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Metoprolol - 12:08 PM\n Hydromorphone (Dilaudid) - 03:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 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: 92 (89 - 109) bpm\n BP: 141/71(88) {127/63(83) - 149/90(101)} mmHg\n RR: 19 (19 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 4,403 mL\n 997 mL\n PO:\n TF:\n 194 mL\n IVF:\n 3,558 mL\n 530 mL\n Blood products:\n Total out:\n 3,960 mL\n 1,780 mL\n Urine:\n 3,260 mL\n 1,780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 443 mL\n -783 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 1120 K/uL\n 7.5 g/dL\n 96 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 7 mg/dL\n 102 mEq/L\n 133 mEq/L\n 25.0 %\n 15.4 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n 03:00 PM\n 08:20 PM\n 09:00 PM\n 02:56 AM\n 01:25 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n 15.4\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n 25.0\n Plt\n 1\n 1109\n 1173\n 1120\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 27\n Glucose\n 135\n 142\n 115\n 105\n 96\n Other labs: PT / PTT / INR:15.3/32.0/1.3, ALT / AST:16/22, Alk Phos / T\n Bili:100/0.7, Amylase / Lipase:111/194, Differential-Neuts:70.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:11.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:359 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PANCREATITIS, ACUTE\n THROMBOCYTOSIS (INCLUDING ESSENTIAL THROMBOCYTOSIS, ET)\n ELECTROLYTE & FLUID DISORDER, OTHER\n DELIRIUM / CONFUSION\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:30 AM 83. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 09:07 PM\n Multi Lumen - 10:10 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": "2159-05-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 684374,
"text": "TITLE:\n Chief Complaint: AMS, respiratory distress\n 24 Hour Events:\n MULTI LUMEN - START 10:10 PM\n - CT abdomen/ thorax done: large sequestered fluid collection in\n abdomen, increasing pleural effusion in Left lung -- IR to drain\n tomorrow am\n - Right IJ placed for TPN to start after procedure tomorrow\n - 1st attempt to place3 left IJ but clotted\n - d/c tube feeds tonight at 12am for procedure tomorrow, will advance\n post procedure\n - d/c heparin drip at 1800units/hr at 6 am tomorrow for procedure, will\n restart after drains placed\n - heme consult, said to delay any thrombotic w/u until after rx. course\n with heparin\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 10:30 AM\n Vancomycin - 08:36 PM\n Ciprofloxacin - 08:38 PM\n Cefipime - 10:20 PM\n Fluconazole - 11:30 PM\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Metoprolol - 12:08 PM\n Hydromorphone (Dilaudid) - 03:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 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: 92 (89 - 109) bpm\n BP: 141/71(88) {127/63(83) - 149/90(101)} mmHg\n RR: 19 (19 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 4,403 mL\n 997 mL\n PO:\n TF:\n 194 mL\n IVF:\n 3,558 mL\n 530 mL\n Blood products:\n Total out:\n 3,960 mL\n 1,780 mL\n Urine:\n 3,260 mL\n 1,780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 443 mL\n -783 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///25/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 1120 K/uL\n 7.5 g/dL\n 96 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 7 mg/dL\n 102 mEq/L\n 133 mEq/L\n 25.0 %\n 15.4 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n 03:00 PM\n 08:20 PM\n 09:00 PM\n 02:56 AM\n 01:25 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n 15.4\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n 25.0\n Plt\n 1\n 1109\n 1173\n 1120\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 27\n Glucose\n 135\n 142\n 115\n 105\n 96\n Other labs: PT / PTT / INR:15.3/32.0/1.3, ALT / AST:16/22, Alk Phos / T\n Bili:100/0.7, Amylase / Lipase:111/194, Differential-Neuts:70.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:11.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:359 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n DELIRIUM / CONFUSION\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis s/p splenectomy for\n ruptured spleen who returns to the with fevers and tachycardia in\n the setting of recent enteric leak repair.\n # Fevers and Leukocytosis:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . The line has since been\n removed. Other possible sources for infection include empyema\n (although thoracentesis on did not show evidence of organisms),\n pancreatitis (lipase slightly increasing), or pneumonia.\n - start fluconazole for coverage\n - start cefepime for broad gram negative and anaerobic coverage (has\n penicillin allergy)\n - continue vancomycin and cipro\n - f/u sensitivities , bcx, fungal cx, c. diff\n - will discuss possibility of thoracentesis with surgery if he\n continues to be febrile despite appropriate antibiotics\n - CT abdomen and pelvis with possible IR drainage today.\n # Delirium:\n This may be secondary to his pain medications or could be a\n manifestation of severe infection +/- sepsis. If he is bacteremic or\n fungemic, would also consider the possibility of septic emboli, but not\n at threshold to image head without supportive culture data.\n - pain not well controlled, increase dilaudid to .25 mg IV q 2 hours.\n - haldol prn, per psych recs in chart\nconfirm QTc prior to dosing\n - ABG without hypercarbia\n # Anemia, Hct 30-31 on admission, currently 23.7, concerning for\n possible bleed considering heparin gtt\n one supratherapeutic measure\n on .\n - follow serial Hcts\n - active type and screen\n - If Hct drops less than current 23.7, contact surgery immediately for\n discussion re: transfusion.\n - CT abdomen/pelvis to evaluate for bleed.\n # Tachypnea with respiratory alkalosis:\n Likely related to pain, although he may also have some anxiety from\n being disoriented.\n - improve control, consider pain cosult.\n # Sinus Tachycardia:\n Likely multifactorial in setting of pain, PE, tachypnea/respiratory\n distress, and infection.\n - would avoid beta blocking sinus tachycardia and rather would treat\n underlying causes\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n - note that pt is infected with encapsulated organism\n # Subsegmental PEs:\n - stop heparin gtt per surgery today for CT Abdomen/Pelvis and possible\n IR intervention\n # Elevated platelets:\n be inflammatory reaction, but elevation of platelets is extremely\n pronounced.\n - consult heme\n - monitor\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # Comm: with mom \n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:30 AM 83. mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 09:07 PM\n Multi Lumen - 10:10 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nutrition",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 684407,
"text": "Objective\n Pertinent medications: RISS, pantoprazole, 2gm Magnesium Sulfate\n Labs:\n Value\n Date\n Glucose\n 96 mg/dL\n 01:25 AM\n Glucose Finger Stick\n 182\n 06:00 AM\n BUN\n 7 mg/dL\n 01:25 AM\n Creatinine\n 0.6 mg/dL\n 01:25 AM\n Sodium\n 133 mEq/L\n 01:25 AM\n Potassium\n 4.5 mEq/L\n 01:25 AM\n Chloride\n 102 mEq/L\n 01:25 AM\n TCO2\n 25 mEq/L\n 01:25 AM\n Albumin\n 2.2 g/dL\n 01:25 AM\n Calcium non-ionized\n 7.6 mg/dL\n 01:25 AM\n Phosphorus\n 3.2 mg/dL\n 01:25 AM\n Ionized Calcium\n 1.05 mmol/L\n 08:20 PM\n Magnesium\n 1.9 mg/dL\n 01:25 AM\n Current diet order / nutrition support: TPN: 2.2L (340g dextrose/120 g\n protein/40g fat)\n provides 2036kcal and 120g protein, Replete with\n Fiber (3/4 strength) at 10ml/hr\n currently on hold for procedure\n GI: Abdomen obese with positive bowel sounds\n Assessment of Nutritional Status\n Specifics:\n 39 year old male s/p ex-lap, LOA, distal pancreatectomy and total\n splenectomy , c/ return to OR -s/p reopening of laparotomy,\n LOA, repair of roux limb of jejunum and gastric pouch, and JT\n placement. Patient started on TPN , now at goal, meeting 100%\n estimated nutrition needs. Patient going to IR today for drainage of\n fluid collection in abdomen. Tube feedings were being run at 10ml/hr,\n stopped for procedure, but will restart after.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. TPN: 2L (345g dextrose/130g protein/45g lipids) with 100NaCl,\n 55NaPO4, 25KPO4, 8MgSO4, 12CaGluc\n 2. Once able to start tube feeds, recommend Replete with Fiber @10mL/hr\n to increase 10mL q4hr to goal 95 mL/hr (2280 kcals/141g protein)\n 3. No residuals checks with J-tube, monitor tolerance via abd exam,\n patient complaints, BM's\n 4. Will follow\n Please page with questions\n 11:25 AM\n"
},
{
"category": "General",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Generic Note",
"row_id": 684389,
"text": "TITLE: REHAB SERVICES\n PHYSICAL THERAPY\n Checked in on Pt this AM but RN he is going down for procedure\n under conscious sedation. Will attempt to f/u for PT eval once Pt is\n alert and able to participate in OOB activity. Thank you.\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 684476,
"text": "Chief Complaint: Sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Much improved overnight. No resp. distress.\n Transferred IR this AM for percutaneous drainage for left\n intraabdominal fluid collection --> removal of >200 ml purulant tan\n colored material.\n Also left chest tube drain placed, with removal of 300 cc\n serosanguinous fluid.\n Tachycardia improved.\n Improved pain control overnight, receiving q2h dilaudid.\n Much increased pain upon return from IR.\n History obtained from Medical records\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Cefipime - 10:20 PM\n Fluconazole - 11:30 PM\n Vancomycin - 07:47 AM\n Ciprofloxacin - 08:42 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 12:08 PM\n Hydromorphone (Dilaudid) - 07:47 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: 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 Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, Tube feeds, Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, No(t) Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:55 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: 36.6\nC (97.8\n HR: 98 (89 - 109) bpm\n BP: 140/80(94) {127/63(83) - 149/90(101)} mmHg\n RR: 20 (19 - 28) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 4,403 mL\n 2,199 mL\n PO:\n TF:\n 194 mL\n IVF:\n 3,558 mL\n 1,342 mL\n Blood products:\n Total out:\n 3,960 mL\n 2,500 mL\n Urine:\n 3,260 mL\n 2,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 443 mL\n -301 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, No(t) Thin, 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), 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: No(t) Soft, No(t) Non-tender, No(t) Bowel sounds present,\n Distended, Tender: , No(t) Obese, Surgical scar in midline, appears\n intact\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Not assessed, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.5 g/dL\n 1120 K/uL\n 96 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 7 mg/dL\n 102 mEq/L\n 133 mEq/L\n 25.0 %\n 15.4 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n 03:00 PM\n 08:20 PM\n 09:00 PM\n 02:56 AM\n 01:25 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n 15.4\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n 25.0\n Plt\n 1\n 1109\n 1173\n 1120\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 27\n Glucose\n 135\n 142\n 115\n 105\n 96\n Other labs: PT / PTT / INR:15.3/32.0/1.3, ALT / AST:16/22, Alk Phos / T\n Bili:100/0.7, Amylase / Lipase:111/194, Differential-Neuts:70.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:11.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:359 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n 39 yomh/o recurrent pancreatitis, recent surgery for splenectomy,\n enteric leak now with post-operative respiratory distress and delerium\n (recurrent).\n RESPIRATORY DISTRESS\n Much improved. Multifactorial. Suspect\n contribution of bacteremia and sepsis, acidosis, left pleural effusion,\n left atalectasis, pulmonary emboli (off anticoagulation), and abdominal\n pain (splinting). Plan treat sepsis, antibiotics, iv fliuds, optimize\n pain management, maintain upright position. Consider left\n thoracentesis if expands.\n TACHYCARDIA\n likley reflects respiratory distress, pain, hypovolemia,\n possible pulmonary embolism. Monitor HR, check EKG. Replete iv fluid,\n optimize pain, treat sepsis/bacteremia.\n SEPSIS -- evidence for line-related infection and now suspect\n peritoneal source. For Abd CT imaging to assess for collection.\n Continue Cipro, Cefopime, Vanco, Fluconozole.\n BACTEREMIA\n GPC, possible line related, but concern for enteric\n infection. Remove central lines if possible (use peripheral if\n feasible). Continue Vanco.\n PULMONARY EMBOLI\n left, subsegmental, multiple. Continue\n anticoagulation --> monitor PTT 60-80.\n PLEURAL EFFUSION\n suspect sympathetic and related to abdominal\n surgeries. Doubt empyema, but consider diagnostic thoracentesis.\n Monitor.\n s/p ENTERIC LEAK -- NGT with intermittent suction, antibiotics, await\n culture results. For Abd CT today.\n PAIN MANAGEMENT\n post-op. s/p PCA pump --> need to optimize dosing\n and interval.\n s/p SPLENECTOMY -- will need meningococcal and pneumococcal vaccines\n FLUID\n desire net volume expension.\n THROMBOCYTOSIS\n perhaps reactive. ? reactive. be contributing to\n clotting (pulmonary emboli, clot on PICC line) as value exceeds 1\n million. Monitor. Hematology consult.\n DELERIUM\n recurrent. Possible related to medications and contribution\n of sepsis (toxic-metabolic). Improved this AM.\n NUTRITIONAL SUPPORT -- NPO. Trophic TF. Resume TPN once central\n access established.\n RECURRENT PANCREATITS -- Unclear cause, but consider cystic fibrosis\n given family history. Recheck amylase, lipase and monitor clinical\n exam.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:30 AM 83. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: Heparin gtt)\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684526,
"text": "Pancreatitis, acute\n Assessment:\n Pt with hx of multiple episodes of pancreatitis. Pt with pigtail\n draining serous fluid. Two JP drains intact draining minimal\n serosanguinous fluid. Staples in abd intact, open to air. Positive\n bowel sounds. TMax 100 PO. Abdomen slightly distended however soft.\n Currently receiving tube feeds at 20 ml/hr.\n Action:\n Pt receiving tube feeds through J tube. Pain being controlled with PCA\n pump with good rerlief. Pt slept throughout most of night.\n Response:\n Ongoing. Pt comfortable. Slept through most of night.\n Plan:\n Continue to monitor drain output. ? increase in tube feeds. Monitor\n for pain and s/s of infection.\n Pleural effusion, acute\n Assessment:\n Received pt on 2 LNC. Sats 95-100%. LS clear with diminished bases.\n Chest tube on left side to water seal. Never hooked to suction.\n Draining serous fluid. Pt states that his breathing\nis better\n Action:\n Chest tube remains to water seal. Dressing CD&I. No crepitous.\n Response:\n Ongoing.\n Plan:\n Continue to monitor chest tube site and drainage. Monitor resp status.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Received pt on 1800 units/hr IV heparin gtt. PTT checked at midnight\n 65.4.\n Action:\n Pt remains on heparin gtt at 1800 units/hr for goal PTT 60-100.\n Response:\n 0600 PTT pending.\n Plan:\n Continue to monitor PTT and adjust heparin gtt according to sliding\n scale.\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 683701,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n - Peritoneal fluid growing GNR: hemophilus\n - coag negative staph from ; prob. contamination redraw cx tomorrow\n - received 25mg albumin, low urine output resolved\n - receiving dilaudid PCA with adequate pain control\n - EKG showed no evidence of prolonged \n - pt states that his abdomen feels less distended, has not passed gas\n since surgery\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:30 PM\n Metronidazole - 01:11 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Hydromorphone (Dilaudid) - 01:05 PM\n Heparin Sodium - 06:31 PM\n Pantoprazole (Protonix) - 12:00 AM\n Metoprolol - 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 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37\nC (98.6\n HR: 108 (101 - 126) bpm\n BP: 140/75(90) {116/60(75) - 148/80(98)} mmHg\n RR: 17 (17 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 23 (10 - 23)mmHg\n Total In:\n 7,360 mL\n 1,359 mL\n PO:\n TF:\n IVF:\n 6,405 mL\n 894 mL\n Blood products:\n 500 mL\n Total out:\n 1,725 mL\n 535 mL\n Urine:\n 1,435 mL\n 495 mL\n NG:\n 225 mL\n Stool:\n Drains:\n 65 mL\n 40 mL\n Balance:\n 5,635 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Gen: Lying comfortably in bed, NAD\n HEENT: EOMI, PERRLA, no lymphadenopathy\n CV: tachycardic, No MRG\n Pulm: crackles in R bases, decreased BS in L bases\n Peripheral Vascular: strong radial and DP pulses\n Skin: no rashes or lesions, abdominal dressing intact with no evidence\n of drainage or pus\n Neurologic: alert and oriented x2\n Tubes/drains: abd drains with serosanguinous fluid\n Labs / Radiology\n 994 K/uL\n 7.9 g/dL\n 142 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 25.8 %\n 20.7 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n WBC\n 21.9\n 20.7\n Hct\n 31.6\n 25.8\n Plt\n 1058\n 994\n Cr\n 0.7\n 0.6\n Glucose\n 135\n 142\n Other labs: PT / PTT / INR:15.8/150.0/1.4, ALT / AST:21/32, Alk Phos /\n T Bili:52/0.7, Amylase / Lipase:65/110, Differential-Neuts:79.0 %,\n Band:0.0 %, Lymph:16.0 %, Mono:3.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Albumin:2.2 g/dL, LDH:357 IU/L, Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:1.9\n mg/dL\n Cx: Blood x1 : coag negative staph\n peritoneal fluid: HAEMOPHILUS, \n intraabd abcess: gram - rods\n Assessment and Plan\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis who presented with\n ruptured spleen and underwent splenectomy who then returned to the OR\n for repair of an enteric leak, now transferred to the ICU in the\n setting of respiratory distress and massive pleural effusion.\n # Tachypnea and Pleural effusion: Pt sating well on 5 L nasal canula.\n CT yesterday showed significant L sided plural effusion.\n This effusion appears to have been present since before the surgery and\n the patient is not in respiratory distress. Plan to hold on tap for\n now, however will re-consider if patients respiratory status\n deteriorates or he shows worsening signs of infecion.\n -continue O2 by nasal cannula\n -monitor ABGs\n - taper narcotics\n #Anemia : no evidence of bleed as patient has not had any bloody BMs or\n emesis. Pt also states that his abdomen is less distended and\n clinically he does not have any evidence of bleeding from his surgical\n site or into his abdomen. While this changes is most likely dilution\n in the context of recent fluid resusitation, we remain concerned for GI\n bleed or bleed into the abdomen from his surgical site. Normal\n haptoglobin and unconjugated bilirubin suggest that it is not\n hemolytic, and marrow is responding appropriately with increased retic\n ct.\n -closely follow hematocrit\n -type and screen 3 units\n # coag negative staph : pt with one cx coag negative staph. Will\n continue to cx until negative.\n -serial cxs\n -replace lines if bacteremia persists\n -continue vancomycin\n # s/p repair of enteric leak : pt now with GNR isolated in peritoneal\n fluid and abcess growing haemophilus.\n - continue NG tube to intermittent suction\n - continue cipro/flagyl\n - appreciate surgery input\n # Sinus Tachycardia:Likely multifactorial in setting of pain, PE,\n tachypnea/respiratory distress, and infection. Persisting despite\n fluid resusitation, however expect continued improvement with treatment\n of infection. Will hold of on BBlocker for now and attempt to tx\n underlying cause.\n # Pain: Well controlled on dilaudid PCA. Req\nd one dose of IV\n dilaudid for break through pain\n - wean to orals today\n -IV dilaudid for breakthrough pain\n - bowel regimen while on narcotics once he is taking PO meds\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n # Subsegmental PEs:\n - hold on heparin gtt during acute post-op period\n - discuss with surgery re: timing of restarting heparin gtt\n # Leukocytosis:\n Likely from enteric leak, recent surgery, and GPCs in blood.\n - f/u culture data\n - address sources of infection as discussed above\n # Elevated platelets: Trending down, likely acute inflammatory\n response.\n -continue to follow.\n # Anemia, Hct stable at 31:\n Note that patient's haptoglobin was less than assay on admission labs\n .\n - send hemolysis work-up\n - active type and screen\n # Delirium:\n Patient has self-extubated earlier during his hospital course. Per\n surgery, his NG tube needs to continue to suction for decompression of\n his bowel.\n - appreciate psych recs\n - frequent reorientation\n - haldol PRN\n - EKG to monitor \n - restraints to avoid pulling at tubes/lines\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # FEN: strict NPO including for meds; LR continuous at 125 with\n boluses PRN; note that pt has feeding J tube, but unclear indication at\n present\n # PPx: subQ heparin; continue IV PPI started on floor\n # Access: 20g PIV, left IJ (will need to be re-sited)\n # Comm: with mom \n # Code: confirmed FULL\n # Dispo: to surgical floor once stable\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:31 PM 83 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 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": "2159-05-15 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 684568,
"text": "TITLE:\n Chief Complaint:\n HPI:\n \n -heparin restarted\n -advance tube feeds 10 ml q 4 hrs to 100/hr\n -PCA restarted\n - recs to transfer to floor \n -no microrganisms seen in pleural fluid or abcess\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Cefipime - 10:00 AM\n Ciprofloxacin - 07:22 PM\n Vancomycin - 08:29 PM\n Fluconazole - 10:09 PM\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 07:47 AM\n Fentanyl - 10:00 AM\n Midazolam (Versed) - 10:00 AM\n Metoprolol - 12:21 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.9\n HR: 99 (82 - 101) bpm\n BP: 133/77(90) {129/68(85) - 150/90(104)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 4,798 mL\n 919 mL\n PO:\n TF:\n 166 mL\n 130 mL\n IVF:\n 2,800 mL\n 248 mL\n Blood products:\n Total out:\n 8,245 mL\n 2,905 mL\n Urine:\n 6,785 mL\n 2,710 mL\n NG:\n Stool:\n Drains:\n 480 mL\n 115 mL\n Balance:\n -3,447 mL\n -1,986 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 1124 K/uL\n 7.5 g/dL\n 129 mg/dL\n 0.5 mg/dL\n 8 mg/dL\n 29 mEq/L\n 101 mEq/L\n 4.0 mEq/L\n 135 mEq/L\n 25.1 %\n 13.9 K/uL\n [image002.jpg]\n \n 2:33 A6/25/ 03:41 AM\n \n 10:20 P6/26/ 04:04 AM\n \n 1:20 P6/26/ 07:14 AM\n \n 11:50 P6/27/ 03:00 PM\n \n 1:20 A6/27/ 08:20 PM\n \n 7:20 P6/27/ 09:00 PM\n 1//11/006\n 1:23 P6/28/ 02:56 AM\n \n 1:20 P6/29/ 01:25 AM\n \n 11:20 P6/29/ 05:45 PM\n \n 4:20 P6/30/ 04:53 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n 15.4\n 13.9\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n 25.0\n 23.8\n 25.1\n Plt\n 1\n 1109\n 1173\n 1120\n 1124\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n 0.6\n 0.5\n TC02\n 27\n Glucose\n 135\n 142\n 115\n 105\n 96\n 129\n Other labs: PT / PTT / INR:14.9/40.6/1.3, ALT / AST:24/33, Alk Phos / T\n Bili:133/0.5, Amylase / Lipase:80/120, Differential-Neuts:70.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:11.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:359 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PANCREATITIS, ACUTE\n THROMBOCYTOSIS (INCLUDING ESSENTIAL THROMBOCYTOSIS, ET)\n ELECTROLYTE & FLUID DISORDER, OTHER\n DELIRIUM / CONFUSION\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n ICU Care\n Nutrition:\n Replete () - 12:48 PM 20 mL/hour\n TPN w/ Lipids - 06:31 PM 83. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 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": "2159-05-15 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 684570,
"text": "TITLE:\n Chief Complaint:\n HPI:\n \n -heparin restarted\n -advance tube feeds 10 ml q 4 hrs to 100/hr\n -PCA restarted\n - recs to transfer to floor \n -no microrganisms seen in pleural fluid or abcess\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Cefipime - 10:00 AM\n Ciprofloxacin - 07:22 PM\n Vancomycin - 08:29 PM\n Fluconazole - 10:09 PM\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 07:47 AM\n Fentanyl - 10:00 AM\n Midazolam (Versed) - 10:00 AM\n Metoprolol - 12:21 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.9\n HR: 99 (82 - 101) bpm\n BP: 133/77(90) {129/68(85) - 150/90(104)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 4,798 mL\n 919 mL\n PO:\n TF:\n 166 mL\n 130 mL\n IVF:\n 2,800 mL\n 248 mL\n Blood products:\n Total out:\n 8,245 mL\n 2,905 mL\n Urine:\n 6,785 mL\n 2,710 mL\n NG:\n Stool:\n Drains:\n 480 mL\n 115 mL\n Balance:\n -3,447 mL\n -1,986 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///29/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 1124 K/uL\n 7.5 g/dL\n 129 mg/dL\n 0.5 mg/dL\n 8 mg/dL\n 29 mEq/L\n 101 mEq/L\n 4.0 mEq/L\n 135 mEq/L\n 25.1 %\n 13.9 K/uL\n [image002.jpg]\n \n 2:33 A6/25/ 03:41 AM\n \n 10:20 P6/26/ 04:04 AM\n \n 1:20 P6/26/ 07:14 AM\n \n 11:50 P6/27/ 03:00 PM\n \n 1:20 A6/27/ 08:20 PM\n \n 7:20 P6/27/ 09:00 PM\n 1//11/006\n 1:23 P6/28/ 02:56 AM\n \n 1:20 P6/29/ 01:25 AM\n \n 11:20 P6/29/ 05:45 PM\n \n 4:20 P6/30/ 04:53 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n 15.4\n 13.9\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n 25.0\n 23.8\n 25.1\n Plt\n 1\n 1109\n 1173\n 1120\n 1124\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n 0.6\n 0.5\n TC02\n 27\n Glucose\n 135\n 142\n 115\n 105\n 96\n 129\n Other labs: PT / PTT / INR:14.9/40.6/1.3, ALT / AST:24/33, Alk Phos / T\n Bili:133/0.5, Amylase / Lipase:80/120, Differential-Neuts:70.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:11.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:359 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PANCREATITIS, ACUTE\n THROMBOCYTOSIS (INCLUDING ESSENTIAL THROMBOCYTOSIS, ET)\n ELECTROLYTE & FLUID DISORDER, OTHER\n DELIRIUM / CONFUSION\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis s/p splenectomy for\n ruptured spleen who returns to the with fevers, AMS, tachycardia\n in the setting of recent enteric leak repair.\n # Fevers and Leukocytosis:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . The line has since been\n removed. Other possible sources for infection include empyema\n (although thoracentesis on did not show evidence of organisms),\n pancreatitis (lipase slightly increasing), pneumonia, or abd fluid\n collection.\n - continue fluconazole for albicans coverage\n - continue cefepime for broad gram negative and anaerobic coverage (has\n penicillin allergy)\n - continue vancomycin and cipro\n - f/u sensitivities , bcx, fungal cx, c. diff\n - IR drainage today of abdominal and pleural fluid collections\n # Delirium:\n This may be secondary to his pain medications or could be a\n manifestation of severe infection +/- sepsis. If he is bacteremic or\n fungemic, would also consider the possibility of septic emboli, but not\n at threshold to image head without supportive culture data.\n - pain not well controlled, restart dilaudid PCA\n - haldol prn, per psych recs in chart\nconfirm QTc prior to dosing\n # Anemia: Stable, however will follow closely given his recent surgery\n and anticoagulation.\n - follow serial Hcts\n - active type and screen\n - If Hct drops less than current 23.7, contact surgery immediately for\n discussion re: transfusion.\n # Tachypnea with respiratory alkalosis: improved since initial ICU\n stay. Likely related to pain, although he may also have some anxiety\n from being disoriented.\n - continue pain control\n # Sinus Tachycardia:\n Likely multifactorial in setting of pain, PE, tachypnea/respiratory\n distress, and infection. Improved since initial infection\n - would avoid beta blocking sinus tachycardia and rather would treat\n underlying causes\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n - note that pt is infected with encapsulated organism\n # Subsegmental PEs:\n - restart heparin drip today\n # Elevated platelets:\n be inflammatory reaction, but elevation of platelets is extremely\n pronounced.\n - consult heme\n - monitor\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # Comm: with mom \n ICU Care\n Nutrition:\n Replete () - 12:48 PM 20 mL/hour\n TPN w/ Lipids - 06:31 PM 83. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 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": "2159-05-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683550,
"text": "39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, and now transferred to MICU for post-op\n respiratory distress.\n Tachycardia, Other\n Assessment:\n HR 100\ns-110\ns in sinus tach.\n Action:\n Given Lopressor 2.5 mg IV Q 6 hours. Given 5% Albumin in 500ml x 1.\n Remains on LR at 125 ml/hr.\n Response:\n HR maintained in 100\ns in sinus rythym.\n Plan:\n Continue to monitor and give Lopressor 2.5 mg IV Q 6 hours.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known hx of PE. Received pt on 6 liters face mask. Sats\n 95-100%. Pt c/o\na little shortness or breath\n. LS clear with\n diminished bases. Also initially on standing SC Heparin TID. PTT 26.5\n this am.\n Action:\n SC Heparin d/c\nd and pt started on Heparin gtt at 1700 units/hr at\n 1100. O2 weaned down to 5LNC.\n Response:\n Pt comfortable on NC. 1700 PTT pending.\n Plan:\n Continue to monitor PTT and resp status.\n s/p laperotomy, Pain control (acute pain, chronic pain)\n Assessment:\n S/P laperotomy. Abd dressings cd&i. Abd firm and distended. Pt on\n low con\nt wall suction via NGT. 2 JP drains present draining\n serous/serosanguinous fluid. J tube clamped. PCA pump with Dilaudid\n working well for pt.\n Action:\n Monitor for pain. Given 0.5 mg IV Dilaudid bolus x 1 for breakthrough\n pain with good effect.\n Response:\n NGT draining bilious fluid. Drainage amount documented. See\n Metavision. Pt currently A&O x 3.\n Plan:\n Continue pain management. Monitor incision site and f/u with surgery.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683682,
"text": "39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, and now transferred to MICU for post-op\n respiratory distress.\n Tachycardia, Other\n Assessment:\n HR 100\ns-110\ns in sinus tach.\n Action:\n Given Lopressor 2.5 mg IV Q 6 hours. Remains on LR at 125 ml/hr.\n Response:\n HR maintained in 100\ns in sinus rythym.\n Plan:\n Continue to monitor and give Lopressor 2.5 mg IV Q 6 hours.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known hx of PE. Started on Heparin gtt on . On 3 L NC.\n Action:\n SCD on. PTT Q6 hr.\n Response:\n PTT> 150 at midnight. Drip adjusted as per order. O2 sat 94-98%,\n denies resp. Distress.\n Plan:\n Continue to monitor PTT and resp status. Next PTT due at 0800.\n s/p laperotomy, Pain control (acute pain, chronic pain)\n Assessment:\n S/P laperotomy. Abd dressings cd&i. Abd firm and distended. Pt on\n low con\nt wall suction via NGT. 2 JP drains present draining\n serous/serosanguinous fluid. J tube clamped. PCA pump with Dilaudid\n working well for pt.\n Action:\n Monitor for pain.\n Response:\n NGT draining bilious fluid. Pt currently A&O x 3. Pain level \n and Pt. states Pain tolerable. Takeing naps intermitenly.\n Plan:\n Continue pain management. Monitor incision site and f/u with surgery.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684688,
"text": "Bacteremia\n Assessment:\n Tmax 100.1 this a.m. Pigtail drain via LUQ draining slightly turbid\n serosanguinous fluid\n per team this is an improvement. VSS. Pt. with\n minimal complaints today. Abdomen is softly distened.\n Action:\n Pt. continues on Vanco, Cipro, Cefipime, and Fluconazole. Drain care\n done this a.m. Tube feeds increased per order; pt. remains on TPN.\n Response:\n Temp down 99.4 at noontime. Vital signs remain stable. Pt. tolerating\n TF\n Plan:\n Continue present regimen, monitor and treat as indicated. To transfer\n to floor today.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt. with known PE, hemodynamically stable, no complaint of SOB.\n Action:\n PTT drawn, Heparin gtt titrated per sliding scale.\n Response:\n Afternoon PTT is pending.\n Plan:\n Continue to assess PTT and titrate heparin gtt per protocol.\n Pleural effusion, acute\n Assessment:\n LS diminished at bases with bibasilar crackles. Denies SOB. Left PCT\n in place, though no fluctuation or output noted. Sats stable.\n Action:\n Team aware of CT assessment. IS encouraged.\n Response:\n No change in pulmonary assessment.\n Plan:\n Mobilize pt, pulmonary hygiene. ?Plan to d/c CT to be addressed with\n team.\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-10 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 683424,
"text": "TITLE:\n Chief Complaint: respiratory distress\n HPI:\n Mr. is a 39yo gentleman with h/o recurrent pancreatitis admitted\n with ruptured spleen who is transferred to the unit in the setting of\n post-op respiratory distress.\n He was initially admitted to an OSH with LUQ pain, rigors, and\n lipase of 1100. He was initially treated for pancreatitis but had\n ongoing bilious emesis and developed fevers to 103. At that time, he\n was transferred to for further care on .\n Upon arrival at , he was found to have a CT scan concerning for\n splenic rupture. He was started on vancomycin, levofloxacin, and\n flagyl and he underwent splenic artery embolization on . He\n underwent splenectomy with distal pancreatectomy on . He was doing\n well post-op until he developed fevers and tachycardia. On , he\n had a CT torso that revealed left subsegmental PEs and a fluid\n collection in the LUQ with drain in place. He was on a heparin gtt.\n His course was complicated by significant left pleural effusion that\n was tapped on , yielding 500cc of serosanguinous fluid, exudative\n by Light's criteria. In addition, psychiatry was contact for\n delirium and recommended haldol as needed. Because of continued fevers\n with increasing abdominal distention, the team pursued a CT abd/pelvis\n that revealed the LUQ fluid pocket now had air consistent with an\n enteric leak. He therefore went back to the OR on for repair of\n his enteric leak.\n Per report, the surgery was fairly involved with a gastric and omental\n patch. Nevertheless, he was extubated post-op. He then developed\n tachypnea into the 30s. A chest x-ray demonstrated significant\n worsening of his pleural effusion with almost total white-out of his\n left lung field, and he was sent to the ICU for further care.\n Upon arrival in the ICU, he was tachypneic and c/o some labored\n breathing. He was also having significant abdominal pain.\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Home Meds:\n (per prior notes, pt unable to confirm):\n Viokase with meals prn\n Vicodin\n Past medical history:\n Family history:\n Social History:\n Pancreatic pseudocyst formation s/p cyst gastrostomy for drainage\n Following pseudocyst drainage, has had multiple admissions for\n pancreatitis\n \"Erosive gastritis and gastric varices\"\n Fatty liver on imaging, possible non-alcoholic fatty liver disease\n s/p appendectomy\n s/p cholecystectomy\n Surgery: \n Positive for cystic fibrosis in some cousins. His dad had brain\n cancer.\n Lives with his mom. he has worked as an accountant. Denies\n smoking or alcohol.\n Review of systems:\n Flowsheet Data as of 04:09 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.9\nC (100.3\n HR: 134 (134 - 138) bpm\n BP: 112/72(82) {98/72(73) - 128/77(82)} mmHg\n RR: 32 (26 - 32) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 74 Inch\n Total In:\n 1,629 mL\n PO:\n TF:\n IVF:\n 1,629 mL\n Blood products:\n Total out:\n 0 mL\n 220 mL\n Urine:\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,409 mL\n Respiratory\n SpO2: 95%\n Physical Examination\n 99.5 137 128/77 30s 98% on 6L by face mask\n 40cc of concentrated urine in Foley.\n Pleasant man who is tachypneic and shaking in pain, keeps eyes closed\n during most of interview.\n Pupils small and equal. No scleral icterus.\n NG tube in place. Face symmetric. Mucous membranes dry. Tongue\n midline.\n Neck supple, no adenopathy.\n S1, S2, regular tachycardia.\n Tachypneic but lying flat without difficulty. Air movement b/l but has\n dependent crackles on both sides.\n Abd: Surgical dressings in place. No bowel sounds. Mildly soft.\n Tender diffusely.\n Neuro: Oriented to month and hospital (), though he often\n brings up irrelevant topics. Speech intact. Hand grip intact b/l.\n Wiggles toes b/l.\n Ext: warm, well perfused. DP +1 b/l. No LE edema. Pneumoboots in\n place.\n Labs / Radiology\n [image002.jpg]\n Pathology:\n I. Spleen and distal pancreas (A - G):\n 1. Fragmented spleen with adhesions, focal infarction, hemorrhage, and\n evidence of previous embolization with associated thrombus.\n 2. Fibroadipose tissue with reactive changes and focal acute and\n chronic inflammation.\n 3. No viable pancreatic tissue seen.\n II. Omentum (H - I):\n Marked reactive changes and focal acute and chronic inflammation.\n Imaging:\n CTA Chest/Abd/Pelvis :\n 1. Small filling defects within subsegmental branches to the left upper\n lobe pulmonary arterial branches, compatible with pulmonary emboli.\n 2. Large left pleural effusion, with associated\n atelectasis/consolidation of the adjacent lung.\n 3. Status post splenectomy and distal pancreatectomy, with a collection\n in the left upper quadrant with associated adjacent peritoneal\n enhancement, consistent with inflammatory change. A drain lies within\n the inferior aspect of the collection.\n 4. Dilated loops of small bowel, could reflect a postoperative ileus.\n 5. Small amount of free fluid in abdomen, with high density fluid in\n the pelvic cul-de-sac, decreased in extent from prior study.\n LE doppler : No evidence of DVT of bilateral lower extremities.\n CT Abd/Pelvis :\n 1. Status post splenectomy and distal pancreatectomy. Collection\n containing air and fluid in the left upper quadrant with adjacent\n peritoneal enhancement is not larger. However, there is apparent\n contiguity of this fluid collection anteriorly with an adjacent loop of\n small bowel. While there is no contrast opacification of the collection\n to confirm, this is consistent with enteric leak. The surgical drain\n remains within the fluid collection.\n 2. Small amount of fluid of intermediate density remains in the pelvis\n but slightly less than that seen three days prior.\n 3. Moderate nonhemorrhagic left pleural effusion is unchanged with\n adjacent atelectasis in the left lower lobe. Few patchy peripheral\n opacities in the visualized right middle and lower lobes appear similar\n to that previously seen and again may represent infectious or\n inflammatory etiology versus atelectasis.\n CXR (MY READ): Left IJ in place. NG tube extends below\n diaphragm. Complete white-out of left lung fields with effusion.\n Assessment and Plan\n 39yo gentleman with h/o recurrent pancreatitis who presented with\n ruptured spleen and underwent splenectomy who then returned to the OR\n for repair of an enteric leak, now transferred to the ICU in the\n setting of respiratory distress and massive pleural effusion.\n # Tachypnea and Pleural effusion:\n Unclear if imaging is misleading as patient was in semi-erect position,\n which may have caused fluid to move superiorly on film.\n - obtain repeat CXR in erect position to confirm size of effusion\n - although surgery did not want to re-tap effusion, would favor\n thoracentesis +/- pigtail catheter placement as fluid is likely to be\n infected given probable communication with LUQ fluid collection\n - pt currently oxygenating very well and not showing signs of tiring,\n likely because he has excellent respiratory reserve given young age.\n will monitor closely\n - follow ABGs, particularly given that high dose narcotics may blunt\n his tachypnea\n # Sinus Tachycardia:\n Likely multifactorial in setting of pain, PE, tachypnea/respiratory\n distress, and infection.\n - would avoid beta blocking sinus tachycardia and rather would treat\n underlying causes\n # s/p repair of enteric leak:\n - continue NG tube to intermittent suction\n - continue cipro/flagyl\n - appreciate surgery input\n - f/u peritoneal fluid culture\n - obtain BCx\n # GPCs from CVL blood Cx :\n - will need his line re-sited\n - continue vanc for now\n # Pain:\n - continue dilaudid PCA and consider increasing dose if his pain does\n not improve\n - bowel regimen while on narcotics once he is taking PO meds\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n # Subsegmental PEs:\n - hold on heparin gtt during acute post-op period\n - discuss with surgery re: timing of restarting heparin gtt\n # Leukocytosis:\n Likely from enteric leak, recent surgery, and GPCs in blood.\n - f/u culture data\n - address sources of infection as discussed above\n # Elevated platelets:\n be inflammatory reaction, but elevation of platelets is extremely\n pronounced.\n - monitor\n # Anemia, Hct stable at 31:\n Note that patient's haptoglobin was less than assay on admission labs\n .\n - send hemolysis work-up\n - active type and screen\n # Delirium:\n Patient has self-extubated earlier during his hospital course. Per\n surgery, his NG tube needs to continue to suction for decompression of\n his bowel.\n - appreciate psych recs\n - frequent reorientation\n - haldol PRN\n - EKG to monitor QTc\n - restraints to avoid pulling at tubes/lines\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # FEN: strict NPO including for meds; LR continuous at 125 with\n boluses PRN; note that pt has feeding J tube, but unclear indication at\n present\n # PPx: subQ heparin; continue IV PPI started on floor\n # Access: 20g PIV, left IJ (will need to be re-sited)\n # Comm: with mom \n # Code: confirmed FULL\n # Dispo: to surgical floor once stable\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683504,
"text": "39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, transferred to MICU for post-op\n respiratory distress.\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Pleural effusion, acute\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684543,
"text": "Pancreatitis, acute\n Assessment:\n Pt with hx of multiple episodes of pancreatitis. Pt with pigtail\n draining serous fluid. Two JP drains intact draining minimal\n serosanguinous fluid. Staples in abd intact, open to air. Positive\n bowel sounds. TMax 100 PO. Abdomen slightly distended however soft.\n Currently receiving tube feeds at 20 ml/hr.\n Action:\n Pt receiving tube feeds through J tube. Pain being controlled with PCA\n pump with good rerlief. Pt slept throughout most of night.\n Response:\n Ongoing. Pt comfortable. Slept through most of night. Current temp\n 97.9 PO.\n Plan:\n Continue to monitor drain output. ? increase in tube feeds. Monitor\n for pain and s/s of infection.\n Pleural effusion, acute\n Assessment:\n Received pt on 2 LNC. Sats 95-100%. LS clear with diminished bases.\n Chest tube on left side to water seal. Never hooked to suction.\n Draining serous fluid. Pt states that his breathing\nis better\n Action:\n Chest tube remains to water seal. Dressing CD&I. No crepitous.\n Response:\n Ongoing.\n Plan:\n Continue to monitor chest tube site and drainage. Monitor resp status.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Received pt on 1800 units/hr IV heparin gtt. PTT checked at midnight\n 65.4.\n Action:\n Pt remains on heparin gtt at 1800 units/hr for goal PTT 60-100.\n Response:\n 0600 PTT pending.\n Plan:\n Continue to monitor PTT and adjust heparin gtt according to sliding\n scale.\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-10 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 683525,
"text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, transferred to MICU for post-op\n respiratory distress.\n Initially admitted to outside hospital with LUQ pain, rigors,\n and lipase of 1100 --> treated for pancreatitis, but ongoing bilious\n emesis and T= 103 prompted transfer to for further care on\n .\n Upon arrival to , CT scan suggested splenic rupture -->\n vancomycin, levofloxacin, and flagyl, and splenic artery embolization\n on , and subsequent splenectomy with distal pancreatectomy on\n . Post-op developed fevers and tachycardia. On CT\n torso revealed left subsegmental pulmonary emboli and a fluid\n collection in the LUQ with drain in place --> heparin gtt.\n Hospital course complicated by significant left pleural effusion -->\n diagnostic thoracentesis , yielding 500 cc of serosanguinous\n fluid, exudative by Light's criteria. Continued fevers, increasing\n abdominal distention --> repeat CT abd/pelvis revealed LUQ fluid\n collection with air (concern for enteric leak). Return to OR \n for repair.\n Per report, the surgery was fairly involved with a gastric and omental\n patch. Extubated post-op, but developed tachypnea. CXR with apparent\n significant worsening of left pleural effusion --> transferred to MICU\n service for further evaluation and mangement.\n Upon arrival in the ICU, he was tachypneic and c/o some labored\n breathing, tachypnea. He was also having significant abdominal pain.\n Tachycardia. Improved with iv fluids and pain mangement.\n This AM, states to feel somewhat improved.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 08:09 AM\n Ciprofloxacin - 09:15 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:14 AM\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n PANCREATITIS, RECURRENT\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\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 Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:50 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (98.9\n HR: 115 (108 - 138) bpm\n BP: 128/69(84) {98/67(73) - 128/77(84)} mmHg\n RR: 33 (22 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 12 (10 - 17)mmHg\n Total In:\n 3,450 mL\n PO:\n TF:\n IVF:\n 3,450 mL\n Blood products:\n Total out:\n 0 mL\n 580 mL\n Urine:\n 330 mL\n NG:\n 200 mL\n Stool:\n Drains:\n 50 mL\n Balance:\n 0 mL\n 2,870 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, Diaphoretic, Mild\n distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 1058 K/uL\n 31.6 %\n 10.2 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 12 mg/dL\n 23 mEq/L\n 103 mEq/L\n 4.9 mEq/L\n 135 mEq/L\n 21.9 K/uL\n [image002.jpg]\n 03:41 AM\n WBC\n 21.9\n Hct\n 31.6\n Plt\n 1058\n Cr\n 0.7\n Glucose\n 135\n Other labs: PT / PTT / INR:15.3/26.5/1.3, ALT / AST:26/36, Alk Phos / T\n Bili:65/0.9, Amylase / Lipase:49/54, Differential-Neuts:89.8 %,\n Lymph:5.9 %, Mono:3.9 %, Eos:0.1 %, Fibrinogen:357 mg/dL, Albumin:2.2\n g/dL, LDH:443 IU/L, Ca++:6.9 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR\n Microbiology: Blood culture () +GPC\n Assessment and Plan\n 39 yomh/o recurrent pancreatitis, recent surgery for splenectomy,\n enteric leak now with post-operative respiratory distress.\n RESPIRATORY DISTRESS\n multifactorial. Suspect contribution of\n bacteremia and sepsis, acidosis, left pleural effusion, left\n atalectasis, pulmonary emboli (off anticoagulation), and abdominal\n pain. Plan treat sepsis, antibiotics, iv fliuds, optimize pain\n management, maintain upright position. Consider left thoracentesis if\n expands.\n TACHYCARDIA\n likley reflects respiratory distress, pain, hypovolemia,\n possible pulmonary embolism. Monitor HR, check EKG. Replete iv fluid,\n optimize pain, treat sepsis/bacteremia.\n BACTEREMIA\n GPC, possible line related, but concern for enteric\n infection. Remove central lines if possible (use peripheral if\n feasible). Empirical antimicrobials, including Vanco/Cipro/Flagyl.\n PULMONARY EMBOLI\n left, subsegmental, multiple. Plan resume\n anticoagulation as per Surgery.\n PLEURAL EFFUSION\n suspect sympathetic and related to abdominal\n surgeries.\n s/p ENTERIC LEAK -- NGT with intermittent suction, antibiotics, await\n culture results.\n PAIN MANAGEMENT\n post-op. PCA pump, optimize dosing.\n s/p SPLENECTOMY -- will need meningococcal and pneumococcal vaccines\n FLIUD\n desire net volume expension.\n THROMBOCYTOSIS\n perhaps reactive. Monitor.\n DELERIUM\n improved.\n RECURRENT PANCREATITS -- Unclear cause, but consider cystic fibrosis\n given family history. Recheck amylase, lipase and monitor clinical\n exam.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 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: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-10 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 683526,
"text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, transferred to MICU for post-op\n respiratory distress.\n Initially admitted to outside hospital with LUQ pain, rigors,\n and lipase of 1100 --> treated for pancreatitis, but ongoing bilious\n emesis and T= 103 prompted transfer to for further care on\n .\n Upon arrival to , CT scan suggested splenic rupture -->\n vancomycin, levofloxacin, and flagyl, and splenic artery embolization\n on , and subsequent splenectomy with distal pancreatectomy on\n . Post-op developed fevers and tachycardia. On CT\n torso revealed left subsegmental pulmonary emboli and a fluid\n collection in the LUQ with drain in place --> heparin gtt.\n Hospital course complicated by significant left pleural effusion -->\n diagnostic thoracentesis , yielding 500 cc of serosanguinous\n fluid, exudative by Light's criteria. Continued fevers, increasing\n abdominal distention --> repeat CT abd/pelvis revealed LUQ fluid\n collection with air (concern for enteric leak). Return to OR \n for repair.\n Per report, the surgery was fairly involved with a gastric and omental\n patch. Extubated post-op, but developed tachypnea. CXR with apparent\n significant worsening of left pleural effusion --> transferred to MICU\n service for further evaluation and mangement.\n Upon arrival in the ICU, he was tachypneic and c/o some labored\n breathing, tachypnea. He was also having significant abdominal pain.\n Tachycardia. Improved with iv fluids and pain mangement.\n This AM, states to feel somewhat improved.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 08:09 AM\n Ciprofloxacin - 09:15 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:14 AM\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n PANCREATITIS, RECURRENT\n Cystic fibrosis in some cousins. Father had brain cancer.\n Occupation: accountant\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other:\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 Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:50 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (98.9\n HR: 115 (108 - 138) bpm\n BP: 128/69(84) {98/67(73) - 128/77(84)} mmHg\n RR: 33 (22 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 12 (10 - 17)mmHg\n Total In:\n 3,450 mL\n PO:\n TF:\n IVF:\n 3,450 mL\n Blood products:\n Total out:\n 0 mL\n 580 mL\n Urine:\n 330 mL\n NG:\n 200 mL\n Stool:\n Drains:\n 50 mL\n Balance:\n 0 mL\n 2,870 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, Diaphoretic, Mild\n distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 1058 K/uL\n 31.6 %\n 10.2 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 12 mg/dL\n 23 mEq/L\n 103 mEq/L\n 4.9 mEq/L\n 135 mEq/L\n 21.9 K/uL\n [image002.jpg]\n 03:41 AM\n WBC\n 21.9\n Hct\n 31.6\n Plt\n 1058\n Cr\n 0.7\n Glucose\n 135\n Other labs: PT / PTT / INR:15.3/26.5/1.3, ALT / AST:26/36, Alk Phos / T\n Bili:65/0.9, Amylase / Lipase:49/54, Differential-Neuts:89.8 %,\n Lymph:5.9 %, Mono:3.9 %, Eos:0.1 %, Fibrinogen:357 mg/dL, Albumin:2.2\n g/dL, LDH:443 IU/L, Ca++:6.9 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR\n Microbiology: Blood culture () +GPC\n Assessment and Plan\n 39 yomh/o recurrent pancreatitis, recent surgery for splenectomy,\n enteric leak now with post-operative respiratory distress.\n RESPIRATORY DISTRESS\n multifactorial. Suspect contribution of\n bacteremia and sepsis, acidosis, left pleural effusion, left\n atalectasis, pulmonary emboli (off anticoagulation), and abdominal\n pain. Plan treat sepsis, antibiotics, iv fliuds, optimize pain\n management, maintain upright position. Consider left thoracentesis if\n expands.\n TACHYCARDIA\n likley reflects respiratory distress, pain, hypovolemia,\n possible pulmonary embolism. Monitor HR, check EKG. Replete iv fluid,\n optimize pain, treat sepsis/bacteremia.\n BACTEREMIA\n GPC, possible line related, but concern for enteric\n infection. Remove central lines if possible (use peripheral if\n feasible). Empirical antimicrobials, including Vanco/Cipro/Flagyl.\n PULMONARY EMBOLI\n left, subsegmental, multiple. Plan resume\n anticoagulation as per Surgery.\n PLEURAL EFFUSION\n suspect sympathetic and related to abdominal\n surgeries.\n s/p ENTERIC LEAK -- NGT with intermittent suction, antibiotics, await\n culture results.\n PAIN MANAGEMENT\n post-op. PCA pump, optimize dosing.\n s/p SPLENECTOMY -- will need meningococcal and pneumococcal vaccines\n FLIUD\n desire net volume expension.\n THROMBOCYTOSIS\n perhaps reactive. Monitor.\n DELERIUM\n improved.\n RECURRENT PANCREATITS -- Unclear cause, but consider cystic fibrosis\n given family history. Recheck amylase, lipase and monitor clinical\n exam.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 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: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-10 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 683527,
"text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, transferred to MICU for post-op\n respiratory distress.\n Initially admitted to outside hospital with LUQ pain, rigors,\n and lipase of 1100 --> treated for pancreatitis, but ongoing bilious\n emesis and T= 103 prompted transfer to for further care on\n .\n Upon arrival to , CT scan suggested splenic rupture -->\n vancomycin, levofloxacin, and flagyl, and splenic artery embolization\n on , and subsequent splenectomy with distal pancreatectomy on\n . Post-op developed fevers and tachycardia. On CT\n torso revealed left subsegmental pulmonary emboli and a fluid\n collection in the LUQ with drain in place --> heparin gtt.\n Hospital course complicated by significant left pleural effusion -->\n diagnostic thoracentesis , yielding 500 cc of serosanguinous\n fluid, exudative by Light's criteria. Continued fevers, increasing\n abdominal distention --> repeat CT abd/pelvis revealed LUQ fluid\n collection with air (concern for enteric leak). Return to OR \n for repair.\n Per report, the surgery was fairly involved with a gastric and omental\n patch. Extubated post-op, but developed tachypnea. CXR with apparent\n significant worsening of left pleural effusion --> transferred to MICU\n service for further evaluation and mangement.\n Upon arrival in the ICU, he was tachypneic and c/o some labored\n breathing, tachypnea. He was also having significant abdominal pain.\n Tachycardia. Improved with iv fluids and pain mangement.\n This AM, states to feel somewhat improved.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 08:09 AM\n Ciprofloxacin - 09:15 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:14 AM\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n PANCREATITIS, RECURRENT\n Pancreatic pseudocyst formation s/p cyst gastrostomy for drainage\n Multiple admissions for pancreatitis\n \"Erosive gastritis and gastric varices\"\n Fatty liver on imaging, possible non-alcoholic fatty liver disease\n s/p appendectomy\n s/p cholecystectomy\n Cystic fibrosis in some cousins. Father had brain cancer.\n Occupation: accountant\n Drugs: denies\n Tobacco: denies\n Alcohol: denies\n Other:\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 Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:50 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (98.9\n HR: 115 (108 - 138) bpm\n BP: 128/69(84) {98/67(73) - 128/77(84)} mmHg\n RR: 33 (22 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 12 (10 - 17)mmHg\n Total In:\n 3,450 mL\n PO:\n TF:\n IVF:\n 3,450 mL\n Blood products:\n Total out:\n 0 mL\n 580 mL\n Urine:\n 330 mL\n NG:\n 200 mL\n Stool:\n Drains:\n 50 mL\n Balance:\n 0 mL\n 2,870 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, Diaphoretic, Mild\n distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 1058 K/uL\n 31.6 %\n 10.2 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 12 mg/dL\n 23 mEq/L\n 103 mEq/L\n 4.9 mEq/L\n 135 mEq/L\n 21.9 K/uL\n [image002.jpg]\n 03:41 AM\n WBC\n 21.9\n Hct\n 31.6\n Plt\n 1058\n Cr\n 0.7\n Glucose\n 135\n Other labs: PT / PTT / INR:15.3/26.5/1.3, ALT / AST:26/36, Alk Phos / T\n Bili:65/0.9, Amylase / Lipase:49/54, Differential-Neuts:89.8 %,\n Lymph:5.9 %, Mono:3.9 %, Eos:0.1 %, Fibrinogen:357 mg/dL, Albumin:2.2\n g/dL, LDH:443 IU/L, Ca++:6.9 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR\n Microbiology: Blood culture () +GPC\n Assessment and Plan\n 39 yomh/o recurrent pancreatitis, recent surgery for splenectomy,\n enteric leak now with post-operative respiratory distress.\n RESPIRATORY DISTRESS\n multifactorial. Suspect contribution of\n bacteremia and sepsis, acidosis, left pleural effusion, left\n atalectasis, pulmonary emboli (off anticoagulation), and abdominal\n pain. Plan treat sepsis, antibiotics, iv fliuds, optimize pain\n management, maintain upright position. Consider left thoracentesis if\n expands.\n TACHYCARDIA\n likley reflects respiratory distress, pain, hypovolemia,\n possible pulmonary embolism. Monitor HR, check EKG. Replete iv fluid,\n optimize pain, treat sepsis/bacteremia.\n BACTEREMIA\n GPC, possible line related, but concern for enteric\n infection. Remove central lines if possible (use peripheral if\n feasible). Empirical antimicrobials, including Vanco/Cipro/Flagyl.\n PULMONARY EMBOLI\n left, subsegmental, multiple. Plan resume\n anticoagulation as per Surgery.\n PLEURAL EFFUSION\n suspect sympathetic and related to abdominal\n surgeries.\n s/p ENTERIC LEAK -- NGT with intermittent suction, antibiotics, await\n culture results.\n PAIN MANAGEMENT\n post-op. PCA pump, optimize dosing.\n s/p SPLENECTOMY -- will need meningococcal and pneumococcal vaccines\n FLIUD\n desire net volume expension.\n THROMBOCYTOSIS\n perhaps reactive. Monitor.\n DELERIUM\n improved.\n RECURRENT PANCREATITS -- Unclear cause, but consider cystic fibrosis\n given family history. Recheck amylase, lipase and monitor clinical\n exam.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 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: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-10 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 683493,
"text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, transferred to MICU for post-op\n respiratory distress.\n Initially admitted to outside hospital with LUQ pain, rigors,\n and lipase of 1100 --> treated for pancreatitis, but ongoing bilious\n emesis and T= 103 prompted transfer to for further care on\n .\n Upon arrival to , CT scan suggested splenic rupture -->\n vancomycin, levofloxacin, and flagyl, and splenic artery embolization\n on , and subsequent splenectomy with distal pancreatectomy on\n . Post-op developed fevers and tachycardia. On CT\n torso revealed left subsegmental pulmonary emboli and a fluid\n collection in the LUQ with drain in place --> heparin gtt.\n Hospital course complicated by significant left pleural effusion -->\n diagnostic thoracentesis , yielding 500 cc of serosanguinous\n fluid, exudative by Light's criteria. Continued fevers, increasing\n abdominal distention --> repeat CT abd/pelvis revealed LUQ fluid\n collection with air (concern for enteric leak). Return to OR \n for repair.\n Per report, the surgery was fairly involved with a gastric and omental\n patch. Extubated post-op, but developed tachypnea. CXR with apparent\n significant worsening of left pleural effusion --> transferred to MICU\n service for further evaluation and mangement.\n Upon arrival in the ICU, he was tachypneic and c/o some labored\n breathing, tachypnea. He was also having significant abdominal pain.\n Tachycardia. Improved with iv fluids and pain mangement.\n This AM, states to feel somewhat improved.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 08:09 AM\n Ciprofloxacin - 09:15 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:14 AM\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n PANCREATITIS, RECURRENT\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\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 Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:50 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (98.9\n HR: 115 (108 - 138) bpm\n BP: 128/69(84) {98/67(73) - 128/77(84)} mmHg\n RR: 33 (22 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 12 (10 - 17)mmHg\n Total In:\n 3,450 mL\n PO:\n TF:\n IVF:\n 3,450 mL\n Blood products:\n Total out:\n 0 mL\n 580 mL\n Urine:\n 330 mL\n NG:\n 200 mL\n Stool:\n Drains:\n 50 mL\n Balance:\n 0 mL\n 2,870 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, Diaphoretic, Mild\n distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 1058 K/uL\n 31.6 %\n 10.2 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 12 mg/dL\n 23 mEq/L\n 103 mEq/L\n 4.9 mEq/L\n 135 mEq/L\n 21.9 K/uL\n [image002.jpg]\n 03:41 AM\n WBC\n 21.9\n Hct\n 31.6\n Plt\n 1058\n Cr\n 0.7\n Glucose\n 135\n Other labs: PT / PTT / INR:15.3/26.5/1.3, ALT / AST:26/36, Alk Phos / T\n Bili:65/0.9, Amylase / Lipase:49/54, Differential-Neuts:89.8 %,\n Lymph:5.9 %, Mono:3.9 %, Eos:0.1 %, Fibrinogen:357 mg/dL, Albumin:2.2\n g/dL, LDH:443 IU/L, Ca++:6.9 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR\n Microbiology: Blood culture () +GPC\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 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: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-10 00:00:00.000",
"description": "Physician Attending Admission Note - MICU",
"row_id": 683497,
"text": "Chief Complaint: Respiratory distress\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, transferred to MICU for post-op\n respiratory distress.\n Initially admitted to outside hospital with LUQ pain, rigors,\n and lipase of 1100 --> treated for pancreatitis, but ongoing bilious\n emesis and T= 103 prompted transfer to for further care on\n .\n Upon arrival to , CT scan suggested splenic rupture -->\n vancomycin, levofloxacin, and flagyl, and splenic artery embolization\n on , and subsequent splenectomy with distal pancreatectomy on\n . Post-op developed fevers and tachycardia. On CT\n torso revealed left subsegmental pulmonary emboli and a fluid\n collection in the LUQ with drain in place --> heparin gtt.\n Hospital course complicated by significant left pleural effusion -->\n diagnostic thoracentesis , yielding 500 cc of serosanguinous\n fluid, exudative by Light's criteria. Continued fevers, increasing\n abdominal distention --> repeat CT abd/pelvis revealed LUQ fluid\n collection with air (concern for enteric leak). Return to OR \n for repair.\n Per report, the surgery was fairly involved with a gastric and omental\n patch. Extubated post-op, but developed tachypnea. CXR with apparent\n significant worsening of left pleural effusion --> transferred to MICU\n service for further evaluation and mangement.\n Upon arrival in the ICU, he was tachypneic and c/o some labored\n breathing, tachypnea. He was also having significant abdominal pain.\n Tachycardia. Improved with iv fluids and pain mangement.\n This AM, states to feel somewhat improved.\n Patient admitted from: OR / PACU\n History obtained from Medical records\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 02:00 AM\n Vancomycin - 08:09 AM\n Ciprofloxacin - 09:15 AM\n Infusions:\n Other ICU medications:\n Metoprolol - 06:14 AM\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n PANCREATITIS, RECURRENT\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\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 Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:50 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37.2\nC (98.9\n HR: 115 (108 - 138) bpm\n BP: 128/69(84) {98/67(73) - 128/77(84)} mmHg\n RR: 33 (22 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 12 (10 - 17)mmHg\n Total In:\n 3,450 mL\n PO:\n TF:\n IVF:\n 3,450 mL\n Blood products:\n Total out:\n 0 mL\n 580 mL\n Urine:\n 330 mL\n NG:\n 200 mL\n Stool:\n Drains:\n 50 mL\n Balance:\n 0 mL\n 2,870 mL\n Respiratory\n O2 Delivery Device: Aerosol-cool\n SpO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, Thin, No(t) Anxious, Diaphoretic, Mild\n distress\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 1058 K/uL\n 31.6 %\n 10.2 g/dL\n 135 mg/dL\n 0.7 mg/dL\n 12 mg/dL\n 23 mEq/L\n 103 mEq/L\n 4.9 mEq/L\n 135 mEq/L\n 21.9 K/uL\n [image002.jpg]\n 03:41 AM\n WBC\n 21.9\n Hct\n 31.6\n Plt\n 1058\n Cr\n 0.7\n Glucose\n 135\n Other labs: PT / PTT / INR:15.3/26.5/1.3, ALT / AST:26/36, Alk Phos / T\n Bili:65/0.9, Amylase / Lipase:49/54, Differential-Neuts:89.8 %,\n Lymph:5.9 %, Mono:3.9 %, Eos:0.1 %, Fibrinogen:357 mg/dL, Albumin:2.2\n g/dL, LDH:443 IU/L, Ca++:6.9 mg/dL, Mg++:2.4 mg/dL, PO4:3.8 mg/dL\n Imaging: CXR\n Microbiology: Blood culture () +GPC\n Assessment and Plan\n 39 yomh/o recurrent pancreatitis, recent surgery for splenectomy,\n enteric leak now with post-operative respiratory distress.\n RESPIRATORY DISTRESS\n multifactorial. Suspect contribution of\n bacteremia and sepsis, acidosis, left pleural effusion, left\n atalectasis, pulmonary emboli (off anticoagulation), and abdominal\n pain. Plan treat sepsis, antibiotics, iv fliuds, optimize pain\n management, maintain upright position. Consider left thoracentesis if\n expands.\n TACHYCARDIA\n likley reflects respiratory distress, pain, hypovolemia,\n possible pulmonary embolism. Monitor HR, check EKG. Replete iv fluid,\n optimize pain, treat sepsis/bacteremia.\n BACTEREMIA\n GPC, possible line related, but concern for enteric\n infection. Remove central lines if possible (use peripheral if\n feasible). Empirical antimicrobials, including Vanco/Cipro/Flagyl.\n PULMONARY EMBOLI\n left, subsegmental, multiple. Plan resume\n anticoagulation as per Surgery.\n PLEURAL EFFUSION\n suspect sympathetic and related to abdominal\n surgeries.\n s/p ENTERIC LEAK -- NGT with intermittent suction, antibiotics, await\n culture results.\n PAIN MANAGEMENT\n post-op. PCA pump, optimize dosing.\n s/p SPLENECTOMY -- will need meningococcal and pneumococcal vaccines\n FLIUD\n desire net volume expension.\n THROMBOCYTOSIS\n perhaps reactive. Monitor.\n DELERIUM\n improved.\n RECURRENT PANCREATITS -- Unclear cause, but consider cystic fibrosis\n given family history. Recheck amylase, lipase and monitor clinical\n exam.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 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: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683598,
"text": "39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, and now transferred to MICU for post-op\n respiratory distress.\n Tachycardia, Other\n Assessment:\n HR 100\ns-110\ns in sinus tach.\n Action:\n Given Lopressor 2.5 mg IV Q 6 hours. Given 5% Albumin in 500ml x 1.\n Remains on LR at 125 ml/hr.\n Response:\n HR maintained in 100\ns in sinus rythym.\n Plan:\n Continue to monitor and give Lopressor 2.5 mg IV Q 6 hours.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known hx of PE. Received pt on 6 liters face mask. Sats\n 95-100%. Pt c/o\na little shortness or breath\n. LS clear with\n diminished bases. Also initially on standing SC Heparin TID. PTT 26.5\n this am.\n Action:\n SC Heparin d/c\nd and pt started on Heparin gtt at 1700 units/hr at\n 1100. O2 weaned down to 3 LNC.\n Response:\n Pt comfortable on NC. 1700 PTT 33.2\n given 4500 unit IV bolus and\n dose up to 2150 units/hr per sliding scale.\n Plan:\n Continue to monitor PTT and resp status.\n s/p laperotomy, Pain control (acute pain, chronic pain)\n Assessment:\n S/P laperotomy. Abd dressings cd&i. Abd firm and distended. Pt on\n low con\nt wall suction via NGT. 2 JP drains present draining\n serous/serosanguinous fluid. J tube clamped. PCA pump with Dilaudid\n working well for pt.\n Action:\n Monitor for pain. Given 0.5 mg IV Dilaudid bolus x 1 for breakthrough\n pain with good effect.\n Response:\n NGT draining bilious fluid. Drainage amount documented. See\n Metavision. Pt currently A&O x 3.\n Plan:\n Continue pain management. Monitor incision site and f/u with surgery.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 681739,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt remains febrile Tmax 101.\n Action:\n Tylenol po and fan applied. Blood culture results pending. Vancomycin\n 1000mg given x 1 during IR procedure.\n Response:\n Temp down to 100.6. Blood cultures pending.\n Plan:\n Awaiting blood cultures. Monitor WBC and temp. For OR for removal of\n speen.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues to c/o pain to left abdomen and back. Pt grimacing\n with activity.\n Action:\n Started on PCA of Hydromorphone and given boluses for pain control. Pt\n encouraged to use PCA. Pt repositioned in bed and back rub given.\n Response:\n Pain down to on pain scale.\n Plan:\n Continue with PCA for pain control. Encourage pt and remind pt to use\n PCA. Bolus of hydromorphone given for total of 1.5mg IV.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683653,
"text": "39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, and now transferred to MICU for post-op\n respiratory distress.\n Tachycardia, Other\n Assessment:\n HR 100\ns-110\ns in sinus tach.\n Action:\n Given Lopressor 2.5 mg IV Q 6 hours. Remains on LR at 125 ml/hr.\n Response:\n HR maintained in 100\ns in sinus rythym.\n Plan:\n Continue to monitor and give Lopressor 2.5 mg IV Q 6 hours.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known hx of PE. Started on Heparin gtt on . On 3 L NC.\n Action:\n SCD on. PTT Q6 hr.\n Response:\n PTT> 150 at midnight. Drip adjusted as per order. O2 sat 94-98%,\n denies resp. Distress.\n Plan:\n Continue to monitor PTT and resp status. Next PTT due at 0800.\n s/p laperotomy, Pain control (acute pain, chronic pain)\n Assessment:\n S/P laperotomy. Abd dressings cd&i. Abd firm and distended. Pt on\n low con\nt wall suction via NGT. 2 JP drains present draining\n serous/serosanguinous fluid. J tube clamped. PCA pump with Dilaudid\n working well for pt.\n Action:\n Monitor for pain.\n Response:\n NGT draining bilious fluid. Pt currently A&O x 3. Pain level \n and Pt. states Pain tolerable. Takeing naps intermitenly.\n Plan:\n Continue pain management. Monitor incision site and f/u with surgery.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 681621,
"text": "39 year old male with history of pancreatitis was admitted to \n Hospital a week ago with fevers and LLQ pain x1wk. Pt was treated with\n levaquin and flagyl but no diagnosis given. Pt frustrated and left AMA.\n Pt decided on pursuing further treatment at . Pt in ED was febrile\n and had an elevated WBC. CT scan of abdomen showed ?splenic abscess vs.\n hemorrhage. Pt\ns given Vanco, Levaquin, and Flagyl in ED. Blood, Urine\n and Stool cultures collected. Hct dropped from 32.3 to 27.2 and pt was\n transfused with 1 unit PRBC. Pt transferred to TSICU for further\n monitoring, serial Hcts and possible embolization of bleed.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 681797,
"text": "39 year old male with history of pancreatitis was admitted to \n Hospital a week ago with fevers and LLQ pain x1wk. Pt was treated with\n levaquin and flagyl but no diagnosis given. Pt frustrated and left AMA.\n Pt decided on pursuing further treatment at . Pt in ED was febrile\n and had an elevated WBC. CT scan of abdomen showed splenic lesion with\n hemorrhagic bleed. Pt transferred to TSICU for further monitoring,\n serial Hcts and IR embolization.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt tmax of 103.3. Diaphoretic, Tachycardic to 130s. Hct stable. WBC\n count elevated.\n Action:\n Blood cultures redrawn, labs taken. Serial Hcts. Tylenol given. Fan and\n cool cloth in place.\n Response:\n Temp decreased to 101. Pending lab cultures.\n Plan:\n Start possible antbx regimen. Give Tylenol as needed. Pt planned for\n add-on in the OR today for splenectomy.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complains of pain in left upper quadrant and radiating to back.\n Pt slightly anxious at baseline.\n Action:\n Pt repositioned and on Dilaudid PCA. IVP dilaudid given for\n breakthrough pain and ativan given for anxiety. Emotional support\n provided.\n Response:\n Pt more comfortable with pain regimen.\n Plan:\n Continue with Dilaudid PCA. ? epidural once splenectomy performed.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684442,
"text": "Pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known PE, obtained off heparin gtt for procedure\n Action:\n Heparin restarted after procedure, trending ptt q6hrs\n Response:\n 1800 labs pending\n Plan:\n Ongoing, continue to trend q6hr ptt, next draw 0000\n Pleural effusion, acute\n Assessment:\n Large left sided effusion\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 683659,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:30 PM\n Metronidazole - 01:11 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Hydromorphone (Dilaudid) - 01:05 PM\n Heparin Sodium - 06:31 PM\n Pantoprazole (Protonix) - 12:00 AM\n Metoprolol - 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 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37\nC (98.6\n HR: 108 (101 - 126) bpm\n BP: 140/75(90) {116/60(75) - 148/80(98)} mmHg\n RR: 17 (17 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 23 (10 - 23)mmHg\n Total In:\n 7,360 mL\n 1,359 mL\n PO:\n TF:\n IVF:\n 6,405 mL\n 894 mL\n Blood products:\n 500 mL\n Total out:\n 1,725 mL\n 535 mL\n Urine:\n 1,435 mL\n 495 mL\n NG:\n 225 mL\n Stool:\n Drains:\n 65 mL\n 40 mL\n Balance:\n 5,635 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 994 K/uL\n 7.9 g/dL\n 142 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 25.8 %\n 20.7 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n WBC\n 21.9\n 20.7\n Hct\n 31.6\n 25.8\n Plt\n 1058\n 994\n Cr\n 0.7\n 0.6\n Glucose\n 135\n 142\n Other labs: PT / PTT / INR:15.8/150.0/1.4, ALT / AST:21/32, Alk Phos /\n T Bili:52/0.7, Amylase / Lipase:65/110, Differential-Neuts:79.0 %,\n Band:0.0 %, Lymph:16.0 %, Mono:3.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Albumin:2.2 g/dL, LDH:357 IU/L, Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:1.9\n mg/dL\n Assessment and Plan\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:31 PM 83 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 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": "2159-05-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 683660,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n -Peritoneal fluid growing GNR: hemophilus\n - coag negative staph from ; prob. contamination redraw cx tomorrow\n - received 25mg albumin, low urine output resolved\n -receiving dilaudid PCA with adequate pain control\n - EKG showed no evidence of prolonged QTc\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:30 PM\n Metronidazole - 01:11 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Hydromorphone (Dilaudid) - 01:05 PM\n Heparin Sodium - 06:31 PM\n Pantoprazole (Protonix) - 12:00 AM\n Metoprolol - 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 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37\nC (98.6\n HR: 108 (101 - 126) bpm\n BP: 140/75(90) {116/60(75) - 148/80(98)} mmHg\n RR: 17 (17 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 23 (10 - 23)mmHg\n Total In:\n 7,360 mL\n 1,359 mL\n PO:\n TF:\n IVF:\n 6,405 mL\n 894 mL\n Blood products:\n 500 mL\n Total out:\n 1,725 mL\n 535 mL\n Urine:\n 1,435 mL\n 495 mL\n NG:\n 225 mL\n Stool:\n Drains:\n 65 mL\n 40 mL\n Balance:\n 5,635 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 994 K/uL\n 7.9 g/dL\n 142 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 25.8 %\n 20.7 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n WBC\n 21.9\n 20.7\n Hct\n 31.6\n 25.8\n Plt\n 1058\n 994\n Cr\n 0.7\n 0.6\n Glucose\n 135\n 142\n Other labs: PT / PTT / INR:15.8/150.0/1.4, ALT / AST:21/32, Alk Phos /\n T Bili:52/0.7, Amylase / Lipase:65/110, Differential-Neuts:79.0 %,\n Band:0.0 %, Lymph:16.0 %, Mono:3.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Albumin:2.2 g/dL, LDH:357 IU/L, Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:1.9\n mg/dL\n Assessment and Plan\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:31 PM 83 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 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": "2159-05-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 683663,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n -Peritoneal fluid growing GNR: hemophilus\n - coag negative staph from ; prob. contamination redraw cx tomorrow\n - received 25mg albumin, low urine output resolved\n -receiving dilaudid PCA with adequate pain control\n - EKG showed no evidence of prolonged QTc\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:30 PM\n Metronidazole - 01:11 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Hydromorphone (Dilaudid) - 01:05 PM\n Heparin Sodium - 06:31 PM\n Pantoprazole (Protonix) - 12:00 AM\n Metoprolol - 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 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37\nC (98.6\n HR: 108 (101 - 126) bpm\n BP: 140/75(90) {116/60(75) - 148/80(98)} mmHg\n RR: 17 (17 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 23 (10 - 23)mmHg\n Total In:\n 7,360 mL\n 1,359 mL\n PO:\n TF:\n IVF:\n 6,405 mL\n 894 mL\n Blood products:\n 500 mL\n Total out:\n 1,725 mL\n 535 mL\n Urine:\n 1,435 mL\n 495 mL\n NG:\n 225 mL\n Stool:\n Drains:\n 65 mL\n 40 mL\n Balance:\n 5,635 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 994 K/uL\n 7.9 g/dL\n 142 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 25.8 %\n 20.7 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n WBC\n 21.9\n 20.7\n Hct\n 31.6\n 25.8\n Plt\n 1058\n 994\n Cr\n 0.7\n 0.6\n Glucose\n 135\n 142\n Other labs: PT / PTT / INR:15.8/150.0/1.4, ALT / AST:21/32, Alk Phos /\n T Bili:52/0.7, Amylase / Lipase:65/110, Differential-Neuts:79.0 %,\n Band:0.0 %, Lymph:16.0 %, Mono:3.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Albumin:2.2 g/dL, LDH:357 IU/L, Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:1.9\n mg/dL\n Assessment and Plan\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis who presented with\n ruptured spleen and underwent splenectomy who then returned to the OR\n for repair of an enteric leak, now transferred to the ICU in the\n setting of respiratory distress and massive pleural effusion.\n # Tachypnea and Pleural effusion:\n Unclear if imaging is misleading as patient was in semi-erect position,\n which may have caused fluid to move superiorly on film.\n - obtain repeat CXR in erect position to confirm size of effusion\n - although surgery did not want to re-tap effusion, would favor\n thoracentesis +/- pigtail catheter placement as fluid is likely to be\n infected given probable communication with LUQ fluid collection\n - pt currently oxygenating very well and not showing signs of tiring,\n likely because he has excellent respiratory reserve given young age.\n will monitor closely\n - follow ABGs, particularly given that high dose narcotics may blunt\n his tachypnea\n # Sinus Tachycardia:\n Likely multifactorial in setting of pain, PE, tachypnea/respiratory\n distress, and infection.\n - would avoid beta blocking sinus tachycardia and rather would treat\n underlying causes\n # s/p repair of enteric leak:\n - continue NG tube to intermittent suction\n - continue cipro/flagyl\n - appreciate surgery input\n - f/u peritoneal fluid culture\n - obtain BCx\n # GPCs from CVL blood Cx :\n - will need his line re-sited\n - continue vanc for now\n # Pain:\n - continue dilaudid PCA and consider increasing dose if his pain does\n not improve\n - bowel regimen while on narcotics once he is taking PO meds\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n # Subsegmental PEs:\n - hold on heparin gtt during acute post-op period\n - discuss with surgery re: timing of restarting heparin gtt\n # Leukocytosis:\n Likely from enteric leak, recent surgery, and GPCs in blood.\n - f/u culture data\n - address sources of infection as discussed above\n # Elevated platelets:\n be inflammatory reaction, but elevation of platelets is extremely\n pronounced.\n - monitor\n # Anemia, Hct stable at 31:\n Note that patient's haptoglobin was less than assay on admission labs\n .\n - send hemolysis work-up\n - active type and screen\n # Delirium:\n Patient has self-extubated earlier during his hospital course. Per\n surgery, his NG tube needs to continue to suction for decompression of\n his bowel.\n - appreciate psych recs\n - frequent reorientation\n - haldol PRN\n - EKG to monitor QTc\n - restraints to avoid pulling at tubes/lines\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # FEN: strict NPO including for meds; LR continuous at 125 with\n boluses PRN; note that pt has feeding J tube, but unclear indication at\n present\n # PPx: subQ heparin; continue IV PPI started on floor\n # Access: 20g PIV, left IJ (will need to be re-sited)\n # Comm: with mom \n # Code: confirmed FULL\n # Dispo: to surgical floor once stable\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:31 PM 83 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 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": "2159-05-11 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 683813,
"text": "39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, and now transferred to MICU for post-op\n respiratory distress.\n Tachycardia, Other\n Assessment:\n HR 100\ns-110\ns in sinus tach.\n Action:\n Given Lopressor 2.5 mg IV Q 6 hours. Remains on LR at 125 ml/hr.\n Response:\n HR maintained in 100\ns in sinus rythym.pt temp 101.4 blood and urine\n cultures sent\n Plan:\n Continue to monitor and give Lopressor 2.5 mg IV Q 6 hours.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known hx of PE. Started on Heparin gtt on . On 3 L NC.\n Action:\n SCD on. PTT Q6 hr.\n Response:\n ptt@830 55.6 oob to chair without distress. Not increased per team due\n to 5 pt hct drop.\n Plan:\n Continue to monitor PTT and resp status. Next PTT due at 1400\n s/p laprotomy, Pain control (acute pain, chronic pain)\n Assessment:\n S/P laperotomy. Dsd Removed this morning. Abd firm and distended. But\n pt states that abdomen feels less tense than yesterday and that he is\n burping but unsure if he has flatus. Pt on low con\nt wall suction\n via NGT. 2 JP drains present draining serous/serosanguinous fluid. J\n tube clamped. PCA pump with Dilaudid working well for pt.\n Action:\n Monitor for pain.\n Response:\n NGT draining bilious fluid. Pt currently A&O x 3. Pain level 0-4/10\n and Pt. states Pain tolerable. Coughing and expectorating mod amounts\n of thick tan secretions using is 750-x10 oob to chair x2 with 2person\n assist.\n Plan:\n Continue pain management. Monitor incision site and f/u with surgery.\n Demographics\n Attending MD:\n T.\n Admit diagnosis:\n SPLENIC HEMORRHAGE\n Code status:\n Full code\n Height:\n 74 Inch\n Admission weight:\n 109 kg\n Daily weight:\n 113.6 kg\n Allergies/Reactions:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Precautions:\n PMH: Anemia, Pancreatitis\n CV-PMH:\n Additional history: subsequential PE, confusion, agitation ( called\n code purple few days back ) h/o 22 episodes of acute pancreatitis.\n Surgery / Procedure and date: - distal pancreatectomy and\n splenectomy\n - exp laprotomy ,lysis of adhesions, repair of jejunal\n enterotomy,gastric serosal patch,and J tube placement.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:152\n D:85\n Temperature:\n 101.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 29 insp/min\n Heart Rate:\n 116 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 4,248 mL\n 24h total out:\n 1,630 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 04:04 AM\n Potassium:\n 4.6 mEq/L\n 04:04 AM\n Chloride:\n 103 mEq/L\n 04:04 AM\n CO2:\n 26 mEq/L\n 04:04 AM\n BUN:\n 12 mg/dL\n 04:04 AM\n Creatinine:\n 0.6 mg/dL\n 04:04 AM\n Glucose:\n 142 mg/dL\n 04:04 AM\n Hematocrit:\n 26.5 %\n 07:14 AM\n Finger Stick Glucose:\n 166\n 06:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 4 /MICU 411\n Transferred to: 12R /82\n Date & time of Transfer: . 1945HRS\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 683771,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n - Peritoneal fluid growing GNR: hemophilus\n - coag negative staph from ; prob. contamination redraw cx tomorrow\n - received 25mg albumin, low urine output resolved\n - receiving dilaudid PCA with adequate pain control\n - EKG showed no evidence of prolonged \n - pt states that his abdomen feels less distended, has not passed gas\n since surgery\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:30 PM\n Metronidazole - 01:11 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Hydromorphone (Dilaudid) - 01:05 PM\n Heparin Sodium - 06:31 PM\n Pantoprazole (Protonix) - 12:00 AM\n Metoprolol - 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 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37\nC (98.6\n HR: 108 (101 - 126) bpm\n BP: 140/75(90) {116/60(75) - 148/80(98)} mmHg\n RR: 17 (17 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 23 (10 - 23)mmHg\n Total In:\n 7,360 mL\n 1,359 mL\n PO:\n TF:\n IVF:\n 6,405 mL\n 894 mL\n Blood products:\n 500 mL\n Total out:\n 1,725 mL\n 535 mL\n Urine:\n 1,435 mL\n 495 mL\n NG:\n 225 mL\n Stool:\n Drains:\n 65 mL\n 40 mL\n Balance:\n 5,635 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Gen: Lying comfortably in bed, NAD\n HEENT: EOMI, PERRLA, no lymphadenopathy\n CV: tachycardic, No MRG\n Pulm: crackles in R bases, decreased BS in L bases\n Peripheral Vascular: strong radial and DP pulses\n Skin: no rashes or lesions, abdominal dressing intact with no evidence\n of drainage or pus\n Neurologic: alert and oriented x2\n Tubes/drains: abd drains with serosanguinous fluid\n Labs / Radiology\n 994 K/uL\n 7.9 g/dL\n 142 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 25.8 %\n 20.7 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n WBC\n 21.9\n 20.7\n Hct\n 31.6\n 25.8\n Plt\n 1058\n 994\n Cr\n 0.7\n 0.6\n Glucose\n 135\n 142\n Other labs: PT / PTT / INR:15.8/150.0/1.4, ALT / AST:21/32, Alk Phos /\n T Bili:52/0.7, Amylase / Lipase:65/110, Differential-Neuts:79.0 %,\n Band:0.0 %, Lymph:16.0 %, Mono:3.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Albumin:2.2 g/dL, LDH:357 IU/L, Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:1.9\n mg/dL\n Cx: Blood x1 : coag negative staph\n peritoneal fluid: HAEMOPHILUS, \n intraabd abcess: gram - rods\n Assessment and Plan\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis who presented with\n ruptured spleen and underwent splenectomy who then returned to the OR\n for repair of an enteric leak, now transferred to the ICU in the\n setting of respiratory distress and massive pleural effusion.\n # Tachypnea and Pleural effusion: Pt sating well on 5 L nasal canula.\n CT yesterday showed significant L sided plural effusion.\n This effusion appears to have been present since before the surgery and\n the patient is not in respiratory distress. Plan to hold on tap for\n now, however will re-consider if patients respiratory status\n deteriorates or he shows worsening signs of infecion.\n -continue O2 by nasal cannula, will turn down and monitor today\n -monitor ABGs\n - taper narcotics\n #Anemia : no evidence of bleed as patient has not had any bloody BMs or\n emesis. Pt also states that his abdomen is less distended and\n clinically he does not have any evidence of bleeding from his surgical\n site or into his abdomen. While this changes is most likely dilution\n in the context of recent fluid resusitation, we remain concerned for GI\n bleed or bleed into the abdomen from his surgical site. Normal\n haptoglobin and unconjugated bilirubin suggest that it is not\n hemolytic, and marrow is responding appropriately with increased retic\n ct.\n -closely follow hematocrit\n -type and screen 3 units\n # coag negative staph : pt with one cx coag negative staph. Will\n continue to cx until negative.\n -serial cxs\n -replace lines if bacteremia persists\n -continue vancomycin\n # s/p repair of enteric leak : pt now with GNR isolated in peritoneal\n fluid and abcess growing haemophilus.\n - continue NG tube to intermittent suction\n - continue cipro/flagyl\n - appreciate surgery input\n # Sinus Tachycardia:Likely multifactorial in setting of pain, PE,\n tachypnea/respiratory distress, and infection. Persisting despite\n fluid resusitation, however expect continued improvement with treatment\n of infection. Will hold of on BBlocker for now and attempt to tx\n underlying cause.\n # Pain: Well controlled on dilaudid PCA. Req\nd one dose of IV\n dilaudid for break through pain\n - wean to orals today\n -IV dilaudid for breakthrough pain\n - bowel regimen while on narcotics once he is taking PO meds\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n # Subsegmental PEs:\n - hold on heparin gtt during acute post-op period\n - discuss with surgery re: timing of restarting heparin gtt\n # Leukocytosis:\n Likely from enteric leak, recent surgery, and GPCs in blood.\n - f/u culture data\n - address sources of infection as discussed above\n # Elevated platelets: Trending down, likely acute inflammatory\n response.\n -continue to follow.\n # Delirium: Improved. Pt oriented, has not attemped to pull tubes\n while in ICU. Ekg performed for haldol monitoring was normal.\n - appreciate psych recs\n - frequent reorientation\n - haldol PRN\n - restraints as needed o avoid pulling at tubes/lines\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - follow amylase, lipase and monitor clinical exam\n # FEN: strict NPO including for meds\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:31 PM 83 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: heparin\n Stress ulcer: pansoprazole\n VAP: elevated head of bed, spirometry\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: to when stable\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 681714,
"text": "TSICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o fever/chills;\n he went 9 days ago to OSH where he was admitted, had an elevated lipase\n and emesis; he was treated there conservatively for presumed\n pancreatitis & given abx; he left AMA & now has come to w/ LUQ pain,\n possible splenic rupture vs. abscess seen on CT abd. Has had no\n hypotension in ED.\n Chief complaint:\n PMHx:\n recurrent acute pancreatitis, s/p ERCP & drainage of biliary sludge;\n s/p appy, s/p open chole; s/p drainage of pancreatic pseudocyst\n Current medications:\n 24 Hour Events:\n admitted\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:50 AM\n Other medications:\n Flowsheet Data as of 07:37 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: 123 (115 - 123) bpm\n BP: 164/89(110) {162/89(106) - 164/91(110)} mmHg\n RR: 26 (24 - 28) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 4,275 mL\n PO:\n Tube feeding:\n IV Fluid:\n Blood products:\n 275 mL\n Total out:\n 0 mL\n 2,140 mL\n Urine:\n 240 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 2,135 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ////\n Physical Examination\n General Appearance: Anxious\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (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: 39yo with hx of acute gallstone pancreatitis now\n with possible splenic hematoma vs. abscess, going to IR for drain\n today.\n Neurologic: Neuro checks Q: 4 hr, change morphine to dilaudid for pain.\n Will order PCA dilaudid.\n Cardiovascular: tachy, receiving 1 U PRBCs now, no h/o cardiac disease\n Pulmonary: NC O2, pain control to avoid splinting\n Gastrointestinal / Abdomen: NPO, f/u final CT abd read; IR consulted\n for poss embolization of splenic vessels\n Nutrition: NPO\n Renal: Foley, follow UOP. Will give fluids for contrast load today.\n Hematology: anemia. Serial Hct, Hct q 4h.\n Endocrine: euglycemia. RISS\n Infectious Disease: afebrile, leukocytosis elevated, likely\n inflammatory vs. abscess. Will readdress Empiric coverage need.\n Lines / Tubes / Drains: Foley, PIV x2\n Wounds:\n Imaging:\n Fluids: LR@100cc/hr\n Consults: General surgery, IR\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\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: 32mins\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 681726,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt remains febrile Tmax 101.\n Action:\n Tylenol po and fan applied. Blood culture results pending. Vancomycin\n 1000mg given x 1 during IR procedure.\n Response:\n Plan:\n Awaiting blood cultures. Monitor WBC and temp. For OR for removal of\n speen.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt continues to c/o pain to left abdomen and back. Pt grimacing\n with activity.\n Action:\n Started on PCA of Hydromorphone and given boluses for pain control. Pt\n encouraged to use PCA. Pt repositioned in bed and back rub given.\n Response:\n Pain down to on pain scale.\n Plan:\n"
},
{
"category": "Respiratory ",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 682011,
"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 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: 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: No response (sleeping / sedated)\n :\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI=31\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Pt weaned overnight to CPAP 5/5. Plan to extubate later in morning.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683810,
"text": "39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, and now transferred to MICU for post-op\n respiratory distress.\n Tachycardia, Other\n Assessment:\n HR 100\ns-110\ns in sinus tach.\n Action:\n Given Lopressor 2.5 mg IV Q 6 hours. Remains on LR at 125 ml/hr.\n Response:\n HR maintained in 100\ns in sinus rythym.pt temp 101.4 blood and urine\n cultures sent\n Plan:\n Continue to monitor and give Lopressor 2.5 mg IV Q 6 hours.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known hx of PE. Started on Heparin gtt on . On 3 L NC.\n Action:\n SCD on. PTT Q6 hr.\n Response:\n ptt@830 55.6 oob to chair without distress. Not increased per team due\n to 5 pt hct drop.\n Plan:\n Continue to monitor PTT and resp status. Next PTT due at 1400\n s/p laperotomy, Pain control (acute pain, chronic pain)\n Assessment:\n S/P laperotomy. Dsd Removed this morning. Abd firm and distended. But\n pt states that abdomen feels less tense than yesterday and that he is\n burping but unsure if he has flatus. Pt on low con\nt wall suction\n via NGT. 2 JP drains present draining serous/serosanguinous fluid. J\n tube clamped. PCA pump with Dilaudid working well for pt.\n Action:\n Monitor for pain.\n Response:\n NGT draining bilious fluid. Pt currently A&O x 3. Pain level 0-4/10\n and Pt. states Pain tolerable. Coughing and expectorating mod amounts\n of thick tan secretions using is 750-x10 oob to chair x2 with 2person\n assist.\n Plan:\n Continue pain management. Monitor incision site and f/u with surgery.\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 681865,
"text": "SICU\n HPI:\n 39 yo M w/ h/o recurrent acute pancreatitis, w/ 9 day h/o fever/chills;\n he went 9 days ago to OSH where he was admitted, had an elevated lipase\n and emesis; he was treated there conservatively for presumed\n pancreatitis & given abx; he left AMA & now has come to w/ LUQ pain,\n possible splenic rupture vs. abscess seen on CT abd. Has had no\n hypotension in ED.\n .\n PMHx:\n PMH: recurrent acute pancreatitis\n PSH: appy, CCY\n pancreatic pseudocyst drainage (?cyst gastrostomy) ( Hosp)\n : Viokase with meals ; Vicodin prn\n Current medications:\n 1. 1000 mL LR 2. Acetaminophen 3. Albuterol 0.083% Neb Soln 4. Docusate\n Sodium (Liquid) 5. Famotidine 6. . HYDROmorphone (Dilaudid) 8. Insulin\n 9. Ipratropium Bromide Neb 10. Lorazepam\n 24 Hour Events:\n BLOOD CULTURED - At 03:45 AM\n URINE CULTURE - At 03:45 AM\n FEVER - 103.3\nF - 12:00 AM\n EVENTS:IR embolized splenic artery\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 12:00 PM\n Infusions:\n Other ICU medications:\n Morphine Sulfate - 06:50 AM\n Famotidine (Pepcid) - 08:05 PM\n Lorazepam (Ativan) - 10:33 PM\n Hydromorphone (Dilaudid) - 10:37 PM\n Other medications:\n Flowsheet Data as of 04:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.6\nC (103.3\n T current: 38.2\nC (100.8\n HR: 123 (102 - 127) bpm\n BP: 133/86(98) {124/62(85) - 169/104(118)} mmHg\n RR: 17 (12 - 44) insp/min\n SPO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 5,875 mL\n 418 mL\n PO:\n Tube feeding:\n IV Fluid:\n 1,600 mL\n 418 mL\n Blood products:\n 275 mL\n Total out:\n 4,375 mL\n 580 mL\n Urine:\n 2,475 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,500 mL\n -162 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 95%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), Tachycardia\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Groin no hematoma\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\n Labs / Radiology\n 474 K/uL\n 10.1 g/dL\n 111 mg/dL\n 0.7 mg/dL\n 31 mEq/L\n 4.1 mEq/L\n 14 mg/dL\n 95 mEq/L\n 133 mEq/L\n 30.8 %\n 24.4 K/uL\n [image002.jpg]\n 06:30 AM\n 11:07 AM\n 02:57 PM\n 06:29 PM\n 10:29 PM\n 02:32 AM\n WBC\n 17.9\n 24.4\n Hct\n 29.4\n 28.4\n 30.7\n 30.2\n 30.6\n 30.8\n Plt\n 436\n 474\n Creatinine\n 0.7\n 0.7\n Glucose\n 99\n 111\n Other labs: PT / PTT / INR:14.3/28.2/1.2, CK / CK-MB / Troponin\n T:272//, ALT / AST:27/67, Alk-Phos / T bili:66/2.8, Amylase /\n Lipase:88/156, Fibrinogen:652 mg/dL, Albumin:2.7 g/dL, LDH:855 IU/L,\n Ca:8.0 mg/dL, Mg:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), PAIN CONTROL (ACUTE\n PAIN, CHRONIC PAIN)\n Assessment and Plan: 39 yo male with ac pancreatitis now with possible\n splenic bleed\n NEURO:Pain better controlled on Dilaudid PCA; Ativan prn;\n CVS:Stable; tachycardia likely SIRS.\n PULM:No issues, oxygenating well.\n GI: IR embolized splenic artery; For distal pancreatectomy splenectomy\n on ; Talk to team about nasojej tube in OR\n RENAL: Cr WNL, follow UOP\n HEME: Hct 32 ->27; got 1 U PRBCs in ED; Crits stable at 30\n ENDO:RISS\n euglycemic\n Infectious Disease: WBC 15 on admit; increased to 24.4\n Lines / Tubes / Drains: foley, PIV\n Fluids: LR @ 100\n Consults: Gen Surgery\n Billing Diagnosis: Other: pancreatitis\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 06:42 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status:\n Disposition: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682013,
"text": "39 year old male with history of pancreatitis was admitted to \n Hospital a week ago with fevers and LLQ pain x1wk. Pt was treated with\n levaquin and flagyl but no diagnosis given. Pt frustrated and left AMA.\n Pt decided on pursuing further treatment at . Pt in ED was febrile\n and had an elevated WBC. CT scan of abdomen showed splenic lesion with\n hemorrhagic bleed.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n To OR today for splenectomy and distal pancreatectomy, splenic artery\n was hemorrhaging during surgery and pt was given lots of blood products\n and crystalloid. Pt tachycardic. HCT\ns stable, UOP adequate. Pt\n intubated on CMV post-op. Primary dsg on midline abdominal incision.\n Large JP drain left lateral abdomen draining moderate amts of\n serosanguinous fluid. Pt remains febrile to 100.8\n Action:\n -Serial Hcts\n -Kefzol given x3 doses post-op\n -Multilumen IJ central line placed\n -tylenol given\n Response:\n Pt continues to be tachycardic, Hct\ns remain stable. Febrile, Pt weaned\n to CPAP 5/5 with ABG wnl.\n Plan:\n Plan for extubation in the am. Monitor Hcts.\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-15 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 684677,
"text": "TITLE:\n Chief Complaint:\n HPI:\n \n -heparin restarted\n -advance tube feeds 10 ml q 4 hrs to 100/hr\n -PCA restarted\n - recs to transfer to floor \n -no microrganisms seen in pleural fluid or abcess\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Cefipime - 10:00 AM\n Ciprofloxacin - 07:22 PM\n Vancomycin - 08:29 PM\n Fluconazole - 10:09 PM\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 07:47 AM\n Fentanyl - 10:00 AM\n Midazolam (Versed) - 10:00 AM\n Metoprolol - 12:21 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 06:30 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.8\nC (100\n Tcurrent: 36.6\nC (97.9\n HR: 99 (82 - 101) bpm\n BP: 133/77(90) {129/68(85) - 150/90(104)} mmHg\n RR: 19 (14 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 4,798 mL\n 919 mL\n PO:\n TF:\n 166 mL\n 130 mL\n IVF:\n 2,800 mL\n 248 mL\n Blood products:\n Total out:\n 8,245 mL\n 2,905 mL\n Urine:\n 6,785 mL\n 2,710 mL\n NG:\n Stool:\n Drains:\n 480 mL\n 115 mL\n Balance:\n -3,447 mL\n -1,986 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///29/\n Physical Examination\n PHYSICAL EXAM\n GENERAL: drowsy, 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 .\n LUNGS: decreased breath sounds in left lung field; chest tube in place\n ABDOMEN: diffusely tender, midabdominal incision c/d/I +BS, JP drains\n in place, peritoneal drain with fibrinous straw colored fluid,\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial\n pulses.\n SKIN: stable blister on right volar wrist\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, no\n evidence of psychoses or delerium\n Labs / Radiology\n 1124 K/uL\n 7.5 g/dL\n 129 mg/dL\n 0.5 mg/dL\n 8 mg/dL\n 29 mEq/L\n 101 mEq/L\n 4.0 mEq/L\n 135 mEq/L\n 25.1 %\n 13.9 K/uL\n [image002.jpg]\n \n 2:33 A6/25/ 03:41 AM\n \n 10:20 P6/26/ 04:04 AM\n \n 1:20 P6/26/ 07:14 AM\n \n 11:50 P6/27/ 03:00 PM\n \n 1:20 A6/27/ 08:20 PM\n \n 7:20 P6/27/ 09:00 PM\n 1//11/006\n 1:23 P6/28/ 02:56 AM\n \n 1:20 P6/29/ 01:25 AM\n \n 11:20 P6/29/ 05:45 PM\n \n 4:20 P6/30/ 04:53 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n 15.4\n 13.9\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n 25.0\n 23.8\n 25.1\n Plt\n 1\n 1109\n 1173\n 1120\n 1124\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n 0.6\n 0.5\n TC02\n 27\n Glucose\n 135\n 142\n 115\n 105\n 96\n 129\n Other labs: PT / PTT / INR:14.9/40.6/1.3, ALT / AST:24/33, Alk Phos / T\n Bili:133/0.5, Amylase / Lipase:80/120, Differential-Neuts:70.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:11.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:359 IU/L, Ca++:7.3 mg/dL,\n Mg++:1.9 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PANCREATITIS, ACUTE\n THROMBOCYTOSIS (INCLUDING ESSENTIAL THROMBOCYTOSIS, ET)\n ELECTROLYTE & FLUID DISORDER, OTHER\n DELIRIUM / CONFUSION\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis s/p splenectomy for\n ruptured spleen who returns to the with fevers, AMS, tachycardia\n in the setting of recent enteric leak repair.\n # Fevers and Leukocytosis:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . The line has since been\n removed with no other positive cultures. Patient had IR drainage of\n intraabdominal abscess and pleural effusion yesterday with subjective\n improvement in pain\n - Intraabdominal drains in place, chest tube appears to be\n malfunctioning obstruction or positioning\n -continue fluconazole for albicans coverage\n - continue cefepime for broad gram negative and anaerobic coverage (has\n penicillin allergy)\n - continue vancomycin and cipro\n - f/u sensitivities , bcx, fungal cx\n - c. diff toxins negative x 2\n - pain well controlled on PCA\n # Delirium: Patient initially had problems with delirium when he was\n brought back to the . This may be secondary to his pain\n medications or could be a manifestation of severe infection +/-\n sepsis. If he is bacteremic or fungemic, would also consider the\n possibility of septic emboli, but not at threshold to image head\n without supportive culture data.\n - pain better controlled with dilaudid PCA\n - haldol prn, per psych recs in chart\nconfirm QTc prior to dosing\n # Anemia: Stable, however will follow closely given his recent surgery\n and anticoagulation.\n - follow serial Hcts\n - active type and screen\n - If Hct drops less than current 23.7, contact surgery immediately for\n discussion re: transfusion.\n # Tachypnea with respiratory alkalosis: improved since initial ICU\n stay. Likely related to pain, although he may also have some anxiety\n from being disoriented.\n - continue pain control\n # Sinus Tachycardia:\n Likely multifactorial in setting of pain, PE, tachypnea/respiratory\n distress, and infection. Improved since initial infection\n - would avoid beta blocking sinus tachycardia and rather would treat\n underlying causes\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n - note that pt is infected with encapsulated organism\n # Subsegmental PEs:\n - continue heparin drip\n # Elevated platelets:\n be inflammatory reaction, but elevation of platelets is extremely\n pronounced. Patient may also have an underlying predisposition to\n thrombosis. While there is a 5% risk of thrombosis in the setting of\n post-splenectomy thrombocytosis, the only intervention would be\n systemic anticoagulation and the patient is already on heparin for PE\n -appreciate heme recs\n - if a thrombophilia w/u is felt to be warranted, must wait until\n patient has been off heparin\n # Recurrent pancreatitis:\n Unclear cause, althought cystic fibrosis is a possibility given strong\n family history. While salt test was negative, consider sending out for\n CF gene mutation assay.\n - recheck amylase, lipase and monitor clinical exam\n # Comm: with mom \n ICU Care\n Nutrition:\n Replete () - 12:48 PM 20 mL/hour\n TPN w/ Lipids - 06:31 PM 83. mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 10:10 PM\n Prophylaxis:\n DVT: on therapeutic heparin\n Stress ulcer: pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: stable, transfer to floor\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-10 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683454,
"text": "Mr. is a 39yo gentleman with h/o recurrent pancreatitis admitted\n with ruptured spleen who is transferred to the unit in the setting of\n post-op respiratory distress\n Tachycardia, Other\n Assessment:\n Received the pt from PACU,HR 130\ns,st, febrile, BP stable,low urine\n output. Pt with ? sepsis.\n Action:\n Received iv antibiotics vanco,cipro from PACU and flagyl given in icu.\n Received 2lit LR for tachycardis and low urine output for ?\n dehydration. Seen by surgery and icu team several times and evaluated.\n Blood c/s 1 of 2 and urine c./s sent. Lopressor q 6h. IVF LR @ 125\n cc/hr.\n Response:\n HR down to 120;s, ST, BP stable. Urine output remained twards the lower\n side. Continued as febrile.\n Plan:\n Monitor VS, f/u with c/s reports. Hydrate as needed.\n s/p exp laprotomy , Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p exp laprotomy, small dry dressing and a big dressing on\n abdomen,abd firm distended,pt with pain mostly while on any activity.\n BS absent. NGT connected to low cont.suction draining bilious. 2 JP\n drains and J tube in place, clamped. Bilateral pedal edema.pt with h/o\n PE, not on heparin now. Venodynes on .\n Action:\n Received dilaudid bolus doses from PACU as pt pt awake to use PCA,\n started PCA dose 0.25mg in ICU ,pt used PCA very frequently initially\n ,and then slept. Not used very often by morning. Lethargic. Awake,\n alert x 2.\n Response:\n Pt with better pain relief with PCA dose. JP drains and NGT drainage\n emptied and documented.\n Plan:\n Contine with pain management, monitor incision site , and f/u with\n surgery and icu team .\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 683737,
"text": "Chief Complaint: sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Pain control improved today.\n Overall, states to be much improved.\n Denies dyspnea - states breathing much easier.\n Using incentive spirometer.\n Up in chair.\n Heparin resumed yesterday.\n TPN resumed.\n History obtained from Medical records\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Metronidazole - 01:11 AM\n Vancomycin - 08:07 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:05 PM\n Heparin Sodium - 06:31 PM\n Pantoprazole (Protonix) - 12:00 AM\n Metoprolol - 12:00 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: NPO, No(t) Tube feeds, No(t) Parenteral nutrition\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: Mild\n Pain location: Abd surgical incision\n Flowsheet Data as of 11:39 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: 115 (101 - 125) bpm\n BP: 137/72(88) {120/60(75) - 148/85(98)} mmHg\n RR: 24 (17 - 33) insp/min\n SpO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 8 (7 - 23)mmHg\n Total In:\n 7,360 mL\n 2,868 mL\n PO:\n TF:\n IVF:\n 6,405 mL\n 1,920 mL\n Blood products:\n 500 mL\n Total out:\n 1,725 mL\n 985 mL\n Urine:\n 1,435 mL\n 945 mL\n NG:\n 225 mL\n Stool:\n Drains:\n 65 mL\n 40 mL\n Balance:\n 5,635 mL\n 1,883 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///26/\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: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Clear : , No(t) Crackles : , No(t) Bronchial: , No(t)\n Wheezes : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: No(t) Soft, No(t) Non-tender, No(t) Bowel sounds present,\n Distended, No(t) Tender: , No(t) Obese, Firm, but much less tender;\n Midline surgical incision with staples, and 2 JP drains from left\n quadrants.\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): ox3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Normal\n Labs / Radiology\n 7.9 g/dL\n 994 K/uL\n 142 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 26.5 %\n 20.7 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n WBC\n 21.9\n 20.7\n Hct\n 31.6\n 25.8\n 26.5\n Plt\n 1058\n 994\n Cr\n 0.7\n 0.6\n Glucose\n 135\n 142\n Other labs: PT / PTT / INR:15.8/55.6/1.4, ALT / AST:21/32, Alk Phos / T\n Bili:52/0.7, Amylase / Lipase:65/110, Differential-Neuts:79.0 %,\n Band:0.0 %, Lymph:16.0 %, Mono:3.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Albumin:2.2 g/dL, LDH:357 IU/L, Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:1.9\n mg/dL\n Assessment and Plan\n 39 yomh/o recurrent pancreatitis, recent surgery for splenectomy,\n enteric leak now with post-operative respiratory distress.\n RESPIRATORY DISTRESS\n Much improved. Multifactorial. Suspect\n contribution of bacteremia and sepsis, acidosis, left pleural effusion,\n left atalectasis, pulmonary emboli (off anticoagulation), and abdominal\n pain. Plan treat sepsis, antibiotics, iv fliuds, optimize pain\n management, maintain upright position. Consider left thoracentesis if\n expands.\n TACHYCARDIA\n likley reflects respiratory distress, pain, hypovolemia,\n possible pulmonary embolism. Monitor HR, check EKG. Replete iv fluid,\n optimize pain, treat sepsis/bacteremia.\n BACTEREMIA\n GPC, possible line related, but concern for enteric\n infection. Remove central lines if possible (use peripheral if\n feasible). Empirical antimicrobials, including Vanco/Cipro/Flagyl.\n PULMONARY EMBOLI\n left, subsegmental, multiple. Resumed\n anticoagulation as per Surgery --> monitor PTT 60-80\n PLEURAL EFFUSION\n suspect sympathetic and related to abdominal\n surgeries.\n s/p ENTERIC LEAK -- NGT with intermittent suction, antibiotics, await\n culture results.\n PAIN MANAGEMENT\n post-op. PCA pump, optimize dosing.\n s/p SPLENECTOMY -- will need meningococcal and pneumococcal vaccines\n FLIUD\n desire net volume expension.\n THROMBOCYTOSIS\n perhaps reactive. Monitor.\n DELERIUM\n resolved.\n NUTRITIONAL SUPPORT -- NPO. Continue TPN.\n RECURRENT PANCREATITS -- Unclear cause, but consider cystic fibrosis\n given family history. Recheck amylase, lipase and monitor clinical\n exam.\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:31 PM 83 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Nutrition",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 683740,
"text": "Objective\n Pertinent medications: Heparin drip, RISS, protonix, abx, LR @125mL/hr,\n others noted\n Labs:\n Value\n Date\n Glucose\n 142 mg/dL\n 04:04 AM\n Glucose Finger Stick\n 167\n 06:00 AM\n BUN\n 12 mg/dL\n 04:04 AM\n Creatinine\n 0.6 mg/dL\n 04:04 AM\n Sodium\n 136 mEq/L\n 04:04 AM\n Potassium\n 4.6 mEq/L\n 04:04 AM\n Chloride\n 103 mEq/L\n 04:04 AM\n TCO2\n 26 mEq/L\n 04:04 AM\n pH (urine)\n 5.5 units\n 03:41 AM\n Albumin\n 2.2 g/dL\n 03:41 AM\n Calcium non-ionized\n 6.9 mg/dL\n 04:04 AM\n Phosphorus\n 1.9 mg/dL\n 04:04 AM\n Magnesium\n 2.1 mg/dL\n 04:04 AM\n ALT\n 21 IU/L\n 04:04 AM\n Alkaline Phosphate\n 52 IU/L\n 04:04 AM\n AST\n 32 IU/L\n 04:04 AM\n Amylase\n 65 IU/L\n 04:04 AM\n Total Bilirubin\n 0.7 mg/dL\n 04:04 AM\n WBC\n 20.7 K/uL\n 04:04 AM\n Hgb\n 7.9 g/dL\n 04:04 AM\n Hematocrit\n 26.5 %\n 07:14 AM\n Current diet order / nutrition support: TPN 6/26/09L 2.2L (345\n dextrose/130 gr protein/45 fat) 2143 kcals\n GI: Abd: soft/dist/hypo bs/-flatus\n Assessment of Nutritional Status\n Specifics:\n 39 year old male s/p ex-lap, LOA, distal pancreatectomy and total\n splenectomy , c/ return to OR -s/p reopening of laparotomy,\n LOA, repair of roux limb of jejunum and gastric pouch, and JT\n placement. Patient started on TPN , now at goal, meeting 100%\n estimated nutrition needs. PO4 repletion noted-will also increase in\n TPN today.\n Medical Nutrition Therapy Plan - Recommend the Following\n Continue c/ goal TPN- rec entered in POE\n Once able to start tube feeds, recommend Replete c/ Fiber @10mL/hr to\n increase 10mL q4hr to goal 95 mL/hr (2280 kcals/141 gr protein)\n No residuals c/ JT, monitor tolerance via abd exam, patient complaints,\n BM's\n BG and lyte management as you are\n Please page c/?\"s #\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684230,
"text": "Delirium / confusion\n Assessment:\n Pt A&Ox3, with some confused responses at times, able to follow\n commands, able to use call light appropriately, visiting with friends\n Action:\n Monitoring\n Response:\n Delirium largely resolved/resolving, pt with some confused statements\n this am, now with all appropriate comments and conversation\n Plan:\n Continue to monitor MS, if pt becomes acutely delirious will start\n haldol after baseline EKG obtained.\n Pleural effusion, acute\n Assessment:\n Pt on Cxray with large left sided pleural effusion, effusion was tapped\n micro from which had no growth, pt with limited breath sounds on\n the left, absent in the left lower lobe, denies SOB, maintaining sats\n on 2 L NC\n Action:\n CT chest performed\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n HR: 97-115 SR-ST, no ectopy noted\n Action:\n Pt receiving Metoprolol as ordered\n Response:\n Ongoing, pt\ns HR since admission low 110s\n Plan:\n Continue Metoprolol as ordered, continue to monitor\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting abd pain at worst at 10/10 in RLQ\n Action:\n Administering PRN dilaudid as ordered, frequency of order increased, pt\n provided with cough pillow, encouraged to deep breath\n Response:\n With increased frequency of PRN dilaudid pt with better control of pain\n Plan:\n Continue with PRNs as ordered for now, if unable to control pain with\n current regiment would increase dosing, if continues to have ongoing\n pain issues pt may require pain consult\n Leukocytosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-12 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684048,
"text": "pt with h/o pancreatitis, 0n underwent distal pancratectomy and\n splenectomy , pt from 7S , continued with tachycardia,HR 120-130's and\n ongoing fever, took for 2nd surgery, exp laprotomy on , OP\n procedures: lysis of adhesions,repair of jejunal enterotomy,gastric\n serosal patch ,J tube placement.pt having 2 JP drains,foley in place,\n Lt IJ central line..VSS, HR 130's and having low grade fever,RR high\n 20's- 30's ,laboured breathing,sats 94-96% with 6lit face mask.\n transffered to for observation and further management .pt received\n vanco,cipro and lopresor and iv dilaudid from PACU. PCA dilaudid not\n connected as pt not much awake to use PCA.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-03 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 682010,
"text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n To OR today for splenectomy and distal pancreatectomy, splenic artery\n was hemorrhaging during surgery and pt was given lots of blood products\n and crystalloid. Pt tachycardic. HCT\ns stable, UOP adequate. Pt\n intubated on CMV post-op. Primary dsg on midline abdominal incision.\n Large JP drain left lateral abdomen draining moderate amts of\n serosanguinous fluid. Pt remains febrile to 100.8\n Action:\n -Serial Hcts\n -Kefzol given x3 doses post-op\n -Multilumen IJ central line placed\n -tylenol given\n Response:\n Pt continues to be tachycardic, Hct\ns remain stable. Febrile, Pt weaned\n to CPAP 5/5 with ABG wnl.\n Plan:\n Plan for extubation in the am. Monitor Hcts.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683723,
"text": "39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, and now transferred to MICU for post-op\n respiratory distress.\n Tachycardia, Other\n Assessment:\n HR 100\ns-110\ns in sinus tach.\n Action:\n Given Lopressor 2.5 mg IV Q 6 hours. Remains on LR at 125 ml/hr.\n Response:\n HR maintained in 100\ns in sinus rythym.\n Plan:\n Continue to monitor and give Lopressor 2.5 mg IV Q 6 hours.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known hx of PE. Started on Heparin gtt on . On 3 L NC.\n Action:\n SCD on. PTT Q6 hr.\n Response:\n ptt@830 55.6 oob to chair without distress.\n Plan:\n Continue to monitor PTT and resp status. Next PTT due at 1400\n s/p laperotomy, Pain control (acute pain, chronic pain)\n Assessment:\n S/P laperotomy. Abd dressings cd&i. Abd firm and distended. Pt on\n low con\nt wall suction via NGT. 2 JP drains present draining\n serous/serosanguinous fluid. J tube clamped. PCA pump with Dilaudid\n working well for pt.\n Action:\n Monitor for pain.\n Response:\n NGT draining bilious fluid. Pt currently A&O x 3. Pain level \n and Pt. states Pain tolerable. Takeing naps intermitenly.\n Plan:\n Continue pain management. Monitor incision site and f/u with surgery.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 683724,
"text": "39 yom h/o recurrent pancreatitis recently admitted with ruptured\n spleen --> surgical resection, and now transferred to MICU for post-op\n respiratory distress.\n Tachycardia, Other\n Assessment:\n HR 100\ns-110\ns in sinus tach.\n Action:\n Given Lopressor 2.5 mg IV Q 6 hours. Remains on LR at 125 ml/hr.\n Response:\n HR maintained in 100\ns in sinus rythym.\n Plan:\n Continue to monitor and give Lopressor 2.5 mg IV Q 6 hours.\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known hx of PE. Started on Heparin gtt on . On 3 L NC.\n Action:\n SCD on. PTT Q6 hr.\n Response:\n ptt@830 55.6 oob to chair without distress. Not increased per team due\n to 5 pt hct drop.\n Plan:\n Continue to monitor PTT and resp status. Next PTT due at 1400\n s/p laperotomy, Pain control (acute pain, chronic pain)\n Assessment:\n S/P laperotomy. Removed this morning. Abd firm and distended. But pt\n states that abdomen feels less tense than yesterday and that he I\n burping but unsure if he has flatus. Pt on low con\nt wall suction\n via NGT. 2 JP drains present draining serous/serosanguinous fluid. J\n tube clamped. PCA pump with Dilaudid working well for pt.\n Action:\n Monitor for pain.\n Response:\n NGT draining bilious fluid. Pt currently A&O x 3. Pain level \n and Pt. states Pain tolerable. Takeing naps intermitenly.\n Plan:\n Continue pain management. Monitor incision site and f/u with surgery.\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684222,
"text": "Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Pleural effusion, acute\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Leukocytosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684231,
"text": "Delirium / confusion\n Assessment:\n Pt A&Ox3, with some confused responses at times, able to follow\n commands, able to use call light appropriately, visiting with friends\n Action:\n Monitoring\n Response:\n Delirium largely resolved/resolving, pt with some confused statements\n this am, now with all appropriate comments and conversation\n Plan:\n Continue to monitor MS, if pt becomes acutely delirious will start\n haldol after baseline EKG obtained.\n Pleural effusion, acute\n Assessment:\n Pt on Cxray with large left sided pleural effusion, effusion was tapped\n micro from which had no growth, pt with limited breath sounds on\n the left, absent in the left lower lobe, denies SOB, maintaining sats\n on 2 L NC\n Action:\n CT chest performed\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n HR: 97-115 SR-ST, no ectopy noted\n Action:\n Pt receiving Metoprolol as ordered\n Response:\n Ongoing, pt\ns HR since admission low 110s\n Plan:\n Continue Metoprolol as ordered, continue to monitor\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting abd pain at worst at 10/10 in RLQ\n Action:\n Administering PRN dilaudid as ordered, frequency of order increased, pt\n provided with cough pillow, encouraged to deep breath\n Response:\n With increased frequency of PRN dilaudid pt with better control of pain\n Plan:\n Continue with PRNs as ordered for now, if unable to control pain with\n current regiment would increase dosing, if continues to have ongoing\n pain issues pt may require pain consult\n Leukocytosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684284,
"text": "Pancreatitis, acute\n Assessment:\n Pt with persistent fevers, low grade this shift tmax 100.2, reporting\n LLQ abd pain, two JP drains in place in this area with no drainage\n Action:\n Receiving antibiotics as ordered, Ct torso done\n Response:\n Pt with abd absess per CT, continues with low grade temp though\n trending down\n Plan:\n Continue antibiotics as ordered, continue to follow temp curve, f/u\n culture data, CT guided drain placement tomorrow\n Delirium / confusion\n Assessment:\n Pt A&Ox3, with some confused responses at times, able to follow\n commands, able to use call light appropriately, visiting with friends\n Action:\n Monitoring\n Response:\n Delirium largely resolved/resolving, pt with some confused statements\n this am, now with all appropriate comments and conversation\n Plan:\n Continue to monitor MS, if pt becomes acutely delirious will start\n haldol after baseline EKG obtained.\n Pleural effusion, acute\n Assessment:\n Pt on Cxray with large left sided pleural effusion, effusion was tapped\n micro from which had no growth, pt with limited breath sounds on\n the left, absent in the left lower lobe, denies SOB, maintaining sats\n on 2 L NC\n Action:\n CT chest performed\n Response:\n Large left sided pleural effusion\n Plan:\n Effusion to be tapped in conjunction with CT guided abscess drain\n tomorrow\n Tachycardia, Other\n Assessment:\n HR: 97-115 SR-ST, no ectopy noted\n Action:\n Pt receiving Metoprolol as ordered\n Response:\n Ongoing, pt\ns HR since admission low 110s\n Plan:\n Continue Metoprolol as ordered, continue to monitor\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting abd pain at worst at 10/10 in LLQ\n Action:\n Administering PRN dilaudid as ordered, frequency of order increased, pt\n provided with cough pillow, encouraged to deep breath\n Response:\n With increased frequency of PRN dilaudid pt with better control of pain\n Plan:\n Continue with PRNs as ordered for now, if unable to control pain with\n current regiment would increase dosing, if continues to have ongoing\n pain issues pt may require pain consult\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684238,
"text": "Pancreatitis, acute\n Assessment:\n Pt with persistent fevers, low grade this shift tmax 100.2, reporting\n LLQ abd pain, two JP drains in place in this area with no drainage\n Action:\n Receiving antibiotics as ordered, Ct torso done\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Pt A&Ox3, with some confused responses at times, able to follow\n commands, able to use call light appropriately, visiting with friends\n Action:\n Monitoring\n Response:\n Delirium largely resolved/resolving, pt with some confused statements\n this am, now with all appropriate comments and conversation\n Plan:\n Continue to monitor MS, if pt becomes acutely delirious will start\n haldol after baseline EKG obtained.\n Pleural effusion, acute\n Assessment:\n Pt on Cxray with large left sided pleural effusion, effusion was tapped\n micro from which had no growth, pt with limited breath sounds on\n the left, absent in the left lower lobe, denies SOB, maintaining sats\n on 2 L NC\n Action:\n CT chest performed\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n HR: 97-115 SR-ST, no ectopy noted\n Action:\n Pt receiving Metoprolol as ordered\n Response:\n Ongoing, pt\ns HR since admission low 110s\n Plan:\n Continue Metoprolol as ordered, continue to monitor\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting abd pain at worst at 10/10 in LLQ\n Action:\n Administering PRN dilaudid as ordered, frequency of order increased, pt\n provided with cough pillow, encouraged to deep breath\n Response:\n With increased frequency of PRN dilaudid pt with better control of pain\n Plan:\n Continue with PRNs as ordered for now, if unable to control pain with\n current regiment would increase dosing, if continues to have ongoing\n pain issues pt may require pain consult\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684224,
"text": "Delirium / confusion\n Assessment:\n Pt A&Ox3, with some confused responses at times, able to follow\n commands, able to use call light appropriately, visiting with friends\n Action:\n Monitoring\n Response:\n Delirium largely resolved/resolving, pt with some confused statements\n this am, now with all appropriate comments and conversation\n Plan:\n Continue to monitor MS, if pt becomes acutely delirious will start\n haldol after baseline EKG obtained.\n Pleural effusion, acute\n Assessment:\n Action:\n Response:\n Plan:\n Tachycardia, Other\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Leukocytosis\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684354,
"text": "Events: Central line placement (RIJ) done, position confirmed after\n x-ray and after x-ray line pulled out and now OK to use\n TPN started\n Heparin gtt off at 6 am for procedure in IR\n Pancreatitis, acute\n Assessment:\n Pt with persistent low grade temp, c/o LLQ abd and back pain, two JP\n drains in place in this area with no drainage, surgical site dressing\n dry and intact and elevated amylase and lypase\n Action:\n Continue antibiotics as ordered, TPN started after CVL placement, NPO\n for procedure in AM\n Response:\n Pt with abd abscess per CT, continues with low grade temp, and abd\n pain, No drainage in JP drain\n Plan:\n Continue antibiotics as ordered, continue to follow temp curve, f/u\n culture data, CT guided drain placement tomorrow, continue TPN\n Delirium / confusion\n Assessment:\n Pt A&Ox3, able to follow commands, and co operative with care,able to\n use call light appropriately,\n Action:\n Monitoring\n Response:\n Delirium largely resolved/resolving.\n Plan:\n Continue to monitor MS, if pt becomes acutely delirious will start\n haldol after baseline EKG obtained.\n Pleural effusion, acute\n Assessment:\n Pt on C x-ray with large left sided pleural effusion, effusion was\n tapped micro from which had no growth, pt with limited breath\n sounds on the left, absent in the left lower lobe, denies SOB,\n maintaining sats on 2 L NC\n Action:\n HOB 30-45, continue to monitor\n Response:\n Large left sided pleural effusion for tapping in AM\n Plan:\n Effusion to be tapped in conjunction with CT guided abscess drain\n tomorrow\n Tachycardia, Other\n Assessment:\n HR: 95-115 SR-ST, no ectopy noted, no chest pain, patient with low\n grade temp\n Action:\n Pt receiving Metoprolol as ordered\n Response:\n Ongoing, pt\ns HR since admission low 110s\n Plan:\n Continue Metoprolol as ordered, continue to monitor\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting abd pain at worst at 8/10 in LLQ and occasional back pain\n Action:\n Administering PRN dilaudid as ordered, dose increased to 0.5mg q 2hrs,\n pt provided with cough pillow, encouraged to deep breath\n Response:\n With increased frequency of PRN dilaudid pt with better control of pain\n Plan:\n Continue with PRNs as ordered for now, if unable to control pain with\n current regiment would increase dosing, if continues to have ongoing\n pain issues pt may require pain consult\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 683703,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n - Peritoneal fluid growing GNR: hemophilus\n - coag negative staph from ; prob. contamination redraw cx tomorrow\n - received 25mg albumin, low urine output resolved\n - receiving dilaudid PCA with adequate pain control\n - EKG showed no evidence of prolonged \n - pt states that his abdomen feels less distended, has not passed gas\n since surgery\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:30 PM\n Metronidazole - 01:11 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Hydromorphone (Dilaudid) - 01:05 PM\n Heparin Sodium - 06:31 PM\n Pantoprazole (Protonix) - 12:00 AM\n Metoprolol - 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 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37\nC (98.6\n HR: 108 (101 - 126) bpm\n BP: 140/75(90) {116/60(75) - 148/80(98)} mmHg\n RR: 17 (17 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 23 (10 - 23)mmHg\n Total In:\n 7,360 mL\n 1,359 mL\n PO:\n TF:\n IVF:\n 6,405 mL\n 894 mL\n Blood products:\n 500 mL\n Total out:\n 1,725 mL\n 535 mL\n Urine:\n 1,435 mL\n 495 mL\n NG:\n 225 mL\n Stool:\n Drains:\n 65 mL\n 40 mL\n Balance:\n 5,635 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Gen: Lying comfortably in bed, NAD\n HEENT: EOMI, PERRLA, no lymphadenopathy\n CV: tachycardic, No MRG\n Pulm: crackles in R bases, decreased BS in L bases\n Peripheral Vascular: strong radial and DP pulses\n Skin: no rashes or lesions, abdominal dressing intact with no evidence\n of drainage or pus\n Neurologic: alert and oriented x2\n Tubes/drains: abd drains with serosanguinous fluid\n Labs / Radiology\n 994 K/uL\n 7.9 g/dL\n 142 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 25.8 %\n 20.7 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n WBC\n 21.9\n 20.7\n Hct\n 31.6\n 25.8\n Plt\n 1058\n 994\n Cr\n 0.7\n 0.6\n Glucose\n 135\n 142\n Other labs: PT / PTT / INR:15.8/150.0/1.4, ALT / AST:21/32, Alk Phos /\n T Bili:52/0.7, Amylase / Lipase:65/110, Differential-Neuts:79.0 %,\n Band:0.0 %, Lymph:16.0 %, Mono:3.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Albumin:2.2 g/dL, LDH:357 IU/L, Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:1.9\n mg/dL\n Cx: Blood x1 : coag negative staph\n peritoneal fluid: HAEMOPHILUS, \n intraabd abcess: gram - rods\n Assessment and Plan\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis who presented with\n ruptured spleen and underwent splenectomy who then returned to the OR\n for repair of an enteric leak, now transferred to the ICU in the\n setting of respiratory distress and massive pleural effusion.\n # Tachypnea and Pleural effusion: Pt sating well on 5 L nasal canula.\n CT yesterday showed significant L sided plural effusion.\n This effusion appears to have been present since before the surgery and\n the patient is not in respiratory distress. Plan to hold on tap for\n now, however will re-consider if patients respiratory status\n deteriorates or he shows worsening signs of infecion.\n -continue O2 by nasal cannula\n -monitor ABGs\n - taper narcotics\n #Anemia : no evidence of bleed as patient has not had any bloody BMs or\n emesis. Pt also states that his abdomen is less distended and\n clinically he does not have any evidence of bleeding from his surgical\n site or into his abdomen. While this changes is most likely dilution\n in the context of recent fluid resusitation, we remain concerned for GI\n bleed or bleed into the abdomen from his surgical site. Normal\n haptoglobin and unconjugated bilirubin suggest that it is not\n hemolytic, and marrow is responding appropriately with increased retic\n ct.\n -closely follow hematocrit\n -type and screen 3 units\n # coag negative staph : pt with one cx coag negative staph. Will\n continue to cx until negative.\n -serial cxs\n -replace lines if bacteremia persists\n -continue vancomycin\n # s/p repair of enteric leak : pt now with GNR isolated in peritoneal\n fluid and abcess growing haemophilus.\n - continue NG tube to intermittent suction\n - continue cipro/flagyl\n - appreciate surgery input\n # Sinus Tachycardia:Likely multifactorial in setting of pain, PE,\n tachypnea/respiratory distress, and infection. Persisting despite\n fluid resusitation, however expect continued improvement with treatment\n of infection. Will hold of on BBlocker for now and attempt to tx\n underlying cause.\n # Pain: Well controlled on dilaudid PCA. Req\nd one dose of IV\n dilaudid for break through pain\n - wean to orals today\n -IV dilaudid for breakthrough pain\n - bowel regimen while on narcotics once he is taking PO meds\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n # Subsegmental PEs:\n - hold on heparin gtt during acute post-op period\n - discuss with surgery re: timing of restarting heparin gtt\n # Leukocytosis:\n Likely from enteric leak, recent surgery, and GPCs in blood.\n - f/u culture data\n - address sources of infection as discussed above\n # Elevated platelets: Trending down, likely acute inflammatory\n response.\n -continue to follow.\n # Delirium: Improved. Pt oriented, has not attemped to pull tubes\n while in ICU. Ekg performed for haldol monitoring was normal.\n - appreciate psych recs\n - frequent reorientation\n - haldol PRN\n - restraints as needed o avoid pulling at tubes/lines\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # FEN: strict NPO including for meds; LR continuous at 125 with\n boluses PRN; note that pt has feeding J tube, but unclear indication at\n present\n # PPx: subQ heparin; continue IV PPI started on floor\n # Access: 20g PIV, left IJ (will need to be re-sited)\n # Comm: with mom \n # Code: confirmed FULL\n # Dispo: to surgical floor once stable\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:31 PM 83 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 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": "2159-05-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 683704,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n - Peritoneal fluid growing GNR: hemophilus\n - coag negative staph from ; prob. contamination redraw cx tomorrow\n - received 25mg albumin, low urine output resolved\n - receiving dilaudid PCA with adequate pain control\n - EKG showed no evidence of prolonged \n - pt states that his abdomen feels less distended, has not passed gas\n since surgery\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:30 PM\n Metronidazole - 01:11 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Hydromorphone (Dilaudid) - 01:05 PM\n Heparin Sodium - 06:31 PM\n Pantoprazole (Protonix) - 12:00 AM\n Metoprolol - 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 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37\nC (98.6\n HR: 108 (101 - 126) bpm\n BP: 140/75(90) {116/60(75) - 148/80(98)} mmHg\n RR: 17 (17 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 23 (10 - 23)mmHg\n Total In:\n 7,360 mL\n 1,359 mL\n PO:\n TF:\n IVF:\n 6,405 mL\n 894 mL\n Blood products:\n 500 mL\n Total out:\n 1,725 mL\n 535 mL\n Urine:\n 1,435 mL\n 495 mL\n NG:\n 225 mL\n Stool:\n Drains:\n 65 mL\n 40 mL\n Balance:\n 5,635 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Gen: Lying comfortably in bed, NAD\n HEENT: EOMI, PERRLA, no lymphadenopathy\n CV: tachycardic, No MRG\n Pulm: crackles in R bases, decreased BS in L bases\n Peripheral Vascular: strong radial and DP pulses\n Skin: no rashes or lesions, abdominal dressing intact with no evidence\n of drainage or pus\n Neurologic: alert and oriented x2\n Tubes/drains: abd drains with serosanguinous fluid\n Labs / Radiology\n 994 K/uL\n 7.9 g/dL\n 142 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 25.8 %\n 20.7 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n WBC\n 21.9\n 20.7\n Hct\n 31.6\n 25.8\n Plt\n 1058\n 994\n Cr\n 0.7\n 0.6\n Glucose\n 135\n 142\n Other labs: PT / PTT / INR:15.8/150.0/1.4, ALT / AST:21/32, Alk Phos /\n T Bili:52/0.7, Amylase / Lipase:65/110, Differential-Neuts:79.0 %,\n Band:0.0 %, Lymph:16.0 %, Mono:3.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Albumin:2.2 g/dL, LDH:357 IU/L, Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:1.9\n mg/dL\n Cx: Blood x1 : coag negative staph\n peritoneal fluid: HAEMOPHILUS, \n intraabd abcess: gram - rods\n Assessment and Plan\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis who presented with\n ruptured spleen and underwent splenectomy who then returned to the OR\n for repair of an enteric leak, now transferred to the ICU in the\n setting of respiratory distress and massive pleural effusion.\n # Tachypnea and Pleural effusion: Pt sating well on 5 L nasal canula.\n CT yesterday showed significant L sided plural effusion.\n This effusion appears to have been present since before the surgery and\n the patient is not in respiratory distress. Plan to hold on tap for\n now, however will re-consider if patients respiratory status\n deteriorates or he shows worsening signs of infecion.\n -continue O2 by nasal cannula\n -monitor ABGs\n - taper narcotics\n #Anemia : no evidence of bleed as patient has not had any bloody BMs or\n emesis. Pt also states that his abdomen is less distended and\n clinically he does not have any evidence of bleeding from his surgical\n site or into his abdomen. While this changes is most likely dilution\n in the context of recent fluid resusitation, we remain concerned for GI\n bleed or bleed into the abdomen from his surgical site. Normal\n haptoglobin and unconjugated bilirubin suggest that it is not\n hemolytic, and marrow is responding appropriately with increased retic\n ct.\n -closely follow hematocrit\n -type and screen 3 units\n # coag negative staph : pt with one cx coag negative staph. Will\n continue to cx until negative.\n -serial cxs\n -replace lines if bacteremia persists\n -continue vancomycin\n # s/p repair of enteric leak : pt now with GNR isolated in peritoneal\n fluid and abcess growing haemophilus.\n - continue NG tube to intermittent suction\n - continue cipro/flagyl\n - appreciate surgery input\n # Sinus Tachycardia:Likely multifactorial in setting of pain, PE,\n tachypnea/respiratory distress, and infection. Persisting despite\n fluid resusitation, however expect continued improvement with treatment\n of infection. Will hold of on BBlocker for now and attempt to tx\n underlying cause.\n # Pain: Well controlled on dilaudid PCA. Req\nd one dose of IV\n dilaudid for break through pain\n - wean to orals today\n -IV dilaudid for breakthrough pain\n - bowel regimen while on narcotics once he is taking PO meds\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n # Subsegmental PEs:\n - hold on heparin gtt during acute post-op period\n - discuss with surgery re: timing of restarting heparin gtt\n # Leukocytosis:\n Likely from enteric leak, recent surgery, and GPCs in blood.\n - f/u culture data\n - address sources of infection as discussed above\n # Elevated platelets: Trending down, likely acute inflammatory\n response.\n -continue to follow.\n # Delirium: Improved. Pt oriented, has not attemped to pull tubes\n while in ICU. Ekg performed for haldol monitoring was normal.\n - appreciate psych recs\n - frequent reorientation\n - haldol PRN\n - restraints as needed o avoid pulling at tubes/lines\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # FEN: strict NPO including for meds; LR continuous at 125 with\n boluses PRN; note that pt has feeding J tube, but unclear indication at\n present\n # PPx: subQ heparin; continue IV PPI started on floor\n # Access: 20g PIV, left IJ (will need to be re-sited)\n # Comm: with mom \n # Code: confirmed FULL\n # Dispo: to surgical floor once stable\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:31 PM 83 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 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": "2159-05-11 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 683705,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n \n - Peritoneal fluid growing GNR: hemophilus\n - coag negative staph from ; prob. contamination redraw cx tomorrow\n - received 25mg albumin, low urine output resolved\n - receiving dilaudid PCA with adequate pain control\n - EKG showed no evidence of prolonged \n - pt states that his abdomen feels less distended, has not passed gas\n since surgery\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Ciprofloxacin - 08:00 PM\n Vancomycin - 08:30 PM\n Metronidazole - 01:11 AM\n Infusions:\n Heparin Sodium - 1,700 units/hour\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:09 AM\n Hydromorphone (Dilaudid) - 01:05 PM\n Heparin Sodium - 06:31 PM\n Pantoprazole (Protonix) - 12:00 AM\n Metoprolol - 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 05:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.2\nC (100.7\n Tcurrent: 37\nC (98.6\n HR: 108 (101 - 126) bpm\n BP: 140/75(90) {116/60(75) - 148/80(98)} mmHg\n RR: 17 (17 - 33) insp/min\n SpO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 109 kg (admission): 109 kg\n Height: 74 Inch\n CVP: 23 (10 - 23)mmHg\n Total In:\n 7,360 mL\n 1,359 mL\n PO:\n TF:\n IVF:\n 6,405 mL\n 894 mL\n Blood products:\n 500 mL\n Total out:\n 1,725 mL\n 535 mL\n Urine:\n 1,435 mL\n 495 mL\n NG:\n 225 mL\n Stool:\n Drains:\n 65 mL\n 40 mL\n Balance:\n 5,635 mL\n 828 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///26/\n Physical Examination\n Gen: Lying comfortably in bed, NAD\n HEENT: EOMI, PERRLA, no lymphadenopathy\n CV: tachycardic, No MRG\n Pulm: crackles in R bases, decreased BS in L bases\n Peripheral Vascular: strong radial and DP pulses\n Skin: no rashes or lesions, abdominal dressing intact with no evidence\n of drainage or pus\n Neurologic: alert and oriented x2\n Tubes/drains: abd drains with serosanguinous fluid\n Labs / Radiology\n 994 K/uL\n 7.9 g/dL\n 142 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.6 mEq/L\n 12 mg/dL\n 103 mEq/L\n 136 mEq/L\n 25.8 %\n 20.7 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n WBC\n 21.9\n 20.7\n Hct\n 31.6\n 25.8\n Plt\n 1058\n 994\n Cr\n 0.7\n 0.6\n Glucose\n 135\n 142\n Other labs: PT / PTT / INR:15.8/150.0/1.4, ALT / AST:21/32, Alk Phos /\n T Bili:52/0.7, Amylase / Lipase:65/110, Differential-Neuts:79.0 %,\n Band:0.0 %, Lymph:16.0 %, Mono:3.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Albumin:2.2 g/dL, LDH:357 IU/L, Ca++:6.9 mg/dL, Mg++:2.1 mg/dL, PO4:1.9\n mg/dL\n Cx: Blood x1 : coag negative staph\n peritoneal fluid: HAEMOPHILUS, \n intraabd abcess: gram - rods\n Assessment and Plan\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis who presented with\n ruptured spleen and underwent splenectomy who then returned to the OR\n for repair of an enteric leak, now transferred to the ICU in the\n setting of respiratory distress and massive pleural effusion.\n # Tachypnea and Pleural effusion: Pt sating well on 5 L nasal canula.\n CT yesterday showed significant L sided plural effusion.\n This effusion appears to have been present since before the surgery and\n the patient is not in respiratory distress. Plan to hold on tap for\n now, however will re-consider if patients respiratory status\n deteriorates or he shows worsening signs of infecion.\n -continue O2 by nasal cannula\n -monitor ABGs\n - taper narcotics\n #Anemia : no evidence of bleed as patient has not had any bloody BMs or\n emesis. Pt also states that his abdomen is less distended and\n clinically he does not have any evidence of bleeding from his surgical\n site or into his abdomen. While this changes is most likely dilution\n in the context of recent fluid resusitation, we remain concerned for GI\n bleed or bleed into the abdomen from his surgical site. Normal\n haptoglobin and unconjugated bilirubin suggest that it is not\n hemolytic, and marrow is responding appropriately with increased retic\n ct.\n -closely follow hematocrit\n -type and screen 3 units\n # coag negative staph : pt with one cx coag negative staph. Will\n continue to cx until negative.\n -serial cxs\n -replace lines if bacteremia persists\n -continue vancomycin\n # s/p repair of enteric leak : pt now with GNR isolated in peritoneal\n fluid and abcess growing haemophilus.\n - continue NG tube to intermittent suction\n - continue cipro/flagyl\n - appreciate surgery input\n # Sinus Tachycardia:Likely multifactorial in setting of pain, PE,\n tachypnea/respiratory distress, and infection. Persisting despite\n fluid resusitation, however expect continued improvement with treatment\n of infection. Will hold of on BBlocker for now and attempt to tx\n underlying cause.\n # Pain: Well controlled on dilaudid PCA. Req\nd one dose of IV\n dilaudid for break through pain\n - wean to orals today\n -IV dilaudid for breakthrough pain\n - bowel regimen while on narcotics once he is taking PO meds\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n # Subsegmental PEs:\n - hold on heparin gtt during acute post-op period\n - discuss with surgery re: timing of restarting heparin gtt\n # Leukocytosis:\n Likely from enteric leak, recent surgery, and GPCs in blood.\n - f/u culture data\n - address sources of infection as discussed above\n # Elevated platelets: Trending down, likely acute inflammatory\n response.\n -continue to follow.\n # Delirium: Improved. Pt oriented, has not attemped to pull tubes\n while in ICU. Ekg performed for haldol monitoring was normal.\n - appreciate psych recs\n - frequent reorientation\n - haldol PRN\n - restraints as needed o avoid pulling at tubes/lines\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # FEN: strict NPO including for meds; LR continuous at 125 with\n boluses PRN; note that pt has feeding J tube, but unclear indication at\n present\n # PPx: subQ heparin; continue IV PPI started on floor\n # Access: 20g PIV, left IJ (will need to be re-sited)\n # Comm: with mom \n # Code: confirmed FULL\n # Dispo: to surgical floor once stable\n ICU Care\n Nutrition:\n TPN w/ Lipids - 06:31 PM 83 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 12:43 AM\n 20 Gauge - 12:44 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": "2159-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684292,
"text": "Pancreatitis, acute\n Assessment:\n Pt with persistent fevers, low grade this shift tmax 100.2, reporting\n LLQ abd pain, two JP drains in place in this area with no drainage\n Action:\n Receiving antibiotics as ordered, Ct torso done\n Response:\n Pt with abd absess per CT, continues with low grade temp though\n trending down\n Plan:\n Continue antibiotics as ordered, continue to follow temp curve, f/u\n culture data, CT guided drain placement tomorrow\n Delirium / confusion\n Assessment:\n Pt A&Ox3, with some confused responses at times, able to follow\n commands, able to use call light appropriately, visiting with friends\n Action:\n Monitoring\n Response:\n Delirium largely resolved/resolving, pt with some confused statements\n this am, now with all appropriate comments and conversation\n Plan:\n Continue to monitor MS, if pt becomes acutely delirious will start\n haldol after baseline EKG obtained.\n Pleural effusion, acute\n Assessment:\n Pt on Cxray with large left sided pleural effusion, effusion was tapped\n micro from which had no growth, pt with limited breath sounds on\n the left, absent in the left lower lobe, denies SOB, maintaining sats\n on 2 L NC\n Action:\n CT chest performed\n Response:\n Large left sided pleural effusion\n Plan:\n Effusion to be tapped in conjunction with CT guided abscess drain\n tomorrow\n Tachycardia, Other\n Assessment:\n HR: 97-115 SR-ST, no ectopy noted\n Action:\n Pt receiving Metoprolol as ordered\n Response:\n Ongoing, pt\ns HR since admission low 110s\n Plan:\n Continue Metoprolol as ordered, continue to monitor\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting abd pain at worst at 10/10 in LLQ\n Action:\n Administering PRN dilaudid as ordered, frequency of order increased, pt\n provided with cough pillow, encouraged to deep breath\n Response:\n With increased frequency of PRN dilaudid pt with better control of pain\n Plan:\n Continue with PRNs as ordered for now, if unable to control pain with\n current regiment would increase dosing, if continues to have ongoing\n pain issues pt may require pain consult\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 684451,
"text": "TITLE:\n Chief Complaint: AMS, respiratory distress\n 24 Hour Events:\n MULTI LUMEN - START 10:10 PM\n - CT abdomen/ thorax done: large sequestered fluid collection in\n abdomen, increasing pleural effusion in Left lung -- IR to drain\n - Right IJ placed for TPN to start after procedure tomorrow\n - tube feeds dc\nd in anticipation of procedure\n - d/c heparin drip at 1800units/hr at 6 am tomorrow for procedure, will\n restart after drains placed\n - heme consult, said to delay any thrombotic w/u until after rx. course\n with heparin\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 10:30 AM\n Vancomycin - 08:36 PM\n Ciprofloxacin - 08:38 PM\n Cefipime - 10:20 PM\n Fluconazole - 11:30 PM\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Metoprolol - 12:08 PM\n Hydromorphone (Dilaudid) - 03:00 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:06 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: 92 (89 - 109) bpm\n BP: 141/71(88) {127/63(83) - 149/90(101)} mmHg\n RR: 19 (19 - 28) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 4,403 mL\n 997 mL\n PO:\n TF:\n 194 mL\n IVF:\n 3,558 mL\n 530 mL\n Blood products:\n Total out:\n 3,960 mL\n 1,780 mL\n Urine:\n 3,260 mL\n 1,780 mL\n NG:\n Stool:\n Drains:\n Balance:\n 443 mL\n -783 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97% on 3.5 L\n ABG: ///25/\n Physical Examination\n PHYSICAL EXAM\n GENERAL: Lying comfortably in bed, NAD\n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral\n icterus. EOMI. MMM. OP clear. Neck Supple.\n CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs\n or . JVP not assessed\n LUNGS: CTAB anteriorly, poor air movement\n ABDOMEN: decreased BS Soft, NT, ND. Well healed surgical incision,\n drains with serous fluid.\n EXTREMITIES: 2+ dorsalis pedis/ posterior tibial pulses.\n SKIN: No rashes/lesions, ecchymoses.\n NEURO: A&Ox3.\n Labs / Radiology\n 1120 K/uL\n 7.5 g/dL\n 96 mg/dL\n 0.6 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 7 mg/dL\n 102 mEq/L\n 133 mEq/L\n 25.0 %\n 15.4 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n 03:00 PM\n 08:20 PM\n 09:00 PM\n 02:56 AM\n 01:25 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n 15.4\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n 25.0\n Plt\n 1\n 1109\n 1173\n 1120\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n 0.6\n TCO2\n 27\n Glucose\n 135\n 142\n 115\n 105\n 96\n Other labs: PT / PTT / INR:15.3/32.0/1.3, ALT / AST:16/22, Alk Phos / T\n Bili:100/0.7, Amylase / Lipase:111/194, Differential-Neuts:70.0 %,\n Band:0.0 %, Lymph:18.0 %, Mono:11.0 %, Eos:1.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:359 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n DELIRIUM / CONFUSION\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis s/p splenectomy for\n ruptured spleen who returns to the with fevers, AMS, tachycardia\n in the setting of recent enteric leak repair.\n # Fevers and Leukocytosis:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . The line has since been\n removed. Other possible sources for infection include empyema\n (although thoracentesis on did not show evidence of organisms),\n pancreatitis (lipase slightly increasing), pneumonia, or abd fluid\n collection.\n - continue fluconazole for albicans coverage\n - continue cefepime for broad gram negative and anaerobic coverage (has\n penicillin allergy)\n - continue vancomycin and cipro\n - f/u sensitivities , bcx, fungal cx, c. diff\n - IR drainage today of abdominal and pleural fluid collections\n # Delirium:\n This may be secondary to his pain medications or could be a\n manifestation of severe infection +/- sepsis. If he is bacteremic or\n fungemic, would also consider the possibility of septic emboli, but not\n at threshold to image head without supportive culture data.\n - pain not well controlled, restart dilaudid PCA\n - haldol prn, per psych recs in chart\nconfirm QTc prior to dosing\n # Anemia: Stable, however will follow closely given his recent surgery\n and anticoagulation.\n - follow serial Hcts\n - active type and screen\n - If Hct drops less than current 23.7, contact surgery immediately for\n discussion re: transfusion.\n # Tachypnea with respiratory alkalosis: improved since initial ICU\n stay. Likely related to pain, although he may also have some anxiety\n from being disoriented.\n - continue pain control\n # Sinus Tachycardia:\n Likely multifactorial in setting of pain, PE, tachypnea/respiratory\n distress, and infection. Improved since initial infection\n - would avoid beta blocking sinus tachycardia and rather would treat\n underlying causes\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n - note that pt is infected with encapsulated organism\n # Subsegmental PEs:\n - restart heparin drip today\n # Elevated platelets:\n be inflammatory reaction, but elevation of platelets is extremely\n pronounced.\n - consult heme\n - monitor\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # Comm: with mom \n ICU Care\n Nutrition:\n TPN w/ Lipids - 01:30 AM 83. mL/hour, tube\n feeds\n Glycemic Control:\n Lines:\n 20 Gauge - 09:07 PM\n Multi Lumen - 10:10 PM\n Prophylaxis:\n DVT: restart heparin post procedure\n Stress ulcer: pansoprazole\n VAP:\n Comments:\n Communication: Comments: Comm: with mom \n Code status: Full code\n Disposition: likely tomorrow, will discuss with surgery\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 684195,
"text": "Chief Complaint: Tachycardia, delerium, sepsis\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Pt. returned to MICU service last PM for management of tachycardia,\n recurrent delerium and respiratory distress.\n Hallucinations last PM, resolved this AM.\n Disinclined to take deep breaths due to LLQ pain.\n Receiving Dilaudid iv boluses (off PCA pump).\n Tolerating trophic TF.\n Clots noted on PICC line at the time of d/c line.\n Heparin drip on hold pending possible procedures.\n History obtained from Medical records\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 10:30 AM\n Fluconazole - 11:00 PM\n Ciprofloxacin - 07:43 AM\n Vancomycin - 08:30 AM\n Cefipime - 10:02 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 08:30 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n 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, 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, Parenteral nutrition\n Respiratory: No(t) Cough, Dyspnea, Tachypnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, 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 Flowsheet Data as of 10:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 37.6\nC (99.6\n HR: 99 (97 - 121) bpm\n BP: 133/79(92) {131/66(82) - 149/85(99)} mmHg\n RR: 24 (23 - 29) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 1,442 mL\n 2,478 mL\n PO:\n TF:\n 113 mL\n IVF:\n 1,442 mL\n 2,365 mL\n Blood products:\n Total out:\n 300 mL\n 1,030 mL\n Urine:\n 300 mL\n 1,030 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,142 mL\n 1,448 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n ABG: 7.53/31/61/26/3\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress,\n No(t) Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical\n adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: 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 : , Diminished: left base, No(t) Absent : , No(t) Rhonchorous:\n )\n Abdominal: No(t) Soft, Non-tender, Bowel sounds present, Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): ox3; appropriate, Movement: Purposeful, No(t)\n Sedated, No(t) Paralyzed, Tone: Normal\n Labs / Radiology\n 7.5 g/dL\n 1173 K/uL\n 105 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 10 mg/dL\n 104 mEq/L\n 136 mEq/L\n 23.7 %\n 19.4 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n 03:00 PM\n 08:20 PM\n 09:00 PM\n 02:56 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n Plt\n 1\n 1109\n 1173\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n TCO2\n 27\n Glucose\n 135\n 142\n 115\n 105\n Other labs: PT / PTT / INR:15.6/70.7/1.4, ALT / AST:18/25, Alk Phos / T\n Bili:101/0.8, Amylase / Lipase:113/228, Differential-Neuts:91.0 %,\n Band:2.0 %, Lymph:4.0 %, Mono:1.0 %, Eos:0.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:391 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Microbiology: Peritoneal culture -- + , haemophilous\n (non-influenza)\n Assessment and Plan\n 39 yomh/o recurrent pancreatitis, recent surgery for splenectomy,\n enteric leak now with post-operative respiratory distress and delerium\n (recurrent).\n RESPIRATORY DISTRESS\n Much improved. Multifactorial. Suspect\n contribution of bacteremia and sepsis, acidosis, left pleural effusion,\n left atalectasis, pulmonary emboli (off anticoagulation), and abdominal\n pain (splinting). Plan treat sepsis, antibiotics, iv fliuds, optimize\n pain management, maintain upright position. Consider left\n thoracentesis if expands.\n TACHYCARDIA\n likley reflects respiratory distress, pain, hypovolemia,\n possible pulmonary embolism. Monitor HR, check EKG. Replete iv fluid,\n optimize pain, treat sepsis/bacteremia.\n SEPSIS -- evidence for line-related infection and now suspect\n peritoneal source. For Abd CT imaging to assess for collection.\n Continue Cipro, Cefopime, Vanco, Fluconozole.\n BACTEREMIA\n GPC, possible line related, but concern for enteric\n infection. Remove central lines if possible (use peripheral if\n feasible). Continue Vanco.\n PULMONARY EMBOLI\n left, subsegmental, multiple. Continue\n anticoagulation --> monitor PTT 60-80.\n PLEURAL EFFUSION\n suspect sympathetic and related to abdominal\n surgeries. Doubt empyema, but consider diagnostic thoracentesis.\n Monitor.\n s/p ENTERIC LEAK -- NGT with intermittent suction, antibiotics, await\n culture results. For Abd CT today.\n PAIN MANAGEMENT\n post-op. s/p PCA pump --> need to optimize dosing\n and interval.\n s/p SPLENECTOMY -- will need meningococcal and pneumococcal vaccines\n FLUID\n desire net volume expension.\n THROMBOCYTOSIS\n perhaps reactive. ? reactive. be contributing to\n clotting (pulmonary emboli, clot on PICC line) as value exceeds 1\n million. Monitor. Hematology consult.\n DELERIUM\n recurrent. Possible related to medications and contribution\n of sepsis (toxic-metabolic). Improved this AM.\n NUTRITIONAL SUPPORT -- NPO. Trophic TF. Resume TPN once central\n access established.\n RECURRENT PANCREATITS -- Unclear cause, but consider cystic fibrosis\n given family history. Recheck amylase, lipase and monitor clinical\n exam.\n ICU Care\n Nutrition:\n Replete () - 12:09 AM 20 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 09:07 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2159-05-13 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 684196,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 09:12 PM\n Blood culture x2 and for fungal\n FEVER - 101.9\nF - 06:25 PM\n Pt mental state fluctuates in and out of delerium\nOtherwise no acute\n events.\n Started on cefepime and fluconazole, continued vanc and cipro\n Allergies:\n Erythromycin Base\n Unknown; Diarrh\n Amoxicillin\n Rash;\n Last dose of Antibiotics:\n Metronidazole - 10:30 AM\n Vancomycin - 10:06 PM\n Ciprofloxacin - 10:06 PM\n Cefipime - 10:50 PM\n Fluconazole - 11:00 PM\n Infusions:\n Heparin Sodium - 1,800 units/hour\n Other ICU medications:\n Hydromorphone (Dilaudid) - 01:15 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.8\nC (101.9\n Tcurrent: 38.4\nC (101.2\n HR: 115 (99 - 121) bpm\n BP: 139/77(87) {131/66(82) - 149/85(99)} mmHg\n RR: 26 (23 - 29) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 113.6 kg (admission): 113.6 kg\n Height: 74 Inch\n Total In:\n 1,442 mL\n 1,475 mL\n PO:\n TF:\n 67 mL\n IVF:\n 1,442 mL\n 1,407 mL\n Blood products:\n Total out:\n 300 mL\n 560 mL\n Urine:\n 300 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,142 mL\n 915 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.53/31/61/26/3\n Physical Examination\n General: Pt lying in bed, moving little pain\n HEENT: Dry mucous membranes, PERRL, oropharynx clear except for NG tube\n in place. NC in place. Neck supple.\n Lungs: coarse, decreased breath sounds over anterior left lower lung\n fields. Otherwise clear to auscultation bilaterally.\n CV: RRR, no murmurs gallops or rubs.\n Abd: soft, tender to deep palpation to right of midline, tender to\n light touch over JP drain incision sites over left abdomen. +BS.\n Dressing c/d/i. serosanguinous drainage from JP drains.\n Ext: 3+ edema in bilateral lower extremities. Pulses palpable in\n bilateral LE.\n Skin: warm to touch.\n Neuro: patient alert, oriented X3. spontatneous mvmt of all 4\n extremities. CN II-XII grossly intact.\n Labs / Radiology\n 1173 K/uL\n 7.5 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 10 mg/dL\n 104 mEq/L\n 136 mEq/L\n 23.7 %\n 19.4 K/uL\n [image002.jpg]\n 03:41 AM\n 04:04 AM\n 07:14 AM\n 03:00 PM\n 08:20 PM\n 09:00 PM\n 02:56 AM\n WBC\n 21.9\n 20.7\n 21.8\n 21.6\n 19.4\n Hct\n 31.6\n 25.8\n 26.5\n 23.7\n 23.7\n Plt\n 1\n 1109\n 1173\n Cr\n 0.7\n 0.6\n 0.5\n 0.6\n TCO2\n 27\n Glucose\n 135\n 142\n 115\n 105\n Other labs: PT / PTT / INR:15.6/70.7/1.4, ALT / AST:18/25, Alk Phos / T\n Bili:101/0.8, Amylase / Lipase:113/228, Differential-Neuts:91.0 %,\n Band:2.0 %, Lymph:4.0 %, Mono:1.0 %, Eos:0.0 %, Fibrinogen:357 mg/dL,\n Lactic Acid:1.3 mmol/L, Albumin:2.2 g/dL, LDH:391 IU/L, Ca++:7.5 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n ELECTROLYTE & FLUID DISORDER, OTHER\n DELIRIUM / CONFUSION\n PLEURAL EFFUSION, ACUTE\n TACHYCARDIA, OTHER\n BACTEREMIA\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n PULMONARY EMBOLISM (PE), ACUTE\n LEUKOCYTOSIS\n 39yo gentleman with h/o recurrent pancreatitis s/p splenectomy for\n ruptured spleen who returns to the with fevers and tachycardia in\n the setting of recent enteric leak repair.\n # Fevers and Leukocytosis:\n Patient now has and non-influenza Hemophilus growing in the\n cultures from his recent abdominal surgery. He also had coag negative\n staph growing from his PICC line from . The line has since been\n removed. Other possible sources for infection include empyema\n (although thoracentesis on did not show evidence of organisms),\n pancreatitis (lipase slightly increasing), or pneumonia.\n - start fluconazole for coverage\n - start cefepime for broad gram negative and anaerobic coverage (has\n penicillin allergy)\n - continue vancomycin and cipro\n - f/u sensitivities , bcx, fungal cx, c. diff\n - will discuss possibility of thoracentesis with surgery if he\n continues to be febrile despite appropriate antibiotics\n - CT abdomen and pelvis with possible IR drainage today.\n # Delirium:\n This may be secondary to his pain medications or could be a\n manifestation of severe infection +/- sepsis. If he is bacteremic or\n fungemic, would also consider the possibility of septic emboli, but not\n at threshold to image head without supportive culture data.\n - pain not well controlled, increase dilaudid to .25 mg IV q 2 hours.\n - haldol prn, per psych recs in chart\nconfirm QTc prior to dosing\n - ABG without hypercarbia\n # Anemia, Hct 30-31 on admission, currently 23.7, concerning for\n possible bleed considering heparin gtt\n one supratherapeutic measure\n on .\n - follow serial Hcts\n - active type and screen\n - If Hct drops less than current 23.7, contact surgery immediately for\n discussion re: transfusion.\n - CT abdomen/pelvis to evaluate for bleed.\n # Tachypnea with respiratory alkalosis:\n Likely related to pain, although he may also have some anxiety from\n being disoriented.\n - improve control, consider pain cosult.\n # Sinus Tachycardia:\n Likely multifactorial in setting of pain, PE, tachypnea/respiratory\n distress, and infection.\n - would avoid beta blocking sinus tachycardia and rather would treat\n underlying causes\n # Recent Splenectomy:\n - will need meningococcal and pneumococcal vaccines\n - note that pt is infected with encapsulated organism\n # Subsegmental PEs:\n - stop heparin gtt per surgery today for CT Abdomen/Pelvis and possible\n IR intervention\n # Elevated platelets:\n be inflammatory reaction, but elevation of platelets is extremely\n pronounced.\n - consult heme\n - monitor\n # Recurrent pancreatitis:\n Unclear cause, although would consider cystic fibrosis given family\n history.\n - recheck amylase, lipase and monitor clinical exam\n # Comm: with mom \n ICU Care\n Nutrition:\n Replete () - 12:09 AM 10 mL/hour\n Glycemic Control: insulin SS\n Lines:\n 20 Gauge - 09:07 PM\n Prophylaxis:\n DVT: on heparin gtt\n Stress ulcer: pantoprazole\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Pending results of imaging\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684448,
"text": "Pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting left sided abd pain in upper and lower quadrants, at\n worst at best, described pain as constant and stabbing, pain worse\n with reposition, received on PRN dilaudid regimen 0.5mg q2hr\n Action:\n Pt down to CT for procedure off the floor for about 3 hours, CT RN\n provided sedation for procedure, pt received 100mcg fent from CT RN,\n started on PCA when back on floor, pt able to use PCA appropriately\n Response:\n Pt\ns pain with greater control now on PCA, reporting immense pain peri\n procedure, still not reaching a pain free state though with much\n improvement, pt is reporting pain in left side and lower back at times\n Plan:\n Continue to monitor pain control, encourage pt to use PCA as needed, if\n unable to control pt\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known PE, obtained off heparin gtt for procedure\n Action:\n Heparin restarted after procedure, trending ptt q6hrs\n Response:\n 1800 labs pending\n Plan:\n Ongoing, continue to trend q6hr ptt, next draw 0000\n Pleural effusion, acute\n Assessment:\n Large left sided pleural effusion per Cxray and Ct torso, pt with no\n resp distress or compromise, maintaining sats on 2L NC\n Action:\n CT guided pig tail placed in left chest, draining straw colored\n drainage, spec sent for culture, chest tube attached to pleurovac to\n water seal\n Response:\n Pt has put out about 1000ml from pig tail thus far, out put initially\n steady now slowing, resp status remains the same,\n Plan:\n Continue to monitor chest tube site, continue to monitor out put, f/u\n culture data\n"
},
{
"category": "Nursing",
"chartdate": "2159-05-14 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 684446,
"text": "Pancreatitis, acute\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt reporting left sided abd pain in upper and lower quadrants, at\n worst at best, described pain as constant and stabbing, pain worse\n with reposition, received on PRN dilaudid regimen 0.5mg q2hr\n Action:\n Pt down to CT for procedure, laid on right side for about\n Response:\n Plan:\n Pulmonary Embolism (PE), Acute\n Assessment:\n Pt with known PE, obtained off heparin gtt for procedure\n Action:\n Heparin restarted after procedure, trending ptt q6hrs\n Response:\n 1800 labs pending\n Plan:\n Ongoing, continue to trend q6hr ptt, next draw 0000\n Pleural effusion, acute\n Assessment:\n Large left sided pleural effusion per Cxray and Ct torso, pt with no\n resp distress or compromise, maintaining sats on 2L NC\n Action:\n CT guided pig tail placed in left chest, draining straw colored\n drainage, spec sent for culture, chest tube attached to pleurovac to\n water seal\n Response:\n Pt has put out about 1000ml from pig tail thus far, out put initially\n steady now slowing, resp status remains the same,\n Plan:\n Continue to monitor chest tube site, continue to monitor out put, f/u\n culture data\n"
},
{
"category": "ECG",
"chartdate": "2159-05-10 00:00:00.000",
"description": "Report",
"row_id": 242066,
"text": "Sinus tachycardia\nNormal ECG except for rate\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1086056,
"text": " 9:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls asseess for ptx.\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with recurrent pancreatitis, s/p multiple tries of IJ.\n REASON FOR THIS EXAMINATION:\n pls asseess for ptx.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:34 P.M., \n\n HISTORY: Recurrent pancreatitis and IJ line placement attempts.\n\n IMPRESSION: AP chest compared to :\n\n No pneumothorax or mediastinal widening. Large left pleural effusion and left\n lower lobe collapse are longstanding. Right lung clear aside from relatively\n mild basal atelectasis. Heart size normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-14 00:00:00.000",
"description": "THORACOSTOMY TUBE INSERTION",
"row_id": 1086095,
"text": " 9:12 AM\n THORACOSTOMY TUBE INSERTION; CT PARACENTESIS Clip # \n CT GUIDANCE DRAINAGE; CT GUIDED NEEDLE PLACTMENT\n Reason: pls drain fluid collection\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ********************************* CPT Codes ********************************\n * THORACOSTOMY TUBE INSERTION CT PARACENTESIS *\n * CT GUIDANCE DRAINAGE CT GUIDED NEEDLE PLACTMENT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with recurrent pancreatitis with increasing pancreatic fluid\n collection.\n REASON FOR THIS EXAMINATION:\n pls drain fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recurrent pancreatitis with increasing pancreatic fluid\n collection. Also, large left pleural effusion. Please place drainage\n catheters into both collections.\n\n COMPARISON: .\n\n After the risks and benefits of the procedure were explained to the patient,\n written, informed consent was obtained. A pre-procedure timeout was\n performed, confirming three patient identifiers. The patient was placed\n supine on the CT table. A non-contrast CT examination through the lower chest\n and upper abdomen was performed for localization and planning purposes.\n\n The exam again demonstrates a large left pleural effusion, simple in\n attenuation. There is atelectasis of the imaged portion of the left lower\n lobe. There is no pericardial effusion. The non-contrast appearance of the\n liver is unremarkable. The patient is post-cholecystectomy, splenectomy, and\n distal pancreatectomy. The remaining pancreatic head is unchanged in\n appearance from . Findings related to a prior Roux-en-Y cyst\n enterostomy are not significantly changed from . A large collection is\n again noted in the splenectomy bed, which is not significantly changed in size\n from the prior study, measuring 12.5 cm AP x 8.8 cm TV x at least 9 cm SI. The\n fluid is again low in density. The surgically placed drainage catheter is in\n unchanged position at the posterolateral aspect of the collection. Adrenal\n glands are unremarkable. There is no hydronephrosis of the imaged portions of\n the kidneys. The previously described additional intra-abdominal fluid\n collection, superficially, near the xiphoid process, has not significantly\n changed, measuring 6.5 x 2.7 cm in axial dimensions. Again, it is not as well\n defined as the other collections.\n\n PROCEDURE: Prior to performance of the procedure the plan to separately\n drain left upper quadrant collection and left pleural effusion with\n indwelling catheters to be left at both sites, was confirmed with the\n ordering physician . via telephone. A preprocedure time out was\n performed using two patient identifiers. Sites appropriate for percutaneous\n access to the left pleural effusion and the left upper abdominal collection\n (Over)\n\n 9:12 AM\n THORACOSTOMY TUBE INSERTION; CT PARACENTESIS Clip # \n CT GUIDANCE DRAINAGE; CT GUIDED NEEDLE PLACTMENT\n Reason: pls drain fluid collection\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n were marked on the skin. The sites were prepped and draped in the usual\n sterile fashion. Attention was initially directed toward the left upper\n abdominal collection. 1% lidocaine was administered for local anesthesia.\n Under CT fluoroscopic guidance, an 18 gauge needle was advanced into\n the collection, and wire was advanced through the needle. The\n needle was exchanged for 6 and 8 French dilators, and an 8 French \n catheter was placed over the wire into the collection. Approximately 345 cc\n of purulent material were drained. A drainage bag was secured to the\n catheter.\n\n The abdominal catheter was then covered with sterile drapes, and the chest was\n re-prepped and draped in sterile fashion. A new sterile tray, gloves and\n materials were opened and used for this separate procedure. 1% lidocaine was\n administered for local anesthesia. Under direct CT fluoroscopic guidance, an\n 18 gauge needle was advanced into the left pleural fluid. A small\n sample was aspirated for Gram stain and culture, and the pleural fluid was\n clear yellow in appearance. wire was placed through the needle, and\n the needle was exchanged for 6 and 8 French dilators. An 8 French \n catheter was then placed over the wire into the left pleural collection. The\n pleural catheter was attached to a Pleur-Evac drain and wall suction, to be\n allowed to slowly drain.\n\n A post-procedure scan was performed to assess catheter positioning. The exam\n demonstrates appropriately positioned left pleural and left upper abdominal\n drainage catheters, and near-complete resolution of the left upper abdominal\n collection. A moderate to large amount of left pleural fluid remained at the\n time of the scan as the Pleur-Evac was allowed to slowly drain the effusion.\n There is a small amount of air in the left pleural space on the post-procedure\n study.\n\n The patient tolerated the procedure well, and there were no immediate\n complications. Dr. , the attending radiologist, was present and\n supervising throughout the procedure.\n\n Moderate sedation was provided by administering divided doses of Versed and\n fentanyl (100 mcg fentanyl and 3 mg Versed) throughout a total intra-service\n time of 80 minutes during which the patient's hemodynamic parameters were\n continuously monitored.\n\n IMPRESSION:\n 1. Successful 8 French catheter placement into the left upper\n abdominal collection, yielding 345 cc of purulent material. A sample was sent\n for Gram stain, culture, and sensitivity.\n\n 2. Successful 8 French catheter placement into the left pleural\n (Over)\n\n 9:12 AM\n THORACOSTOMY TUBE INSERTION; CT PARACENTESIS Clip # \n CT GUIDANCE DRAINAGE; CT GUIDED NEEDLE PLACTMENT\n Reason: pls drain fluid collection\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n space, with aspiration of clear yellow pleural fluid. A small sample was sent\n for Gram stain, culture, and sensitivity. The catheter was placed to\n PleurEvac suction for slow evacuation of the effusion given its size.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1085497,
"text": " 10:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for effusion/consolidation\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man w/ ruptured spleen s/p distal panc/splenectomy c/b PE now s/p\n re-exploration w/ increased RR and L chest wheeze\n REASON FOR THIS EXAMINATION:\n pls eval for effusion/consolidation\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Tachypnea in a patient with ruptured spleen after\n distal pancreatectomy and splenectomy.\n\n Compared to prior radiograph from , there is interval increase in\n opacification of the left hemithorax most likely consistent with an additional\n interval increase in large left pleural effusion. The underlying parenchymal\n process potentially can be present but is less likely due to homogeneous\n appearance of the opacification. The NG tube tip is in the stomach. The two\n abdominal drains are seen in the left upper quadrant. The left internal\n jugular line tip is at the mid SVC. The minimal atelectasis at the left base\n is present, grossly unchanged consistent with area of atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1086977,
"text": " 4:13 PM\n CHEST (PA & LAT) Clip # \n Reason: Lung against wall. Please evaluate pleural effusion.\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with plearal effustion. chest tube off suction for 4+ hours.\n Please evaluate lung capacity\n REASON FOR THIS EXAMINATION:\n Lung against wall. Please evaluate pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS\n\n CLINICAL INFORMATION: Pleural effusion.\n\n FINDINGS:\n\n Comparison is made to the prior study from . There are small\n bilateral pleural effusions with bibasilar atelectasis. Upper lung zones are\n relatively clear. The appearance of the chest is unchanged from the prior\n study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1085914,
"text": " 12:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: spiking temps, r/o infection\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39M w/ ruptured spleen s/p distal panc/splenectomy c/b PE S/P ex. lap\n REASON FOR THIS EXAMINATION:\n spiking temps, r/o infection\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever.\n\n A single frontal radiograph of the chest demonstrates little interval change\n in a large left-sided pleural effusion when compared with . The\n support lines have been removed. No pneumothorax is appreciated. Bibasilar\n atelectasis persists. Cardiomediastinal contours are unchanged. Trachea is\n midline.\n\n IMPRESSION:\n\n Interval removal of support lines.\n\n Little interval change in the appearance of the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1086226,
"text": " 5:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39yo gentleman with h/o recurrent pancreatitis who presented with ruptured\n spleen now transferred to the ICU in the setting of respiratory distress, AMS\n and massive pleural effusion\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ruptured spleen, respiratory distress, evaluation for interval\n change.\n\n FINDINGS: As compared to the previous radiograph, there is little overall\n change. No substantial increase of the left-sided pleural effusion, unchanged\n pre-existing retrocardiac atelectasis. Unchanged size of the cardiac\n silhouette, no abnormalities noted in the right lung. A right central venous\n access line might have been pulled back by 1-2 cm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-16 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1086447,
"text": " 11:51 AM\n CHEST (PA & LAT) Clip # \n Reason: confirm placement of pleural drain and r/o worsening effusio\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with ruptured spleen s/p distal panc/slenectomy c/b PE. s/p IR\n placement of chest tube for drainage of pleural effusion. Now febrile with\n decreased drain output.\n REASON FOR THIS EXAMINATION:\n confirm placement of pleural drain and r/o worsening effusion or post-op PNA\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST \n\n HISTORY: Splenectomy and distal pancreatectomy. Chest drain for pleural\n effusion. Now febrile.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Thin drainage catheter triangulates to the left lateral costal pleural space\n at the level of the fifth interspace. Moderate left pleural effusion\n is smaller compared to . Small loculated left pneumothorax is new.\n Left lower lobe collapse persists. Atelectasis at the right lung base is\n mild, improved since . Right jugular line tip projects over the low\n SVC. No right pneumothorax. Dr. was paged and I reported these\n findings by telephone to the physician who responded.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1086756,
"text": " 10:19 AM\n CHEST (PA & LAT) Clip # \n Reason: chest tube put to suction, has LLL reexpanded? Thanks\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39M w/ ruptured spleen s/p distal panc/splenectomy c/b PE S/P ex. lap\n REASON FOR THIS EXAMINATION:\n chest tube put to suction, has LLL reexpanded? Thanks\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Chest tube put to suction.\n\n Two views. Comparison with . There is interval improvement in a small\n left effusion and volume loss in the left lower lobe. The right lung remains\n expanded and clear. The heart is normal in size. Mediastinal structures are\n unchanged. A right internal jugular catheter has been removed. A left chest\n tube remains in place. The bony thorax is grossly intact.\n\n IMPRESSION: Interval improvement in left effusion and volume loss in the left\n lower lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1084687,
"text": " 5:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: fever\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man s/p distal pancreatectomy and splenectomy\n REASON FOR THIS EXAMINATION:\n fever\n ______________________________________________________________________________\n WET READ: JXRl FRI 8:47 PM\n extubated, NG tube removed. unchanged left IJ line. low lung volumes.\n increased left effusion with underlying consolidation/atelectasis from .\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Portable AP chest.\n\n COMPARISON: Two days prior.\n\n HISTORY: Distal pancreatectomy and splenectomy. Fever.\n\n FINDINGS:\n\n The left IJ central line terminates in the SVC. The patient is status post\n extubation. Again noted is a moderate layering left-sided pleural effusion as\n well as right-sided pleural effusion with some adjacent atelectasis. Tubing\n is identified in the region of the stomach, though is not completely\n visualized.\n\n IMPRESSION:\n\n No interval change in bilateral effusions and right-sided subjacent\n atelectasis. Status post extubation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1085505,
"text": " 12:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change in effusion\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with total white-out of left lung field, very tachypneic in\n unit, unclear if this is due to semi-erect position on prior CXR. PLEASE have\n pt completely erect.\n REASON FOR THIS EXAMINATION:\n eval for change in effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Tachypnea.\n\n Portable AP chest radiograph was compared to prior chest radiographs dating\n back to and CT torso from .\n\n The lung volumes remain very low. The left large pleural effusion is layering\n and is consistent with obscuration of most of the left hemithorax. When\n compared to prior radiographs from , there is overall no\n significant change, but compared to , there is overall increase\n in the opacification of the hemithorax or the left hemithorax, which might be\n consistent with interval increase in pleural effusion. Underlying parenchymal\n process is less likely, although cannot be entirely excluded .\n\n The right basal opacity is present, grossly unchanged. The right upper lung\n is unremarkable. The cardiomediastinal silhouette is stable. The left\n internal jugular line tip is at the mid low SVC. The NG tube tip is in the\n stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1086064,
"text": " 10:51 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: pls assess line placement.\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with new RIJ.\n REASON FOR THIS EXAMINATION:\n pls assess line placement.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:07 P.M., .\n\n HISTORY: New right IJ line placement.\n\n IMPRESSION: AP chest compared to , at 9:34 p.m.:\n\n Tip of the new right internal jugular line projects over the mid right atrium.\n No pneumothorax, mediastinal widening or right pleural effusion. Large left\n pleural effusion and probable left lower lobe collapse are longstanding.\n Heart size is normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1087072,
"text": " 12:59 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for post-CT pull PTX\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man s/p pigtail CT removal\n REASON FOR THIS EXAMINATION:\n eval for post-CT pull PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old status post pigtail chest tube removal. Evaluate for\n pneumothorax.\n\n PA and lateral chest radiographs, compared to , show removal of\n left basal pigtail catheter. Low lung volumes, bibasilar atelectasis, and\n small bilateral pleural effusions are unchanged. The cardiomediastinal\n contour is normal. There is no pneumothorax.\n\n IMPRESSION: No pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1085184,
"text": " 2:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change s/p thoracentesis\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pleural effusion\n REASON FOR THIS EXAMINATION:\n interval change s/p thoracentesis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pleural effusion after thoracentesis.\n\n FINDINGS: In comparison with the study of , there is little overall\n change in the appearance of the pleural effusion on the left. Adjacent\n atelectasis is again seen at the left base and there is improvement in the\n streaks of atelectasis at the right base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-08 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1085324,
"text": " 5:49 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: With PO/IV contrast to assess LUQ collection and leak.\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with ruptured spleen s/p distal panc/splenectomy\n REASON FOR THIS EXAMINATION:\n With PO/IV contrast to assess LUQ collection and leak.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc TUE 10:34 PM\n 8.9 x 5.9 _____ fluid- and gas-containing collection in the left upper\n quadrant with adjacent peritoneal enhancement is not larger compared to three\n days prior. There is apparent contiguity of the anteroinferior aspect of this\n collection with an adjacent loop of small bowel. Although no oral contrast is\n seen within the collection, air fills the apparent wide opening (8 mm wide)\n (2:36). Small amount of fluid of intermediate density in the pelvis appears\n slightly smaller than three days prior. Moderate nonhemorrhagic pleural\n effusion on the left is not changed, with adjacent atelectasis of the left\n lower lobe. Small peripheral patchy airspace opacities are nonspecific and\n could represent inflammatory or infectious etiology and are similar to that\n seen three days prior.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 39-year-old male with ruptured spleen, status post distal\n pancreatectomy and splenectomy, here to reassess left upper quadrant\n collection and leak.\n\n COMPARISON: CT torso from and .\n\n TECHNIQUE: MDCT axial imaging was performed through the abdomen and pelvis\n after administration of Gastrografin and 100 mL of IV Optiray 350. Multiplanar\n reformatted images were then obtained.\n\n CT ABDOMEN WITH IV CONTRAST: Moderate nonhemorrhagic left pleural effusion\n appears similar in size to that seen three days prior and is associated with\n relaxation atelectasis in the adjacent left lower lobe. Very mild\n subsegmental atelectasis is also noted in the right lung base, slightly\n improved from three days prior. Patchy small areas of wedge shaped peripheral\n and peribronchovascular opacities persist in the visualized right lower and\n middle lobes. No new pericardial effusion is seen. The pulmonary arteries\n are not well opacified and only partially imaged and therefore the previously\n seen pulmonary emboli cannot be commented on for change.\n\n The patient is status post distal pancreatectomy and splenectomy. Surgical\n clips and embolization material causes a large amount of streak artifact in\n the resection bed. A collection with air-fluid level in the left upper\n quadrant within the resection bed measures approximately 8.9 x 5.9 x 7.7 cm\n (2:33, 301B:61). The size is not significantly changed compared to \n and again there is surrounding peritoneal enhancement. A surgical drain again\n is seen with tip terminating within the collection inferiorly. On today's\n (Over)\n\n 5:49 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: With PO/IV contrast to assess LUQ collection and leak.\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n study there appears to be contiguity between this collection with the adjacent\n small bowel loop, with a relatively wide opening measuring approximately 8 mm\n wide filled with air (2:36, 300B:30-31, 301B:53). The density within the\n collection measures 14 , markedly less dense than the opacified bowel\n contents (oral contrast seen to the level of the transverse colon), without\n definite evidence of oral contrast material within this collection.\n\n The patient has had prior cholecystectomy. The liver, remaining pancreatic\n head and uncinate, adrenal glands, and both kidneys and ureters appear normal.\n Trace fluid anterior to the left kidney is likely post-surgical. The stomach\n and duodenum appear unremarkable. Mild dilatation of the more proximal loops\n of small bowel may represent some amount of ileus, with diameter measuring up\n to 5 cm (300B:28). The ascending and transverse colon appear unremarkable.\n Minimal stranding and fluid is seen along the left paracolic gutter, likely\n due to the left upper quadrant inflammatory process, with additional fluid and\n stranding in right lower quadrant. Mild stranding and fluid is also seen\n underlying the longitudinal anterior abdominal scar.\n\n The abdominal aorta maintains normal caliber throughout. Again, scattered\n left paraaortic nodes may be reactive, with the largest measuring 11 mm in\n short axis (2:43).\n\n CT PELVIS WITH IV CONTRAST: Small bubble of gas within the urinary bladder is\n likely due to recent instrumentation with Foley catheter in place. The\n prostate, seminal vesicles, and rectosigmoid colon appear unremarkable. Fluid\n of intermediate density within the pelvis appears slightly decreased from\n three days prior. Minimal stranding along the right femoral vessels likely\n represents post-procedural change from prior angiography.\n\n OSSEOUS STRUCTURES: Degenerative changes are noted in the lower thoracic\n spine. No region of bony destruction is seen concerning for malignancy.\n\n IMPRESSIONS:\n 1. Status post splenectomy and distal pancreatectomy. Collection containing\n air and fluid in the left upper quadrant with adjacent peritoneal enhancement\n is not larger. However, there is apparent contiguity of this fluid collection\n anteriorly with an adjacent loop of small bowel. While there is no contrast\n opacification of the collection to confirm, this is consistent with enteric\n leak. The surgical drain remains within the fluid collection.\n\n 2. Small amount of fluid of intermediate density remains in the pelvis but\n slightly less than that seen three days prior.\n\n 3. Moderate nonhemorrhagic left pleural effusion is unchanged with adjacent\n atelectasis in the left lower lobe. Few patchy peripheral opacities in the\n (Over)\n\n 5:49 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: With PO/IV contrast to assess LUQ collection and leak.\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n visualized right middle and lower lobes appear similar to that previously seen\n and again may represent infectious or inflammatory etiology versus\n atelectasis.\n\n Findings were discussed with Dr. at approximately 9:00 p.m.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1084924,
"text": " 12:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for interval change in effusion\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with pleural effusion\n REASON FOR THIS EXAMINATION:\n Eval for interval change in effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: Left pleural effusion.\n\n FINDINGS: Moderate left pleural effusion appears similar to the previous\n examination with adjacent atelectasis at the left base. Patchy and linear\n atelectasis at right lung base is improving.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-08 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1085325,
"text": ", T. 5S 5:49 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: With PO/IV contrast to assess LUQ collection and leak.\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with ruptured spleen s/p distal panc/splenectomy\n REASON FOR THIS EXAMINATION:\n With PO/IV contrast to assess LUQ collection and leak.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 8.9 x 5.9 _____ fluid- and gas-containing collection in the left upper\n quadrant with adjacent peritoneal enhancement is not larger compared to three\n days prior. There is apparent contiguity of the anteroinferior aspect of this\n collection with an adjacent loop of small bowel. Although no oral contrast is\n seen within the collection, air fills the apparent wide opening (8 mm wide)\n (2:36). Small amount of fluid of intermediate density in the pelvis appears\n slightly smaller than three days prior. Moderate nonhemorrhagic pleural\n effusion on the left is not changed, with adjacent atelectasis of the left\n lower lobe. Small peripheral patchy airspace opacities are nonspecific and\n could represent inflammatory or infectious etiology and are similar to that\n seen three days prior.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-05 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1084782,
"text": " 11:37 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please eval for PE and abdominal abscess. NO PO CONTRAST.\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man s/p distal pancreatectomy and splenectomy now with recurrent\n fevers of unknown origin and tachycardia\n REASON FOR THIS EXAMINATION:\n please eval for PE and abdominal abscess. NO PO CONTRAST.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc SAT 2:29 PM\n Small filling defects to subsegmental pulmonary arterial branches to the left\n upper lobe, c/w pulmonary emboli. Large left pleural effusion with associated\n atelectasis/consolidation of the lung. S/p splenectomy + pancreatomy with a\n LUQ fluid collection measuring 8 cm in maximal dimensions and contains a\n drain. Dilated loops of small bowel, may reflect an ileus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 39-year-old male status post distal pancreatectomy and splenectomy,\n now with recurrent fevers of unknown origin and tachycardia. Evaluate for PE\n and abdominal abscess.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images were obtained from the thoracic inlet to the\n symphysis pubis with administration of IV contrast only. Coronal and sagittal\n reformations were obtained. Additional oblique reformations were obtained of\n the chest.\n\n CT OF THE CHEST WITH IV CONTRAST: The heart and pericardium are unremarkable,\n without pericardial effusion. A few scattered mediastinal lymph nodes are\n seen, which are not pathologically enlarged. Within subsegmental branches to\n the left upper lobe, there are central filling defects (2:35, 34, 33),\n compatible with pulmonary emboli. Assessment of the pulmonary arteries to the\n right lower lobe are limited. No secondary signs to suggest right heart\n strain are seen.\n\n There is a large left pleural effusion, with associated atelectasis of the\n adjacent lung. Scattered patchy airspace opacities within the right middle\n and lower lobes are also seen, which may be infectious/inflammatory, or could\n reflect atelectasis. Tiny locules of air are seen within the epicardial fat,\n likely post-surgical.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: Patient is status post splenectomy and\n distal pancreatectomy with surgical clips creating streak artifact, slightly\n limiting evaluation. There is a collection in the left upper quadrant,\n containing air and fluid, measuring approximately 8 cm in maximal dimensions,\n with adjacent peritoneal enhancement seen. A drain is present, which appears\n to be seated within the inferior aspect of the collection.\n\n (Over)\n\n 11:37 AM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: please eval for PE and abdominal abscess. NO PO CONTRAST.\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The patient is status post cholecystectomy, with a small amount of pneumobilia\n seen. The liver is otherwise unremarkable. The adrenal glands and kidneys\n are within normal limits.\n\n There are mildly dilated loops of small bowel, particularly within the right\n mid abdomen, measuring up to approximately 4.5 cm. This could reflect a\n postoperative ileus as no discrete transition point is identified. Few\n scattered mesenteric and retroperitoneal lymph nodes are seen, slightly\n enlarged, with a periaortic lymph node measuring 1.3 cm in short axis (4:43),\n and may be reactive. Fluid is seen tracking along the pericolic gutters, with\n a trace amount of perihepatic free fluid and interloop free fluid noted.\n\n CT OF THE PELVIS WITH IV CONTRAST: Foley catheter is in the bladder, with\n retained contrast seen within the bladder. Rectum and prostate are\n unremarkable. There is a small amount of high density fluid in the pelvic\n cul-de-sac, decreased in extent from prior study.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is identified.\n\n IMPRESSION:\n 1. Small filling defects within subsegmental branches to the left upper lobe\n pulmonary arterial branches, compatible with pulmonary emboli.\n 2. Large left pleural effusion, with associated atelectasis/consolidation of\n the adjacent lung.\n 3. Status post splenectomy and distal pancreatectomy, with a collection in\n the left upper quadrant with associated adjacent peritoneal enhancement,\n consistent with inflammatory change. A drain lies within the inferior aspect\n of the collection.\n 4. Dilated loops of small bowel, could reflect a postoperative ileus.\n 5. Small amount of free fluid in abdomen, with high density fluid in the\n pelvic cul-de-sac, decreased in extent from prior study.\n\n Findings were discussed with Dr. at the time of interpretation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1085772,
"text": " 1:23 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p right 47cm DlPicc\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with s/p abd requiring tpn/hep/ivf\n REASON FOR THIS EXAMINATION:\n s/p right 47cm DlPicc\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old male status post abdominal surgery with new PICC\n line.\n\n Single AP chest radiograph compared to , shows placement of a new\n right PICC line, which terminates in the lower SVC. The lung volumes remain\n low with peristent bibasilar atelectasis. Large left pleural effusion is\n unchanged. The cardiomediastinal contour is stable. Left IJ central venous\n catheter tip overlies the mid SVC. There is no pneumothorax.\n\n IMPRESSION:\n\n 1. Large left pleural effusion and bibasilar atelectasis.\n 2. Right PICC line as described.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-05 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1084783,
"text": " 11:43 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: SWELLING, TACHYCARDIA\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with Pancreatitis\n REASON FOR THIS EXAMINATION:\n tachycardia\n ______________________________________________________________________________\n WET READ: JXKc SAT 12:14 PM\n No DVT\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 39-year-old male with pancreatitis, evaluate for DVT.\n\n No prior studies available for comparison.\n\n FINDINGS: Grayscale and color Doppler son of bilateral common femoral,\n superficial femoral, and popliteal veins were obtained. There is normal\n compressibility, flow, and augmentation without evidence of DVT. Compression\n of the posterior tibial and peroneal veins of the calf were demonstrated,\n without evidence of thrombus.\n\n IMPRESSION: No evidence of DVT of bilateral lower extremities.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-13 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1086032,
"text": " 2:24 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for change in left pleural effusion or evidence of intr\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with recent splenic rupture s/p splenectomy who then went back\n to OR for repair of enteric leak with persistent fevers. Can get PO contrast\n through J tube.\n REASON FOR THIS EXAMINATION:\n eval for change in left pleural effusion or evidence of intra-abdominal abscess\n or hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): CXWc SUN 3:51 PM\n 1. Large rim-enhancing fluid collection in the splenectomy bed measuring 12.6\n x 8.3 x 10.8 cm. No evidence of enteric fistula at this time (no oral contrast\n in the collection). Percutaneous drainage catheter terminating in the\n posterior portion of the collection appears adequately positioned but likely\n not functioning well.\n 2. Small amount of free fluid in mesentery and pelvis with inflammatory\n changes around the collection.\n 3. Smaller intra-abdominal fluid collection near the xyphoid process contains\n foci of air, not as well-defined as the larger collection, could reflect\n phlegmon/developing abscess.\n 4. Large left pleural effusion without septation, pleural enhancement or other\n evidence of infection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 39-year-old man with persistent fevers following repair of\n enteric leak. Previously, he underwent splenectomy for spontaneous splenic\n rupture.\n\n COMPARISON: CT abdomen and pelvis of .\n\n TECHNIQUE: MDCT-acquired axial images were obtained through the chest,\n abdomen and pelvis following administration of oral and intravenous contrast\n material. Multiplanar reformatted images were generated.\n\n CT CHEST WITH IV CONTRAST: There is a large left pleural effusion, without\n internal septation or pleural enhancement. Pleural fluid is relatively low\n density, consistent with simple fluid. There is mild compressive atelectasis.\n On the right, there is mild dependent atelectasis, but no pleural effusion or\n consolidation. The large left pleural effusion results in mild rightward\n mediastinal shift.\n\n The heart is normal in size, without pericardial effusion. Within the distal\n SVC and the left brachiocephalic vein, there are small filling defects\n consistent with nonocclusive thrombus. On the CT, a central venous\n catheter was in place at the site of current thrombus. Great vessels are\n otherwise unremarkable. There is no hilar, mediastinal or axillary\n lymphadenopathy by size criteria. The tracheobronchial tree is patent to\n (Over)\n\n 2:24 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for change in left pleural effusion or evidence of intr\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n subsegmental levels.\n\n CT ABDOMEN WITH IV CONTRAST: The patient is post splenectomy and distal\n pancreatectomy, with dense surgical material resulting in extensive artifact\n in the left upper quadrant.\n\n The patient has undergone prior Roux-en-Y cyst enterostomy for a prior\n pancreatic body pseudocyst, and recently underwent repair of the Roux limb,\n with surgical notes stating a gastric serosal patch was performed by suturing\n the back wall of the stomach to the Roux limb of the jejunum. On the current\n study, oral contrast material is noted within the stomach, jejunum and ileum,\n extending into the large bowel to the sigmoid colon. There is no\n extravasation of oral contrast material outside the bowel lumen.\n\n Within the splenectomy bed, there is a large rim-enhancing fluid collection\n measuring 10.8 (craniocaudal), 12.6 x 8.3 cm fluid collection. Fluid within\n this collection is uniformly low density, with a small amount of high-density\n material along the posterior wall, which could reflect focal thickening of the\n rim of the collection. A percutaneous catheter extends into this collection,\n terminating in the posterior aspect.\n\n An additional intra-abdominal fluid collection is found within the abdominal\n cavity, relatively superficially, near the xiphoid process (2:57, 55)\n containing a few small foci of air. However, this collection is not as well\n defined as the other collection. This collection measures 2.4 x 3.5 x 5.5 cm.\n A small amount of free fluid also tracks through the mesentery and into the\n pelvis.\n\n The patient is post cholecystectomy. The liver demonstrates a small region of\n decreased attenuation adjacent to the gallbladder fossa, which could reflect a\n small area of fatty infiltration. The liver is otherwise unremarkable. The\n pancreatic head appears within normal limits. The distal pancreas is absent.\n The adrenal glands, stomach, and duodenum are unchanged. The kidneys enhance\n and excrete contrast symmetrically without hydronephrosis or renal masses.\n There is no retroperitoneal lymphadenopathy by size criteria. Small lymph\n nodes are scattered throughout the mesentery, particularly in the left upper\n quadrant.\n\n CT PELVIS WITH IV CONTRAST: A rectal tube and Foley catheter are in place. A\n small amount of air layers non-dependently in the urinary bladder. Loops of\n large and small bowel are grossly unremarkable, with mild wall thickening of\n left upper quadrant loops, which could reflect reactive inflammatory change.\n The urinary bladder, distal ureters and prostate gland are grossly\n unremarkable. As noted, a small amount of simple fluid layers within the\n pelvis. There is no pelvic or inguinal lymphadenopathy by size criteria.\n (Over)\n\n 2:24 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for change in left pleural effusion or evidence of intr\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n OSSEOUS STRUCTURES: There is no fracture or worrisome bony lesion. Mild\n degenerative changes are noted. Soft tissues are notable for postoperative\n inflammatory changes of the subcutaneous tissues of the anterior abdominal\n wall.\n\n IMPRESSION:\n 1. Large rim-enhancing fluid collection in the splenectomy bed measuring 12.6\n x 8.3 x 10.8 cm, concerning for abscess. No evidence of enteric fistula at\n this time, as there is no oral contrast within the collection. A percutaneous\n drainage catheter terminating posteriorly within the collection appears\n adequately positioned, but does not appear to be well functioning. This is\n amenable to percutaneous revision or new catheter placement.\n 2. Smaller intra-abdominal fluid collections adjacent to the xiphoid process\n containing small foci of air. Additional collections are not well defined,\n and do not represent abscess at this time.\n 3. Large left pleural effusion without septation, pleural enhancement or\n other evidence of infection.\n 4. Mild bowel wall thickening, particularly in the left upper quadrant,\n likely reactive.\n 5. Nonocclusive venous thrombus in the SVC and left brachiocephalic vein at\n the site of prior central venous catheter.\n\n Findings discussed with Dr. by Dr. .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-13 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1086033,
"text": ", T. 2:24 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for change in left pleural effusion or evidence of intr\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with recent splenic rupture s/p splenectomy who then went back\n to OR for repair of enteric leak with persistent fevers. Can get PO contrast\n through J tube.\n REASON FOR THIS EXAMINATION:\n eval for change in left pleural effusion or evidence of intra-abdominal abscess\n or hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Large rim-enhancing fluid collection in the splenectomy bed measuring 12.6\n x 8.3 x 10.8 cm. No evidence of enteric fistula at this time (no oral contrast\n in the collection). Percutaneous drainage catheter terminating in the\n posterior portion of the collection appears adequately positioned but likely\n not functioning well.\n 2. Small amount of free fluid in mesentery and pelvis with inflammatory\n changes around the collection.\n 3. Smaller intra-abdominal fluid collection near the xyphoid process contains\n foci of air, not as well-defined as the larger collection, could reflect\n phlegmon/developing abscess.\n 4. Large left pleural effusion without septation, pleural enhancement or other\n evidence of infection.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1084293,
"text": " 7:36 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: eval tube placement and line\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with line and ETT\n REASON FOR THIS EXAMINATION:\n eval tube placement and line\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: For line placement.\n\n FINDINGS: In comparison with the study of , there has been placement of\n an endotracheal tube with its tip approximately 6.7 cm above the carina.\n Nasogastric tube extends well into the stomach. However, the right IJ\n catheter extends into the right subclavian system and into the axillary vein.\n\n Haziness in the lower left lung is again consistent with layering pleural\n effusion. Bibasilar atelectasis is again seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-01 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1083918,
"text": " 12:05 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please assess for abscess, fluid collection, free air\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with history of CCY, appendectomy, pancreatic pseudocyst with\n elevated lipase, elevated WBC, and abdominal pain\n REASON FOR THIS EXAMINATION:\n please assess for abscess, fluid collection, free air\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AGLc TUE 3:16 AM\n large hypodense mass in spleen with mass effect and fluid of intermediate\n density in abdomen. fluid posterior to spleen has layering fluid-fluid level,\n possible hematocrit level. findings concerning for hemorrhage from spleen.\n other considerations include abscess. clinical correlation rec'd. findings\n d/ .\n\n somewhat dilated loops of small bowel noted in right abdomen, up to 4.5 cm.\n findings could represent focal ileus, although partial or early obstruction is\n not excluded.\n WET READ VERSION #1 AGLc TUE 3:00 AM\n large hypodense mass in spleen with mass effect and fluid of intermediate\n density in abdomen. fluid posterior to spleen has layering fluid-fluid level,\n possible hematocrit level. findings concerning for hemorrhage from spleen.\n other considerations include abscess. clinical correlation rec'd. findings\n d/ .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 39-year-old male with a history of cholecystectomy, appendectomy,\n pancreatic pseudocyst, now with elevated lipase, leukocytosis, and abdominal\n pain, here to evaluate for abscess, fluid collection or free air.\n\n COMPARISON: CT abdomen of and MRCP of .\n\n TECHNIQUE: MDCT axial imaging was performed through the abdomen and pelvis\n after administration of oral contrast and 130 mL of IV Optiray. Multiplanar\n reformatted images were then obtained.\n\n CT ABDOMEN WITH IV CONTRAST: There is a small-to-moderate left and trace\n right pleural effusion. Consolidation is noted in the lung bases,\n particularly posteriorly, likely representing atelectasis, although aspiration\n and/or infection cannot be excluded. The visualized central airways are\n patent. No mediastinal or axillary adenopathy is noted. No pericardial\n effusion is seen.\n\n Again, heterogeneous enhancement is noted of the liver, likely due to\n geographic fatty infiltration, similar to that seen on prior CT abdomen. The\n patient is status post cholecystectomy. Again, the pancreatic body is\n atrophied, and the pancreatic head is unremarkable. Again, the pancreatic\n tail is focally enlarged laterally and shows slightly heterogeneous\n enhancement. There is mild stranding along the pancreatic body/tail. Small\n (Over)\n\n 12:05 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please assess for abscess, fluid collection, free air\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n locules of fluid are again noted adjacent to the pancreatic tail and along the\n splenic hilum.\n\n The predominant abnormality is a new, 10.9 x 5.4 x 4.6 cm slightly\n heterogeneous hypodense mass seen along the anterior tip of the spleen and\n causes bulging of the capsule. Fluid is also seen throughout the abdomen,\n tracking along the spleen, liver, bilateral paracolic gutters and into the\n pelvis. The fluid is of intermediate density. However, note is made of\n layering high density within the fluid posterior to the spleen, c/w a\n hematocrit level. Findings are most concerning for hemorrhage from the spleen\n with extension of the hemorrhage into the abdomen. Stranding in the right\n upper quadrant is also noted.\n\n The adrenal glands, kidneys, ureters, and the stomach appear unremarkable.\n There is mild dilation of some loops of small bowel, particularly in the right\n abdomen, and the remaining small bowel is nondilated but contains fluid. The\n distal colon is relatively collapsed. Again, there is a bowel containing\n umbilical hernia, without CT evidence for incarceration or bowel obstruction.\n The abdominal aorta maintains normal caliber. Mesenteric and retroperitoneal\n lymph nodes are subcentimeter, not meeting CT size criteria for adenopathy.\n\n CT PELVIS WITH IV CONTRAST: The urinary bladder, distal ureters, prostate,\n seminal vesicles, and the non-opacified and nondilated rectosigmoid colon\n appear unremarkable. Again, intermediately dense fluid is seen within the\n pelvis. No free air is seen. No adenopathy is noted.\n\n OSSEOUS STRUCTURES: Degenerative changes are noted along the mid thoracic\n spine.\n\n IMPRESSIONS:\n 1. Large hypodense splenic mass /hemorrhage expanding the capsule with\n intermediately dense fluid noted throughout the abdomen. Findings are\n concerning for splenic hematoma with extension into the abdominal cavity and\n with hematocrit level posterior to the spleen. Findings may be related to\n inflammation of the pancreas, although focal source of bleeding is not\n identified.\n\n 2. Enlargement and slightly heterogeneous enhancement of the pancreatic tail\n again noted. There may be pancreatitis along the body/tail.\n\n 3. Fatty liver with gastric and splenic varices.\n\n 4. Bowel containing umbilical hernia.\n\n 5. Mildly dilated loops of small bowel in the right abdomen, likely due to\n ileus.\n (Over)\n\n 12:05 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please assess for abscess, fluid collection, free air\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Findings were initially posted on the ED dashboard and findings regarding the\n spleen were discussed with Dr. at 2:45 a.m.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-02 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1084318,
"text": " 10:59 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval line placement, ptx\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with new line\n REASON FOR THIS EXAMINATION:\n eval line placement, ptx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: New line placement.\n\n FINDINGS: The aberrant right jugular catheter has been removed and replaced\n with a left IJ catheter that extends to the lower portion of the SVC. Little\n change in the appearance of the heart and lungs.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-04-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1083906,
"text": " 8:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with abdominal pain and elevated WBC\n REASON FOR THIS EXAMINATION:\n please eval for free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 39-year-old male with abdominal pain and elevated\n WBC. Evaluate for free air.\n\n EXAMINATION: Single upright portable chest radiograph.\n\n COMPARISONS: Not available.\n\n FINDINGS: Low lung volumes accentuate the pulmonary vasculature. There is\n bibasilar atelectasis, and an underlying parenchymal consolidation cannot be\n excluded. Small right pleural effusion. No evidence of pneumothorax.\n Cardiomediastinal contours are unremarkable. The visualized osseous\n structures are normal.\n\n IMPRESSION: Bibasilar atelectasis, and an underlying consolidation cannot be\n excluded. Small right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2159-05-01 00:00:00.000",
"description": "EMBO NON NEURO",
"row_id": 1083977,
"text": " 9:59 AM\n OTHER EMBO Clip # \n Reason: embo spl art pls\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n Contrast: OPTIRAY Amt: 90\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO EA 1ST ORDER ABD/PEL/LOWER EXT *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * F/U STATUS INFUSION/EMBO -59 DISTINCT PROCEDURAL SERVICE *\n * TRANCATHETER EMBOLIZATION MOD SEDATION, FIRST 30 MIN. *\n * MOD SEDATION, EACH ADDL 15 MIN MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE MOD SEDATION, EACH ADDL 15 MIN *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 39 year old man with ? splenic hemorrhage\n REASON FOR THIS EXAMINATION:\n embo spl art pls\n ______________________________________________________________________________\n FINAL REPORT\n DIAGNOSIS: Splenic hemorrhage, chronic pancreatitis.\n\n INDICATION: Splenic hemorrhage.\n\n ANESTHESIA: Moderate anesthesia was provided by administering divided doses\n of 200 mcg of fentanyl and 1.5 mg of Versed throughout the total intraservice\n time of 2 hours during which the patient's hemodynamic parameters were\n continuously monitored. Local anesthesia was established with approximately\n 10 cc of buffered lidocaine.\n\n PROCEDURE:\n 1. Selective splenic artery angiogram.\n 2. Embolization and followup postembolization splenic angiogram.\n\n PHYSICIANS: Dr. and Dr. . Dr. was the attending\n physician who was present and supervising throughout the entire procedure.\n\n COMPLICATIONS: None.\n\n TECHNIQUE AND FINDINGS: After the risks, benefits, and alternatives of the\n proposed procedure as well as those of conscious sedation were thoroughly\n explained to the patient, and informed consent was obtained the patient was\n taken to the angiography suite and placed in supine position. The right groin\n was prepped and draped in the usual sterile fashion. A pre-procedure timeout\n was performed. Next, the skin was anesthetized along the puncture site and\n small skin was made. A 18 gauge needle was passed through the skin and\n into the right common femoral artery. A 0.035 wire was passed\n through the needle into the abdominal aorta. The needle was removed and\n a angiographic 5 French sheath was placed over the wire. The inner introducer\n (Over)\n\n 9:59 AM\n OTHER EMBO Clip # \n Reason: embo spl art pls\n Admitting Diagnosis: SPLENIC HEMORRHAGE\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n was removed. The side-arm was connected to continue saline flush. Next, C2\n Glide catheter was used to select the celiac axis and the catheter was\n advanced over the wire into the splenic artery. A splenic angiogram\n was performed. The angiogram demonstrates a patent splenic artery with no\n evidence of active extravasation or pseudoaneurysm formation. As per our\n discussion with Dr. of general surgery, it was decided to proceed with\n empiric embolization of the spleen. The C2 catheter was advanced over a\n 035 inch glide wire into the splenic artery hilium. Embolization was then\n performed with one block of Gelfoam as well as two 6- mm x 14 cm coils\n (platinum). Repeat angiogram was performed demonstrating complete occlusion of\n the splenic artery without evidence of retrograde filling of the spleen. The\n catheter was removed and angiogram was performed at the level of the femoral\n artery prior to deployment of angioseal. Patient tolerated the procedure well\n without immediate complication.\n\n IMPRESSION:\n 1. Selective splenic artery angiogram demonstrating no evidence for\n extravasation or pseudoaneurysm formation.\n 2. Uncomplicated coil and Gelfoam embolization of splenic artery.\n\n\n\n\n"
}
] |
22,136 | 195,307 | Summary of hospital course by system: Respiratory: The patient was with respiratory distress. The infant intubated in delivery room and received Survanta x1. Extubated to CPAP on day of life 1 within 24 hours. Continued on CPAP for 7 days until day of life 7 and then alternated between nasal cannula O2 and room air and then finally transitioned to room air on day of life 19 and remains in room air at the time of transfer and the infant is on caffeine for apnea of prematurity. | Mild SC/IC retractionsnoted. G/D: tEMp. LSC/= w/ mild retractions. cont with Caffiene.#2 SEPSIS O: Infant remains on Ampi and Gent. INfantturned and repositioned q4hours with cares. Resolved with prone position and decrease in CPAP.Active BS. A:stable P: COnt. A: stable P:COnt. One medium spit noted this shift.Abdomen soft, round, +BS, no loops. PKU done. A:comfortable in RA P: Support resp needs#3 TF's 120cc/k. SNNP PICC line procedure noteConsent obtained. Infant tol procedure well. On TF of 120cc/k/day. Sincetransitioned to isolette has been consistently in RA. Infant remains on caffiene.A: Increase in spells. Mild SC/ICretractions noted. remains on O2 via NC, 500cc, FiO2 30-45, RR38-60, LS clear and equal, ITC/ SC retractions present. Font s/f.Infant a/a with cares. Settleswell with containment and pacifier. Sepsis: Infant reamsin on AMp./Gent, Blod cx. RR 60-80's stable on CPAP cont to follow tomonitor resp. RR 30-60's stable on CPAP cont to follow. Abg 7.32/30/55/16/-9 aware. Bili this am 7.1 and 0.5. continue toasess. Settles out on belly with binkieand containment. BBS clear and =.Mild retractions evident. A: breathingcomfortably P: support resp needs#3 TF's 120cc/k. Infant made NPO R\tindocyn. Labs noted & PN adjusted accordingly. ABG sent: 7.32/30/55/16/-9. MIN ASP. RR 40-60's stable on CPAP cont to follow. Nicu packet given. Made NPO again for PDA and indocin. and fiesty with cares. BP 66/46 53. continue to asess. Update given. Labs noted and PN adjusted accordingly. Continue to support, update, andeducate . continue to asess. NPN 7p-7a#1 Infant conts. RR 28-50's with mild IC and SCretractions. UOP ~ 2.8cc/k++ for 8hrs. will check bili and lytes in the am.7) soft murmur noted this am by . continue to support.6) infant jaundiced. GIR from PN ~8.1 mg/kg/min.GI: Abdomen benign. Kangarroo'd- tol well. 1 spell toHR78 this shift; QSR. Active BSthroughout. Mild retractions IC/SC. A: Stable onNC. fiO2 .21, bs clear, rr 40-60 with mild retractions. Good UOP; nostool yet. Eyesprotected.A: HyperbiliP: Recheck in AM. Took temp, changeddiaper. Calories advancedto SC22. Cont oncaffeine. Resp. P: Continueto monitor.#4: O: Temp stable in servo isolette. Noresidual noted. Oncaffeine. RR30's-60's with mild ic/sc retractions. P/Cont. P/Cont. P/Cont. Abdomen benign, voiding, nostool so far this shift. A/Occasional spitting noted.Otherwise pt is well appearing. Stablein NCO2. Abd benign. Updated, askingappropriate questions. Sm spits noted. Mild retractions noted. Respiratory CarePt cont on prong CPAP. Infantbreathing comfortably and tolerating short periods of timeoff CPAP while being repositioned with cares.FEN:TF= 120cc/kg/d. LS c/=. Spoke at length w/NNP. BS clear and =, mildic/sc ret; color jaund/pink. Did have 1 desat 72, qsr. Temp stable in servo isolette. A: AGA. Cont PN as ordered.#4 G/D: Infant remains on an open warmer w/i a nestedsheepskin. UAC has 1/2NS withhep infusing at 1cc/h. A: Doing well off CPAP, occ spells P: monitor forincreasing spells#3 Presently on 100cc/k/d TF, IVF D19.5, IL & NS inf at90cc/k/d. F/u temps 99.0, 99.2ax. P: cont to support, involve, update.#6 O: bili 3.4/0.4- lites off at 0900. for sepsis r/t prematur. Infant remains off CPAP and in rm air since :30 withno increased WOB, RR stable, SaO2>94. RR 30's-70's w/baseline mild sc/icretractions. abdbenign, vdg per flow sheet, traces mec stools, hypoactivebowel sounds, girth stable. for sepsis r/t prematur.3 alt in FEN r/t prematur.4 alt in G+D r/t premat.5 alt parenting r/t NICUadmissREVISIONS TO PATHWAY: 1 Alt in resp r/t premat. RR=30-60's, sats 95-100%, RA, small amoount nasal breakdown, mild ic/sc retx. Commenced on amp/gent.DS on admission 43, given D10W bolus and subsequent DS's 121, 118. BS CLEAR.REP RATE 56-78 WITH IC/SC RETRACTIONS. Temps stable inservo isolette. Stable temp in servo isolette. LS clear andequal. Hatadded. Resp. Infant hasa central PICC. Fio2 .21, bs clear, rr 30-60 with mild retractions. Ptremains NPO. P: present care#3 O: TF 100cc/k/d via PICC, remains NPO for now. UO 1.2cc/k/h thus far thi sshift. Updated by this RN. BBS =/clear. BBS =/clear. LSdiminished to clear bilat. Updated atbedside. G&D. A/ Stable. Nomumrur. CV. Lytessent 2100: 127/5.5/96/13/24. Stable temp in heated isolette. Abd benign. BBS clear and =. NICU NSG NOTE#1. Lytes today: Na-129, K-5.0 (hemolyzed), Cl-100, TCO2-12, BUN-48, creat-1.0. DS= 92.DEV: Temps stable while nested in servo isolette. Repositioned with cares. A: Appropriatefor gestational age. Elec(22:30): 126/4.9/98/10. abd sl. CBG 2100:7.33/30/31/17/-9. Last CBG7.31/27/46/14/-11. FeS04 and Vit E.G&D: CGA=31-4/7 wk. Lungs clear/equal,color ruddy pink, RR 30's-60's w/mild baseline retractions.one brady this shift w/prongs out, QSR. CBG(22:30): 7.28/30/43/15/-11; notified. bili 5.1/0.3 today.HUS wnl., stable.Assessment: Nasal and spell issues at noted above.Continue to monitor apnea. Infant hashad one spell so far this shift. Temp99.1 at next care. Lung soundsclear/=, mild SC/IC retractions noted. Stable temp in servo isolette. HypoglycemiaPlan as stated above. Neck supple with intact clavicles.Resp: Endotracheal tube in place. RR40's-60's with mild ic/sc retractions. CTA and good and equal aeration B/L.Cardiac: HR 140-160s, BP 53/19 (32). PPV given with improvement and establishment of regular respirations. NPN#1/#7Infant remains on nasal prong CPAP 5cm; 21% with sats >94%.BS clear= with mild retractions. Right leg always had good peripheral pulses.Studies:CBC w diff, bld cx pendingFirst d/s 43 --> rec;d D10w 2ml/k x 1 dose, repeat pendingBabygram requestedImpression/Plan:1. P: Continue to monitor.#3: O: Current weight 1520g (+20g). Testes undescended B/L.Spine: No sacral anomaliesExtrem: Warm and pink except for some residual pallor of the right foot.Metabolic: D-stick 43Impression:1. UACremains in place infusing 1/2 NS with 1/2 u hep/cc at1.0cc/h. monitor a's and b's.#3 O: TF remain 100cc/k/d iv/pg. Mild SC/IC retractions noted atbaseline. A: mild O2 requirementP: wean as . HAS HAD ONE BRADY AND ONE DESATOVERNIGHT.A:STABLE, FEW SPELLSP:CONTINUE TO MONITOR CLOSELY#3F/E/NO:TF AT 100CC/KG. P: Cont to monitor.#3 O: TF= 100cc/kg/d. abd benign, vdg perflow sheet, needs to stool, girth stable. Lytes this am 137/6.2 (hemolyzed)/104/23/37/1. A: Stable on CPAP. Sats remaining91-98%. Presents aspink/ sl jaundiced.A: Issue now resolved.P: Will follow clinically. RR30's-60's with mild IC/SC retractions. Receiving IVF of starterTPN D10 and plain D10 infusing via PIV both at 2.3cc/h. Glucose infusion rate from PN ~6.9mg/kg/min.GI: Abd benign.A/Goals:Remains NPO. jaundice P: one last check w/next lytestomorrow. Infant cont on caffiene. RR 50's-80's w/mildbaseline sc/ic retractions. EIP & VNA options placed in record. Color remains pink/ sljaundiced.A: O2 requirement continues.P: Cont to support adequate oxygenation. | 123 | [
{
"category": "Echo",
"chartdate": "2112-08-30 00:00:00.000",
"description": "Report",
"row_id": 81236,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease.\nStatus: Inpatient\nDate/Time: at 10:00\nTest: Portable TTE (Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-27 00:00:00.000",
"description": "Report",
"row_id": 1981084,
"text": "SNNP PICC line procedure note\nConsent obtained. Time out done to assure right patient and procedure. Infant premedicated with sucrose pacifier. PICC line cut to measure 20 cm. Infant's right leg prepped and draped. PICC line easily threaded into right saphanous vein under sterile condition x2 sticks. PICC line inserted into 15 cm mark. Line had good blood return and flushed well. CXR confirmed to be non-central. Dressing secure with 5 mark line outside under sterile tegaderm. Infant tolerated procedure well.\n\n SNNP\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-28 00:00:00.000",
"description": "Report",
"row_id": 1981085,
"text": "NPN 7p-7a\n\n\n#1 Received infant on prong CPAP 6cm ~ 26%. Since\ntransitioned to isolette has been consistently in RA. CPAP\ndecreased to 5cm. BBS clear and =. Mild retractions. Sats\n95-97%. On caffeine. Two spells had thus far overnoc. Soft\nintermittent murmur heard. Evaluated by NNP Buck. A:\ncomfortable in RA P: Support resp needs\n\n#3 TF's 120cc/k. Enteral feeds reintroduced at 2100 @\n20cc/k. Has received 4.5cc of SC20 q 4hrs on a pump over\n15mins. Remaining PN and IL infusing via PICC without\nincident. Abdomen full with soft scattered loops first two\ncares. Resolved with prone position and decrease in CPAP.\nActive BS. No discoloration evident. Small emesis x 1 and\nnoted to have some \"bubbling\" of formula around her mouth x\nseveral after the 9pm care which required bulbing. Lg air\naspirates only. UOP ~ 3.8cc/k. No stool passed. DS 85. A:\nimpaired nutrition P:Support nutritional needs\n\n#4 Transitioned to isolette from warmer. Temp max 99.6x.\nIsolette weaned as needed. Fiesty with handling. Settles\nwell with containment and pacifier. PKU done. A: AGA P:\nSupport developmental needs\n\n#5 No parental contact thus far overnoc.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-08 00:00:00.000",
"description": "Report",
"row_id": 1981147,
"text": "NPN/1900-0700\n\n\n#1 RESP: Infant remains in 500cc flow NC, 21-27% FiO2. RR\n30-50's. LSC/= w/ mild retractions. Has had 2 spells thus\nfar this shift; qsr. On caffeine. Stable. Cont. to\nmonitor resp. needs.\n#3 FEN: Wt 1455, ^10gms. TF=140cc/k/d. Enteral feeds of\nSC20 ^ to 120cc/k and IVF of D10 4NaCL infusing thru picc at\n20cc/k. Tolerating gavage feeds over 50 min w/ no spits.\nAbd. benign. Girth=21.5cm. Voiding/no stools. DS=68.\nPlan to advance feeds 10cc/k as tolerated.\n#4 DEVELOPMENT: Nested on sheepskin in servo isolette; temps\nstable. Active/sl. irritable w/ cares; settles when prone\nand has firm boundaries. Sucks on pacifier when offered.\nAFOF. AGA. Support developmental needs.\n#5 : No parental contact this shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-08 00:00:00.000",
"description": "Report",
"row_id": 1981148,
"text": "Attending Note\nDay of life 14 PMA 30 \nin nasal cannula 500 cc 21-30% FiO2 RR 30-50\nmild retractions 19 spells in 24 hours\non caffeine\nno murmur HR 130-160 BP 75/32 mean 48\nweight 1455 up 10 on 140 cc/kg/day enteral at 120 cc/kg/day of SSC 20 cal/oz IVF D10w at 20 cc/kg/day adv enteral 10 cc/kg/day \nno spits minimal aspirate\nstable girth\nd stick 86\nvoiding and large mec stool\nin servo isolette stable temp\n visit daily\n\nImp-infant making progress\nRESP-will continue nasal cannula because of spells. Will consider CPAP if spells continue\nFEN-will continue to advance enteral feeds. Will increase total fluids to 150 cc/kg/day\nWill have a reapeat state screen sent today\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-08 00:00:00.000",
"description": "Report",
"row_id": 1981149,
"text": "Nursing Progress NOte:\n\nRESP:\nO: Infant cont in NC 500cc/ 21-35% FiO2. RR 30-60's with\nsats 94-100%. Lung sounds clear and equal. Mild SC/IC\nretractions noted. Nasal/ oral sx x1 for moderate thick\nsecretions. Occasional drifting noted to 81-89%. Infant has\nalso had 7 noted a/b spells thus far this shift. Color is\npink and well perfused. Remains on caffiene.\nA: Infant remains stable on O2 therapy.\nP: Cont to monitor closely. Cont on caffiene.\n\nFEN:\nO: TF increased to 150cc/kg: enteral feeds adv'd to 130cc/kg\nof SC 20 (32cc) Q4H. Gavage feedings run over 50 min. IVF\nrunning at 20cc/kg. No spits noted so far this shift.\nMinimal aspirates. Girth stable. Abdomen soft, round, +BS,\nno loops. Infant voiding and has not yet stooled this shift.\n\nA: Tolerating feeds well.\nP: Cont to advance feeds 10cc/kg as ordered.\n\nDEV:\nO: Temps stable; nested in a servo isolette. Font s/f.\nInfant a/a with cares. Tone WNL: MAE. Infant brings hands to\nface. Occasionally sucks on pacifier. Sleeps well with firm\nboundaries. Out for kangaroo care; tolerated well.\nA: AGA\nP: Cont to support development.\n\nSOC:\nO: Mom in this afternoon with son, and infant's grandmother.\nUpdated regarding infant's status and plan of care. Mom\nindependent with diaper change and temp. Kangarooed infant;\nresponding well to infant cues. Mom will be back to visit\ntomorrow at 1300.\nA: Bonding well with infant\nP: Cont to support, educate and keep informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-08 00:00:00.000",
"description": "Report",
"row_id": 1981150,
"text": " PHysical Exam\nPE: pinkk AFOF, breath sounds diminished before nasal plug removed by bulb suctioning, nasal septum healing with scab inside nose, scab on external septum off, mild retracting, no murmur, abd soft, non distended, + bowel sounds, PICC right foot without redness or swelling dressing intact, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-27 00:00:00.000",
"description": "Report",
"row_id": 1981081,
"text": "Neonatology\nDOL 2, CGA 29 weeks.\n\nCVR: Continue on CPAP 6 cm, 21-24% FiO2. RR 60-80s, lungs clear. No spells. On caffeine. Hemodynamically stable, no murmur noted.\n\nFEN: Wt 1245, down 100 grams. TF 120 cc/kg/day, IVF at 100 cc/kg/day, enteral feeds started this am at 20 cc/kg/day. Thus far feedings tolerated well. Voiding, no stool overnight. Lytes 144/5.5/112/20. Dstik 93.\n\nGI: Bili 8.1/0.4, started phototherapy.\n\nID: On amp/gent, blood cx NGTD.\n\nDEV: On warmer.\n\nIMP: Former 28+ wk infant with RDS, doing well. Stable on CPAP following surfactant therapy. Tolerating initiation of enteral feeds. Mild hyperbilirubinemia.\n\nPLANS:\n- Continue CPAP, monitor resp status.\n- Continue caffeine.\n- Continue enteral feeds, gradual advancement.\n- Continue PN.\n- Plan PICC line today.\n- Phototherapy, check bili in am.\n- D/C abx.\n- HUS this week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-27 00:00:00.000",
"description": "Report",
"row_id": 1981082,
"text": "Neonatology SNNP Note\n, DOL 2, PMA 29 wks, current wgt 1245gms down 100\n\nPE:\n\nNEURO: Infant nested on an open warmer, AFOS, sutures sl overlap, infant active on exam, MAE x4. PLAN: Continue to follow clinically, HUS on .\n\nCARDIAC: Color pink/jaundice, under phototherapy, no audible murmur, RRR, HR 130-140's, BP 78/44 with a mean 53, pulses palpable =x4, cap refill < 3secs, membranes pink and moist. PLAN: Continue to follow clinically.\n\nRESP: Infant continues on CPAP of 6 with FiO2 21-24%, breath sounds =clear with mild subcostal retractions, RR 60-80's, no apnea/bradycardia on caffeine. PLAN: Continue to monitor clinically, obtain cbg as clinically indicated.\n\nFEN: TF 120ml/kg/day of 100ml/kg/day of D10w PN/IL and enteral feeds of BM/SC20 at 20ml/kg/day, lytes Na 144, K 5.5, Cl 112, CO2 20, with T-bili 8.5/0.4/8.1. PLAN: Continue with TF of 120 ml/kg/feeds, keep feeds the same with no advancement, check lytes and TG on and check T-Bili in am. Obtain consent for PICC line from parents.\n\nID: 48 hrs blood culture (-). PLAN: Discontinue Ampicillin/Gentamicin\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam, no stool in 24hrs. PLAN: Continue to follow clinically.\n\nGU: Voiding in diapers, normal preterm male genitalia.\n\n SNNP\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-07 00:00:00.000",
"description": "Report",
"row_id": 1981143,
"text": "NPN 1900-0700\n\n\n#1Resp. Pt. remains on O2 via NC, 500cc, FiO2 30-45, RR\n38-60, LS clear and equal, ITC/ SC retractions present. Sat\nmainly 90-95. Pt. has had 5 bradys so far tonight, QSR to\nmod. stim. to resolve(8/24hrs). aware. Pt. remains on\ncaffeine. Plan to continue highflow O2 and caffeine, monitor\nfor spells, increased WOB.\n\n#3FEN. Wt 1445gms, up 25gms. On TF of 120cc/k/day. Enteral\nfeeds of SC20 increased to 100cc/k/day. IVF of PN D11.8\ninfusing via PICC line at 20cc/k/day. Dstick 97. No spits,\nminimal aspirates. Abd. soft, pink, active bowel sounds, no\nnoted loops. Girth 22cm. Urine output last 24 hrs,\n2.6cc/k/hr, last 8 hrs, 2.2cc/k/hr. No stool since .\nPlan to advance feeds by 10cc/k. Monitor I/O, monitor\nfor tolerance of feeds.\n\n#4G/D. Pt. nested on sheepskin in servo control isolette,\ntemp stable. and active with cares, MAE, AFF. Settles\nwell between cares. Plan to support dev. needs.\n\n#5Parenting. No contact with so far tonight.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-26 00:00:00.000",
"description": "Report",
"row_id": 1981076,
"text": "SNNP Procedure note\nUAC removal:\n\nUAC removed intact, with no bleeding noted at umbilicus. Infant tol procedure well.\n\n\n SNNP\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-07 00:00:00.000",
"description": "Report",
"row_id": 1981144,
"text": "Attending Note\nDay of life 13 PMA 30 \nin nasal cannula 500 cc of 21-30% sat 90-97% RR 30-60\nmild retractions\n10 spells in 24 hours on caffeine\nHR 140-160 BP 67/33 mean 44\nweight 1445 up 25 grams on 120 cc/kg/day with enterals at 100 cc/kg/day and PN at 20 cc/kg/day adv 10 cc/kg/day \nno spits minimal aspirate\nstable girth\nD stick 97\nvoiding 2.6 cc/kg/hr no stool last night\nin servo isolette\n and active with care\n\nImp-stable making progress\nRESP-will continue to monitor for spells\nFEN-will increase to 140 cc/kg/day and continue to advance enteral feeds. Will write for IVF\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-07 00:00:00.000",
"description": "Report",
"row_id": 1981145,
"text": " Physical Exam\nPE: pink, mid jaundice, AFOF, sutures slightly override, nasal cannula in place, nasal septum healing with a scab, breath sounds clear/equal with mild intercostal retracting, no murmur, normal perfusion, abd soft, non distended, non tender, soft bowel sounds, PICC in place with intact dressing, sleeping, reactive to exam with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-07 00:00:00.000",
"description": "Report",
"row_id": 1981146,
"text": "Nursing Progress Note:\n\nRESP:\nO: Infant cont in NC 500cc, of 21-30% FiO2. Infant RR\n30-50's with sats remaining 92-100%. 11 spells noted so far\nthis shift; MD/ aware. Also had several drifting sats to\n86-89%; QSR. LS clear and equal. Mild SC/IC retractions\nnoted. Nasal sx x2: removed lg plugs. Color remains pink and\nwell perfused. Infant remains on caffiene.\nA: Increase in spells. Team aware.\nP: Cont to monitor infant closely.\n\nFEN:\nO: TF increased today to 140cc/kg: enteral feeds at 110cc/kg\nof SC 20 (=26cc Q4H), IVF of D11.8 PN @ 30cc/kg. Gavage\nfeeds running over 50 min. One medium spit noted this shift.\nAbdomen soft, round, +BS, no loops. Girth 21.5cm. Minimal\naspirates. Infant voiding qs and passed meconium stool x1.\nA: Tolerating feeds well.\nP: Cont to advance feeds 10cc/kg as ordered.\n\nDEV:\nO: Infant temps stable; nested in a servo isolette. Font\ns/f. Infant a/a with cares. Tone within normal limits; MAE.\nInfant reaches hands to face. Settles well with firm\nboundaries.\nA: AGA\nP: Cont to support development.\n\nSOC:\nO: Mom called x1 this am. Updated regarding infant's status\nand plan of care. Mom plans to visit for 1700 cares.\nA: Involved in infant care.\nP: Cont to support, educate and keep informed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-26 00:00:00.000",
"description": "Report",
"row_id": 1981077,
"text": "Neonatology SNNP note\nDOL 1, PMA- 28 6/7wks, Birth weight 1345gms\n\nPE:\n\nNEURO: Infant nested on warmer, AFOS, sutures sl overlap, occassional flails extremities with exam, MAE x4. PLAN: Continue to follow clinically, HUS on .\n\nCARDIAC: Color pink/ruddy, no audible murmur on exam, RRR, HR 120-140's, BP 57/25 with mean 36, pulses palpable = x4, cap refill < 3secs, membranes pink and moist. PLAN: Continue to follow clinically for PDA.\n\nRESP: Infant on CPAP of 6 with FiO2 21%, RR 50-70's, breath sounds = clear with mild subcostal retractions, no apnea/bradycardia.\nPLAN: Continue on CPAP and follow clinically.\n\nFEN: Infant NPO, TF 100ml/kg/day of starter D10W PN with plain D10w pigggy back PIV, heparinized normal salene through UAC, NPO, lytes today Na 140, K 4.1, Cl 112, CO2 15, T.Bili today 4.9/0.3/4.6 with LL of 6.5, trig today pending. PLAN: UAC discontinued, check lytes and bili in am, start PN tonight with acetate\n\nID: On ampicillin and gentamicin for 48 hrs r/o, blood culture pending. PLAN: Discontinue antibiotics in 48 hrs pending (-) blood culture.\n\nGI: abd soft and round, + bowel sounds, no HSM, no palpable masses on exam. PLAN: Continue to follow clinically.\n\nGU: Voiding in diapers, normal preterm male genitalia.\n\n SNNP\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-26 00:00:00.000",
"description": "Report",
"row_id": 1981078,
"text": "NPN 1500-2300\n\n\n#1 RESP O: Infant remains on NPCPAP 6 25% 02, BBS equal and\nclear, mild retractions, no spells. A: Alt in RESP P: cont\nto assess for increased wob, monitor and document all\nspells. cont with Caffiene.\n#2 SEPSIS O: Infant remains on Ampi and Gent. Blood culture\nneg to date. P: cont on antibiotics as ordered.\n#3 FEN O: Infant remains on TF 100cc/kday of TPn via PIV\ninfusing well, remains NPO, d/s stable,uop brisk. UAC\nremoved today. abd soft, hypoactive bs. No stool. A: alt in\nFEN P: cont with IVF as ordered. strict I&O's, wt q day.\n#5 PARENTING O: Mom and dad in to visit today, asking\nappropriate questions and updated on infan'ts progress. P;\ncont to inform and support family as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-27 00:00:00.000",
"description": "Report",
"row_id": 1981079,
"text": "RESPIRATORY CARE NOTE\nBaby remains on Prong CPAP 6 Fio2 21%. Breath sounds are clear. Baby is on caffeine. RR 60-80's stable on CPAP cont to follow\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-27 00:00:00.000",
"description": "Report",
"row_id": 1981080,
"text": "NICU NPN\n\n\n1. RESP: Infant reamsin on CPAP 6 21-25 % FIO2 throughout\nnight. Breathing comfortable, lungs clear, no spells. A:\nstable P: COnt. to monitor resp. status.\n\n2. Sepsis: Infant reamsin on AMp./Gent, Blod cx. negative\nto date. If cx. negative team will plan to place PICC line\ntoday. A/P: Meds given as ordered, no s/s of sepsis.\n\n3. F/N: INfant NPO, TF 100cc/k/d of IVF D10 infusing via\nleft hand peripheral, no s/s of infiltrate/phlebitis. wt\n-100grams ovrnight, voiding good amounts, no stool\novernight. Plan to introduce enteral feeds 20cc/k at next\ncares, increasing TF to 120cc/k/d. DS 93 A: stable P:\nPlanning to introduce enteral feeds today.\n\n4. G/D: tEMp. stable in servo mode isolette. INfant\nturned and repositioned q4hours with cares. A: stable P:\nCOnt. to support G/D.\n\n5. PArents: No contact thus far in shift.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-06 00:00:00.000",
"description": "Report",
"row_id": 1981139,
"text": "Attending Note\nDay of life 12 PMA 30 \nin nasal cannula 500 cc of 30-40% RR 40-60 mild retractions\n3 bradys last night for total of 11 in 24 hour on caffeiene\nHR 150-160 BP 68/35 mean 46\nweight unclear today on 100 cc/kg/day enteral at 80 cc/kg/day of SSC 20 cal/oz adv 10 cc/kg/day getting PN/IL 20 cc/kg/day\nvoiding 2.0 cc/kg/hr but no stool last night\nin servo controlled isolette\n\nImp-making slow progress\nRESP-having more spells. Will continue to monitor. Will consider bolus caffeine and/or CPAP if persistent problem\n increase total fluids to 120 cc/kg/day. Will advance enterals 10 cc/kg/day \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-06 00:00:00.000",
"description": "Report",
"row_id": 1981140,
"text": "Attending Note\nPhysical Exam\nGen well appearing active no distress\nlungs clear bilaterally\nCV regular rate and rhythm no murmur\nAbd soft with active bowel sounds no masses or distention\nGU normal preterm male\nExt warm well perfused brisk cap refill\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-06 00:00:00.000",
"description": "Report",
"row_id": 1981141,
"text": "Clinical Nutrition:\nO:\n~30 week CGA BB on DOL 12.\nWT: 1420(+35)(25-50 %ile); BWT: 1345g. Average wt gain over past week ~22g/kg/day.\nHC: 26cm(<10th %ile); last: 26cm\nLN: 39.5cm(25-50 %ile); last: 40cm\nLabs noted.\nNutrition: TF @ 120cc/kg/day. EN feeds SSC 20 @ 80cc/kg/day, >10cc . PN infusing via central picc. Projected intake for next 24hrs from PN ~21kcal/kg/day & 2g pro/kg/day; from EN feeds ~60kcal/kg/day, ~1.6g pro/kg/day & ~3.3g fat/kg/day. Glucose infusion rate from PN ~2.6mg/kg/min.\nGI: Abd benign\n\nA/Goals:\nTolerating feeds w/o GI problems; pg fed. Advancing as PN tapers. Labs noted & PN adjusted accordingly. Currently meeting recs for pro/kg/day. Current feeds & PN not yet meeting recs for kcal/vits/mins; feeds advancing. Growth is slightly exceeding recs of ~15-20g/kg/day; represents catch-up growth. HC/LN gains not meeting recs of ~0.5-1cm/wk for HC gain & of ~1cm/wk for LN gain. Will follow long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-06 00:00:00.000",
"description": "Report",
"row_id": 1981142,
"text": "1. remains on 500cc flow ~30% O2 nasal cannula,\nRR40-60, ic/sc retractions, BS clear and equal, please see\nflow sheet for spells-on caffeine, continue to monitor.\n3. TF 120cc/k/d, feedings of SC20 at 90/k =21cc q4 pg,\nPND14 infusing at 30/k through central PICC line with dry,\nintact dressing, abd soft, no loops, active bowel sounds,\nminimal aspirates, no spits, voiding, please see flow sheet\nfor last stool. continue to advance feedings by 10cc/k \nas tolerated (to 120).\n4. temp stable in servo isolette, nested in sheepskin with\nboundaries, active and with cares, sucks on pacifier.\n5. Mom here ~1300 with MGM, kangaroo'd with for ~2h,\nDad also in to visit, continue to update and offer support\nto very loving, concerned .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 1981095,
"text": "Clinical Nutrition\nO:\n~29 wk CGA BB on DOL 4.\nWT: 1165 g (-5)(~25th %Ile); birthwt: 1345 g. WT currently down ~13% from birth wt\nHC: 26 cm (~10th to 25th %Ile); last: 27 cm\nLN: 40 cm (~50th to 75th %Ile); last: 40 cm\nMEds include indocin.\nLabs noted\nNutrition: 130 cc/kg/day TF. NPO. Infant was started on feeds on DOL 2, but made NPO this morning due to PDA. PN infusing via central PICC Line; projected intake for next 24hrs from PN ~82 kcal/kg/day, ~3.5 g pro/kg/day and ~2.9 g fat/kg/day. GIR from PN ~8.1 mg/kg/min.\nGI: Abdomen benign. No stool.\n\nA/Goals:\nTolerating PN with good BS control. Made NPO again for PDA and indocin. Labs noted and PN adjusted accordingly. Current PN meeting recs for pro/fat and vits. Not yet meeting recs for kcals or minerals; still advancing PN as tolerated to goal. Growth should improve when able to restart feeds and advance to initial goal. WIll continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 1981096,
"text": "SOCIAL WORK\nFamily meeting held today with parents, neonatology attending, and social work. Parents brought up to date on infant's current status and care plan. They asked several appropriate questions. Mother to be d/c'd today, somewhat teary at end of meeting as she anticiaptes seperation from infant. Clear from mother's questions she has a good understanding of info offered to her. Informed parents of parking stickers. Infant not eligible for SSI based on birth weight. Will re-consider if complications arise.\nOverall parents appear to be adjusting well to premature delivery, nicu admission. They appear to be supportive of eachother, open to support offered to them by staff. They are aware I will continue to follow for support, information and resources. Please call should additional needs arise. Thank you.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 1981097,
"text": "NPN 7a-7p\n\n\n1) infant remains on Prong cpap 5 in 21%. no desats. 1 brady\nthus far today. BS clear. RR 30-50's with mild i/c s/c\nretractions. remains on caffeine. continue to asess.\n3) TF increased to 130cc/kg/day. Infant made NPO R\\t\nindocyn. IVF of PN d10 and iL infusing via central pic.\nAbdomen soft and sl full. I/m soft loops noted. aG stable.\nNo stool thus far today. Voided 2.5cc kg/hour over last\nhours. continue to asess. Piv hl placed in hand for indocyn.\n4) Infant irritable with cares but settles in between.\nSleeping nested in sheepskin. temps stable in a servo\nisolette. Likes pacifier. Continue to support dev.needs.\n5) parents here most of day. Update given. Asking lots of\nquestions. Dr and SW held a family meeting with\nparents. Nicu packet given. Parents participating in cares.\nDad kangarooed the baby this am. infant tolerated well. Mom\nwas dc'd home today. continue to support.\n6) infant jaundiced. Remains on single phototherapy. Eye\nshades in place. Bili this am 7.1 and 0.5. continue to\nasess. will check bili and lytes in the am.\n7) soft murmur noted this am by . Not heard today by this\nRN . Infant made npo and started on 1st course of indocyn.\nReceived 1st dose. Needs 2 more every 12 hours. Normal\npulses. Quiet precordium. BP 66/46 53. continue to asess.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-28 00:00:00.000",
"description": "Report",
"row_id": 1981086,
"text": "RESPIRATORY CARE NOTE\nBaby received on Prong CPAP 6 FiO2 21%. CPAP decreased to 5. Two brady spells so far tonight. Baby is on caffeine. Breath sounds are clear. RR 40-60's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-28 00:00:00.000",
"description": "Report",
"row_id": 1981087,
"text": "Neonatology Attending\nAddendum - Physical Examination\n\nHEENT AFSF\nCHEST mild intercostal 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 AGA and symm; MAE symm\nINTEG normal\nMSK normal insp/palp/ROM all ext\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 1981091,
"text": "NPN 7p-7a\n\n\n#1 Infant conts. on prong CPAP 5cm 21%. BBS clear and =.\nMild retractions evident. ABG sent: 7.32/30/55/16/-9. \n aware. No interventions planned at this time. On IV\ncaffeine. One QSR spell had thus far overnoc. Intermittent\nmurmur ausculated yest no longer heard. A: breathing\ncomfortably P: support resp needs\n\n#3 TF's 120cc/k. PN and IL infusing via PICC without\nincident @ 100cc/k. Enteral feeds of SC20 presently @\n20cc/k. Infant is receiving 4.5cc q 4hrs over 10 mins.\nAbdomen is soft with active BS. AG stable. No emesis.\nMinimal residual. UOP ~ 2.8cc/k++ for 8hrs. No stool passed.\nAm lytes/trigs pending. A: tolerating feeds P: Support\nnutritional needs\n\n#4 T max 100.1x. Temp probe cover changed with improvement.\nIrritable with handling. Settles out on belly with binkie\nand containment. Nested on sheepskin. A: AGA P: support\ndevelopmental needs\n\n#5 No parental contact thus far overnoc. Fam. mtg today\n2:30pm.\n\n#6 Color jaundiced. Under single spotlight phototherapy. AM\nbili pending. No stool passed. A: ^ bili P: Follow labs\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 1981092,
"text": "RESPIRATORY CARE NOTE\nBaby remains on Prong CPAP 5 FiO2 21%. Breath sounds are clear. One brady so far tonight. Baby is on caffeine. Abg 7.32/30/55/16/-9 aware. RR 30-60's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 1981093,
"text": "Attendign Note\nDay of life 4 PMA 29 2/7\nCPAP 5 FiO2 21% RR 30-60 on caffeine ABG 7.32/30/55/16/-9\n4 spells in 24 hours\nHR 120-150 BP 55/32 mean 37\nnew murmur present this am c/w PDA\nweight 1165 down 5 on 120 cc/kg/day of Enteral 20 cal/oz of SSC 20 cal/oz and PN D10 and Il\nD stick 71\nvoiding 3.3 cc/kg/hr\nno aspirates no spits\non single photo bili 7.1/0.5\nNa 137 K 6.5 Cl 110 CO2 10 TG 128\nparent had kangaroo care\n\nImp-infant in stable condition\nRESP-will continue CPAP for now\nCV-will begin indocin for PDA. will have a PDA check on tomorrow\nFEN-will make NPO today. Will increase to 130 cc/kg/day. Will increase the electrolytes in PN\nFamily-will have a family meeting today 2 pm\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-11 00:00:00.000",
"description": "Report",
"row_id": 1981160,
"text": "NPN 1900-0730\n\n\n1. Remains in NC 500cc, 21% with sats in the 90-100%.\nLungs clear with upper airway congestion. Suctioned nares\nonce for small yellow plug. RR 28-50's with mild IC and SC\nretractions. On caffeine. 2 A&B's thus far; see flowsheet\nfor details. Continue to monitor for A&B/desats.\n\n3. Wt up 15gm to 1480gm. TF 150cc/k/d SC24. Feeds gavaged\nover 1hr and 20mins for history of spits. Abdomen benign.\nVoiding and no stool thus far. Max aspirate was 3cc,\npartially digested formula. Tolerating gavage feeds thus\nfar. Continue to monitor tolerance to feeds.\n\n4. Temp stable nested on sheepskin in servo isolette.\n and fiesty with cares. MAE, brings hands to face.\nRest well inbetween cares. AFSF. Continue to promote\ndevelopment.\n\n5. Mom called and updated on plan of care. Mom plans to\nvisit tomorrow at 1300. Continue to support, update, and\neducate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-11 00:00:00.000",
"description": "Report",
"row_id": 1981161,
"text": "Neonatology Doing well. REmains in NC)2.\nComfortABLE appearing. Contineus with intermittetn spells. Will attempt to wean flow as tolerated. No murmur on exam.\n\nWt 1480 up 15. Tolerating feeds at 150 cc/k/d of 24 cal.Abdomen Abdomen benign on exam. benign. WIll increase to 26 cal and monitor tolerance.\n\nContinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-11 00:00:00.000",
"description": "Report",
"row_id": 1981162,
"text": "1. continues in nasal cannula 200cc flow, RA,\nRR30-50's, BS clear, equal, sc retractions, one brady so far\nthis shift-on caffeine, continue to monitor.\n3. TF 150cc/k/d SC26 37cc q4h pg over 1h 20 min, sm spit x1,\nabd soft, girth stable, aspirates ~3cc, no loops, voiding\nand apssing guiac neg stool. continue to monitor/assess.\n4. temp stable in servo isolette, nested in sheepskin with\nboundaries, very active and with cares.\n5. here ~1300, Dad kangaroo'd with for ~2h,\ntolerated well. continue to update and offer\nsupport.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-11 00:00:00.000",
"description": "Report",
"row_id": 1981163,
"text": "NP NOTE\nPE: small groing preterm infant neslted in isolette. Aple pink well perfused oin hoigh flow canula\nAFOF sutures sl overriding. Ng in place, MMMP\nChest is clear, equal bs, mild SCR\nCV: RRR, no murmur, pylses+2=\nAbd: soft active bs\nGU: imature male\nEXt:, \nNeuro:active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-12 00:00:00.000",
"description": "Report",
"row_id": 1981164,
"text": "#1 PT CONT ON NC 100CC OF RA, SATS >95%. LS ARE CLEAR AND\nEQUAL, UPPER AIRWAY CONG. PT HAD BRADY WITH DESATS X1, QSR.\nCONT ON CAFF.\n#3 TF 150CC/KG SC26. PT TOLERATING FEEDS OVER 1HR 20MIN. NO\nSPITS. MIN ASP. ABD BENIGN. VOIDING AND STOOLING, HEME NEG.\n\nWEIGHT INCREASE 15GM.\n#4 PT HAD BRADY WITH DESAT X1, QSR. CONT ON CAFF.\n#5 NO CONTACT FROM FAMILY THIS SHIFT.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-12 00:00:00.000",
"description": "Report",
"row_id": 1981165,
"text": " Physical Exam\nPE: pink, AFOF, nasal septum with moist scab, breath sounds clear/equal with mild retracting, no murmur, abd soft, + bowel sounds, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-12 00:00:00.000",
"description": "Report",
"row_id": 1981166,
"text": "Attending Note\nDay of life 18 PMA 31 \nin nasal cannula 100cc of 21% flow\n1 spells on caffeine RR 40-50 sat 95-100%\nno murmur HR 150-170's BP 68/32 mean 43\nweight 1495 up 15 on 150 cc/kg/day of SSC 26 cal/oz pg over 1 hr 20 min\nvoiding and stooling\nin servo isolette\n\nImp-making slow progreess\nwill add beneprotein (promod replacement)\nwill begin iron and vit E\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-28 00:00:00.000",
"description": "Report",
"row_id": 1981088,
"text": "Neonatology Attending\nDOL 3 / PMA 29-1/7 weeks\n\n remains on CPAP now 5 cm H2O in room air. On caffeine with two bradycardias overnight.\n\nIntermittent murmur. BP 78/34 (45).\n\nBilirubin slightly decreased to 8.1 on phototherapy.\n\nWt 1170 (-80) on TFI 120 cc/kg/day including PICC PN-D10W/IL at 100 cc/kg/day anad enteral feeds at 20 cc/kg/day. Feeds held briefly yesterday for distention but subsequently well-tolerated. Abd now benign. Urine output 3.8 cc/kg/hr. No stools overnight. D-stick 85.\n\nA&P\n28-5/7 week GA infant with RDS, respiratory and feeding immaturity\n-Continue to monitor for respiratory maturity\n-Continue on CPAP for now\n-COntinue on current enteral intake\n-Repeat lytes and bilirubin in 24 hours; continue phototherapy\n-Follow murmur clinically for now given intermittent and without apparent hemodynamic significance\n-Cranial ultrasound this week\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-28 00:00:00.000",
"description": "Report",
"row_id": 1981089,
"text": "NPN DAYS\n\n\nRESP:\nInfant remains in prong CPAP 5 fi02 21% all day. 1 spell to\nHR78 this shift; QSR. Cont to monitor for spells. Cont on\ncaffeine. Mild retractions noted. Lungs clear. Infant\nbreathing comfortably and tolerating short periods of time\noff CPAP while being repositioned with cares.\n\nFEN:\nTF= 120cc/kg/d. IVF @ 100cc/kg of PND10 with IL through a\nPICC line in right leg. EF @ 20cc/kg of SC20. At first care\ninfant noted to be cool and had a 1cc slight green tinged\naspirate. MD notified; feeding held until infant warm. 0800\nfeeding given at 1100 once temp stable for 1 hr. Active BS\nthroughout. No spits since feeding. AG stable. Good UOP; no\nstool yet. Will cont to monitor infants tolerance to feeds.\nNo advance plan as of yet.\n\nDEV:\nInfant irritable with cares but sleeping well b/w cares.\nTemp instability most likely r/t weaning of isolette too\nquickly on night shift. Warmed infant with warming lights\nand inc servo temp and infant's temp has been stable since\nthen (monitoring q1-2h until stable). Parents kangaroo QD as\ntolerated. A+A with cares, sucking binky weakly.\n\nPARENTS:\nMom, dad and 12 brother in to visit today. Dad is very\nnervous, but enthusiastic about changing infants diaper for\nthe first time today. Missed his chance to hold infant r/t\ntemp instability in a.m. Mom plans to kangaroo at next care.\nMom bringing in friends today. Very supportive and loving\nfamily. Updated and educated throughout day.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-28 00:00:00.000",
"description": "Report",
"row_id": 1981090,
"text": "Respiratory Care\nPt cont on prong CPAP. fiO2 .21, bs clear, rr 40-60 with mild retractions. On caffeine. 3 spells noted thus far this shift. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 1981094,
"text": " Physical exam\nAwake and alert. AFOF with good tone and activity. Breath sounds clear and equal on CPAP with good transmission and mild retractions. Soft grade II/VI murmur at LUSB, normal pulses, pink and well perfused. Mild jaundice. Abdomen soft and rounded with active BS, no HSM or masses. PICC line dressing secure and site clear.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-10 00:00:00.000",
"description": "Report",
"row_id": 1981156,
"text": "Nursing NICU Note\n\n\n1. Resp. O/PT remains on NC FiO2 21% with a 500ml/min flow.\nPlease refer to flowsheet for spells noted this shift.\nOccasional quickly self resolving sat drifts also noted to\nthe mid 80s also. A/Still having occasional spells while on\ncaffeine. P/Cont. to monitor for A/B and desaturations and\nintervene as pt needs.\n\n3. F/N. O/TF remain at 150cc/k/d of SC22 pngt over 1\nhour and 10min. Please refer to flowsheet for examinations\nof pt from this shift. Sm spits noted. No stool passed thus\nfar this shift. Voiding. A/Occasional spitting noted.\nOtherwise pt is well appearing. P/Cont. to monitor for s/s\nof feeding intolerance.\n\n4. G/D. O/Temp stable on servo in an isolette. Waking prior\nto being fed. Awake and at care times. Settles easily\nand has restful sleep periods in between care times. A/Alt.\nin G/D. P/Cont. to support pt's growth and dev. needs.\n\n5. . O/No contact from this shift thus far.\nA/Unable to assess involvement at this time. P/Cont.\nto support and educate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-10 00:00:00.000",
"description": "Report",
"row_id": 1981157,
"text": "Neonatology Attending\n\nDOL 16 PMA 31 weeks\n\nIn NCO2 500 ml RA for stimulation. R 30s-60s. 5 A/B in 24 hours. On caffeine.\n\nNo murmur. BP 66/34 mean 44\n\nOn 150 ml/kg/d SC 22 pg q4 over 80 minutes. Voiding. Stooling. Wt 1465 grams (up 30).\n\n in and up to date.\n\nA: Stable. Improved A/B with high flow NCO2 and caffeine. Tolerating feeds.\n\nP: Monitor\n Increase to 24 cal\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-10 00:00:00.000",
"description": "Report",
"row_id": 1981158,
"text": "1. continues in 500cc flow 21%O2 nasal cannula,\nRR30-50's, sc retractions, 2 bradys so far this shift-please\nsee flow sheet for details, on caffeine.\n3. TF 150cc/k/d SC24 36cc q4h pg over ~80 min, abd soft, no\nloops, active bowel sounds, AG stable~24cm, minimal\naspirates, no spits, voiding and passing guiac neg stool.\n4. temp stable in servo isolette, nested in sheepskin with\nboundaries, active and with cares, brings hands to\nface and tries to suck on fingers. continue to assess growth\nand development.\n5. here this am, Dad kangaroo'd with for ~1h,\ncontinue to update and offer support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-10 00:00:00.000",
"description": "Report",
"row_id": 1981159,
"text": "NP NOTE\nPE: small preterm ifnant neslted in isolette pale pink, weel prefused in RA flow, nasal canula\nAFOF sturees overriding, eyes clear, nares patent, MMMP\nChest is clear, equal bs, fair exchange. mild SCR\nCV:RRR, no murmur, pulses+2=\nAbd: soft, active bs\nGU: immature\nEXT: , \nNeuro: flexed posture symemtric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-27 00:00:00.000",
"description": "Report",
"row_id": 1981083,
"text": "NPN 1600\n\n\n#1 Resp: Infant remains on nasal prong CPAP of 6cms, 21-24%\nthis AM, required 30% for approx 1hr this afternoon. RR\n40-60. Mild retractions IC/SC. Color ruddy/jaundiced.\nNo spells. On caffeine.\nA: Stable on nasal prong CPAP.\nP: Cont to monitor for change in resp. status.\n#2 ID: Antibiotics d/c'd today. Bld cultures negative.\nTemps wnl. Activity wnl for age.\nA: r/o sepsis complete.\nP: cont to monitor for s/s of sepsis.\n#3 F/N: TF 120cc/kg/d. PIV infusing PN D10 @ 5.6cc/hr. #5F\nNG tube @ 17cms placed this AM, infant fed 20cc/kg, 4.5cc\nSimSC 20. Infant spit up X3, abd distended w/ some small\nloops, AG from 21cms-23cms. Feeding held at 12pm and 4pm.\nAbd less distended and AG back to 21cms. Bowel snds present,\nactive. Infant has passed mec stool X2 today.\nPICC line placed in the right foot.\nA: PICC line placed, infant w/ ?CPAP belly.\nP: Resume feeds at later time. Monitor for s/s of feeding\nintolerance. Cont PN as ordered.\n#4 G/D: Infant remains on an open warmer w/i a nested\nsheepskin. Alert and active. Up to kangaroo w/ mom at 12pm.\nTemps 99.6ax-97.9ax. Irritable at times.\nA: AGA, 29 wkr.\nP: Cont dev. supports. Place in isolette.\n#5 Parents: Mom and Dad up this AM. Dad anxious about\nphototherapy and PICC line placement. Spoke at length w/\nNNP. Parents happy to have infant held by mom today.\nMom has decided to formula feed this baby.\nA: Invested loving parents, anxious about issues.\nP: Cont to keep parents informed. Encourage participation in\ncare. Dad would like to kangaroo tomorrow.\n#6 Bili: Placed under double phototherapy this AM. Eyes\nprotected.\nA: Hyperbili\nP: Recheck in AM.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-09 00:00:00.000",
"description": "Report",
"row_id": 1981151,
"text": "NPN 1900-0700\n\n\n#1: O: Infant continues in NC O2, 500cc flow, 21%. RR\n30's-60's with mild ic/sc retractions. LS c/=. No spells so\nfar this shift. Infant continues on caffeine. A: Stable on\nNC. P: Continue to monitor.\n\n#3: O: Current weight 1435g (-20g). TF 150cc/kg/day. Enteral\nfeeds are currently at 140cc/kg/day of sc 20, 34cc q4 hours\nand are being advanced by 10cc/kg . PIC was heplocked at\n0100 this shift when feeds advanced to 140cc/kg. Infant\nwill be at full feeds at 1pm. Abdomen benign, voiding, no\nstool so far this shift. Girth stable at 22cm, no spits.\nInfant had a max aspirate of 5cc which was partially\ndigested and was returned. A: tolerating feeds. P: Continue\nto monitor.\n\n#4: O: Temp stable in servo isolette. Infant is and\nactive with cares, sleeps well in between. Brings hands to\nface for comfort and sucks pacifier when offered. Remains\nnested in sheepskin. A: AGA. P: Continue to support growth\nand development.\n\n#5: O: No contact.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-09 00:00:00.000",
"description": "Report",
"row_id": 1981152,
"text": "Attending Note\nProcedure Note PICC line removal\nIndication no need for central access\nTime out to make sure correct patient and correct procedure\nInfant monitored with CVR monitor and oximeter\nPICC removed and bandage placed\nInfant tolerated procedure well with no complications\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-09 00:00:00.000",
"description": "Report",
"row_id": 1981153,
"text": "Attending Note\nDay of life 15 PMA 30 \nin nasal cannula 500 cc of 21%\n11 spell in 24 hours on caffeine\nHR 140-160 BP 64/32 mean 43\n1435 down 20 on 150 cc/kg/day of SSC 20 cal/oz at 140 cc/kg/day will advance to full feeds today\nvoiding and stooling\nactive and \n\nImp-making progress\nRESP-will continue to monitor for spells\nFEN-will advance to 150 cc/kg/day will advance to 22 cal/oz\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-09 00:00:00.000",
"description": "Report",
"row_id": 1981154,
"text": "NPN DAYS\n\n\n1. Remains in NCO2 500cc at 21%. LS clear. RR 30-50's. On\ncaffeine. No bradys noted. Did have 1 desat 72, qsr. Stable\nin NCO2. Monitor.\n\n3. TF advanced to 150cc/kg this afternoon. Calories advanced\nto SC22. Gavaged over 60min. Spit x1. Abd benign. No\nresidual noted. Voiding, no stool.\n\n4. Temp stable in servo isolette. Nested with sheepskin.\n and active with cares. AGA.\n\n5. Mother in for afternoon cares. Updated, asking\nappropriate questions. Independent with cares. Kangarood\ninfant- well. Loving family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-09 00:00:00.000",
"description": "Report",
"row_id": 1981155,
"text": " Physical Exam\nAwake and . AFOF with good tone and activity. Breath sounds clear and equal on nasal cannula with mild retractions. No audibel murmur, well perfused with normal pulses. Abdomen soft and rounded with active bS, no HSM or masses.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-02 00:00:00.000",
"description": "Report",
"row_id": 1981124,
"text": "Nursing Progress Note\n\n\n#1 Respiratory-- O: Remains in RA, sats 90s. Brady x2 &\n50. Caffeine dose ^ and bolus given. BS clear and =, mild\nic/sc ret; color jaund/pink. RR 40s-50s; HR 130s-140s Up to\n160 at times. No murmer. BP 70/40 mean 43. A: Stable in RA\nwith occ spells on caffeine. P: Cont to monitor in RA off\nCPAP, give caffeine per order, monitor for spells\n\n#3 Nutrition-- O: Total flds 100cc/kg/d. Adv feeds ^ to\n20cc/kg/d= 4.5cc SC20 q4h over 15 min- tol well, no\nspits/asp. IV flds_ NS d/c at 1545 (was 20cc/kg/d); TPN D17\nwith lytes ^ at 1745 at 80cc/kg/d= 3.7cc/h with IL at .8cc/h\nvia PICC line infusing well. VQS (13cc and 9cc in 8h). Abd\nexam benign, Ag 21-22cm, +BS, no distention. A: Monitor tol\nto feeds, check lytes, bili and HCT in am, monitor d/s.\n\n#4 Development-- O: and quiet at times, otherwise\nsleepy/drowsy. Temp stable, nested in seveo isolette, on\nsheepskin with boundaries. Hands to mouth. sucking on\npacifier. Tol Kangarroo care x 90 min with mom. A: AGA P;\nCont to support development\n\n#5 Parenting-- O: Mom and dad in at 1300. Took temp, changed\ndiaper. Kangarroo'd- tol well. Updated re status and plan.\nPleased with baby's progress. A: Involved and concerned P:\nCont to support and keep informed\n\n#6 ^ BIli-- Jaund A: rebound bili today stable P: Check bili\nin am\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-03 00:00:00.000",
"description": "Report",
"row_id": 1981125,
"text": "NPN 7p-7a\n\n\n#1 cont to do well in rm air with SaO2 >94, LS clear\nand equal, mild IC/SC retractions, has had several bradys\ntonight 2 req some mild stim. nasal septum remains reddened\nand excoriated. aware. A: cont with some spells P:\nmonitor closely for now.\n#3 cont on 100cc/k/d TF, IV presently PN17 with IL at\n80cc/k/k and PO feeds of SC20 at 20cc/k/d, tol feeds well,\nno asp, no spits, AG stable at 20.5, Abd soft, +BS, no loops\nor distention. U/O 1.2cc/k/h, no stool tonight. DS 109 &\n112. A: tol feeds, P: no change at present\n#4 stable in servo isolette, sleeping between feeds, calm\nwith cares, cont with occ spells, sucks some on pacifier. A:\nAGA P: cont to support development\n#5 mom called, glad he is still not needing CPAP or ,\n visit on Saturday. A: involved family P: cont to\nsupport and inform\n#6 remains sl jaundice, bili pnd.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-03 00:00:00.000",
"description": "Report",
"row_id": 1981126,
"text": "Neonatology NP Note\nPE\nnested in isolette\nAFOF, sagital and lamboidal sutures slightly over riding\nmild subcostal/intercostal retractions in room air, lungs clear/=\nboth nares with erythema and escar, 1-2 mm band of escar on lower outer nasal septum and uppermost part of philtrum\nRRR, no murmur, pink and well perfused\nabdomen soft, notnende and nondistended, active bowel sounds\nPICC insertion site in left foot with occlusive dressing, no erythema or edema\nactive with age appropriate tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-03 00:00:00.000",
"description": "Report",
"row_id": 1981127,
"text": "Neonatology- Progress Note\nPE: remains in his isolette, nested in room air, bbs cl=, nasal eschar, no erythemia, nasal gavage in place, rrr s1s2 no murmur, abd soft, full nontender, right leg Picc line in place and secure, active with exam\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-02 00:00:00.000",
"description": "Report",
"row_id": 1981120,
"text": "NPN 7p-7a\n\n\n#1 Infant received on CPAP 5, RA. Sao2 >95. RR 40-60, LS\nclear and equal with mild subcostal/intercostal retractions.\n At first care, infant removed from CPAP for weight check.\nNasal septum noted to be reddened with sl break down. \n consulted by RRT , decision made to trial off\nCPAP. Infant remains off CPAP and in rm air since :30 with\nno increased WOB, RR stable, SaO2>94. He has had 3 bradys\nsince off CPAP, one to 52 and requiring mild stim others\nQSR. A: Doing well off CPAP, occ spells P: monitor for\nincreasing spells\n#3 Presently on 100cc/k/d TF, IVF D19.5, IL & NS inf at\n90cc/k/d. PG feeds of SC20 at 10cc/k/d. Abd benign, soft,\n+BS, no loops or distention, vdg qs, no stool. A.M. sodium\nreported at 123, recheck same specimen 131, will send 2nd\nspecimen. A: tol feeds, ? low sodium P: recheck lytes\n#4 stable in servo isolette, calm with cares, sleeping well\nbetween, sucks some on pacifier. A: AGA P: cont to support\ndevelopment\n#5 Mom called, pleased that he is tol feeds so far, wondered\nif he is off CPAP. Plans to visit today. A: involved family\nP: cont to support and inform\n#6 bili this a.m. 4.1/0.3 sl jaundice, not presently under\nphototherapy. A: sl increase of rebound P: per team\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-02 00:00:00.000",
"description": "Report",
"row_id": 1981121,
"text": "Neonatology Attending Progress Note:\nDOl #8\nPMA 29 6/7 weeks\nnow in RA. clear/equal. RR=30-60's, sats 95-100%, RA, small amoount nasal breakdown, mild ic/sc retx. 5 bradys --4 self-resolved\ncaffeine, HR=140-160's, no murmur\ns/p indomethacin x1 course, no PDA on post-echo\nwt=1340g (inc 65g), on TF=100cc/kg/d picl in place. feeds at 10cc/kg/d. tolerating well, NS fluid\nvoiding 2.2,no stool\ndstx=86\n131/4.8/100/14 (Na increased from 127, HCO3 up from 11)\nbili=4.1 (inc from 3.4 yesterday) rebound\nImp/Plan: premie infant with resolved PDA, resolving RDS, apnea of prematurity, trophic feeds\n--continue to monitor closely for murmur\n--will increase Caffeine dose and give caffeine bolus, monitor for spells, may need to go back on CPAP if increased number/severity of spells\n--recheck bili in am\n--recheck lytes in am\n--check crit in am.\n--continue to keep at 100cc/kg/d. increase to Na 7 in PN, d/c NS line. increased feeds to 20cc/kg/d\n--continue rest of present management\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-02 00:00:00.000",
"description": "Report",
"row_id": 1981122,
"text": " ON-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in isolette, room air off CPAP\nSKin: warm and dry; color pink\nHEENT: anterior fontanel open, level sutures opposed; nasal skin breakdown\nChest: breath sounds clear/=\nCV: RRR, no murmur; normal S1 S2; pulses +2\nAbd: cord remnant on/drying; soft; no masses; + bowel sounds\nGU: preterm male, testes undescended\nExt: moivng all\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-02 00:00:00.000",
"description": "Report",
"row_id": 1981123,
"text": " ON-Call\nP-CVL infusing right leg, dressing intact, no edema or erythema at site.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-25 00:00:00.000",
"description": "Report",
"row_id": 1981067,
"text": "Nursing Admit note\n28 wkr, 1345gm product of 35 yo G3, P1-2 mother. Infant admitted from L+D, see attending/fellow's note for delivery details.\n\nInfant arrived on NICU intubated, centrally pink, lethargic. R leg noted to be pale-white in color extending from hip to toes. Perfusion to this LE spontaneously returned over ~40min.\n\nPLaced on SIMV 20/5 rate 25. Crse BS bilat. Icr/scr. Minimal respiratory effort. Surfed x1.\nLast ABG 5pm: 7.32/37/93/20/-6 (weaned on PIP and rate--currently vent settings 19/5 rate 21.)\n\nTemp on arrival 96.1 rectal--additional warming lights placed on infant, and infant placed on warmer bag. F/u temps 99.0, 99.2ax. VSS at present. BP means >30. Last cuff BP 61/20 (34). Low HR noted at times 110's-140's.\n\nCBC and BC sent. CBC benign. BC pndg. Commenced on amp/gent.\n\nDS on admission 43, given D10W bolus and subsequent DS's 121, 118. TF 100/k/d, NPO. Starter PND10 and D10W infusing via PIV. 1/2NS w/hep infusing via UAC. UVC attempted without success. Void x1, no stool as yet. Belly soft adn benign in appearance.\n\nNested on sheepskin. Active w/cares, sleeping majority of shift. Sucking on paci. Tone improved over shift. Baby meds given.\n\nMom and dad visited, given update and brief intro to NICU. Parents approp concerned. Mom wishes to formula feed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-25 00:00:00.000",
"description": "Report",
"row_id": 1981068,
"text": "1 Alt in resp r/t premat.\n2 pot. for sepsis r/t prematur.\n3 alt in FEN r/t prematur.\n4 alt in G+D r/t premat.\n5 alt parenting r/t NICUadmiss\n\nREVISIONS TO PATHWAY:\n\n 1 Alt in resp r/t premat.; added\n Start date: \n 2 pot. for sepsis r/t prematur.; added\n Start date: \n 3 alt in FEN r/t prematur.; added\n Start date: \n 4 alt in G+D r/t premat.; added\n Start date: \n 5 alt parenting r/t NICUadmiss; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-26 00:00:00.000",
"description": "Report",
"row_id": 1981069,
"text": "Respiratory Care\nBaby received on simv 21 19/5 21%,ABG 7.40/29/52/19/-4 decreased to R 18 17/5.Decsion made to extubate placed on cpap 6 21%.BS coarse.Sx prior to extubation sm clear secs.He was started on caffeine prior to being extubated,.RR 30-40's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-26 00:00:00.000",
"description": "Report",
"row_id": 1981070,
"text": "NPN 1900-0700\n\n\n1. RESP: Infant received on SIMV 19/5 X21 with FiO2 21%.\nABG at 2130 was 7.40/29. Infant loaded with caffeine at\n2300 and was extubated to CPAP 6 at 2400. Lung sounds are\ncoarse to clear. RR 30-40's and sats >92%. Mild IC/SC\nretractions. No spells/desats noted.\n\n2. : Infant remains on Ampi and Gent. Blood cultures\npending.\n\n3. F&N: TF remain at 100cc/k/d. NPO. UAC has 1/2NS with\nhep infusing at 1cc/h. PIV has starter PN and D10W infusing\nwell at 2.3cc/h each. Abd benign. BS+. A/G 22 cm. Lytes\nto be checked at 24 hours of age. D/S 116. U/O 3.2cc/k/h.\nNo stool noted.\n\n4. DEV: is active and alert during his cares.\nTemp stable nested on sheepskin on servo-radiant warmer. He\nputs his hands to his face and sucks on his pacifier at\ntimes.\n\n5. PAR: Mom called for update X1.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-05 00:00:00.000",
"description": "Report",
"row_id": 1981134,
"text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS IN NC 500CC 30-50% WITH SATS 94-100%. BS CLEAR.\nREP RATE 56-78 WITH IC/SC RETRACTIONS. INCREASED WOB NOTED\nAT TIMES DURING THE SHIFT. SUCTIONED X2 FOR SMALL TO MOD AMT\nSECRETIONS. HAS HAD 7 SPELLS OVERNIGHT--NO FURTHER SPELLS\nSINCE INCREASED NC FLOW. AWARE. REMAINS ON CAFFEINE AS\nORDERED\nA:INCREASED SPELLS, IMPROVED SINCE CHANGE IN FLOW\nP:CONTINUE TO MONITOR RESP STATUS AND SPELLS CLOSELY\n\n#3F/E/N\nO:TF AT 100CC/KG. ENTERAL FEEDS T 60CC/KG SCF20 14CC Q4HR\nPG. IVF D15PN AND IL INFUSING AT 40CC/KG VIA PICC LINE. PICC\nINFUSING WITHOUT S/S OF INFILTRATE. ABDOMEN SOFT, ROUND WITH\nGOOD BS. NO SPITS AND NO LOOPS. AG 21.5-22.5CM. VOIDING\n2CC/KG X8HR, GLYCERIN GIVEN--RESULTS PENDING. WT UP\n35GM--FLUIDS BASED ON BW PER ORDER. LYTES PENDING\nA:TOLERATING FEEDS WELL\nP:CONTINUE TO MONITOR TOELRANCE TO FEEDS, ADVANCE 10CC/KG\n AS TOLERATED, CHECK RESULTS OF LYTES\n\n#4G&D\nO:IN SERVO CONTROL ISOLETTE WITH ELEVATED TEMP X1 (99.2).\nACTIVE/MAE WITH CARES; SLEEPING WELL BETWEEN. NESTED ON\nSHEEPSKIN W/BOUNDARIES. FONTANEL SOFT AND FLAT; SUTURES\nSMOOTH.\nA:AGA\nP:CONTINUE TO MONITOR\n\n#5PARENTING\nO:NO CONTACT\nA:UNABLE TO ASSESS\nP:CONTINUE OT SUPPORT, EDUCATE AND KEEP UP TO DATE\n\n#6BILI\nO:COLOR PINK/SL JAUNDICE. BILI PENDING\nA:BORDERLINE REBOUND FROM SUNDAY\nP:CHECK BILI\n\nMURMUR HEARD-- AWARE\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-05 00:00:00.000",
"description": "Report",
"row_id": 1981135,
"text": "BABY HAD ADDITIONAL SPELL AFTER CHANGING NC TO HIGH FLOW. ORDER CBC,DIFF AND BLOOD CX OBTAINED.LYTES/BILI OBTAINED ALSO PER ORDER. CBC BENIGN, CX PENDING. SMALL MEC STOOL AFTER GLYCERIN THIS AM\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-05 00:00:00.000",
"description": "Report",
"row_id": 1981136,
"text": "Neonatology Attending\nDOL 11 / PMA 30-2/7 weeks\n\nIn NC 500 cc/min of 45% FIO2. Nasal excoriation healing well. Fourteen bradycardias in 24 hours, but much improved with only 1 since NC prongs and increased flow started overnight.\n\nMurmur noted intermittently (s/p indomethacin). BP 74/30 (46).\n\nRepeat WBC 12.7 (42 poly 1 band) and blood culture negative. Not on antibiotics.\n\nBilirubin 5.3 (not under phototherapy).\n\nWt 1420 (+35) on TFI 100 cc/kg/day including enteral feeds 60 cc/kg/day SC20 and IV PN-D15W/IL at 40 cc/kg/day. Tolerating feeds well. Abd benign. Voiding 2 cc/kg/hr and stooling with glycerin. D-stick 87. Lytes 138/5.1/105/23.\n\nTemp well-maintained in servo isolette.\n\nA&P\n28-5/7 week GA with RDS, respiratory immaturity, s/p PDA\n-Continue on NC oxygen and monitor nasal integrity\n-Monitor urine output and serum electrolytes\n-Continue to advance enteral intake by 10 cc/kg/day as tolerated\n-Continue TFI 100 cc/kg/day and begin to increase tomorrow\n-Follow intermittent murmur clinically and consider repeat echo if persistent\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-31 00:00:00.000",
"description": "Report",
"row_id": 1981109,
"text": "Attending Note\nDay of life 6 PMA 29 4/7\nCPAP 5 FiO2 21% on caffeine RR 30-50 one spell in 24 hours CBG 7.25/30/45/15/-11\nHR 150-160 ECHO no PDA yesterday\nhct 38.8\nweigth 1265 up 50 on 100 cc/kg/day of PN D12 and Il via central PICC NPO\non phototherapy\nhypoactive bowel sounds\nUO 1.5 cc/kg/hr but no stool\nD stick 92\n\nImp-making slow progress\nwill continue CPAP for now\nFEN-will recheck lytes today. Will continue TF at 100 cc/kg/hr. will consider feed later today\nNEURO-will have a head ultrasound tomorrow\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-31 00:00:00.000",
"description": "Report",
"row_id": 1981110,
"text": "Respiratory Care\nPt received on nasal prong CPAP +5cm's with the fio2 21%. Pt's resp rates 30's to 60's, on caffine. B/S clear and equal. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-01 00:00:00.000",
"description": "Report",
"row_id": 1981114,
"text": "REEPIRATORY CARE NOTE\nBaby remains on Prong CPAP 5 FiO2 21%. Suctioned nares for sm amt of white secretions. Breath sounds are clear. One brady so far tonight. Baby is on caffeine. RR 40-60's cap gas 7.33/30/31/17/-9. Stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-01 00:00:00.000",
"description": "Report",
"row_id": 1981115,
"text": "Neonatology Attending Note\nDay of life 7 PMA 29 5/7\nCPAP 5 FiO2 21% RR 40-60 on caffeine 4 spells in 24 hour CBG 7.33/30\nHR 140-160 BP 81/42 mean 55\nweight 1275 up 10 grams on 100 cc/kg/day getting PN/Il at 80 cc/kg/day and NS at 20 cc/kg/day\nNa 127 K 4.8 Cl 95 CO2 13 BUN 57 Cr 1.3 dstick 92-96\nhypoactive bowel sounds but stooling each diaper\n1.6 cc/kg/hr urine output\nbili 3.4/0.3\nHead US today was normal\n\nIMP-infant making progress\nFEN-will continue total fluids of 100 cc/kg/day. Will continue to give NS until tomorrow. Will begin enteral feeds of 10 cc/kg/day of SSC. Will increase the Na in the PN because PN volume will decrease with the initiation of enteral feeds.\nGI-will give a trial off phototherapy\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-01 00:00:00.000",
"description": "Report",
"row_id": 1981116,
"text": " ON-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in isolette, on NP CPAP via prongs, under phototherapy\nSkin: warm and dry; color pink; P-CVL in right leg, dressing intact\nHEENT: anterior fontanel open, level; sutures opposed\nChest: breath sounds clear/=; mild retractions\nCV: RRR, no murmur; normal S1 S2; pulses +2\nABd: soft; no masses; cord remnant on/drying; + bowel sounds\nGU: preterm male; testes descending\nExt: moving all\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-01 00:00:00.000",
"description": "Report",
"row_id": 1981117,
"text": "Nursing Progress Note\n\n\n#1 O: nasal prong cpap 5cms 21%, lungs clear/equal, color\npink/sl. jaundice. RR 30's-70's w/baseline mild sc/ic\nretractions. Caffeine as ordered. no spells thus far this\nshift P: present care, wean from cpap as tol, document\napnea/bradycardia episodes\n#3 O: TF remain 100cc/k/d. presently 20cc/k/d NS piggybacked\ninto 70cc/k/d PN D18/IL via central PICC, enteral feeds\nstarted at 1300 at 10cc/k/d SSC20. oral pg, tol well. abd\nbenign, vdg per flow sheet, traces mec stools, hypoactive\nbowel sounds, girth stable. P: monitor DS, lytes tonight,\ntol to feeds.\n#4 O: temp cool after HUS this morning, stable this\nafternoon. HUS nl MD. /active, calmer w/ bili\nlights off. tol KC w/ mom for 75mins. P: cont to assess and\nsupport developmentally\n#5 O: mom here, updated, thrilled w/no bili lites and calmer\nbaby. held for 75mins. P: cont to support, involve, update.\n#6 O: bili 3.4/0.4- lites off at 0900. P: check rebound in\nmorning.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-01 00:00:00.000",
"description": "Report",
"row_id": 1981118,
"text": "Respiratory Care\nPt cont on prong CPAP. Fio2 .21, bs clear, rr 30-60 with mild retractions. On caffeine. 1 spell noted thus far this shift. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-02 00:00:00.000",
"description": "Report",
"row_id": 1981119,
"text": "RESPIRATORY CARE NOTE\nBaby received on CPAP 5 FiO2 21%. At hrs baby was taken off CPAP and palced in room air. RR 40-60's Breath sounds are clear. Three spells so far tonight since off CPAP. Baby is on caffeine. Stable in room air. Cont to follow\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-31 00:00:00.000",
"description": "Report",
"row_id": 1981111,
"text": "Nursing Progress Note\n\n7 alt in CV\n\n#1 O: nasal prong cpap 5cms/21% FiO2. Lungs clear/equal,\ncolor ruddy pink, RR 30's-60's w/mild baseline retractions.\none brady this shift w/prongs out, QSR. P: present care\n#3 O: TF 100cc/k/d via PICC, remains NPO for now. Presently\nhas PN D12/IL infusing at 80cc/k/d and NS at 20cc/k/d. lytes\nto be drawn at 1600 and will adjust fluids accordingly. abd\nbenign, vdg per flow sheet and passing mec stools. girth\nstable/ hypoactive bowel sounds. P: check lytes as ordered,\nadjust fluids, ? start feeds soon.\n#4 O: temp stable on servo in heated isolette, active and\nalert, sl. irritable. tol KC for 75mins w/o problems,\nsettles easily. pacifier to calm. P: HUS tomorrow.\n#5 O: family in, updated. mom held for 75mins, asking\nappropriate questions, very involved.\n#6 O: single bili lite w/eye shields in place. P: recheck\ntomorrow.\n#7 O: no murmur heard P: resolve.\n\nREVISIONS TO PATHWAY:\n\n 7 alt in CV; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-31 00:00:00.000",
"description": "Report",
"row_id": 1981112,
"text": "NP NOTE\nPE: small preterm ifnant neslted in isolette under phototherapy, pink well perfused on prong CPAP.\nAFOF sutures approxmated, eyes clear, ng in place, MMMP\nChest is symmetric with good exchange, mild ICR.\nCV: RRR, no murmur, pulses+2=\nAbd: soft,full, active bs\nGU: testes in canals\nEXT: PICC intact, PIV in place, MAE\nneuro: active wih good tone.\n\nMother updated at bedside.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-01 00:00:00.000",
"description": "Report",
"row_id": 1981113,
"text": "NPN 1900-0700\n\n\nRESP: Infant remains on nasal prong CPAP 5, FiO2 21%. LS\ndiminished to clear bilat. IC/SC retractions. O2 sats\n>90%. Sxn'd nares x1 scant amt clear secretions. CBG 2100:\n7.33/30/31/17/-9. 1 brady thus far this shift. HR 52; QSR.\nPt is on caffeine. Continue to monitor.\n\nFEN: BW 1345g CW 1275g (up 10g). TF 100cc/k/day. Pt\nremains NPO. PICC patent and infusing PND18 + IL at\n80cc/k/day; NS at 20cc/k/day. Abd soft, round, no loops,\nactive BS. AG=20.5-23cm. Voiding QS, mec stool x2. Lytes\nsent 2100: 127/5.5/96/13/24. Lytes to be repeated at 0500\nwith trig, BUN, Creat. DS= 92.\n\nDEV: Temps stable while nested in servo isolette. A/a with\ncares, sleeps well btwn. Irritable at times, settles well\nwith pacifier, moves hands to face. , , AGA.\n\nPAR: Mom called for update x2. Updated by this RN. Asking\napprop questions. Continue to support and update as needed.\n\nBILI: Infant under single photoRx for recent bili of\n3.9/0.4. Eye mask in place. Mec stool x2. Bili to be sent\nat 0500. Continue to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-14 00:00:00.000",
"description": "Report",
"row_id": 1981176,
"text": "NPN 1500-2300\n\n\n#1 RESP O: Infant remains on RA 02 sats >95%, BBS equal and\nclear, mild retractions, no desats or bradys this shift. A:\nALt in RESP P: cont to assess for increased wob, monitor and\ndocument all spells. Cont with Caffiene.\n#3 FEN O: Infant remains on TF 150cc/k/day of SC28 with\nBeneprotien via ngt feeds, well, one small spit, min\naspirates, voiding well, stooled heme neg. abd sl. full. A:\nalt in FEN P: cont to assess for increased feeding\nintolerence, wt q day.\n#5 PARENTING O: No contact from this shift. P: cont\nto inform and support family as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-15 00:00:00.000",
"description": "Report",
"row_id": 1981180,
"text": "Neonatology - discharge physical\n\nInfant active with good tone. AFOF. + red reflex OU. LIps, gums, palates. Chest symmetrical, breath sounds clear and equal. He is pink, well perfused, no murmur auscultated. Pulses of normal quality/character. Abd soft, active bowel sounds, no HSM. Normal male genitalia, testes in canal. Patent anus. Spine straight. Clavicles intact, hips stable. Stable temp in heated isolette. Plan today for transfer to Hospital. given report and ready for transfer. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-30 00:00:00.000",
"description": "Report",
"row_id": 1981105,
"text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is receiving course of indomethacin for presumed duct. He is comfortable on CPAP of 5, fio2 21%. Breath sounds clear and equal. He remains NPO. Abd soft, hypoactive bowel sounds, voiding 0.7cc/kg/hr, no stool overnight. Lytes today: Na-129, K-5.0 (hemolyzed), Cl-100, TCO2-12, BUN-48, creat-1.0. He remains under signle phototherapy. PN/IL infusing via intact PICC line in right leg. Stable temp in servo isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-15 00:00:00.000",
"description": "Report",
"row_id": 1981177,
"text": "NPN 11p-7a\n\n\n#1 In RA with sats 98-100%. BBS clear and =. Mild\nretractions present. On caffeine. No spells. A: breathing\ncomfortably in RA P: follow resp exam\n\n#3 TF's 150cc/k. Receiving 39cc of SC28+beneprotein on a\npump over 1hr 40mins. No emesis or residuals. Abdominal exam\nunremarkable. Voiding and stooling-heme neg. A: tolerating\nfeeds P: support nutritional needs\n\n#4 Temps 97.8-97.9x in off isolette while swaddled. Hat\nadded. Active and with handling. Sleeps well. Likes\npacifier. Repositioned with cares. A: aGa P: support\ndevelopmental needs\n\n#5 No parental contact thus far overnoc.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-15 00:00:00.000",
"description": "Report",
"row_id": 1981178,
"text": "Attending Note\nDay of life 21 PMA 31 \nin room air RR 30-60 sat 98-100% mild retraction\non caffeine no spells in 24 hour\nHR 130-160 BP 68/39 mean 46\nweight 1570 up 45 grams on 150 cc/kg/day of SSC 28 cal/oz with beneprotein pg over an hour 15 min\nvoiding and large heme negative stool\non iron and vit E\nMom visited and kangaroo care\n\nImp-infant making good progress\nwill continue to monitor for spells\nwill increase to 30 cal/oz today\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-15 00:00:00.000",
"description": "Report",
"row_id": 1981179,
"text": "NPN 7a-7p\n\n\n#1 Resp: Infant in room air with resp rate 30s-50s and sat\n100%. Lung sounds clear and equal with mild IC/SC\nretractions. No spells so far this shift. On caffeine. A:\nInfant stable in room air with no spells. P: Cont to\nmonitor.\n\n#3 FEN: TF 150 cc/kg of Special Care 28 w/beneprotein (39 cc\nq4h gavaged over 1 hr 40 min d/t spits). Will increase to 30\ncalories at next feeding. No spits, min asp. Abdomen pink\nand soft with active bowel sounds and no loops. AG stable,\n23-23.5 cm. Voiding and no stool so far this shift. On vit E\nand iron. A: Infant tolerating feedings well. P:Cont to\nmonitor and supp nutritional needs.\n\n#4 Dev: Infant swaddled in an off isolette, temp stable.\n and active during cares and sleeps well in between.\nQuiet during feedings and when held. A: Appropriate\nfor gestational age. P: Cont to supp dev needs.\n\n#5 : Mom in at 1300 for cares and was updated.\nChanged diaper, took temperature, and held infant.A:\nIndependent and very appropriate. P: Cont to supp and\nupdate.\n\nInfant will be transferred to Hospital Special Care\nNursery at 1500 by RN.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-30 00:00:00.000",
"description": "Report",
"row_id": 1981106,
"text": "NICU NSG NOTE\n\n\n#1. Resp. O/ Conts on Prong CPAP 5 in 21%. LS clear and\nequal. RR 30-60's. IC/SubC retractions. No spells. Last CBG\n7.31/27/46/14/-11. A/ Alt in resp status r/t prematurity. P/\nCont to monitor resp status closely. Monitor for increased\neffort/support. Plan for repeat CBG this eve.\n\n#3. FEN. O/ TF decreased to 120cc/k/d. Last Na 125. Fluids\nare PN D12 with IL at 100cc/k/d. NS at 20cc/k/d. Infant has\na central PICC. UO 1.2cc/k/h thus far thi sshift. No stool.\nAbd exam benign. NPO. DS 93. A/ Alt in FEN r/t prematurity.\nP/ Repeat lytes this eve. Monitor closely. UO improving s/p\nlast dose indo.\n\n#4. G&D. O/ Awake and alert with cares. Temps stable in\nservo isolette. MAE. Nested on sheepskin. Cares\nclustered.Kangaroo'd x1h today. A/ AGA. P/ Cont to support\ndevelopmental needs of infant.\n\n#5. Parenting. P/ Mom and dad in for cares. Updated at\nbedside. Mom changed diaper and took temp. Mmo kangaroo'd\ninfant. A/ Updated and involved. P/ Cont to provide info and\nsupport to family.\n\n#6. Bili. Remains under single phototherapy with eye shields\nin place. NPO. No stool. Hyperbili of prematurity. Repeat\nbili in am.\n\n#7. CV. O/ Pink and well perfused. No PDA by ECHO. No\nmumrur. BP 66/43 (51). Nl pulses. Last dose indo at 1300\ntoday. A/ Stable. P/ Cont to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-31 00:00:00.000",
"description": "Report",
"row_id": 1981107,
"text": "NPN:\n\nRESP: CPAP 5cm, 21%. Sats 98-100%. RR=40-50s with SC/IC retraction. BBS =/clear. CBG(22:30): 7.28/30/43/15/-11; notified. No A&Bs thus far tonight; none over past 24 h. Remains on Caffeine.\n\nCV: No murmur. HR=130-140s. BP=54/29 (37). Color pink w/jaundice. Perfusion good. Hct=38.8 ().\n\nFEN: Wt=1265g (+ 50g). TF=100cc/kg/d (fluids decreased from 120->100cc/kg/d due to Elec results). PN(D-12) and IL infusing well via central PICC line. Dx=92. Elec(22:30): 126/4.9/98/10. Elec to be rechecked at 0800. Abd soft, rounded, active bs, no loops. U/O=1.4cc/kg/h over 24-h period yesterday; ~ 2.4cc/kg/h over past 4 h. No stool for ~ 3.5 days.\n\nBILI: Single phx. Bili 5.6/0.4 ().\n\nG&D: CGA=29-4/7 wk. Temp stable in servo-controlled isolette. Active and sl irritable w/cares. Nested in sheepskin and resting well. Sucks on pacifier intermittently. HUS on .\n\nSOCIAL: No contact w/.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-31 00:00:00.000",
"description": "Report",
"row_id": 1981108,
"text": "Respiratory Care Note\nPt. continues on 5cmh2O of nasal prong CPAP and 21%. BS clear. On Caffeine. No spells documented thus far. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-13 00:00:00.000",
"description": "Report",
"row_id": 1981172,
"text": "1. remains in RA, color pink, BS clear, RR 40-70,\nic/sc retractions, on caffeine, please see flow sheet for\nspells.\n3. TF 150cc/k/d SC28 with benepro 38cc over 1h 40 min. no\nspits, 2cc max aspirate, abd soft, no loops, active bowel\nsounds, voiding and passing guiac neg stool, on vitamin e,\nferinsol.\n4. temps sl warm in air heat isolette, removed one blanket\nand weaned isolette temp x1, swaddled with sheepskin, loves\nto suck on pacifier and very and active with cares.\n5. here, Mom kangaroo' for ~2h, planning to\ngo back to work next wk and requesting care times of 08 12 4\nif possible. continue to update and offer support.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 1981098,
"text": "Rehab/OT\n\nInfant seen for OT observation. Noted infant strengths, stress signals, and ways to maximize infant comfort. Discussed findings and the role of OT / developmental care. Care plan placed at the bedside. OT to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-29 00:00:00.000",
"description": "Report",
"row_id": 1981099,
"text": "Respiratory Care\nPt received on nasal prong CPAP +5cm's with the fio2 21%. Pt's resp rates 30's to 60's with clear B/S. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-14 00:00:00.000",
"description": "Report",
"row_id": 1981173,
"text": "NPN:\n\nRESP: Sats 97-98% in RA. RR=50-60s with SC retraction. BBS =/clear. No A&Bs thus far tonight; x 1 over past 24-h period. Caffeine.\n\nCV: No murmur. HR=160-170. BP=73/41 (51). Color pale pink w/good perfusion. Hct=33 ().\n\nFEN: Wt=1525g (+ 5g). TF=150cc/kg/d; 38cc SSC-28 w/beneprotein q 4 h via gavage over 100 minutes. Abd benign. No spits. Voiding; no stool since yesterday. FeS04 and Vit E.\n\nG&D: CGA=31-4/7 wk. Temp stable in air-controlled isolette; weaning isolette temp. Active and w/cares. Swaddled and nested in sheepskin. Resting well.\n\nSOCIAL: No contact w/.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-14 00:00:00.000",
"description": "Report",
"row_id": 1981174,
"text": "Attending Note\nDay of life 20 PMA 31 \nin room air RR 50-60 mild retractions\non caffeine 4 spells in 24 hour all QSR or mild stim\nHR 160-180 BP 73/41 mean 51\nweight 1525 up 5 grams on 150 cc/kg/day of SSC 28 cal/oz with beneprotein pg\nstable girth\nvoiding but no stool overnight\non vit E and iron\nin off isolette\nparent visit daily\n\nImp-stable currently\nRESP-stable making progress. Will monitor for spells\nFEN-will monitor weight gain on current calories\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-14 00:00:00.000",
"description": "Report",
"row_id": 1981175,
"text": "NPN 7p-7a\n\n\n#1 Resp: Infant in room air with resp rate 30s-70s and sat\n95-100%. Lung sounds clear and equal and mild IC/SC\nretractions. No spells so far this shift. On caffeine. A:\nInfant stable in room air with no spells. P: Cont to\nmonitor.\n\n#3 FEN: TF 150 cc/kg of Special Care 28 w/beneprotein (38 cc\nq4h gavaged over 1h 40 min). One small and one medium spit.\nMax asp 4.2 cc. Abdomen pink and soft with active bowel\nsounds and no loops. AG stable, 23 cm. Voiding and heme\nnegative stool. On vit E and iron. A: Infant tolerating\nfeedings well w/occasional spit. P: Cont to support\nnutritional needs.\n\n#4 Dev: Infant swaddled in an off isolette. Temp 100.3\ndegrees at 0900-sheepskin and extra blanket removed. Temp\n99.1 at next care. and active during cares and sleeps\nwell in between. A: Appropriate for gestational age. P: Cont\nto support developmental needs. Possible trial in open crib\npending temp at next care times.\n\n#5 : Mom in at 1300 to kangaroo infant. Dad in at\n1400. updated. A: Independent and appropriate with\ncares. P: Cont to support and update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-30 00:00:00.000",
"description": "Report",
"row_id": 1981100,
"text": "NPN\n\n\n#1/#7\nInfant remains on nasal prong CPAP 5cm; 21% with sats >94%.\nBS clear= with mild retractions. Color is pink and sl.\njaundiced. Murmer not audible. Good perfusion noted; quiet\nprecordium. Infant has had one spell tonight to 50s that\nwas SR. Infant received his second dose of Indocin as\nordered. BP has been stable.\n\n#3\nInfant remains on TF=130cc/k. NPO. Wt is up 50gms-1215.\nPICC intact with PN D10W and lipids infusing as ordered.\nDS=69. HL flushed and is patent. Abd is soft and full;\nsoft intermittent loops noted; active BS; no stool. Urine\noutput is slowly decreasing (~2.4cc/k over past 24 hours;\n.8cc/k over the last 6 hours). Labwork drawn-please see lab\nsheet.\n\n#4\nInfant remains in a heated isolette on servo; temp has been\nstable. Infant is alert and irritable with cares; does suck\non the pacifier; quiet once cares are complete. Nestled in\nsheepskin with boundaries.\n\n#5\nMom called x1 last evening for an update. She plans to\nvisit this afternoon.\n\n#6\nInfant remains under single phototherapy with eyes covered.\nBili this am: 5.6/0.2/5.4\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-30 00:00:00.000",
"description": "Report",
"row_id": 1981101,
"text": "Respiratory Care Note\nPt. continues on 5cmH2O od nasal prong CPAP and 21%. BS clear. On Caffeine. One documented spell thus far. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-30 00:00:00.000",
"description": "Report",
"row_id": 1981102,
"text": "Attending Note\nDay of life 5 PMA 29 3/7\nCPAP 5 FiO2 21% RR 30-50 clear breath sounds two-three spells in the past 24 hours on caffeine\nCV intermittent murmur not heard today getting indocin HR 130-150 BP 69/33 mean 48\nweight 1215 up 50 grams on 130 cc/kg/day NPO getting PN and Il via PICC\nsoft abodomen with stable girth\nvoiding down from 2.4 to 0.7 cc/kg/hr this am and stooled once\nNa 129 K 5.0 Cl 100 CO2 12 BUN 48 Cr 1.0 D stick 69\nbili 5.6/0.2 on single photo\nstable temp\n\nIMP-infant in stable condition\nRESP-will continue to on CPAP. Will check a CBG today.\nCV-He is being treated for PDA. will have duct check today. Will consider a second course of indocin if PDA still present\nFEN-will increase to Na in the PN today. Will decrease the protein in the PN. Will repeat the lytes this afternoon.\nRENAL-urine output down likely due to indocine. Will follow clinically. will repeat the BUN and Cr later today.\nGI-will continue phototherapy for now. Will plan to recheck bili in am.\nHEME-will check recheck hct on tomorrow\nNEURO-will have a head ultrasound on Thursday\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-30 00:00:00.000",
"description": "Report",
"row_id": 1981103,
"text": "Case Management Note\nChart has been reviewed and I am following for any d'c planning needs along with team & family. EIP & VNA options have been placed in record. I will cont to follow\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-30 00:00:00.000",
"description": "Report",
"row_id": 1981104,
"text": "Respiratory Care\nPt received on nasal prong CPAP +5cm's with the fio2 21%. Pt's resp rates 30's to 50's on caffine with clear B/S. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-25 00:00:00.000",
"description": "Report",
"row_id": 1981064,
"text": "Neonatology Attending Admission Note\n\nHistory, exam and management plan reviewed with Dr. , MD. History as stated above. I would add:\n- prenatal screens: O+, antibody negative, RPR NR, RI and GBS unknown,\n- maternal medical history of cervical dysplasia requiring cryo in ,\n- maternal medications included lexapro, zantac, and zofran\n\nPerinatal sepsis risk factors include: prematurity and unknown GBS status.\n\nInfant emerged with good tone and spont cry but failed to consistently establish respirations. Routine drying, suctioning and stimulation provided with only some improvement. PPV given with improvement and establishment of regular respirations. Due to increased work of breathing and poor aeration electively intubated in the delivery room. Apgars 6,8.\n\nExamined infant myself and agree with above. Exam significant for poor bilateral aeration and retractions, and pallor of right leg in the DR , with steady improvement and the leg is currently pink and symmetrical in color and perfusion with other leg. Right leg always had good peripheral pulses.\n\nStudies:\nCBC w diff, bld cx pending\nFirst d/s 43 --> rec;d D10w 2ml/k x 1 dose, repeat pending\nBabygram requested\n\nImpression/Plan:\n1. Preterm male newborn\n2. AGA\n3. RDS\n4. r/o sepsis\n5. Hypoglycemia\n\nPlan as stated above. Will keep family updated.\n\nOB: service, delivered by Dr. \nPedi: Dr. , .\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-25 00:00:00.000",
"description": "Report",
"row_id": 1981065,
"text": "Umbilical Line Placement\nPt was identified by wrist band and under sterile conditions umbilical arterial and venous lines were placed. A size 5Fr double lumen catheter was irrigated with heparinized normal saline in both ports and was then advanced into the umbilical venous line and a free flow of blood was obtained at the level of 5.5cm. The catheter secured in place with a suture. A size 3.5Fr single lumen catheter was irrigated with heparinized normal saline and was advanced into the umbilical artery and a free flow of blood was obtained at 13cm length. The catheter secured in place with sutures. An abdominal-chest film was ordered and the tip of the umbilical arterial line is high in the T7-T8 area. The tip of the umbilical venous line was in the liver. So the umbilical venous line removed. There are no immediate or late complications.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-25 00:00:00.000",
"description": "Report",
"row_id": 1981066,
"text": "Respiratory Care Note\n28 week infant delivered via C-section - intubated in delivery room for respiratory distress - #2.5ETT secure at 7.5cm at lip - CXR confirms placement - BS coarse, sx'd for sm-mod white secretions - given 5.4cc's Survanta at 1200 in 4 aliquots, tol well. Noted to have periods of apnea at times on ventilator. Current settings 20/5, R25 - CBG at 1320 was 7.28/46/43/23/-4 with no changes made. Follow blood gases, wean as tolerated - continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-04 00:00:00.000",
"description": "Report",
"row_id": 1981131,
"text": " PHysical Exam\nPE: pink, mild jaundice, AFOF, sutures slightly override, nasal septum pink, with scab, seems to be healing well, breath sounds clear/equal with mild retracting, no murmur, well perfused, abd soft, non distended, + bowel sounds, PICC right ankle with intact dressing, no redness, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-12 00:00:00.000",
"description": "Report",
"row_id": 1981167,
"text": "Clinical Nutrition:\nO:\n~31 week CGA BB on DOL 18.\nWT: 1495g(+15)(25-50 %ile); BWT: 1345g. Average wt gain over past week ~11g/kg/day.\nHC: N/A\nLN: N/A\nMeds include Fe & Vit.E\nLabs not due yet.\nNutrition: 150cc/kg/day as SSC 26 w/ beneprotein(replacement for promod); pg over 70mins. Projected intake for next 24hrs ~150cc/kg/day, providing ~130kcal/kg/day & ~4.3g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds over extended feeding times w/o GI problems; pg fed. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is not yet meeting recs of ~15-20g/kg/day for WT gain; feeds advancing. HC/LN measurements N/A for comparison. Will cont. to follow w/ team & participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-12 00:00:00.000",
"description": "Report",
"row_id": 1981168,
"text": "0700- NPN\n\n\nRESP: Infant is in a nasal cannula, 100cc/min flow and 21%\nfi02. RR 40s-50s, 02 saturation 96-100%. Lung sounds\nclear/=, mild SC/IC retractions noted. No bradys or desats\nas of this writing. Plan to trial out of nasal cannula later\nthis shift.\n\nFEN: TF 150cc/kg/d SC26 with beneprotein = 37cc q4hrs pg'd\nover 1hr 10min. No spits, max aspirate 4cc (nonbilious).\nAbdomen soft, round, active BS. Voiding and stooling, guiac\nnegative.\n\nDEV: Temps stable, nested with sheepskin in servo control\nisolette. MAE, fontanels soft and flat. and active\nwith cares, sleeping between cares. Brings hands to face for\ncomfort. AGA.\n\nPARENTING: Mom was in at 1300 and kangaroo'd infant for\nabout 2hrs. Dad was in as well, near the time that Mom was\nfinishing kangaroo'ing. are appropriate and\ninvested.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-13 00:00:00.000",
"description": "Report",
"row_id": 1981169,
"text": "NPN 1900-0700\n\n\n#1: O: Infant remains in RA, maintaining sats 96-100%. RR\n40's-60's with mild ic/sc retractions. LS c/=. Infant has\nhad one spell so far this shift. Continues on caffeine. A:\nStable in RA. P: Continue to monitor.\n\n#3: O: Current weight 1520g (+20g). Tf 150cc/kg/day of sc26\nwith beneprotein, 38cc q4 hours gavaged over 80min. Abdomen\nbenign, voiding, no stool so far this shift. Max aspirate\n4cc. One small spit. Infant started on iron and vitE. A:\nTolerating feeds. P: Continue with current feeding plan.\n\n#4: O: Temp stable in servo isolette. Infant is and\nactive with cares, sleeps well in between. Brings hands to\nface for comfort and sucks pacifier when offered. Remains\nnested in sheepskin. A: AGA. P: Continue to support growth\nand development.\n\n#5: O: No contact.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-13 00:00:00.000",
"description": "Report",
"row_id": 1981170,
"text": "Attending Note\nDay of life 19 PMA 31 \nin room air since yesterday RR 40-60 mild retractions on caffeine\n3 bradys last night (4 in 24 hours) all during feeding one required BBO2\nHR 160-170 BP 68/24 mean 39\nweight 1520 up 25 grams on 150 cc/kg/day of SSC 26 cal/oz with beneprotein all pg\nvoiding and stooling heme negative\non vit E and iron\nin servo isolette\nactive with cares\n visit daily\n\nImp-stable currently\nRESP-will monitor for spells\nFEN-will advance to 28 cal/oz\nWill wean isolette as tolerated\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-13 00:00:00.000",
"description": "Report",
"row_id": 1981171,
"text": "Neonatology - Progress Note\n\nInfant is active with good tone. AFOF. He is pink, well perfused, no murmur auscultated. He is comfortable in room air, breath sounds clear and equal. He is tolerating enteral feeds, abd soft, active bowel sounds, voiding and stooling. Stable temp in servo isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-25 00:00:00.000",
"description": "Report",
"row_id": 1981063,
"text": "Admission Note\nInfant is a 1345 grams male born to a 35 years old female at 28 5/7 weeks of gestation due to premature labor and fetal bradycardia by C-sesction.\n\nMother is a 35 years old female G3 P1. EDC . GA at delivery 28 5/7 weeks. Prenatal screens: O positive and antibody negative. HBsAg, RPR, Rubella and GBS status unknown at the time of delivery. She presented to L&D with strong uterine contractions and has received only one dose of Betamethasone before delivery. A son done revealed of 50% and normal male fetus. She started to have continued contractions and fetal bradycardia was observed so a decision to do a stat C-section was made.\n\nMother's antenatal history is significant for anemia only. she is on Iron supplementation.\n\nThe baby boy has scores of 6 at one minute and 8 at five minutes. He was given routine care and BMV ventilation followed by Endotracheal intubation and was borught to the NICU on ETT and PPV. The delivery room PE was remarkable for pallor of the right lower limb.\n\nPhysical Examination:\nWeight: 1345 gms (50-75%), Length: 40 cm (75%) and HC 27 cm (75%)\nGeneral: Pink except for some residual pallor of the right foot.\nHEENT: AFOF and small. No caput or head molding. Sutures normal. No dysmorphism. No cleft lip or palate. Nares patent. Oral mucosa moist and ears normal. PERLA and normal red reflex B/L. Neck supple with intact clavicles.\nResp: Endotracheal tube in place. No 2.5 and lip mark is at 7cm. On mechanical ventilation. SIMV 25, PIP 15, PEEP 5 and FiO2 30%. O2 sat >95%. CTA and good and equal aeration B/L.\nCardiac: HR 140-160s, BP 53/19 (32). Normal S1 and S2 with no added sounds. Full femoral pulses B/L.\nAbdomen: Soft non distended. No masses and BS present. Anus seems patent\nGU: Normal male external genitalia. Testes undescended B/L.\nSpine: No sacral anomalies\nExtrem: Warm and pink except for some residual pallor of the right foot.\nMetabolic: D-stick 43\n\nImpression:\n1. Prematurity at 28 5/7 weeks GA\n2. RDS/HMD\n3. R/O Sepsis\n\nPlan:\nContinuous cardio-respiratory monitoring.\nResp: Continue ETT and SIMV as described. Administor surfactant and a CXR to confirm the tube position and to assess for HMD. As infant weans from ventilator monitoring for development of AOP.\nCardiac: Monitor BP and also for the development of a PDA.\nFEN: NPO. Umbilical lines. D10 W @ 50ml/kg and PN @ 50 ml/kg. Monitoring of Dextrosticks. Close monitoring of fluid and electrolyte status.\nID: CBC and Blood culture for evaluation of sepsis and start Ampicillin and Gentamicin empirically with duration pending lab results and clinical status\nMetabolic: Maintain temperature and glucose levels\nNeuro: Initial HUS screening as < 32 weeks GA will be needed in days\nEye exam: GA 28+ weeks so need an eye exan for ROP in week .\n\nD/W Dr \n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-03 00:00:00.000",
"description": "Report",
"row_id": 1981128,
"text": "Neo Attending\nDay 9 now 30 wk pma\nrespr: off CPAP due to nasal septum excoriation, black scab vs. necrotic area. No inflammation. appears more like scab today.\nOn CPAP, infant had some spells. 7 spells (HR in 40 50s, desaturations to 80s; apnea in passed. On RA. On caffeine. Maintenance caf at 8 cc/kg/day.\n\ncv: No murmur; mbp 45.\nwt 1355 gm , up 15 gm\nTF 140 cc/kg/day.\ns/p low Na. Now corrected to 140. remainder of lytes wnl.\nOn TPN/IL + enteral feeds at 20 cc/kg/day. Advance 20 cc/kg/day.\nNeeds to stool.\nUOP was decreasing over night, but overall uop = 2 cc/kg/hr.\nbili lights off . bili 5.1/0.3 today.\nHUS wnl.\n, stable.\n\nAssessment: Nasal and spell issues at noted above.\nContinue to monitor apnea. Fluids continue at 100 cc/kg/day. Follow UOP and wt. Lytes, bili am. Follow nasal septal recovery.\n\nPt examined and discussed with team.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-03 00:00:00.000",
"description": "Report",
"row_id": 1981129,
"text": "Nursing Progress Note\n\n\n#1 O: remains in room air w/sats 93-100%, lungs cl/=, RR\n50's-70's w/mild sc/ic retractions. bradys in clusters this\nmorning, none this afternoon. nasal septum w/scabbed/?eschar\narea- watching. Caffeine as ordered. A: nasal breakdown>\ncpap would be difficult. P: monitor for inc\napnea/bradycardias.\n#3 O: remains fluid restricted 100cc/k/d; presently 30cc/k/d\nenteral feeds SSC20 and increasing by 10cc/k/ as . IV\nPN D17/IL infusing via central PICC. abd benign, vdg per\nflow sheet, needs to stool, girth stable. P: present care,\nadv as .\n#4 O: temp stable on servo/heated isolette, and active\nw/cares, pacifier to calm, KC for 2h w/dad and well. P:\npresent care to support developmentally\\\n#5 O: family in to visit, dad held for 2hours, updated at\nbedside. A: involved P: support.\n#6 O: jaundiced, bili 5.1/0.3, no stool P: check bili in\nmorning, lites as needed.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-04 00:00:00.000",
"description": "Report",
"row_id": 1981132,
"text": "NICU Attending Note\n\nDOL # 10 = 30 1/7 weeks PMA with resolving HMD, A/B, issues of fluid and nutrition. Agree with full .\n\nCVR/RESP: RRR without murmur, skin pink and well perfused, mild retractions, BS clear/=, remains off CPAP with nasal septum recovering nicely, on caffeine, A/B of prematurity x 3 in last 24 hours. Some O2 sat drifts this am, placed in nasal trough O2, 400 cc/min flow, 100% FiO2. Not using cannula due to nasal septum injury. Will continue to monitor, supplemental O2 as needed.\n\nFEN: Abd benign, weight today 1385 gm, up 30 gm, (BW 1345), 100 mL/kg/day, fluid restricted due to decreased u/o s/p indo. On enterals at 50 mL/kg/day, remainder PN/IL. Voiding, no stool x 3 days. u/o had been up to 2 mL/kg/hour, now back down to 1 mL/kg/hour. Lytes this am 137/6.2 (hemolyzed)/104/23/37/1. Will continue with TF of 100 mL/kg/day for now, probably liberalize tomorrow, continue to advance by 10 mL/kg , recheck lytes in 48 hours.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-04 00:00:00.000",
"description": "Report",
"row_id": 1981133,
"text": "Nursing Progress Note\n\n\n#1 O: received in room air w/sats 89-93%, started having\ndrifts to 80's this morning, not coming up on own. placed on\nnasal trough 400cc>100cc flow/100% to keep sats >88. unable\nto use regular cannula d/t nasal septum breakdown/healing.\nLungs clear/equal, color pink/jaundiced. RR 50's-80's w/mild\nbaseline sc/ic retractions. Caffeine as ordered, cont to\nhave bradys w/apnea - see flow sheet. A: mild O2 requirement\nP: wean as . monitor a's and b's.\n#3 O: TF remain 100cc/k/d iv/pg. Enteral feeds SSC20\npresently 50cc/k/d ad adv. by 10cc/k/ as . IV PN/IL\nvia central PICC infusing at 50cc/k/d. abd benign, vdg per\nflow sheet, no stool. A: doing well w/adv feeds, not as dry\nas last night. P: adv as , ? start basing weight on\npresent weight vs. birth weight.\n#4 O: kc w/dad for 2hours and well, w/cares,\npacifier to settle, temp stable on servo. P: cont to assess\nand support developmentally.\n#5 O: mom/dad in to visit, dad held for 2hours, asking\nappropriate questions. very loving w/baby P: cont to update\nand support.\n#6 O: still sl. jaundice P: one last check w/next lytes\ntomorrow. glycerine suppos. to encourage stooling\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-04 00:00:00.000",
"description": "Report",
"row_id": 1981130,
"text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS IN RA WITH SATS 91-95%. RESP RATE 50-76 WITH MILD\nIC/SC RETRACTIONS. HAS HAD ONE BRADY AND ONE DESAT\nOVERNIGHT.\nA:STABLE, FEW SPELLS\nP:CONTINUE TO MONITOR CLOSELY\n\n#3F/E/N\nO:TF AT 100CC/KG. ENTERAL FEEDS AT 40CC/KG=9CC Q4HR PG. IVF\nD16PN AND IL VIA PICC IN LEG INFUSING WELL AT 60CC/KG.\nABDOMEN SOFT, FULL WITH GOOD BS. NO LOOPS AND NO SPITS. AG\n21.5-22.5CM. DS 105. LYTES THIS AM 137/6.2/104/23, BUN 37\nAND CR 1.0-- NOTIFIIED OF LABS RESULTS AS WELL AS LOW\nU/O.\nA:STABLE, LOW U/O\nP:CONTINUE TO MONITOR LYTES CLOSELY, FOLLOW U/O AND WT.\nCONTINUE TO ADVANCE 10CC/KG AS TOLERATED\n\n#4G&D\nO:IN SERVO CONTROL ISOLETTE WITH STABLE TEMPERATRUE\n(SLIGHTLY HIGH X1 WITH LOOSE PROBE COVER). BABY NESTED ON\nSHEEPSKIN W/BOUNDARIES. ACTIVE/MAE WITH CARES; SLEEPING WELL\nBETWEEN. FONTANEL SOFT AND FLAT; ANT SUTURE SMOOTH,\nPOSTERIOR OVERRIDING\nA:AGA\nP:CONTINUE TO SUPPORT AND MONITOR\n\n#5PARENTING\nO:MOM X1 FOR UPDATE\nA:INVOLVED, INVESTED \nP:CONTINUE TO SUPPORT,EDUCATE AND KEEP UP TO DATE. WILL BE\nIN AT 0900\n\n#6BILI\nO:SECOND REBOUND THIS AM 5.4/0.3. PROBLEM D/C'D\nA:PROBLEM RESOLVED\nP:D/C PROBLEM\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-26 00:00:00.000",
"description": "Report",
"row_id": 1981071,
"text": "Attending Note\nDay of life 1 PMA 28 \ns/p SIMV and single surf dose now on CPAP 6 FiO2 21% RR 50-70\non caffeine with no spells\nHR 120-140 MBP 33-41 BP 57/25 mean 36\nweight 1345 at birth on 100 cc/kg/day all UAC 1/2 NS and PIV with starter PN and D 10 W NPO abdomen benign\nD stick 111\nvoiding but no stool\non amp/gent blood cultures pending\non warmer active and alert\nmom visits\n\nImp-making progress\nwill continue CPAP\nwill monitor for spells\nwill monitor for signs of a PDA\nwill have a lytes and bili at 24 hours today\nwill keep total fluids at 100 cc/kg/day\nwill plan to d/c UAC today\nwill plan for amp/gent for 48 hours\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-26 00:00:00.000",
"description": "Report",
"row_id": 1981072,
"text": "NPN 0700-1500\n\n\n#1 O: Received infant on prong CPAP of 6cm. FIO2 21%. RR\n30's-60's with mild IC/SC retractions. LS clear and =. No\na's or b's this shift. On caffeine. A: Stable on CPAP. P:\nCont to monitor.\n\n#2 O: On amp and gent as ordered. Active and alert with\ncares. A: No obvious s/s of sepsis. P: Cont to monitor.\n\n#3 O: TF= 100cc/kg/d. Infant NPO. Receiving IVF of starter\nTPN D10 and plain D10 infusing via PIV both at 2.3cc/h. UAC\nremains in place infusing 1/2 NS with 1/2 u hep/cc at\n1.0cc/h. Abdomen flat, soft and pink. Hypoactive BS. UO=\n3.8cc/kg/h in last 8h. No stool. DS 111, 106. Lytes, bili\nand trig drawn at 24h; pending presently. A: NPO. P: Cont to\nmonitor.\n\n#4 O: Maintaining temp on heated isolette set in servo mode.\nNested in sheepskin with boundaries in place. Waking with\ncares; opening eyes and looking around at times. AFSF.\nSettles nicely when placed prone. Offered pacifier but not\ninterested. Does bring hands to face for comfort. A: AGA. P:\nCont to support development.\n\n#5 O: Both parents in to visit; updated by this RN and MD\nthis am. ASking appropriate questions. Touching infant and\nquietly talking to him. A: Involved, loving. P: Cont to\nsupport and update.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-26 00:00:00.000",
"description": "Report",
"row_id": 1981073,
"text": "Case Management Note\nChart has been reviewed and events noted. EIP & VNA options placed in record. I will cont to follow along and assist w/any d'c palnning needs along with team & family\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-26 00:00:00.000",
"description": "Report",
"row_id": 1981074,
"text": "Respiratory Care Note\nInfant received on NCPAP +6, 21% - remains in prong CPAP - RR's 30's-40's, BS clear, no distress noted - on caffeine, no spells thus far this shift. Continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-08-26 00:00:00.000",
"description": "Report",
"row_id": 1981075,
"text": "Clinical Nutrition:\nO:\n28 week gestational age BB, AGA, now on DOL 1.\nBWT: 1345g(~75th %ile).\nHC @ Birth: 27cm(50-75th %ile)\nLN @ Birth: 40cm(~75th %ile)\nNutrition: TF @ 100cc/kg/day. NPO. Starter PN D10 & IVF's D10W infusing via PIV until PN is atarted later. Projected intake for next 24hrs from PN ~44kcals/kg/day & ~2.5g pro/kg/day. Glucose infusion rate from PN ~6.9mg/kg/min.\nGI: Abd benign.\n\nA/Goals:\nRemains NPO. UAC D/C'd. UAC placement failed. Starter PN & IVF's infusing via PIV as described above. Initial goal for PN ~90-110kcal/k/day, ~3-3.5g pro/kg/day & ~3g fat/kg/day. Advancing per protocol. Limitations may preclude being able to deliver adequate nutrition from PN via PIV. When able to start EN feeds, initial goals are ~150cc/kg/day BM/SSC 24 providing ~120kcal/kg/day & ~3.2-3.3g pro/kg/day. Further advances as per growth & tolerance. Appropriate to start Fe & Vit.E 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 nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-05 00:00:00.000",
"description": "Report",
"row_id": 1981137,
"text": "Nursing Progress Note:\n\nRESP:\nO: Infant cont in NC 500cc/ 45-55% FiO2. 5 a/b spells noted\nso far this shift; most QSR. RR 30-60's. Sats remaining\n91-98%. LS clear and equal. Mild SC/IC retractions noted at\nbaseline. Infant cont on caffiene. Color remains pink/ sl\njaundiced.\nA: O2 requirement continues.\nP: Cont to support adequate oxygenation. Cont caffiene as\nordered.\n\nFEN:\nO: TF 100cc/kg: enteral feeds advanced to 70cc/kg of SC 20\n(=17cc) Q4H, and IVF at 30cc/kg of D15 (1.3cc/hr) and IL\n(.5cc/hr). TF now based on current weight. Abdomen soft,\nround, +BS, no loops. Girth 21.5cm. Minimal aspirates. No\nspits. Infant voiding and has not yet stooled this shift.\nA: Tolerating feeds well.\nP: Cont to advance enteral feeds 10cc/kg as ordered.\n\nDEV:\nO: Temps stable; nested in a servo isolette. Font s/f.\nInfant a/a with cares; not yet waking prior. Tone within\nnormal limits. Infant brings hands to face. Settles well\nwith firm boundaries. Kangarooed with mom x2hrs; tolerated\nwell.\nA: AGA\nP: Cont to support development.\n\nSOC:\nO: Mom in to visit for 1300 cares. Updated regarding\ninfant's status and plan of care by this RN. Mom independent\nwith temp and diaper change. Kangarooed infant well;\nresponding well to infant cues. Asking appropriate\nquestions. Dad in to visit between cares. desire\ncircumcision at appropriate time. Mom will be back tomorrow\nfor 1300 cares.\nA: bonding well with infant.\nP: Cont to support, educate and keep informed.\n\nBili:\nO: Rebound this am 5.3/0.4. No phototherapy. Presents as\npink/ sl jaundiced.\nA: Issue now resolved.\nP: Will follow clinically.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-06 00:00:00.000",
"description": "Report",
"row_id": 1981138,
"text": "NPN\n\n\nNPN#1 O= remains on high flow NCO2 500cc in mostly 35-40%\nFIO2 with sats 92-97%, RR= 40's-60's, LS clear & equal bilat\nwith mild IC/SCR..occ ^ WOB after cares but settles, sxn'd\nx1 for mod THY plugs from nares, x2 spells overnight ( x9 in\nlast 24hrs), cont on caffeine as ordered A= less spells\novernight/ cont on high flow O2 P= cont to monitor\n#/severity of spells, follow WOB , wean O2 as , cont plan\nof care\n\nNPN#3 O= WT= 1420 ^35gms, TF at 100cc/kg/d ( fluid\nrestricted).. enteral feeds adv to 80cc/kg/d of SC20\nq4hrs.. well, min asp AG= 21.5-22.0, abd exam softly\nrounded +active BS, no loops, adv feeds by 10cc/kg/..IVF\nPND14 infusing well via PIC..lipids d/c'd as ordered , no\nstool overnigh, ou= 2.4cc/kg/last 24hrs, no labs overnight\nA= feeds P= cont with feeding plan as ordered, I & O's\n\nNPN#4 O= remains on servo in heated isolette with stable\ntemp, AF soft & flat, active & with cares, good tone,\nnested in sheepskin with boudaries in place A= behaviors app\nfor GA P= cont to assess & support dev needs\n\nNPN#5 O= mom called x1 overnight..asking app questions/\nupdated provided..no further contact thus far this shift,\nmom states will be in for today's1300 cares A= involved mom\nP= cont to teach/ update & support\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-01 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 920733,
"text": " 7:07 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: r/o IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 28 5/7 weeks, now 1 week old\n REASON FOR THIS EXAMINATION:\n r/o IVH\n ______________________________________________________________________________\n FINAL REPORT\n HEAD ULTRASOUND: This is our initial head ultrasound on this baby born at 29\n weeks, now 1 week old.\n\n Scans through the anterior fontanelle with limited views through the mastoid\n foramen did not demonstrate any abnormalities. There is no evidence of\n intraventricular hemorrhage or ventriculomegaly.\n\n IMPRESSION: Normal head ultrasound.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-27 00:00:00.000",
"description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT",
"row_id": 920179,
"text": " 4:26 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: line placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with Prematurity and new PICC line\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AND ABDOMEN ON AT 15:27 HOURS\n\n CLINICAL HISTORY: Infant with prematurity and new PICC line placement.\n\n FINDINGS: A supine portable radiograph of the chest and abdomen is compared\n to the prior babygram obtained on at 13:28 hours. The endotracheal\n tube and umbilical arterial catheter have been removed. There is now an NG\n tube with its distal tip in the stomach and a right femoral line with its\n distal tip at the level of L5-S1, probably within the right external iliac\n vein. Heart size is normal. The lungs are mildly hyperinflated. There is a\n mild-to-moderate ground-glass appearance of the lung parenchyma bilaterally,\n significantly improved compared to the prior study. There is mild-to-moderate\n gaseous distention of bowel loops, increased compared to the prior study.\n However, there is no radiographic evidence of obstruction, pneumatosis, or\n perforation.\n\n IMPRESSION:\n 1. Significant improvement in bilateral lung aeration since the prior study.\n 2. Right-sided PICC line, probably within the external iliac vein.\n 3. Mild-to-moderate gaseous distention of the bowel as described above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-25 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 919877,
"text": " 12:11 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: r/o rds\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n premature infant, respiratory distress, intubated.\n REASON FOR THIS EXAMINATION:\n r/o rds\n ______________________________________________________________________________\n FINAL REPORT\n Prematurity, respiratory distress. Day of life zero. Film demonstrates a\n nasogastric tube reaching approximately one vertebral body above the carina.\n The lung volumes are moderate and there are diffuse reticular, granular\n opacities throughout the lungs with air bronchograms consistent with RDS.\n There is no evidence of pneumothorax, pleural effusion or cardiomegaly.\n\n IMPRESSION: Findings consistent with RDS.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-08-25 00:00:00.000",
"description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT",
"row_id": 919896,
"text": " 2:28 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT; -76 BY SAME PHYSICIANClip # \n Reason: Confirmation of the position of the tips of UA and UV lines\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with Prematurity and umbilical lines\n REASON FOR THIS EXAMINATION:\n Confirmation of the position of the tips of UA and UV lines\n ______________________________________________________________________________\n FINAL REPORT\n Infant with prematurity andumbilical lines.\n\n EXAMINATION: at 1328 compared to the film earlier the same day. ET\n tube is just below the thoracic inlet. The lungs are diffusely hazy in\n appearance with almost complete opacification of both lungs compared to the\n prior examination. The umbilical venous catheter terminates probably within\n the portal vein. The umbilical arterial catheter terminates at T7.\n\n IMPRESSION: Interval worsening of the lungs with diffuse hazy opacity.\n UVC/UAC catheter and ET tube as described.\n\n"
}
] |
27,995 | 129,731 | Pt was brought to the OR from the ER where under general anesthesia he underwent thoracic laminectomy T4-7 with resection of intradural extramedullary mass. He tolerated this procedure well , was extubated and transferred to the ICU for close neurologic monitoring. Post op his LE motor remained 0/5. He had sensory level at T6. His SBP was maintained > 100 for cord perfusion. He was on decadron and tapered. His dresssing was clean and dry and was removed post op day 2 and incision was well healing with staples.He had IVC filter placed prophylactically. He weas seen by PT and PT as well as social work for his acute change in physical exam. He is incontinent of stool at times. He has a foley catheter in place. Post-operatively, some of the sensation in his lower extremeities has returned, howver his mobility and propriception have not. He is stable medically at the time of discharge. | T1 sagittal and axial images were obtained following gadolinium. T11-T12 endplate mild enhancement and intervertebral fluid which has an appearance similar to that of discitis or osteomyelitis. Mild eventration of the right hemidiaphragm is seen. Decreased rectal tone.Foley draining adequate amts CYU. The cardiac and mediastinal contours are otherwise within normal limits with slight unfolding of the aorta with wall calcifications. Right bundle-branchblock with left anterior fascicular block. Within the T11- T12 vertebral body endplate, there is mild enhancement as well as fluid within the intervertebral disc. Evaluate cauda equina and for compression. Gadolinium-enhanced sequences were performed. TECHNIQUE: Multiplanar T1- and T2-weighted images of the thoracic and lumbar spine were obtained. View #3 - AP view of the tspine - ET and NG tubes noted. 2.6 x 1.0 x 1.2-cm ovoid faintly enhancing intradural, extramedullary lesion that does not demonstrate contiguity with either the vertebral body or (Over) 6:52 AM MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # Reason: eval: cauda equina, cord compression (PLEASE CALL RADIOLOGY Contrast: MAGNEVIST Amt: 17 FINAL REPORT (REVISED) (Cont) disc. hemodynmicsdata: neuro: alert and oriented. Posterior to the T5 and T6 vertebral bodies, there is a 2.6 x 1.0 x 1.2-cm T2 hyperintense, T1 isointense faintly enhancing ovoid mass within the intradural extramedullary compartment. A-line positional.LS clear, diminished at bases. probe vs overlying object -- points toward the lower most aspect of the T4 vertebral body. Neuro exam unchanged. MR THORACIC SPINE: There is normal alignment and vertebral body height of the visualized thoracic spine. A preprocedure timeout was performed. SICU NPN 2300-0700:S-"Want to lay flat. IMPRESSION: Status post laminectomies from T4 to T6 level with removal of the previously noted mass. Sinus rhythm. PERRL. Simple appearing renal cysts. pt following commands-moving upper extremies.not able to move legs. At T11-T12, at the site of endplate enhancement and disc fluid, there is a mild diffuse disc bulge with no evidence of foraminal narrowing or central canal stenosis. The previously noted mass in the anterior portion of the spinal canal in intradural extramedullary location has been resected. Abdomen softly distended. The right groin was prepped and draped in standard sterile fashion. T7 hemangioma. Within the T7 vertebral body, there is a T1- and T2-weighted hyperintense lesion consistent with a hemangioma. +BS. IMPRESSION: Successful placement of an OptEase filter in the infrarenal inferior vena cava. There are small R waves in theinferior leads consistent with possible prior inferior myocardial infarction.No previous tracing available for comparison. IMPRESSION: 1. moves upper extremities. A final fluoroscopic image was obtained to confirm filter placement. hydrocortisone iv given as orderd.resp: o2 on at 3liters of nasal prongs. Based on this diagnostic findings, it was determined that the placement of an IVC filter would be indicated. back dsg intact. Marker overlies the interspace between the presumptive L3 and L4 spinous processes. Degenerative changes are seen at the glenohumeral joints bilaterally. given. Using the iliac crest as a reference point, the lower marker ovelies the interspace between the L3 and L4 spinous processes and the upper marker overlies the soft tissues posterior to the T10/11 disc space, pointing toward the lower T10 vertebral body. TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the thoracic spine were obtained before gadolinium. Mild canal narrowing with no cord compression at L3-L4 by diffuse disc bulge and ligamentum flavum hypertrophy. Severe mid thoracic cord compression at the T5-T6 level by the above- described intradural extramedullary mass, with mild adjacent cord edema. Both feet +babinksi.NSR. appetite good and drinking po fluids.action: neuro signs q2hrs. L2 and L5 metastatic vertebral body lesions. SINGLE VIEW CHEST, PORTABLE UPRIGHT: The heart has a slight left ventricular configuration. SBP 110-120's. tol. There is a mild diffuse disc bulge at L3-L4 and L4-L5 with mild foraminal narrowing and no appreciable canal stenosis. The renal veins were identified at the level of L1. perl.no n/v. Left axis deviation. IMPRESSION: No acute cardiopulmonary disease. no ectopy seeen. does not move lower extremities. Please place IVC filter for PE prophylaxis. The remaining soft tissues are unremarkable. View #1 - Lateral view of the lumbar spine. focus. follows commands. An additional linear density - ? moves upper extremities off the bed. An OptEase filter was placed below the level of the renal veins. lower extremities does not move. There is no appreciable foraminal narrowing throughout the entire thoracic spine. Moving BUE with normal strength. Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: CK LEVEL Admitting Diagnosis: T-SPINE MASS FINAL REPORT INDICATION: Intraoperative spot fluoroscopic views demonstrating probes at multiple levels in thoracolumbar spine. No ectopy. RADIOLOGISTS: Drs. 4. The spinal cord no longer demonstrates displacement from the posterior aspect of the vertebral bodies indicating no significant residual mass is present. 7. pupils equal and reactive. and . abd. ; LUMBAR SP,SINGLE FILM IN O.R. A venogram was performed demonstrating a single patent inferior vena cava, with no evidence of thrombosis. Multiple overlying surgical devices and gauze noted. Multilevel degenerative changes are again identified in the thoracic region with disc protrusion and indentation on the spinal cord at T11-12 level. | 11 | [
{
"category": "Radiology",
"chartdate": "2189-01-08 00:00:00.000",
"description": "O LUMBAR SP,SINGLE FILM IN O.R.",
"row_id": 988771,
"text": " 5:19 PM\n T-SPINE IN O.R.; LUMBAR SP,SINGLE FILM IN O.R. Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: CK LEVEL\n Admitting Diagnosis: T-SPINE MASS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intraoperative spot fluoroscopic views demonstrating probes at\n multiple levels in thoracolumbar spine.\n\n Three intra-operative films were obtained.\n\n View #1 - Lateral view of the lumbar spine. Marker overlies the interspace\n between the presumptive L3 and L4 spinous processes.\n\n View #2 - Lateral view of the tspine. Using the iliac crest as a reference\n point, the lower marker ovelies the interspace between the L3 and L4 spinous\n processes and the upper marker overlies the soft tissues posterior to the\n T10/11 disc space, pointing toward the lower T10 vertebral body. An additional\n linear density _- ? probe vs overlying object -- points toward the lower most\n aspect of the T4 vertebral body.\n\n View #3 - AP view of the tspine - ET and NG tubes noted. Multiple overlying\n surgical devices and gauze noted. Correlation with real-time findings is\n recommended for full assessment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-12 00:00:00.000",
"description": "PERC PLCMT IVC FILTER",
"row_id": 989192,
"text": " 7:52 AM\n IVC GRAM/FILTER Clip # \n Reason: Please place IVC filter for PE prophylaxis\n Admitting Diagnosis: T-SPINE MASS\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * INTERUP IVC 2ND ORDER OR> VENOUS SYSTEM *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with paraplegia after cord hemorrhage (T5)\n REASON FOR THIS EXAMINATION:\n Please place IVC filter for PE prophylaxis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man with a thoracic cord tumor, status post\n resection, complicated by hemorrhage. Please place IVC filter for PE\n prophylaxis.\n\n RADIOLOGISTS: Drs. and . Dr. , the\n attending radiologist, was present and supervising throughout the procedure.\n\n TECHNIQUE/FINDINGS: The risks and benefits were discussed with the patient's\n son, and written informed consent was obtained. A preprocedure timeout was\n performed. The right groin was prepped and draped in standard sterile\n fashion. Ultrasound was used to identify and confirm patency of the right\n common femoral vein. Under ultrasonographic guidance and after the\n administration of 5 cc of 1% lidocaine, a 19-gauge needle was advanced into\n the right common femoral vein, and a 0.035 wire was advanced into the\n distal IVC, through which an Omniflush catheter was advanced into the\n contralateral external iliac vein. A venogram was performed demonstrating a\n single patent inferior vena cava, with no evidence of thrombosis. The renal\n veins were identified at the level of L1. Based on this diagnostic findings,\n it was determined that the placement of an IVC filter would be indicated. An\n OptEase filter was placed below the level of the renal veins. The vascular\n sheath was removed, and manual compression was held for 10 minutes to achieve\n hemostasis. A final fluoroscopic image was obtained to confirm filter\n placement. The patient tolerated the procedure well with no immediate\n complications.\n\n IMPRESSION: Successful placement of an OptEase filter in the infrarenal\n inferior vena cava. This may be retrieved within 14 days of placement if\n indicated, or left in permanently.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-08 00:00:00.000",
"description": "MR T-SPINE W &W/O CONTRAST",
"row_id": 988630,
"text": " 6:52 AM\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \n Reason: eval: cauda equina, cord compression (PLEASE CALL RADIOLOGY\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with LE numbness/weakness, poor rectal tone\n REASON FOR THIS EXAMINATION:\n eval: cauda equina, cord compression (PLEASE CALL RADIOLOGY RESIDENT IN HOUSE\n TO CHECK STUDY IMMEDIATELY UPON COMPLETION)\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 78-year-old man with lower extremity numbness and weakness and\n poor rectal tone. Evaluate cauda equina and for compression.\n\n No comparison studies.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images of the thoracic and lumbar\n spine were obtained. Gadolinium-enhanced sequences were performed.\n\n MR THORACIC SPINE: There is normal alignment and vertebral body height of the\n visualized thoracic spine. Within the T7 vertebral body, there is a T1- and\n T2-weighted hyperintense lesion consistent with a hemangioma. Within the T11-\n T12 vertebral body endplate, there is mild enhancement as well as fluid within\n the intervertebral disc. These findings do raise the possibility of a\n discitis and osteomyelitis. Degenerative changes typically do not demonstrate\n enhancement as well as fluid within the intervertebral disc.\n\n Posterior to the T5 and T6 vertebral bodies, there is a 2.6 x 1.0 x 1.2-cm T2\n hyperintense, T1 isointense faintly enhancing ovoid mass within the intradural\n extramedullary compartment. This mass is exerting severe compression upon the\n thoracic cord resulting in adjacent cord edema. There is no appreciable\n foraminal narrowing throughout the entire thoracic spine. A CT through this\n region may be helpful to assess calcification.\n\n At T11-T12, at the site of endplate enhancement and disc fluid, there is a\n mild diffuse disc bulge with no evidence of foraminal narrowing or central\n canal stenosis.\n\n MR : Within the anterosuperior L2 vertebral body and near the entire\n left L5 vertebral body, there is loss of marrow signal and enhancement likely\n to represent metastatic disease, particularly the given provided history of\n prostate cancer.\n\n There is a mild diffuse disc bulge at L3-L4 and L4-L5 with mild foraminal\n narrowing and no appreciable canal stenosis. There are several bilateral\n simple-appearing renal cysts. The remaining soft tissues are unremarkable.\n\n IMPRESSION:\n\n 1. 2.6 x 1.0 x 1.2-cm ovoid faintly enhancing intradural, extramedullary\n lesion that does not demonstrate contiguity with either the vertebral body or\n (Over)\n\n 6:52 AM\n MR W &W/O CONTRAST; MR W & W/O CONTRAST Clip # \n Reason: eval: cauda equina, cord compression (PLEASE CALL RADIOLOGY\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n disc. Diagnositic possibilities include meningioma, and nerve sheath tumor.\n It is less likely to represent a metastatic lesion given its lack of\n association with the vertebral bodies and minimal contrast enhancement.\n\n 2. Severe mid thoracic cord compression at the T5-T6 level by the above-\n described intradural extramedullary mass, with mild adjacent cord edema.\n\n 3. T11-T12 endplate mild enhancement and intervertebral fluid which has an\n appearance similar to that of discitis or osteomyelitis. However, clinical\n correlation is recommended given that an explanation of this patient's\n symptoms can be provided by the compressing mass at T5-T6. There is no\n foraminal narrowing or central stenosis at this level.\n\n 4. T7 hemangioma.\n\n 5. L2 and L5 metastatic vertebral body lesions.\n\n 6. Mild canal narrowing with no cord compression at L3-L4 by diffuse disc\n bulge and ligamentum flavum hypertrophy.\n\n 7. Simple appearing renal cysts.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 988708,
"text": " 12:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for intrathoracic pathology\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with thoracic spine mass, likely to OR today\n REASON FOR THIS EXAMINATION:\n Evaluate for intrathoracic pathology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Thoracic spine mass, preoperative for laminectomy.\n\n COMPARISONS: None.\n\n SINGLE VIEW CHEST, PORTABLE UPRIGHT: The heart has a slight left ventricular\n configuration. The cardiac and mediastinal contours are otherwise within\n normal limits with slight unfolding of the aorta with wall calcifications.\n Mild eventration of the right hemidiaphragm is seen. The lungs are clear.\n Degenerative changes are seen at the glenohumeral joints bilaterally.\n\n IMPRESSION: No acute cardiopulmonary disease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2189-01-09 00:00:00.000",
"description": "MR T-SPINE W &W/O CONTRAST",
"row_id": 988894,
"text": " 3:00 PM\n MR W &W/O CONTRAST Clip # \n Reason: residual tumor at T5-7, with and without contrast please,ple\n Admitting Diagnosis: T-SPINE MASS\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p excision of spinal cord tumor, please do STIR images\n REASON FOR THIS EXAMINATION:\n residual tumor at T5-7, with and without contrast please,please do STIR images\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the thoracic spine.\n\n CLINICAL INFORMATION: Patient with thoracic mass status post surgery.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n thoracic spine were obtained before gadolinium. T1 sagittal and axial images\n were obtained following gadolinium.\n\n FINDINGS: Since the previous MRI examination of , the patient has\n undergone laminectomies from T4 to T6 level. The previously noted mass in the\n anterior portion of the spinal canal in intradural extramedullary location has\n been resected. There is increased signal seen within the spinal cord at this\n level which is persistent from the previous study. No spinal cord now extends\n to the anterior aspect of the spinal canal, indicating removal of the tumor\n without evidence of significant residual mass. No fluid collections are seen\n within the spinal canal or at the laminectomy site.\n\n Multilevel degenerative changes are again identified in the thoracic region\n with disc protrusion and indentation on the spinal cord at T11-12 level.\n\n IMPRESSION: Status post laminectomies from T4 to T6 level with removal of the\n previously noted mass. The spinal cord no longer demonstrates displacement\n from the posterior aspect of the vertebral bodies indicating no significant\n residual mass is present. No evidence of fluid collection seen at the\n laminectomy site. No intraspinal fluid collection or hematoma. Increased\n signal within the spinal cord at T5 and T6 levels indicating cord\n edema/myelomalacia. Other changes as above.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2189-01-09 00:00:00.000",
"description": "Report",
"row_id": 1628494,
"text": "Nursing Progress Note\nSee Carevue for specifics\n\nEvents: Pt down for MRI of T-spine without incident.\n\nPt 3 per family. Pt is Italian speaking, understands little English. Family at bedside most of shift. PERRL. Moving BUE with normal strength. No spontaneous movement BLE. Both feet +babinksi.\nNSR. HR 80's. No ectopy. SBP 110-120's. Goal >100. A-line positional.\nLS clear, diminished at bases. Sats 97-100% on 3 L NC.\nTolerating reg diet. +BS. Abdomen softly distended. Decreased rectal tone.\nFoley draining adequate amts CYU. Pt takes Lasix po at home, has not been restarted.\n\nPlan: Continue neuro checks q 2, hemodynamic monitoring, transfer to floor in am, PT/OT consults, Continue provide support to pt and family and keep updated of plan.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2189-01-10 00:00:00.000",
"description": "Report",
"row_id": 1628495,
"text": "SICU NPN 2300-0700:\nS-\"Want to lay flat.\"\n\nSEE CAREUVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-VSS. Neuro exam unchanged. Uneventful shift. Will call out to floor today. Transfer not complete.\n\nA/P:\nCall out to floor today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2189-01-10 00:00:00.000",
"description": "Report",
"row_id": 1628496,
"text": "focus update note\nplease see flowsheet for full details\n\nT max 98 heart rate 60-80s, 108-140/50-60\n\nresp; pt on r/a o2sat 95-100% lung sounds clear diminished bases\n\npain; minimal complaints of discomfort, pt complained of incisional pain only with repositioning in bed, at 0900 pt given tylenol 650 mg with good effect\n\ngu/gi: good appetite ate full breakfast and dinner, no bm, on , need to start bowel regime, urine output amber with sedement 30-150cc hr\n\nneuro: pt itallian speaking only, alert oriented x 3, family in to interpret all day, pupils 3mm with brisk reaction, perla, pt has good strength in upper torso and normal strength in bilaterall upper extremities, unable to move hips or legs bilaterally, reflexive movements in bilateral feet to stimulation, multi podus boots applied to pt to prevent foot drop, pt awiting neuro step down bed\n\nplan; transfer to neuro step down when bed available, continue with neuro assessment, and provided supportive care as needed\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2189-01-11 00:00:00.000",
"description": "Report",
"row_id": 1628497,
"text": "focus. hemodynmics\ndata: neuro: alert and oriented. moves upper extremities off the bed. lower extremities does not move. follows commands. pupils equal and reactive. back dsg intact. no complaints of pain. hydrocortisone iv given as orderd.\n\nresp: o2 on at 3liters of nasal prongs. breath sounds clear. coughing but not raising any sputum. o2sats 93-99%,\n\ncardiac: in nsr. no ectopy seeen. bp 110-120's.\n\ngu: foley patent and draining yellow urine.\n\ngI abd softly distended. no stool. given. appetite good and drinking po fluids.\n\naction: neuro signs q2hrs. does not move lower extremities. moves upper extremities. family updated\n\nresponse: monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2189-01-09 00:00:00.000",
"description": "Report",
"row_id": 1628493,
"text": "adm from or last evening-drowsy but arousable initially-after 1 hr w/ family @ bedside-> alert and oriented per son who interpret for pt who only speaks italian. pt following commands-moving upper extremies.\nnot able to move legs. perl.\nno n/v. tol. sponges soaked w/ water. abd. softly distended/ +bs\nno c/o pain.\nurines low->fliud bolus x2 given-foley irrig for patency-immed 200cc c/y/u drained.\nback dsg d&i.\nblood sugars slightly ^-tx'd w/ riss.\n"
},
{
"category": "ECG",
"chartdate": "2189-01-08 00:00:00.000",
"description": "Report",
"row_id": 218116,
"text": "Artifact is present. Sinus rhythm. Left axis deviation. Right bundle-branch\nblock with left anterior fascicular block. There are small R waves in the\ninferior leads consistent with possible prior inferior myocardial infarction.\nNo previous tracing available for comparison.\n\n"
}
] |
23,523 | 179,699 | Pt admitted with diagnosis of central cord syndrome. Solumedrol drip started and given for 48 hours. Pt had surgery Ant fusion C4-6, Post fusion C3-6 Pts R.uext improved slightly post op. Left uext and b/l lower exts had significant improvement. Pt dc'd to rehab | TECHNIQUE: Axial MDCT images through the thoracic spine without IV contrast, with coronal and sagittal reformations. At L4-L5 and L5-S1 level, disc and facet degenerative changes are seen with mild disc bulging without spinal stenosis. Fluid/mucosal thickening of the maxillary and ethmoid sinuses, without evidence of adjacent fracture. IMPRESSION: Disc and facet degenerative changes at L4-5 and L5-S1 levels, otherwise unremarkable study. Incidental hemangioma is seen in the T8 vertebral body. 2:49 PM CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: fx/dislocation MEDICAL CONDITION: s/p wave injury with initial numbness.paralysis, now upper extremity weakness REASON FOR THIS EXAMINATION: fx/dislocation No contraindications for IV contrast WET READ: 3:46 PM Degenerative changes. NGT d/c'd this am by Dr. (ortho). There is mild degenerative spurring of the anterior endplates. 2) Subtle, linear fracture through the inferior facet of C6 on the right. with numbness and paresthesias. 2:49 PM CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # Reason: fx/dislocation MEDICAL CONDITION: s/p wave injury with initial numbness.paralysis, now upper extremity weakness REASON FOR THIS EXAMINATION: fx/dislocation No contraindications for IV contrast WET READ: 3:45 PM T1 spinous process fracture. Bowel sounds hypoactive. TECHNIQUE: Axial MDCT images through the cervical spine without IV contrast. CT LUMBAR SPINE FINDINGS: The lumbovertebral bodies are well aligned without evidence of fracture or traumatic listhesis. cv:hr 69-58 sr to sb no ectopy,sbp 140/'s to 154/neuro: alert and oriented. stockings on and compression sleeves.Resp status: intubated(difficult intub per anesth req boogie)bbs clear. Nursed with logroll and c-spine precautions.Rt arm has significant deficit, with pt able to only slightly wiggle fingers and move arm by shrugging shoulder.Lt arm pt able to lift against gravity but has poor fine motor movement. Remains NPO with NGT to suction. There is a subtle, linear fracture through the inferior facet of C6 on the right.No other fractures are identified. UpdateO: Neuro status: prpfol remains on. flds replaced intraop 4liters & prbc x1 unit. Resp Care,Pt. CT T-SPINE FINDINGS: There is normal alignment of the thoracic vertebra. Mild disk bulging essentially at L4-5 and L5-S1 level. FINDINGS: AP CHEST: Study is limited secondary to the underlying trauma board. sbp 100 on adm. prpfl briefly off w slt movement noted of lt arm and chest. Mild disc bulging is seen at T8-9 level. TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the thoracic spine were acquired. Abnormal signal within the interspinous region at C4-5 and C5-6 levels indicating injury to the interspinous ligament without evidence of disruption. Rt arm weakr than lt.Perl 3mm brisk.Denies pain upon questioning but grimacing w any interventions.Pt remains intubated and sedated, req additional versed for comfort.Resp status: remains intub w adeq abg.on simv mode & fio2 50%peep 5 ps 5A/P: ? There are displaced fractures through the spinous processes of C7 and T1. Hypoactive bowel sounds. Disc protrusion and bulging with mild- to-moderate spinal stenosis at C5-6 level. Placed on A/C then changed to SIMV when assisting. Moves all extremities, decreased movement on right, especially upper right extremity. The spinal cord demonstrates normal intrinsic signal without extrinsic compression or intraspinal hematoma. Mild multilevel degenerative changes are seen. FINAL REPORT INDICATION: The patient hit by wave with lower paresthesias. Fractures of the spinous processes of the C3 and C4 are suspected on the CT. Having temporary episodes of hypertension with SBP to 160s, quickly resolving after activity or conversation is over.ENDOCRINE:Covered for hyperglycemia per sliding scale.FLUIDS:D5 n/2 with 20meq KCl at 125/hr.GI:Abd rounded, soft, non tender. AP PELVIS: Study is limited by the underlying trauma board artifact. IMPRESSION: No definite fracture identified. Pt is unable to use call light d/t decreased moblility. The paraspinal soft tissues are unremarkable. When comfortable 120-130 systolic. Clip # Reason: C4-C7 LAMINECTOMY W/ DISCECTOMY Admitting Diagnosis: WEAKNESS FINAL REPORT STUDY: Cervical spine. IMPRESSION: Spinous process fractures of C7 and T1 with soft tissue injury/edema posterior to the spinous processes in the upper thoracic region. Initially no mvment of rt arm now mae spont and to command. (See CT C-Spine for cervival fractures). IMPRESSION: Normal pelvis and left hip. Hydromorphone ordered for breakthrough pain. WET READ VERSION #1 3:27 PM C7 & T1 spinous process fractures. Limited evaluation of the hips demonstrates no definite evidence of acute fractures. IMPRESSION: T1 spinous process fracture. TECHNIQUE: Axial MDCT images through the brain without IV contrast. Anesth standby as difficult intubation.Check labs and rx as ordered/needed. There is normal alignment of the cervical vertebral bodies. Limited assessment of the soft tissue structures and lungs throughout the mid thorax is unremarkable. Again seen is the fracture through the spinous process of T1. Ivflds: d51/2 s + kcl @ 125A/P: s/p antpost cervical fusion c3-c7 & t1 w ebl 1liter. FINAL REPORT INDICATION: Trauma, rule out fracture. TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the lumbar spine were obtained. There is disc protrusion at C5-6 with mild narrowing of the spinal canal. Limited evaluation of the lung apices are unremarkable. FINDINGS: There is extensive soft tissue edema posterior to the spinous processes in the cervical region. There is significant degenerative disease and hypertrophy of the facet joints, without evidence of a definite displaced fracture. FINDINGS: There is no acute intracranial hemorrhage. | 18 | [
{
"category": "Nursing/other",
"chartdate": "2163-09-14 00:00:00.000",
"description": "Report",
"row_id": 1569629,
"text": "cv:hr 69-58 sr to sb no ectopy,sbp 140/'s to 154/\n\nneuro: alert and oriented. moves both legs on bed. strneth equal both legs. pt can move r arm on bed..moves r arm from shoulder. pt tried to squeeze with r hand and there was slight movement in PALM. more movement in left arm. pt can bend l arm and when trying to squeeze l hand there is some movement in fingers. sensation intact in both arms.pupils equal and reactive. j in place. log roll and cervical spine precautions. dressing anterior and posterior neck dry and intact. hemovac.. no drainage.\n\ngi: ng to low continous wall suction..bilious.npo.positive bowel sounds.\n\ngu:foley draining clear yellow urine.\n\nresp: o2 via shovel mask at 40 % o2 sats 96-98% see careview for abg's. lungs sounds clear bilateral.\n\npain: pt c/o discomfort inback, pressure in hands..Pt sates he like his hands are swollen,,hands are edematous and elevated on pillows. medicated with morphine 2 mg iv times on and morphine 4 mg sc with good effect. slept in short naps.\n\nendo: q 6 hour blood sugars conered with slding scale insulin\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-09-14 00:00:00.000",
"description": "Report",
"row_id": 1569630,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nNeuro: PT is awake, alert and orientated x 3. Afebrile. Sat up in bed and then pivoted to chair with PT and OT x assist of three. Pt very weak on legs, but able to move all extremities. RUE is the weakest and only moves on the bed, unable to lift. Lift and fall on all other extremities. Pt is unable to use call light d/t decreased moblility. ..OT paged and new call light ordered for pt to use on floor. In room and patient teacher by OT.\n\nCV/GU: HR normal sinus rhythm. BP 140-150, 130's when sitting up. Flattening A-line, d/c'd upon transfer orders per trauma team. Following cuff pressures. Good urine output via foley cath.\n\nGI: bowel sounds hypoactive, soft. NGT d/c'd this am by Dr. (ortho). House diet ordered for tonight\n\nREsp: cool areosol mask this morning and then placed on 4 liter nasal cannula. Tolerated well. Incentive spirometer with nursing help, pt is unable to hold spirometer up to mouth. Lungs sound clear.\n\nPlan: Transfer to floor as soon as bed available. wife would like to be notified as to where and when pt transfered.\nPlease refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-09-12 00:00:00.000",
"description": "Report",
"row_id": 1569624,
"text": "Postop adm note\nO: Pt adm from O.R. s/p a/p cervical fusion w hemovac drain to surgical site posteriorly. Intubated & sedated on propofol at 50mcg/kg/m. sbp 100 on adm. prpfl briefly off w slt movement noted of lt arm and chest. Restarted prpfl w adeq bp.\nNeuro status; perl 2mm plan per ho keep sedated overnight with ppf off for neuro check at 2330.,otherwise pt to remain flat in bed, sedated overnight, logroll only. J collar in place.. Ant drsg d/i\n\nCv status: sr rate 70's.Sbp 100-120's. Distal pulses palp. stockings on and compression sleeves.\n\nResp status: intubated(difficult intub per anesth req boogie)bbs clear. Initial O2 sat 89-91% on 50%-> fio2 ^ 100% w pao2 >300-> weaning fio2.\n\nGi status: no ngt. abd soft hypoactive bowel snds+.H2 blocker for gi prophylax.\n\nGu status: uop cl yellow urine via foley.\n\nHeme/Id: hct 37 preop Ancef intraop to cont x 48hrs postop. Postop labs results pending.\n Ivflds: d51/2 s + kcl @ 125\nA/P: s/p antpost cervical fusion c3-c7 & t1 w ebl 1liter. flds replaced intraop 4liters & prbc x1 unit. Check postop labs. Wean fio2 as tol. Propofol off at 2330 for neuro exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-09-13 00:00:00.000",
"description": "Report",
"row_id": 1569625,
"text": "Update\nO: Neuro status: prpfol remains on. Pt awake to stim. & following commands. Initially no mvment of rt arm now mae spont and to command. Rt arm weakr than lt.Perl 3mm brisk.Denies pain upon questioning but grimacing w any interventions.\nPt remains intubated and sedated, req additional versed for comfort.\nResp status: remains intub w adeq abg.on simv mode & fio2 50%peep 5 ps 5\n\nA/P: ? wean to extub today,**? Anesth standby as difficult intubation.Check labs and rx as ordered/needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-09-13 00:00:00.000",
"description": "Report",
"row_id": 1569626,
"text": "Resp Care,\nPt. admitted from OR intubated # 7.5 ET taped at 23@lip. BS equal. Placed on A/C then changed to SIMV when assisting. Fio2 weaned down to 60%. See carevue, maintain current vent settings.\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-09-13 00:00:00.000",
"description": "Report",
"row_id": 1569627,
"text": "Nursing Note 7a-3p:\nNursing Assessment:\n\nNeuro: Pt extubated at 1330. Alert and orientated x 3. Moves all extremities, decreased movement on right, especially upper right extremity. Lift and fall left arm and both legs, moves right arm on bed only. afebrile. Medicated with morphine ivp for pain with good effect but only short-acting. Hydromorphone ordered for breakthrough pain. wife in visiting pre and post extubation.\n\nCV/GU: SBP elevated (up to sbp 160s) when awake and in pain. When comfortable 120-130 systolic. HR normal sinus rhythm. Good urine output.\n\nGI: NGT to lcws with brownish-red drainage. Bowel sounds hypoactive. Pt is to begin bowel regimen.\n\nResp: Extubated and on humidified face mask, sat 97-99%. ABG pending. Strong productive cough. Lung sounds clear with diminished bases.\n\nPlan: Continue with bed flat (reverse Trendelenberg) and logroll 24 hours (until tonight 10pm?). raise head of bed prior to that only if necessary. If able wait to raise HOB due to leak (pt may complain of headache). Continue to monitor for pain and for HTN.\n\nPLease refer to carevue for details.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2163-09-13 00:00:00.000",
"description": "Report",
"row_id": 1569628,
"text": "Nursing Progress Note:\nPlease refer to CareVue for specifics.\n\nPt condition satisfactory.\n\nNEURO:\nAwake, oriented, pleasant and cooperative. Complaining of intermittant pain to neck, back, buttocks, receiving morphine prn with good but short effect.\n J in situ. Nursed with logroll and c-spine precautions.\nRt arm has significant deficit, with pt able to only slightly wiggle fingers and move arm by shrugging shoulder.\nLt arm pt able to lift against gravity but has poor fine motor movement. Able to squeeze fingers but with severe weakness.\nAble to lift legs against resistance, but marginally stronger on Lt.\n\nRESP:\nTolerating humidified 02 40% via face tent. Has strong cough. Managing secretions well. Chest clear, taking deep breaths with encouragement. Sao2 97-100%.\n\nHEMODYNAMICALLY:\nSR 60s, no ectopy. Peripherally edematous, warm, capillary refill < 3 seconds. Having temporary episodes of hypertension with SBP to 160s, quickly resolving after activity or conversation is over.\n\nENDOCRINE:\nCovered for hyperglycemia per sliding scale.\n\nFLUIDS:\nD5 n/2 with 20meq KCl at 125/hr.\n\nGI:\nAbd rounded, soft, non tender. Hypoactive bowel sounds. Remains NPO with NGT to suction. Possibly for commencement of sips tomorrow.\nTo be commenced on bowel regime this pm.\n\nGU:\nFoley patent and draining clear yellow-amber urine in good volumes (> 150/hr).\n\nSKIN:\nSurgical dressings intact to ant and post neck. Hemovac drain patent and intact with minimal drainage in tubing, non in collection chamber.\nButtocks slightly pink but skin intact and care attended.\n\nSOCIAL:\nVisited by wife and friends, wive requesting update from Dr when he next rounds.\nNoted screening has been commenced.\n\nPLAN:\nTo remain HOB< 30 degrees per ortho request.\nContinue morphine prn.\nConsider PCA pain meds when dexterity to Lt hand improves.\nContinue c-spine precautions.\nConsider commencement of sips/diet and removal of NGT tomorrow.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-09-12 00:00:00.000",
"description": "O C-SPINE NON-TRAUMA 2-3 VIEWS IN O.R.",
"row_id": 878291,
"text": " 5:19 PM\n C-SPINE NON-TRAUMA VIEWS IN O.R. Clip # \n Reason: C4-C7 LAMINECTOMY W/ DISCECTOMY\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Cervical spine. Intraoperative images. .\n\n HISTORY: 52-year-old man anticipating C4 through C7 laminectomy with\n discectomy.\n\n FINDINGS AND IMPRESSION: The dictating radiologist was not present during the\n procedure. Two intraoperative lateral views of the cervical spine\n demonstrates a marker at the level of the C4 vertebral body. Would refer to\n the surgical report for further details.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2163-09-08 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 877839,
"text": " 2:30 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: fx/disloc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with wave injury, initial numbness x 4 extr\n REASON FOR THIS EXAMINATION:\n fx/disloc\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:44 PM\n Fractures of the C7 and T1 spinous prcoess, as well as the inferior facet of\n C6 on the right.\n\n\n WET READ VERSION #1 3:27 PM\n C7 & T1 spinous process fractures.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 68-year-old man hit by wave. with numbness and paresthesias.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial MDCT images through the cervical spine without IV contrast.\n\n CT C-SPINE FINDINGS: C1 through T1 are well visualized. There is normal\n alignment of the cervical vertebral bodies. There are displaced fractures\n through the spinous processes of C7 and T1. There are fractures through the\n spinous processes of C3 & C4 that extend into the laminae. There is a subtle,\n linear fracture through the inferior facet of C6 on the right.No other\n fractures are identified. No osseous fragments are seen retropulsed into the\n spinal canal. Limited evaluation of the lung apices are unremarkable. The\n surrounding soft tissue structures and airways are normal.\n\n IMPRESSION:\n 1) Fractures through the spinous processes of C3, C4, C7 and T1, which extend\n into the lamina at the level of C3 and C4.\n 2) Subtle, linear fracture through the inferior facet of C6 on the right.\n 3) Considering the patient's symptoms, cervical MRI is recommended for better\n evaluation of the cord and potential ligamentous injury.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-09-08 00:00:00.000",
"description": "CT T-SPINE W/O CONTRAST",
"row_id": 877840,
"text": " 2:49 PM\n CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: fx/dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p wave injury with initial numbness.paralysis, now upper extremity weakness\n REASON FOR THIS EXAMINATION:\n fx/dislocation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:45 PM\n T1 spinous process fracture.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The patient hit by wave with lower paresthesias.\n\n COMPARISONS: None.\n TECHNIQUE: Axial MDCT images through the thoracic spine without IV contrast,\n with coronal and sagittal reformations.\n\n CT T-SPINE FINDINGS: There is normal alignment of the thoracic vertebra.\n There is extensive osteophytic spurring throughout the course of the thoracic\n spine. Again seen is the fracture through the spinous process of T1. No other\n acute fractures are seen. There is no encroachment upon the spinal cord\n throughout the course of the thoracic spine. Limited assessment of the soft\n tissue structures and lungs throughout the mid thorax is unremarkable. No rib\n fractures are identified.\n\n IMPRESSION: T1 spinous process fracture. (See CT C-Spine for cervival\n fractures).\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-09-08 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 877841,
"text": " 2:49 PM\n CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: fx/dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n s/p wave injury with initial numbness.paralysis, now upper extremity weakness\n REASON FOR THIS EXAMINATION:\n fx/dislocation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:46 PM\n Degenerative changes. No fractures seen in the lumbar spine.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma, rule out fracture.\n\n COMPARISONS: None.\n TECHNIQUE: Axial MDCT images through the lumbar spine with coronal and\n sagittal reformations.\n\n CT LUMBAR SPINE FINDINGS: The lumbovertebral bodies are well aligned without\n evidence of fracture or traumatic listhesis. There is mild degenerative\n spurring of the anterior endplates. There is significant degenerative disease\n and hypertrophy of the facet joints, without evidence of a definite displaced\n fracture. Surrounding soft tissue structures are unremarkable. SI joints and\n sacrum are normal. Mild disk bulging essentially at L4-5 and L5-S1 level.\n\n IMPRESSION: No definite fracture identified. Severe hypertrophy and\n degenerative changes involving the lower lumbar facet joints and posterior\n elements.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-09-08 00:00:00.000",
"description": "MR CERVICAL SPINE",
"row_id": 877849,
"text": " 3:11 PM\n MR CERVICAL SPINE Clip # \n Reason: r/o soft tissue/spinal cord injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with wave injury, initial numbness/paralysis x 4 extremities,\n now Bilat upper extr weakness/tingling\n REASON FOR THIS EXAMINATION:\n r/o soft tissue/spinal cord injury\n ______________________________________________________________________________\n FINAL REPORT\n CERVICAL SPINE\n\n CLINICAL INFORMATION: The patient with injury to the cervical spine with\n numbness and question of paralysis in all four extremities, now with bilateral\n upper extremity weakness and tingling, for further evaluation.\n\n TECHNIQUE: T1, T2, and inversion recovery sagittal and T2 axial images of the\n cervical spine were acquired. Correlation was made with the CT examination of\n same day, .\n\n FINDINGS: There is extensive soft tissue edema posterior to the spinous\n processes in the cervical region. Fractures of the spinous processes of C6,\n C7, and T1 are visualized. Fractures of the spinous processes of the C3 and\n C4 are suspected on the CT. There is no evidence of abnormal signal seen\n within the vertebral bodies. Abnormal signal is seen in the interspinous\n region at C4-5 and C5-6 levels. There is no evidence of disruption of the\n interspinous ligament or posterior longitudinal ligament seen. There is\n subtle increased signal seen in the anterior portion of C4-5 disc suspicious\n for injury to the anterior spinous ligament. There is disc protrusion at C5-6\n with mild narrowing of the spinal canal. Subtle increased signal is seen\n within the spinal cord at C4-5 level, which could be secondary to cord edema.\n There is no evidence of intraspinal hematoma or fluid collection seen. There\n is fluid seen anterior to the spine in the upper cervical region, which is\n could be to soft-tissue edema or hemorrhage.\n\n IMPRESSION: Fractures of the spinous processes of C7 and T1 and probably\n other spinous processes in the cervical region. Extensive soft tissue signal\n abnormalities in the cervical region posterior to the spinous processes.\n Abnormal signal within the interspinous region at C4-5 and C5-6 levels\n indicating injury to the interspinous ligament without evidence of disruption.\n No evidence of vertebral malalignment. Disc protrusion and bulging with mild-\n to-moderate spinal stenosis at C5-6 level. Subtle increased signal within the\n spinal cord at C4-5 level could be due to cord edema. Subtle signal change at\n the anterior C4-5 disc could be due to injury to anterior spinous ligament.\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-09-08 00:00:00.000",
"description": "MR THORACIC SPINE",
"row_id": 877850,
"text": " 3:12 PM\n MR THORACIC SPINE Clip # \n Reason: spinal cord injury/soft tissue injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with wave injury, initial numbness/paralysis x 4 extremities,\n now Bilat upper extr weakness/tingling\n REASON FOR THIS EXAMINATION:\n spinal cord injury/soft tissue injury\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THORACIC SPINE\n\n CLINICAL INFORMATION: Rule out fracture.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n thoracic spine were acquired.\n\n FINDINGS: There are soft tissue signal abnormalities with fractures of C7 and\n T1 spinous processes known from CT and MRI of the cervical spine. The\n thoracic vertebral bodies from T1 to T12 level demonstrate no evidence of\n compression fracture or marrow edema. Incidental hemangioma is seen in the T8\n vertebral body. Mild multilevel degenerative changes are seen. Mild disc\n bulging is seen at T8-9 level. The spinal cord demonstrates normal intrinsic\n signal without extrinsic compression or intraspinal hematoma.\n\n IMPRESSION: Spinous process fractures of C7 and T1 with soft tissue\n injury/edema posterior to the spinous processes in the upper thoracic region.\n No evidence of compression fracture or marrow edema in the thoracic vertebral\n bodies. No evidence of intraspinal hematoma. No evidence of cord\n compression.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-09-08 00:00:00.000",
"description": "MR L SPINE SCAN",
"row_id": 877851,
"text": " 3:12 PM\n MR L SPINE SCAN Clip # \n Reason: spinal cord injury/soft tissue injury\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 52 year old man with wave injury, initial numbness/paralysis x 4 extremities,\n now Bilat upper extr weakness/tingling\n REASON FOR THIS EXAMINATION:\n spinal cord injury/soft tissue injury\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF LUMBAR SPINE\n\n CLINICAL INFORMATION: Status post trauma.\n\n TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the\n lumbar spine were obtained.\n\n FINDINGS: From T12-L1 to L3-4, no abnormalities are seen. At L4-L5 and L5-S1\n level, disc and facet degenerative changes are seen with mild disc bulging\n without spinal stenosis.\n\n From L1-S3 level, the visualized bony structures demonstrate no evidence of\n abnormal marrow signal to indicate marrow edema or fracture. There is no\n evidence of intraspinal hematoma or thecal sac compression seen. The conus is\n located at normal level. The paraspinal soft tissues are unremarkable.\n\n IMPRESSION: Disc and facet degenerative changes at L4-5 and L5-S1 levels,\n otherwise unremarkable study. No evidence of fracture or marrow edema seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-09-08 00:00:00.000",
"description": "HIP 1 VIEW",
"row_id": 877852,
"text": " 3:22 PM\n HIP 1 VIEW Clip # \n Reason: HIP PAIN\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE LEFT HIP PERFORMED ON \n\n CLINICAL HISTORY: Trauma, now with hip pain.\n\n FINDINGS: Single AP view of the left hip demonstrates no definite evidence\n for acute fracture on the single image.\n\n IMPRESSION: Unremarkable view of the left hip.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2163-09-08 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 877838,
"text": " 2:29 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o fx/bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with wave injury, initial numbness x 4 extr\n REASON FOR THIS EXAMINATION:\n r/o fx/bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:05 PM\n No intracranial hemorrhage or mass effect.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial MDCT images through the brain without IV contrast.\n\n FINDINGS: There is no acute intracranial hemorrhage. There is no mass effect\n or shift of normally midline structures. The ventricles, cisterns, and sulci\n are unremarkable. Bone windows demonstrate no acute fracture or other osseous\n abnormality. Fluid/mucosal thickening of the maxillary and ethmoid sinuses,\n without evidence of adjacent fracture.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage, fracture, or other\n traumatic injury.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2163-09-08 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 877834,
"text": " 2:23 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: r/o fx/disloc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with wave injury, L hip pain, numbness\n REASON FOR THIS EXAMINATION:\n r/o fx/disloc\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP VIEW OF CHEST AND AP PELVIS PERFORMED ON \n\n CLINICAL HISTORY: 62-year-old man with trauma. Left hip pain.\n\n FINDINGS:\n\n AP CHEST:\n\n Study is limited secondary to the underlying trauma board. There is poor\n inspiratory effort with crowding of the pulmonary vasculature. However, no\n focal pleural effusions or contusions are identified. Mediastinum is\n prominent; however, this may be technical. Osseous structures are grossly\n intact.\n\n AP PELVIS:\n\n Study is limited by the underlying trauma board artifact. Limited evaluation\n of the hips demonstrates no definite evidence of acute fractures. The rest of\n the pelvis is grossly unremarkable. Visualization of the sacrum is limited by\n the overlying bowel gas.\n\n IMPRESSION:\n\n No definite evidence for traumatic injury to the chest or pelvis allowing for\n the limitation of the studies.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2163-09-10 00:00:00.000",
"description": "L HIP UNILAT MIN 2 VIEWS LEFT",
"row_id": 878025,
"text": " 10:52 AM\n HIP UNILAT MIN 2 VIEWS LEFT Clip # \n Reason: r/o fx/disloc\n Admitting Diagnosis: WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with wave injury, L hip pain, numbness\n REASON FOR THIS EXAMINATION:\n r/o fx/disloc\n ______________________________________________________________________________\n FINAL REPORT\n LEFT HIP\n\n HISTORY: Injury with pain and numbness.\n\n The AP view of the pelvis was obtained along with AP and frog lateral views of\n the left hip. Bony structures are intact. There are no apparent fractures.\n Joint spaces are preserved.\n\n IMPRESSION: Normal pelvis and left hip.\n\n\n"
}
] |
16,754 | 108,483 | The patient ruled in for a heart attack and Cardiothoracic was consulted. He was found to have multi-vessel disease. The patient was taken to the Operating Room on , where a coronary artery bypass graft times three and a aortic valve replacement was performed. The patient did well postoperatively and was transferred to the CSRU for recovery. The patient was slowly extubated and chest tubes were discontinued. The patient was transferred to the Floor. Wires were removed and Foley catheter was also removed. The patient continued to do well, however, prior to chest tube removal, the patient had a slow air leak which required prolonged suction. The patient was transferred to the floor with the chest tube in place and continued to do well. Physical Therapy was consulted for mobility and for strength and he continued to improve on the floor. He handled a regular diet and chest tube was put on water-seal. After repeated chest x-rays, he still showed continued expansion of the lung. The chest tube was discontinued on after chest x-ray examination post pull chest x-ray which showed no pneumothorax and the patient continued to do well. The patient was discharged to a rehabilitation facility in stable condition. | Mild (1+) mitral regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is moderate aortic stenosiswith trace aortic regurgitation is seen. A false tendon is seen in the leftventricle (normal variant).LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: mid anterior - akinetic; mid anteroseptal -hypokinetic; mid inferolateral - hypokinetic; mid anterolateral - hypokinetic;anterior apex - akinetic; inferior apex - akinetic; apex - hypokinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is mildly dilated. Thereis moderate aortic valve stenosis. There is moderate symmetric left ventricular hypertrophy. Mild (1+) mitral regurgitation isseen. CT'S PATENT FRO MODERATE AMT SERO-SANG DRAINAGE, LEAK PRESENT. 3) Unchanged residual pneumothorax in the left apex. Right ventricular chamber size and free wall motion arenormal. The aortic root and ascending aorta are mildly dilated. There ismoderate mitral annular calcification. There islipomatous hypertrophy of the interatrial septum.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. There is mild cardiac enlargement and upper zone redistribution of the pulmonary vasculature. There is focal area of obscuration of the right hemidiaphragm that supports this possibility. Theleft ventricular cavity is mildly dilated. There ismoderate aortic valve stenosis. Bibasilar atelectatic changes and small pleural effusions are noted. Overall left ventricular systolicfunction is severely depressed.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets are severely thickened/deformed. The leftventricular cavity is mildly dilated. The leftventricular cavity is mildly dilated. Left ventricular wall thicknesses arenormal. There is a small residual pneumothorax in the left apical region extending to the left paramediastinal region. IMPRESSION: 1) Mild increase in density in the right base with obscuration of the right hemidiaphragm. There issevere mitral annular calcification. Trace aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Trace aortic regurgitationis seen.3. The left ventricular cavity is mildly dilated. Prominent right and left paratracheal soft-tissue density presumably reflects lordotic patient positioning. Preoperative assessment.Height: (in) 70Weight (lb): 167BSA (m2): 1.94 m2BP (mm Hg): 130/70Status: InpatientDate/Time: at 16:51Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. Sinus bradycardiaLong QTc intervalQRS changes V3/V4 - probably due to LVH but consider anterior infarctLVH with secondary ST-T changesSince previous tracing of , rate decreased There is mild prominence of the pulmonary vasculature suggesting edema. Findings suggest mild CHF. There is slight residue bibasilar atelectasis. Sinus bradycardiaConsider prior inferior myocardial infarctionLeft ventricular hypertrophy with ST-T abnormalitiesConsider also anterior ischemia - clinical correlation is suggestedSince previous tracing of , rate slower The ascending aorta is mildlydilated.AORTIC VALVE: The aortic valve leaflets are moderately thickened. There is no pericardial effusion.Compared with the prior studyt of , the regional dysfunction is moreclearly defined.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). IMPRESSION: Slight left heart failure. Trace aortic regurgitation is seen.MITRAL VALVE: The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen.TRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Suboptimal image quality due to poor echo windows.Conclusions:1. Sinus rhythmPossible anterior infarct - age undeterminedLateral ST-T changes suggest myocardial injury/ischemiaNo previous tracing r/o pneumo FINAL REPORT INDICATION: Status post CABG, status post chest tube removal. Sinus rhythmLong QTc intervalConsider prior inferior myocardial infarctionLeft ventricular hypertrophy with ST-T abnormalitiesConsider also ischemia - clinical correlation is suggestedSince previous tracing of , right precordial T wave changes slightlyless prominent The tips of the papillary muscles arecalcified. Rule out pneumothorax. Overall improvement, with trace residue pneumothoraces at the apices. Mild tricuspid [1+]regurgitation is seen.PERICARDIUM: There is no pericardial effusion.GENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,the echo findings indicate a moderate risk (prophylaxis recommended). Findings suggest some degree of cardiac failure. There is bilateral pleural effusion left greater than right. Left ventricular function. There is mild pulmonary edema. CHEST, PA & LATERAL: Comparison is made to . The cardiac silhouette is within normal limits. There isprobably moderate to severe aortic valve stenosis. Bilateral subsegmental atelectatic changes. A left-sided chest tube remains in place, the distal tip overlying the left hemidiaphragm level. Irregular ectopic atrial rhythm- demand atrial pacingPossible anterior infarct - age undeterminedInferior/lateral ST-T changes suggest myocardial injury/ischemiaSince previous tracing of , paced rhythm present IMPRESSION: Postoperative chest radiograph with bilateral pleural effusion and left base atelectasis. There is minimal residue subcutaneous emphysema in the left supraclavicular region. ABG ON CPAP 7.31. CXR 4hours s/p ct to h2o seal. CXR 4hours s/p ct to h2o seal. The distal half of the inferiorwall is thin/akinetic. There are small bilateral pneumothoraces present. PATIENT/TEST INFORMATION:Indication: Congestive heart failure.Status: InpatientDate/Time: at 08:15Test: TTE(Focused views)Doppler: Focused pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: There is moderate symmetric left ventricular hypertrophy. Resolving right lower lobe process. IMPRESSION: Mild diffuse coarsening of interstitial markings, which may be chronic. There is cardiomegaly, and the patient is status post recent CABG. Now with right groin bruit at site of catheter insertion. There is mild, diffuse coarsening of interstitial markings, which may be chronic. Query consolidation in the right lower lobe. REASON FOR THIS EXAMINATION: R/o pseudoaneurysm FINAL REPORT HISTORY: Cardiac catheterization with right inguinal bruit. Residue bibasilar atelectasis. Again seen are right basilar atelectatic changes and new left base atelectatic changes. FINDINGS: A left chest tube is seen with its tip at the left lower lung field unchanged in position compared to . | 20 | [
{
"category": "Radiology",
"chartdate": "2112-09-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 767699,
"text": " 2:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O HEMO/PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with long tobacco hx who presents with dyspnea, EKG changes.\n\n REASON FOR THIS EXAMINATION:\n R/O HEMO/PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Dyspnea\n\n COMPARISON: \n\n PORTABLE CHEST: The ET tube, NG tube, right sided Swan-Ganz catheter and left\n side chest tube are properly positioned. There is no pneumothorax. There is\n mild prominence of the pulmonary vasculature suggesting edema. There is\n bilateral pleural effusion left greater than right. There is left basilar\n atelectasis, as well. There are sternal wires and skin staples overlying the\n heart consistent with a recent CABG.\n\n IMPRESSION: Postoperative chest radiograph with bilateral pleural effusion and\n left base atelectasis. There is mild pulmonary edema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 767939,
"text": " 3:18 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pneumothorax. CXR 4hours s/p ct to h2o seal.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with h/o CAD, DM, smoking s/p cath now with fever, inc. white\n count\n REASON FOR THIS EXAMINATION:\n ? pneumothorax. CXR 4hours s/p ct to h2o seal.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 74 y/o man with history of CAD, diabetes, now with\n fever. Rule out pneumothorax.\n\n COMPARISON: Chest x-ray from is available for comparison.\n\n FINDINGS: The cardiac silhouette is enlarged. There is increased vascular\n markings in both lung fields predominantly in the upper lobes consistent with\n vascular redistribution. Findings suggest some degree of cardiac failure.\n There is mild increase in density in the right base. This may be related to\n poor inspiration. However, a consolidation in the right lower lobe cannot be\n excluded. There is focal area of obscuration of the right hemidiaphragm that\n supports this possibility.\n\n A chest tube is demonstrated in the left base. There is a small residual\n pneumothorax in the left apical region extending to the left paramediastinal\n region. This pneumothorax has not changed compared with previous films.\n\n The patient is status post medial sternotomy.\n\n IMPRESSION:\n 1) Mild increase in density in the right base with obscuration of the right\n hemidiaphragm. Query consolidation in the right lower lobe.\n 2) Cardiomegaly with redistribution. Findings suggest mild CHF.\n 3) Unchanged residual pneumothorax in the left apex.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2112-09-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 767864,
"text": " 1:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: d/c chest tube, ?sucked in air R chest\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with h/o CAD, DM, smoking s/p cath now with fever, inc. white\n count\n REASON FOR THIS EXAMINATION:\n d/c chest tube, ?sucked in air R chest\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest tube discontinued. New fever, increased white count.\n\n FINDINGS:\n\n A left chest tube is seen with its tip at the left lower lung field unchanged\n in position compared to . Again seen are right basilar atelectatic\n changes and new left base atelectatic changes. Pulmonary vascular markings are\n not distended and appear unchanged. No definite new consolidation is seen.\n There is no pneumothorax.\n\n The patient has been extubated and central venous catheters have been removed.\n The lateral costophrenic sulci are sharply marginated.\n\n IMPRESSION:\n\n Left chest tube remains in place. Bilateral subsegmental atelectatic changes.\n No significant difference vs. prior in the appearance of the heart, lungs and\n mediastinum.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-20 00:00:00.000",
"description": "ART DUP EXT LO UNI;F/U",
"row_id": 767520,
"text": " 2:55 PM\n ART DUP EXT LO UNI;F/U Clip # \n Reason: R/o pseudoaneurysm\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with CAD, HTN, DM2, hyperchol, s/p cath on with question\n of bruit over site and indeterminate U/S overnight.\n\n REASON FOR THIS EXAMINATION:\n R/o pseudoaneurysm\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiac catheterization with right inguinal bruit.\n\n FINDINGS: Duplex and color Doppler of the right inguinal area demonstrates no\n evidence of , fistula, or hematoma.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-19 00:00:00.000",
"description": "R FEMORAL VASCULAR US RIGHT",
"row_id": 767447,
"text": " 12:45 AM\n FEMORAL VASCULAR US RIGHT Clip # \n Reason: 74 M post-cath with bruit at R groin entry site, r/o pseudoa\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with CAD, HTN, DM2, hyperchol\n REASON FOR THIS EXAMINATION:\n 74 M post-cath with bruit at R groin entry site, r/o pseudoaneurysm\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: History of diabetes, hypercholesterolemia, CAD status post\n cardiac catheterization. Now with right groin bruit at site of catheter\n insertion. Rule out pseudoaneurysm.\n\n COMPARISONS: None.\n\n RIGHT GROIN ULTRASOUND: The common femoral artery and vein show normal blood\n flow. There is a possible communication tract between the common femoral\n artery and vein which exhibits both venous and arterial flow. However,\n doppler evaluation of this tract is not chracteristic for an AV fistula. No\n significant groin hematoma is seen. No pseudoaneurysm is identified.\n\n IMPRESSION: Limited evaluation performed on call. Unusual structure appears\n to connect the common femoral artery and vein but shows no typical Doppler\n flow pattern. Re- evaluation in the presence of an attending radiologist is\n recommended.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-21 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 767594,
"text": " 11:11 AM\n CHEST (PA & LAT) Clip # \n Reason: r/o PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with h/o CAD, DM, smoking s/p cath now with fever, inc. white\n count\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever and leukocytosis after cardiac catheterization.\n\n CHEST, PA & LATERAL: Comparison is made to . There is mild cardiac\n enlargement and upper zone redistribution of the pulmonary vasculature.\n Thickened septal lines are noted in both lower lung zones. There are no\n definite pleural effusions. There is no parenchymal consolidation. The\n skeletal structures are unremarkable.\n\n IMPRESSION: Slight left heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 768051,
"text": " 8:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p CABG\n\n REASON FOR THIS EXAMINATION:\n r/o pneumo\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE CHEST.\n\n INDICATION: S/P CABG. Evaluate for ptx.\n\n COMPARISON IS MADE TO PREVIOUS STUDY OF ONE DAY EARLIER.\n\n Patient is s/p median sternotomy and coronary bypass surgery. There are small\n bilateral pneumothoraces present. In retrospect, these are present on prior\n study of one day earlier and slightly increased in the interval. Cardiac and\n mediastinal contours are stable. Bibasilar atelectatic changes and small\n pleural effusions are noted. A left-sided chest tube remains in place, the\n distal tip overlying the left hemidiaphragm level. There is increased\n subcutaneous emphysema in the left chest wall.\n\n IMPRESSION: Slight increase in size of bilateral pneumothoraces.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 767984,
"text": " 11:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumo. Please take CXR at noon.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n r/o pneumo. Please take CXR at noon.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P CABG and suspicion for pneumothorax.\n\n COMPARISON: at 15:35\n\n FINDINGS: The current study was obtained in a markedly different degree of\n obliquity. I do not see definite evidence for left pneumothorax on this\n projection. Compared to the previous study there is less density at the right\n lung base and discoid atelectasis of the left mid-lung. There is no evidence\n for new consolidation. A somewhat shallow level of inspiration is observed.\n Radiopaque catheter overlies the mid-abdomen and as it courses superiorly to\n the diaphragm seen over the left lateral costophrenic sulcus. I am unclear if\n this is inside or outside the patient. The left chest tube is normal and\n visualized.\n\n IMPRESSION:\n\n No evidence of pneumothorax on this film. Marked differences in obliquity\n represent limitations and comparison. No new infiltrates. Resolving right\n lower lobe process. Atelectatic changes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 768060,
"text": " 9:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct removal. r/o pneumo\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p CABG\n\n REASON FOR THIS EXAMINATION:\n s/p ct removal. r/o pneumo\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG, status post chest tube removal. Evaluate for\n pneumothorax.\n\n FINDINGS: AP portable erect chest radiograph at 9:49 A.M. Comparison\n is made to AP portable erect chest radiograph at 8:44 A.M.\n\n There is cardiomegaly, and the patient is status post recent CABG. There is\n minimal trace residue bilateral pneumothoraces at the apices which are barely\n visible. There is minimal residue subcutaneous emphysema in the left\n supraclavicular region. There is slight residue bibasilar atelectasis.\n Compared to earlier chest radiograph there is overall improvement.\n\n IMPRESSION:\n 1. Overall improvement, with trace residue pneumothoraces at the apices.\n Residue bibasilar atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2112-09-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 767276,
"text": " 4:06 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for pulmonary edema.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with long tobacco hx who presents with dyspnea, EKG changes.\n REASON FOR THIS EXAMINATION:\n Evaluate for pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: EKG change.\n\n PORTABLE CHEST: There are no prior studies for comparison. The current study\n is taken with the patient in a lordotic position. The bony thorax is intact.\n The cardiac silhouette is within normal limits. No mediastinal or hilar mass\n is seen. Prominent right and left paratracheal soft-tissue density presumably\n reflects lordotic patient positioning.\n\n There is mild, diffuse coarsening of interstitial markings, which may be\n chronic. There is no definite CHF or overt air space infiltrate. The lateral\n costophrenic angles are sharp, without effusion.\n\n IMPRESSION: Mild diffuse coarsening of interstitial markings, which may be\n chronic. Are there any old films for comparison?\n\n"
},
{
"category": "Echo",
"chartdate": "2112-09-20 00:00:00.000",
"description": "Report",
"row_id": 65774,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Left ventricular function. Preoperative assessment.\nHeight: (in) 70\nWeight (lb): 167\nBSA (m2): 1.94 m2\nBP (mm Hg): 130/70\nStatus: Inpatient\nDate/Time: at 16:51\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. There is\nlipomatous hypertrophy of the interatrial septum.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity is mildly dilated. A false tendon is seen in the left\nventricle (normal variant).\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: mid anterior - akinetic; mid anteroseptal -\nhypokinetic; mid inferolateral - hypokinetic; mid anterolateral - hypokinetic;\nanterior apex - akinetic; inferior apex - akinetic; apex - hypokinetic;\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is mildly dilated. The ascending aorta is mildly\ndilated.\n\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. There is\nmoderate aortic valve stenosis. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification. The tips of the papillary muscles are\ncalcified. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing,\nthe severity of mitral regurgitation may be significantly UNDERestimated.]\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: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity is mildly dilated. Resting regional wall\nmotion abnormalities include severe hypokinesis of the distal half of the\nanterior septum and anterior walls and apex. The distal half of the inferior\nwall is thin/akinetic. No left ventricular thrombus is seen. The remaining\nwalls contract well. Right ventricular chamber size and free wall motion are\nnormal. The aortic root and ascending aorta are mildly dilated. The aortic\nvalve leaflets are moderately thickened. There is moderate aortic stenosis\nwith trace aortic regurgitation is seen. The mitral valve leaflets and\nsupporting structures are mildly thickened. Mild (1+) mitral regurgitation is\nseen. [Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] There is no pericardial effusion.\n\nCompared with the prior studyt of , the regional dysfunction is more\nclearly defined.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2112-09-18 00:00:00.000",
"description": "Report",
"row_id": 65880,
"text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure.\nStatus: Inpatient\nDate/Time: at 08:15\nTest: TTE(Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: There is moderate symmetric left ventricular hypertrophy. The\nleft ventricular cavity is mildly dilated. Overall left ventricular systolic\nfunction is severely depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are severely thickened/deformed. There\nis moderate aortic valve stenosis. Trace aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are moderately thickened. There is\nsevere mitral annular calcification. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. There is moderate symmetric left ventricular hypertrophy. The left\nventricular cavity is mildly dilated. Overall left ventricular systolic\nfunction is severely depressed.\n2. The aortic valve leaflets are severely thickened/deformed. There is\nprobably moderate to severe aortic valve stenosis. Trace aortic regurgitation\nis seen.\n3. The mitral valve leaflets are moderately thickened. There is severe mitral\nannular calcification. Mild (1+) mitral regurgitation is seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2112-09-17 00:00:00.000",
"description": "Report",
"row_id": 142299,
"text": "Sinus rhythm\nPossible anterior infarct - age undetermined\nLateral ST-T changes suggest myocardial injury/ischemia\nNo previous tracing\n\n"
},
{
"category": "ECG",
"chartdate": "2112-09-22 00:00:00.000",
"description": "Report",
"row_id": 142295,
"text": "Irregular ectopic atrial rhythm\n- demand atrial pacing\nPossible anterior infarct - age undetermined\nInferior/lateral ST-T changes suggest myocardial injury/ischemia\nSince previous tracing of , paced rhythm present\n\n"
},
{
"category": "ECG",
"chartdate": "2112-09-20 00:00:00.000",
"description": "Report",
"row_id": 142296,
"text": "Sinus rhythm\nLong QTc interval\nConsider prior inferior myocardial infarction\nLeft ventricular hypertrophy with ST-T abnormalities\nConsider also ischemia - clinical correlation is suggested\nSince previous tracing of , right precordial T wave changes slightly\nless prominent\n\n"
},
{
"category": "ECG",
"chartdate": "2112-09-19 00:00:00.000",
"description": "Report",
"row_id": 142297,
"text": "Sinus bradycardia\nConsider prior inferior myocardial infarction\nLeft ventricular hypertrophy with ST-T abnormalities\nConsider also anterior ischemia - clinical correlation is suggested\nSince previous tracing of , rate slower\n\n"
},
{
"category": "ECG",
"chartdate": "2112-09-18 00:00:00.000",
"description": "Report",
"row_id": 142298,
"text": "Sinus bradycardia\nLong QTc interval\nQRS changes V3/V4 - probably due to LVH but consider anterior infarct\nLVH with secondary ST-T changes\nSince previous tracing of , rate decreased\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-22 00:00:00.000",
"description": "Report",
"row_id": 1481296,
"text": "NEURO: LETHARGIC THO EASILY ROUSED. NOW ORIENTED X 3, ANSWERS ?'S CLEARLY, FOLLOWS COMMANDS, ASKING APPROPRIATE ?'S, LIKE \"I DID OK?\".\nRESP: WEARING FACE MASK AT 70%, MAINTAINS O2 SAT ^ 95 WHEN LEAVES MASK ON, EXPLAINED HIS NEED TO WEAR THE MASK. TAKING DEEP BREATHS, POOR COUGH. NEED SPUTUM C/S.\nGI: TAKING ICE CHIPS.\nGU: URINE CLEAR YELLOW.\nENDO: INSULIN GTT ON, FOLLOWING PROTOCOL.\nID: ^ TEMP, BLD C/S DRAWN FROM A LINE AND CVP PORT OF SWAN, URINE FOR A, C/S AND FUNGAL DRAWN. DOSE OF IV LEVOQUIN GIVEN, NEED ID APPROVAL IN AM TO CONTINUE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-23 00:00:00.000",
"description": "Report",
"row_id": 1481297,
"text": "PT. DEVELOPED A JUNCTIONAL RHYTHM WITH RATE OF 70'S (NODAL TACH) WITH MAP 56. HUO DOWN TO 20CC. DR. NOTIFIED. 500CC HESPAN GIVEN. CO/CI WNL. PACER TURNED UP TO RATE OF 90 (A-PACING) WITH IMPROVED BP AND HUO PICKING UP AFTER HESPAN IN. MAP 70'S WITH PAD 18. CVP 12. PACING CONTINUED DUE TO UNDERLYING RHYTHM OF NSR ALTERNATING WITH NODAL.\n\nPT. AWAKE MOST OF THE TIME. MOANING CONSTANTLY BUT PLEASANT AND COOPERATIVE. SAYS THAT HE CAN'T FALL ASLEEP.\n\nCHEST TUBE DRNG MINIMAL ALTHOUGH THERE IS AN AIR LEAK. SAO2 >95%.\nCOUGHS AND SWALLOWS SECRETIONS.\n\nDENIES MUCH DISCOMFORT AND MOVES WELL IN BED WHEN REPOSITIONED.\n\nINSULIN DRIP OFF @ 0215 FOR BS 62. HOURLY BS'S TO BE CONTINUED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2112-09-22 00:00:00.000",
"description": "Report",
"row_id": 1481295,
"text": "ADMITTED AT ~12 NOON FROM OR, S/P CABG X 3 AND AVR. INTUBATED ON IV PROPOFOL, APROTONIN INFUSING. CT'S PATENT FRO MODERATE AMT SERO-SANG DRAINAGE, LEAK PRESENT. ACT 125, COAG'S SENT WITH ADMIT LAB WORK. CS CLEAR DIMINISHED IN BASES, ALMOST ABSENT IN LT BASE. URINE CLEAR, ADEQUATE AMTS. DOPPLERABLE DP PULSES.\nEPISODE AFTER TURNING OF DESATING TO MID 80'S, AMBUED AND SUCTIONED WITH SMALL EFFECT, PATIENT PLACED BACK ON 100% WITH 10 PEEP, CXR DONE, REPORTED AS NL. O2 SAT ^ TO 100%, AFTER NL CXR WEANING AGAIN. ABG ON CPAP 7.31. AMBUED AND SUCTIONED FOR MODERATE TAN SECRETIONS.\nSB/P ^ , PATIENT DENIES PAIN, SEDATED WITH MINIMAL EFFECT. IV NTG ^, WILL TITRATE TO SB/P OF 130, MEAN 65.\nGLUCOSE NL TILL 1600, INSULIN GTT ^, AFTER 3 UNIT , FOLLOW PROTOCOL.\nFAMILY IN.\n"
}
] |
73,375 | 150,561 | His chest CT on a previous admission showed a 14 x 9 mm ground glass nodule in the right lower lobe. Thoracic Surgery was consulted regarding the lung nodule and recommended follow up in several months with no need to delay surgery now. Following several days of optimal medical management, he was brought to the Operating Room on where he underwent an aortic valve replacement and coronary artery bypass graft. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition on Neo Synephrine, Epinephrine and Propofol infusions. He was seen by the renal service for his renal insufficiency. Pressors wer eweaned to off and he was extubated on POD #3, and gently diuresed toward his preop weight. Chest tubes and pacing wires removed per protocol. He transferred to the floor on POD #4 to begin increasing his activity level. Electrophysiology was consulted for postop atrial fibrillation with conversion pauses. Amiodarone was stopped per theri recommendation. Coumadin was started on POD #6. Metolazone was added on POD #7 to facilitate diuresis. His renal numbers remained stable for days and at discharge the Lasix was changed to an oral form for an additional week of diuresis. The gola INR is 2-2.5 for atrial dysrhythmia and will be managed by the rehabilitation facility. He was discharged to Rehab on . Appointments for follow up were made as appropriate. Medications at discharge were as noted. | Unchanged retrocardiac atelectasis, the tubes and lines are in unchanged position. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. There are simple atheroma in thedescending thoracic aorta. Mild to moderate (+) aortic regurgitationis seen. Unchanged LV and RV systolci function2. Suboptimal image quality - poor echo windows.Conclusions:PRE-BYPASS: The left atrium is normal in size. FINDINGS: As compared to the previous radiograph, there is unchanged mild cardiomegaly and moderate pulmonary edema. However, a mild-to-moderate right pleural effusion has newly occurred. Stable pleural effusions. Borderline size of the cardiac silhouette, no pneumothorax. Mild CM, vasc congestion, pulm edema. Mild mitral annularcalcification. Mild (1+) mitralregurgitation is seen. Moderate retrocardiac and right basal atelectasis. Sternotomy wires are unchanged. There is mild cardiomegaly and mild pulmonary edema. Previously present interstitial edema has resolved. Normal LV wall thickness and cavity size.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending aorta diameter. There is mild cardiomegaly and mild-to-moderate pulmonary edema. No larger pleural effusions. Normal descending aorta diameter.Simple atheroma in descending aorta.AORTIC VALVE: Three aortic valve leaflets. Valvular heart disease.Status: InpatientDate/Time: at 12:51Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. There is no pericardial effusion.POST CPB:1. FINDINGS: As compared to the previous radiograph, there is no relevant change. FINDINGS: As compared to the previous radiograph, there is no relevant change. Compared to theprevious of no change. Mild to moderate (+) AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Cardiomegaly is unchanged. FINDINGS: Heart is upper limits of normal in size. FINDINGS: In comparison with the earlier study of this date, the chest tube has been removed and there is no evidence of pneumothorax. The pre-existing right pleural effusion could have minimally decreased in extent. Left ventricular function. Leftventricular wall thicknesses and cavity size are normal. Right ventricularchamber size and free wall motion are normal. Pulmonary vascularity is normal. Lower lung volumes, but otherwise little change. Lungs are currently clear, and there are no pleural effusions or acute skeletal findings. No PS.Physiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. Mild thickening of mitral valve chordae. The right internal jugular central line remains at the right atrial SVC junction. Overall small lung volumes with signs of mild overhydration. All four pulmonary veins not identified.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. FINDINGS: The lung volumes are low. FINDINGS: PA and lateral chest radiographs were obtained. The monitoring and support devices are unchanged. The monitoring and support devices are in unchanged position. IMPRESSION: Aortic valvular calcifications, consistent with history of aortic stenosis. No newly appeared focal parenchymal opacity. No radiographically evident pneumothorax. FINDINGS: In comparison with study of , the Swan-Ganz catheter has been removed and replaced with a right IJ catheter that extends to the lower portion of the SVC. Small bilateral pleural effusions are present. The other monitoring and support devices are in unchanged position. Mild atelectatic changes are seen at the left base. No focal parenchymal opacity suggesting pneumonia. Aortic valvular calcifications are present, consistent with history of aortic stenosis. Non-specific lateral ST-T wave changes. The lung volumes are low. Tubes and lines in std position. Retrocardiac atelectasis or consolidation. No TEE relatedcomplications. No pneumothorax is present. There is severe aortic valvestenosis (valve area 0.8-1.0cm2). No spontaneous echo contrast or thrombus in thebody of the LAA. LINE PLACEMENT Clip # Reason: CARDIAC SURGERY. Sinus rhythm. Mitral valve disease. Pleural effusion, tamponade, pneumothorax, pulmonary edema. There is a developing retrocardiac opacity suggestive of left lower lobe atelectasis. FINAL REPORT CHEST RADIOGRAPH INDICATION: Status post CABG and cardiac surgery. No spontaneous echo contrast orthrombus is seen in the body of the left atrium or left atrial appendage. No change in valve structure and function The tubes and lines are in expected position. No evidence of pneumothorax. No evidence of pneumothorax. The mitral valve leaflets are mildly thickened. FINDINGS: In comparison with the study of , the monitoring and support devices remain in place. 2.5 cm below the top of the aortic arch. There is no evidence of new focal parenchymal opacity suggesting pneumonia. Coronary artery disease. PATIENT/TEST INFORMATION:Indication: Aortic valve disease. Severe AS (area 0.8-1.0cm2). COMPARISON: Numerous prior chest radiographs, most recently . WET READ: MLHh 10:50 PM Low lung vols. Severely thickened/deformed aorticvalve leaflets. 10:20 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: CT's dc'd. 4:49 PM CHEST PORT. Prosthetic valve function. COMPARISON: No comparison available at the time of dictation. IMPRESSION: Developing left lower lobe atelectasis. 10:27 AM CHEST PORT. A catheter or pacing wire isseen in the RA.LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2Dimages. I certifyI was present in compliance with HCFA regulations. There are three aortic valve leaflets. The aorticvalve leaflets are severely thickened/deformed. Continued enlargement of the cardiac silhouette in this patient with intact midline sternal wires following cardiac surgery. evalute for pneumo FINAL REPORT HISTORY: CABG, to assess for pneumothorax. | 11 | [
{
"category": "Radiology",
"chartdate": "2137-02-01 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1173512,
"text": " 4:49 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: CARDIAC SURGERY. Pleural effusion, tamponade, pneumothorax,\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with CABG/AVR\n REASON FOR THIS EXAMINATION:\n CARDIAC SURGERY. Pleural effusion, tamponade, pneumothorax, pulmonary edema.\n ______________________________________________________________________________\n WET READ: MLHh 10:50 PM\n Low lung vols. Mild CM, vasc congestion, pulm edema. Retrocardiac\n atelectasis or consolidation. Tubes and lines in std position.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG and cardiac surgery.\n\n COMPARISON: No comparison available at the time of dictation.\n\n FINDINGS: The lung volumes are low. There is mild cardiomegaly and mild\n pulmonary edema. Moderate retrocardiac and right basal atelectasis. No\n larger pleural effusions. No focal parenchymal opacity suggesting pneumonia.\n The tubes and lines are in expected position. No radiographically evident\n pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173675,
"text": " 7:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate/effusion\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p cabg/avr\n REASON FOR THIS EXAMINATION:\n eval for infiltrate/effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The monitoring and support devices are in unchanged position.\n Overall small lung volumes with signs of mild overhydration. The pre-existing\n right pleural effusion could have minimally decreased in extent. Borderline\n size of the cardiac silhouette, no pneumothorax. No newly appeared focal\n parenchymal opacity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173541,
"text": " 8:20 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: hypoxia\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with s/p cabg and AVR\n REASON FOR THIS EXAMINATION:\n hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, hypoxia.\n\n COMPARISON: , 5 p.m.\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. The lung volumes are low. There is mild cardiomegaly and\n mild-to-moderate pulmonary edema. Unchanged retrocardiac atelectasis, the\n tubes and lines are in unchanged position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173597,
"text": " 9:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxia\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with s/p CABG and AVR\n REASON FOR THIS EXAMINATION:\n hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post CABG, hypoxia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is unchanged mild\n cardiomegaly and moderate pulmonary edema. However, a mild-to-moderate right\n pleural effusion has newly occurred. There is no evidence of new focal\n parenchymal opacity suggesting pneumonia. The monitoring and support devices\n are unchanged. No evidence of pneumothorax. 2.5 cm below the top of the\n aortic arch.\n\n The other monitoring and support devices are in unchanged position.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-01-31 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 1173341,
"text": " 3:08 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CHEST PAIN\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with aortic stenosis and CAD, planned for CABG/AVR\n REASON FOR THIS EXAMINATION:\n Pre-op evaluation for CABG/AVR\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST OF \n\n COMPARISON: .\n\n FINDINGS: Heart is upper limits of normal in size. Pulmonary vascularity is\n normal. Previously present interstitial edema has resolved. Lungs are\n currently clear, and there are no pleural effusions or acute skeletal\n findings. Aortic valvular calcifications are present, consistent with history\n of aortic stenosis.\n\n IMPRESSION: Aortic valvular calcifications, consistent with history of aortic\n stenosis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-07 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1174225,
"text": " 8:36 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for pleural effusions\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p AVR/CABG\n REASON FOR THIS EXAMINATION:\n eval for pleural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post AVR, CABG, evaluate for pleural effusions.\n\n COMPARISON: Numerous prior chest radiographs, most recently .\n\n FINDINGS: PA and lateral chest radiographs were obtained. Small bilateral\n pleural effusions are present. There is a developing retrocardiac opacity\n suggestive of left lower lobe atelectasis. Cardiomegaly is unchanged. The\n right internal jugular central line remains at the right atrial SVC junction.\n No pneumothorax is present. Sternotomy wires are unchanged.\n\n IMPRESSION: Developing left lower lobe atelectasis. Stable pleural\n effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173773,
"text": " 7:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man s/p avr\n REASON FOR THIS EXAMINATION:\n eval for effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AVR.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. No evidence of pneumothorax. Continued enlargement\n of the cardiac silhouette in this patient with intact midline sternal wires\n following cardiac surgery. Mild atelectatic changes are seen at the left\n base.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1173800,
"text": " 10:20 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: CT's dc'd. evalute for pneumo\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with s/p CABG and AVR\n REASON FOR THIS EXAMINATION:\n CT's dc'd. evalute for pneumo\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG, to assess for pneumothorax.\n\n FINDINGS: In comparison with the earlier study of this date, the chest tube\n has been removed and there is no evidence of pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-02-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1173939,
"text": " 10:27 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: evaluate new RIJ TLC\n Admitting Diagnosis: CHEST PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 83 year old man with s/p cardiac surgery, RIJ line changed over wire\n REASON FOR THIS EXAMINATION:\n evaluate new RIJ TLC\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right IJ catheter change.\n\n FINDINGS: In comparison with study of , the Swan-Ganz catheter has been\n removed and replaced with a right IJ catheter that extends to the lower\n portion of the SVC. Lower lung volumes, but otherwise little change.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2137-02-01 00:00:00.000",
"description": "Report",
"row_id": 97757,
"text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Prosthetic valve function. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 12:51\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the\nbody of the LAA. All four pulmonary veins not identified.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA.\n\nLEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D\nimages. Normal LV wall thickness and cavity size.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Normal descending aorta diameter.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Severe AS (area 0.8-1.0cm2). Mild to moderate (+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. Suboptimal image quality - poor echo windows.\n\nConclusions:\nPRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast or\nthrombus is seen in the body of the left atrium or left atrial appendage. Left\nventricular wall thicknesses and cavity size are normal. Right ventricular\nchamber size and free wall motion are normal. There are simple atheroma in the\ndescending thoracic aorta. There are three aortic valve leaflets. The aortic\nvalve leaflets are severely thickened/deformed. There is severe aortic valve\nstenosis (valve area 0.8-1.0cm2). Mild to moderate (+) aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral\nregurgitation is seen. There is no pericardial effusion.\n\nPOST CPB:\n1. Unchanged LV and RV systolci function\n2. No change in valve structure and function\n\n\n"
},
{
"category": "ECG",
"chartdate": "2137-02-01 00:00:00.000",
"description": "Report",
"row_id": 267010,
"text": "Sinus rhythm. Non-specific lateral ST-T wave changes. Compared to the\nprevious of no change.\n\n"
}
] |
24,069 | 181,968 | The patient was admitted to the preoperative holding area on . He underwent a left carotid endarterectomy without complication and was transferred to the post anesthesia care unit in stable condition. Patient developed atrial fibrillation and bradycardia requiring Neo-Synephrine support. His rule out was negative. The patient developed on at about 3 A.M. in the morning mental status changes associated with hypoxia with a pCO2 of 80 and CO2 of 67. The chest x-ray showed possible hump. The patient was begun on IV heparin. CTA was obtained which showed a left lower lobe pulmonary embolus. Patient became aphasic with right sided flaccidness. The heparin was discontinued. CTA of the head was obtained which showed a large hemorrhagic stroke. He was given 2 units of fresh frozen plasma and a unit of platelets. He required Neo-Synephrine and dobutamine for blood pressure control. Neurosurgery was consulted. The patient was begun on a Dilantin load and he underwent on a left parietal frontal craniotomy with evacuation of hemorrhage. Intraoperatively the patient experienced asystole but was resuscitated. Inferior vena cava filter was placed. Because of history of atrial fibrillation the patient was admitted to the thoracic Intensive Care Unit for continued care. The patient continued on a prednisone taper. He developed transient thrombocytopenia. His heparin dependent antibodies were negative. EPS was consulted secondary to the patient's atrial fibrillation and bradycardia. They felt that a pacemaker was not indicated at this time although external pacemaker leads were applied. A nasogastric tube was placed on and tube feeds were begun. The patient was noted to have a left neck hematoma which was stable. A a CPAP was tried. The patient failed. The patient was begun on Zosyn for gram negative rods in his sputum culture and a right lower lobe infiltrate on chest x- ray. White count at that time was 7.4. Levofloxacin was added on to his Zosyn for broader pseudomonas coverage in his sputum. On the patient was finally extubated. A swallowing study was done at the bedside. The patient did show signs of aspiration with delayed swallowing. The study was terminated because of concern for respiratory compromise and the patient remained n.p.o. on tube feeds. On the patient self discontinued his tube feed and his arterial line. The Dobhoff was replaced. IV heparinization was started slowly. On the patient was transferred to the vascular Intensive Care Unit for continued monitoring and care. Physical therapy and occupational therapy evaluations were begun. On the patient desaturated to an O2 of 59%. He was transferred to the Intensive Care Unit. He required IV Lasix and Lopressor for rate control. And nebulizers and aggressive pulmonary care. On patient remained in the Intensive Care Unit. Stool for C difficile was sent and patient's stool was positive and patient was started on . On a repeat swallow was attempted but held secondary to the patient being n.p.o. for a PEG placement. On the patient underwent endoscopic percutaneous gastric tube placement. The patient continued to do well, tolerated his tube feeds. On patient was transferred to the vascular intensive care unit for continued monitoring and care. On physical therapy continued to work with the patient. IV heparin and Coumadinization conversion was continued. Renal screening was begun. The patient will be discharged to rehabilitation when he is in a steady therapeutic INR state of 2 to 3.0. The patient will follow up with Dr. as directed post discharge from rehabilitation. He should follow up with his primary care physician. | cvl right IJ site w/ mod amt serosang drainage, dsg changed prn.gi: belly soft, nt/nd. NIBP IN PLACE AS ALINE IS POSITIONAL AND DAMPENED. Nodding appropriately to questions.CV: Pt with PMH of chronic Afib. LYTES PER CAREVUE. Pt is c-diff+. Echo pending ( as per order)RESP: Propofol d/c,. Lopressor Q4hrs as indicated. HAD TEE-RESULTS PENDING.RESP: INTUBATED #7.5/21. bs hypo. abg stable.cv: dopamine dosing continued, weaned slightly this am. Adm Dilantin. bp stable 1teens-130sys, conts on po metoprolol . CONTINUES ON ZOSYN AND LEVOFLOXACIN ADDED. TOLERATING LOPRESSOR DOSE. AM RSBI 43.GI/GU: ABD SOFT AND DISTENDED WITH +BS. mannitol, decadron weaning. CPT and nebs Q2-4hrs. ABG 7.45/40/98/29. FS Q6HRS WITH SSRI. Pt transferred d/t respiratory distress. SICU NN: See carevue for specifics. RIGHT LE WITHDRAWS EASILY TO LIGHT STIMULATION, SPONT MOVEMENT OF R ARM NOTED BY PT TODAY. Pt started on Maint IVF over to remain NP0. Continues on Zosyn and Levofloxacin.Skin: Staples to head c/d/i. Rehab. Follows commands inconsistently, normal strength on LUE. Tnf back to . PTT is being checked Q6H.access: double lumen RIJ.GI/ GU: abdomen soft and distended, bowel sounds positive, TF @ goal via Dobhoff tube. ?wean sedation, vent settings if agitation improves when awake. One bm today, cdiff sample sent. CXR WITH ? FOLLOWS COMMANDS.LUNGS DIMINISHED AT BASES WITH SLIGHT CRACKLES RLL. l arm remains restrained d/t attempting to pull out foley, ngt.cv- remains in afib rate 70-90's occ pvc's noted. titrate tf to goal rate, cont sedation, serial neuro checks. WILL BE DC'D IN AM.RESP- INUBATED AND VENTED. ATROVASTATIN STARTED TODAY.GI- ABD SOFT DISTENDED WITH POS BS. CONT Q1HR NVS AND PERIODIC NVS OFF PROPOFOL. LABILE HEMODYNAMICS, DOPA AND NIPRIDE DEPENDENT AT THIS TIME. heparin gtt now at 1200u/h, ptt due at .gi- abd soft distended + bs, 2 medium soft brown guiac negative stools. DOPA AND NIPRIDE AS NEEDED. SS WAS TIGHTENED TODAY.ID- TEMP MAX 99.6. CONT ON DILANTIN. Resp CarePt. TUBE WAS POST PYLORIC BY XRAY. REPLACE THIS EVE [ AWAIT TEAM]...OTHERWISE CHEM/ CBC UNREMARKABLE...RESP..LLL PE..FILTER NOW IN PLACE, ABG SATISFACTORY PRESENTLY ON AC 700X12 PEEP @ 5 , REPAET CXR TAKEN AS ? L CEA INCISION STERISTRIPPED W/ OLD BLDY DNGE, NO ERYTHEMANOTED. PTT at 0930.access: RSC double lumen.gi/gu: Belly is soft/distended with + BS. CPT done w/turns. Palpable pulses bilaterally.GI: Abdomen soft, +BS. IN FOR REPEAT LEVEL IN AM. Chest PT with turns. RESTARTED DOPA AT 2.0 MCG/KG/MIN W/ CONT PAUSES AND SLOW RESPONSE. Generalized edema.Respir: LS are diminished bil at bases and clear upper lobes. WEANED OFF X1 AND HR 40'S AFIB W/ FREQUENT PAUSES. LS CLEAR, DIMINISHED AT R BASE.RENAL/METABOLIC: ADEQUATE U/O. MARKED R SIDED HEMIPARESIS. REPLETE LYTES. RESTART TF ONCE FT PLACEMENT VERIFIED BY XRAY. LACTATE 2.0.GI: REMAINS NPO W/ ABSENT BS. Craniotomy site healed, OTA, no drainage.POC: transfer to floor. Head CT done.PLAN: Attempt to wean off of Nipride gtt and Dopamine gtt. CONT ON MANNITOL, DECADRON AND DILANTIN. TO HAVE TEE DONE TOMMORROW.GI- ABD SOFT DISTENDED WITH POS BS. ALINE DAMPENED UNTIL REDRESSED THIS AM NOW CORRELATING WITH NIBP. FS 159/94 COVERED WITH SSRI. RT STUCK FOR ABG 7.46/40/83/29. +PE (was on heperin earlier today)GI: abd distended. WAS ON NIPRIDE AND DOPA. LYTES PER CAREVUE. LYTES PER CAREVUE. RIGHT INFILTRATE.GI/GU: ABD SOFT AND DISTENDED WITH +BS. EPISODE SOB, CTA +PE, STARTED ON HEPARIN GTT. received pt from CTscan, intubated. SBP 120-130.GI- ABD SOFT WITH POS BS. FS 202/130 COVERED WITH SSRI. ABG 7.45/40/112/29. OFF AT MIDNOC, NOW NPO FOR TEE. TOLERATING LOPRESSOR DOSE. FOCUS; NURSING PROGRESS NOTEMR IS S/P LEFT CEA. MOVES LE'S. ATIVAN ATC FOR DT PROPHYLAXIS WAS CHANGED TO PRN. ABG 7.42/42/113/29. Respiratory CarePt weaned to minimal settings on CPAP/PSV. LS CLEAR TO COARSE WITH DIMINISHED RIGHT BASE. dilantin level therapeutic, cont dose as ordered. ppp bilat, mild generalized edema noted. TRANSFERRED TO TSICU AFTER OR. Continues with chest PT. MICU NPN 7P-7ANEURO: EXAM UNCHANGED, PLEASE SEE CAREVUE FOR SPECIFICS. focus; addendumgi- doboff in the right main stem by xray. o2 sats stable.cv: dopamine and nipride remain off, remains in afib, rare pvc's noted. RESP CAREPT REMAINS ON CPAP-PARAMETERS NOTED. TOLERATING HIS LOPRESSOR. PER DR XRAY SHOWS PROPER PLACEMENT OF TUBE. TEAM THIS AM SAID HE LAST CXR LOOKED "A LITTLE WET". FS Q6HR WITH SSRI.ID: TMAX 99.3 WITH WBC 10. LEFT ARM RESTRAINED AS HE HAS GONE FOR ETT. BP 103-139/39-66. Plan: lighten sedation, wean ventilatory support. SLIGHT MOVEMENT OF RUE, WITHDRAWS TO NAILBED PRESSURE. bs present. BS CLEAR DIMINISHED AT THE BASES.CARDIAC- HR 70-80'S AFIB WITH RARE TO OCCASIONAL PVC'S. Physiologic mitral regurgitation is seen (within normal limits).Moderate [2+] tricuspid regurgitation is seen. Since the previous tracingof ventricular ectopy is absent.TRACING #1 The right ventricular cavity is mildly dilatedwith mild global free wall hypokinesis. Atrial fibrillationVentricular premature complexesLeft anterior fascicular blockSince previous tracing of the same date, inferior T wave changes decreased andventricular ectopy present There is nopericardial effusion.IMPRESSION: Low normal biventricular systolic function without regionaldysfunction. Atrial fibrillation with PVCs or aberrant ventricular conduction.Left anterior fascicular blockIncomplete RBBB Again noted is a small right-sided pleural effusion and associated atelectasis at the right base along with some atelectasis at the left lower lobe. Moderate mitral annularcalcification. Moderate tricuspid regurgitation. The aortic root is mildly dilated. Left anterior fascicular block. Left anterior fascicular block. Atrial fibrillation with slow ventricular responseLeft anterior fascicular blockNonspecific inferior T wave abnormalitiesProminent precordial T wave changesCannot exclude in part ischemia or possible hyperkalemiaClinical correlation is suggestedSince previous tracing of , ventricular rate markedly slower and furtherT wave changes present Right jugular CV line is in mid SVC. The mitral valve leaflets are mildlythickened. Physiologic MR (within normal limits).TRICUSPID VALVE: Normal tricuspid valve leaflets. Pulmonary artery systolichypertension.Based on AHA endocarditis prophylaxis recommendations, the echo findingsindicate a moderate risk (prophylaxis recommended). Atrial fibrillation. Atrial fibrillation. Also of note, there is a small blood layering in the lateral ventricles bilaterally. There is mild pulmonary arterysystolic hypertension. The right jugular CV line is in the distal SVC. Small bilateral pleural effusions. Atrial fibrillationDiffuse nonspecific ST-T wave abnormalitiesSince previous tracing, left anterior fascicular block resolved and ventricularrate faster | 61 | [
{
"category": "Nursing/other",
"chartdate": "2136-10-15 00:00:00.000",
"description": "Report",
"row_id": 1576148,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nPt transfered from at approx 9am with RN and resident . Pt transferred d/t respiratory distress. ? Intubation d/t hypercarbia. Pt arrived to Sicu on 4l NC sating 98%. Current assesment is as follows:\nNeuro: Pt more alert as day progressed PaC02 40. Pt alert/arouses to voice. Follows commands inconsistently. MAE. Right side very flaccid. Pupils equal and brisk. Pt has garbled speech. Nodding appropriately to questions.\nCV: Pt with PMH of chronic Afib. Currently on heparin gtt @1200units/hr for PE. SBP Stable. Lopressor Q4hrs as indicated. +PP\nResp: Lungs diminished scattered rhonci throughout. CPT and nebs Q2-4hrs. + cough. Sats remain >95% on 3LNC. ABG later showing improving hypercarbia with worsening oxygenation. MD's aware. Pt with history of ? COPD and long term smoker. No new intervention other than cont aggressive pulm toilet.\nGI/GU: NPO upon arrival. ? Peg tomorrow. Pt started on Maint IVF over to remain NP0. Abd soft NT + BS no Bm's today. Pt is c-diff+. Foley is patent drng yellow urine. Some hematuria noted team is aware. (MD ).\nEndo: RISS\nID: + clearing pneumonia on abx therapy\nPlan: PEG tomorrow ? Tnf back to . Pt family would like to speak with social worker and case mmgt RE: ? Rehab.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-16 00:00:00.000",
"description": "Report",
"row_id": 1576149,
"text": "npn\nneuro: alert at times but unalbe to say his name, oriented x 0, speech is garbled and uncomprehensible. perrla at 3 to 4mm. pt left arm restrained because he can become combative towards staff.\n\npain: no isues\n\ncad hr 80's a-fib with occas. pvc. b/p 125/68 to 92/49. am K= 3.8 replete\n\nresp ls clear, sats 93 ro 100% rr teens to 20's. continues on nc at 3l with alb neb Q/4 hours, chest pt also.am abg 7.48,39/77\n\ngi: bs+ dobhoff remains in place, no stool overnight. needs sample taken for c=diff and vrre.\n\ngu: uo 30 to 60 cc/hr urine is yelow but with sedient\n\nendo: bs 110x2. no ssi coverage needed.\n\nlabs: hct 31.3, ptt/pt 14.1/46.4, K+ 3.8 and mag 1.9 both being repleted)\n\nplan: check pt/ptt at 1100am. cont to monitor mag and K+ infusions. heprain bolused and gtt increased by 200 units/hr. **pt to have peg placement tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-16 00:00:00.000",
"description": "Report",
"row_id": 1576150,
"text": "SICU NN: See carevue for specifics. Patient alert, right sided facial droop, right arm flaccid. Speech is garbled although patient attempts to communicate. Patient is communicating by nodding and appears frustrated at times. Patient appears to be appropriate to name. Patient pulled out dobhoff last night. Left arm restrained for safety. 4-5L nc in place, chest pt Q2h. Afib on cardiac monitor. BP wnl. NGT remains out and po meds on , md aware, flagyl changed to iv. Patient most likely will recieve peg tomorrow. One bm today, cdiff sample sent. Foley intact and patent. Skin intact. Head incision well approximated with no drainage. Patient without signs and symptoms of pain. OOB to chair today. Spoke with family (wife and daughter) regarding plan of care at length.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-06 00:00:00.000",
"description": "Report",
"row_id": 1576122,
"text": "Nursing NOte:\nREVIEW OF SYSTEMS:\n\nCV: Dopamine weaned off, bp= 102/59-129/65 (arterial), art. line 7 pt.s lower than NBP, hr=74-85 a.fib, rare pvc. Ext. cool, weak dp bil. Echo pending ( as per order)\n\nRESP: Propofol d/c,. PSV ventilation, 5PS, 5 peep, tv=770, rate=12, sat=100%, suctioned for mod. large amt. of thick light yellow secretions.\n\nGI: Abd. distended, soft, hypoactived BS, impact with fiber at 60cc/hr, no residual.\n\nGI: Foley to gravity, amber urine 24-100cc/hr\n\nSKIN: Mottled face, neck, head incision with staples, clean and dry, abraded left lower arm, tegamderm intact. Ext. cool. Ecchymotic areas arms bil.\n\nMENTATION: PERL, 3mm-4mm bil., opens eyes to name, does not consistently follow commands, left arm +5/+5, withdraws right arm to painful stimuli, random movement of left leg, inconsistently wiggles toes right foot. Fentanyl 50 mcg x2 given for restless. Episode of reaching left arm into air, ativan started 1mg q6 hours. + cough, + gag. Sleeping in naps througout the day. Mannitol d/c, decadron decreased.\n\nENDO: Insulin as per sl. scale\n\nID: Low grade temp 100.1\n\nSOCIAL: Children in to visit most of day. Asking questions and making notations of any and all changes of care. SICU MD, met with daughter and answered many questions. Dr. met with children in am and addressed their questions and concerns.\n\nPLAN: Continue with pul. toilet, continue with ativan as per order, echo pending ( as per order), increase TF to goal as per order, continue with neuro assessment, monitor dilantin level. Provide support to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-09 00:00:00.000",
"description": "Report",
"row_id": 1576132,
"text": "MICU NPN 7P-7A\nNEURO: NO CHANGES IN EXAM OTHER THAN PATIENT SEEMS MORE ALERT AND INTERACTIVE. DOZING BUT EASILY AROUSABLE. WHEN FAMILY VISITING HE WAS NODDING AND FOLLOWING CONVERSATIONS BETWEEN FAMILY MEMBERS. FOLLOWING COMMANDS MORE CONSISTENTLY. STILL FULL STRENGTH/MOVEMENT OF LUE REQUIRING RESTRAINT. HE WILL PULL HIMSELF OVER TO TRY TO REACH TUBE. MOVING BLE'S. SLIGHT MOVEMENT OF RUE. PATIENT MORE COOPERATIVE WITH TURNING/CPT. WAS ASSISTING WITH LIFTING LEGS FOR BATH. PERL @3MM AND BRISK. GAG AND COUGH IMPAIRED BUT SEEM TO BE IMPROVING. ON DILANTIN, NO SEIZURE ACTIVITY NOTED. C/O HA AND GIVEN 25MCG OF FENTANYL WITH EFFECT. ALSO RECEIVED 0.5MG ATIVAN THIS MORNING SO WE COULD CHANGE HIS ETT TAPE THAT HE WAS TONGUING OUT. CT YESTERDAY PRELIM READ SHOWED NO CHANGES WITH BLEED.\n\nCARDIAC: HR 37-81 AFIB WITH NO ECTOPY. PATIENT HAD A FEW EPISODES OF HR IN THE 40'S. NO CHANGE TO BP. BP 103-137/41-66 VIA NIBP AS ART LINE IS DAMPENED. TOLERATING LOPRESSOR DOSE. ECHO SHOWED EF OF 45%. PPP. HCT STABLE @33.8.\n\nRESP: REMAINS ON CPAP 5/5 40% WITH TV'S 600'S, RR 16-21 AND SATS 92-99%. ABG 7.45/40/98/29. LS CLEAR WITH COARSE RIGHT BASE. SXTED Q2HRS OR MORE FOR THICK TAM TENACIOUS SPUTUM. AM RSBI 43.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. NO STOOL. OGT IN PLACE. UOP 18-140CC/HR YELLOW AND CLEAR.\n\nFEN: IVF @KVO. LYTES PER CAREVUE. FS Q6HRS WITH SSRI. TUBE FEEDS @90CC/HR WITH MINIMAL RESIDUALS. FREE WATER Q4HRS.\n\nID: TMAX 99.8. WBC 7. CONTINUES ON ZOSYN AND LEVOFLOXACIN ADDED. SPUTUM APPEARS TO BE GROWING PSEUDOMONAS.\n\nSKIN: STAPLES TO HEAD C/D/I. COCCYX PINK, LEFT NECK EDEMATOUS WITH STERI STRIPS.\n\nACCESS: RIGHT ART LINE WHICH DOES NOT DRAW WELL AND IS BLEEDING. RIJ CVL IS ALSO BLEEDING.\n\nSOCIAL/DISPO: FULL CODE. WIFE/DAUGHTER VISITING LAST NOC. ?'S ANSWERED. NO DEFINITIVE PLANS TODAY. CONTINUE TO TREAT PNA IN HOPES OF EXTUBATION IN NEAR FUTURE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-09 00:00:00.000",
"description": "Report",
"row_id": 1576133,
"text": "Resp Care\nPt remains on mech vent-parameters noted. Pt attempted to pull ETT out. Found to be in position. Checked with CO2 detector and bilat breath sounds. Pt continues to lack gag and have thick tan secretions. Will continue mech vent and wean as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-09 00:00:00.000",
"description": "Report",
"row_id": 1576134,
"text": "NPN 07:00-19:00 MICU\n*Please refer to Carevue for additional patient information\n\nROS:\nNeuro: Alert, nodding, following commands. Only slight movement of fingers in RUE this am. LUE remains restrained, LLE lifting and stretching, RLE moves on bed. Continues to have impaired gag (slightly stronger than this am) and weak cough. Pain: Fentanyl x2 given (HA, and repositioning ETT, as well as tongued OGT out)Plan: continue to monitor secretions/treat PNX, monitor gag, in hopes of extubation in near future.\n\nCV: HR A-fib (low 50)60-70's, SBP 1-teens-120's/60's, Lopressor given.\nART line dampened, continue to follow NBP.\n\nREsp: No vent changes PS 5/5/40%, o2 sat's ~93-94%, Small-moderate amounts of thick tan secretons, sxn q 4hr, lessening throughout day.\n\nGI/GU: TF's at goal, minimal residuals. +bs, no bm.RISS. U/o wnl, amber, clear.\n\nID: Tmax 99.8 po, Tylenol to be given. Continues on Zosyn and Levofloxacin.\n\nSkin: Staples to head c/d/i. Left neck with edema, steris in place.\nAccess: RIJ, bldg, A-line dampened, bldg.\n\nSocial: Daughter and Wife in to visit, spoke to Cardiologist ?still waiting to speak to Neuro Team.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-13 00:00:00.000",
"description": "Report",
"row_id": 1576146,
"text": "micu npn 1900-0700\nplease see carevue flowsheet for all objective data\n\ntransfer note in chart, pt continues to await a telemetry bed on a medical floor\n\nneuro- remains unchanged, able to nod to y/n questions. denies pain. mae. l arm remains restrained d/t attempting to pull out foley, ngt.\n\ncv- remains in afib rate 70-90's occ pvc's noted. bp stable 1teens-130sys, conts on po metoprolol . k noted to be 3.6 w/first lasix dose o/n. repleted w/total of 60meq kcl. since has received another dose of lasix. awaiting am labs. remains on 1200u/hr heparin, last ptt w/in range of 50-70sec. only s+s of bleeding is from foley catheter which he has been yanking at when it is w/in reach. hct5 remains stable. conts to have various areas of bruising on large skin surfaces'.\n\nresp- remains on 35% cool neb. sats high 90's all night. able to cough secretions. +somewhat weak gag, intact cough. cpt o/n done, ?if he is asperating what he coughs up though at times. rr mid20's.\n\ngi/gu- some controversy on position of ngt, cxr reshot, radiologist read was that it was in the stomach, although it can and should be advanced 4 cm. this was done, no repeat cxr was taken, tube feeds were resumed per dr . +bs, soft brown stool x3 o/n. urine pink as above, lasix given x2 for goal at 1l neg o/n, at 0300, pt was ~650cc neg. surgical team in close contact.\n\ncont to support, pulm toilet, follow neuro status.. cont to await bed on floor\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-13 00:00:00.000",
"description": "Report",
"row_id": 1576147,
"text": "npn 7a-7p\nneuro: responds with a nod to questions, PERL @ 3 mm. Follows commands inconsistently, normal strength on LUE. MAE on bed. Soft wrist restraint on left arm as patient attempts to pull Foley.\n\nresp: humidified face tent, sats 95-97%. LS coarse throughout, strong productive cough.\n\nCV: atrial fibrillation, with HR 60s-90s. No ectopy. Heparin drip @ 1250 u/hr. PTT is being checked Q6H.\n\naccess: double lumen RIJ.\n\nGI/ GU: abdomen soft and distended, bowel sounds positive, TF @ goal via Dobhoff tube. Large liquid stool this shift. Patent Foley catheter, with slightly blood tinged urine.\n\nEndo: RISS\n\nID: afebrile, continues on piperacillin and levofloxacin.\n\nSkin: please see carevue.\n\nDispo: full code.\n\nSocial: Wife and three children in to visit today.\n\nPlan: transfer to VICU. Next PTT @ 2130.\n\nnote written by: , BCSN\nreviewed and co-signed by: , RN\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-05 00:00:00.000",
"description": "Report",
"row_id": 1576118,
"text": "Respiratory Care\nPt remains on current ventilator settings with changes made this shift. Breath sounds diminished throughout.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-17 00:00:00.000",
"description": "Report",
"row_id": 1576151,
"text": "assessment as noted\n\nres: ls coarse , + cough productive-swallows swcretions , on 4 lnc maintains so2>98, ct pt done with turns\n\ncv: in a/fib, on heparin 1400, ptt was teraputic, rare pvcs, bp stable\n\ngu: dark urine, getting lasix 20 with increased u/o,\n\nneuro: follows simple commands inconsistantly, r. side paresis, strong l. arm--restrained (see carevue for further assessment)\n\ngi: remains npo, no ngt was inserted, planned for peg ? date. abd soft, no stool, + bs\n\nsocial: family called and was updated\n\nid: no fever, on c-diff precautions.\n\na: alteration in neuro status d/t brain hemmorrhage\n potential for clots displacement d/t a/fib\n\nplan: confurm peg date, ? transfer , cont in heparin gtt , ? coumadin when takes po\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-17 00:00:00.000",
"description": "Report",
"row_id": 1576152,
"text": "FOCUS; STATUS UPDATE\nDATA;\nSEE CAREVUE FOR SPECIFIC DETAILS.\n\nPT LETHARGIC BUT EASILY AROUSABLE IF NOT AWAKE. LOOKS AT SPEAKER WITH L SIDED GAZE MOSTLY. ON CLOSER EXAM HE WILL TURN TO A SPEAKER ON HIS RIGHT IF PROMPTED. PERL 3-4MM. MOVES L SIDE ACTIVELY IN BED, LIFTING AND HOLDING UP L ARM. RIGHT LE WITHDRAWS EASILY TO LIGHT STIMULATION, SPONT MOVEMENT OF R ARM NOTED BY PT TODAY. PIVOTED OOB TO CHAIR AND HOYERED BACK TO BED. FOLLOWS COMMANDS.\n\nLUNGS DIMINISHED AT BASES WITH SLIGHT CRACKLES RLL. AUDIBLE THICK UPPER AIRWAY SECRETIONS. STRONG PRODUCTIVE COUGH(SWALLOWS), POSITIVE GAG. SATS 98-100% ON 4L NC O2. AT RISK FOR AIRWAY OBSTRUCTION BY POORLY CONTROLLED TONGUE DUE TO STROKE. MAINTAINED SITTING UP IN BED AT 45DEGREES. WIFE STATES THIS IS IMPROVED SINCE YESTERDAY.\n\nURINE BLOOD TINGED THIS AM. DR. NOTIFIED. COAGS MONITORED. HEPARIN GTT STOPPED FOR POSSIBLE PEG PLACEMENT. RESUMED THIS AFTERNOON.\n\nFAMILY MEETING WITH DR. . QUESTIONS ASKED AND ANSWERED RE: PEG PROCEDURE AND PT STATUS. PRIMARY TEAM NOTIFIED THAT FAMILY WANTS UPDATE AND WILL SPEAK TO THEM. PEG POSTPONED UNTIL AM.\n\nPLAN:\nCPT, MONITOR RESP STATUS. MONITOR COAGS Q6HR FOR GOAL PTT 60-70. PEG IN AM WITH POSSIBILITY OF INTUBATION FOR PROCEDURE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-18 00:00:00.000",
"description": "Report",
"row_id": 1576153,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nNeuro: Pt opens eyes to voice and occasionally follows some commands. Moving left side in bed frequently, squeezes with left hand and releases to command. Slight movement in right side in bed occasionally but not to command. Pupils are equal and briskly reactive.\n\nCV/GU: CV stable, lopressor as ordered. Good urine output. Bilat. pedal pulses palpable. Hep gtt increased.\n\nGI: bowel sounds present. Abdomen soft. ? PEG in am after family discusses with primary team. No tpn tonight, ? in am after family meeting.\n\nResp: lungs coarse and with diminished bases. Strong cough. Chest PT. Nasal cannula at 3 liters/.\n\nPlan: ?PEG, ?tpn, dilantin level pending. PTT at 2300 34, gtt increased at 0000 and another level due 6 hours following at 6am. (level drawn at 4 am with morning labs only 4 hours post increase in gtt) PLease refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-18 00:00:00.000",
"description": "Report",
"row_id": 1576154,
"text": "FULL CODE Contact Precautions - sputum NKDA\n\n\nNeuro: In am, pt was very lethargic, not opening his eyes, not cooperative w/ PT as he had been yesterday. He did follow commands by moving his L extrems; R side extrems he moved to tactile stim. PT stood and pivoted pt - very difficult! But once pt was in the chair and family arrived, he was much more alert and interactive, even attempting to speak to wife. At 1300, pt was intubated and sedated for PEG placement at the bedside and remained on low-dose propofol until his extubation at 1800. Pupils 3mm/brisk bilat. On Dilanitin - no seizure activity noted. Head incision approx - no drainage, no dressing.\n\nCV: HR=80-90s, afib, no ectopy. BP 110-130s/50-60s, but BP did < w/ sedation for short period. Periph pulses +, extrems warm, no edema. Heparin gtt was d/c'd this am for PEG placement and will be restarted at 2200 at 1400 units/hr (previous rate w/ last PTT=62). On lopressor 5mg IVP q6hr. Afternoon dose held w/ pt receiving sedation.\n\nResp: Pt was on 3L n/p prior to intubation for procedure. He was weaned down immed to CPAP/PS 5/5 after PEG placement and Fi02 weaned down from 100% to 40% just before extubation to 35% CMM. 02sat 97-98%. Suctioned for thick tan, occ bloody secretions via ETT - sputum cx sent. Otherwise, pt has strong cough, very congested, but unable to cough it out. BS prior to intubation coarse and diminished in bases bilat and while intubated and able to suction well, BS clearer.\n\nGI/GU: Abd soft, +BS, +BMx2 - heme neg. NPO. PEG placement done and will be able to use it tomorrow for meds/feedings. Foley cath w/ clear yellow urine and it more amber now - adequated amt. Receives lasix q am and diureses well.\n\nID: T=99.0 axil - on ceftaz and flagyl.\n\nLabs: BS=101-104, not requiring insulin per RISS. Last PTT at 0600 = 62 w/ heparin gtt at 1400 units. Since heparin gtt was d/c'd for procedure, PTT not obtained. Heparin to restart at 1400 units/hr at 10pm w/ next PTT due at 0400.\n\nAccess: RIJ double lumen cath - ports patent.\n\nSocial: Wife, daughters and other friends in to visit. Team and Dr. also spoke to wife and daughter this am prior to PEG placement.\n\nPlan: Continue to monitor neuro status. Adm Dilantin. Monitor resp status post extubation - resp tx prn. Monitor caridiac status. Update family on pt's status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-06 00:00:00.000",
"description": "Report",
"row_id": 1576119,
"text": "nursing prog note\n\nneuro: remains lightly sedated, moving ble on bed while sedated. exam much improved when lightened, inconsist. follows commands, moving left side well. withdraws from pain to right. perrla, nods and shakes head to ques. becomes very agitated when lightened, thrashing left arm, attempting to sit up. mannitol, decadron weaning. dilantin dose increased last eve.\n\nresp: ac mode, 50%, 700x12, 5 peep. no changes made overnight. ls coarse to clear to upper fields. o2 sats stable. secretions becoming thicker, tan in color, sputum cx obtained. abg stable.\n\ncv: dopamine dosing continued, weaned slightly this am. nipride weaned to off overnight. hr remains in afib, w/ occas. pvc's. rate 60s-90s. ppp bilat, mild generalized edema noted. goal sbp 120-140 maintained. a line dampened, diff. to draw back from. following nibp since 0330. icu team aware. cvl right IJ site w/ mod amt serosang drainage, dsg changed prn.\n\ngi: belly soft, nt/nd. bs hypo. no flatus, no bm. og placed by icu team, placement verified via XR. tf started, titrated to goal.\n\ngu: foley patent amber clear urine, qs.\n\nendo: bg's elevated, sliding scale tightened.\n\nid: afebrile, wbc stable from this am.\n\nskin: no new issues, coccyx reddened, barrier cream applied, repositioned often. incision to left neck w/ old bloody drainage, steristrips intact. small amt bleeding from left scalp incision overnight, resolved w/out intervention.\n\nsocial: pt's wife, called overnight for update, daughter called this early am for same. family supportive, asking many questions. reinforced visiting hour schedule last evening with entire family present.\n\nplan: cont to wean dopamine if possible, follow hemodynamics. titrate tf to goal rate, cont sedation, serial neuro checks. ?wean sedation, vent settings if agitation improves when awake.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-08 00:00:00.000",
"description": "Report",
"row_id": 1576130,
"text": "NURSING PROGRESS NOTE 0700-1900 HOURS:\n** FULL CODE\n\n** ALLERGY: NKDA\n\n** ACCESS: RIGHT RADIAL ALINE (DAMPENED, POSITIONAL AND WITH SEROSANG LEAKAGE-DSG CHANGED TODAY), RIGHT IJ TLC WHICH HAS OOZED BLOOD TODAY-DSG CHANGED X 2 WITH CLOT MAINTAINED AND AT THIS TIME WITH IV BAG AS WEIGHTED PRESSURE.\n\nNEURO: LETHARGIC BUT OPENS EYES AND CAN FOLLOW SOME SIMPLE COMMANDS. DID NOD ON OCCASION. NORMAL STRENGTH WITH LEFT ARM-MOVES LEFT LEG, MOVES RIGHT LEG SLIGHT AMT ON BED BUT NO MOVEMENT FROM RIGHT ARM. PEARL AT 3MM AND BRISK. GETS RESTLESS WITH LEFT ARM-PULLS AT COVERS AND WILL REACH FOR TUBE. REPEAT HEAD CT TONIGHT FOR F/U-RESULTS PENDING. NO NOTED NEURO CHANGES, NO SEIZURES.\n\nCARDIAC: AFIB WITH HR OF 60'S-80'S-INITIALLY HELD NOON DOSE OF LOPRESSOR-THAN GAVE LATER AS HR WAS INCREASED. NO ECTOPY. SBP >100. NIBP IN PLACE AS ALINE IS POSITIONAL AND DAMPENED. HAD TEE-RESULTS PENDING.\n\nRESP: INTUBATED #7.5/21. SETTINGS REMAIN CPAP 5/5 WITH LAST ABG ADEQUATE AT 7.46/40/83. NO ATTEMPTS TO EXTUBATE DO TO COPIOUS SECRETIONS-VERY THICK AND FREQUENT. SATS >96%. CXR WITH ? INFILTRATE. CHEST PT GIVEN Q 4 HOURS.\n\nGI/GU: ABD SOFTLY DISTENDED-SEVERAL SMALL BM'S TODAY. PROMOTE WITH FIBER AT GOAL OF 90CC/HR-RESTARTED AFTER TEE. POS BS. FOLEY WITH CLEAR, YELLOW URINE. >35CC/HR.\n\nID: ON ZOSYN FOR GNR. WBC THIS AM 7.4. AFEBRILE.\n\nENDO: FS QID WITH S.S. AS ORDERED.\n\nPSYCHOSOCIAL: SPOUSE AND DAUGHTER PRESENT THROUGHOUT DAY-UPDATED BY THIS NURSE 'S.\n\nSKIN: CEA SITE WITH STERI-STRIPS; C, D AND INTACT-AREA ECCHYMOTIC. SUTURES TO HEAD DRY AND INTACT WITH NO DRAINAGE.\n\nDISPO: CONT PULM TOILETING UNTIL APPROPRIATE TO EXTUBATE, MED REGIMEN, ICU SUPPORTIVE CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-09 00:00:00.000",
"description": "Report",
"row_id": 1576131,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV with no parameter changes throughout the night. Morning abg results determined a metabolic alkalemia with good oxygenation. SX'd for copious amounts of thick, tan secretions.\n\nRSBI = 43.3 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-12 00:00:00.000",
"description": "Report",
"row_id": 1576144,
"text": "npn 7-7am\n\nPt is awaiting a bed in the VICU, transfer orders have been written.\n\nneuro: No changes in neuro exam. MAE on the bed. Is able to move L arm with normal strength. Nods when spoken to, but have been unable to elicit a verbal response from him this shift. Does make incomprehensible sounds. PERL at 3mm. No pain issues. Reamins on dilantin, no seizure activity noted.\n\nresp: NC with sats 97%. LS clear. Weak productive cough.\n\ncv: Afib in the 60-70's, no ectopy. BP 120-140's. Is on po lopressor.\nHeparin gtt at 1100 units/hour. PTT at 0930.\n\naccess: RSC double lumen.\n\ngi/gu: Belly is soft/distended with + BS. TF at goal via dobhoff tube.Small stool this am. PAtent foley with amber clear urine.\n\nskin: Sutures to scalp intact without drainage. Skin tears on R arm covered by tegaderm.\n\nendo: RISS.\n\nsocial: No contact from family overnight.\n\ndispo: full code.\n\nplan: PTT at 0930. Transfer to VICU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-12 00:00:00.000",
"description": "Report",
"row_id": 1576145,
"text": "nursing note: 7a-7p\nneuro- pt alert, nodding to questions. garbled incomprehenisble speech. perla. mae in bed. r side deficit. sutures removed from craniotomy site.\n\nresp- ls coarse with faint crackles at bases. given 20mg iv lasix with good results. on 2l n/c but changed to 30% face tent purely for the humidification. congested npc despite cpt.\n\ncv- hr afib 70's occasional pvc's. bp stable 110's-130's. heparin gtt now at 1200u/h, ptt due at .\n\ngi- abd soft distended + bs, 2 medium soft brown guiac negative stools. pedi-ngt in place for feeding and meds. pt pulled ngt out some, I was able to reinsert but am waiting for cxr confirmation.\n\ngu- foley patent for adquate amber clear u/o diuresed approx 1 liter from lasix dose.\n\nid- afebrile. remains on zosyn.\n\naccess- rij double lumen central line intact.\n\nsocial- daughters and wife at bedside, updated by rn and multiple interdisciplinary team members. aware of pending transfer when tele bed available. pt was oob to chair with OT. hoyered back to bed. family doing ROM exercises at their request.\n\ndispo- full code, continue pulmonary toileting, neuro monitoring.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-19 00:00:00.000",
"description": "Report",
"row_id": 1576155,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nPt stable overnight. Only opens eyes to voice occasionally. Occasionally follows commands, squeezes with left hand, no movement right upper extremity. Tmax 99 axillary. Weaned from 50%cool aersol to 3 liters nasal cannula. Chest PT with turns. Lungs coarse with diminished bases. Hep gtt restarted at 2230 and PTT drawn at 430am. Check q 6. +bm x 1. Good urine output, lasix as scheduled. Cont to monitor HR and BP adn resp status. Start tube feeds today? Emotional support for pt's wife.\n\nPlease refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-19 00:00:00.000",
"description": "Report",
"row_id": 1576156,
"text": "Please see carevur for specifics.\n\nNeuro: Arousable to stimuli, does not consistently follow commands, PERL. Moves left ext to nailbed pressure, moves RLE on bed and lifts and hold RUE. Aphasic.\n\nCardio: Afib, 5mg IV lopressor every four hours. IV heparin at 1400 units/hour, awaiting recent PTT results. Generalized edema.\n\nRespir: LS are diminished bil at bases and clear upper lobes. Pt. has occasionally nonproductive cough. Chest PT and pt OOB throughout shift. O2 sat 95-97% on 2-3L NC.\n\nGI: Abd soft +bsx4, Respalor via PEG atrted at 10cc/hr to be advanced by 10cc every four hours for goal rate of 100cc/hr. No stool this shift.\n\nEndo: RISS as ordered.\n\nGU: foley, c/y/u.\n\nSKIN: intact. Craniotomy site healed, OTA, no drainage.\n\nPOC: transfer to floor. Monitor VS, i/o, neuro, adv TF as ordered, emotional support to family as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-20 00:00:00.000",
"description": "Report",
"row_id": 1576157,
"text": "Nursing note:\nNEURO: Arousable to voice, does not follow commands. Squeezing w/LUE but not necessarily to command. Moves LUE w/normal strength, moves LLE on bed. Minimal movement to R. side. PERRLA. Aphasic. Will nod head yes/no to ?s at times.\nRESP: Lung sounds coarse, weak productive cough w/encouragement. CPT done w/turns. 3L NC w/good sats, cool mist applied when pt. sleeping due to pt's mouth breathing when asleep.\nCV: Tmax 99-101 axillary. Afib in 70s. Skin pale, warm and dry. SBP 120s. Palpable pulses bilaterally.\nGI: Abdomen soft, +BS. No stool. Tolerating Tfs increasing slowly to goal 100cc/hr st. Respalor.\nGU: Foley patent adequate amount amber urine.\nENDO: Glucose stable, SSRI PRN.\nSkin : Intact.\n\nA/P: Stable for tx to vs. floor in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-20 00:00:00.000",
"description": "Report",
"row_id": 1576158,
"text": "Nursing note:\nAddendum:\nCV: Heparin gtt @ 1400u/hr, PTT stable @ 71.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-20 00:00:00.000",
"description": "Report",
"row_id": 1576159,
"text": " 15/07\n NEURO PT REMAINS ALERT EXPRESSIVE APHASIA REMAINS RANDOM MOTION LEFT SIDE ONLY PERL PAIN ON TURING NO AREA PMI\n RESP CLEAR STRONG COUGH 4L NP SAT 99\n HEART S1S2 CHRONIC AF M MITIAL AREA PULSES POS 3 THRU OUT\n GI POS B/S SMALL STOOL TOL T/F WELL HEP DRIP IN PROGRESS CENTRAL LINE R I J REMOVED PER ORDER\n PLAN OF CARE REHAB ROM CPT OOB TO CHAIR REALITY BASED CARE FAMILY SUPPORT\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-04 00:00:00.000",
"description": "Report",
"row_id": 1576114,
"text": "NURSING NOTE 0700HRS- 1600HRS\n\n\nS/P LEFT FRONTAL PARIETAL CRANEOTOMY FOR BASAL GANGLIA HAEMMORRHAGIC STROKE...ALSO INSERTION OF IVC FILTER WHILST IN OR...ASYSTOLIC EVENT WHEN FIRST ADMITTED TO OR REQUIRING CPR\n\nSENT TO OR @ 08.15HRS AFTER RECEIVING PLATLETS/PLASMA ON DOPAMINE TO INCREASE HR AND NIPRIDE FOR B/P CONTROL\n\nNEURO..SEDATED UPON RETURN @ 40MCGS , AT THAT POINT WITHDRAWL OF LEFT ARM THAT WAS PURPOSEFUL BUT NO OTHER MOVEMENT, PUPILS EQUAL REACTVE....TEAM SWITCHED OF SEDATION TO EVAL @ 16.00HRS AND TO MINIMAL STIMULI DID MOVE LEFT ARM/ LEG OPENED EYES TO COMMAND BUT LIITLE OR NO REACTION TO PAINFUL STIMULI OF THE RT...TO CONTINUE TO OBSERVE NEURO OBS Q 1HRLY//LOADED WITH PHENYTOIN, NO SEIZURE ACTIVITY NOTED AND MANNITOL/DEXAMETHASONE COMMNCED\n\n\nCVS...AIM B/P < 140, ON NIPRIDE FOR CONTROL,PRESENTLY @ 0.5MCGS/KG...DOPAMINE CONTINUES TO MAINATAIN HR >60 PRESENTLY @ 2.0 [ TITARTED DOWN FROM 6]IN AF HR PREVIUOS LOW @ 30BPM THIS AM, PADS INSITU\nAFEBRILE ON ANTIBIOTICS..B/S STABLE\nPOST OP LABS SHOW PHOS LOW TO BE REPLACED AND PLATLETS @ 88 ? REPLACE THIS EVE [ AWAIT TEAM]...OTHERWISE CHEM/ CBC UNREMARKABLE...\n\n\nRESP..LLL PE..FILTER NOW IN PLACE, ABG SATISFACTORY PRESENTLY ON AC 700X12 PEEP @ 5 , REPAET CXR TAKEN AS ? CRACKED RIB DURING CPR IN OR AWAIT RESULT...LUNGS SOUND CLEAR...SATS 100%.. REPEAT THIS EVE\n\nG/I..UNABLE TO PLACE OG TUBE ? WHY UNABLE RO PASS..TO ATTEMPT AGAIN PM...BOWEL SOUNDS PRESNT/SOFT\n\n\nGU...GOOD URINE OUTPUT...IV FLUIDS PUT TO KVO\n\nSKIN..CHRONIC RED AREA ON SACRUM ? CAUSE...SKIN FRAGILE..CRANIOTOMY DRESSSING DRY/INTACT..PREVIOS SURGERY LEFT NECK DRY INTACT\n\nLINES ...DOUBLE LUMEN RT IJ PLACED IN OR, X3 PERIPHERALS I9N PLACE\n\n\nSOCIAL...WIFE X2 DAUGHTERS HERE..ACCOMMODATION NOW SORTED BY SOCILA WORK TEAM\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-05 00:00:00.000",
"description": "Report",
"row_id": 1576115,
"text": "TSICU NPN\nO: ROS\nNEURO: PT SEDATED ON PROPOFOL AND LIGHTENED PERIODICALLY FOR COMPLETE NEURO EXAM. BEST EXAM OFF PROPOFOL: PEARL 3MM BILAT, IMPAIRED GAG AND COUGH. PT OPENS EYES TO SPEECH AND IS NODDING APPROPRIATELY TO QUESTIONS. SMILING WHEN INTERACTIVE W/ FAMILY. MOVING LUE PURPOSEFULLY AND TO COMMAND. ABLE TO LIFT AND HOLD LUE OFF BED. WIGGLES TOES ON L TO COMMAND. RUE W/ MINIMAL MOVEMENT ON BED TO PAINFUL STIMULI, RLE MOVES ON BED TO PAIN AND SPONTANEOUSLY BUT PT UNABLE TO LIFT R SIDE AT ALL. CONT ON MANNITOL, DECADRON AND DILANTIN. NO EVIDENCE OF SZ ACTIVITY.\n\nCV: HR 60'S AFIB W/ OCCASIONAL PVC'S. REMAINS ON DOPA TO INCREASE HR. WEANED OFF X1 AND HR 40'S AFIB W/ FREQUENT PAUSES. RESTARTED DOPA AT 2.0 MCG/KG/MIN W/ CONT PAUSES AND SLOW RESPONSE. BRIEFLY INCREASED TO 5MCG/KG/MIN, HR UP TO 70'S BUT PROARRHYTHMIC AT HIGHER DOSE W/ FREQUENT PVC'S. NIPRIDE AT LOW DOSE TO MAINTAIN SBP 100-140. (SEE CAREVUE FLOWSHEET) PADS REMAIN IN PLACE. ATROPINE AT BEDSIDE.\n\nRESP: REMAINS FULLY VENTED ON AC 500X12, 50% AND 5PEEP W/ STABLE ABG.\n02SATS 98%. SXN FOR SM-MOD THICK YELLOW SECRETIONS. LS CLEAR, DIMINISHED AT R BASE.\n\nRENAL/METABOLIC: ADEQUATE U/O. NET BODY BALANCE +2.5 LITERS AT MN.\nK WNL, CA AND PHOS REPLETED. LACTATE 2.0.\n\nGI: REMAINS NPO W/ ABSENT BS. ABD SOFT. DENIES NAUSEA. PT IS W/OUT GASTRIC TUBE, TOL WELL.\n\nENDO: SS INSULIN AND RECEIVING 2-4UNITS Q6HRS.\n\nHEME: HCT REMAINS STABLE AT 33.3 W/ INR 1.2. PLT CT REMAINS STABLE AT 112.\n\nID: AFEBRILE. CONT ON CEFAZOLIN.\n\nSKIN: FRAGILE SKIN W/ MULTIPLE SKINTEARS AND BRUISING. BACKSIDE INTACT. L CEA INCISION STERISTRIPPED W/ OLD BLDY DNGE, NO ERYTHEMA\nNOTED. CRANIOTOMY INCISION COVERED W/ PRIMARY DSG, D&I.\n\nSH: FAMILY IN AND ASKING MANY QUESTIONS. PT'S CHILDREN V SUPPORTIVE OF PT AND HIS WIFE. THEY ARE STAYING IN A HOTEL NEARBY AND WILL BE CHECKING IN BY PHONE AND IN TO VISIT IN AM.\n\nA: SOME COGNITIVE ABILITY NOTED S/P HEMMORHAGIC STROKE. MARKED R SIDED HEMIPARESIS. LABILE HEMODYNAMICS, DOPA AND NIPRIDE DEPENDENT AT THIS TIME. NO EVIDENCE OF INCREASED BLEEDING.\n\nP: CONT TO MONITOR AND SUPPORT HEMMODYNAMICS. DOPA AND NIPRIDE AS NEEDED. REPLETE LYTES. CONT Q1HR NVS AND PERIODIC NVS OFF PROPOFOL. CONT DECADRON, MANNITOL AND DILANTIN. MONITOR SERIAL HCTS, COAGS, PLTS. PULM TOILET. WEAN AS TOLERATED. CONT PT AND FAMILY SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-05 00:00:00.000",
"description": "Report",
"row_id": 1576116,
"text": "Respiratory Therapy\nPt remains orally intubated on full ventilatory support. No vent changes overnight. Please see carevue for specifics\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-05 00:00:00.000",
"description": "Report",
"row_id": 1576117,
"text": "Nursing Note--A Shift\nPlease see carevue for complete assessment and specifics.\n\nNEURO: Propofol off for 20+minutes--PERRLA 3 and brisk. Follows simple commands with his left extremities. Intermittently nods and shakes head appropriately to simple questions. Moves his RUE on the bed. RLE moves minimally. All 4 ext withdraw to noxious stimuli. Weak gag and weak cough. Gets very agitated with propofol off for 30 minutes. Head CT done today.\n\nCARDIAC: Afebrile. HR 48-92 AFIB. SBP 110-150 goal is 120-140. On Dopamine gtt to maintain HR above 40-50's. On Nipride gtt to maintain SBP goal. Cardiology consult today decided that pacemaker not necessary at this time. Possible CEA site edema could be the cause of the brady cardia and hypotension. Will reevaluate after swelling subsides if symptoms still present.\n\nRESP: Deep sxn for small to moderate amts of thick clear secretions. LSCTA. Tol AC vent settings of , 700 50%.\n\nGI: Abd soft BS absent.\n\nGU: foley intact draining large amts of clear yellow urine.\n\nINTEG: CEA site erethematous and edematous. Left frontal and parietal edema. Primary dressing intact with no staining.\n\nOther: 1x bolus dose of Dilantin 500mg for Dilantin level of 6.8. Cardiology consult done. Head CT done.\n\nPLAN: Attempt to wean off of Nipride gtt and Dopamine gtt. Possible CPAP tomorrow. Possible Duobhoff placement and starting TF this afternoon, Continue with frequent NEURO checks.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-07 00:00:00.000",
"description": "Report",
"row_id": 1576125,
"text": "RESPIRATORY CARE\n\n\n Pt continues on PSV 5/5 .40% IN NARD B/S ess clear sx'ing for a large amount of thick yellow/tan secretions. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-07 00:00:00.000",
"description": "Report",
"row_id": 1576126,
"text": "FOCUS. NURSING PROGRESS NOTE\n78 YEAR OLD S/O L CEA WITH HOSPITAL COURSE COMPLICATED BY PE AND LEFT HEMMORRAGIC STROKE S/P CRANI WITH EVACUATION AND IVC FILTER PLACEMENT.\nREVEIW OF SYSTEMS\nNEURO- HE IS ALERT AT TIMES. PEARL. OBEYS COMMANDS BUT IS INCONSITENT WITH THIS. LIFTS AND HOLD LUE. MINIMAL MOVEMENT OF RUE. DOES MOVE THIS RUE BY WITHDRAWING TO PAINFUL STIMULI. BOTH LOWER EXTREMITIES MOVE ON BED. NODS YES AND NO TO QUESTIONS. AT TIMES NEEDS TO BE ASKED QUESTIONS A FEW TIMES BEFORE HE WILL NOD. CONT ON DILANTIN. LEVEL WAS THERAPEUTIC AT 12.7 YESTERDAY. IN FOR REPEAT LEVEL IN AM. CONT ON ATIVAN Q 6 HOURS ATC FOR DT PROPHYLAXIS. STEROIDS DECREASED TODAY. WILL BE DC'D IN AM.\nRESP- INUBATED AND VENTED. ON 40% FIO2 PEEP OF 5 AND 5 PS RESP 16-18 WITH TV OF 600-800CC. COPIOUS YELLOW THICK SECRETIONS THIS AM. GLUCOSE CHECKED ON THEM TO MAKE SURE HE WAS NOT ASPIRATING TF IT WAS IN THE 30'S. NEW CULT SENT. CULT FROM NOT SPECIATED YET. ONCE IT IS WILL START HIM ON APPROPRIATE ANTIBIODICS. BS CLEAR AFTER SUCTINING DIMINISHED AT THE BASES. RECEIVING CPT TO HELP MOBILIZE SECRETIONS.\nCARDIAC- HR 60-70'S AFIB. STARTED ON LOPRESSOR 25MG PO BID TODAY. TOLERATED WELL LOWEST HEART RATE WENT WAS TO 59 FOR A BEAT OR TWO. ALINE DAMPENDED. SBP BY ALINE 94-128. BY CUFF SBP 117-138. ? TO HAVE TEE DONE TOMMORROW.\nGI- ABD SOFT DISTENDED WITH POS BS. NO STOOL TODAY. PASING FLATUS. ON TF VIA OGT OF PROMOTE WITH FIBER AT GOAL RATE OF 90CC/HR. MIN RESIDUALS.\nGU- FOLEY PATENT DRAINING CLEAR YELLOW URINE AT 40-120CC/HR.\nENDO- SS INSULIN TIGHTENED. BS 154 AT NOON TX WITH 6U REG.\nID- WBC DOWN TO 10. TEMP MAX 100.1 PO 100.4 RECTAL DOWN TO 99.9. COPIOUS YELLOW SECRETIONS VIA ETT TODAY. PER TSICU TEAM WILL START ON ANTIBIODICS ONCE SPUTUM CULT FROM YESTERDAY SPECIALTED OUT. WOULD ALSO START ANTIBIODICS IF PATIENT SPIKES OR HIS WBC INCREASES.\nSOCIAL- MULT FAMILY MEMBERS IN TO VISIT TODAY. MULT FAMILY MEMBERS QUESTIONS ANSWERED BY THIS NURSE.\nDISPO- REMAINS IN THE MICU A FULL CODE.\nPLAN- VIGOUROUS CPT.\n CHECK FOR RETURN OF SPECIATION OF SPUTUM CULT FROM STILL PENDING.\n NEURO CHECKS Q 1 HOUR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-08 00:00:00.000",
"description": "Report",
"row_id": 1576127,
"text": "Resp Care\nPt. remains intubated on minimal vent. settings. VT's 600cc range with avg. MV 8-13lpm. No abgs. No distress.\nBs: scattered rhonchi. Sxn'd q2 for copious amts. of thick tan sputum.\nPlaN: would not recommend extubation d/t excessive secreations and lack of gag reflex.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-10 00:00:00.000",
"description": "Report",
"row_id": 1576137,
"text": "FOCUS; NURSING PROGRESS NOTE\n78 YEAR OLD MALE S/P L HOSPITAL COURSE COMPLICATED BY PE AND LEFT HEMMORRHAGIC STROKE.\nREVEIW OF SYSTEMS-\nNEURO- IS ALERT. OPENS EYES SPONTANEOUSLY. WILL FOLLOW COMMANDS BUT MOST OFTEN NEEDS TO BE ASKED A FEW TIMES BEFORE HE WILL DO WHAT YOU ASK OF HIM. MOVES RIGHT UPPER EXTREMITIE OFF BED. MOVES LE ON BED. RIGHT ARM WITHDRAWS TO PAIN. WHEN EXTUBATED NOT TALKING MUCH EXCEPT YES AND NO. WHEN FAMILY IN STATED TO THEM HE WAS BORED AND WHEN WOULD HE GO HOME. DILANTIN LEVEL 13.6, DILANTIN TO BE INFATAB THGAT CAN BE CRUSHED AND GIVEN WITH TF.\nRESP- THIS AM HE WAS INTUBATED AND VENTED. ON 40% FIO2 PEEP 5 AND 5 PS THIS AM. ON THIS HE WAS BREATHING IN THE MID TEENS TO LOW 20'S WITH TV 500CC OR GREATER. HE WAS EXTUBATED SHORTLY AFTER 1330 AND PLACED ON 40% COOL NEB. ON THIS HE IS BREATHING IN THE MID TEENS TO LOW 20'S. SATS MID TO HIGH 90'S. BS ARE COARSE COUGHING AND AT TIMES RAISING THICK WHITE SPUTUM THAT IS YANKERED OUT OF HIS MOUTH. CPT Q 4 HOURS.\nCARDIAC- HR 60-70 AFIB WITH OCCASIONAL PVC'S. SBP 110-120'S. ALINE CAME OUT TODAY. DR MADE AWARE. CONTINUES ON LOPRESSOR. ATROVASTATIN STARTED TODAY.\nGI- ABD SOFT DISTENDED WITH POS BS. TF PLACED ON HOLD THIS AM FOR EXTUBATION THIS AFTERNOON. POST EXTUBATION ATTEMPTED TO GIVE PAITNET A SIP OF H20. HE COUGHED AND TURNED BLUE RIGHT AFTER SWOLLOWING. SPEECH AND SWOLLOW HERE AND SAID HE DID NOT PASS SWOLLOWING OF SMALL AMOUNT NECTAR CONSISTENCY NEEDS TO BE NPO. THEY WILL ASSESS AGAIN ON FRIDAY. DOBOFF PLACED BY TSICU RESIDENT. XRAY DONE POST PLACEMENT. TUBE WAS POST PYLORIC BY XRAY. FEW MINUTES AFTER CONFIRMATION PATIENT PULLED THE TUBE EVEN THOUGH HE WAS RESTRAINED. NEW ONE TO BE PLACED AND PATIENT TO START ON TF.\nGU- FOLEY PATENT DRAINING CLEAR AMBER URINE 30CC/HR OR GREATER.\nENDO- BS AT NOON 105. SS WAS TIGHTENED TODAY.\nID- TEMP MAX 99.6. CONT ON LEVO AND ZOSYN FOR PSEUDOMONAS IN SPUTUM.\n WIFE AND IN TO VISIT. THEY WERE UPDATED BY THIS NURSE.\nDISP0- REMAINS IN MICUA FULL CODE.\nPLAN- REPLACE DOBOFF FT.\n RESTART TF ONCE FT PLACEMENT VERIFIED BY XRAY.\n CONT TO MONITOR NEURO STATUS.\n CPT AS ORDERED.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-08 00:00:00.000",
"description": "Report",
"row_id": 1576128,
"text": "MICU NPN 7P-7A\nNEURO: NEURO EXAM UNCHANGED FROM LAST NIGHT. AT TIMES IS ALERT, OTHER TIMES AROUSABLE TO VOICE/STIMULUS. HAVE TO REPEAT HIS NAME SEVERAL TIMES BEFORE HE OPENS HIS EYES. PERL @4MM AND BRISK. FOLLOWS COMMANDS ALTHOUGH INCONSISTENTLY AND HE NEEDS TO BE ASKED MANY TIMES. LEFT ARM RESTRAINED AS HE HAS NORMAL STRENGTH IN THIS ARM AND WILL REACH FOR ETT. MOVEMENT NOTED TO BIL LE'S AND SLIGHT MOVEMENT TO RUE. WITHDRAWS TO NAILBED PRESSURE AND LOCALIZES PAIN. WILL NOD ON OCCASION BUT YOU MUST BE PERSISTENT. NO SIGNS OF SEIZURE ACTIVITY. ON DILANTIN, AM LEVEL 18. GAG AND COUGH IMPAIRED. ATIVAN ATC FOR DT PROPHYLAXIS WAS CHANGED TO PRN. PATIENT IS STRONG AND RESISTIVE TO TURNING.\n\nCARDIAC: HR 41-85 AFIB WITH RARE PAUSE. NO ECTOPY. TOLERATING HIS LOPRESSOR. BP 105-151/41-74 VIA NIBP AS ART LINE IS DAMPENED AND UNRELIABLE. PPP. HCT STABLE @34. TEE TO BE PERFORMED TODAY.\n\nRESP: ON CPAP 5/5 40% WITH RR 15-22 AND SATS 94-98%. TV'S 500-600. RT STUCK FOR ABG 7.46/40/83/29. LS CLEAR TO COARSE WITH DIMINISHED RIGHT BASE. SXTED FOR COPIOUS TAN THICK SPUTUM. CXR SHOWS ? RIGHT INFILTRATE.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. HAD ONE MEDIUM PASTY BROWN STOOL THAT WAS OB-. OGT IN PLACE. 30-110CC UOP/HR YELLOW AND CLEAR.\n\nFEN: IVF @KVO. TUBE FEEDS AT GOAL OF 90CC/HR WITH NO RESIDUALS. OFF AT MIDNOC, NOW NPO FOR TEE. FS 159/94 COVERED WITH SSRI. LYTES PER CAREVUE.\n\nID: TMAX 99.2 WITH AM WBC 7.4. SPUTUM GROWING GNR AND ?INFILTRATE ON CXR, PATIENT STARTED ON ZOSYN.\n\nSKIN: STAPLES TO HEAD C/D/I. NECK EDEMATOUS, NO DRNG, STERI STRIPS INTACT. AHD SKINTEARS/ABRASIONS TO BILAT FOREARMS. COCCYX PINK.\n\nACCESS: PIV X2. RIGHT ART LINE WHICH CANNOT DRAW BACK. RIJ CVL.\n\nSOCIAL/DISPO: FULL CODE. FAMILY IN LAST NIGHT, ASKING MANY ?'S, SPOKE WITH TSICU RESIDENT AND THIS NURSE. WIFE HAS CALLED TWICE DURING THE NIGHT FOR UPDATES. PLAN TODAY FOR TEE. ?CHANGE ART LINE OVERWIRE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-08 00:00:00.000",
"description": "Report",
"row_id": 1576129,
"text": "RESP CARE\nPT REMAINS ON CPAP-PARAMETERS NOTED. DUE TO EXCESSIVE SECRETION PRODUCTION, PT WILL REMAIN INTUBATED AT THIS TIME. SUCTION FOR COPIOUS AMTS OF THICK TAN SECRETIONS. HEAD CT-RESULTS PENDING.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-10 00:00:00.000",
"description": "Report",
"row_id": 1576138,
"text": "Resp Care\nPt received on mech vent-parameters noted. Pt extubated to 50% cool mist aerosol. Breath sounds are coarse bilat. Suction for thick white secretions. Pt had improved gag and strong cuff leak.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-10 00:00:00.000",
"description": "Report",
"row_id": 1576139,
"text": "FOCUS; ADDENDUM\nCARDIAC- HEPARIN DRIP STARTED AS ORDERED BY DR . DRIP AT 1750U/HR UP AT 1730. WILL NEED PTT AT 2330. GOAL PTT 50-70. TO FOLLOW SS AS ORDERED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-10 00:00:00.000",
"description": "Report",
"row_id": 1576140,
"text": "focus; addendum\ngi- doboff in the right main stem by xray. per dr to dc. tube dc'd by this nurse. dilantin to be changed to iv for now and she will attempt another ft later this pm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-11 00:00:00.000",
"description": "Report",
"row_id": 1576141,
"text": "npn 7-7am\n\nNo changes overnight.\n\nneuro: Pt MAE on the bed. Normal strength in LUE. Follows commands consistently. Speech is garbled and unable to assess mental status. No seizure activity. No complaints of pain overnight. No episodes of agitation.\n\nresp: Pt is on shovel mask and sats range from 93-97%. Continues with chest PT. Pt has a weak cough. LS coarse.\n\ncv: Afib with a rate in the 60-70's. BP 120-140's. Received IV lopressor 7.5mg at 2400 because Dobhoff tube not yet replaced.\nHeparin gtt continues at 1750 units/h. Level drawn at 2330 last evening was theraputic.\n\naccess: R sc double lumen.\n\ngi/gu: Belly is soft distended with + BS.No BM this shift. Patent foley with adequate amounts of amber colored urine.\nFailed swallow eval yesterday-- needs Dobhoff.\n\nEndo: RISS.\n\nSkin: Staples to top of head are intact, no drainage noted.\n\nSocial: Family visited last evening and wife called late last night.\n\nDispo: Full code.\n\nPlan: Continue to monitor neuro status, place feeding tube.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-11 00:00:00.000",
"description": "Report",
"row_id": 1576142,
"text": "addendum\n\nAt 0600 Heparin gtt was decreased to 1000 units/h per Dr of the vascular service. Order was written in POE and she will speak with the TSICU team regarding the new rate.\n\nPlease check a PTT at 12 noon.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-11 00:00:00.000",
"description": "Report",
"row_id": 1576143,
"text": "FOCUS; NURSING PROGRESS NOTE\nMR IS S/P LEFT CEA. HOSPITAL COURSE COMPLICATED BY PE , LEFT HEMORRHAGIC CVA AND PSEUDOMONAS PNA.\nREVIEW OF SYSTEMS-\nNEURO- ALERT. MOVES LUE WITH NL STRENGTH. LE MOVE ON BED AND RUE MOVES TO PAINFUL STIMULI. PEARL. OBEYS COMMANDS BUT IS INCONSISTENT IN DOING THIS. DOES SPEAK AT TIMES CLEARLY. AT OTHER TIMES HIS SPEECH IS GARBLED.\nRESP- ON 2L NC SATS HIGH 90'S. RESP 16-19. BS CLEAR DIMINISHED AT THE BASES.\nCARDIAC- HR 70-80'S AFIB WITH RARE TO OCCASIONAL PVC'S. SBP 120-130.\nGI- ABD SOFT WITH POS BS. NEW DOBOFF PLACED BY DR . PER DR XRAY SHOWS PROPER PLACEMENT OF TUBE. TF STARTED FS PROMOTE WITH FIBER AT 45CC/HR. IT WAS KEPT AT THIS RATE FOR 2 HOURS. NO RESIDUAL SO WAS ADVANCED TO THE GOAL HE HAD BEEN ON OF 90CC/HR. NO STOOL TODAY. LAST STOOL YESTERDAY.\nGU- FOLEY PATENT DRAING CLEAR YELLOW TO AMBER URINE. RECEIVED 20MG IV LASIX THIS AM WAS NEG 680CC AT 1800. GOAL IS FOR 1LITER TODAY. DR NOTIFIED AND AN ADDITIONAL 20MG IV LASIX GIVEN AT 1800.\nENDO- BS 99-124 TX WITH SS.\nDISPO- AWAITING A VICU BED. NONE AVAILABLE THIS PM.\n WIFE AND DAUGHTER IN TODAY. UPDATED BY THIS NURSE. SURGEON ALSO UPDATED THE FAMILY TODAY.\nPLAN- TO VICU WHEN BED AVAILABLE.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-04 00:00:00.000",
"description": "Report",
"row_id": 1576112,
"text": "Respiratory Care Note\nCalled to pt's bedside on 9 for intubation. Pt intubated with a #7.5ETT for airway protection. ETCO2 positive color change. BS are clear and equal. Pt taken to CT Scan of head which revealed a large hemorrhagic stroke. Pt transported on vent to MICUA w/o incident. Plan to remain on current settings at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-04 00:00:00.000",
"description": "Report",
"row_id": 1576113,
"text": "shift note 600-700\npt s/p left carotid on . received pt from CTscan, intubated. pt apparently had changed of LOC with right sided flaccid when up on floor.\n\nneuro: does not follow commands, aggitated. moves lower extremities equally to painful stimuli, right arm slight movement to pain, but much weaker than left. left with purposeful movements. PEARL 2mm, sluggish. ct scan positive for large left hemmorrhage bleed.\n\ncardiac: slow afib with PVC's rate ranging 25-60. aline to right radial, ABP 80-90, Dopamine started, currently at 4mcg, Neosynthpherine started but off now (range 0.4-.08mcg)\n\nresp: vented, AC/ rate 14, 700 TV, 100% +5, thick tan secreations from ETT. coarse lungs sounds. +PE (was on heperin earlier today)\n\nGI: abd distended. Bowel sounds present.\n\nGU:foley inserted, clear yellow urine\n\nSkin: skin is fragile and multiple skin tears. left carotid steri strips intact. neck swollen.\n\nIV: currently on Dopamine at 4mcg, received 2 units of FFP, propofol at 10.9mcg\n\nplan: to OR for evacuation of bleed\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-07 00:00:00.000",
"description": "Report",
"row_id": 1576123,
"text": "nursing prog note\n\nneuro: pt alert, moving x3 on bed, good strength noted to left side. little movement to right arm. perrla, size 4mm. inconsistently following commands, nods and shakes head to ques. occas agitated, ativan dosing cont, prn fentanyl given for c/o pain. dilantin level therapeutic, cont dose as ordered. decadron weaned.\n\nresp: cpap+ps tol well, 40%, , abg wnl. ls clear to diminished, coarse at times to upper fields, clearing well w/ sx. large amts thick tan/yellow secretions noted (pt w/ hx smoking). cough, gag impaired. o2 sats stable.\n\ncv: dopamine and nipride remain off, remains in afib, rare pvc's noted. rate 60s-100s. bp stable, goal sbp < 140 maintained. ppp bilat, mild generalized edema noted. fluid bolus last evening effective for improved u/o.\n\ngi: belly soft, nt/nd. +flatus, no bm. bs present. tf titrated toward goal, residuals minimal.\n\ngu: uo improved as above, amber clear urine qs overnight.\n\nendo: bg's 140s, sliding scale coverage prn.\n\nid: tmax 100, no abx coverage at this time. sputum cx pending from .\n\nskin: edema to neck improved although remains marked. steri strips to left CEA incision, old bloody drainage noted. left scalp incisions ota, staples intact, no drainage. coccyx slightly reddened, no breakdown noted to area.\n\nsocial: daughter, called for update, ques answered.\n\nplan: cont serial neuro exams, titrate tf to goal. monitor hemodynamics, advance activity tomorrow. ?initiate rehab screening. ?trach vs extubation within next few days, to be reevaluated once neck edema is improved.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-07 00:00:00.000",
"description": "Report",
"row_id": 1576124,
"text": "MICU NPN 3A-7A\nPATIENT TRANSFERRED FROM TSICU IS A 78Y/O MALE WITH H/O ANGINA, AFIB ON COUMADIN, CAD, CVA IN , DM, ETOH, CHF. CAME IN HAD LEFT CEA ON , WENT TO FLOOR. EPISODE SOB, CTA +PE, STARTED ON HEPARIN GTT. APHASIA, MENTAL STATUS CHANGES, FLACCID, HEAD CT LEFT HEMMORHAGIC STROKE ON TOP OF OLD CVA. TO OR ON FOR CRANIOTOMY AND EVACUATION. WHEN TRANSFERRED ON TO OR TABLE BECAME BRADYCARDIC AND THEN ASYSTOLIC, CPR DONE AND PATIENT BACK IMMEDIATELY. TRANSFERRED TO TSICU AFTER OR. ISSUES WITH BP AND BRADYCARDIA. WAS ON NIPRIDE AND DOPA. SEEN BY EP, NO NEED FOR PERMANENT OR TEMP PACER RIGHT NOW. NOW WEANING VENT AND FOLLOWING SERIAL NEURO EXAMS.\n\nNEURO: PATIENT AROUSABLE TO VOICE, ALERT AT TIMES. OPEN EYES, PERL @4MM AND BRISK. FOLLOWING COMMANDS INCONSISTENTLY. FULL MOVEMENT OF LEFT ARM REQUIRING WRIST RESTRAINT. MOVES LE'S. SLIGHT MOVEMENT OF RUE, WITHDRAWS TO NAILBED PRESSURE. IMPAIRED GAG AND COUGH. NO SIGNS OF PAIN. HAS PRN FENTANYL. ON DILANTIN NO SIGNS OF SEIZURE ACTIVITY. ATIVAN ATC FOR AGITATION.\n\nCARDIAC: HR 60-70'S WITH OCCASIONAL PAUSE WITH HR DROPPING IN THE 50'S. NO ECTOPY. SBP 97-120 VIA ART LINE. HCT STABLE @34.\n\nRESP: ON CPAP 5/5 40% WITH RR 13-17 AND SATS 96-99%. ABG 7.42/42/113/29. LS CLEAR WITH DIMINISHED BASES AND SXTED FOR THICK YELLOW SPUTUM.\n\nGI/GU: ABD SOFT WITH +BS. NO STOOL. OGT IN PLACE. 40-160CC UOP AMBER AND CLEAR.\n\nFEN: IVF @KVO. LYTES PER CAREVUE. TUBE FEEDS @80CC/HR GOAL 90CC/HR. NO RESIDUALS. FS Q6HR WITH SSRI.\n\nID: TMAX 99.3 WITH WBC 10. SPUTUM GROWING GNR, GPC, GPR. NO ABX AS OF YET.\n\nSKIN: STAPLES TO HEAD OTA, LEFT NECK EDEMATOUS WITH STERI STRIPS.\n\nACCESS: PIV X3, RIGHT ART LINE, RIJ CVL.\n\nSOCIAL/DISPO: UNKNOWN IF FAMILY KNOWS HE WAS MOVED. VERY SUPPORTIVE. ASKS MANY ?'S ACCORDING TO TSICU NURSE. PATIENT IS A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-10 00:00:00.000",
"description": "Report",
"row_id": 1576135,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV with no parameter changes throughout the night. Morning abg results revealed a mild metabolic alkalemia with good oxygenation.\n\nRSBI = 33.9 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-06 00:00:00.000",
"description": "Report",
"row_id": 1576120,
"text": "Respiratory Therapy\nPt remain orally intubated on full ventilatory support. BS coarse diminished rt base, Sx for moderate amts thick yellow/tan secretions. No vent changes overnight. Plan: lighten sedation, wean ventilatory support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-06 00:00:00.000",
"description": "Report",
"row_id": 1576121,
"text": "Respiratory Care\nPt weaned to minimal settings on CPAP/PSV. No apparent signs of increased WOB or SOB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2136-10-10 00:00:00.000",
"description": "Report",
"row_id": 1576136,
"text": "MICU NPN 7P-7A\nNEURO: EXAM UNCHANGED, PLEASE SEE CAREVUE FOR SPECIFICS. ALERT AND FOLLOWING COMMANDS. LEFT ARM RESTRAINED AS HE HAS GONE FOR ETT. C/O HEADACHE, RELIEVED WITH 50MCG FENTANYL. COUGH INTACT, STRONG WHEN SXTED, GAG ?IMPROVED. NO SEIZURE ACTIVITY. CONTINUES ON DILANTIN, CHANGE TO PO. PATIENT RESTLESS/AGITATED AT TIMES.\n\nCARDIAC: HR 69-86 WITH OCCASIONAL DROP INTO THE 40'S. AFIB WITH OCCASIONAL PVC'S. TOLERATING LOPRESSOR DOSE. BP 103-139/39-66. ALINE DAMPENED UNTIL REDRESSED THIS AM NOW CORRELATING WITH NIBP. PPP. HCT STABLE @33. NO SIGNS OF BLEEDING.\n\nRESP: REMAINS ON CPAP 5/5 40% WITH TV'S 600-700, RR 16-23 AND SATS 93-97%. ABG 7.45/40/112/29. LS RHONCHEROUS->COARSE AND SXTED FOR THICK WHITE SPUTUM ALTHOUGH HE WAS SXTED LESS FREQUENTLY. COPIOUS ORAL SECRETIONS. TEAM THIS AM SAID HE LAST CXR LOOKED \"A LITTLE WET\". RSBI 34. WAIT A COUPLE MORE DAYS BEFORE TRYING EXTUBATION VS. TRACH.\n\nGI/GU: ABD SOFT AND DISTENDED WITH +BS. NO STOOL. OGT IN PLACE. UOP 40-80CC/HR, YELLOW AND CLEAR.\n\nFEN: IVF @KVO, +8L ON PAPER. WEIGHT UP 5KG SINCE ADMIT. TEAM DIURESE HIM TODAY. LYTES PER CAREVUE. FS 202/130 COVERED WITH SSRI. TUBE FEEDS @90CC/HR WITH MINIMAL RESIDUALS. FREE WATER Q4HRS.\n\nID: TMAX 98.9 WITH WBC 6.6. CONTINUES ON ZOSYN AND LEVOFLOXACIN FOR PSUEDOMONAS IN SPUTUM.\n\nSKIN: STAPLES TO HEAD C/D/I. LEFT NECK LESS EDEMATOUS, RED/PURPLE WITH NO DRNG AND STERO STRIPS INTACT. COCCYX PINK. ABRASIONS TO BOTH FOREARMS COVERED WITH TELFA AND DSD.\n\nACCESS: RIJ CVL, WAS BLEEDING. RIGHT ART LINE BLEEDING.\n\nSOCIAL/DISPO: FULL CODE. NO VISITORS LAST BUT DAUGHTER AND WIFE BOTH CALLED FOR UPDATES.\n"
},
{
"category": "Echo",
"chartdate": "2136-10-08 00:00:00.000",
"description": "Report",
"row_id": 79498,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Cardiac arrest. Left ventricular function.\nHeight: (in) 72\nWeight (lb): 180\nBSA (m2): 2.04 m2\nBP (mm Hg): 138/48\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 14:15\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPatient supine, intubated.\nLateral e'=0.15m/s\nSeptal e' = 0.10m/s\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild global LV\nhypokinesis. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Mildly dilated aortic root. Focal calcifications in aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. Mild thickening of mitral valve chordae. Calcified tips of\npapillary muscles. Physiologic MR (within normal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Significant\nPR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is markedly elongated. The right atrium is markedly dilated.\nLeft ventricular wall thicknesses and cavity size are normal with mild global\nleft ventricular hypokinesis. The right ventricular cavity is mildly dilated\nwith mild global free wall hypokinesis. The aortic root is mildly dilated. The\naortic valve leaflets are mildly thickened but aortic stenosis is not present.\nNo aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. Physiologic mitral regurgitation is seen (within normal limits).\nModerate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. Significant pulmonic regurgitation is seen. There is no\npericardial effusion.\n\nIMPRESSION: Low normal biventricular systolic function without regional\ndysfunction. Moderate tricuspid regurgitation. Pulmonary artery systolic\nhypertension.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-04 00:00:00.000",
"description": "CT 100CC NON IONIC CONTRAST",
"row_id": 881305,
"text": " 12:04 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o PE\n Admitting Diagnosis: CAROTID STENOSIS,L/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with decreased O2 sats.\n REASON FOR THIS EXAMINATION:\n r/o PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old male with decreased O2 sats. Rule out PE.\n\n COMPARISONS: No comparisons are available.\n\n TECHNIQUE: 64-MDCT axial images of the chest were obtained with IV contrast\n in the pulmonary artery phase. Nonionic IV contrast was used due to the rapid\n bolus necessary for this study. 100 cc of Optiray 350 were administered.\n\n CTA OF THE CHEST: There are multiple small bilateral axillary lymph nodes\n that do not meet CT criteria for pathology. There are multiple enlarged\n mediastinal lymph nodes in the AP window and precarinal regions. The largest\n one is the one in the AP window which measures 13 mm.\n\n There is no pericardial effusion. The heart is enlarged in size with\n enlargement of all the . Severe coronary artery calcifications\n involving the left main coronary artery, LAD, circumflex, and right coronary\n artery.\n\n Examination of the pulmonary artery branches demonstrates\n bilateral subsegmental filling defects in the lower lobes. There are\n bilateral small pleural effusions. Examination of the lung windows\n demonstrates emphysematous changes of the lungs. There are bibasilar\n atelectases. There is no evidence of pneumothorax. There is a small amount\n of gas in the inferior aspect of the neck related to recent carotid\n endarterectomy.\n\n Limited images of the upper abdomen demonstrate a low attenuation area in the\n right lobe of the liver measuring 1.2 cm, likely representing a liver cyst.\n\n Examination of the bone windows demonstrates no suspicious lytic or blastic\n lesions.\n\n IMPRESSION:\n 1. Bilateral lower lobes subsegmental pulmonary embolus.\n 2. Emphysematous changes of the lungs.\n 3. Multiple enlarged mediastinal lymph nodes as described above. Clinical\n correlation recommended. A followup CT in three months should be considered.\n 4. Small bilateral pleural effusions.\n 5. Heavy coronary artery calcifications.\n 6. Cardiomegaly.\n (Over)\n\n 12:04 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: r/o PE\n Admitting Diagnosis: CAROTID STENOSIS,L/SDA\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n"
},
{
"category": "ECG",
"chartdate": "2136-10-04 00:00:00.000",
"description": "Report",
"row_id": 210577,
"text": "Atrial fibrillation with slow ventricular response\nLeft anterior fascicular block\nNonspecific inferior T wave abnormalities\nProminent precordial T wave changes\nCannot exclude in part ischemia or possible hyperkalemia\nClinical correlation is suggested\nSince previous tracing of , ventricular rate markedly slower and further\nT wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2136-10-27 00:00:00.000",
"description": "Report",
"row_id": 210574,
"text": "Atrial fibrillation with PVCs or aberrant ventricular conduction.\nLeft anterior fascicular block\nIncomplete RBBB\n\n"
},
{
"category": "ECG",
"chartdate": "2136-10-15 00:00:00.000",
"description": "Report",
"row_id": 210575,
"text": "Atrial fibrillation, average ventricular rate 111. Since the previous tracing\nof the ventricular response rate is faster. There has been a further\nleft axis deviation. Technical artifacts are noted. Leads VI and V3 were not\nobtained. Minimal change in ST-T wave abnormalities is seen.\n\n"
},
{
"category": "ECG",
"chartdate": "2136-10-05 00:00:00.000",
"description": "Report",
"row_id": 210576,
"text": "Atrial fibrillation\nDiffuse nonspecific ST-T wave abnormalities\nSince previous tracing, left anterior fascicular block resolved and ventricular\nrate faster\n\n"
},
{
"category": "ECG",
"chartdate": "2136-10-03 00:00:00.000",
"description": "Report",
"row_id": 210801,
"text": "Atrial fibrillation\nVentricular premature complexes\nLeft anterior fascicular block\nSince previous tracing of the same date, inferior T wave changes decreased and\nventricular ectopy present\n\n"
},
{
"category": "ECG",
"chartdate": "2136-10-03 00:00:00.000",
"description": "Report",
"row_id": 210802,
"text": "Atrial fibrillation. Left anterior fascicular block. Non-specific inferior\nT wave changes. Since the previous tracing of inferior T wave changes\nare more prominent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2136-10-02 00:00:00.000",
"description": "Report",
"row_id": 210803,
"text": "Atrial fibrillation. Left anterior fascicular block. Modest right ventricular\nconduction delay pattern - is non-specific. Since the previous tracing\nof ventricular ectopy is absent.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-12 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 882528,
"text": " 10:14 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: thoracoabdominal film please eval feedi ng tube\n Admitting Diagnosis: CAROTID STENOSIS,L/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with desaturation, POD 1 L carotid endarterectomy,\n s/p NGT placement\n REASON FOR THIS EXAMINATION:\n thoracoabdominal film please eval feedi ng tube\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of carotid endarterectomy with desaturation. Feeding tube placement.\n\n The distal end of the feeding tube is in the proximal stomach. Right jugular\n CV line is in mid SVC. No pneumothorax. There is cardiomegaly with pulmonary\n vascular engorgement and bilateral pleural effusions. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-04 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 881393,
"text": " 2:40 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? interval change.\n Admitting Diagnosis: CAROTID STENOSIS,L/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with desaturation, POD 1 L carotid endarterectomy, s/p ICH\n evac.\n REASON FOR THIS EXAMINATION:\n ? interval change.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 2:50 P.M., \n\n INDICATION: Patient with poor oxygenation, recent carotid endarterectomy, and\n intracranial hemorrhage.\n\n There are bilateral basilar opacities, which may have increased slightly since\n at 6:30 a.m. A right IJ catheter has been inserted terminating in the\n lower SVC. There is no pneumothorax following line insertion. Position of\n the ETT is similar to the earlier chest x-ray this morning.\n\n IMPRESSION: Right IJ line insertion as described.\n\n Increasing basilar effusions since 6:30 a.m.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-10 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 882188,
"text": " 5:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval Dobhoff tube placement.\n Admitting Diagnosis: CAROTID STENOSIS,L/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with desaturation, POD 1 L carotid endarterectomy, s/p\n ICH\n REASON FOR THIS EXAMINATION:\n Eval Dobhoff tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man with desaturation. Evaluate Dobbhoff tube\n placement.\n\n COMPARISON: Two hours earlier. The position of the Dobbhoff tube has been\n changed and it now appears to coil at the thoracic inlet with its tip in the\n right main stem bronchus. The right jugular CV line is in the distal SVC.\n There is no pneumothorax. Again noted is a small right-sided pleural effusion\n and associated atelectasis at the right base along with some atelectasis at\n the left lower lobe. There is persistent cardiomegaly.\n\n These findings were discussed with Dr. at 6:30 p.m.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2136-10-04 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 881371,
"text": " 12:16 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval. post-op.\n Admitting Diagnosis: CAROTID STENOSIS,L/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man s/p evacuation of L intraparenchymal hematoma.\n REASON FOR THIS EXAMINATION:\n Eval. post-op.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man with left intraparenchymal hematoma status post\n evacuation. Evaluate postop.\n\n TECHNIQUE: CT head without IV contrast.\n\n HEAD CT WITHOUT CONTRAST: Compared to prior exam 7 hours earlier, there is\n significant reduction of mass effect in the left cerebral hemisphere. This is\n likely secondary to the significant reduction in the left basal ganglia\n intraparenchymal hematoma. Moderate amount of residual blood is still seen.\n Adjacent to the hematoma, there are pockets of air likely secondary to\n postoperative changes. There is also a small amount of adjacent edema. Also\n of note, there is a small blood layering in the lateral ventricles\n bilaterally. Post-surgical changes are seen in the left frontal calvarium and\n adjacent soft tissues.\n\n IMPRESSION:\n\n Interval reduction in the size of the left intraparenchymal hematoma with\n associated decrease in mass effect.\n\n\n"
}
] |
23,905 | 145,496 | Pt came to ED via EMS, Pt was combative and was with blood in nares and mouth, patient was preoxygenation and Rapid sequence intubation was achieved. On admission Pt had radiologic studies that showed: Chest CT 1. Opacity in the posterior lungs bilaterally that may represent atelectasis with aspiration also a consideration. There is occlusion of the left lower obe bronchus with near total collapse/consolidation of the left lower lobe. There is ill defined opacity in the right apex that may represent early contusion or aspiration. 2. Incidentally noted right-sided aortic arch Head CT 1. No evidence of intracranial hemorrhage or edema. No areas of infarction. 2. Evidence of resolving cerebral edema when compared to the previous study | When sedated VS are stable.ID tmax 100.3, pt cont on levaquin q24 H, pt now dyaphoretic. LR maintenance with K repletion prn .GI:Abd soft, OGT to suction. po lopressor cont.HEME: H/H stable.GI: TF changed to 1/2str promote w/ fiber + 80g Promod at 45cc/hr. T/SICU NPN 2300-0700:REVIEW OF SYSTEMS:NEURO: SEDATED ON PROPOFOL, ABLE TO OPEN EYES/MOVE EXTREMITIES W/O LIGHTENING FROM RATE OF 80MCG/HR: WHEN LIGHTENED, PT INCONSISTENTLY TO COMMAND, ATTEMPTS TO TRACK W/EYES, PERRLA 3MM/BSK, STRONG COUGH, GAG INTACT. Propofol weaned off. soft, hypoactive bs.GU: Foley to gravitySKIN: IntactMENTATION: Propofol weaned off, mso4 5mg/hr, midazolam 3 mg/hr, pt. TLS cleared but c-collar insitu.HEMODYNAMICALLY:ST, higher when awake. REFER TO CAREVIEW FOR ABG DATA.GI: ABD SOFTLY DISTENDED, (+)HYPOACTIVE BS, (+)RF. BP stable, hypertensive when lightened.Some ST elevation this am, 12 lead attended and markers cycled.FLUIDS/LYTES:Hyperkalemic this am, rechecked throughout day and resolved. R MOUTH HAS A SM ABRASION.CLEANSED AND LEFT OPN TO AIR. PERL> pt cont on Ativan 2 mg q8. Occasional I/E wheezing relieved with inhalers.CV: HR 80s NSR, no ectopy noted. SBP 110-128/RESP: INTUBATED. C-COLLAR INTACT, C-SPINE PRECAUTIONS MAINTAINED.CV: HR SR 90'S, SBP 140-150'S, HYPERDYNAMIC VS WHEN LIGHTENED. MSO4 drip and midazolam drip added. suctioned for copious thick yellow secretionsCV: Tachycardic 90s-100s, 140s-160s/60-70s, hypertensive when lightenedGI: tolerating tf, abd softly distended, +Bowel soundsGU: foley with adequate green urine, lytes repletedENDO: BS covered with RISSID: tmax 101.4, tylenol given, +sputum culture from - LEVAQUIN started QD,SKIN: no issuesPlan: follow cultures, wean from vent as tolerated, pulmonary toilet, start bowel regime (no bm since admission), monitor and support as indicated. Pboots/sq heparin cont.GI: Abd benign. ?add HC03 to IV fluids.Wean vent support as able.Titrate tube feeds up as tolerated.Continued More settled neurologically this pm also, so being retried on PSV at this time.HEMODYNAMICALLY:ST most of day. bp 130s on admit, more hypotensive w/ propofol infusion. BP 160S-180S/70s-90s despite lopressor ATC and prn. TF cont at goal with minimal residuals.GU: Adequate u/o via foley. Cont sq heparin/pboots.GI: Lg BM x2 today after dulcolax PR. head, c spine negative upon prelim. EKG done per orders, note sinus tachycardia. Started IV lopressor prn for tachycardia with mild effect.HEME: H/H stable. CK's slightly lower.HEME: H/H stable. NSG NOTEROS: CV:SOMETIMES HYPERTENSIVE WITH STIMULATION AND CHANGE TO PSV.ON LOPRESSOR 50MG PO BID.REMAINS IN NSR WITHOUT ECTOPI. Resp CarePt remains intubated and vented on PSV 20/10 with Vt around 400-450cc and RR 20-upper 30s with agitation. Repeat lytes pending.GI:Abd soft, non distended. LS diminished on right side and clear. ls clear, dimin to bases bilat. resp careremains intub/vent supported. Off propofol, opens eyes to voice. Tylenol given with effect. Peripheral IV x1 & cordis in use.NEURO:Sedated on propofol and prn lorazepam. Patient weaned off and on PSV and A/C. ETT withdrawn 1cm and resecured. upon admission to , pt sedated, intubated. When lightened, pt MAE and appears to be attempting to sit up/get OOB. No BM this shift.GU: Adequate u/o via foley. PH 7.44/ C02 43/ Pa02 110/ HC03 30. Pt has very strong, bronchospastic cough.CV: HR 90s-110s ST no ectopy noted. A nonobstructive valgus pattern is visualized. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PERICARDIUM: No pericardial effusion.Conclusions:1. ABG's with low-normal oxygenation. CT PELVIS WITH IV CONTRAST: The bladder is not fully distended. PATIENT/TEST INFORMATION:Indication: Left ventricular function.Height: (in) 73Weight (lb): 235BSA (m2): 2.31 m2BP (mm Hg): 170/92HR (bpm): 104Status: InpatientDate/Time: at 12:44Test: Portable TTE (Complete)Doppler: Full doppler and color dopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolicfunction (LVEF>55%). The heart size and mediastinal contours are unchanged. 3) Stable left lower lobe collapse vs. consolidation. There is a right-sided aorta. CT ABDOMEN WITHOUT AND WITH IV CONTRAST: Few images through the lung bases demonstrate a patchy opacity in the lingula. An endotracheal tube is in unchanged position, with tip 5.6 cm from the carina. IMPRESSION: 1) Lines and tubes in unchanged position. A nasogastric tube was quelled within the distal stomach. BP 140s-160s/70s.HEME: H/H stable. IMPRESSION: Normal right upper quadrant ultrasound. Lung sounds clear sx white secreations via ETT. No resp distress noted, = rise and fall of chest. No significantly enlarged inguinal lymph nodes. Incidentally noted right-sided aortic arch. A nonobstructive bowel gas pattern is visualized in the imaged portion of the abdomen. However, at the medial portion of the left base, there is a tiny pneumothorax visualized. The right-sided aortic arch is again noted. FINDINGS: An endotracheal tube is in place with tip terminating 3.8 cm from the carina. An incidental note is made of a right-sided aortic arch. A more confluent area of opacity in the left retrocardiac region is unchanged. Sinus tachycardiaExrensive ST elevation, consider pericarditisSince previous tracing of , no significant change 4) Right lower lobe patchy opacity could represent atelectasis or consolidation. IMPRESSION: 1) New left-sided PICC with tip in mid SVC. A nasogastric tube terminates below the diaphragm, but the side port is probably just above the GE junction level. There is partial opacification of the ethmoid sinuses. AP VIEW OF THE CHEST: The ET tube terminates at the thoracic inlet. IMPRESSION: Endotracheal tube in good position. A bilateral patchy parenchymal opacities, more prominent in the interval within the right perihilar region and right base. An endotracheal tube remains in place, currently terminating about 2.5 cm above the carina. Stable patchy right perihilar opacity. Cardiac and mediastinal contours are stable with note made of a right-sided aortic arch. There are bilateral alveolar opacities with a central perihilar predominance. There is a right-sided aortic arch. INDICATION: Hypoxia. These findings partially overlap with previously described findings of contusion and/or aspiration. Non-fusion of the C1 ring posteriorly with well corticated edges suggestive of a congenital fusion anomoly. Stable left lower lobe collapse vs. consolidation. Proximal port is in the distal esophagus. ET tube and NG tube are in place. Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE FINAL REPORT (Cont) | 69 | [
{
"category": "Nursing/other",
"chartdate": "2133-07-12 00:00:00.000",
"description": "Report",
"row_id": 1574768,
"text": "Nursing Note:\nREVIEW OF SYSTEMS:\n\nCV: Hemodynamic status stable, hr=90, nsr, bp= 108/67- 119/76,\n + dp bil. Increased hr with restlessness, continues on metoprolol as per order.\n\nRESP: PS 15, 10 peep, fio2=50%, vigorous cough this am with any stimulation of ETT. Propofol increased to 150 mcg/kg/min. MSO4 drip and midazolam drip added. Propofol weaned off. Strong cough but pt. calms easily. Mod. amt. of thick white secretions, resp. rate =16, tv=600. Ulcerated area on right side of lip, ETT retaped on left side.\n\nGI: Pt. coughed out feeding tube, -gastric tube placed, feedings resumed after cxr done, promote with promod at 20cc/hr, abd. soft, hypoactive bs.\n\nGU: Foley to gravity\n\nSKIN: Intact\n\nMENTATION: Propofol weaned off, mso4 5mg/hr, midazolam 3 mg/hr, pt. opens eyes to name, eyes drift upward, difficulty in focusing. Follows commands, wiggles toes, squeezes hand to command, nods head to simple questions. PERL 2-3 mm bil. + corneals.\n\nID: wbc elevated to 18, 2 random sets of blood cult. sent\n\nENDO: Insulin as per sl. scale\n\nSOCIAL: Father in to visit, informed of plan to wean off propofol and start ms04. No other visitors.\n\nPLAN: COntinue to monitor v/s, increase tube feedings as tol, monitor BS, titrate sedation as per order, wean from vent as tol. as per order, replete lytes as needed. Provide support as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-12 00:00:00.000",
"description": "Report",
"row_id": 1574769,
"text": "Respiratory Care Note:\n Patient changed to versed and morphine today with good results. He now opens his eyes and moves toes on command without becoming agitated. Bite block removed from mouth and he has not been biting on ET tube. He still has a moderate amount of thick yellow sputum but will hopefully wean better on these meds. See Carevue flowsheet. Plan to continue weaning as tolerated with RSBI in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-13 00:00:00.000",
"description": "Report",
"row_id": 1574770,
"text": "Resp: Pt remains on psv 14/10 noc. Bs auscultated reveal bilateral coarse sounds. Suctioned for copious amounts of thick yellow (greenish) secretions. Sending sputum sample this am. MDI's administered Q4 hrs combivent with no adverse reactions. Pt more alert today following commands. AM ABG pending. Will continue to wean appropriately.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-13 00:00:00.000",
"description": "Report",
"row_id": 1574771,
"text": "CV:VSS HR 88-106 SR -ST. CONTINUES ON LOPRESSOR IV 10 MG Q 6 HOURS. SBP 110-128/\n\nRESP: INTUBATED. SUCTIONED FOR MODERATE AMOUNTS THICK YELLOW SPUTUM. SPUTUM HAS A STRONG ODOR .PT HAS A VIGOROUS COUGH WHEN HE NEEDS SUCTIONING OR WHEN HE IS BEING SUCTIONED BUT PT CAN BE TALKED INTO CALMING COUGH AND KEEPING MOUTH OPEN A BIT TO SUCTION.\n\nNEURO: PT IS CURRENTLY ON MORPHINE 5 MG/HR AND MIDAZOLAM 3 MG/HR. HE RESPONDS EASILY WHEN SPOKEN TO AND OBEYS COMMANDS. MMAE TO COMMAND AND HAS EQUAL STRENGTH BILATERAL. HE AWAKENS STARTLED AND LOOKS AROUND ROOM AND CALMS WHEN EXPLANATIONS OF HIS LOCATION AND CONDITION ARE REPORTED TO HIM.REQUIRED A FEW BOLUS OF MORPHINE AND /OR VERSED DURING NIGHT TO ACCOMPLISH TASKS SUCH AS COLLAR CARE.\n\nGI: TOOLERATING TUBE FEED STR PROMOTE WITH PROMOD AT 45 CC/HR GOAL IS 80 CC. RESIDUALS ARE 20-30 CC.POS BOWEL SOUNDS, NO BM THIS SHIFT.\n\nGU: FOLEY DRAINING CLEAR BROWN URINE IN ADEQUATE AMOUNTS\n\nINTEG: SKIN INTACT. R MOUTH HAS A SM ABRASION.CLEANSED AND LEFT OPN TO AIR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-04 00:00:00.000",
"description": "Report",
"row_id": 1574734,
"text": "Social Work\nSW met with pt's father, , in family waiting room this morning. SW was consulted to speak with family about the possibility of reaching pt's brother, who is in the in . mother and sister were in to see pt as well, but had left the hospital to go home. SW contact the Red Cross and left a message for them to call SW or pt's father. SW will continue to follow. Page if needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-04 00:00:00.000",
"description": "Report",
"row_id": 1574735,
"text": "Patient remains on mechanical ventilation with good ABG.Plan to switch patient to PSV when less sedated and source of temp resolved.Suction for small to moderate amount of bloody secretion will continue resp care as necessary.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-04 00:00:00.000",
"description": "Report",
"row_id": 1574736,
"text": "Nursing Progress Note:\nPlease see CareVue and FHP for specifics.\n\nRESP:\nPt still has high vent support requirements but able to wean Fi02 to 60%. Pt breathing above set rate but shallow and labored when lightened off propofol. Plan to change to PSV when will tolerate being lightened enough to do so. Chest coarse at times. Violent cough, lifting head off bed, thick bloodstained secretions.\nCXR attneded.\n\nNEURO:\nSedated on propofol for safety. Off sedation, will not open eyes or obey commands. Bilat arms move towards midline and fight restraints but do not reach to ETT. Legs bend at knees at best. PEARL. TLS cleared but c-collar insitu.\n\nHEMODYNAMICALLY:\nST, higher when awake. Peripheries warm to tepid. BP stable, hypertensive when lightened.\nSome ST elevation this am, 12 lead attended and markers cycled.\n\nFLUIDS/LYTES:\nHyperkalemic this am, rechecked throughout day and resolved. LR maintenance with K repletion prn .\n\nGI:\nAbd soft, OGT to suction. NPO. Some bloodstained secretions in oropharynx.\n\nID:\nTmax 100.7. No antibiotics.\n\nRENAL:\nGood urine output. at times.\n\nSKIN:\nNo active issues at this time.\n\nSOCIAL:\nFamily visiting and met with and RN for update. Asking appropriate questions. Paged social worker regarding pt's brother who is in Corps serving in - awaiting contact from or pt's brother.\n\nPLAN:\nWean vent as able.\nContinue support for family.\nCycle cardiac markers.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-05 00:00:00.000",
"description": "Report",
"row_id": 1574737,
"text": "Resp Care\nPt remains on vent and intubated with #7.5 @ 25 at lip. Bs course bilat. Suctioned mod amt of thick blood-tinged secretions. Abgd are within parameters. Plan to maintain settings and wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-06 00:00:00.000",
"description": "Report",
"row_id": 1574744,
"text": "NPN \nROS:\n\nNEURO: patient sedated on propofol gtt and ativan PRN. when lightened from sedation, patient opens eyes to voice, moves all extremities, follows commands inconsistently, weakly squeezes hands off and on, c-collar on and intact\n\nCV: HR 100-110s, hypertensive 160s-180s/80-90s, lopressor PRN and standing with minimal effect; team aware, trying to increase sedation with more efffect on bp. +pp,\n\nRESP: remains vented on AC 500x18 40% 10 peep 20 ps; breathing over vent up to 26-28 breaths/min. ls coarse, copious thick yellow sputum suctioned.\n\nGI: tolerating tf at goal 45cc/hr, abd softly distended, +bowel sounds\n\nGU: good urine output via foley, green colored\n\nENDO: BS wNL, no coverage needed on my time\n\nSKIN: intact.\n\nsocial: wean vent as tolerated, EKG this evening per team, monitor and full support as indicated\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-07 00:00:00.000",
"description": "Report",
"row_id": 1574745,
"text": "assessment as noted\n\n\nRES: TRYING TO WEAN, DOWN TO CPAP 8PEEP, 18 PS-GETTING HYPERDYNAMIC AND TACHYPNEIC AND WAS PUT BACK ON 20PS. LS COARSE WITH MOD AMNT THICK YELLOW SPUTUM.\n\nNEURO: FOCCUSES, PARTIALLY FOLLOWS WHEN OFF SEDATION, MAE STRONG, STRONG COUGH AND GAG, +CORNEAL,\n\nCV: MOSTLY IN S.TACH, NO ECTOPY, WITH SBP 150-180, ON LOPRESSOR, PER EDEMA PRESENT, +PULSES; SEDATION WAS INCREASED TO CONTROL BP\n\nID: MRSA RECTAL AND NASAL WERE SENT OFF AS WELL AS VRE STOOL SWAB. NOANX WERE STARTED.TEMP 100-101.3 TREATED WITH TYLENOL\n\nGI: TOL T.FEDING WELL, NO BM..+BS\n\nSKIN: INTACT, DIAPHORETIC POST TYLENOL\n\nSOCIAL: FATHER CALLED LAST NIGHT AND WAS UPDATED\n\nPLAN: FOLLOW NEURO,CV, TRY TO WEAN OFF VENT, TREAT FEVER\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-07 00:00:00.000",
"description": "Report",
"row_id": 1574746,
"text": "Pt remains intubated. Pt placed on PSV 20/8peep 40% during the night at 1:00am RR 28-33. VT 400-500's . 02 sats in high 90's. BS: Few scattered rhonchi. Sx for mod amts of thick pale yellow secretions. Attempted to decrease PSV to 18,,RR increased into mid 30's. ABG's drawn at 5:00am revealed ph 7.40/ C02 41/ PA02 85/ HC03 26. Increased PSV back to 20. RR 25-29 VT's 500's. Plan is to cont PSV as tolerated and attempt to decrease PSV to maintain adequate ventilation and oxygenation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-07 00:00:00.000",
"description": "Report",
"row_id": 1574747,
"text": " NPN\nEVENTS: patient to head CT today without incident. results pending\n\nROS: see carevue for details\n\nNEURO: patient remains sedated on propofol. when lightened patient opens eyes to voice, moves all extremities, did move feet to command, x1, did not squeeze hand or show thumb. tracks. when woken this morning patient has extremly strong cough and O2 saturation dropped to low 80s, patient was re-sedated, and O2 sat recovered slowly over an hour.\n\nRESP: remains vented on cpap 40% 20PS, 10 PEEP. ls coarse, O2 sat 95-99%, LS coarse, diminished. suctioned for copious thick yellow secretions\n\nCV: Tachycardic 90s-100s, 140s-160s/60-70s, hypertensive when lightened\n\nGI: tolerating tf, abd softly distended, +Bowel sounds\n\nGU: foley with adequate green urine, lytes repleted\n\nENDO: BS covered with RISS\n\nID: tmax 101.4, tylenol given, +sputum culture from - LEVAQUIN started QD,\n\nSKIN: no issues\n\nPlan: follow cultures, wean from vent as tolerated, pulmonary toilet, start bowel regime (no bm since admission), monitor and support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-08 00:00:00.000",
"description": "Report",
"row_id": 1574754,
"text": "Nursing progress Note\nS/O_ Review of Systems\n Pt sedated on propofol at 80 mcg/kg/min, pt off of gtt briefly and pt is awake and following command consistently with all four extremities,with good strength, able to do thumbs up with left hand. PERL> pt cont on Ativan 2 mg q8. Fentanyl 100 mcg given q2 with effect. cervical collar remains on.\n pt remains in NSR rate increases to >100 when awake and coughing.Pt becomes hypertensive as well. Lopressor 50 mg cont per FT. When sedated VS are stable.\nID tmax 100.3, pt cont on levaquin q24 H, pt now dyaphoretic.\n Pt remains on PSV of 18 with RR 20-30's with TV of 500, pt has increased secretions of thick yellow sputum, pt has extremely strong cough, causing all his extremities to flail about when he is suctioned. Breath sounds are coarse. Sats 94-98.\nGI- tol TF at goal of 45, asp 20cc , abd is soft and distended, with hypoactive bowel sounds.\nGU- good U/O via foley cath.\nskin - intact, but diaphoretic\nsocial- pt father in to visit, and called later on in the evening , all questions answered. he would like to give permission for sister to visit.\nA/ pt needing fentanyl to keep pt sedated. Pt has increased sputum production. Pt now able to folllow commands with all extremities consistently.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-09 00:00:00.000",
"description": "Report",
"row_id": 1574755,
"text": "Respiratory Care:\n\nPatient intubated on mechanical support. Pt. requiring increased Fio2/Peep due to desating to low 90's after being turned. Current vent settings Psv 18, Peep 12, Fio2 60%. Spont vols 450's. RR increasing to mid 30's-40's at times with manupulation. Abg's improved. O2 sats increasing to 97%. Bronchospastic cough with sxing. Sx'd for moderate amounts of thick yellow secretions. Combivent MDI given Q4hr. Plan: Continue with mechanical support and wean Fio2/Peep as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-09 00:00:00.000",
"description": "Report",
"row_id": 1574756,
"text": "T/SICU NPN 2300-0700:\n\nREVIEW OF SYSTEMS:\n\nNEURO: SEDATED ON PROPOFOL, ABLE TO OPEN EYES/MOVE EXTREMITIES W/O LIGHTENING FROM RATE OF 80MCG/HR: WHEN LIGHTENED, PT INCONSISTENTLY TO COMMAND, ATTEMPTS TO TRACK W/EYES, PERRLA 3MM/BSK, STRONG COUGH, GAG INTACT. BECOMES INCREASINGLY AGITATED REQUIRING INCREASED SEDATION; ATIVAN AND FENTANYL ALSO GIVEN W/EFFECT. C-COLLAR INTACT, C-SPINE PRECAUTIONS MAINTAINED.\n\nCV: HR SR 90'S, SBP 140-150'S, HYPERDYNAMIC VS WHEN LIGHTENED. PERIPHERAL PULSES EASILY PALPABLE. HCT STABLE. RECEIVES LOPRESSOR 50MG. HEPARIN AND PB'S FOR DVT PROPHYLAXIS.\n\nRESP: LUNG SOUNDS COARSE, BASES DIMINISHED. SXN FOR SM<->MOD AMTS THICK YELLOW SECRETIONS. CONTINUES ON CPAP+PS: EPISODE OF DESATURATION AFTER TURN/REPOSITION/AM CARE - SATS LOW (87-90%), RR INCREASED/ NASAL FLARING AND DECREASED VT'S - SEDATION INCREASED, PEEP UP TO 12 AND FIO2 INCREASED TO 60%. T/SICU HO AWARE, CXR ORDERED/; RT FOLLOWING PT FOR AS WELL. REFER TO CAREVIEW FOR ABG DATA.\n\nGI: ABD SOFTLY DISTENDED, (+)HYPOACTIVE BS, (+)RF. TF INFUSING AT GOAL RATE VIA OGT - SCANT RESIDUALS. COLACE GIVEN, PREVACID FOR GI PROPHYLAXIS, NO BM THIS SHIFT.\n\nGU: FOLEY CATHETER PATENT DRAINING ADEQUATE HOURLY VOLUMES OF CLEAR/GREEN COLORED URINE.\n\nENDO: GLUCOSE LEVELS 129/111 - COVERED PER S/S AS NEEDED.\n\nID: TMAX 100.7, WBC'S 13.0 (12.4) - CONTINUES ON LEVAQUIN AS ORDERED.\n\nSKIN: GROSSLY INTACT. SM AREA OF BREAKDOWN NOTED TO CORNER OF MOUTH (LIP-UPPER RIGHT) - ETT ROTATED TO LEFT SIDE. BACK/BUTTOCKS INTACT.\n\nSOCIAL: FATHER PHONED THIS AM FOR UPDATE - AFFECT/QUESTIONS/CONCERNS APPROPRIATE - ALL QUESTIONS ANSWERED, SUPPORT GIVEN.\n\nA/P: LOW GRADE TEMPS, CONTINUES ON CPAP; DIFFICULTY BALANCING SEDATION WEAN WITH BRONCHOSPASTIC RESPIRATORY ISSUES. POORLY TOLERATES TURNS/REPOSITIONING. CONTINUE PER CURRENT PLAN OF CARE, SEDATION AND VENT WEANS AS TOLERATED, PAIN MGT, PULMONARY HYGEINE (AS TOLERATED), BOWEL REGIMAN, TF AS ORDERED, GLUCOSE MONITORING, FULL SUPPORT/COMFORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-09 00:00:00.000",
"description": "Report",
"row_id": 1574757,
"text": "Respiratory Care Note:\n Patient weaned slightly on PSV mode of ventilation with abg pending at this time. Respiratory rate is slightly elevated post suctioning for thick yellowish sputum. He receives combivent Q6. BS slightly decreased t/o. Plan to continue with slow wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-09 00:00:00.000",
"description": "Report",
"row_id": 1574758,
"text": "NPN 0700-1900\nNEURO: Attempted to wean propofol using IVP ativan and haldol. Able to wean pt to 50mcg/kg/hr, however pt still has episodes of agitation and violent bronchospasms. No further weaning at this time. Fentanyl 100mcg x 2 for pain. Pt MAE, and follows commands. Occasionally nods to yes/no questions. Pt still has poor tolerance for turning and nsg care despite new sedatives.\n\nRESP: Attempted to wean FiO2 to 50%, ABG with paO2 of 77 and sats 94%. O2 increased back up to 60%. Able to wean PS to 14. LS clear and diminished. Occasional I/E wheezing relieved with inhalers.\n\nCV: HR 80s NSR, no ectopy noted. BP 140s-160s/70s-80s. po lopressor cont.\n\nHEME: H/H stable.\n\nGI: TF changed to 1/2str promote w/ fiber + 80g Promod at 45cc/hr. Tol well. No BM as of yet. Senna tabs given x 2 today in addition to standing dose of colace.\n\nGU: U/O green, but adequate in amt. Per team, goal is to keep pt euvolemic or negative if possible.\n\nID: Temps 99-100. Levaquin cont.\n\nENDO: No coverage per RISS.\n\nSKIN: Grossly intact. Right side of mouth with small pressure sore. No drainage noted.\n\nSOCIAL: Father phoned in for updates. Plan to visit in eve.\n\nASMT: Pt s/p hanging complicated by alteration in oxygenation. Cont to require vent support for adequate oxygenation.\n\nPLAN: Cont to monitor vs, wean sedation as tol, aggressive pulmonary hygiene, bowel regimen, cont vent support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-10 00:00:00.000",
"description": "Report",
"row_id": 1574759,
"text": "ASSESSMENT AS NOTED\n\nRES: REMAINS ON 12PEEP, 14 PS, PO2-79, LS COARSE, THICK YELLOW SPUTUM\n+STRONG COUGH\n\nCV: STABLE BP, IN NSR, PERIPHERAL EDEMA, +PULSES, WARM SKIN\n\nNEURO: FOLLOWS SIMPLE COMMANDS WHEN OFF PROPOFOL, STRONG, TRYING TO SIT UP, FOCCUSES, NODS , C-COLLAR ON\n\nID: LOW GRADE TEMP 99-100, ON LEVOFLOX QD\n\nGU: U/O WNL, GREEN URINE\n\nGI: TOLERATES T.FEEDING WELL, NO BM, +BS, SOFT ABD\n\nPLAN: CONT TO WEAN OFF VENT, SYMPTOMATIC TREATMENT FEVER\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-10 00:00:00.000",
"description": "Report",
"row_id": 1574760,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Morning abg results revealed a compensated metabolic alkalemia with mild hypoxemia on the current settings.\n\nNo RSBI measured due to the level of PEEP currently required.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-10 00:00:00.000",
"description": "Report",
"row_id": 1574761,
"text": "Resp Care\n\nPt remains intubated and on CPAP/PSV. MV was been in the 10-11L range and increases with agitation. TV's in the high 400's and rr generally in the mid to high 20's. BS diminished in lower lobes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-13 00:00:00.000",
"description": "Report",
"row_id": 1574772,
"text": "Respiratory Care Note:\n Patient weaned and extubated this am. He appears comfortable now on 4lpm nasal O2 with SaO2 of 96%. BS with good aeration bilat. Patient able to cough productively and spontaneously as needed. Vent discontinued from bedside. Will continue to monitor oximetry and provide bronchodilator therapy as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-04 00:00:00.000",
"description": "Report",
"row_id": 1574732,
"text": "Resp Care\nPt received vented and intubated with # 7.5 @ 27. Suctioned mod amt of bloody secretions. Plan to continue to mointor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-04 00:00:00.000",
"description": "Report",
"row_id": 1574733,
"text": "nursing admit/progress note\n\nPt 26 yo male admitted from ED s/p apparent fall, striking head in own home. Pt was found by father with a dog collar around his neck, and was cut loose from collar, falling and striking head. accurate course of events unknown at this time. pt was intubated at scene, GCS 5 upon arrival of EMS, GCS same upon arrival to ED. TLS spine films, CT head, c spine, abdomen, chest all completed prior to transfer to ICU. head, c spine negative upon prelim. read. upon admission to , pt sedated, intubated. father arrived approx 45 min after pt to ICU, in to visit, updated on pt's status, all ques answered, plan of care from this point forward also discussed.\n\nneuro: pt sedated w/ propofol, given vecuronium by ED staff during TLS films. perrla, size 2mm bilat. no spont movement, no withdrawl to stim. very strong cough, gag noted.\n\nresp: ac mode, 100%, 400x28, peep 15 on arrival, o2 sats 96-97%. ls clear, dimin to bases bilat. equal chest expansion, equal breath sounds bilat. sx mod amts bloody thin secretions.\n\ncv: tachycardic 120s, no ectope. bp 130s on admit, more hypotensive w/ propofol infusion. ppp bilat, weakly. feet cool to touch. LR infusing 150cc/h. EKG done per orders, note sinus tachycardia. cbc, lytes pending.\n\ngi: belly soft, bs absent. og to lws w/ mod amts bloody bile. placement verified.\n\ngu: foley patent, clear yellow qs. urine sent for toxicology.\n\nid: normothermic, no abx.\n\nskin: no compromise noted on initial exam, old bloody drainage to nose, mouth, and on face.\n\nsocial: father in to visit shortly after pt arrived, as above all ques answered, spoke to Dr. regarding pt's condition.\n\na: s/p ?suicide attempt by choking, s/p fall, striking head. remains intubated, sedated. await official reads of all scans, films. requiring much vent support to maintain adequate o2 levels.\n\np: serial neuro exams, follow hemodynamics, monitor resp status d/t likely aspiration of blood after striking head. ? repeat head CT within next 24h.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-05 00:00:00.000",
"description": "Report",
"row_id": 1574738,
"text": "NPN 1900-0700\nNEURO: Pt sedated on propofol gtt. When lightened, pt MAE and appears to be attempting to sit up/get OOB. Inconsistently follows commands. Fentanyl x 2 for ?of pain as evidenced by tachycardia.\n\nRESP: FiO2 decreased to 50%. ABG's/Sats WNL. LS diminished on right side and clear. Strong productive cough. Often breathes over vent 5-8 breaths.\n\nCV: HR 100S-110S ST. BP 140s-160s/60s-70s despite fentanyl for ?of pain. Cardiac enzymes elevated. Started IV lopressor prn for tachycardia with mild effect.\n\nHEME: H/H stable. Sq heparin/pboots.\n\nGI: Abd soft, nontender/nondistended. OGT to LCS. No BM this shift.\n\nGU: Adequate u/o via foley. Lytes repleted. Urine starting to become pink in color with pink sediment.\n\nID: Tmax 100.7, WBC trending upward. No abx ordered at this time.\n\nENDO: Glucose WNL via serum labs.\n\nSKIN: Grossly intact; no issues.\n\nSOCIAL: Parents in for visit on eve shift. Request that girlfriend does not visit or be given any info.\n\nASMT: Pt s/p hanging and alteration in resp status.\n\nPLAN: Cont to monitor vs, neuro checks, pulmonary hygiene, monitor cardiac enzymes, ?attempt to wean sedation/vent settins in AM, psych consult and ?need for 1:1 sitter when pt extubated and able to communicate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-05 00:00:00.000",
"description": "Report",
"row_id": 1574739,
"text": "Nursing Progress Note:\nPlease see CareVue for specifics.\n\nRESP:\nWeaned to PSV this am and intially tolerating well. Tachypneic at times to 30s but good volumes and ABGs on 18/10 cmH20 40%. At 1300hrs, pt's ETT was rotated to Rt side of mouth and advanced per order by 2cm. Pt became extremely bronchospastic, coughing violently ++++, producing copious secretions, biting ETT impairing ventilation, desaturated to 40s, despite sedation bolus prior to intervention and 200mg propofol boluses total during episode. ETT withdrawn 1cm and resecured. Oral airway inserted. CXR repeated (shows ETT still well above carina). Pt remained tachypneic to 40s after this episode for >45minutes, despite further sedation, therefore returned to control mode ventilation. More settled this pm. Chest remains coarse but less so than at 1300hrs. Still producing thick bloodstained-tan secretions. More settled neurologically this pm also, so being retried on PSV at this time.\n\nHEMODYNAMICALLY:\nST most of day. No ectopy. Hypertensive to 160s systolic with only minimal effect from prn metoprolol. Discussed with Dr , scheduled Beta blocker to be added.\nCardiac markers cycled. CKs >8000. Repeat labs being sent.\nPeripheries warm and well perfused. Peripheral IV x1 & cordis in use.\n\nNEURO:\nSedated on propofol and prn lorazepam. Off propofol, opens eyes to voice. PEARL. Regards examiner and turns head towards father's voice. Moves all 4 limbs spontaneously, though not purposfully. Pt obeying commands well this am, slower this pm, possibly due to added lorazepam due to extreme agitation this afternoon. Good strength, resists passive range of motion by staff but not always cooperative with exam.\nC-collar insitu.\nNodded head to acknowledge pain x1, fentanyl given, pt settled but little change in vital signs.\n\nENDOCRINE:\nBlood sugars 90-130s. NPO until this afternoon.\n\nFLUIDS/LYTES:\nContinues to receive LR at 150mls/hr. Repeat lytes pending.\n\nGI:\nAbd soft, non distended. Bowel sounds improving. OGT initially to suction, now receiving tube feeds Promote with fiber at 10mls/hr. Passing flatus, no stool today.\n\nID:\nLow grade fever only, no antibiotics at this time.\n\nRENAL:\nGood urine output via foley, but green color this pm. Noted rising CKs. Pt has also received large doses of propofol. ?rhabdo or propofol staining. Repeat lytes sent. Plan has not yet been finalized- no other orders. IV fluids continue.\n\nSKIN:\nNo active issues at this time. Lips and hands becomming more edematous. Peripheral IV Lt arm removed due to redness.\n\nSOCIAL:\nFather in to visit today. Was present for neuro wake-up per his request and spent time visiting with pt. Updated on plan and condition.\nNo contact from Cross as yet (pt's brother serving in and social worker with Red Cross to contact pt's brother).\n\nPLAN:\nFollow repeat lytes and CKs.\n?add HC03 to IV fluids.\nWean vent support as able.\nTitrate tube feeds up as tolerated.\nContinued\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-05 00:00:00.000",
"description": "Report",
"row_id": 1574740,
"text": "(Continued)\n support for family.\nPsych eval and suicide precautions when extubated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-05 00:00:00.000",
"description": "Report",
"row_id": 1574741,
"text": "Patient weaned off and on PSV and A/C. Very agitated when not properly sedated,has good ABG wil wean to extubate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-06 00:00:00.000",
"description": "Report",
"row_id": 1574742,
"text": "NPN 1900-0700\nNEURO: Pt sedated on propofol gtt; gradually weaned overnight and given ivp ativan d/t labs lipemic from propofol. When lightened, pt inconsistently follows commands. Wiggles toes and sticks out tongue, however only moves upper extremities to noxious stimuli.\n\nRESP: Pt initially on CPAP, with stable ABG. Shortly after midnight wake up pt became tachypneic with RR high 40s, increased WOB and nasal flaring despite sedation. Pt placed back on CMV to rest overnight with improvement. Sats/ABG'S WNL. LS diminished to right side. Pt has very strong, bronchospastic cough.\n\nCV: HR 90s-110s ST no ectopy noted. BP 160S-180S/70s-90s despite lopressor ATC and prn. CK's slightly lower.\n\nHEME: H/H stable. Pboots/sq heparin cont.\n\nGI: Abd benign. +bowel sounds. TF adv as tol. No BM this shift.\n\nGU: U/O green in color. goal hourly u/o is >100cc/hr. Plan is to add NaHCO3 to IVF if CK's >10,000 to prevent rhabdo.\n\nID: Tmax 101.2. Pan cultured. Tylenol given with effect. WBC trending up. Family states pt had a cold before admission.\n\nENDO: No coverage needed per RISS.\n\nSKIN: Grossly intact, no breakdown noted.\n\nSOCIAL: Family in for brief visit on eves and updated on POC.\n\nASMT: Pt s/p hanging now complicated by alteration in resp status when sedation is decreased.\n\nPLAN: Cont to monitor vs, neuro checks, pulmonary hygiene, cont to wean sedation and vent as tol, SW/psych consult when extubated and appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-06 00:00:00.000",
"description": "Report",
"row_id": 1574743,
"text": "RESP CARE\nPT REMAINS INTUBATED AND VENTED ON FULL VENTILATORY SUPPORT. ATTEMPTED TO WEAN ON PSV HOWEVER PT BECAME AND TACHYCARDIC REQUIRING INCREASED LEVEL OF SUPPORT. BS CLEAR TO COURSE SXING FOR MOD TO LARGE AMTS OF THICK YELLOW SECRETIONS. HEATED WIRE CIRCUIT PLACED FOR BETTER HUMIDIFICATION. WILL CONT WITH VENT SUPPORT AND REASSESS DAILY FOR READINESS TO WEAN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-10 00:00:00.000",
"description": "Report",
"row_id": 1574762,
"text": "NPN 0700-1900\nNEURO: Pt with frequent burst of agitation despite ATC and prn ativan. Propofol gtt cont, however dose decreased d/t slightly lipemic labs. Pt often found thrashing in bed, with bronchospastic cough, and increase RR. Haldol 3mg po ATC started. Fentanyl x2 for pain.\n\nRESP: No vent changes made. Pt cont with low PaO2 despite 60%FiO2 and 12peep. LS coarse. LLL very diminished; almost absent.\n\nCV: HR 90s BP 140s-160s/70s-80s. SBP can be as high as 210 when agitated or lightened. A-line re-sited. PICC line with red port clotted off. TPA ordered, however cannont administer d/t line cannot be flushed.\n\nHEME: H/H stable. Cont sq heparin/pboots.\n\nGI: Lg BM x2 today after dulcolax PR. Hypo bowel sounds. TF cont at goal with minimal residuals.\n\nGU: Adequate u/o via foley. Lasix 10mg IV given today. u/o 900 post lasix. Lytes WNL.\n\nID: Temps 99-100. Blood cultures from a-line on positive for gram positive rods in anaerobic bottle (see CCC for specifics). Per Dr. , likely skin contaminants d/t the names of the organisms they could possibly be. A-line re-sited. Levaquin cont.\n\nENDO: No coverage needed per RISS.\n\nSKIN: Right mouth sore unchanged. Overall skin grossly intact.\n\nSOCIAL: Parents in today for brief visits.\n\nASMT: Pt s/p hanging complicated by alteration in oxygenation.\n\nPLAN: Cont to monitor VS, provide adequate sedation for maxium oxygenation, pulmonary hygiene, neuro checks.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-07 00:00:00.000",
"description": "Report",
"row_id": 1574748,
"text": "Resp Care\n\nPt remains intubated and vented on PSV 20/10 with Vt around 400-450cc and RR 20-upper 30s with agitation. BS clear to course sxing for mod amts of thick tan/yellow secretions. Pt transported to and from CT scan without any incident. Oxygenatiion/ventilation stable on present settings. WIll continue with wean and rest on A/C overnoc if needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-07 00:00:00.000",
"description": "Report",
"row_id": 1574749,
"text": "addendum to previous NPN\npropofol turned off at 5 pm for neuro exam. much improved since this morning. patient opening eyes, tracking. squeezed both hands and pushed with foot on my hand. PERLA , briskly reactive. Patient tolerated lightening much better this afternoon, maintaining an O2 sat above 95% and ABP high 150s.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-08 00:00:00.000",
"description": "Report",
"row_id": 1574750,
"text": "Pt remains intubated and mechanically ventilated. Pt switched to CMV 20/500/10p/60%. Pt tachypenic in 40-50's, extremely agitated on PSV 20/10peep. 02 sat decreased into low 90's while on 40%. FI02 increased to 60%. ABG's drawn. PH 7.44/ C02 43/ Pa02 110/ HC03 30. Pt given boluses of propafol during the night. Will re-eval in am to see if pt can tolerate PSV ventilation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-08 00:00:00.000",
"description": "Report",
"row_id": 1574751,
"text": "ASSESSMENT AS NOTED\n\nRES: PT WAS SWITCHED TO A/C LAST NIGHT TO KEEP PO2 ADEQUATE AND FO2 UP TO 60%, LARGE AMNT OF THICK YELLOW RPUTUM, STRONG COUGH, BITE LOCK IS IN PLACE, CXR WAS DONE\n\nCV: HYPERDYNAMIC WHEN AWAKE, TACHY, + PULSES, PERIPH EDEMA,\n\nNEURO: WHEN OFF SEDATION FOLLOWS SIMPLE COMMANDS INCONSISTENTLY, C-COLLAR ON, FOCCUSES TO NAME, MAE, STRONG GAG, COUGH, PERIPH IV LOCK ARE PATENT\n\nGI: TOLERATES TF WELL, NO RESIDUAL, +BS,\n\nID:TEMPS 100-101.5, TREATED WITH TYLENOL, FAN IS ON, STARTED ON LEVAQUIN LAST NIGHT\n\nPLAN:KEEP TEMP<100, PULM TOILET\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-08 00:00:00.000",
"description": "Report",
"row_id": 1574752,
"text": "NSG NOTE\n\nROS:\n\n CV:SOMETIMES HYPERTENSIVE WITH STIMULATION AND CHANGE TO PSV.ON LOPRESSOR 50MG PO BID.REMAINS IN NSR WITHOUT ECTOPI.\n\n RESP:CHANGED FROM CMV TO PSV AT 8AM.ON 20 PSV,10 CPAP,50% WITH VT 475-500,RR 29,ABGS 7.44-41-84,SAT 94.PSV DECREASED TO 18,SAME SETTINGS.VT SAME,RR 23.7.41-45-103 WITH SAT 96-98.SX FOR SM THICK WHITE SPUTUM.HAS AIRWAY IN PLACE D/T BITING ETT.AM CXR SLIGHTLY BETTER THAN YESTERDAY.\n\n NEURO:OPENS EYES,WRIGGLES TOES,DOES NOT SQUEEZE HAND OR SHOW THUMBS.HAS VERY STRONG COUGH,LIFTS OFF BED WITH COUGHING.QUESTION AWARENESS.HEAD CT FORM SHOWS RESOLVING CEREBRAL EDEMA.NEEDS PROPOFOL UNTIL READY FOR EXTUBATION.\n\n GI:ON GOAL TF AT 45CC(WHILE 0N PROPOFOL)PROMOTE WITH FIBER.\n+ BS,NO STOOL.\n\n GU:UO 75-150\n\n SKIN:INTACT,COLLAR CARE DONE.\n\n ID:T MAX 100.3.ON LEVOQUIN\n\n ENDO:BS 68 AT 12N.\n\n PLAN:PT TO IR THIS PM FOR PIC LINE.NO FURTHER WEANING ON PSV UNTIL AFTER PROCEDURE,THEN ASSESS.\n\n SOCIAL:FATHER CALLED,WILL BE IN THIS PM,IS AWARE OF IR PLANS.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-08 00:00:00.000",
"description": "Report",
"row_id": 1574753,
"text": "resp care\nremains intub/vent supported. received in ac mode. changed to psv mode, requiring ps of at least 18 for vt close to 500 cc's. occas tachypneic. transported to I.R , tolerated well , lg amt secretions mobilized post transport...yellow thick with strong cough effort. requires sedation bolus to ease coughing spasms. requiring peep 10, pneumonia, not yet ready to wean further.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-11 00:00:00.000",
"description": "Report",
"row_id": 1574763,
"text": "ROS:\n\nNeuro: Sedated on propofol at 100 mcg/kg/min, haldol and ativan as scheduled. Awake, follows commands. MAEs x 4 to command. Sedation needed d/t forcefull coughing.\n\nCV: RSR w/o ecotpy. VSS. Peripheral pulses palpable w/ease. has left radial ABP line. Generalized puffiness. Heparin sq and p boots for dvt prophylaxis.\n\nResp: Remains orally intubated and on vent. CPAP+PS , 60%. Lung sounds clear sx white secreations via ETT. No resp distress noted, = rise and fall of chest. Forcefull coughing fits causing entire body except for buttox to leave the bed. Coughing controled well w/propofol.\n\nGI: Abd firm round w/hypo active BS. Oral sump initially w/TF infusing. Large bile emesis at beginning of shift, OG connected to LCS (HO, Dr. aware). 350 cc of bile initially returned when connected to LCS. Reglan initiated. Protonix for GI prophylaxis.\n\nGU: Foley patent draining clear green urine in QS\n\nLabs: pending at the time of this note.\n\nENDO: FSG not requiring coverage from RSSI\n\nSocial: Father phoned at for update.\n\nPlan: Sedation management. Pulmonary toileting. Monitor residules and restart TF ASAP. Monitor I/o, goal to be 1-2 liters -.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-11 00:00:00.000",
"description": "Report",
"row_id": 1574764,
"text": "Respiratory Care:\nPatient remains on CPAP/PSV ventilatory support with no parameter changes made throughout the night. Morning abg results revealed a compensated mild metabolic alkalemia with good oxygenation.\n\nNo RSBI measured due to the level of PEEP and FIO2 currently required.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-11 00:00:00.000",
"description": "Report",
"row_id": 1574765,
"text": "NPN 0700-1500\nNEURO: Pt sedated on propofol gtt and ATC ivp ativan. Pt able to interact and follow commands with propofol dose cut in half, however sedation needed d/t pt becomes diaphoretic, tachypneic, and with extreme bronchospastic cough when lightened. MAE, follows commands.\n\nRESP: FiO2 decreased to 50%, peep to 10. ABG's with low-normal oxygenation. LS with occasionall I/E wheezes; relieved with suctioning. Sats 95-99%.\n\nCV: HR 80s NSR, no ectopy noted. BP 140s-160s/70s.\n\nHEME: H/H stable. Sq heparin/pboots cont.\n\nGI: Large amt bilious output via OGT (~2L for this shift). All po meds changed to IV. +Bowel sounds. No BM this shift. ABD xray taken, results pending.\n\nGU: Adequate u/o via foley. Afternoon K+ of 3.8 to be repleted.\n\nID: Afebrile this shift. Cont levaquin until early next week.\n\nENDO: No coverage needed per RISS.\n\nSKIN: Grossly intact. Pressure sore to right mouth healing.\n\nSOCIAL: Father in for visit and spoke with Dr. for updates.\n\nASMT: Pt s/p hanging complicated by alteration in oxygenation.\n\nPLAN: Cont to monitor vs, cont sedation while pt is intubated, neuro checks, f/u with abd xray, monitor labs, ? anticipate trach and peg if no improvement in oxygenation by next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-11 00:00:00.000",
"description": "Report",
"row_id": 1574766,
"text": "Respiratory Care Note:\n Patient continues weaning from vent although he continues to require sedation to tolerate intubation. Suctioned for pale yellow secretions. ABG with normal acid base status. See Carevue for specifics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2133-07-12 00:00:00.000",
"description": "Report",
"row_id": 1574767,
"text": "cv: bp stable. hr 108-94 st -sr no ectopy. on iv lopressor with good respoonse. hr decreases to 90's after dose.\n\ngi: ng lcws draining green bilious. ng had been pulled back by ho and plan to monitor amount of ng drainage overnoc.bs hypoactive. drainage decreased to total of 200cc so tf restarted at 0600 promote w fiber and promod.\nbegun at 10 cc/hr..increase as ordered.\n\ngu: foley draining green urine clear..adequate amounts\n\nneuro: opens eyes to stimulation. moving feet on bed. pt is able to lift both arms.perrl. sedated with propophol aat 100 mics/ kg/min and requiring ativan 2 mg iv q 6 hours. pt received and additional dose af ativan 2 mg iv ..pt was coughing forcefully and moving entire body with the force of the cough so ativan with good effect.\ncervical collar in place.\n\nresp: copious oral secretions and copious thin yellow secretions. suctioned ~q 1 hour. bs coarse with diminished. wheezy at times after suctioning but decrease wheezing after combivent. see abg on careview.\n\nendo: bs 1119 requiirng no coverage.\n"
},
{
"category": "Echo",
"chartdate": "2133-07-06 00:00:00.000",
"description": "Report",
"row_id": 79768,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 73\nWeight (lb): 235\nBSA (m2): 2.31 m2\nBP (mm Hg): 170/92\nHR (bpm): 104\nStatus: Inpatient\nDate/Time: at 12:44\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic\nfunction (LVEF>55%). Normal regional LV systolic function.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. There is mild symmetric left ventricular hypertrophy with normal cavity\nsize and systolic function (LVEF>55%). Regional left ventricular wall motion\nis normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871286,
"text": " 10:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: EVAL POSS ASPIRATION.\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with\n REASON FOR THIS EXAMINATION:\n EVAL POSS ASPIRATION.\n ______________________________________________________________________________\n FINAL REPORT\n History of trauma and intubation with possible aspiration.\n\n Endotracheal tube is 7 cm above carina. NG tube is in fundus of stomach.\n Heart size is borderline for supine technique. There is a right-sided aorta.\n There are a large areas of opacity in the right upper lobe and in the left\n midzone, and in addition, in the left lower lobe. These could represent\n pulmonary contusions and/or be related to aspiration. No definite\n pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-16 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 872786,
"text": " 12:17 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Eval for kidney perfusion status\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n Field of view: 43 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p stabbing w/ liver lac and kidney hematoma\n REASON FOR THIS EXAMINATION:\n Eval for kidney perfusion status\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post stabbing with history of liver laceration and kidney\n hematoma.\n\n TECHNIQUE: Multiple axial images of the abdomen and pelvis were obtained both\n prior to and following the administration of 150 cc of Optiray. The first\n series of (non-contrast) images of the abdomen were actually obtained\n following the administration of 30 cc of Optiray IV after a 15-minute delay.\n\n CT ABDOMEN WITHOUT AND WITH IV CONTRAST: Few images through the lung bases\n demonstrate a patchy opacity in the lingula. There is consolidation at the\n left lung base. The left lung base consolidation appears to have improved\n from the partially visualized lung bases from a thoracic spine CT of . However, at the medial portion of the left base, there is a tiny\n pneumothorax visualized. There is some atelectasis at the right base, this is\n significantly improved from the prior study.\n\n Non-contrast images (as previously described, these were obtained about 15\n minutes after the injection of 30 cc of Optiray) demonstrate residual contrast\n in the calices with excretion by the ureters.\n\n Post-contrast images demonstrate satisfactory excretion from both kidneys.\n There is normal cortical enhancement. No renal hematoma is identified. There\n is no stranding of the perinephric fat. The liver is unremarkable.\n\n The gallbladder, spleen, pancreas and adrenal glands are unremarkable. The\n loops of bowel are normal in appearance. There is no free air or free fluid\n in the abdomen.\n\n CT PELVIS WITH IV CONTRAST: The bladder is not fully distended. The\n prostate, rectum is unremarkable. There is no free air or free fluid in the\n pelvis. No significantly enlarged inguinal lymph nodes.\n\n BONE WINDOWS: No suspicious lytic or blastic lesions.\n\n Findings communicated to Dr. on .\n\n IMPRESSION:\n 1. Small loculated pneumothorax at left lung base. Its full extent is not\n visualized on this abdominal study.\n (Over)\n\n 12:17 PM\n CT ABD W&W/O C; CT PELVIS W&W/O C Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Eval for kidney perfusion status\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n Field of view: 43 Contrast: OPTIRAY Amt: 150CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Consolidation at the left base has improved. Consolidation at the right\n base has significantly improved.\n 3. Normal appearance of both kidneys. Normal appearance of the liver.\n 4. Normal excretion identified from both kidneys.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-15 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 872623,
"text": " 8:55 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: Eval for liver/gallbladder process\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with elevated LFTs\n REASON FOR THIS EXAMINATION:\n Eval for liver/gallbladder process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old with transaminitis.\n\n No prior studies.\n\n FINDINGS: The liver is normal in echogenicity without focal mass. The\n gallbladder is normal without stones or sludge. Common bile duct measures 4\n mm. There is no intrahepatic ductal dilation. The free fluid is seen in the\n right upper quadrant. There is no evidence of gallbladder wall thickening or\n edema.\n\n Color imaging demonstrates normal hepatopetal flow within the main portal\n vein.\n\n IMPRESSION: Normal right upper quadrant ultrasound.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-16 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 872760,
"text": " 9:45 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with aspiration PNA\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup aspiration.\n\n The heart is normal in size. Bilateral mid and lower lung zone opacities are\n somewhat improved since . The Dobhoff tube and the PICC line have\n been removed. The right-sided aortic arch is again noted. There is no\n pneumothorax.\n\n IMPRESSION: Improved but significant residual opacities at the lung bases\n persist since .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871399,
"text": " 1:49 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check ETT position.\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with hanging injury, intubated. ETT positioned and pt became\n briefly agitated, hypoxic.\n REASON FOR THIS EXAMINATION:\n check ETT position.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM.\n\n History of hanging injury with intubation.\n\n Endotracheal tube is 4 cm above carina. NG tube is in fundus of stomach. No\n pneumothorax. There are persistent bilateral ill-defined patchy opacities in\n both mid and lower zones, left greater than right, consistent with multilobe\n contusions/consolidation/aspiration change. No pneumothorax. The right CPA\n region is not included on the film.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-04 00:00:00.000",
"description": "CT RECONSTRUCTION",
"row_id": 871276,
"text": " 6:08 AM\n CT T-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: Please do recons to eval Tspine. Plain films inadequate\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p fall, hanging attempt\n REASON FOR THIS EXAMINATION:\n Please do recons to eval Tspine. Plain films inadequate\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall, status post hanging attempt.\n\n TECHNIQUE: Axial images of the thoracic spine were obtained with coronal and\n sagittal reformatted images.\n\n FINDINGS: The alignment is normal. The disc spaces are maintained. There is\n no loss of vertebral body height. No paravertebral hematoma identified.\n\n IMPRESSION: No evidence of acute fracture or dislocation. Note that the\n lungs are better evaluated on CT scan of the torso of the same date.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-04 00:00:00.000",
"description": "CT L-SPINE W/O CONTRAST",
"row_id": 871277,
"text": " 6:08 AM\n CT L-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: Please do recons to eval Lspine. Plain films inadequate\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p fall, hanging attempt\n REASON FOR THIS EXAMINATION:\n Please do recons to eval Lspine. Plain films inadequate\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post hanging attempt, status post fall.\n\n TECHNIQUE: Axial images of the lumbar spine were obtained with coronal and\n sagittal reformatted images.\n\n FINDINGS: The alignment is normal. There is no loss of vertebral body\n height. The disc spaces are maintained. No paravertebral hematoma\n identified.\n\n IMPRESSION: No evidence of acute fracture or malalignment.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-12 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 872363,
"text": " 1:18 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval NGT\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p anoxic brain injury with large ngt outputs\n\n REASON FOR THIS EXAMINATION:\n eval NGT\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN .\n\n Comparison one day earlier.\n\n INDICATION: Nasogastric tube assessment.\n\n A nasogastric tube remains in place within the stomach. A nonobstructive\n bowel gas pattern is visualized in the imaged portion of the abdomen. Within\n the imaged portion of the chest, there remains an area of increased opacity in\n the left retrocardiac region, most likely due to atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-11 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 872275,
"text": " 12:43 PM\n PORTABLE ABDOMEN Clip # \n Reason: please assess location of ngt / eval for ileus vs obstructio\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man s/p anoxic brain injury with large ngt outputs\n REASON FOR THIS EXAMINATION:\n please assess location of ngt / eval for ileus vs obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Nasogastric tube assessment.\n\n A nasogastric tube was quelled within the distal stomach. A nonobstructive\n valgus pattern is visualized. There is questionable increased opacity in the\n left retrocardiac region within the imaged portion of the lung base, but this\n area is incompletely evaluated on this abdominal radiograph.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872085,
"text": " 4:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ards\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with hanging injury, intubated. evolving R-sided infiltrate\n on prior CXR\n REASON FOR THIS EXAMINATION:\n ards\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post hanging injury, evaluate ARDS.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable upright chest.\n\n FINDINGS: A left-sided PICC is again seen with tip terminating in the distal\n SVC. Nasogastric tube extends below the diaphragm with tip terminating below\n the borders of the radiograph. The heart size and mediastinal contours are\n unchanged. There is interval improvement in patchy bilateral pulmonary\n parenchymal opacity, with stable dense opacification of the left retrocardiac\n region and obscuration of the left hemidiaphragm. An endotracheal tube is in\n unchanged position, with tip 5.6 cm from the carina. The osseous structures\n appear unchanged.\n\n IMPRESSION: 1) Lines and tubes in unchanged position.\n\n 2) Interval improvement in patchy bilateral pulmonary parenchymal opacities.\n\n 3) Stable left lower lobe collapse vs. consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-04 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 871269,
"text": " 4:32 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT RECONSTRUCTION\n CT 150CC NONIONIC CONTRAST\n Reason: eval for intraabdominal intra thoracic bleed, fractures\n Field of view: 50 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man s/p trauma\n REASON FOR THIS EXAMINATION:\n eval for intraabdominal intra thoracic bleed, fractures\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl SAT 5:26 AM\n Collapse/consolidation of the posterior portions of the right upper and left\n upper lobes. Near total collapse/consolidation of the left lower lobe.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Trauma.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired images of the chest, abdomen, and pelvis were\n obtained after the administration of IV contrast.\n\n CT OF THE CHEST WITH IV CONTRAST: Incidental note is made of a right-sided\n aortic arch. There is opacity in the posterior portions of the right upper\n and left upper lobes. There is near total collapse/consolidation of the left\n lower lobe. Ill defined opacity in the right lung apex is also seen. The left\n lower lobe bronchus is occuluded. An ET tube and NG tube are in place. No\n pneumothorax is identified. The heart and pericardium are unremarkable.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: An NG tube terminates in the stomach. The\n liver, gallbladder, pancreas, spleen, adrenal glands, kidneys, stomach, small\n bowel, and large bowel are unremarkable. There are multiple small mesenteric\n lymph nodes that do not meet CT criteria for pathologic enlargement. There is\n no free air or free fluid.\n\n CT OF THE PELVIS WITH IV CONTRAST: The bladder contains a Foley catheter.\n There is air in the bladder, likely secondary to recent catheterization. The\n rectum and sigmoid colon are unremarkable. There is no free pelvic fluid. A\n catheter is noted entering via the right groin.\n\n Bone windows demonstrate no suspicious lytic or sclerotic foci. No rib\n fractures identified.\n\n MULTIPLANAR REFORMATTED IMAGES: The coronal and sagittal reformatted images\n were useful in delineating the above pathology, particularly useful in\n delineating the osseous anatomy. The alignment of the spine is normal. No\n compression fractures are identified.\n\n IMPRESSION:\n 1. Opacity in the posterior lungs bilaterally that may represent atelectasis\n (Over)\n\n 4:32 AM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT RECONSTRUCTION\n CT 150CC NONIONIC CONTRAST\n Reason: eval for intraabdominal intra thoracic bleed, fractures\n Field of view: 50 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n with aspiration also a consideration. There is occlusion of the left lower obe\n bronchus with near total collapse/consolidation of the left lower lobe.\n There is ill defined opacity in the right apex that may represent early\n contusion or aspiration.\n 2. Incidentally noted right-sided aortic arch.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-04 00:00:00.000",
"description": "T-SPINE",
"row_id": 871271,
"text": " 5:07 AM\n T-SPINE; L-SPINE (AP & LAT) Clip # \n Reason: r/o fx/dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man attempted hanging and fall\n REASON FOR THIS EXAMINATION:\n r/o fx/dislocation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n TWO VIEWS OF THE THORACIC SPINE: The alignment is normal. There is no loss\n of vertebral body height. The disc spaces are maintained. Evaluation of T1\n is limited.\n\n TWO VIEWS OF THE LUMBAR SPINE: The alignment is normal. There is no loss of\n vertebral body height. The disc spaces are maintained. Note is made of\n contrast material present within the collecting systems.\n\n IMPRESSION: No evidence of acute fracture or malalignment of the T or L\n spines.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-04 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 871267,
"text": " 4:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intercranial bleed, fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man s/p head trauma\n REASON FOR THIS EXAMINATION:\n r/o intercranial bleed, fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT acquired images of the head were obtained without IV\n contrast.\n\n FINDINGS: There is no evidence of acute intra or extra-axial hemorrhage. The\n -white matter differentiation is preserved. There is no hydrocephalus or\n shift of normally midline structures. The basilar cisterns are patent. No\n skull fractures are identified. There is partial opacification of the ethmoid\n sinuses.\n IMPRESSION: No evidence of acute intracranial hemorrhage. No fracture\n identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-04 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 871268,
"text": " 4:32 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: eval for cervical fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 27 year old man s/p head trauma\n REASON FOR THIS EXAMINATION:\n eval for cervical fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JJMl SAT 5:09 AM\n No evidence of acute fracture or malalignment.\n Non-fusion of the C1 ring posteriorly with well corticated edges suggestive of\n a congenital fusion anomoly.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n TECHNIQUE: Axial images of the cervical spine were obtained with coronal and\n sagittal reformatted images.\n\n FINDINGS: The alignment is normal. There is no prevertebral soft tissue\n swelling. There is no loss of vertebral body height. The disk spaces are\n maintained. The imaged portions of the lungs demonstrate bilateral opacities\n posteriorly. ET tube and NG tube are in place. The arch of C1 is non-fused\n posteriorly.\n\n IMPRESSION: No evidence of acute fracture or malalignment.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872465,
"text": " 9:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check placement of feeding tube\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with hanging injury, intubated. evolving R-sided\n infiltrate on prior CXR\n REASON FOR THIS EXAMINATION:\n check placement of feeding tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 26-year-old male with hanging injury.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: AP upright single view of the chest.\n\n FINDINGS: There is a feeding tube with the tip in the distal stomach. There\n is a left subclavian central line with the tip in the distal SVC. Cardiac and\n mediastinal contours are unchanged when compared to prior study. There is\n marked worsening of left retrocardiac opacity that could represent\n atelectasis, pneumonia or aspiration. There is also a patchy opacity in the\n right base in the right retrocardiac area that could represent aspiration as\n well vs. atelectasis. There is no pneumothorax. The lung volumes are lower.\n\n IMPRESSION:\n 1) Interval exchange of NG tube for a feeding tube with the tip in the distal\n stomach.\n 2) Interval extubation.\n 3) Interval worsening of left retrocardiac opacity, which is now large and\n could represent linear atelectasis, pneumonia or aspiration.\n\n 4) Right lower lobe patchy opacity could represent atelectasis or\n consolidation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-11 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 872289,
"text": " 4:22 PM\n PORTABLE ABDOMEN Clip # \n Reason: please assess location of ngt\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with postpyloric ngt; would like it in stomach\n REASON FOR THIS EXAMINATION:\n please assess location of ngt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Nasogastric tube placement.\n\n Comparison is made to previous abdominal radiograph of earlier the same date.\n\n A nasogastric tube has been repositioned in the interval and is no longer\n coiled. Its tip is within the body of the stomach. Within the imaged portion\n of the lower chest, patchy opacities noted in the left retrocardiac region\n appear slightly improved.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-04 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 871265,
"text": " 4:12 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Trauma.\n\n AP VIEW OF THE CHEST: The ET tube terminates at the thoracic inlet. An NG\n tube is coiled within the esophagus. There is a right-sided aortic arch.\n There are bilateral lower lobe medial opacities that interpreted in\n conjunction with the CT scan of the same day represent posterior\n collapse/consolidation. No pleural effusion is seen. No pneumothorax\n identified. No rib fractures identified.\n\n AP VIEW OF THE PELVIS: A central venous line is present in the right groin.\n No evidence of acute fracture or dislocation.\n\n The above was discussed with the trauma team at the time of interpretation of\n the study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-08 00:00:00.000",
"description": "CATH INFUSN,PER/CENT/MID(NOT DIAL)",
"row_id": 871785,
"text": " 7:20 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC placement. already attempted by IV team.\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\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 26 year old man s/p trauma, needing IV access, no further peripherals\n available. assess by IV team and referred to IR.\n REASON FOR THIS EXAMINATION:\n PICC placement. already attempted by IV team.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 26-year-old male status post trauma with need for IV access. Please\n place PICC line.\n\n PROCEDURE: The procedure was performed by Dr. and Dr. \n . Dr. , the staff radiologist, was present and supervising the\n procedure. The patient was placed supine on the angiography table. His left\n upper extremity was prepped and draped in the standard sterile fashion. Since\n no suitable superficial vein was visible, ultrasound was used for localization\n of an appropriate vein. The left basilic vein was patent and compressible.\n The skin and subcutaneous tissues in the left arm were anesthetized with 3 cc\n of 1% lidocaine. Using ultrasound guidance, the patent and compressible left\n basilic vein was accessed with a 21-gauge micropuncture needle. A standard\n 0.018 guidewire was advanced through the access needle into the superior vena\n cava under fluoroscopic visualization. The skin entry site was incised with a\n #11 blade scalpel. The access needle was replaced with a 5-French\n micropuncture sheath. Based on the markers on the guidewire, it was\n determined that a length of 44 cm would be appropriate. The PICC line was\n then trimmed to length and advanced over the guidewire, through the peel-away\n sheath, into the superior vena cava under fluoroscopic guidance. The\n guidewire and peel- away sheath were removed. The catheter was flushed,\n capped, and heplocked. It was secured to the skin using a StatLock device. A\n dry sterile dressing was applied.\n\n FINDINGS: A final AP chest x-ray was obtained, demonstrating the tip of the\n catheter to be present in the superior vena cava.\n\n COMPLICATIONS: None.\n\n MEDICATIONS: 1% lidocaine.\n\n IMPRESSION: Successful placement of a 44-cm 5-French dual-lumen PICC line via\n the left basilic vein. The tip of the catheter is present in the superior\n vena cava. The catheter is ready for immediate use.\n (Over)\n\n 7:20 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC placement. already attempted by IV team.\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871605,
"text": " 4:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ards\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with hanging injury, intubated. ETT positioned and pt\n became briefly agitated, hypoxic.\n REASON FOR THIS EXAMINATION:\n r/o ards\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n INDICATION: Hypoxia. Question ARDS.\n\n An endotracheal tube remains in place, currently terminating about 2.5 cm\n above the carina. A nasogastric tube terminates below the diaphragm, but the\n side port is probably just above the GE junction level. The cardiac\n silhouette is enlarged. There has been interval increased width of the\n vascular pedicle as well as of the hilar and perihilar vasculature. There are\n bilateral alveolar opacities with a central perihilar predominance. A more\n confluent area of opacity in the left retrocardiac region is unchanged. Note\n is also made of a small left pleural effusion. An incidental note is made of\n a right-sided aortic arch.\n\n IMPRESSION:\n 1. Vascular engorgement and increasing perihilar opacities, suggesting a\n component of pulmonary edema from volume overload. These findings partially\n overlap with previously described findings of contusion and/or aspiration.\n 2. No significant change in confluent left retrocardiac opacity.\n 3. Side port of nasogastric tube is likely above the GE junction level and\n could be advanced for more optimal placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 871680,
"text": " 12:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: HANGING INJURY, ANOXIC BRAIN INJURY\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man, prior hanging injury, non-improving clinical exam with ?\n anoxic brain injury.\n REASON FOR THIS EXAMINATION:\n compare to prior\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Prior hanging injury, not improving clinical exam with possible\n anoxic brain injury.\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, or shift of normally midline structures. There is no gross\n cerebral edema or areas of hypoattenuation to indicate infarction. The -\n white matter differentiation is more clearly defined when compared to the\n previous study, and there is increased prominence of the sulci. This\n indicates resolving cerebral edema. There is mucosal thickening within the\n left maxillary sinus as well as the ethmoid, sphenoid, and frontal air cells.\n\n IMPRESSION:\n 1. No evidence of intracranial hemorrhage or edema. No areas of infarction.\n 2. Evidence of resolving cerebral edema when compared to the previous study.\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871926,
"text": " 5:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for causes of desaturation\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with hanging injury, intubated. evolving R-sided infiltrate\n on prior CXR\n REASON FOR THIS EXAMINATION:\n please eval for causes of desaturation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hanging injury, intubated, evolving right-sided infiltrate.\n Evaluate for desaturation.\n\n COMPARISON: .\n\n TECHNIQUE: Single AP portable semi-upright chest.\n\n FINDINGS: An endotracheal tube is in place with tip terminating 3.8 cm from\n the carina. Nasogastric tube terminates below the diaphragm and below the\n borders of the radiograph. Interval placement of left-sided PICC with tip in\n mid SVC. No pneumothorax. A bilateral patchy parenchymal opacities, more\n prominent in the interval within the right perihilar region and right base.\n Stable consolidation vs. collapse within the left lower lobe. Prominence of\n the pulmonary vasculature appears slightly improved in the interval.\n\n The osseous structures appear unchanged.\n\n IMPRESSION: 1) New left-sided PICC with tip in mid SVC. Other lines and\n tubes in stable position.\n\n 2) Slight progression of patchy pulmonary opacity within the right mid lung,\n stable within the left mid lung. Slight decrease in prominence of the upper\n zone pulmonary vasculature. Stable left lower lobe collapse vs.\n consolidation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871776,
"text": " 4:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare with prior\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with hanging injury, intubated. evolving R-sided infiltrate on\n prior CXR\n REASON FOR THIS EXAMINATION:\n compare with prior\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup infiltrate.\n\n COMPARISON: .\n\n Tip of the endotracheal tube remains in good position, 3.1 cm above the\n carina. The left costophrenic angle is not included on the film. There is a\n dense opacity between the left side of the heart consistent with atelectasis\n or infiltrate. There is a mild pulmonary vascular redistribution, which may\n related to the supine positioning of the film.\n\n IMPRESSION: Endotracheal tube in good position. No significant change in the\n appearance of the lungs since the prior study. Compared to the prior study,\n the NG tube has been pulled back and the tip of the NG tube is now just within\n the stomach. Proximal port is in the distal esophagus. The NG tube should be\n advanced.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 872354,
"text": " 12:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pneumonia\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with hanging injury, intubated. evolving R-sided infiltrate\n on prior CXR\n REASON FOR THIS EXAMINATION:\n eval pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n\n Prior comparison, .\n\n INDICATION: Evaluate pneumonia.\n\n Endotracheal tube, left PICC line and nasogastric tube remain in satisfactory\n position. Cardiac and mediastinal contours are stable with note made of a\n right-sided aortic arch. There has been interval improved aeration in the\n left lower lobe with residual patchy opacities remaining with some associated\n inferior displacement of the left hilum. A band like opacity is noted at the\n left lung base. Patchy opacities in the right perihilar region are probably\n not significantly changed allowing for technical differences of the studies.\n\n IMPRESSION:\n 1. Marked improved aeration in left lower lobe with residual patchy and\n linear opacities remaining.\n 2. Stable patchy right perihilar opacity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2133-07-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 871383,
"text": " 10:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: compare to prior.\n Admitting Diagnosis: HEAD INJURY-RESPIRATORY FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old man with hanging injury, intubated.\n REASON FOR THIS EXAMINATION:\n compare to prior.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM.\n\n History of having injury and intubation.\n\n Endotracheal tube is 9 cm above the carina. Tip located at level of just\n above the thoracic inlet. NG tube is in fundus of stomach. No pneumothorax.\n There has been partial resolution of the bilateral pulmonary opacities with\n some persistent patchy opacity in the right and left lungs, predominantly in\n the left lower lobe.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2133-07-07 00:00:00.000",
"description": "Report",
"row_id": 212161,
"text": "Sinus tachycardia\nMinor nonspecific ST-T wave abnormalities\nSince previous tracing of , widespread ST-T wave abnormalities of\npericarditis not seen\n\n"
},
{
"category": "ECG",
"chartdate": "2133-07-04 00:00:00.000",
"description": "Report",
"row_id": 212162,
"text": "Sinus tachycardia\nTachycardia and extensive ST elevation suggests pericarditis\nNo previous tracing\n\n"
},
{
"category": "ECG",
"chartdate": "2133-07-04 00:00:00.000",
"description": "Report",
"row_id": 212163,
"text": "Sinus tachycardia\nExrensive ST elevation, consider pericarditis\nSince previous tracing of , no significant change\n\n"
}
] |
55,423 | 159,199 | 53M with NSCLC SCC stage IV (brain met s/p resection and cyberknife) s/p C1 of carboplatin gemcitabine on who presented to clinic with fatigue found to have a HCT of 17 now s/p ICU stay with 5 units PRBCs. . # GASTROINTESTINAL BLEEDING - Patient had guaiac positive stool in the ED (confirmed by GI physician) with an unsuccessful nasogastric lavage. There was initial concern for upper gastrointestinal bleeding given his hematocrit of 17% (10% drop since ) - though that was after transfusion for a hematocrit of 23% on . Patient has been taking Ibuprofen for headache while on steroids, which could predispose the patient to gastritis among other issues. Patient does report history of polyps on colonoscopy 6-years prior and has known diverticular disease, which could be a source for lower GI bleeding. We initiated a Protonix infusion following a bolus and consulted the GI specialists. He was maintained NPO with plans for endoscopy, however HCT stabilized and he remained hemodynamically stable without evidence of or hematochezia. He received 5 units of packed red cells on admission for his hematocrit of 17%. His HCT stabilized between 24 and 25. Given risks associated with intervention and the lack of evidence for acute bleeding the decision was made to empirically treat with PPI without endoscopy. The protonix gtt was changed to IV BID and then omeprazole 40 mg po BID. His INR was elevated likely in the setting malnutrition and he was given 1 unit of PRBC and vitamin K. Patient was monitored overnight and continued to remain stable. He was discharged with plans to avoid NSAIDS and with a prescription for a PPI. . # SEVERE MICROCYTIC ANEMIA - Patient has unclear hematocrit baseline and has known anemia with recent hematocrit of 23% following recent transfusion in clinic. Chronic GI bleeding, marrow suppression given his underlying malignancy vs. marrow suppressive therapy could be contributing. We monitored his hematocrit serially and transfused as needed. . # METASTATIC NON-SMALL CELL LUNG CANCER - The patient is status-post resection and cyberknife of brain metastatsis and first cycle of chemotherapy. He was continued on his Keppra dosing for seizure prophylaxis and oxycontin and oxycodone for pain. The patient was evaluated by the palliative care team. Patient decided at this time he is interested in full aggressive care including CPR and intubation but not prolonged intubation. Once he feels that he is declining and nearing death, he says that he will likely choose to die without resuscitation but is not at that point now. Patient was discharged with plans for home visiting care (minimal services at this time) and potential bridge to hospice should that be decided as the next step. Patient has plans to follow up with his outpatient oncologist next week and issues of goals of care will be discussed during that visit. . # SINUS TACHYCARDIA - On reviewing his record, patient's baseline heart rate has been in the 110-120s (lowest HR recorded in clinic was 112), except for a single EKG from documenting a rate of 80 bpm. Unclear etiology likely anemia. Patient continued to have sinus tachycardia despite blood tranfusions and IVF making hypovolemia less likely. Had CTA chest on which was negative for PE and patient remained in no respiratory distress, without pleuritic chest pain, and maintained oxygen saturations in the 90s on room air. LENIs were negative for DVT. Also, likely component of overlying anxiety. . # ASTHMA, COPD - Patient denies history of COPD, however given his smoking history, this was likely. Patient did not appear to be in exacerbation during admission. He was treated with albuterol nebulizer treatments as needed. . # FEVERS - Patient had reported temperature of 99.2F in the ED, and was given Cefepime for unclear source. The patient does have stable and chronic non-productive cough, but his CXR did not appear to demonstrate pneumonia. An infectious work-up was performed with reassuring blood and urine cultures. . TRANSITION OF CARE ISSUES: 1. goals of care ongoing discussion: patient desires chemotherapy but has been told he is unlikely to benefit. At this time patient is full code. He was discharged with plans to have a home hospice nurse (but not full hospice team). 2. patient will need his HCT checked at follow up 3. blood cultures pending at time of discharge 4. patient was full code on this admission | Incompletely evaluated large right lower lobe pulmonary mass, not significantly changed in size compared to CT from . There is a trace pericardial effusion, as before. IMPRESSION: No bilateral lower extremity DVT. There is a -type hernia involving the transverse colon along the mid ventral abdominal wall (2:34), unchanged in appearance. Scattered aortic and biiliac artery calcifications are seen. BILATERAL LOWER EXTREMITY ULTRASOUND: There is normal compressibility, flow, and augmentation in the bilateral common femoral, greater saphenous, superficial and deep femoral, and popliteal veins. ABDOMEN CT: Within the right lower lobe, there is a large mass, measuring up to 12.5 x 10.5 cm in its greatest axial dimensions, not significantly changed in size compared to , but incompletely evaluated on this non-contrast study. Relative hypodensity of blood within the ventricles compared to the myocardium is consistent with anemia. There is moderate subcutaneous edema. For example, a previously seen tiny left paraaortic node now measures 2.7 x 1.3 cm (2:47) and a previously 11 x 9 mm aortocaval node now measures 16 x 13 mm (2:38). The abdominal aorta is normal in caliber. As mentioned on the previous CT report, this mass encases the right inferior pulmonary vein. The small bowel is within normal limits. Nonspecific lucency within the left iliac bone, not significantly changed in appearance. Otherwise,unchanged.TRACING #1 The liver is within normal limits. BONE WINDOW: Within the left iliac bone, there is a small lucency (2:58), nonspecific in nature, but not significantly changed in appearance compared to CT from . RP bleed No contraindications for IV contrast FINAL REPORT INDICATION: Hematocrit drop, evaluate for retroperitoneal bleed. PELVIS CT: The bladder is unremarkable. The spleen, pancreas, adrenal glands, and kidneys are within normal limits. A small right renal hypodensity seen on prior CT from is not well assessed on the current study given the lack of intravenous contrast material. There is no retroperitoneal hematoma. IMPRESSION: No acute cardiopulmonary process. Elsewhere, the lungs are grossly clear. No pathologically enlarged pelvic lymph nodes are seen. There is evidence of prior partial colectomy (2:66). Sinus tachycardia. Sinus tachycardia. Lack of intravenous contrast material limits assessment of the abdominal organs. There is stable right basilar opacity compatible with patient's known lung mass. The stomach is unremarkable. Cardiomediastinal silhouette is again notable for thickening of the right paratracheal stripe compatible with known mediastinal adenopathy. Coarse prostatic calcifications are seen. The remainder of the visualized portions of lung bases are clear. COMPARISON: CT abdomen and pelvis from . Mild gallbladder wall thickening likely relates to the gallbladder's contracted state. No suspicious blastic lesions are seen. Osseous and soft tissue structures are grossly unremarkable. As before, the patient is status post bilateral L4 and L5 laminectomies. No evidence of a retroperitoneal hematoma. Large right basilar mass and mediastinal adenopathy. TECHNIQUE: MDCT axial images were acquired from the lung bases through the lesser trochanters without the administration of oral or intravenous contrast material. There is no free fluid in the pelvis. There is no free fluid or free air in the abdomen. There is no bowel wall thickening or obstruction. ST segment elevation is difficult to compare due to artifact butprobably no major change.TRACING #2 Markedly increased retrocrural, retroperitoneal, and mesenteric lymphadenopathy, as described above. Baseline artifact. -type ventral abdominal wall hernia, involving the transverse colon. Multilevel (Over) 3:54 PM CT ABD & PELVIS W/O CONTRAST Clip # Reason: ? ST-T wave abnormalities.Since the previous tracing of the rate is slightly faster. 3:54 PM CT ABD & PELVIS W/O CONTRAST Clip # Reason: ? No evidence of obstruction or strangulation. IMPRESSION: 1. Extensive retrocrural, retroperitoneal, and mesenteric lymphadenopathy is increased compared to CT from . No prior examinations for comparison. Since the previous tracing the rate isslower. An old posterior left tenth rib fracture is again seen. Question pneumonia or effusion. RP bleed FINAL REPORT (Cont) degenerative changes of the thoracolumbar spine are most severe at L4-5 and L5-S1 where there is marked endplate sclerosis and disc vacuum phenomenon. Early R wave progression. 4. FINDINGS: Two portable AP views of the chest are compared to previous exam from . 3. 2. 5. Multiplanar reformations were performed. 10:29 AM BILAT LOWER EXT VEINS Clip # Reason: rule out DVT Admitting Diagnosis: GASTROINTESTINAL BLEED MEDICAL CONDITION: 53 year old man with metastatic NSCLC presenting with asymmetric swelling of legs REASON FOR THIS EXAMINATION: rule out DVT FINAL REPORT INDICATION: 53-year-old male with metastatic non-small cell lung carcinoma, asymmetric leg swelling. | 5 | [
{
"category": "Radiology",
"chartdate": "2122-01-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1230829,
"text": " 3:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna/effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with cancer, anemia, dyspnea\n REASON FOR THIS EXAMINATION:\n eval for pna/effusion\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY: \n\n HISTORY: 52-year-old male with cancer, anemia, and dyspnea. Question\n pneumonia or effusion.\n\n FINDINGS: Two portable AP views of the chest are compared to previous exam\n from . There is stable right basilar opacity compatible with\n patient's known lung mass. Elsewhere, the lungs are grossly clear.\n Cardiomediastinal silhouette is again notable for thickening of the right\n paratracheal stripe compatible with known mediastinal adenopathy. Osseous and\n soft tissue structures are grossly unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process. Large right basilar mass and\n mediastinal adenopathy.\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-01-28 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1230932,
"text": " 10:29 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: rule out DVT\n Admitting Diagnosis: GASTROINTESTINAL BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with metastatic NSCLC presenting with asymmetric swelling of\n legs\n REASON FOR THIS EXAMINATION:\n rule out DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old male with metastatic non-small cell lung carcinoma,\n asymmetric leg swelling.\n\n No prior examinations for comparison.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND: There is normal compressibility, flow,\n and augmentation in the bilateral common femoral, greater saphenous,\n superficial and deep femoral, and popliteal veins. Color flow is also noted\n in the posterior tibial and peroneal veins. There is moderate subcutaneous\n edema.\n\n IMPRESSION: No bilateral lower extremity DVT.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2122-01-27 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1230838,
"text": " 3:54 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? RP bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with drop in Hct, no clear source\n REASON FOR THIS EXAMINATION:\n ? RP bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hematocrit drop, evaluate for retroperitoneal bleed.\n\n TECHNIQUE: MDCT axial images were acquired from the lung bases through the\n lesser trochanters without the administration of oral or intravenous contrast\n material. Multiplanar reformations were performed.\n\n COMPARISON: CT abdomen and pelvis from .\n\n ABDOMEN CT: Within the right lower lobe, there is a large mass, measuring up\n to 12.5 x 10.5 cm in its greatest axial dimensions, not significantly changed\n in size compared to , but incompletely evaluated on this\n non-contrast study. As mentioned on the previous CT report, this mass encases\n the right inferior pulmonary vein. The remainder of the visualized portions\n of lung bases are clear. Relative hypodensity of blood within the ventricles\n compared to the myocardium is consistent with anemia. There is a trace\n pericardial effusion, as before.\n\n Lack of intravenous contrast material limits assessment of the abdominal\n organs. The liver is within normal limits. Mild gallbladder wall thickening\n likely relates to the gallbladder's contracted state. The spleen, pancreas,\n adrenal glands, and kidneys are within normal limits. A small right renal\n hypodensity seen on prior CT from is not well assessed on the\n current study given the lack of intravenous contrast material. The stomach is\n unremarkable. The small bowel is within normal limits. There is a\n -type hernia involving the transverse colon along the mid ventral\n abdominal wall (2:34), unchanged in appearance. There is evidence of prior\n partial colectomy (2:66). There is no bowel wall thickening or obstruction.\n There is no free fluid or free air in the abdomen. Extensive retrocrural,\n retroperitoneal, and mesenteric lymphadenopathy is increased compared to CT\n from . For example, a previously seen tiny left paraaortic\n node now measures 2.7 x 1.3 cm (2:47) and a previously 11 x 9 mm aortocaval\n node now measures 16 x 13 mm (2:38). The abdominal aorta is normal in\n caliber. Scattered aortic and biiliac artery calcifications are seen. There\n is no retroperitoneal hematoma.\n\n PELVIS CT: The bladder is unremarkable. Coarse prostatic calcifications are\n seen. There is no free fluid in the pelvis. No pathologically enlarged\n pelvic lymph nodes are seen.\n\n BONE WINDOW: Within the left iliac bone, there is a small lucency (2:58),\n nonspecific in nature, but not significantly changed in appearance compared to\n CT from . No suspicious blastic lesions are seen. Multilevel\n (Over)\n\n 3:54 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? RP bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n degenerative changes of the thoracolumbar spine are most severe at L4-5 and\n L5-S1 where there is marked endplate sclerosis and disc vacuum phenomenon. As\n before, the patient is status post bilateral L4 and L5 laminectomies. An old\n posterior left tenth rib fracture is again seen.\n\n IMPRESSION:\n\n 1. No evidence of a retroperitoneal hematoma.\n\n 2. Markedly increased retrocrural, retroperitoneal, and mesenteric\n lymphadenopathy, as described above.\n\n 3. Incompletely evaluated large right lower lobe pulmonary mass, not\n significantly changed in size compared to CT from .\n\n 4. -type ventral abdominal wall hernia, involving the transverse\n colon. No evidence of obstruction or strangulation.\n\n 5. Nonspecific lucency within the left iliac bone, not significantly changed\n in appearance.\n\n"
},
{
"category": "ECG",
"chartdate": "2122-01-27 00:00:00.000",
"description": "Report",
"row_id": 245912,
"text": "Baseline artifact. Sinus tachycardia. Since the previous tracing the rate is\nslower. ST segment elevation is difficult to compare due to artifact but\nprobably no major change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2122-01-27 00:00:00.000",
"description": "Report",
"row_id": 245913,
"text": "Sinus tachycardia. Early R wave progression. ST-T wave abnormalities.\nSince the previous tracing of the rate is slightly faster. Otherwise,\nunchanged.\nTRACING #1\n\n"
}
] |
54,193 | 175,115 | FLOOR COURSE : 79 yo italian speaking male with h/o cirrhosis Hep C, CAD s/p fall and with acute renal failure and elevated T bili. . # Fall - appears to be mechanical rather than syncopal as pt denies dizziness or LOC prior to episode. He felt weak, possibly due to poor nutrition or leg weakness from his diabetes. There may have been a component of orthostatis due to aggressive diuresis after last admission. Only injury was to shoulder without fracture or dislocation. CT head at OSH negative. Physical therapy evaluated patient and recommended rehab. . # NSTEMI/Troponin leak/RBBB - RBBB noted on OSH EKG, likely due to rate 118bpm. RBBB not noted on EKG at . Pt denies chest pain but has h/o CAD with stenting of RCA in . Troponin mildly elevated, possibly due to renal failure. Received ASA 325mg but no heparin needed per cardiology (discussed in ED). Started aspirin 325mg until troponin trended down, then returned to home dose 81mg. Continued statin, niacin SR. . # Acute kidney injury - Pt with elevated creatinine 1.5 on admission. Cr 0.9-1.1 during last admission but 0.6-0.8 prior. FeUrea suggests pre-renal etiology and per friend, pt has poor intake. also be due to hepatorenal syndrome or ATN although no known new insults/meds. ( ECHO with EF >55%). Pt was challenged with albumin 50g x2 and 25gm x1 with improvement in Cr to 1.0. He was given lasix 20mg PO x1 on with good urine output. Spironolactone was held through hospitalization. . # Hyponatremia - Na improved with albumin + NS suggesting hypervolemic hyponatreima, esp given pt's total body fluid overload. Unlikely due to primary polydipsia as pt has low PO fluid intake per friend. clear reason for pt to have SIADH. . # Ascites - pt had diagnostic paracentesis in ED, labs suggest transudate c/w known cirrhosis and portal hypertension. No evidence of SBP. Pt is not uncomfortable and abdomen is not tense. No therapeutic tap done on floor prior to . . # Cirrhosis - pt with known cirrhosis due to Hep C. AST elevated without ALT increase. T bili increased but RUQ US does not show obstruction. RUQ US PRELIM demonstrates persistent thromboses. Per friend, pt is confused but he does not appear encephalopathic. T bili began to trend downwards. INR remained stable 1.3-1.6. He was given lactulose and remained oriented. Nadolol, which he takes for his gastric varices, was stopped due to frequent episodes of hypotension with SBP 70s. . # Anemia - pt with falling Hct (baseline 26-29). Pt had Hct decrease from 35 to 27 sometime between and . He had no evidence of active bleeding on morning of and was transfused 1 unit blood for Hct ~23 without reaction. . # Infiltrate on admission CXR - Pt completed 7 day levo course for PNA last admission. CXR with improving R opacity (likley prior PNA) and persistent peripheral reticular opacities. He was saturating well. He remained afebrile without leukocytosis. Tachypnea is most likely due to lying flat with ascites. No antibiotics were given during his floor course. . # Living situation - friend concerned about patient's ability to care for himself at home. Pt concerned about cost of Nursing home -SW evaluation for available home services/home health aide . # DM - c/b with peripheral neuropathy. His avandaryl was held and he started on humalog ISS. . # Hypothyroidism - continued levothyroxine | Response: CRRT tolerating well, BUN 27/creat 1.3.and lactate 5.2 Plan: Cont CRRT a/o ? - Follow volume status - Receiving CVVHD; monitor lytes q6h and replete prn # Hyperkalemia: Resuscitation with temporizing measures as in HPI. Response: Plan: Suction PRN, monitor vent status Sepsis, Severe (with organ dysfunction) Assessment: A febrile, patient received on levo at 0.3mcg/kg/min and vaspressin 2.4units/hr. Response: Plan: Suction PRN, monitor vent status Sepsis, Severe (with organ dysfunction) Assessment: Pt received on levo at 0.3mcg/kg/min. Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even or slightly neg . Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even or slightly neg . Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even or slightly neg . Response: CRRT tolerating well, BUN 21/creat 1.0.and lactate trending down. - Follow volume status - Receiving CVVHD; monitor lytes q6h and replete prn # Hyperkalemia: Resolved. - Follow volume status - Receiving CVVHD; monitor lytes q6h and replete prn # Hyperkalemia: Resuscitation with temporizing measures as in HPI. - Follow volume status - Receiving CVVHD; monitor lytes q6h and replete prn # Hyperkalemia: Resuscitation with temporizing measures as in HPI. Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even or slightly neg . Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even or slightly neg . Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even or slightly neg . Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even or slightly neg . Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even or slightly neg . Abp 110s-120s/ 60 Action: Transfused 1 unit FFP and 3 units PRBCs, hepatology consulted, CVL dsgs changed x2. Pt underwent RUQ US, L shoulder plain film, and diagnostic paracentesis. Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even. Hypovolemic shock/GI Bleed/Blood Loss Anemia: Remains on levophed - requirement has gone up. Response: Repeat Ica 1.01, K+ 4.2 , BUN/Cr 34/1.3 ABG at 1400 7.35/42/115, KCL and Ca Gluc gtts titrated per SS. Hct cont to drop despite banding and multiple transfusions, Hct 21.5 this am. Response: Remains with metabolic acidosis , high lactate and high k+ Plan: Cont to monitor. Lactate 13.3, K+7.0(treated as above.) Prophylaxis: Subcutaneous heparin . Disposition: ICU ICU Care Nutrition: Glycemic Control: Lines: Multi Lumen - 11:26 AM Prophylaxis: DVT: Stress ulcer: VAP: Comments: Communication: Comments: Code status: DNR- not medically indicated Disposition: Dialysate and replacement fluids B22, K4 Action: K+ and Ca Gluconate titrated per SS, Response: Plan: Cont CRRT a/o ? Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even or slightly . Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even or slightly . Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even or slightly . Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even or slightly . Renal failure, acute (Acute renal failure, ARF) Assessment: Recd p[t on CRRT with FB goal to run about even. Abp 110s-120s/ 60 Action: Transfused 1 unit FFP and 3 units PRBCs, hepatology consulted, CVL dsgs changed x2. Abp 110s-120s/ 60 Action: Transfused 1 unit FFP and 3 units PRBCs, hepatology consulted, CVL dsgs changed x2. # Anuria: Likely secondary to hypotension. # Anuria: Likely secondary to hypotension. Moderate degenerative change at acromioclavicular joint and mild glenohumeral degenerative change. Minimal degenerative changes of the glenohumeral joint with moderate degenerative changes of the AC joint. Minimal degenerative changes of the glenohumeral joint with moderate degenerative changes of the AC joint. Hypovolemic shock/GI Bleed/Blood Loss Anemia: Hct drifting down again but now only on 1 pressor (levophed). Mesenteric ischemia versus global hypoperfusion at this time. Anterior portal patent with slow flow Questionable flow at the posterior right portal . FINDINGS: In comparison with the earlier study of this date, the left subclavian catheter has been pulled back to the mid portion of the SVC. Sinus rhythm with A-V conduction delay. Pulmonary and mediastinal vascular congestion persists and mild pulmonary edema is new. Moderate degenerative changes are noted in the acromioclavicular joint with mild degenerative changes in the glenohumeral joint with early osteophyte formation along the inferior glenoid margin. Left atrial abnormality. full wall-to-wall flow not fully seen, suggestive of peripheral partial thrombus. Respiratory Failure: Cont current vent settings. Sinus rhythm with modest A-V conduction delay. | 85 | [
{
"category": "Social Work",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 505017,
"text": "Social Work:\n SW spoke by phone with pt\ns daughter, (can be reached at\n brother\ns cell phone: ). Offered emotional support and\n addressed her questions re how she and her brother, , might\n proceed with thinking with team about goals of care for pt. Reassured\n her that interdisciplinary team is here for support for them through\n this process and will think with them about options for a plan of\n care. She also raises questions about funeral planning for pt, as she\n states she does not know what pt would want (i.e. issues re funeral, a\n plot, cremation, etc). She states she has been in touch with pt\n attorney, (), who this SW also spoke with\n today: he states he is not aware of pt having a HCP or living will,\n though he will double check his files and be in touch with us re this.\n Provided daughter with contact info for , Director of\n Counseling at Community Health Center, and for pt\ns friend\n \n as both of them seem to know pt more currently than pt\n children do. SW met briefly with pt\ns friend, , at the hospital\n this morning, and he expresses his sadness re pt\ns condition.\n Family meeting scheduled for tomorrow, Friday, at 2:00 to discuss goals\n of care. Daughter, son, daughter\ns sister (who is not pt\ns child but\n who is a doctor), possibly pt\ns cousin, and pt\ns friend will plan\n to attend. SW scheduled an Italian interpreter for so he can\n participate more easily.\n Discussed with MICU resident. Please page SW ( , #) on\n Friday with any questions or concerns. SW will continue to follow.\n , LICSW, #\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505112,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt received off CRRT at 0800, no urine out put, this AM labs BUN 19,\n creat 1.0, Lytes within normal limits, and receiving K phos for low\n phos.\n Action:\n Off CRRT until family meeting today\n Response:\n No urine output, AM labs\n Plan:\n CRRT on hold until the family meeting, continue to monitor labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, off sedation, on AC 40% 500 x 20.\n Bilateral lung sounds clear and diminished bases, O2 sats 98-100%.\n Action:\n Antibiotics continued, pul toilet and MDI\ns as ordered.\n Response:\n Plan:\n Suction PRN, monitor vent status\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt received on levo at 0.3mcg/kg/min. Following the removal of CRRT his\n B/P started drifting down.\n Action:\n The levo was increased to .3mcg/kg/min, Vasopressin was added at 1230\n so that the levo was briefly decreased to .25mcg/kg/min. However the\n effect on his B/P was transient. He also started having PVC\ns with the\n increasing pressor requirement.\n Response:\n His B/P keep drifting down to the 80\ns requiring the levo to be\n titrated up. It is currently on .3mcg/kg/min with the vasopressin.\n Plan:\n Maintain His B/P so that the Maps > 60, from social\n work has arranged a family meeting at 1400 tomorrow to discuss plan of\n care. His 2 children, friend, a step sister and a nephew are\n expected to come.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505115,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt received off CRRT at 0800, no urine out put, this AM labs BUN 19,\n creat 1.0, Lytes within normal limits, and receiving K phos for low\n phos.\n Action:\n Off CRRT until family meeting today\n Response:\n No urine output, AM labs\n Plan:\n CRRT on hold until the family meeting, continue to monitor labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, off sedation, on AC 40% 500 x 20.\n Bilateral lung sounds clear and diminished bases, O2 sats 98-100%.\n Action:\n Antibiotics continued pul toilet and MDI\ns as ordered.\n Response:\n Plan:\n Suction PRN, monitor vent status\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n A febrile, patient received on levo at 0.3mcg/kg/min and vaspressin\n 2.4units/hr. SBP 90-100mmhg monitoring via Lt radial a line. Frequent\n bigeminy and pvc\ns noted\n Action:\n Lytes checked, continued pressors\n Response:\n Plan:\n Maintain His B/P so that the Maps > 60, from social\n work has arranged a family meeting at 1400 tomorrow to discuss plan of\n care. His 2 children, friend, a step sister and a nephew are\n expected to come.\n"
},
{
"category": "Respiratory ",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 505288,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 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: / 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 Plan\n Next 24-48 hours: Comfort measures only\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 on the vent no changes made. See respiratory page of meta vision\n for more information.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505333,
"text": "79 yo man with PMH: Hep C with portal hypertension, DM, PVD, cardiac\n stents and on EGD showing esophageal and gastric varices and\n varices banded. Patient presented from floor with BRBPR and hct 17,\n intubated for airway protection. Patient is in ATN, hyperkalemic and\n lactic acidosis. CRRT initiated on and patient is on levophed gtt.\n Code status: DNR\n Events: Family meeting held, made CMO, pressors and vent removed at\n 1600.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Vasopressin at 2.4units/hr and levophed.37 mcg/kg/min. Pt dropping his\n B/P with med bag changes.\n Action:\n Family meeting held at 1400 with (son), (daughter),\n daughter-in-law, cousin, social worker, Dr. , Dr and Me.\n The condition and prognosis of the patient were explained and they\n agreed that CMO was the best course of action.\n Response:\n The vasopressin and the levophed were stopped at 1630 when the family\n was ready, the vent was changed to 5/5, his RR increased to 40, he was\n placed on a morphine gtt 5mg/hr, pt\ns RR decreased to 34. Family at\n the bedside.\n Plan:\n Maintain comfort.\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-28 00:00:00.000",
"description": "MICU Attending",
"row_id": 505268,
"text": "TITLE: MICU Attending\n Met with Mr. \ns family: his son and daughter (from whom he has\n been estranged for 30 years) and his friend . Representatives from\n nursing and social work, as well as resident Dr. and Italian\n interpreter present at meeting. Informed them that his multi-organ\n failure has shown no signs of improvement and that he is extremely\n unlikely to recover. Discussed that he is in fact worsening with\n inability to be off pressor for even a brief period of time. We will\n transition his care to CMO after they are able to summon other family\n members who may want to be present before transition of care and likely\n imminent passing.\n Patient is critically ill. Time spent: 30 min.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505171,
"text": "Awaiting family meeting today for plan of care, CRRT on hold until\n family meeting\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt received off CRRT at 0800, no urine out put, this AM labs BUN 19,\n creat 1.0, Lytes within normal limits, and receiving K phos for low\n phos.\n Action:\n Off CRRT until family meeting today\n Response:\n No urine output, AM labs BUN 33 and creat 1.8\n Plan:\n CRRT on hold until the family meeting, continue to monitor labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, off sedation, on AC 40% 500 x 20.\n Bilateral lung sounds clear and diminished bases, O2 sats 98-100%.\n Action:\n Antibiotics continued pul toilet and MDI\ns as ordered.\n Response:\n Thick blood tinged secretions, blood gas 7.28/32/98/-10\n Plan:\n Suction PRN, monitor vent status\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n A febrile, patient received on levo at 0.3mcg/kg/min and vaspressin\n 2.4units/hr. SBP 90-100mmhg monitoring via Lt radial a line. Frequent\n bigeminy and pvc\ns noted\n Action:\n Lytes checked, continued pressors\n Response:\n Afebrile, WBC 16.5, lactate 5.7,INR 2.2 and platelet 32.SBP 90-100 on\n levophed and vasopressin gtt\n Plan:\n Maintain His B/P so that the Maps > 60, from social\n work has arranged a family meeting at 1400 tomorrow to discuss plan of\n care. His 2 children, friend, a step sister and a nephew are\n expected to come.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505308,
"text": "79 yo man with PMH: Hep C with portal hypertension, DM, PVD, cardiac\n stents and on EGD showing esophageal and gastric varices and\n varices banded. Patient presented from floor with BRBPR and hct 17,\n intubated for airway protection. Patient is in ATN, hyperkalemic and\n lactic acidosis. CRRT initiated on and patient is on levophed gtt.\n Code status: DNR\n Events: Family meeting held, made CMO, pressors and vent removed at\n 1600.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Vasopressin at 2.4units/hr and levophed.37 mcg/kg/min. Pt dropping his\n B/P with med bag changes.\n Action:\n Family meeting held at 1400 with (son), (daughter),\n daughter-in-law, cousin, social worker, Dr. , Dr and Me.\n The condition and prognosis of the patient were explained and they\n agreed that CMO was the best course of action.\n Response:\n The vasopressin and the levophed were stopped at 1630 when the family\n was ready, the vent was changed to 5/5 and he was placed on a morphine\n gtt.\n Plan:\n Maintain comfort.\n"
},
{
"category": "Social Work",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 504731,
"text": "Social Work:\n SW spoke with pt\ns friend, (), by phone to\n check in and offer support. With Italian being his first language and\n his English appearing somewhat limited, conversation was brief.\n However, SW offered support as he appears to be a close friend of pt\n and perhaps one of his limited contacts in the community. He states he\n might come into the hospital tomorrow morning, and SW offered to meet\n with him in person if he would like this. Provided him with SW contact\n info.\n Also spoke with (), the Director of Counseling at\n Community Health Center where pt\ns PCP is . She\n states she has acted as pt\ns Italian interpreter and case manager at\n the health center for the past two years and expresses her concern for\n how pt is doing. She reports that pt had spoken with her over the\n years re his wish to reconnect with his son and daughter from whom he\n had been estranged for many years. She states she helped pt connect\n with an attorney who was helping him try to locate his children who\n live in the area. She adds that pt had verbally expressed to\n her that if he does reconnect with his children, he would want them to\n be involved in his medical care as needed. Per her report, Ms. \n informed the attorney of pt\ns current admission to with the hope\n that he may inform pt\ns children of this. Pt\ns son and daughter were\n notified of pt\ns admission to the (perhaps by pt\ns attorney,\n though this is somewhat unclear at this time), and they visited pt last\n night in the MICU.\n SW contact pt\ns son, (), to reach out and\n offer family support. He states it is certainly tough to learn of pt\n admission to the hospital and of his current medical status,\n particularly after having no contact with him in about 10 years. He\n states he and his sister/pt\ns daughter, , are in good\n touch with each other (both live in the area) and are supporting\n one another re this difficult situation. Son states he would like to\n stay in communication with the MICU team while pt is admitted here, but\n he is not sure how comfortable he is taking on a decision-making role\n with regard to pt\ns medical care. He states he would like to talk more\n with his sister about this as they try to come to terms with their\n reintroduction to their father in this context. Informed son of SW\n role and availability for support during this process and encouraged\n him to call as needed to discuss this further. He expressed his\n appreciation, and states he plans to talk with his sister today as\n well. SW discussed with MICU team.\n A/P: It will be important that team offer significant support for pt\n son and daughter during any conversations held with them about pt\n condition and goals of care. As son and daughter have been estranged\n from pt for many years, they are understandably ambivalent about\n assuming the role of proxy decision- for pt (per son\ns report).\n Pt\ns children would not be able to speak about their sense of pt\n current wishes, and so guidance and support from team would likely be\n especially helpful in this difficult situation. SW will continue to\n follow for family support. Please page with any questions or concerns.\n , LICSW, #\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 504693,
"text": "Chief Complaint: Hypovolemic Shock, GI Bleed, Blood Loss Anemia,\n Respiratory Failure, 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 Remains on CVVH\n 24 Hour Events:\n Lactate down to 5.2\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 Piperacillin/Tazobactam (Zosyn) - 04:45 AM\n Vancomycin - 09:00 AM\n Infusions:\n Fentanyl - 45 mcg/hour\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\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 Cardiovascular: No(t) Tachycardia\n Respiratory: mechanical ventilation\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 12:20 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 37.1\nC (98.8\n HR: 81 (63 - 83) bpm\n BP: 95/54(67) {75/37(48) - 119/56(75)} mmHg\n RR: 20 (18 - 20) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,581 mL\n 2,924 mL\n PO:\n TF:\n IVF:\n 4,904 mL\n 2,360 mL\n Blood products:\n 3,677 mL\n 564 mL\n Total out:\n 8,695 mL\n 2,545 mL\n Urine:\n 185 mL\n 5 mL\n NG:\n Stool:\n Drains:\n Balance:\n -114 mL\n 379 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): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 25 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 98%\n ABG: 7.30/39/101/19/-6\n Ve: 10.9 L/min\n PaO2 / FiO2: 253\n Physical Examination\n General Appearance: No acute distress, intubated, sedated\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: Non-tender, Distended\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Not assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 10.9 g/dL\n 82 K/uL\n 108 mg/dL\n 1.3 mg/dL\n 19 mEq/L\n 4.4 mEq/L\n 27 mg/dL\n 106 mEq/L\n 137 mEq/L\n 31.9 %\n 13.3 K/uL\n [image002.jpg]\n 08:15 AM\n 02:26 PM\n 02:40 PM\n 06:17 PM\n 07:46 PM\n 08:06 PM\n 02:05 AM\n 02:19 AM\n 08:12 AM\n 08:19 AM\n WBC\n 12.8\n 11.1\n 13.0\n 13.3\n Hct\n 27.7\n 30.3\n 30.3\n 31.9\n Plt\n 49\n 60\n 60\n 49\n 82\n Cr\n 1.3\n 1.3\n TCO2\n 29\n 24\n 22\n 22\n 20\n Glucose\n 152\n 113\n 111\n 108\n Other labs: PT / PTT / INR:18.9/35.5/1.7, ALT / AST:1317/5781, Alk Phos\n / T Bili:356/11.0, Amylase / Lipase:/52, Differential-Neuts:64.0 %,\n Band:8.0 %, Lymph:16.0 %, Mono:10.0 %, Eos:0.0 %, Fibrinogen:156 mg/dL,\n Lactic Acid:5.2 mmol/L, Albumin:2.9 g/dL, LDH:3660 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n HEPATITIS, ISCHEMIC (SHOCK LIVER)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Hemodynamics stable overnight, albeit on 2 pressors. Lactate\n sown to 5.2. Now on CVVH with improved management to acidosis and\n hyperkalemia.\n 1. Hypovolemic shock/GI Bleed/Blood Loss Anemia: Remains on levophed.\n Hct stable\n 2. Acute renal failure: On CRRT with adequate managment of acidosis ond\n hyperkalemia\n 3. Respiratory Failure: Cont current vent settings.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Respiratory ",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 504618,
"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: 21 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 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 Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Hemodynimic instability, Underlying illness not\n resolved\n"
},
{
"category": "Social Work",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Social Work Progress Note",
"row_id": 504727,
"text": "Social Work:\n SW spoke with pt\ns friend, (), by phone to\n check in and offer support. With Italian being his first language and\n his English appearing somewhat limited, conversation was brief.\n However, SW offered support as he appears to be a close friend of pt\n and perhaps one of his limited contacts in the community. He states he\n might come into the hospital tomorrow morning, and SW offered to meet\n with him in person if he would like this. Provided him with SW contact\n info.\n Also spoke with (), the Director of Counseling at\n Community Health Center where pt\ns PCP is . She\n states she has acted as pt\ns Italian interpreter and case manager at\n the health center for the past two years and expresses her concern for\n how pt is doing. She reports that pt had spoken with her over the\n years re his wish to reconnect with his son and daughter from whom he\n had been estranged for many years. She states she helped pt connect\n with an attorney who was helping him try to locate his children who\n live in the area. She adds that pt had verbally expressed to\n her that if he does reconnect with his children, he would want them to\n be involved in his medical care as needed. Per her report, Ms. \n informed the attorney of pt\ns current admission to with the hope\n that he may inform pt\ns children of this. Pt\ns son and daughter were\n notified of pt\ns admission to the (perhaps by pt\ns attorney,\n though this is somewhat unclear at this time), and they visited pt last\n night in the MICU.\n SW contact pt\ns son, (), to reach out and\n offer family support. He states it is certainly tough to learn of pt\n admission to the hospital and of his current medical status,\n particularly after having no contact with him in about 10 years. He\n states he and his sister/pt\ns daughter, , are in good\n touch with each other (both live in the area) and are supporting\n one another re this difficult situation. Son states he would like to\n stay in communication with the MICU team while pt is admitted here, but\n he is not sure how comfortable he is taking on a decision-making role\n with regard to pt\ns medical care. He states he would like to talk more\n with his sister about this as they try to come to terms with their\n reintroduction to their father in this context. Informed son of SW\n role and availability for support during this process and encouraged\n him to call as needed to discuss this further. He expressed his\n appreciation, and states he plans to talk with his sister today as\n well. SW discussed with MICU team.\n A/P: It will be important that team offer significant support for pt\n son and daughter during any conversations held with them about pt\n condition and goals of care. As son and daughter have been estranged\n from pt for many years, they are understandably ambivalent about\n assuming the role of proxy decision- for pt (per son\ns report).\n Pt\ns children would not be able to speak about their sense of pt\n current wishes, and so guidance and support from team would likely be\n helpful in this difficult situation. SW will continue to follow for\n family support. Please page with any questions or concerns.\n , LICSW, #\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504804,
"text": "69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Hemodynamics stable overnight, albeit on 2 pressors. Lactate\n improving though still 5.2. Now on CVVH with improved management to\n acidosis and hyperkalemia.\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\n which are improved from pt receiving plt at the beginning of this\n shift, Hct stable. Cont to ooze from IV/ HD/ central line sites. Foley\n with bright red urine, though output is minimal\n Action:\n Flushed foley cath w/ 120ml sterile H20, returned amber urine ~ 25ml\n more than instilled. Plt ct post tx, 82\n Response:\n Pm labs show Hct stable but Plt cont to trend down to 52. oozing from\n LIJ CVL continues but R IJ HD cath dsg is D&I. INR stable <2\n Plan:\n Cont q 6hr labs fibrinogen, coags, Q12hr Hct , monitor for further s/s\n of bleeding. Transfuse blood/ blood products as needed\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, continue to have mod amt melena stools, oozing blood from\n IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Platelets 82 this am post plt tx. and INR 1.7\n Action:\n HCT stable, continued to monitor, no further blood products this shift\n Response:\n PM labs HCT stable, goal >28, platelet 52 and goal is >50, oozing\n continues as above. Cont to stool melena.\n Plan:\n Monitor Hct q 12hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly neg . Labs\n at. Pt tol CRRT well, UOP 0-5mls, urine bright red with some clots.\n Dialysate and replacement fluids B22 K4. On levophed gtt ABG\ns showing\n worsening metabolic acidosis.\n Action:\n Replacement solutiuon changed to B32 K2 K+ and Ca Gluconate titrated\n per SS, levophed gtt titrated for MAP > 60, no urine output, foleys\n cath flushed, no clots w/ flush, amber urine returned ~25ml.\n Response:\n CRRT tolerating well, BUN 21/creat 1.0.and lactate trending down. pH\n improving slightly\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, lung sounds clear\n bilateral and diminished bases, 02 sat 98-100%, sedated on fentanyl\n 45mcg/hr and versed 2mg/hr. pupils 2mm/brisk, pt unresponsive.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum. Fentanyl and versed gtts weaned off.\n Response:\n Stable, remains sedated as above. Blood gas 7.31/37/126/-6 pupils\n remain 2mm/ brisk, pt unresponsive\n Plan:\n Wean vent/ as tolerated. Monitor responsiveness, restart sedation if\n needed..\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 504658,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - given 2 units platelets, 2 units FFP over the day\n - renal, cont CVVHD\n - renal aware of floppy IJ, but comfortably in place per nursing, thus\n far\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:51 AM\n Piperacillin/Tazobactam (Zosyn) - 04:45 AM\n Infusions:\n Fentanyl - 45 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Octreotide - 50 mcg/hour\n Norepinephrine - 0.14 mcg/Kg/min\n Pantoprazole (Protonix) - 8 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 07:03 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: 35.9\nC (96.6\n HR: 82 (63 - 83) bpm\n BP: 95/49(65) {75/37(48) - 133/65(87)} mmHg\n RR: 20 (18 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,581 mL\n 1,675 mL\n PO:\n TF:\n IVF:\n 4,904 mL\n 1,355 mL\n Blood products:\n 3,677 mL\n 319 mL\n Total out:\n 8,695 mL\n 1,121 mL\n Urine:\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n -114 mL\n 554 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): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 29 cmH2O\n Plateau: 24 cmH2O\n Compliance: 26.3 cmH2O/mL\n SpO2: 97%\n ABG: 7.32/40/138/20/-5\n Ve: 10.5 L/min\n PaO2 / FiO2: 345\n Physical Examination\n General Appearance: General: Intubated, unresponsive to verbal\n stimuli, NAD\n Cardiovascular: RRR, no m/g/r\n Pulmonary: Equal coarse BS bilaterally\n Abdominal: Distended, bowel sounds present\n Extremities: 1+ pitting edema b/l\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 49 K/uL\n 11.5 g/dL\n 111 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 4.3 mEq/L\n 27 mg/dL\n 104 mEq/L\n 137 mEq/L\n 30.3 %\n 13.0 K/uL\n [image002.jpg]\n 06:14 AM\n 07:51 AM\n 08:15 AM\n 02:26 PM\n 02:40 PM\n 06:17 PM\n 07:46 PM\n 08:06 PM\n 02:05 AM\n 02:19 AM\n WBC\n 13.0\n 12.8\n 11.1\n 13.0\n Hct\n 23.4\n 27.7\n 30.3\n 30.3\n Plt\n 59\n 49\n 60\n 60\n 49\n Cr\n 1.4\n 1.3\n 1.3\n TCO2\n 26\n 29\n 24\n 22\n 22\n Glucose\n 200\n 152\n 113\n 111\n Other labs: PT / PTT / INR:20.9/37.1/1.9, ALT / AST:1317/5781, Alk Phos\n / T Bili:356/11.0, Amylase / Lipase:/52, Differential-Neuts:64.0 %,\n Band:8.0 %, Lymph:16.0 %, Mono:10.0 %, Eos:0.0 %, Fibrinogen:154 mg/dL,\n Lactic Acid:5.2 mmol/L, Albumin:2.9 g/dL, LDH:3660 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Imaging: cxr (my read) - mildly worse bilateral infiltrates\n Microbiology: bcx pending\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n HEPATITIS, ISCHEMIC (SHOCK LIVER)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 79 y/o male with hepatitis c cirrhosis, elevated lactate, BRB per NG\n tube, s/p EGD with banding of active variceal bleeding.\n # Hypotension/Bleed: Clearly there is a component of volume loss given\n his blood loss, unclear if there is sepsis. EGD showed variceal bleed\n requiring multiple transfusions of PRBC for falling Hct. Hct currently\n stable at 30.\n - Goal INR <2; goal plt >50; goal finbrinogen >100\n - q6h coags, calcium, cbc, electrolytes\n - Continue Levophed; Vasopressin weaned off\n - Maintain active type and cross x8 units\n - PPI drip\n - Continue Octreotide\n - f/u cultures obtained\n - Tap ascites when stable, ?SBP\n - Vanc/Zosyn empirically\n # Elevated LFTs/Lactate: Likely secondary to necrosis in the context of\n hypotension. ? Mesenteric ischemia versus global hypoperfusion at this\n time. No free air on CXR although not ideal.\n - Improved lactate and LFTs\n - Trend LFTs and lactate daily\n - Volume resuscitation with fluids, blood\n - Patient unstable for further evaluation of bowel at this time.\n # Anuria: Likely secondary to hypotension. Renal consult obtained if\n patient needs urgent dialysis given hyperkalemia. At this point given\n bleeding I am not sure if he would be stable for any CRRT.\n - Follow volume status\n - Follow potassium\n - Receiving CVVHD; monitor lytes q6h and replete prn\n # Hyperkalemia: Resuscitation with temporizing measures as in HPI.\n Repeat K is elevated. Renal aware. Repeat:\n - Calcium gluconate\n - Sodium bicarbonate\n - Glucose/Insulin\n - follow serial K\n .\n FEN: No IVF, replete electrolytes, NPO\n .\n Prophylaxis: IV PPI\n .\n Access: 2 peripherals, left subclavian, R temporary HD line\n .\n Code: DNR (CPR not medically indicated, for discussion see POE and Dr.\n note ).\n .\n Communication: Friend \n .\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504782,
"text": "69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Hemodynamics stable overnight, albeit on 2 pressors. Lactate\n improving though still 5.2. Now on CVVH with improved management to\n acidosis and hyperkalemia.\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\n which are improved from pt receiving plt at the beginning of this\n shift, Hct stable. Cont to ooze from IV/ HD/ central line sites. Foley\n with bright red urine, though output is minimal\n Action:\n Flushed foley cath w/ 120ml sterile H20, returned amber urine ~ 25ml\n more than instilled. Plt ct post tx, 82\n Response:\n Pm labs show Hct stable but Plt cont to trend down to 52. oozing from\n LIJ CVL continues but R IJ HD cath dsg is D&I. INR stable <2\n Plan:\n Cont q 6hr labs fibrinogen, coags, Q12hr Hct , monitor for further s/s\n of bleeding. Transfuse blood/ blood products as needed\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, continue to have mod amt melena stools, oozing blood from\n IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Platelets 82 this am post plt tx. and INR 1.7\n Action:\n HCT stable, continued to monitor, no further blood products this shift\n Response:\n PM labs HCT stable, goal >28, platelet 52 and goal is >50, oozing\n continues as above. Cont to stool melena.\n Plan:\n Monitor Hct q 12hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly neg . Labs\n at. Pt tol CRRT well, UOP 0-5mls, urine bright red with some clots.\n Dialysate and replacement fluids B22 K4. On levophed gtt ABG\ns showing\n worsening metabolic acidosis.\n Action:\n Replacement solutiuon changed to B32 K2 K+ and Ca Gluconate titrated\n per SS, levophed gtt titrated for MAP > 60, no urine output, foleys\n cath flushed, no clots w/ flush, amber urine returned ~25ml.\n Response:\n CRRT tolerating well, BUN 27/creat 1.3.and lactate 5.2\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, lung sounds clear\n bilateral and diminished bases, 02 sat 98-100%, sedated on fentanyl\n 45mcg/hr and versed 2mg/hr.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum.\n Response:\n Stable, remains sedated as above. Blood gas 7.32/40/138/-5\n Plan:\n Wean vent/ sedation as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504783,
"text": "69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Hemodynamics stable overnight, albeit on 2 pressors. Lactate\n improving though still 5.2. Now on CVVH with improved management to\n acidosis and hyperkalemia.\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\n which are improved from pt receiving plt at the beginning of this\n shift, Hct stable. Cont to ooze from IV/ HD/ central line sites. Foley\n with bright red urine, though output is minimal\n Action:\n Flushed foley cath w/ 120ml sterile H20, returned amber urine ~ 25ml\n more than instilled. Plt ct post tx, 82\n Response:\n Pm labs show Hct stable but Plt cont to trend down to 52. oozing from\n LIJ CVL continues but R IJ HD cath dsg is D&I. INR stable <2\n Plan:\n Cont q 6hr labs fibrinogen, coags, Q12hr Hct , monitor for further s/s\n of bleeding. Transfuse blood/ blood products as needed\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, continue to have mod amt melena stools, oozing blood from\n IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Platelets 82 this am post plt tx. and INR 1.7\n Action:\n HCT stable, continued to monitor, no further blood products this shift\n Response:\n PM labs HCT stable, goal >28, platelet 52 and goal is >50, oozing\n continues as above. Cont to stool melena.\n Plan:\n Monitor Hct q 12hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly neg . Labs\n at. Pt tol CRRT well, UOP 0-5mls, urine bright red with some clots.\n Dialysate and replacement fluids B22 K4. On levophed gtt ABG\ns showing\n worsening metabolic acidosis.\n Action:\n Replacement solutiuon changed to B32 K2 K+ and Ca Gluconate titrated\n per SS, levophed gtt titrated for MAP > 60, no urine output, foleys\n cath flushed, no clots w/ flush, amber urine returned ~25ml.\n Response:\n CRRT tolerating well, BUN 21/creat 1.0.and lactate trending down. pH\n improving slightly\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, lung sounds clear\n bilateral and diminished bases, 02 sat 98-100%, sedated on fentanyl\n 45mcg/hr and versed 2mg/hr. pupils 2mm/brisk, pt unresponsive.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum. Fentanyl and versed gtts weaned off.\n Response:\n Stable, remains sedated as above. Blood gas 7.31/37/126/-6 pupils\n remain 2mm/ brisk, pt unresponsive\n Plan:\n Wean vent/ as tolerated. Monitor responsiveness, restart sedation if\n needed..\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 504717,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - Received 2 units platelets, 2 units FFP over the day\n - renal, cont CVVHD\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:51 AM\n Piperacillin/Tazobactam (Zosyn) - 04:45 AM\n Infusions:\n Fentanyl - 45 mcg/hour\n Midazolam (Versed) - 2 mg/hour\n Octreotide - 50 mcg/hour\n Norepinephrine - 0.14 mcg/Kg/min\n Pantoprazole (Protonix) - 8 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 07:03 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: 35.9\nC (96.6\n HR: 82 (63 - 83) bpm\n BP: 95/49(65) {75/37(48) - 133/65(87)} mmHg\n RR: 20 (18 - 23) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 8,581 mL\n 1,675 mL\n PO:\n TF:\n IVF:\n 4,904 mL\n 1,355 mL\n Blood products:\n 3,677 mL\n 319 mL\n Total out:\n 8,695 mL\n 1,121 mL\n Urine:\n 185 mL\n NG:\n Stool:\n Drains:\n Balance:\n -114 mL\n 554 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): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 29 cmH2O\n Plateau: 24 cmH2O\n Compliance: 26.3 cmH2O/mL\n SpO2: 97%\n ABG: 7.32/40/138/20/-5\n Ve: 10.5 L/min\n PaO2 / FiO2: 345\n Physical Examination\n General: Intubated, unresponsive to verbal stimuli, NAD\n Cardiovascular: RRR, GII systolic murmer at LSB and apex\n Pulmonary: Equal coarse BS bilaterally\n Abdominal: Distended but soft, bowel sounds present\n Extremities: 2+ pitting edema b/l\n Labs / Radiology\n 49 K/uL\n 11.5 g/dL\n 111 mg/dL\n 1.3 mg/dL\n 20 mEq/L\n 4.3 mEq/L\n 27 mg/dL\n 104 mEq/L\n 137 mEq/L\n 30.3 %\n 13.0 K/uL\n [image002.jpg]\n 06:14 AM\n 07:51 AM\n 08:15 AM\n 02:26 PM\n 02:40 PM\n 06:17 PM\n 07:46 PM\n 08:06 PM\n 02:05 AM\n 02:19 AM\n WBC\n 13.0\n 12.8\n 11.1\n 13.0\n Hct\n 23.4\n 27.7\n 30.3\n 30.3\n Plt\n 59\n 49\n 60\n 60\n 49\n Cr\n 1.4\n 1.3\n 1.3\n TCO2\n 26\n 29\n 24\n 22\n 22\n Glucose\n 200\n 152\n 113\n 111\n Other labs: PT / PTT / INR:20.9/37.1/1.9, ALT / AST:1317/5781, Alk Phos\n / T Bili:356/11.0, Amylase / Lipase:/52, Differential-Neuts:64.0 %,\n Band:8.0 %, Lymph:16.0 %, Mono:10.0 %, Eos:0.0 %, Fibrinogen:154 mg/dL,\n Lactic Acid:5.2 mmol/L, Albumin:2.9 g/dL, LDH:3660 IU/L, Ca++:8.6\n mg/dL, Mg++:2.1 mg/dL, PO4:2.4 mg/dL\n Imaging: cxr (my read) - mildly worse bilateral infiltrates\n Microbiology: bcx pending\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n HEPATITIS, ISCHEMIC (SHOCK LIVER)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 79 y/o male with hepatitis c cirrhosis, elevated lactate, BRB per NG\n tube, s/p EGD with banding of active variceal bleeding.\n # Hypotension/Bleed: Clearly there is a component of volume loss given\n his blood loss, unclear if there is sepsis. EGD showed variceal bleed\n requiring multiple transfusions of PRBC for falling Hct. Hct currently\n stable at 30.\n - Goal INR <2; goal plt >50; goal finbrinogen >100\n - coags, calcium, cbc, electrolytes\n - Continue Levophed; Vasopressin weaned off\n - Maintain active type and cross x8 units\n - Continue PPI drip\n - Continue Octreotide\n - f/u cultures obtained\n - Tap ascites when stable, ?SBP\n - Vanc/Zosyn empirically\n # Elevated LFTs/Lactate: Likely secondary to necrosis in the context of\n hypotension. ? Mesenteric ischemia versus global hypoperfusion at this\n time. No free air on CXR although not ideal.\n - Improved lactate and LFTs\n - Trend LFTs and lactate daily\n - Volume resuscitation with fluids, blood\n - Patient unstable for further evaluation of bowel at this time.\n # Anuria: Likely secondary to hypotension. Renal consult obtained if\n patient needs urgent dialysis given hyperkalemia. At this point given\n bleeding I am not sure if he would be stable for any CRRT.\n - Follow volume status\n - Receiving CVVHD; monitor lytes q6h and replete prn\n # Hyperkalemia: Resuscitation with temporizing measures as in HPI.\n Repeat K is elevated. Renal aware. Given Calcium gluconate, sodium\n bicarbonate, glucose/Insulin. Now resolved.\n .\n FEN: No IVF, replete electrolytes, NPO\n .\n Prophylaxis: IV PPI\n .\n Access: 2 peripherals, left subclavian, R temporary HD line\n .\n Code: DNR (CPR not medically indicated, for discussion see POE and Dr.\n note ).\n .\n Communication: Friend , . Have family meeting re: goals of care\n in the event patient does not improve in 24-48 hours.\n .\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 504923,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - liver: continue gtt, protonix gtt, CVVH; recommend transition to\n CMO.\n - discussion with son and daughter: made aware of patient's\n poor prognosis. plan to visit pt again today and can further address\n goals of care at that time.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 05:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:16 AM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 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 07:26 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: 36.2\nC (97.2\n HR: 80 (70 - 87) bpm\n BP: 96/51(66) {91/49(62) - 121/59(78)} mmHg\n RR: 20 (20 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,577 mL\n 1,359 mL\n PO:\n TF:\n IVF:\n 5,013 mL\n 1,359 mL\n Blood products:\n 564 mL\n Total out:\n 6,052 mL\n 1,314 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n -475 mL\n 45 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): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability\n PIP: 25 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 100%\n ABG: 7.33/36/103/19/-6\n Ve: 10.1 L/min\n PaO2 / FiO2: 258\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 48 K/uL\n 11.4 g/dL\n 92 mg/dL\n 1.0 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 102 mEq/L\n 133 mEq/L\n 31.9 %\n 12.6 K/uL\n [image002.jpg]\n 02:05 AM\n 02:19 AM\n 08:12 AM\n 08:19 AM\n 02:10 PM\n 02:18 PM\n 07:59 PM\n 08:24 PM\n 01:59 AM\n 02:21 AM\n WBC\n 13.0\n 13.3\n 11.8\n 12.6\n Hct\n 30.3\n 31.9\n 33.0\n 31.9\n Plt\n 49\n 82\n 52\n 48\n Cr\n 1.3\n 1.0\n 1.0\n TCO2\n 22\n 20\n 20\n 20\n 20\n Glucose\n 111\n 108\n 105\n 117\n 92\n Other labs: PT / PTT / INR:21.8/36.8/2.0, ALT / AST:, Alk Phos\n / T Bili:421/17.0, Amylase / Lipase:/52, Differential-Neuts:64.0 %,\n Band:8.0 %, Lymph:16.0 %, Mono:10.0 %, Eos:0.0 %, Fibrinogen:170 mg/dL,\n Lactic Acid:4.9 mmol/L, Albumin:2.9 g/dL, LDH:1420 IU/L, Ca++:9.0\n mg/dL, Mg++:1.9 mg/dL, PO4:1.5 mg/dL\n CXR: mild improvement in overall haziness, particularly at left base,\n compared to yesterday (my read)\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n HEPATITIS, ISCHEMIC (SHOCK LIVER)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 79 y/o male with hepatitis c cirrhosis, elevated lactate, BRB per NG\n tube, s/p EGD with banding of active variceal bleeding.\n # Hypotension/Bleed: Clearly there is a component of volume loss given\n his blood loss, unclear if there is sepsis. EGD showed variceal bleed\n requiring multiple transfusions of PRBC for falling Hct. Hct currently\n stable at 30. Lactic acid improving.\n - Goal INR <2; goal plt >50; goal finbrinogen >100\n - coags, calcium, cbc, electrolytes\n - Daily lactic acid\n - Continue Levophed; Vasopressin weaned off\n - Maintain active type and cross x8 units\n - Continue PPI drip\n - Continue Octreotide\n - f/u cultures obtained\n - Tap ascites when stable, ?SBP\n - Vanc/Zosyn empirically\n # Elevated LFTs/Lactate: Likely secondary to necrosis in the context of\n hypotension. ? Mesenteric ischemia versus global hypoperfusion at this\n time. No free air on CXR although not ideal.\n - Improved lactate and LFTs\n - Trend LFTs and lactate daily\n - Volume resuscitation with fluids, blood\n - Patient unstable for further evaluation of bowel at this time.\n # Anuria: Likely secondary to hypotension. Renal consult obtained if\n patient needs urgent dialysis given hyperkalemia. At this point given\n bleeding I am not sure if he would be stable for any CRRT.\n - Follow volume status\n - Receiving CVVHD; monitor lytes q6h and replete prn\n # Hyperkalemia: Resuscitation with temporizing measures as in HPI.\n Repeat K is elevated. Renal aware. Given Calcium gluconate, sodium\n bicarbonate, glucose/Insulin. Now resolved.\n .\n FEN: No IVF, replete electrolytes, NPO\n .\n Prophylaxis: IV PPI\n .\n Access: 2 peripherals, left subclavian, R temporary HD line\n .\n Code: DNR (CPR not medically indicated, for discussion see POE and Dr.\n note ).\n .\n Communication: Friend , . Have family meeting re: goals of care\n in the event patient does not improve in 24-48 hours.\n .\n Disposition: ICU\n ICU Care\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505060,
"text": "79 yo man with PMH: Hep C with portal hypertension, DM, PVD, cardiac\n stents and on EGD showing esophageal and gastric varices and\n varices banded. Patient presented from floor with BRBPR and hct 17,\n intubated for airway protection. Patient is in ATN, hyperkalemic and\n lactic acidosis. CRRT initiated on and patient is on levophed gtt.\n Code status: DNR\n Events: CRRT clotted and not restarted. Family meeting 1400 tomorrow\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt received on CRRT, fluid balance being kept equal, blood drawn at 8am\n K-4.0, BUN 19, creat 1.0, Phos 1.5\n Action:\n At 9AM following AM care a large clot floated into the lower filter and\n clotted the machine. He was started on K+phos 30mmol over 6hr.\n Response:\n The system was taken down following the blood being given back. Since\n his labs where WNL, CRRT was placed on hold. He has had no urine\n output in 12 hours.\n Plan:\n CRRT on hold until the am.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings unchanged, AC 40% 500 x 20. suctioned x2 for thick\n creamy secretions\n Action:\n Antibiotics given as ordered, Off CRRT his temp has increased to 100.0\n Response:\n Stable vent settings.\n Plan:\n Suction PRN, monitor vent status\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt received on levo at 0.2mcg/kg/min. Following the removal of CRRT his\n B/P started drifting down.\n Action:\n The levo was increased to .3mcg/kg/min, Vasopressin was added at 1230\n so that the levo was briefly decreased to .25mcg/kg/min. However the\n effect on his B/P was transient. He also started having PVC\ns with the\n increasing pressor requirement.\n Response:\n His B/P keep drifting down to the 80\ns requiring the levo to be\n titrated up. It is currently on .3mcg/kg/min with the vasopressin.\n Plan:\n Maintain His B/P so that the Maps > 60, from social\n work has arranged a family meeting at 1400 tomorrow to discuss plan of\n care. His 2 children, friend, a step sister and a nephew are\n expected to come.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504836,
"text": "79 yo man with PMH: Hep C with portal hypertension, DM, PVD, cardiac\n stents and on , last EGD showing esophageal and gastric varices\n and varices banded. Patient presented from floor with BRBPR and hct 17,\n intubated for airway protection. Patient is in ATN, hyperkalemic and\n lactic acidosis. CRRT initiated on and patient is on levophed gtt.\n Code status: DNR\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\ns, Hct\n stable. Oozing from the IV/ HD/ central line sites stopped. Foley with\n bright red urine, though output is minimal\n Action:\n Continue to monitor labs, S/S of bleeding\n Response:\n No bleeding noted, continue to have red color urine, very minimal. M\n labs\n Plan:\n Cont q 6hr labs fibrinogen, coags, Q12hr Hct , monitor for further s/s\n of bleeding. Transfuse blood/ blood products as needed\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, continue to have mod amt melena stools, oozing blood from\n IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Platelets 82 this am post plt tx. and INR 1.7\n Action:\n HCT stable, continued to monitor, no further blood products this shift\n Response:\n PM labs HCT stable, goal >28, platelet 52 and goal is >50, oozing\n continues as above. Cont to stool melena.\n Plan:\n Monitor Hct q 12hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly neg . Labs\n at. Pt tol CRRT well, UOP 0-5mls, urine bright red with some clots.\n Dialysate and replacement fluids B22 K4. On levophed gtt ABG\ns showing\n worsening metabolic acidosis.\n Action:\n Replacement solutiuon changed to B32 K2 K+ and Ca Gluconate titrated\n per SS, levophed gtt titrated for MAP > 60, no urine output, foleys\n cath flushed, no clots w/ flush, amber urine returned ~25ml.\n Response:\n CRRT tolerating well, BUN 21/creat 1.0.and lactate trending down. pH\n improving slightly\n Plan:\n Cont CRRT a/o ?running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, lung sounds clear\n bilateral and diminished bases, 02 sat 98-100%, sedated on fentanyl\n 45mcg/hr and versed 2mg/hr. pupils 2mm/brisk, pt unresponsive.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum. Fentanyl and versed gtts weaned off.\n Response:\n Stable, remains sedated as above. Blood gas 7.31/37/126/-6 pupils\n remain 2mm/ brisk, pt unresponsive\n Plan:\n Wean vent/ as tolerated. Monitor responsiveness, restart sedation if\n needed..\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504905,
"text": "79 yo man with PMH: Hep C with portal hypertension, DM, PVD, cardiac\n stents and on EGD showing esophageal and gastric varices and\n varices banded. Patient presented from floor with BRBPR and hct 17,\n intubated for airway protection. Patient is in ATN, hyperkalemic and\n lactic acidosis. CRRT initiated on and patient is on levophed gtt.\n Code status: DNR\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\ns, Hct\n stable. Oozing from the IV/ HD/ central line sites stopped. Foley with\n bright red urine, though no urine output.\n Action:\n Continue to monitor labs, S/S of bleeding\n Response:\n No bleeding noted, continue to have red color urine, very minimal. M\n labs platelet 48, INR 2.0\n Plan:\n Cont q 6hr labs fibrinogen, coags, Q12hr Hct , monitor for further s/s\n of bleeding. Transfuse blood/ blood products as needed\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Continue to have mod amt melena stools,\n Platelets 82 this am post plt tx. and INR 1.7\n Action:\n HCT stable, continued to monitor, HCT goal>28 and platelets goal >50\n Response:\n No bleeding noted, continue to have , AM labs as above\n Plan:\n Monitor Hct q 12hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly neg . Pt\n tolerating CRRT well, no UOP Dialysate fluid is B22K4and replacement\n fluids B32 K2. On levophed gtt.\n Action:\n K+ and Ca Gluconate titrated per SS, levophed gtt titrated for MAP >\n 60, no urine output,\n Response:\n CRRT tolerating well, BUN/creat 19/1.0, lactate trending down 4.9. pH\n improving slightly 7.33 this am.Levophed gtt ^sed to 0.2mcg/kg/min. k\n 4.1, ionized Ca 1.13\n Plan:\n Cont CRRT a/o ?running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated, off sedation, on CMV 40% 500x20+ PEEP 5, lung\n sounds clear bilateral and diminished bases, 02 sat 98-100%. Patient\n unresponsive.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum.\n Response:\n Stable, cough and gag absent, patient unresponsive, Blood gas\n Plan:\n Wean vent/ as tolerated. Monitor responsiveness, restart sedation if\n needed..\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504907,
"text": "79 yo man with PMH: Hep C with portal hypertension, DM, PVD, cardiac\n stents and on EGD showing esophageal and gastric varices and\n varices banded. Patient presented from floor with BRBPR and hct 17,\n intubated for airway protection. Patient is in ATN, hyperkalemic and\n lactic acidosis. CRRT initiated on and patient is on levophed gtt.\n Code status: DNR\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\ns, Hct\n stable. Oozing from the IV/ HD/ central line sites stopped. Foley with\n bright red urine, though no urine output.\n Action:\n Continue to monitor labs, S/S of bleeding\n Response:\n No bleeding noted, continue to have red color urine, very minimal. M\n labs platelet 48, INR 2.0\n Plan:\n Cont q 6hr labs fibrinogen, coags, Q12hr Hct , monitor for further s/s\n of bleeding. Transfuse blood/ blood products as needed\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Continue to have mod amt melena stools,\n Platelets 82 this am post plt tx. and INR 1.7\n Action:\n HCT stable, continued to monitor, HCT goal>28 and platelets goal >50\n Response:\n No bleeding noted, continue to have , AM labs as above\n Plan:\n Monitor Hct q 12hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly neg . Pt\n tolerating CRRT well, no UOP Dialysate fluid is B22K4and replacement\n fluids B32 K2. On levophed gtt.\n Action:\n K+ and Ca Gluconate titrated per SS, levophed gtt titrated for MAP >\n 60, no urine output,\n Response:\n CRRT tolerating well, BUN/creat 19/1.0, lactate trending down 4.9. pH\n improving slightly 7.33 this am.Levophed gtt ^sed to 0.2mcg/kg/min. k\n 4.1, ionized Ca 1.13\n Plan:\n Cont CRRT a/o ?running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated, off sedation, on CMV 40% 500x20+ PEEP 5, lung\n sounds clear bilateral and diminished bases, 02 sat 98-100%. Patient\n unresponsive.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum.\n Response:\n Stable, cough and gag absent, patient unresponsive, Blood gas\n 7.33/36/103\n Plan:\n Wean vent/ as tolerated. Monitor responsiveness, restart sedation if\n needed..\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504830,
"text": "79 yo man with PMH: Hep C with portal hypertension, DM, PVD, cardiac\n stents and last EGD showing esophageal and gastric varices. Patient\n presented from flor with BRBPR and hct 17, intubated for airway\n protection. Patient is in ATN, hyperkalemic and lactic acidosis. CRRT\n initiated on and patient is on levophed gtt.\n Code status: DNR\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505056,
"text": "79 yo man with PMH: Hep C with portal hypertension, DM, PVD, cardiac\n stents and on EGD showing esophageal and gastric varices and\n varices banded. Patient presented from floor with BRBPR and hct 17,\n intubated for airway protection. Patient is in ATN, hyperkalemic and\n lactic acidosis. CRRT initiated on and patient is on levophed gtt.\n Code status: DNR\n Events: CRRT clotted and not restarted. Family meeting 1400 tomorrow\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt received on CRRT, fluid balance being kept equal, blood drawn at 8am\n K-4.0, BUN 19, creat 1.0, Phos 1.5\n Action:\n At 9AM following AM care a large clot floated into the lower filter and\n clotted the machine. He was started on K+phos 30mmol over 6hr.\n Response:\n The system was taken down following the blood being given back. Since\n his labs where WNL, CRRT was placed on hold. He has had no urine\n output in 12 hours.\n Plan:\n CRRT on hold.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Vent settings unchanged, AC 40% 500 x 20. suctioned x2 for thick\n creamy secretions\n Action:\n Antibiotics given as ordered, Off CRRT his temp has increased to 100.0\n Response:\n Stable vent settings.\n Plan:\n Suction PRN, monitor vent status\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 505182,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Family meeting @ 2pm today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 04:20 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Octreotide - 50 mcg/hour\n Norepinephrine - 0.35 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 07:12 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: 36.9\nC (98.4\n HR: 89 (79 - 94) bpm\n BP: 100/57(73) {90/51(64) - 130/63(85)} mmHg\n RR: 22 (20 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,719 mL\n 784 mL\n PO:\n TF:\n IVF:\n 3,719 mL\n 784 mL\n Blood products:\n Total out:\n 1,434 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,285 mL\n 786 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): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 96%\n ABG: 7.28/32/98./14/-10\n Ve: 12.3 L/min\n PaO2 / FiO2: 245\n Physical Examination\n GEN:\n Cv:\n Pulm:\n Abd; distended\n Extr:\n Labs / Radiology\n 32 K/uL\n 12.3 g/dL\n 129 mg/dL\n 1.8 mg/dL\n 14 mEq/L\n 4.4 mEq/L\n 33 mg/dL\n 100 mEq/L\n 132 mEq/L\n 34.8 %\n 16.5 K/uL\n [image002.jpg]\n 02:18 PM\n 07:59 PM\n 08:24 PM\n 01:59 AM\n 02:21 AM\n 08:10 AM\n 08:33 AM\n 08:12 PM\n 03:59 AM\n 04:35 AM\n WBC\n 12.6\n 16.5\n Hct\n 31.9\n 34.8\n Plt\n 48\n 32\n Cr\n 1.0\n 1.4\n 1.8\n TCO2\n 20\n 20\n 20\n 20\n 16\n Glucose\n 117\n 92\n 103\n 129\n Other labs: PT / PTT / INR:23.1/42.3/2.2, ALT / AST:, Alk Phos\n / T Bili:438/20.9, Amylase / Lipase:/52, Differential-Neuts:64.0 %,\n Band:8.0 %, Lymph:16.0 %, Mono:10.0 %, Eos:0.0 %, Fibrinogen:170 mg/dL,\n Lactic Acid:5.7 mmol/L, Albumin:2.5 g/dL, LDH:1158 IU/L, Ca++:8.8\n mg/dL, Mg++:1.9 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n HEPATITIS, ISCHEMIC (SHOCK LIVER)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 79 y/o male with hepatitis c cirrhosis, elevated lactate, BRB per NG\n tube, s/p EGD with banding of active variceal bleeding.\n *** Family meeting today at 2pm.\n # Hypotension/Bleed: Clearly there is a component of volume loss given\n his blood loss, unclear if there is sepsis. EGD showed variceal bleed\n requiring multiple transfusions of PRBC for falling Hct. Hct currently\n stable at 30. Lactic acid had been improving (rose again on \n however from 4.9 to 5.7). Increased levophed requirement versus\n .\n - Goal INR <2; goal plt >50; goal finbrinogen >100; Hct >25\n - coags, calcium, cbc, electrolytes\n - Daily lactic acid\n - Continue Levophed, wean as tolerated; Vasopressin has been weaned off\n already; goal MAP >65\n - Maintain active type and cross x8 units\n - Continue PPI drip\n - Continue Octreotide\n - f/u cultures obtained\n - consider tap ascites when stable, ?SBP\n - Vanc/Zosyn empirically cont.\n # Elevated LFTs/Lactate: Likely secondary to necrosis in the context of\n hypotension. ? Mesenteric ischemia versus global hypoperfusion at this\n time. No free air on CXR although not ideal.\n - Improved lactate and LFTs\n - Trend LFTs and lactate daily\n - Volume resuscitation with fluids, blood\n - Patient unstable for further evaluation of abdomen at this time\n # Anuria: Likely secondary to hypotension. Renal consult obtained if\n patient needs urgent dialysis given hyperkalemia. At this point given\n bleeding I am not sure if he would be stable for any CRRT.\n - Follow volume status\n - Receiving CVVHD; monitor lytes q6h and replete prn\n # Hyperkalemia: Resolved. Previously, resuscitation with temporizing\n measures as in HPI. Repeat K is elevated. Renal aware. Given Calcium\n gluconate, sodium bicarbonate, glucose/Insulin.\n .\n FEN: No IVF, replete electrolytes, NPO. Replete phos this AM.\n .\n Prophylaxis: IV PPI\n .\n Access: 2 peripherals, left subclavian, R temporary HD line\n .\n Code: DNR (CPR not medically indicated, for discussion see POE and Dr.\n note ).\n .\n Communication: Friend , , daughter (children have not been in\n contact with patient for ~20 years). Have family meeting today at 2pm\n re: goals of care.\n F/u ethics consult recommendations.\n .\n Disposition: ICU\n ICU Care\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n"
},
{
"category": "Respiratory ",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 505024,
"text": "Demographics\n Day of mechanical ventilation: 4\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\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 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: 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": "Nursing",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505037,
"text": "Renal failure, acute (Acute renal failure, ARF)\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": "2174-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505039,
"text": "79 yo man with PMH: Hep C with portal hypertension, DM, PVD, cardiac\n stents and on EGD showing esophageal and gastric varices and\n varices banded. Patient presented from floor with BRBPR and hct 17,\n intubated for airway protection. Patient is in ATN, hyperkalemic and\n lactic acidosis. CRRT initiated on and patient is on levophed gtt.\n Code status: DNR\n Events: CRRT clotted and not restarted. Family meeting 1400 tomorrow\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504868,
"text": "79 yo man with PMH: Hep C with portal hypertension, DM, PVD, cardiac\n stents and on EGD showing esophageal and gastric varices and\n varices banded. Patient presented from floor with BRBPR and hct 17,\n intubated for airway protection. Patient is in ATN, hyperkalemic and\n lactic acidosis. CRRT initiated on and patient is on levophed gtt.\n Code status: DNR\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\ns, Hct\n stable. Oozing from the IV/ HD/ central line sites stopped. Foley with\n bright red urine, though no urine output.\n Action:\n Continue to monitor labs, S/S of bleeding\n Response:\n No bleeding noted, continue to have red color urine, very minimal. M\n labs\n Plan:\n Cont q 6hr labs fibrinogen, coags, Q12hr Hct , monitor for further s/s\n of bleeding. Transfuse blood/ blood products as needed\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Continue to have mod amt melena stools,\n Platelets 82 this am post plt tx. and INR 1.7\n Action:\n HCT stable, continued to monitor, HCT goal>28 and platelets goal >50\n Response:\n Plan:\n Monitor Hct q 12hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly neg . Pt\n tolerating CRRT well, no UOP Dialysate fluid is B22K4and replacement\n fluids B32 K2. On levophed gtt.\n Action:\n K+ and Ca Gluconate titrated per SS, levophed gtt titrated for MAP >\n 60, no urine output,\n Response:\n CRRT tolerating well, BUN/creat lactate trending down. pH improving\n slightly\n Plan:\n Cont CRRT a/o ?running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated, off sedation, on CMV 40% 500x20+ PEEP 5, lung\n sounds clear bilateral and diminished bases, 02 sat 98-100%. Patient\n unresponsive.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum.\n Response:\n Stable, cough and gag absent, patient unresponsive, Blood gas\n Plan:\n Wean vent/ as tolerated. Monitor responsiveness, restart sedation if\n needed..\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504876,
"text": "79 yo man with PMH: Hep C with portal hypertension, DM, PVD, cardiac\n stents and on EGD showing esophageal and gastric varices and\n varices banded. Patient presented from floor with BRBPR and hct 17,\n intubated for airway protection. Patient is in ATN, hyperkalemic and\n lactic acidosis. CRRT initiated on and patient is on levophed gtt.\n Code status: DNR\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\ns, Hct\n stable. Oozing from the IV/ HD/ central line sites stopped. Foley with\n bright red urine, though no urine output.\n Action:\n Continue to monitor labs, S/S of bleeding\n Response:\n No bleeding noted, continue to have red color urine, very minimal. M\n labs platelet 48, INR 2.0\n Plan:\n Cont q 6hr labs fibrinogen, coags, Q12hr Hct , monitor for further s/s\n of bleeding. Transfuse blood/ blood products as needed\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Continue to have mod amt melena stools,\n Platelets 82 this am post plt tx. and INR 1.7\n Action:\n HCT stable, continued to monitor, HCT goal>28 and platelets goal >50\n Response:\n No bleeding noted, continue to have , AM labs as above\n Plan:\n Monitor Hct q 12hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly neg . Pt\n tolerating CRRT well, no UOP Dialysate fluid is B22K4and replacement\n fluids B32 K2. On levophed gtt.\n Action:\n K+ and Ca Gluconate titrated per SS, levophed gtt titrated for MAP >\n 60, no urine output,\n Response:\n CRRT tolerating well, BUN/creat lactate trending down 4.9. pH\n improving slightly 7.33 this am.Levophed gtt ^sed to 0.2mcg/kg/min. k\n 4.1, ionized Ca 1.13\n Plan:\n Cont CRRT a/o ?running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated, off sedation, on CMV 40% 500x20+ PEEP 5, lung\n sounds clear bilateral and diminished bases, 02 sat 98-100%. Patient\n unresponsive.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum.\n Response:\n Stable, cough and gag absent, patient unresponsive, Blood gas\n Plan:\n Wean vent/ as tolerated. Monitor responsiveness, restart sedation if\n needed..\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504878,
"text": "79 yo man with PMH: Hep C with portal hypertension, DM, PVD, cardiac\n stents and on EGD showing esophageal and gastric varices and\n varices banded. Patient presented from floor with BRBPR and hct 17,\n intubated for airway protection. Patient is in ATN, hyperkalemic and\n lactic acidosis. CRRT initiated on and patient is on levophed gtt.\n Code status: DNR\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\ns, Hct\n stable. Oozing from the IV/ HD/ central line sites stopped. Foley with\n bright red urine, though no urine output.\n Action:\n Continue to monitor labs, S/S of bleeding\n Response:\n No bleeding noted, continue to have red color urine, very minimal. M\n labs platelet 48, INR 2.0\n Plan:\n Cont q 6hr labs fibrinogen, coags, Q12hr Hct , monitor for further s/s\n of bleeding. Transfuse blood/ blood products as needed\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Continue to have mod amt melena stools,\n Platelets 82 this am post plt tx. and INR 1.7\n Action:\n HCT stable, continued to monitor, HCT goal>28 and platelets goal >50\n Response:\n No bleeding noted, continue to have , AM labs as above\n Plan:\n Monitor Hct q 12hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly neg . Pt\n tolerating CRRT well, no UOP Dialysate fluid is B22K4and replacement\n fluids B32 K2. On levophed gtt.\n Action:\n K+ and Ca Gluconate titrated per SS, levophed gtt titrated for MAP >\n 60, no urine output,\n Response:\n CRRT tolerating well, BUN/creat 19/1.0, lactate trending down 4.9. pH\n improving slightly 7.33 this am.Levophed gtt ^sed to 0.2mcg/kg/min. k\n 4.1, ionized Ca 1.13\n Plan:\n Cont CRRT a/o ?running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated, off sedation, on CMV 40% 500x20+ PEEP 5, lung\n sounds clear bilateral and diminished bases, 02 sat 98-100%. Patient\n unresponsive.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum.\n Response:\n Stable, cough and gag absent, patient unresponsive, Blood gas\n Plan:\n Wean vent/ as tolerated. Monitor responsiveness, restart sedation if\n needed..\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 504980,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - liver: continue gtt, protonix gtt, CVVH; recommend transition to\n CMO.\n - discussion with son and daughter: made aware of patient's\n poor prognosis. plan to visit pt again today and can further address\n goals of care at that time.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 05:00 PM\n Piperacillin/Tazobactam (Zosyn) - 04:16 AM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 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 07:26 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: 36.2\nC (97.2\n HR: 80 (70 - 87) bpm\n BP: 96/51(66) {91/49(62) - 121/59(78)} mmHg\n RR: 20 (20 - 25) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,577 mL\n 1,359 mL\n PO:\n TF:\n IVF:\n 5,013 mL\n 1,359 mL\n Blood products:\n 564 mL\n Total out:\n 6,052 mL\n 1,314 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n -475 mL\n 45 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): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability\n PIP: 25 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 100%\n ABG: 7.33/36/103/19/-6\n Ve: 10.1 L/min\n PaO2 / FiO2: 258\n Physical Examination\n GEN: nad, non-responsive to voice, touch, sternal rub\n CV: RRR, no m/r/g\n PULM; CTAB\n ABD: soft, NT, +BS, distended\n EDEMA: 1+b/l feet\n SKIN: mottled appearance to feet b/l\n Labs / Radiology\n 48 K/uL\n 11.4 g/dL\n 92 mg/dL\n 1.0 mg/dL\n 19 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 102 mEq/L\n 133 mEq/L\n 31.9 %\n 12.6 K/uL\n [image002.jpg]\n 02:05 AM\n 02:19 AM\n 08:12 AM\n 08:19 AM\n 02:10 PM\n 02:18 PM\n 07:59 PM\n 08:24 PM\n 01:59 AM\n 02:21 AM\n WBC\n 13.0\n 13.3\n 11.8\n 12.6\n Hct\n 30.3\n 31.9\n 33.0\n 31.9\n Plt\n 49\n 82\n 52\n 48\n Cr\n 1.3\n 1.0\n 1.0\n TCO2\n 22\n 20\n 20\n 20\n 20\n Glucose\n 111\n 108\n 105\n 117\n 92\n Other labs: PT / PTT / INR:21.8/36.8/2.0, ALT / AST:, Alk Phos\n / T Bili:421/17.0, Amylase / Lipase:/52, Differential-Neuts:64.0 %,\n Band:8.0 %, Lymph:16.0 %, Mono:10.0 %, Eos:0.0 %, Fibrinogen:170 mg/dL,\n Lactic Acid:4.9 mmol/L, Albumin:2.9 g/dL, LDH:1420 IU/L, Ca++:9.0\n mg/dL, Mg++:1.9 mg/dL, PO4:1.5 mg/dL\n CXR: mild improvement in overall haziness, particularly at left base,\n compared to yesterday (my read)\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n HEPATITIS, ISCHEMIC (SHOCK LIVER)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 79 y/o male with hepatitis c cirrhosis, elevated lactate, BRB per NG\n tube, s/p EGD with banding of active variceal bleeding.\n # Hypotension/Bleed: Clearly there is a component of volume loss given\n his blood loss, unclear if there is sepsis. EGD showed variceal bleed\n requiring multiple transfusions of PRBC for falling Hct. Hct currently\n stable at 30. Lactic acid improving. Increased levophed requirement\n versus .\n - Goal INR <2; goal plt >50; goal finbrinogen >100; Hct >25\n - coags, calcium, cbc, electrolytes\n - Daily lactic acid\n - Continue Levophed, wean as tolerated; Vasopressin has been weaned off\n already; goal MAP >65\n - Maintain active type and cross x8 units\n - Continue PPI drip\n - Continue Octreotide\n - f/u cultures obtained\n - consider tap ascites when stable, ?SBP\n - Vanc/Zosyn empirically cont.\n # Elevated LFTs/Lactate: Likely secondary to necrosis in the context of\n hypotension. ? Mesenteric ischemia versus global hypoperfusion at this\n time. No free air on CXR although not ideal.\n - Improved lactate and LFTs\n - Trend LFTs and lactate daily\n - Volume resuscitation with fluids, blood\n - Patient unstable for further evaluation of abdomen at this time\n # Anuria: Likely secondary to hypotension. Renal consult obtained if\n patient needs urgent dialysis given hyperkalemia. At this point given\n bleeding I am not sure if he would be stable for any CRRT.\n - Follow volume status\n - Receiving CVVHD; monitor lytes q6h and replete prn\n # Hyperkalemia: Resuscitation with temporizing measures as in HPI.\n Repeat K is elevated. Renal aware. Given Calcium gluconate, sodium\n bicarbonate, glucose/Insulin. Now resolved.\n .\n FEN: No IVF, replete electrolytes, NPO. Replete phos this AM.\n .\n Prophylaxis: IV PPI\n .\n Access: 2 peripherals, left subclavian, R temporary HD line\n .\n Code: DNR (CPR not medically indicated, for discussion see POE and Dr.\n note ).\n .\n Communication: Friend , . Have family meeting today (son &\n daughter) re: goals of care.\n Discuss case and goals of care and potential withdrawal of care and\n family\ns role (children with years without contact with patient) with\n ethics service.\n .\n Disposition: ICU\n ICU Care\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n"
},
{
"category": "Nutrition",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 505006,
"text": "Nutrition screen per ICU protocol (was being followed on floor by diet\n tech). Noted hopsital course/events-curretnly intubated, on double\n pressors. ? transition towards CMO also noted- will follow plan.\n"
},
{
"category": "General",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Generic Note",
"row_id": 505079,
"text": "TITLE:\n I met with son and daughter of Mr. at the bedside tonight for\n approximately 30 minutes. I told them that Mr. had a\n catastrophic GI bleed due to varices, which are a complication of liver\n disease. I told them the he had multiorgan failure from this bleeding\n including\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Family Meeting Note",
"row_id": 505080,
"text": "TITLE:\n I met with son and daughter of Mr. at the bedside tonight for\n approximately 30 minutes. I told them that Mr. had a\n catastrophic GI bleed due to varices, which are a complication of liver\n disease. I told them the he had multiorgan failure from this bleeding,\n including renal failure requiring dialysis, liver damage from\n hypotension on top of chronic liver disease, persistent hypotension,\n and likely brain and heart damage as well. I told them that he is off\n sedating medications, but has not yet woken up. They explicitly asked\n if he will ever wake up. I said it is very unlikely, but too early to\n tell as liver patients wake up slowly from sedatives. I told them that\n if he doesn\nt start to respond over the next day or so, it is unlikely\n he will ever wake up. They understood that. I also told them that he\n will likely die from his current condition. Finally, I told them that\n should additional organ systems fail, we will not be able to revive\n him, and that cardiac resuscitation has no chance of success in this\n patient should it come to that. Again, they understood this.\n MD -2\n"
},
{
"category": "Respiratory ",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 504737,
"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 Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 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: Not triggering\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 Hemodynimic instability, Underlying illness not resolved\n"
},
{
"category": "Respiratory ",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 505137,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\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 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 Plan\n Next 24-48 hours: Patient is dnr, no weaning attempted.\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": "2174-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505140,
"text": "Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt received off CRRT at 0800, no urine out put, this AM labs BUN 19,\n creat 1.0, Lytes within normal limits, and receiving K phos for low\n phos.\n Action:\n Off CRRT until family meeting today\n Response:\n No urine output, AM labs\n Plan:\n CRRT on hold until the family meeting, continue to monitor labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, off sedation, on AC 40% 500 x 20.\n Bilateral lung sounds clear and diminished bases, O2 sats 98-100%.\n Action:\n Antibiotics continued pul toilet and MDI\ns as ordered.\n Response:\n Thick blood tinged secretions, blood gas 7.28/32/98/-10\n Plan:\n Suction PRN, monitor vent status\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n A febrile, patient received on levo at 0.3mcg/kg/min and vaspressin\n 2.4units/hr. SBP 90-100mmhg monitoring via Lt radial a line. Frequent\n bigeminy and pvc\ns noted\n Action:\n Lytes checked, continued pressors\n Response:\n Afebrile, WBC 16.5, lactate 5.7 and platelet 32\n Plan:\n Maintain His B/P so that the Maps > 60, from social\n work has arranged a family meeting at 1400 tomorrow to discuss plan of\n care. His 2 children, friend, a step sister and a nephew are\n expected to come.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505304,
"text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 504958,
"text": "Chief Complaint: Respiratory Failure, GI Bleed, Blood Loss Anemia,\n 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 Has has increase in levephed requirement to 0.2\n 24 Hour Events:\n CRRT circuit has clotted off\n History obtained from Medical records, icu team\n Patient unable to provide history: Sedated, Encephalopathy\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 04:16 AM\n Vancomycin - 08:00 AM\n Infusions:\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Norepinephrine - 0.2 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 Respiratory: mechanical ventilation\n Genitourinary: Dialysis\n Pain: No pain / appears comfortable\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: 36.7\nC (98.1\n Tcurrent: 36\nC (96.8\n HR: 86 (70 - 87) bpm\n BP: 97/52(66) {91/49(62) - 130/63(85)} mmHg\n RR: 20 (20 - 25) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 5,577 mL\n 1,999 mL\n PO:\n TF:\n IVF:\n 5,013 mL\n 1,999 mL\n Blood products:\n 564 mL\n Total out:\n 6,052 mL\n 1,434 mL\n Urine:\n 30 mL\n NG:\n Stool:\n Drains:\n Balance:\n -475 mL\n 565 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): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability\n PIP: 25 cmH2O\n Plateau: 20 cmH2O\n Compliance: 35.7 cmH2O/mL\n SpO2: 98%\n ABG: 7.34/35/130/18/-5\n Ve: 10.5 L/min\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: No acute distress, intubated, sedated\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: musical b/l)\n Abdominal: Soft, Non-tender, Distended\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\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 11.4 g/dL\n 48 K/uL\n 103 mg/dL\n 1.0 mg/dL\n 18 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 101 mEq/L\n 133 mEq/L\n 31.9 %\n 12.6 K/uL\n [image002.jpg]\n 08:12 AM\n 08:19 AM\n 02:10 PM\n 02:18 PM\n 07:59 PM\n 08:24 PM\n 01:59 AM\n 02:21 AM\n 08:10 AM\n 08:33 AM\n WBC\n 13.3\n 11.8\n 12.6\n Hct\n 31.9\n 33.0\n 31.9\n Plt\n 82\n 52\n 48\n Cr\n 1.0\n 1.0\n TCO2\n 20\n 20\n 20\n 20\n 20\n Glucose\n 108\n 105\n 117\n 92\n 103\n Other labs: PT / PTT / INR:21.8/36.8/2.0, ALT / AST:, Alk Phos\n / T Bili:421/17.0, Amylase / Lipase:/52, Differential-Neuts:64.0 %,\n Band:8.0 %, Lymph:16.0 %, Mono:10.0 %, Eos:0.0 %, Fibrinogen:170 mg/dL,\n Lactic Acid:4.9 mmol/L, Albumin:2.9 g/dL, LDH:1420 IU/L, Ca++:9.0\n mg/dL, Mg++:1.9 mg/dL, PO4:1.5 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n HEPATITIS, ISCHEMIC (SHOCK LIVER)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Has peesistent pressor requirement\n 1. Hypovolemic shock/GI Bleed/Blood Loss Anemia: Remains on levophed -\n requirement has gone up. Hct stable.\n 2. Acute renal failure: On CRRT - circuit down at the moment. \n reinitiate pending goals of care discussion\n 3. Respiratory Failure: Cont current vent settings.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 505231,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n Family meeting @ 2pm today.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 04:20 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Octreotide - 50 mcg/hour\n Norepinephrine - 0.35 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 07:12 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: 36.9\nC (98.4\n HR: 89 (79 - 94) bpm\n BP: 100/57(73) {90/51(64) - 130/63(85)} mmHg\n RR: 22 (20 - 25) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,719 mL\n 784 mL\n PO:\n TF:\n IVF:\n 3,719 mL\n 784 mL\n Blood products:\n Total out:\n 1,434 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,285 mL\n 786 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): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 33.3 cmH2O/mL\n SpO2: 96%\n ABG: 7.28/32/98./14/-10\n Ve: 12.3 L/min\n PaO2 / FiO2: 245\n Physical Examination\n GEN: nad, unresponsive to verbal or tactile stimuli (incl sternal rub)\n Cv: rrr, no murmurs\n Pulm: ctab, but with harsher breath sounds in upper lung fields\n Abd; distended, soft, nt, could not auscultate bowel sounds clearly\n Extr: + b/l pedal edema\n SKIN; jaundiced, mottled feet appearance.\n Labs / Radiology\n 32 K/uL\n 12.3 g/dL\n 129 mg/dL\n 1.8 mg/dL\n 14 mEq/L\n 4.4 mEq/L\n 33 mg/dL\n 100 mEq/L\n 132 mEq/L\n 34.8 %\n 16.5 K/uL\n [image002.jpg]\n 02:18 PM\n 07:59 PM\n 08:24 PM\n 01:59 AM\n 02:21 AM\n 08:10 AM\n 08:33 AM\n 08:12 PM\n 03:59 AM\n 04:35 AM\n WBC\n 12.6\n 16.5\n Hct\n 31.9\n 34.8\n Plt\n 48\n 32\n Cr\n 1.0\n 1.4\n 1.8\n TCO2\n 20\n 20\n 20\n 20\n 16\n Glucose\n 117\n 92\n 103\n 129\n Other labs: PT / PTT / INR:23.1/42.3/2.2, ALT / AST:, Alk Phos\n / T Bili:438/20.9, Amylase / Lipase:/52, Differential-Neuts:64.0 %,\n Band:8.0 %, Lymph:16.0 %, Mono:10.0 %, Eos:0.0 %, Fibrinogen:170 mg/dL,\n Lactic Acid:5.7 mmol/L, Albumin:2.5 g/dL, LDH:1158 IU/L, Ca++:8.8\n mg/dL, Mg++:1.9 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n HEPATITIS, ISCHEMIC (SHOCK LIVER)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 79 y/o male with hepatitis c cirrhosis, elevated lactate, BRB per NG\n tube, s/p EGD with banding of active variceal bleeding.\n *** Family meeting today at 2pm.\n # Hypotension/Bleed: Clearly there is a component of volume loss given\n his blood loss, unclear if there is sepsis. EGD showed variceal bleed\n requiring multiple transfusions of PRBC for falling Hct. Hct currently\n stable at 30. Lactic acid had been improving (rose again on \n however from 4.9 to 5.7). Increased levophed requirement versus\n .\n - Goal INR <2; goal plt >50; goal finbrinogen >100; Hct >25\n - coags, calcium, cbc, electrolytes\n - Daily lactic acid\n - Continue Levophed and vasopression, wean as tolerated; goal MAP >65\n - Maintain active type and cross x8 units\n - Continue PPI drip\n - Continue Octreotide\n - f/u cultures obtained\n - consider tap ascites when stable, ?SBP\n hold for now\n - Vanc/Zosyn empirically cont.\n # Elevated LFTs/Lactate: Likely secondary to necrosis in the context of\n hypotension. ? Mesenteric ischemia versus global hypoperfusion at this\n time. No free air on CXR although not ideal study.\n - Trend LFTs and lactate daily\n - Volume resuscitation with fluids, blood\n - Patient unstable for further evaluation of abdomen at this time\n - f/u hepatology recs\n # Anuria: Likely secondary to hypotension. Renal consult obtained if\n patient needs urgent dialysis given hyperkalemia. At this point given\n bleeding I am not sure if he would be stable for any CRRT.\n - Hold on next session CVVHD for now; electrolytes ok\n - Acidemic, so could consider CVVHD and bicarb as potential treatments\n - Follow volume status\n # Hyperkalemia: Resolved. Previously, resuscitation with temporizing\n measures as in HPI. Repeat K is elevated. Renal aware. Given Calcium\n gluconate, sodium bicarbonate, glucose/Insulin.\n .\n FEN: No IVF, replete electrolytes, NPO.\n .\n Prophylaxis: IV PPI\n .\n Access: 2 peripherals, left subclavian, R temporary HD line\n .\n Code: DNR (CPR not medically indicated, for discussion see POE and Dr.\n note ).\n .\n Communication: Friend , , daughter (children have not been in\n contact with patient for ~20 years). Have family meeting today at 2pm\n re: goals of care.\n F/u ethics consult recommendations.\n .\n Disposition: ICU\n ICU Care\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505143,
"text": "Awaiting family meeting today, CRRT on hold until family meeting\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt received off CRRT at 0800, no urine out put, this AM labs BUN 19,\n creat 1.0, Lytes within normal limits, and receiving K phos for low\n phos.\n Action:\n Off CRRT until family meeting today\n Response:\n No urine output, AM labs BUN 33 and creat result pending\n Plan:\n CRRT on hold until the family meeting, continue to monitor labs.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received patient orally intubated, off sedation, on AC 40% 500 x 20.\n Bilateral lung sounds clear and diminished bases, O2 sats 98-100%.\n Action:\n Antibiotics continued pul toilet and MDI\ns as ordered.\n Response:\n Thick blood tinged secretions, blood gas 7.28/32/98/-10\n Plan:\n Suction PRN, monitor vent status\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n A febrile, patient received on levo at 0.3mcg/kg/min and vaspressin\n 2.4units/hr. SBP 90-100mmhg monitoring via Lt radial a line. Frequent\n bigeminy and pvc\ns noted\n Action:\n Lytes checked, continued pressors\n Response:\n Afebrile, WBC 16.5, lactate 5.7,INR 2.2 and platelet 32.SBP 90-100 on\n levophed and vasopressin gtt\n Plan:\n Maintain His B/P so that the Maps > 60, from social\n work has arranged a family meeting at 1400 tomorrow to discuss plan of\n care. His 2 children, friend, a step sister and a nephew are\n expected to come.\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 505224,
"text": "Chief Complaint:\n HPI:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 AM\n Piperacillin/Tazobactam (Zosyn) - 04:20 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Octreotide - 50 mcg/hour\n Norepinephrine - 0.35 mcg/Kg/min\n Pantoprazole (Protonix) - 8 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 11:06 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 (97.5\n HR: 90 (82 - 94) bpm\n BP: 114/60(79) {90/51(64) - 119/61(81)} mmHg\n RR: 23 (20 - 25) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,719 mL\n 1,150 mL\n PO:\n TF:\n IVF:\n 3,719 mL\n 1,150 mL\n Blood products:\n Total out:\n 1,434 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 2,285 mL\n 1,150 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): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability\n PIP: 23 cmH2O\n Plateau: 21 cmH2O\n Compliance: 31.3 cmH2O/mL\n SpO2: 97%\n ABG: 7.28/32/98./14/-10\n Ve: 12.4 L/min\n PaO2 / FiO2: 245\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 12.3 g/dL\n 32 K/uL\n 129 mg/dL\n 1.8 mg/dL\n 14 mEq/L\n 4.4 mEq/L\n 33 mg/dL\n 100 mEq/L\n 132 mEq/L\n 34.8 %\n 16.5 K/uL\n [image002.jpg]\n 02:18 PM\n 07:59 PM\n 08:24 PM\n 01:59 AM\n 02:21 AM\n 08:10 AM\n 08:33 AM\n 08:12 PM\n 03:59 AM\n 04:35 AM\n WBC\n 12.6\n 16.5\n Hct\n 31.9\n 34.8\n Plt\n 48\n 32\n Cr\n 1.0\n 1.4\n 1.8\n TCO2\n 20\n 20\n 20\n 20\n 16\n Glucose\n 117\n 92\n 103\n 129\n Other labs: PT / PTT / INR:23.1/42.3/2.2, ALT / AST:, Alk Phos\n / T Bili:438/20.9, Amylase / Lipase:/52, Differential-Neuts:64.0 %,\n Band:8.0 %, Lymph:16.0 %, Mono:10.0 %, Eos:0.0 %, Fibrinogen:170 mg/dL,\n Lactic Acid:5.7 mmol/L, Albumin:2.5 g/dL, LDH:1158 IU/L, Ca++:8.8\n mg/dL, Mg++:1.9 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n GASTROINTESTINAL BLEED, OTHER (GI BLEED, GIB)\n HEPATITIS, ISCHEMIC (SHOCK LIVER)\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Has showed little improvement since initial stabilization on\n the first MICU day - his prognosis is very poor. He is now having\n significant ectopy as well. We are meeting with his estranged\n children, his cousin, and his friend today to discuss his poor\n prognosis. Based on our previous conversations, CMO care would be\n warrented at this point.\n 1. Hypovolemic shock/GI Bleed/Blood Loss Anemia: Continue to elevated\n lavtate. Has persistent pressor requirement.\n 2. Acute renal failure: On hold for the moment\n 3. Respiratory Failure: Cont current vent settings.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 34 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-24 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 504286,
"text": "Chief Complaint: Respiratory distress, lactic acidosis\n HPI:\n 79 yo Italian speaking male with h/o cirrhosis Hep C, who presented\n with chief complaint of weakness to Hospital\n () after falling in bathtub in the water. Per OSH recs, he\n said he \"didn't feel right\" and his \"legs were weak\" and he lowered\n himself into the tub. He hit his left shoulder (unclear how if he\n lowered himself down). Did not hit\n his head, no LOC. He was unable to pull the cord for help and yelled\n until a neighbor came to his assistance. Paramedics took him to \n hospital ED for evaluation.\n At OSH, he underwent a head CT which was normal, and CXR that was\n concerning for PNA. He was thought to be in heart failure and was given\n lasix 40mg IV. He received azithromycin 500mg IV x1 and ceftriaxone 1g\n IV x1. He was also given 1.5L NS. Labs were noteworthy for Na 129, Cr\n of 1.6, and a troponin of 0.12 (last measured here at 0.01). His SBP\n ~90, which is his baseline. EKG there demonstrated RBBB.\n In the ED at , initial vs were: T97.9 P96 BP 101/68 R30 O2 sat\n 97% 2L NC. Labs were notable for troponin of 0.05 and pt received ASA\n 325mg PO x1, no heparin per discussion with cardiology in ED. RBBB seen\n on OSH EKG, but was not noted on EKG at . His T. bili was noted to\n be elevated 3.8 (previously 2.2). Pt underwent RUQ US, L shoulder plain\n film, and diagnostic paracentesis. He was admitted to medicine/liver\n service for evaluation fo and pneumonia. VS on transfer were T\n 97.9 P95 BP 99/57 R32 O2sat 97% RA.\n On the floor patient was noted to have with Cr up to 1.5. He was\n given albumin 50g x 2 and 25g x 1 over three days in addition to 1 U\n PRBC for anemia. Night prior to admission patient with BRBPR but\n stable HCT.\n On AM of transfer patient noted to be tachypnic, epigastric pain,\n lactate 10 on ABG. Hyperkalemic to 6.2, peaked t waves on EKG. calcium\n carbonate administered and transferred to unit.\n In unit was tachypnic and dropping pressures. Intubated. Peripheral\n dopamine started. Left subclavian placed. Renal consult obtained for\n anuria, up volume and hyperkalemia. Inuslin/D50, bicarb administered.\n Surgery consulted for ? mesenteric ischemia. NG tube placed, 100cc old\n blood, now 200cc bright red blood. Liver consulted.\n Patient admitted from: \n History obtained from Medical records\n Patient unable to provide history: Sedated, Encephalopathy,\n Unresponsive, Language barrier\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 10:49 AM\n Vancomycin - 10:51 AM\n Infusions:\n Dopamine - 6 mcg/Kg/min\n Octreotide - 50 mcg/hour\n Other ICU medications:\n Dextrose 50% - 10:30 AM\n Insulin - Regular - 10:30 AM\n Sodium Bicarbonate 8.4% (Amp) - 11:13 AM\n Other medications:\n Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and\n MED Atorvastatin 10 mg PO/NG DAILY\n MED Niacin 500 mg PO BID\n MED Nadolol 40 mg PO DAILY\n Hold for SBP<90 or HR<55\n MED Levothyroxine Sodium 50 mcg PO/NG DAILY\n MED Lactulose 30 mL PO/NG TID Titrate to 3 loose BM daily\n Titrate to 3 loose BM daily\n MED Insulin SC (per Insulin Flowsheet) Sliding Scale\n MED Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol\n MED Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol\n Past medical history:\n Family history:\n Social History:\n -PERCUTANEOUS CORONARY INTERVENTIONS: in mid-RCA on\n . Mid LAD shows 50% long lesion with a 90% discrete 1st\n diagonal lesion. OM1: 70% long lesion, OM2: 80% ostial lesion, and OM3:\n 70% ostial lesion\n --Diabetes mellitus Type II with peripheral neuropathy\n --peripheral vascular disease\n --Chronic hepatitis C genotype 2a/2c (untreated) with cirrhosis portal\n hypertension and splenomegaly. EGD revealing esophageal and\n gastric varices.\n --Chronic mild anemia and thrombocytopenia (thought secondary to\n splenic sequestration)\n --left portal vein thrombosis (seen U/S on )\n --left testicular mass versus recurrent hernia (), was supposed\n to be evaluated by ultrasound\n --osteoarthritis\n --varicose veins\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Smoke: never\n EtOH: never\n Drugs: never\n Italian-speaking\n Lives/works: The patient lives alone. He walks with a walker. He is\n divorced and estranged from his children. His friend stops by\n frequently and cooks for him but is unable to completely care for him.\n Review of systems:\n Flowsheet Data as of 01:28 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.8\nC (98.2\n HR: 105 (84 - 105) bpm\n BP: 89/60(72) {74/38(52) - 89/60(72)} mmHg\n RR: 28 (28 - 47) insp/min\n SpO2: 98%\n Mixed Venous O2% Sat: 97 - 97\n Total In:\n 513 mL\n PO:\n TF:\n IVF:\n 363 mL\n Blood products:\n Total out:\n 0 mL\n 250 mL\n Urine:\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 0 mL\n 263 mL\n Respiratory\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 311 (311 - 311) mL\n RR (Set): 20\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 60%\n PIP: 14 cmH2O\n SpO2: 98%\n ABG: 7.20/31/319//-14\n Ve: 23 L/min\n PaO2 / FiO2: 532\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n )\n Abdominal: Bowel sounds present, Distended, Tender:\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 76 K/uL\n 5.4 g/dL\n 6.5 mEq/L\n 17.2 %\n 18.5 K/uL\n [image002.jpg]\n \n 2:33 A12/7/ 11:43 AM\n \n 10:20 P12/7/ 12:42 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 18.5\n Hct\n 17.2\n Plt\n 76\n TC02\n 13\n Other labs: PT / PTT / INR:24.4/62.1/2.3, Differential-Neuts:64.0 %,\n Band:8.0 %, Lymph:16.0 %, Mono:10.0 %, Eos:0.0 %, Fibrinogen:71 mg/dL,\n Lactic Acid:14.0 mmol/L\n Assessment and Plan\n 79 y/o male with hepatitis c cirrhosis, elevated lactate, BRB per NG\n tube.\n # Hypotension/Bleed: Clearly there is a component of volume loss given\n his blood loss, unclear if there is sepsis.\n - Cultures obtained\n - Vanc/Zosyn empirically\n - Crossmatch 8 units, transfuse 4 units at this time, 4 more on the\n way, FFPs as well.\n - Liver at bedside performing endoscopy now.\n - Tap ascites when stable, ? SBP\n - PPI drip\n - Octreotide\n - - next step if needed.\n - Follow ionized calcium\n # Elevated Lactate: Likely secondary to necrosis in the context of\n hypotension. ? Mesenteric ischemia versus global hyperperfusion at\n this time.\n - Surgery consulted\n - Volume resuscitation with fluids, blood\n - No free air on CXR although not ideal.\n - Patient unstable for further evaluation of bowel at this time.\n # Anuria: Likely secondary to hypotension. Renal consult obtained if\n patient needs urgent dialysis given hyperkalemia. At this point given\n bleeding I am not sure if he would be stable for any CRRT.\n - Follow volume status\n - Follow potassium\n # Hyperkalemia: Resuscitation with temporizing measures as in HPI.\n Repeat K is elevated. Renal aware. Repeat:\n - Calcium gluconate\n - Sodium bicarbonate\n - Glucose/Insulin\n - follow serial K\n .\n FEN: No IVF, replete electrolytes, regular diet\n .\n Prophylaxis: Subcutaneous heparin\n .\n Access: 2 peripherals, left subclavian\n .\n Code: DNR (CPR not medically indicated, for discussion see POE and Dr.\n note ).\n .\n Communication: Friend \n .\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:26 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR- not medically indicated\n Disposition:\n"
},
{
"category": "General",
"chartdate": "2174-10-24 00:00:00.000",
"description": "MICU Attending",
"row_id": 504285,
"text": "TITLE: MICU Attending\n Mr. admitted to the ICU from the hepatology service this AM with\n acute of abdominal pain, tachypnea, and hypotension. Lactate of 10.\n Intubated on arrival to MICU. Post-intubation had worsening shock with\n initiation of dopamine peripherally. Central line placed in L\n subclavian. Levophed started in addition to dopamine\n both now at\n max. Seen by surgery and hepatology. EGD done with finding of large\n amount of blood in esophagus with varices. Varices banded.\n Will plan to continue to support hemodynamically with pressors and\n pRBCs. Reverse coagulopathy. Also has a K of 6.5 with peaked T waves\n renal consulted for possibility of CRRT, though would be difficult to\n initiate in setting of accelerating hemodynamic instability. Will\n treat with Kayexelate, bicarb, calcium, insulin/glucose and monitor K.\n The patient is apparently estranged from his family and has no decision\n maker; he has a friend who is attempting to contact his family if\n possible. Given the severity of his underlying liver disease, the\n severity of his esophageal bleed, and the fact that he is not a\n candidate for TIPS per hepatology team\n CPR would not be indicated.\n An DNR order will be entered into Mr. \ns orders.\n Pt is critically ill. Time spent 60 minutes.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504345,
"text": "79 yo Italian speaking male with h/o cirrhosis Hep C, who presented\n with chief complaint of weakness to Hospital\n () after falling in bathtub in the water. Per OSH recs, he\n said he \"didn't feel right\" and his \"legs were weak\" and he lowered\n himself into the tub. He hit his left shoulder (unclear how if he\n lowered himself down). Did not hit\n his head, no LOC. He was unable to pull the cord for help and yelled\n until a neighbor came to his assistance. Paramedics took him to \n hospital ED for evaluation.\n At OSH, he underwent a head CT which was normal, and CXR that was\n concerning for PNA. He was thought to be in heart failure and was given\n lasix 40mg IV. He received azithromycin 500mg IV x1 and ceftriaxone 1g\n IV x1. He was also given 1.5L NS. Labs were noteworthy for Na 129, Cr\n of 1.6, and a troponin of 0.12 (last measured here at 0.01). His SBP\n ~90, which is his baseline\n On AM of transfer patient noted to be tachypnic, epigastric pain,\n lactate 10 on ABG. Hyperkalemic to 6.2, peaked t waves on EKG. calcium\n carbonate administered and transferred to unit.\n In unit was tachypnic and dropping pressures. Intubated. Peripheral\n dopamine started. Left subclavian placed. Renal consult obtained for\n anuria, up volume and hyperkalemia. Inuslin/D50, bicarb administered.\n Surgery consulted for ? mesenteric ischemia. NG tube placed, 100cc old\n blood, now 200cc bright red blood. Liver consulted.\n Pt appears to be in DIC with fibrinogen 75. PTT 68 and INR 2.4. While\n in SICU from 1030-1800, pt received a total of 4u PRBC\ns, 6units FFP.\n He is on 5.0 mcg/kg/min dopa, 0.16 mcg/kg/min of Levo.\n Pt has no family. He is estranged from his wife and 2 children. He has\n a friend who has been in and is aware of pt\ns grave condition.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n NGT inserted with return of 250cc BRB. Intubated on arrival to SICU.\n CVL into L IJ with L radial art line insertion. Blood cultures sent.\n #18 french foley cath inserted. Pt has no UO. Irrigated foley without\n difficulty and return of amt instilled. However, several hours later.\n BRB out of foley cath. Also at this time, CVL bleeding. Endoscopy done\n this am and lgr pool of blood at junction of esophagus and stomach.\n Area banded by GI team. Temp max 99.0. All PRBC\ns given via heated\n rapid infuser. Pt still needs platelets which were ordered early\n afternoon. They still are not ready. LFT\ns elevated. BUN/CR elevated.\n K+ 7.0. Pt received D50 and 10 u Reg insulin IV. Pt received Vanco and\n Zocyn. Remains on Fentanyl drip at 25 mcg/hr, protonix drip at 8mg/hr,\n octreotide 50 mcg/min, Levo 0.16 mcg/kg/min, Dopa 5 mcg/kg/min, NaHCO3\n drip at 150cc hr. Pls see flow sheet for objective data regarding labs.\n Lactate 13.3 down from 14.4\n Action:\n Multiple blood products given, intubated, titrating pressors to\n maintain sbp >90. Pt is CPR not indicated. Endoscopy done, Multiple\n line placements\n Response:\n Pt is very labile. Remains with hyperkalemia, and metabolic acidosis.\n Plan:\n Con\nt to monitor. Con\nt with resuscitation efforts of pressors, blood\n products and mechanical ventilation. Start CVVHDF as ordered.\n Acidosis, Metabolic\n Assessment:\n Pt with metabolic acidosis. pH 7.12-7.20. CO2 12. Pt is on sodium\n bicarb drip at 150 cc hr. Remains mechanically ventilated with RR 6\n above the set rate of 20. Lactate 13.3, K+7.0(treated as above.)\n Action:\n Attempted vent changes to accommodate pt\ns RR. Pt received 5 amps of\n NaHCO2 prior to the drip.\n Response:\n Remains with metabolic acidosis , high lactate and high k+\n Plan:\n Con\nt to monitor. Start CVVHDF. Attempt to correct acidosis.\n"
},
{
"category": "Respiratory ",
"chartdate": "2174-10-24 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 504353,
"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: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Crackles\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Crackles\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / 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 Comments: tachypneic with rr in the mid 20s\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: Adjust Min. ventilation to control pH\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Hemodynimic instability, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-28 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 505343,
"text": "Pt was CMO with morphing gtt for comfort. Family at bedside. Pt was\n extubated per family at 21:40. Pt expired at 21:51. MD in to pronounce\n pt.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-24 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504332,
"text": "79 yo Italian speaking male with h/o cirrhosis Hep C, who presented\n with chief complaint of weakness to Hospital\n () after falling in bathtub in the water. Per OSH recs, he\n said he \"didn't feel right\" and his \"legs were weak\" and he lowered\n himself into the tub. He hit his left shoulder (unclear how if he\n lowered himself down). Did not hit\n his head, no LOC. He was unable to pull the cord for help and yelled\n until a neighbor came to his assistance. Paramedics took him to \n hospital ED for evaluation.\n At OSH, he underwent a head CT which was normal, and CXR that was\n concerning for PNA. He was thought to be in heart failure and was given\n lasix 40mg IV. He received azithromycin 500mg IV x1 and ceftriaxone 1g\n IV x1. He was also given 1.5L NS. Labs were noteworthy for Na 129, Cr\n of 1.6, and a troponin of 0.12 (last measured here at 0.01). His SBP\n ~90, which is his baseline\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Acidosis, Metabolic\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504496,
"text": "Hepatitis, ischemic (shock liver)\n Assessment:\n pt w/ known hep C cirrhosis, now with grossly elevated LFT\ns, probable\n shock liver. INR>2, plt 59 this am, fibrinogen 152 following 2 units of\n cryo on prev shift. Hct trending down, 21.5 this am, pt oozing blood\n form all IV sites as well as Bright red urine noted in foley bag. Abp\n 110\ns-120\ns/ 60\n Action:\n Transfused 1 unit FFP and 3 units PRBC\ns, hepatology consulted, CVL\n dsgs changed x2.\n Response:\n Rpt Hct 27.7 after 2^nd unit of PRBC\ns, INR , pt cont to ooze blood\n around all lines.\n Plan:\n Cont q 6hr, fibrinogen, coags, CBC, monitor for further s/s of\n bleeding, rpt LFT\ns in am.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even. K+ 3.4, Ica 0.84,\n BUN/Cr 44/1.4 rec\nd pt finishing 3^rd L of D5 with 150meq NA Bicarb ABG\n @ 0800 7.40/45/134. pt tol CRRT well, UOP minimal, <50ml for this\n shift. Urine bright red with some clots.\n Action:\n Dialysate and replacement fluids changed to B22, K4, K+ and Ca\n Gluconate titrated per SS, additional 2g of Ca Gluconate given a/o. pt\n cont to tol running FB even to slightly negative. R IJ HD cath dsg\n changed, surgicell applied to slow/stop oozing of blood around site.\n Foley cath flushed w/ 180ml sterile H20 until clear/pink.\n Response:\n Repeat Ica 1.01, K+ 4.2 , BUN/Cr 34/1.3 ABG at 1400 7.35/42/115, KCL\n and Ca Gluc gtt\ns titrated per SS. Minimal bright red UOP w/ clots\n noted.\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs\n titrate per ss, monitor UOP. Flush foley as needed.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n pt admitted to ICU on w/ acute GI/variceal bleed. EGD done \n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, Hct 21.5 this am. Mod amt melena stools x2, oozing blood\n from IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Action:\n Transfused 3 units PRBC\ns, CVL dsg\ns changed x2.\n Response:\n Hct 27.7 following 2^nd unit of PRBC\ns, oozing continues as above. Cont\n to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, LS clear bilat w/ dim\n bases, ABG\ns as above, 02 sat 98-100%, sedated on fentanyl 25mcg/hr and\n versed 3mg/hr. pt w/d to painful stim.\n Action:\n No vent changes this shift, suctioned for scant amt blood tinged\n sputum.\n Response:\n Stable, remains sedated as above.\n Plan:\n Wean vent/ sedation as tol\n"
},
{
"category": "Respiratory ",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 504404,
"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 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: 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 / 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: resolve metabolic acidosis\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504641,
"text": "69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Hemodynamics stable overnight, albeit on 2 pressors. Lactate\n improving though still 5.2. Now on CVVH with improved management to\n acidosis and hyperkalemia.\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\n probable shock liver. INR> plt 60 this pm, post transfusion HCT 27.7,\n pt oozing blood form all IV sites as well as bright red urine noted in\n foley bag.\n Action:\n Repeat HCT30.3, continue to ooze from puncture sites, INR 1.9 1unit FFP\n given\n Response:\n AM labs LFT elevated, platelet 49, slowing down with oozing from the\n iv sites, HCT stable\n Plan:\n Cont q 6hr labs fibrinogen, coags, CBC, monitor for further s/s of\n bleeding.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, continue to have mod amt melena stools, oozing blood from\n IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Platelets 60 this pm and INR 1.8\n Action:\n HCT 30.3, continued to monitor, FFP 1 unit given\n Response:\n AM labs HCT stable, goal >28, platelet 49 and goal is >50, oozing\n continues as above. Cont to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly . Labs at\n 8pm,\nNa -138, K 4.1, and ionized Ca 1.12. Pt tol CRRT well, UOP 0-5mls,\n urine bright red with some clots. Dialysate and replacement fluids B22\n K4.\n On levophed gtt\n Action:\n K+ and Ca Gluconate titrated per SS, levophed gtt titrated for MAP >\n 60, no urine output, foleys cath flushed,clots present\n Response:\n CRRT tolerating well, BUN 27/creat 1.3.and lactate 5.2\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, lung sounds clear\n bilateral and diminished bases, 02 sat 98-100%, sedated on fentanyl\n 45mcg/hr and versed 2mg/hr.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum.\n Response:\n Stable, remains sedated as above. Blood gas 7.32/40/138/-5\n Plan:\n Wean vent/ sedation as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504532,
"text": "Hepatitis, ischemic (shock liver)\n Assessment:\n pt w/ known hep C cirrhosis, now with grossly elevated LFT\ns, probable\n shock liver. INR>2, plt 59 this am, fibrinogen 152 following 2 units of\n cryo on prev shift. Hct trending down, 21.5 this am, pt oozing blood\n form all IV sites as well as Bright red urine noted in foley bag. Abp\n 110\ns-120\ns/ 60\n Action:\n Transfused 1 unit FFP and 3 units PRBC\ns, hepatology consulted, CVL\n dsgs changed x2.\n Response:\n Rpt Hct 27.7 after 2^nd unit of PRBC\ns, INR , pt cont to ooze blood\n around all lines.\n Plan:\n Cont q 6hr, fibrinogen, coags, CBC, monitor for further s/s of\n bleeding, rpt LFT\ns in am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even. K+ 3.4, Ica 0.84,\n BUN/Cr 44/1.4 rec\nd pt finishing 3^rd L of D5 with 150meq NA Bicarb ABG\n @ 0800 7.40/45/134. pt tol CRRT well, UOP minimal, <50ml for this\n shift. Urine bright red with some clots.\n Action:\n Dialysate and replacement fluids changed to B22, K4, K+ and Ca\n Gluconate titrated per SS, additional 2g of Ca Gluconate given a/o. pt\n cont to tol running FB even to slightly negative. R IJ HD cath dsg\n changed, surgicell applied to slow/stop oozing of blood around site.\n Foley cath flushed w/ 180ml sterile H20 until clear/pink.\n Response:\n Repeat Ica 1.01, K+ 4.2 , BUN/Cr 34/1.3 ABG at 1400 7.35/42/115, KCL\n and Ca Gluc gtt\ns titrated per SS. Minimal bright red UOP w/ clots\n noted.\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs\n titrate per ss, monitor UOP. Flush foley as needed.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n pt admitted to ICU on w/ acute GI/variceal bleed. EGD done \n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, Hct 21.5 this am. Mod amt melena stools x2, oozing blood\n from IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Action:\n Transfused 3 units PRBC\ns, CVL dsg\ns changed x2.\n Response:\n Hct 27.7 following 2^nd unit of PRBC\ns, oozing continues as above. Cont\n to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, LS clear bilat w/ dim\n bases, ABG\ns as above, 02 sat 98-100%, sedated on fentanyl 25mcg/hr and\n versed 3mg/hr. pt w/d to painful stim.\n Action:\n No vent changes this shift, suctioned for scant amt blood tinged\n sputum.\n Response:\n Stable, remains sedated as above.\n Plan:\n Wean vent/ sedation as tol\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504533,
"text": "Hepatitis, ischemic (shock liver)\n Assessment:\n pt w/ known hep C cirrhosis, now with grossly elevated LFT\ns, probable\n shock liver. INR>2, plt 59 this am, fibrinogen 152 following 2 units of\n cryo on prev shift. Hct trending down, 21.5 this am, pt oozing blood\n form all IV sites as well as Bright red urine noted in foley bag. Abp\n 110\ns-120\ns/ 60\n Action:\n Transfused 1 unit FFP and 3 units PRBC\ns, hepatology consulted, CVL\n dsgs changed x2.\n Response:\n Rpt Hct 27.7 after 2^nd unit of PRBC\ns, INR , pt cont to ooze blood\n around all lines.\n Plan:\n Cont q 6hr, fibrinogen, coags, CBC, monitor for further s/s of\n bleeding, rpt LFT\ns in am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even. K+ 3.4, Ica 0.84,\n BUN/Cr 44/1.4 rec\nd pt finishing 3^rd L of D5 with 150meq NA Bicarb ABG\n @ 0800 7.40/45/134. pt tol CRRT well, UOP minimal, <50ml for this\n shift. Urine bright red with some clots.\n Action:\n Dialysate and replacement fluids changed to B22, K4, K+ and Ca\n Gluconate titrated per SS, additional 2g of Ca Gluconate given a/o. pt\n cont to tol running FB even to slightly negative. R IJ HD cath dsg\n changed, surgicell applied to slow/stop oozing of blood around site.\n Foley cath flushed w/ 180ml sterile H20 until clear/pink.\n Response:\n Repeat Ica 1.01, K+ 4.2 , BUN/Cr 34/1.3 ABG at 1400 7.35/42/115, KCL\n and Ca Gluc gtt\ns titrated per SS. Minimal bright red UOP w/ clots\n noted.\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs\n titrate per ss, monitor UOP. Flush foley as needed.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n pt admitted to ICU on w/ acute GI/variceal bleed. EGD done \n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, Hct 21.5 this am. Mod amt melena stools x2, oozing blood\n from IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Action:\n Transfused 3 units PRBC\ns, CVL dsg\ns changed x2.\n Response:\n Hct 27.7 following 2^nd unit of PRBC\ns, oozing continues as above. Cont\n to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, LS clear bilat w/ dim\n bases, ABG\ns as above, 02 sat 98-100%, sedated on fentanyl 25mcg/hr and\n versed 3mg/hr. pt w/d to painful stim.\n Action:\n No vent changes this shift, suctioned for scant amt blood tinged\n sputum.\n Response:\n Stable, remains sedated as above.\n Plan:\n Wean vent/ sedation as tol\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504534,
"text": "Hepatitis, ischemic (shock liver)\n Assessment:\n pt w/ known hep C cirrhosis, now with grossly elevated LFT\ns, probable\n shock liver. INR>2, plt 59 this am, fibrinogen 152 following 2 units of\n cryo on prev shift. Hct trending down, 21.5 this am, pt oozing blood\n form all IV sites as well as Bright red urine noted in foley bag. Abp\n 110\ns-120\ns/ 60\n Action:\n Transfused 1 unit FFP and 3 units PRBC\ns, hepatology consulted, CVL\n dsgs changed x2.\n Response:\n Rpt Hct 27.7 after 2^nd unit of PRBC\ns, INR , pt cont to ooze blood\n around all lines.\n Plan:\n Cont q 6hr, fibrinogen, coags, CBC, monitor for further s/s of\n bleeding, rpt LFT\ns in am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even. K+ 3.4, Ica 0.84,\n BUN/Cr 44/1.4 rec\nd pt finishing 3^rd L of D5 with 150meq NA Bicarb ABG\n @ 0800 7.40/45/134. pt tol CRRT well, UOP minimal, <50ml for this\n shift. Urine bright red with some clots.\n Action:\n Dialysate and replacement fluids changed to B22, K4, K+ and Ca\n Gluconate titrated per SS, additional 2g of Ca Gluconate given a/o. pt\n cont to tol running FB even to slightly negative. R IJ HD cath dsg\n changed, surgicell applied to slow/stop oozing of blood around site.\n Foley cath flushed w/ 180ml sterile H20 until clear/pink.\n Response:\n Repeat Ica 1.01, K+ 4.2 , BUN/Cr 34/1.3 ABG at 1400 7.35/42/115, KCL\n and Ca Gluc gtt\ns titrated per SS. Minimal bright red UOP w/ clots\n noted.\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs\n titrate per ss, monitor UOP. Flush foley as needed.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n pt admitted to ICU on w/ acute GI/variceal bleed. EGD done \n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, Hct 21.5 this am. Mod amt melena stools x2, oozing blood\n from IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Action:\n Transfused 3 units PRBC\ns, CVL dsg\ns changed x2.\n Response:\n Hct 27.7 following 2^nd unit of PRBC\ns, oozing continues as above. Cont\n to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, LS clear bilat w/ dim\n bases, ABG\ns as above, 02 sat 98-100%, sedated on fentanyl 25mcg/hr and\n versed 3mg/hr. pt w/d to painful stim.\n Action:\n No vent changes this shift, suctioned for scant amt blood tinged\n sputum.\n Response:\n Stable, remains sedated as above.\n Plan:\n Wean vent/ sedation as tol\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504630,
"text": "69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Hemodynamics stable overnight, albeit on 2 pressors. Lactate\n improving though still 5.2. Now on CVVH with improved management to\n acidosis and hyperkalemia.\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\n probable shock liver. INR> plt 60 this pm, post transfusion HCT 27.7,\n pt oozing blood form all IV sites as well as bright red urine noted in\n foley bag.\n Action:\n Repeat HCT30.3, continue to ooze from puncture sites, INR 1.9 1unit FFP\n given\n Response:\n AM labs LFT elevated, platelet 49, slowing down with oozing from the\n iv sites, HCT stable\n Plan:\n Cont q 6hr labs fibrinogen, coags, CBC, monitor for further s/s of\n bleeding.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, continue to have mod amt melena stools, oozing blood from\n IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Platelets 60 this pm and INR 1.8\n Action:\n HCT 30.3, continued to monitor, FFP 1 unit given\n Response:\n AM labs HCT stable, goal >28, platelet 49 and goal is >50, oozing\n continues as above. Cont to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly . Labs at\n 8pm,\nNa -138, K 4.1, and ionized Ca 1.12. Pt tol CRRT well, UOP 0-5mls,\n urine bright red with some clots. Dialysate and replacement fluids B22\n K4.\n On levophed gtt\n Action:\n K+ and Ca Gluconate titrated per SS, levophed gtt titrated for MAP >\n 60, no urine output, foleys cath flushed,clots present\n Response:\n CRRT tolerating well, BUN 27/creat 1.3.and lactate 5.2\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, lung sounds clear\n bilateral and diminished bases, 02 sat 98-100%, sedated on fentanyl\n 45mcg/hr and versed 2mg/hr.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum.\n Response:\n Stable, remains sedated as above. Blood gas 7.32/40/138/-5\n Plan:\n Wean vent/ sedation as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504537,
"text": "79 yo Italian speaking male with h/o cirrhosis Hep C, who presented\n with chief complaint of weakness to Hospital\n () after falling in bathtub in the water. Per OSH recs, he\n said he \"didn't feel right\" and his \"legs were weak\" and he lowered\n himself into the tub. He hit his left shoulder (unclear how if he\n lowered himself down). Did not hit\n his head, no LOC. He was unable to pull the cord for help and yelled\n until a neighbor came to his assistance. Paramedics took him to \n hospital ED for evaluation.\n At OSH, he underwent a head CT which was normal, and CXR that was\n concerning for PNA. He was thought to be in heart failure and was given\n lasix 40mg IV. He received azithromycin 500mg IV x1 and ceftriaxone 1g\n IV x1. He was also given 1.5L NS. Labs were noteworthy for Na 129, Cr\n of 1.6, and a troponin of 0.12 (last measured here at 0.01). His SBP\n ~90, which is his baseline\n Events:\n Cont on CRRT, running even to slightly neg.\n Transfused 3 units PRBC\ns 2 FFP, and 1 unit Plt.\n Levophed weaned to 0.04mcg/kg/min\n Cont to ooze from line sites\n Son and Daughter in to visit (they have been estranged from\n pt and have not seen him in ~20years)\n Liver and renal following\n Hepatitis, ischemic (shock liver)\n Assessment:\n pt w/ known hep C cirrhosis, now with grossly elevated LFT\ns, probable\n shock liver. INR>2, plt 59 this am, fibrinogen 152 following 2 units of\n cryo on prev shift. Hct trending down, 21.5 this am, pt oozing blood\n form all IV sites as well as Bright red urine noted in foley bag. Abp\n 110\ns-120\ns/ 60\n Action:\n Transfused 1 unit FFP and 3 units PRBC\ns, hepatology consulted, CVL\n dsgs changed x2.\n Response:\n Rpt Hct 27.7 after 2^nd unit of PRBC\ns, INR 1.9, rec\nd 2^nd unit pf\n FFP, plt this pm 49, tx 1 unit plt, repeat plt ct 60 , pt cont to ooze\n blood around all lines.\n Plan:\n Cont q 6hr, fibrinogen, coags, CBC, monitor for further s/s of\n bleeding, rpt LFT\ns in am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even. K+ 3.4, Ica 0.84,\n BUN/Cr 44/1.4 rec\nd pt finishing 3^rd L of D5 with 150meq NA Bicarb ABG\n @ 0800 7.40/45/134. pt tol CRRT well, UOP minimal, <50ml for this\n shift. Urine bright red with some clots.\n Action:\n Dialysate and replacement fluids changed to B22, K4, K+ and Ca\n Gluconate titrated per SS, additional 2g of Ca Gluconate given a/o. pt\n cont to tol running FB even to slightly negative. R IJ HD cath dsg\n changed, surgicell applied to slow/stop oozing of blood around site.\n Foley cath flushed w/ 180ml sterile H20 until clear/pink.\n Response:\n Repeat Ica 1.01, K+ 4.2 , BUN/Cr 34/1.3 ABG at 1400 7.35/42/115, KCL\n and Ca Gluc gtt\ns titrated per SS. Minimal bright red UOP w/ clots\n noted.\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs\n titrate per ss, monitor UOP. Flush foley as needed.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n pt admitted to ICU on w/ acute GI/variceal bleed. EGD done \n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, Hct 21.5 this am. Mod amt melena stools x2, oozing blood\n from IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Action:\n Transfused 3 units PRBC\ns, CVL dsg\ns changed x2.\n Response:\n Hct 27.7 following 2^nd unit of PRBC\ns, oozing continues as above. Cont\n to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, LS clear bilat w/ dim\n bases, ABG\ns as above, 02 sat 98-100%, sedated on fentanyl 25mcg/hr and\n versed 3mg/hr. pt w/d to painful stim.\n Action:\n No vent changes this shift, suctioned for scant amt blood tinged\n sputum.\n Response:\n Stable, remains sedated as above.\n Plan:\n Wean vent/ sedation as tol\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504581,
"text": "69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Hemodynamics stable overnight, albeit on 2 pressors. Lactate\n improving though still 7.9. Now on CVVH with improved management to\n acidosis and hyperkalemia.\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\n probable shock liver. INR> plt 60 this pm, post transfusion HCT 27.7,\n pt oozing blood form all IV sites as well as bright red urine noted in\n foley bag.\n Action:\n Repeat HCT30.3, continue to ooze from puncture sites\n Response:\n Plan:\n Cont q 6hr, fibrinogen, coags, CBC, monitor for further s/s of\n bleeding, rpt LFT\ns in am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even. K+ 3.4, Ica 0.84,\n BUN/Cr 44/1.4 rec\nd pt finishing 3^rd L of D5 with 150meq NA Bicarb ABG\n @ 0800 7.40/45/134. pt tol CRRT well, UOP minimal, <50ml for this\n shift. Urine bright red with some clots.\n Action:\n Dialysate and replacement fluids changed to B22, K4, K+ and Ca\n Gluconate titrated per SS, additional 2g of Ca Gluconate given a/o. pt\n cont to tol running FB even to slightly negative. R IJ HD cath dsg\n changed, surgicell applied to slow/stop oozing of blood around site.\n Foley cath flushed w/ 180ml sterile H20 until clear/pink.\n Response:\n Repeat Ica 1.01, K+ 4.2 , BUN/Cr 34/1.3 ABG at 1400 7.35/42/115, KCL\n and Ca Gluc gtt\ns titrated per SS. Minimal bright red UOP w/ clots\n noted.\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs\n titrate per ss, monitor UOP. Flush foley as needed.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n pt admitted to ICU on w/ acute GI/variceal bleed. EGD done \n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, Hct 21.5 this am. Mod amt melena stools x2, oozing blood\n from IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Action:\n Transfused 3 units PRBC\ns, CVL dsg\ns changed x2.\n Response:\n Hct 27.7 following 2^nd unit of PRBC\ns, oozing continues as above. Cont\n to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, LS clear bilat w/ dim\n bases, ABG\ns as above, 02 sat 98-100%, sedated on fentanyl 25mcg/hr and\n versed 3mg/hr. pt w/d to painful stim.\n Action:\n No vent changes this shift, suctioned for scant amt blood tinged\n sputum.\n Response:\n Stable, remains sedated as above.\n Plan:\n Wean vent/ sedation as tol\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504583,
"text": "69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Hemodynamics stable overnight, albeit on 2 pressors. Lactate\n improving though still 7.9. Now on CVVH with improved management to\n acidosis and hyperkalemia.\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\n probable shock liver. INR> plt 60 this pm, post transfusion HCT 27.7,\n pt oozing blood form all IV sites as well as bright red urine noted in\n foley bag.\n Action:\n Repeat HCT30.3, continue to ooze from puncture sites\n Response:\n Plan:\n Cont q 6hr labs fibrinogen, coags, CBC, monitor for further s/s of\n bleeding, rpt LFT\ns in am\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, Hct 21.5 this am. Mod amt melena stools x2, oozing blood\n from IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Action:\n Transfused 3 units PRBC\ns, CVL dsg\ns changed x2.\n Response:\n Hct 27.7 following 2^nd unit of PRBC\ns, oozing continues as above. Cont\n to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even. K+ 3.4, Ica 0.84,\n BUN/Cr 44/1.4 rec\nd pt finishing 3^rd L of D5 with 150meq NA Bicarb ABG\n @ 0800 7.40/45/134. pt tol CRRT well, UOP minimal, <50ml for this\n shift. Urine bright red with some clots.\n Action:\n Dialysate and replacement fluids changed to B22, K4, K+ and Ca\n Gluconate titrated per SS, additional 2g of Ca Gluconate given a/o. pt\n cont to tol running FB even to slightly negative. R IJ HD cath dsg\n changed, surgicell applied to slow/stop oozing of blood around site.\n Foley cath flushed w/ 180ml sterile H20 until clear/pink.\n Response:\n Repeat Ica 1.01, K+ 4.2 , BUN/Cr 34/1.3 ABG at 1400 7.35/42/115, KCL\n and Ca Gluc gtt\ns titrated per SS. Minimal bright red UOP w/ clots\n noted.\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs\n titrate per ss, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, LS clear bilat w/ dim\n bases, ABG\ns as above, 02 sat 98-100%, sedated on fentanyl 25mcg/hr and\n versed 3mg/hr. pt w/d to painful stim.\n Action:\n No vent changes this shift, suctioned for scant amt blood tinged\n sputum.\n Response:\n Stable, remains sedated as above.\n Plan:\n Wean vent/ sedation as tol\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504585,
"text": "69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Hemodynamics stable overnight, albeit on 2 pressors. Lactate\n improving though still 7.9. Now on CVVH with improved management to\n acidosis and hyperkalemia.\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\n probable shock liver. INR> plt 60 this pm, post transfusion HCT 27.7,\n pt oozing blood form all IV sites as well as bright red urine noted in\n foley bag.\n Action:\n Repeat HCT30.3, continue to ooze from puncture sites\n Response:\n Plan:\n Cont q 6hr labs fibrinogen, coags, CBC, monitor for further s/s of\n bleeding, rpt LFT\ns in am\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, continue to have mod amt melena stools, oozing blood from\n IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Platelets 60 this pm and INR 1.8\n Action:\n HCT 30.3, continued to monitor\n Response:\n AM labs\n. oozing continues as above. Cont to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly . Labs at\n 8pm,\nPt tol CRRT well, UOP minimal, urine bright red with some\n clots. Dialysate and replacement fluids B22, K4\n Action:\n K+ and Ca Gluconate titrated per SS,\n Response:\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, lung sounds clear\n bilateral and diminished bases, 02 sat 98-100%, sedated on fentanyl\n 45mcg/hr and versed 2mg/hr.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum.\n Response:\n Stable, remains sedated as above.\n Plan:\n Wean vent/ sedation as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-26 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504628,
"text": "69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Hemodynamics stable overnight, albeit on 2 pressors. Lactate\n improving though still 5.2. Now on CVVH with improved management to\n acidosis and hyperkalemia.\n Hepatitis, ischemic (shock liver)\n Assessment:\n Patient w/ known hep C cirrhosis, now with grossly elevated LFT\n probable shock liver. INR> plt 60 this pm, post transfusion HCT 27.7,\n pt oozing blood form all IV sites as well as bright red urine noted in\n foley bag.\n Action:\n Repeat HCT30.3, continue to ooze from puncture sites, INR 1.9 1unit FFP\n given\n Response:\n AM labs LFT elevated, platelet 49, slowing down with oozing from the\n iv sites, HCT stable\n Plan:\n Cont q 6hr labs fibrinogen, coags, CBC, monitor for further s/s of\n bleeding.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n Patient admitted to ICU on w/ acute GI/variceal bleed. EGD done\n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, continue to have mod amt melena stools, oozing blood from\n IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Platelets 60 this pm and INR 1.8\n Action:\n HCT 30.3, continued to monitor, FFP 1 unit given\n Response:\n AM labs HCT stable, goal >28, platelet 49 and goal is >50, oozing\n continues as above. Cont to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even or slightly . Labs at\n 8pm,\nNa -138, K 4.1, and ionized Ca 1.12. Pt tol CRRT well, UOP 0-5mls,\n urine bright red with some clots. Dialysate and replacement fluids B22\n K4.\n On levophed gtt\n Action:\n K+ and Ca Gluconate titrated per SS, levophed gtt titrated for MAP > 60\n Response:\n CRRT tolerating well,\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs and\n titrate per SS, monitor UOP. Flush foley as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, lung sounds clear\n bilateral and diminished bases, 02 sat 98-100%, sedated on fentanyl\n 45mcg/hr and versed 2mg/hr.\n Action:\n No vent changes this shift, suctioned for moderate thick blood tinged\n sputum.\n Response:\n Stable, remains sedated as above.\n Plan:\n Wean vent/ sedation as tolerated.\n"
},
{
"category": "Respiratory ",
"chartdate": "2174-10-27 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 504880,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\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: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n :\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\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 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: appears comfortable, breathing\n in synch with the vent.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Pt is on cvvhd/pressors/ no plans to wean at this\n time.\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": "2174-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504574,
"text": "Hepatitis, ischemic (shock liver)\n Assessment:\n pt w/ known hep C cirrhosis, now with grossly elevated LFT\ns, probable\n shock liver. INR>2, plt 59 this am, fibrinogen 152 following 2 units of\n cryo on prev shift. Hct trending down, 21.5 this am, pt oozing blood\n form all IV sites as well as Bright red urine noted in foley bag. Abp\n 110\ns-120\ns/ 60\n Action:\n Transfused 1 unit FFP and 3 units PRBC\ns, hepatology consulted, CVL\n dsgs changed x2.\n Response:\n Rpt Hct 27.7 after 2^nd unit of PRBC\ns, INR 1.9, rec\nd 2^nd unit pf\n FFP, plt this pm 49, tx 1 unit plt, repeat plt ct 60 , pt cont to ooze\n blood around all lines.\n Plan:\n Cont q 6hr, fibrinogen, coags, CBC, monitor for further s/s of\n bleeding, rpt LFT\ns in am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even. K+ 3.4, Ica 0.84,\n BUN/Cr 44/1.4 rec\nd pt finishing 3^rd L of D5 with 150meq NA Bicarb ABG\n @ 0800 7.40/45/134. pt tol CRRT well, UOP minimal, <50ml for this\n shift. Urine bright red with some clots.\n Action:\n Dialysate and replacement fluids changed to B22, K4, K+ and Ca\n Gluconate titrated per SS, additional 2g of Ca Gluconate given a/o. pt\n cont to tol running FB even to slightly negative. R IJ HD cath dsg\n changed, surgicell applied to slow/stop oozing of blood around site.\n Foley cath flushed w/ 180ml sterile H20 until clear/pink.\n Response:\n Repeat Ica 1.01, K+ 4.2 , BUN/Cr 34/1.3 ABG at 1400 7.35/42/115, KCL\n and Ca Gluc gtt\ns titrated per SS. Minimal bright red UOP w/ clots\n noted.\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs\n titrate per ss, monitor UOP. Flush foley as needed.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n pt admitted to ICU on w/ acute GI/variceal bleed. EGD done \n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, Hct 21.5 this am. Mod amt melena stools x2, oozing blood\n from IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Action:\n Transfused 3 units PRBC\ns, CVL dsg\ns changed x2.\n Response:\n Hct 27.7 following 2^nd unit of PRBC\ns, oozing continues as above. Cont\n to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, LS clear bilat w/ dim\n bases, ABG\ns as above, 02 sat 98-100%, sedated on fentanyl 25mcg/hr and\n versed 3mg/hr. pt w/d to painful stim.\n Action:\n No vent changes this shift, suctioned for scant amt blood tinged\n sputum.\n Response:\n Stable, remains sedated as above.\n Plan:\n Wean vent/ sedation as tol\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504576,
"text": "69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Hemodynamics stable overnight, albeit on 2 pressors. Lactate\n improving though still 7.9. Now on CVVH with improved maagement to\n acidosis and hyperkalemia.\n Hepatitis, ischemic (shock liver)\n Assessment:\n pt w/ known hep C cirrhosis, now with grossly elevated LFT\ns, probable\n shock liver. INR>2, plt 59 this am, fibrinogen 152 following 2 units of\n cryo on prev shift. Hct trending down, 21.5 this am, pt oozing blood\n form all IV sites as well as Bright red urine noted in foley bag. Abp\n 110\ns-120\ns/ 60\n Action:\n Transfused 1 unit FFP and 3 units PRBC\ns, hepatology consulted, CVL\n dsgs changed x2.\n Response:\n Rpt Hct 27.7 after 2^nd unit of PRBC\ns, INR 1.9, rec\nd 2^nd unit pf\n FFP, plt this pm 49, tx 1 unit plt, repeat plt ct 60 , pt cont to ooze\n blood around all lines.\n Plan:\n Cont q 6hr, fibrinogen, coags, CBC, monitor for further s/s of\n bleeding, rpt LFT\ns in am\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Rec\nd p[t on CRRT with FB goal to run about even. K+ 3.4, Ica 0.84,\n BUN/Cr 44/1.4 rec\nd pt finishing 3^rd L of D5 with 150meq NA Bicarb ABG\n @ 0800 7.40/45/134. pt tol CRRT well, UOP minimal, <50ml for this\n shift. Urine bright red with some clots.\n Action:\n Dialysate and replacement fluids changed to B22, K4, K+ and Ca\n Gluconate titrated per SS, additional 2g of Ca Gluconate given a/o. pt\n cont to tol running FB even to slightly negative. R IJ HD cath dsg\n changed, surgicell applied to slow/stop oozing of blood around site.\n Foley cath flushed w/ 180ml sterile H20 until clear/pink.\n Response:\n Repeat Ica 1.01, K+ 4.2 , BUN/Cr 34/1.3 ABG at 1400 7.35/42/115, KCL\n and Ca Gluc gtt\ns titrated per SS. Minimal bright red UOP w/ clots\n noted.\n Plan:\n Cont CRRT a/o ? running pt more negative as b/p tol. Monitor labs\n titrate per ss, monitor UOP. Flush foley as needed.\n Gastrointestinal bleed, other (GI Bleed, GIB)\n Assessment:\n pt admitted to ICU on w/ acute GI/variceal bleed. EGD done \n and varicies banded. Hct cont to drop despite banding and multiple\n transfusions, Hct 21.5 this am. Mod amt melena stools x2, oozing blood\n from IV\ns/CVL/HD lines, and foley draining bright red urine w/ clots.\n Action:\n Transfused 3 units PRBC\ns, CVL dsg\ns changed x2.\n Response:\n Hct 27.7 following 2^nd unit of PRBC\ns, oozing continues as above. Cont\n to stool melena.\n Plan:\n Monitor Hct q 6hr\ns, transfuse as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd pt intubated on CMV 40% 500x20+ PEEP 5, LS clear bilat w/ dim\n bases, ABG\ns as above, 02 sat 98-100%, sedated on fentanyl 25mcg/hr and\n versed 3mg/hr. pt w/d to painful stim.\n Action:\n No vent changes this shift, suctioned for scant amt blood tinged\n sputum.\n Response:\n Stable, remains sedated as above.\n Plan:\n Wean vent/ sedation as tol\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 504437,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 10:30 AM\n INVASIVE VENTILATION - START 11:00 AM\n MULTI LUMEN - START 11:26 AM\n BLOOD CULTURED - At 01:00 PM\n ENDOSCOPY - At 01:22 PM\n ARTERIAL LINE - START 01:34 PM\n DIALYSIS CATHETER - START 05:38 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:51 AM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Fentanyl - 45 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Octreotide - 50 mcg/hour\n Norepinephrine - 0.24 mcg/Kg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 02:15 PM\n Insulin - Regular - 04:11 PM\n Dextrose 50% - 04:12 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 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 35.3\nC (95.5\n HR: 74 (67 - 105) bpm\n BP: 115/57(79) {74/38(52) - 131/75(94)} mmHg\n RR: 22 (20 - 47) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Mixed Venous O2% Sat: 97 - 97\n Total In:\n 6,725 mL\n 3,343 mL\n PO:\n TF:\n IVF:\n 2,594 mL\n 1,800 mL\n Blood products:\n 3,780 mL\n 1,543 mL\n Total out:\n 905 mL\n 2,580 mL\n Urine:\n 205 mL\n 150 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 5,820 mL\n 763 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): 346 (311 - 346) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 28 cmH2O\n Plateau: 25 cmH2O\n Compliance: 25 cmH2O/mL\n SpO2: 100%\n ABG: 7.41/39/117/22/0\n Ve: 13 L/min\n PaO2 / FiO2: 293\n Physical Examination\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, Endotracheal\n tube, NG tube\n Cardiovascular: (Murmur: Systolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n )\n Abdominal: Bowel sounds present, Distended, Tender:\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 66 K/uL\n 9.2 g/dL\n 185 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 3.4 mEq/L\n 56 mg/dL\n 97 mEq/L\n 140 mEq/L\n 27.3 %\n 17.6 K/uL\n [image002.jpg]\n 11:43 AM\n 12:42 PM\n 02:06 PM\n 02:12 PM\n 08:13 PM\n 08:40 PM\n 02:10 AM\n 02:22 AM\n 06:14 AM\n WBC\n 18.5\n 29.1\n 25.0\n 17.6\n Hct\n 17.2\n 32.2\n 22.8\n 27.3\n Plt\n 76\n 70\n 65\n 66\n Cr\n 1.7\n 2.0\n 2.2\n 1.6\n TCO2\n 13\n 11\n 19\n 24\n 26\n Glucose\n 170\n 92\n 143\n 185\n Other labs: PT / PTT / INR:24.2/45.0/2.3, ALT / AST:1663/9939, Alk Phos\n / T Bili:230/6.1, Differential-Neuts:64.0 %, Band:8.0 %, Lymph:16.0 %,\n Mono:10.0 %, Eos:0.0 %, Fibrinogen:89 mg/dL, Lactic Acid:10.1 mmol/L,\n Albumin:2.8 g/dL, LDH: IU/L, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.6 mg/dL\n Microbiology: , , bcx ucx all ntd\n peritoneal fluid ntd, just PMNs\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 79 y/o male with hepatitis c cirrhosis, elevated lactate, BRB per NG\n tube.\n # Hypotension/Bleed: Clearly there is a component of volume loss given\n his blood loss, unclear if there is sepsis.\n - Cultures obtained\n - Vanc/Zosyn empirically\n - Crossmatch 8 units, transfuse 4 units at this time, 4 more on the\n way, FFPs as well.\n - Liver at bedside performing endoscopy now.\n - Tap ascites when stable, ? SBP\n - PPI drip\n - Octreotide\n - - next step if needed.\n - Follow ionized calcium\n # Elevated Lactate: Likely secondary to necrosis in the context of\n hypotension. ? Mesenteric ischemia versus global hyperperfusion at\n this time.\n - Surgery consulted\n - Volume resuscitation with fluids, blood\n - No free air on CXR although not ideal.\n - Patient unstable for further evaluation of bowel at this time.\n # Anuria: Likely secondary to hypotension. Renal consult obtained if\n patient needs urgent dialysis given hyperkalemia. At this point given\n bleeding I am not sure if he would be stable for any CRRT.\n - Follow volume status\n - Follow potassium\n # Hyperkalemia: Resuscitation with temporizing measures as in HPI.\n Repeat K is elevated. Renal aware. Repeat:\n - Calcium gluconate\n - Sodium bicarbonate\n - Glucose/Insulin\n - follow serial K\n .\n FEN: No IVF, replete electrolytes, regular diet\n .\n Prophylaxis: Subcutaneous heparin\n .\n Access: 2 peripherals, left subclavian\n .\n Code: DNR (CPR not medically indicated, for discussion see POE and Dr.\n note ).\n .\n Communication: Friend \n .\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504440,
"text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Assumed care of pt on AC 40/500 X 20/5, pt on fentanyl GTT at 25mcg/hr,\n Octreotide GTT at 50mcg/hr, Sodium Bicarb GTT at 250cc/hr X 3L,\n protonix 8mg/hr and dopamine at 5mcg/kg/min. Pt responding to verbal\n stimuli by opening eyes. HR in a70\ns NSR with rare ectopy, ABP\n 100-110\ns/50-60\ns (70-80), SpO2 of 100%. Lung sounds clear in upper\n lobes bilaterally and diminished in the bases. Pt being suctioned for\n scant amount of blood tinged secretions. Original ABG at beginning of\n the shift was 7.33/35/121/19.Abdomen is soft non-tender with bowel\n sounds present in all quadrants. Foley catheter draining small amounts\n of hematuria. Pt with general edema of +2-+4 with positive pedal\n pulses.\n Action:\n Pt started on CVVHDF at 2200 with replacement and dialysate fluids of\n B32-K0. CVVHDF was started with no difficulties and no clots were\n present. Pt was started on versed at 5mg 2/ 2 interfering with the\n CVVHD machine by moving and creating high pressure of the access line.\n HD dressing line was changed large amounts of bleeding around site.\n Dopamine was switched to vasopressin at 2.4units.hr very briefly.\n Levophed was increased to 0.26mcg. to assist in maintaining ABP greater\n than 65. Overnight pt received 2 units of PRBC, 2 units of\n cryoprecipitate and 5 units of FFP. Pt had one episode of medium size\n melena/clot stool (Resident made aware). Pt received IV antibiotics per\n .\n Response:\n No vent changes made overnight. Potassium whole blood down to 3.4\n (5.9), Lactate 10.1 (12.6), HCT 27.3 (22.8) and WBC 17.6 (25). Levophed\n able to be titrated down to 0.24mcg/kg = ABP 116/54 (78). Fentanyl\n currently at 45mcg and versed at 3mg. Pt continues to be stable on\n CVVHDF and all pressures WNL.\n Plan:\n Obtain CVVHD Labs every 4 and 6hrs, give pt 2 additional units of FFP,\n switch replacement and dialysate fluids to B32-K4. continue with\n current vent settings, provide pt with emotional support.\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 504469,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 10:30 AM\n INVASIVE VENTILATION - START 11:00 AM\n MULTI LUMEN - START 11:26 AM\n BLOOD CULTURED - At 01:00 PM\n ENDOSCOPY - At 01:22 PM\n - Showed variceal bleed\n ARTERIAL LINE - START 01:34 PM\n DIALYSIS CATHETER - START 05:38 PM\n - Received CVVHD with aggressive regimen to decrease K+\n - Dopa changed to Vasopressin, then off. Now only on Levophed.\n HD line placed by renal.\n - Received CVVHD with aggressive regimen to decrease K+\n - Following DIC labs, CBC, lytes\n - Dopa changed to Vasopressin, then off. Now only on Levophed.\n - Serial hcts, FFP and INR check\n - On Vanc/Zosyn\n - Improving lactate\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:51 AM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Fentanyl - 45 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Octreotide - 50 mcg/hour\n Norepinephrine - 0.24 mcg/Kg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 02:15 PM\n Insulin - Regular - 04:11 PM\n Dextrose 50% - 04:12 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 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 35.3\nC (95.5\n HR: 74 (67 - 105) bpm\n BP: 115/57(79) {74/38(52) - 131/75(94)} mmHg\n RR: 22 (20 - 47) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Mixed Venous O2% Sat: 97 - 97\n Total In:\n 6,725 mL\n 3,343 mL\n PO:\n TF:\n IVF:\n 2,594 mL\n 1,800 mL\n Blood products:\n 3,780 mL\n 1,543 mL\n Total out:\n 905 mL\n 2,580 mL\n Urine:\n 205 mL\n 150 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 5,820 mL\n 763 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): 346 (311 - 346) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 28 cmH2O\n Plateau: 25 cmH2O\n Compliance: 25 cmH2O/mL\n SpO2: 100%\n ABG: 7.41/39/117/22/0\n Ve: 13 L/min\n PaO2 / FiO2: 293\n Physical Examination\n General: Intubated, NAD\n Cardiovascular: (Murmur: Systolic)\n Pulmonary: (Expansion: Symmetric), (Breath Sounds: Bronchial: )\n Abdominal: Bowel sounds present, Distended, Tender:\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Labs / Radiology\n 66 K/uL\n 9.2 g/dL\n 185 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 3.4 mEq/L\n 56 mg/dL\n 97 mEq/L\n 140 mEq/L\n 27.3 %\n 17.6 K/uL\n [image002.jpg]\n 11:43 AM\n 12:42 PM\n 02:06 PM\n 02:12 PM\n 08:13 PM\n 08:40 PM\n 02:10 AM\n 02:22 AM\n 06:14 AM\n WBC\n 18.5\n 29.1\n 25.0\n 17.6\n Hct\n 17.2\n 32.2\n 22.8\n 27.3\n Plt\n 76\n 70\n 65\n 66\n Cr\n 1.7\n 2.0\n 2.2\n 1.6\n TCO2\n 13\n 11\n 19\n 24\n 26\n Glucose\n 170\n 92\n 143\n 185\n Other labs: PT / PTT / INR:24.2/45.0/2.3, ALT / AST:1663/9939, Alk Phos\n / T Bili:230/6.1, Differential-Neuts:64.0 %, Band:8.0 %, Lymph:16.0 %,\n Mono:10.0 %, Eos:0.0 %, Fibrinogen:89 mg/dL, Lactic Acid:10.1 mmol/L,\n Albumin:2.8 g/dL, LDH: IU/L, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.6 mg/dL\n Microbiology: , , bcx ucx all ntd\n peritoneal fluid ntd, just PMNs\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 79 y/o male with hepatitis c cirrhosis, elevated lactate, BRB per NG\n tube.\n # Hypotension/Bleed: Clearly there is a component of volume loss given\n his blood loss, unclear if there is sepsis.\n - Cultures obtained\n - Vanc/Zosyn empirically\n - Crossmatch 8 units, transfuse 4 units at this time, 4 more on the\n way, FFPs as well.\n - Liver at bedside performing endoscopy now.\n - Tap ascites when stable, ? SBP\n - PPI drip\n - Octreotide\n - - next step if needed.\n - Follow ionized calcium\n - Serial hcts, FFP and INR check\n # Elevated Lactate: Likely secondary to necrosis in the context of\n hypotension. ? Mesenteric ischemia versus global hyperperfusion at\n this time.\n - Surgery consulted\n - Volume resuscitation with fluids, blood\n - No free air on CXR although not ideal.\n - Patient unstable for further evaluation of bowel at this time.\n # Anuria: Likely secondary to hypotension. Renal consult obtained if\n patient needs urgent dialysis given hyperkalemia. At this point given\n bleeding I am not sure if he would be stable for any CRRT.\n - Follow volume status\n - Follow potassium\n # Hyperkalemia: Resuscitation with temporizing measures as in HPI.\n Repeat K is elevated. Renal aware. Repeat:\n - Calcium gluconate\n - Sodium bicarbonate\n - Glucose/Insulin\n - follow serial K\n .\n FEN: No IVF, replete electrolytes, regular diet\n .\n Prophylaxis: Subcutaneous heparin\n .\n Access: 2 peripherals, left subclavian\n .\n Code: DNR (CPR not medically indicated, for discussion see POE and Dr.\n note ).\n .\n Communication: Friend \n .\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 504428,
"text": "Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 504447,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 10:30 AM\n INVASIVE VENTILATION - START 11:00 AM\n MULTI LUMEN - START 11:26 AM\n BLOOD CULTURED - At 01:00 PM\n ENDOSCOPY - At 01:22 PM\n - Showed variceal bleed\n ARTERIAL LINE - START 01:34 PM\n DIALYSIS CATHETER - START 05:38 PM\n - Received CVVHD with aggressive regimen to decrease K+\n - Dopa changed to Vasopressin, then off. Now only on Levophed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:51 AM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Fentanyl - 45 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Octreotide - 50 mcg/hour\n Norepinephrine - 0.24 mcg/Kg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 02:15 PM\n Insulin - Regular - 04:11 PM\n Dextrose 50% - 04:12 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 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 35.3\nC (95.5\n HR: 74 (67 - 105) bpm\n BP: 115/57(79) {74/38(52) - 131/75(94)} mmHg\n RR: 22 (20 - 47) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Mixed Venous O2% Sat: 97 - 97\n Total In:\n 6,725 mL\n 3,343 mL\n PO:\n TF:\n IVF:\n 2,594 mL\n 1,800 mL\n Blood products:\n 3,780 mL\n 1,543 mL\n Total out:\n 905 mL\n 2,580 mL\n Urine:\n 205 mL\n 150 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 5,820 mL\n 763 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): 346 (311 - 346) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 28 cmH2O\n Plateau: 25 cmH2O\n Compliance: 25 cmH2O/mL\n SpO2: 100%\n ABG: 7.41/39/117/22/0\n Ve: 13 L/min\n PaO2 / FiO2: 293\n Physical Examination\n General: Intubated, NAD\n Cardiovascular: (Murmur: Systolic)\n Pulmonary: (Expansion: Symmetric), (Breath Sounds: Bronchial: )\n Abdominal: Bowel sounds present, Distended, Tender:\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Labs / Radiology\n 66 K/uL\n 9.2 g/dL\n 185 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 3.4 mEq/L\n 56 mg/dL\n 97 mEq/L\n 140 mEq/L\n 27.3 %\n 17.6 K/uL\n [image002.jpg]\n 11:43 AM\n 12:42 PM\n 02:06 PM\n 02:12 PM\n 08:13 PM\n 08:40 PM\n 02:10 AM\n 02:22 AM\n 06:14 AM\n WBC\n 18.5\n 29.1\n 25.0\n 17.6\n Hct\n 17.2\n 32.2\n 22.8\n 27.3\n Plt\n 76\n 70\n 65\n 66\n Cr\n 1.7\n 2.0\n 2.2\n 1.6\n TCO2\n 13\n 11\n 19\n 24\n 26\n Glucose\n 170\n 92\n 143\n 185\n Other labs: PT / PTT / INR:24.2/45.0/2.3, ALT / AST:1663/9939, Alk Phos\n / T Bili:230/6.1, Differential-Neuts:64.0 %, Band:8.0 %, Lymph:16.0 %,\n Mono:10.0 %, Eos:0.0 %, Fibrinogen:89 mg/dL, Lactic Acid:10.1 mmol/L,\n Albumin:2.8 g/dL, LDH: IU/L, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.6 mg/dL\n Microbiology: , , bcx ucx all ntd\n peritoneal fluid ntd, just PMNs\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 79 y/o male with hepatitis c cirrhosis, elevated lactate, BRB per NG\n tube.\n # Hypotension/Bleed: Clearly there is a component of volume loss given\n his blood loss, unclear if there is sepsis.\n - Cultures obtained\n - Vanc/Zosyn empirically\n - Crossmatch 8 units, transfuse 4 units at this time, 4 more on the\n way, FFPs as well.\n - Liver at bedside performing endoscopy now.\n - Tap ascites when stable, ? SBP\n - PPI drip\n - Octreotide\n - - next step if needed.\n - Follow ionized calcium\n - Serial hcts, FFP and INR check\n # Elevated Lactate: Likely secondary to necrosis in the context of\n hypotension. ? Mesenteric ischemia versus global hyperperfusion at\n this time.\n - Surgery consulted\n - Volume resuscitation with fluids, blood\n - No free air on CXR although not ideal.\n - Patient unstable for further evaluation of bowel at this time.\n # Anuria: Likely secondary to hypotension. Renal consult obtained if\n patient needs urgent dialysis given hyperkalemia. At this point given\n bleeding I am not sure if he would be stable for any CRRT.\n - Follow volume status\n - Follow potassium\n # Hyperkalemia: Resuscitation with temporizing measures as in HPI.\n Repeat K is elevated. Renal aware. Repeat:\n - Calcium gluconate\n - Sodium bicarbonate\n - Glucose/Insulin\n - follow serial K\n .\n FEN: No IVF, replete electrolytes, regular diet\n .\n Prophylaxis: Subcutaneous heparin\n .\n Access: 2 peripherals, left subclavian\n .\n Code: DNR (CPR not medically indicated, for discussion see POE and Dr.\n note ).\n .\n Communication: Friend \n .\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Physician Attending Progress Note",
"row_id": 504454,
"text": "Chief Complaint: Hypovolemic shock, respiratory failure, acute renal\n failure, GI Bleed, Blood Loss Anemia\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n CRRT instituted last PM. Did have positional a-line that had to have\n another suture to maintain position/functionality\n 24 Hour Events:\n BLOOD CULTURED - At 10:30 AM\n INVASIVE VENTILATION - START 11:00 AM\n MULTI LUMEN - START 11:26 AM\n BLOOD CULTURED - At 01:00 PM\n ENDOSCOPY - At 01:22 PM\n ARTERIAL LINE - START 01:34 PM\n DIALYSIS CATHETER - START 05:38 PM\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 Vancomycin - 10:51 AM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Fentanyl - 45 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Octreotide - 50 mcg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 02:15 PM\n Insulin - Regular - 04:11 PM\n Dextrose 50% - 04:12 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 Respiratory: mechanical ventilation\n Genitourinary: Foley, Dialysis\n Heme / Lymph: Anemia\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.1\nC (97\n HR: 80 (67 - 105) bpm\n BP: 110/50(71) {74/38(52) - 131/75(94)} mmHg\n RR: 23 (19 - 39) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Mixed Venous O2% Sat: 97 - 97\n Total In:\n 6,725 mL\n 4,659 mL\n PO:\n TF:\n IVF:\n 2,594 mL\n 2,808 mL\n Blood products:\n 3,780 mL\n 1,851 mL\n Total out:\n 905 mL\n 4,246 mL\n Urine:\n 205 mL\n 160 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 5,820 mL\n 417 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): 346 (311 - 346) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 28 cmH2O\n Plateau: 25 cmH2O\n Compliance: 25 cmH2O/mL\n SpO2: 100%\n ABG: 7.40/45/134/26/2\n Ve: 13 L/min\n PaO2 / FiO2: 335\n Physical Examination\n General Appearance: No acute distress, intubated, sedated\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: Non-tender, Distended\n Extremities: Right lower extremity edema: 1+, Left lower extremity\n edema: 1+\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 8.2 g/dL\n 59 K/uL\n 200 mg/dL\n 1.4 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 44 mg/dL\n 94 mEq/L\n 139 mEq/L\n 23.4 %\n 13.0 K/uL\n [image002.jpg]\n 12:42 PM\n 02:06 PM\n 02:12 PM\n 08:13 PM\n 08:40 PM\n 02:10 AM\n 02:22 AM\n 06:14 AM\n 07:51 AM\n 08:15 AM\n WBC\n 29.1\n 25.0\n 17.6\n 13.0\n Hct\n 32.2\n 22.8\n 27.3\n 23.4\n Plt\n 70\n 65\n 66\n 59\n Cr\n 2.0\n 2.2\n 1.6\n 1.4\n TCO2\n 13\n 11\n 19\n 24\n 26\n 29\n Glucose\n 92\n 143\n 185\n 200\n Other labs: PT / PTT / INR:21.5/39.1/2.0, ALT / AST:1663/9939, Alk Phos\n / T Bili:230/6.1, Differential-Neuts:64.0 %, Band:8.0 %, Lymph:16.0 %,\n Mono:10.0 %, Eos:0.0 %, Fibrinogen:152 mg/dL, Lactic Acid:7.9 mmol/L,\n Albumin:2.8 g/dL, LDH: IU/L, Ca++:7.7 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.2 mg/dL\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 69 yo man with cirrhosis in MICU with hypovolemic shock in setting of\n sudden variceal bleed, leading to respiratory failure and acute renal\n failure. Hemodynamics stable overnight, albeit on 2 pressors. Lactate\n improving though still 7.9. Now on CVVH with improved maagement to\n acidosis and hyperkalemia.\n 1. Hypovolemic shock/GI Bleed/Blood Loss Anemia: Hct drifting down\n again but now only on 1 pressor (levophed). Cont to transfuse with Hct\n goal of 28 for now. s/p banding of varices. FFP for INR<2. Very high\n LFT elevation likely to shock liver. Ca repletion\n 2. Acute renal failure: On CRRT with adequate managment of acidosis ond\n hyperkalemia\n 3. Respiratory Failure: Cont current vent settings.\n Remainder of issues per ICU team.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR (do not resuscitate)\n Disposition :ICU\n Total time spent: 40 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 504475,
"text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n BLOOD CULTURED - At 10:30 AM\n INVASIVE VENTILATION - START 11:00 AM\n MULTI LUMEN - START 11:26 AM\n BLOOD CULTURED - At 01:00 PM\n ENDOSCOPY - At 01:22 PM\n - Showed variceal bleed\n ARTERIAL LINE - START 01:34 PM\n DIALYSIS CATHETER - START 05:38 PM\n - Received CVVHD with aggressive regimen to decrease K+\n - Dopa changed to Vasopressin, then off. Now only on Levophed.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 10:51 AM\n Piperacillin/Tazobactam (Zosyn) - 05:49 AM\n Infusions:\n Fentanyl - 45 mcg/hour\n Midazolam (Versed) - 3 mg/hour\n Pantoprazole (Protonix) - 8 mg/hour\n Octreotide - 50 mcg/hour\n Norepinephrine - 0.24 mcg/Kg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 02:15 PM\n Insulin - Regular - 04:11 PM\n Dextrose 50% - 04:12 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 07:51 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 35.3\nC (95.5\n HR: 74 (67 - 105) bpm\n BP: 115/57(79) {74/38(52) - 131/75(94)} mmHg\n RR: 22 (20 - 47) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Mixed Venous O2% Sat: 97 - 97\n Total In:\n 6,725 mL\n 3,343 mL\n PO:\n TF:\n IVF:\n 2,594 mL\n 1,800 mL\n Blood products:\n 3,780 mL\n 1,543 mL\n Total out:\n 905 mL\n 2,580 mL\n Urine:\n 205 mL\n 150 mL\n NG:\n 250 mL\n Stool:\n Drains:\n Balance:\n 5,820 mL\n 763 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): 346 (311 - 346) mL\n RR (Set): 20\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 28 cmH2O\n Plateau: 25 cmH2O\n Compliance: 25 cmH2O/mL\n SpO2: 100%\n ABG: 7.41/39/117/22/0\n Ve: 13 L/min\n PaO2 / FiO2: 293\n Physical Examination\n General: Intubated, unresponsive to verbal stimuli, NAD\n Cardiovascular: RRR, no m/g/r\n Pulmonary: Equal coarse BS bilaterally\n Abdominal: Distended, bowel sounds present\n Extremities: 1+ pitting edema b/l\n Labs / Radiology\n 66 K/uL\n 9.2 g/dL\n 185 mg/dL\n 1.6 mg/dL\n 22 mEq/L\n 3.4 mEq/L\n 56 mg/dL\n 97 mEq/L\n 140 mEq/L\n 27.3 %\n 17.6 K/uL\n [image002.jpg]\n 11:43 AM\n 12:42 PM\n 02:06 PM\n 02:12 PM\n 08:13 PM\n 08:40 PM\n 02:10 AM\n 02:22 AM\n 06:14 AM\n WBC\n 18.5\n 29.1\n 25.0\n 17.6\n Hct\n 17.2\n 32.2\n 22.8\n 27.3\n Plt\n 76\n 70\n 65\n 66\n Cr\n 1.7\n 2.0\n 2.2\n 1.6\n TCO2\n 13\n 11\n 19\n 24\n 26\n Glucose\n 170\n 92\n 143\n 185\n Other labs: PT / PTT / INR:24.2/45.0/2.3, ALT / AST:1663/9939, Alk Phos\n / T Bili:230/6.1, Differential-Neuts:64.0 %, Band:8.0 %, Lymph:16.0 %,\n Mono:10.0 %, Eos:0.0 %, Fibrinogen:89 mg/dL, Lactic Acid:10.1 mmol/L,\n Albumin:2.8 g/dL, LDH: IU/L, Ca++:7.9 mg/dL, Mg++:2.0 mg/dL,\n PO4:4.6 mg/dL\n Microbiology: , , bcx ucx all ntd\n peritoneal fluid ntd, just PMNs\n Assessment and Plan\n SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)\n ACIDOSIS, METABOLIC\n 79 y/o male with hepatitis c cirrhosis, elevated lactate, BRB per NG\n tube, s/p EGD with banding of active variceal bleeding.\n # Hypotension/Bleed: Clearly there is a component of volume loss given\n his blood loss, unclear if there is sepsis. EGD showed variceal bleed\n requiring multiple transfusions of PRBC for falling Hct.\n - Goal INR <2; goal plt >50; goal finbrinogen >100\n - q6h coags, calcium, cbc, electrolytes\n - 3 units PRBC for falling Hct; maintain Hct >28\n - 2 units FFP for INR 2.3\n - Continue Levophed; Vasopressin weaned off\n - Maintain active type and cross x8 units\n - PPI drip\n - Continue Octreotide\n - f/u cultures obtained\n - Tap ascites when stable, ? SBP\n - Vanc/Zosyn empirically\n # Elevated LFTs/Lactate: Likely secondary to necrosis in the context of\n hypotension. ? Mesenteric ischemia versus global hypoperfusion at this\n time.\n - Surgery consulted\n - Trend LFTs and lactate daily\n - Volume resuscitation with fluids, blood\n - No free air on CXR although not ideal.\n - Patient unstable for further evaluation of bowel at this time.\n # Anuria: Likely secondary to hypotension. Renal consult obtained if\n patient needs urgent dialysis given hyperkalemia. At this point given\n bleeding I am not sure if he would be stable for any CRRT.\n - Follow volume status\n - Follow potassium\n - Receiving CVVHD; monitor lytes q6h and replete prn\n # Hyperkalemia: Resuscitation with temporizing measures as in HPI.\n Repeat K is elevated. Renal aware. Repeat:\n - Calcium gluconate\n - Sodium bicarbonate\n - Glucose/Insulin\n - follow serial K\n .\n FEN: No IVF, replete electrolytes, NPO\n .\n Prophylaxis: IV PPI\n .\n Access: 2 peripherals, left subclavian, R temporary HD line\n .\n Code: DNR (CPR not medically indicated, for discussion see POE and Dr.\n note ).\n .\n Communication: Friend \n .\n Disposition: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 11:26 AM\n Arterial Line - 01:34 PM\n 22 Gauge - 04:33 PM\n 20 Gauge - 04:33 PM\n Dialysis Catheter - 05:38 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n"
},
{
"category": "Respiratory ",
"chartdate": "2174-10-25 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 504520,
"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:\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: 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: Blood Tinged /\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: High flow demand\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: Comfort measures only\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 for this critically ill pt.\n, RRT 17:48\n"
},
{
"category": "ECG",
"chartdate": "2174-10-24 00:00:00.000",
"description": "Report",
"row_id": 201966,
"text": "Sinus rhythm with modest A-V conduction delay. Early precordial\nQRS transition. Low precordial lead QRS voltage. Modest ST-T wave changes are\nsuggested but unstable baseline makes assessment difficult. Since the previous\ntracing of the rate is faster, precordial lead QRS voltage is lower,\nthe QTc interval is shorter and further ST-T wave changes are suggested but\nunstable baseline makes comparison difficult.\n\n"
},
{
"category": "ECG",
"chartdate": "2174-10-20 00:00:00.000",
"description": "Report",
"row_id": 201967,
"text": "Sinus rhythm. Prolonged P-R interval. Intraventricular conduction delay.\nProlonged Q-T interval. Compared to the previous tracing of \nQ-T interval has increased.\n\n"
},
{
"category": "ECG",
"chartdate": "2174-10-19 00:00:00.000",
"description": "Report",
"row_id": 201968,
"text": "Sinus rhythm with A-V conduction delay. Left atrial abnormality. Early\nprecordial QRS transition. Low lateral precordial lead QRS voltage. Findings\nare non-specific but clinical correlation is suggested. Since the previous\ntracing of rate is faster and right bundle-branch block is now absent.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-10-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1110255,
"text": " 8:13 AM\n CHEST (PA & LAT) Clip # \n Reason: please eval for acute infectious process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with sob and tachypnia\n REASON FOR THIS EXAMINATION:\n please eval for acute infectious process\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest frontal and lateral views.\n\n CLINICAL INFORMATION: A 79-year-old male with history of shortness of breath\n and tachypnea.\n\n COMPARISON: .\n\n FINDINGS: Low lung volumes persist. Hilar prominence and cephalization of\n flow suggest pulmonary edema, which may be accentuated due to low lung\n volumes. The heart remains enlarged and likely somewhat accentuated by the\n low lung volumes. Previously seen right lung peripheral reticular\n interstitial opacity is less prominent on the current study. While reticular\n interstitial opacity in the peripheral right lung is less prominent as\n compared to the prior exam, subtle peripheral reticular opacities persist\n bilaterally, which may be secondary to component of chronic interstitial lung\n disease. Consider non-emergent high-resolution chest CT as clinically\n indicated for further assessment. No large pleural effusion is seen.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-10-19 00:00:00.000",
"description": "L SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT",
"row_id": 1110256,
"text": " 8:13 AM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Clip # \n Reason: s/p fall onto left shoulder. Evaluate for fracture or disloc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p fall onto left shoulder. Now with weakness in left\n arm.\n REASON FOR THIS EXAMINATION:\n s/p fall onto left shoulder. Evaluate for fracture or dislocation.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): KKgc WED 1:51 PM\n PFI: No acute fractures or dislocation of the left shoulder joint. Minimal\n degenerative changes of the glenohumeral joint with moderate degenerative\n changes of the AC joint.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall on the left shoulder.\n\n LEFT SHOULDER, THREE VIEWS (FOUR RADIOGRAPHS)\n\n COMPARISON: No prior studies available for comparison.\n\n No fractures or dislocation is detected in the left shoulder. Moderate\n degenerative changes are noted in the acromioclavicular joint with mild\n degenerative changes in the glenohumeral joint with early osteophyte formation\n along the inferior glenoid margin. No lytic or sclerotic lesion is\n identified. No abnormal soft tissue calcification or radiopaque foreign body\n is detected.\n\n IMPRESSION:\n 1. No acute fractures or dislocation of the left shoulder joint.\n 2. Moderate degenerative change at acromioclavicular joint and mild\n glenohumeral degenerative change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-10-19 00:00:00.000",
"description": "L SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT",
"row_id": 1110257,
"text": ", EU 8:13 AM\n SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Clip # \n Reason: s/p fall onto left shoulder. Evaluate for fracture or disloc\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with s/p fall onto left shoulder. Now with weakness in left\n arm.\n REASON FOR THIS EXAMINATION:\n s/p fall onto left shoulder. Evaluate for fracture or dislocation.\n ______________________________________________________________________________\n PFI REPORT\n PFI: No acute fractures or dislocation of the left shoulder joint. Minimal\n degenerative changes of the glenohumeral joint with moderate degenerative\n changes of the AC joint.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-10-19 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 1110258,
"text": " 8:17 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: right-upper quadrant ultrasound WITH DOPPLER to check for po\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with ascites, altered mental status.\n REASON FOR THIS EXAMINATION:\n right-upper quadrant ultrasound WITH DOPPLER to check for portal \n thrombosis.\n ______________________________________________________________________________\n WET READ: VSFa WED 10:02 AM\n main portal patent with slow flow. full wall-to-wall flow not fully\n seen, suggestive of peripheral partial thrombus. No flow detected at the Left\n portal , consistent with persistent thrombosis. Anterior portal \n patent with slow flow\n Questionable flow at the posterior right portal . hepatic cirrhosis,\n ascites. persistent contracted GB.\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 79-year-old man with ascites, altered mental status. Right\n upper quadrant ultrasound with Doppler to check portal thrombosis.\n\n TECHNIQUE: Ultrasound of the liver and gallbladder.\n\n COMPARISON: Prior years studies including the most recent abdominal\n ultrasound of /09.\n\n FINDINGS:\n .\n\n The liver is coarsened in echotexture and demonstrates a nodular contour,\n consistent with history of cirrhosis. The gallbladder is again contracted and\n thick walled without intraluminal stone seen. The spleen is enlarged,\n measuring 19.4 cm in length. A moderate amount of ascites persists.\n\n Color and pulse Doppler evaluation was again performed. The main portal \n is patent, with slow flow, hepatopetal in direction. Complete wall-to-wall\n flow is not seen throughout the main portal , with suggestion of possible\n peripheral partial thrombus in the main portal . Again, no flow is seen in\n the left portal consistent with complete thrombosis.\n\n The right anterior branch of the portal is patent. There is questionable\n flow seen into the posterior right portal which is also small in size.\n The hepatic veins and main hepatic artery are patent.\n\n CONCLUSION:\n 1. Cirrhotic liver with splenomegaly and moderate ascites.\n\n 2. Persistent thrombosis of the left portal . Main portal is patent\n with slow flow and without full wall-to-wall flow detected, suggestive of\n possible peripheral, non-occlusive thrombus. Questionable flow at the\n (Over)\n\n 8:17 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: right-upper quadrant ultrasound WITH DOPPLER to check for po\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n posterior right portal , indicate thrombosis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-10-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111096,
"text": " 9:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? new pulmonary process\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with h/o cirrhosis Hep C, CAD s/p fall and with acute renal\n failure and elevated T bili.\n REASON FOR THIS EXAMINATION:\n ? new pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: History of cirrhosis, fall with acute renal failure.\n Questionable new pulmonary process.\n\n COMPARISON: .\n\n FINDINGS: Today's radiograph is limited by severe motion artifacts due to\n bleeding. In unchanged manner, the lung volumes are low. The pre-existing\n parenchymal opacities do not seem to have increased in extent. Unchanged size\n of the cardiac silhouette. No new focal parenchymal opacities. No evidence\n of pleural effusions. No safe evidence of rib fractures.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-10-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111554,
"text": " 3:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with resp distress\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n\n REASON FOR EXAM: Respiratory distress.\n\n COMPARISON: Multiple chest radiographs with the most recent from .\n\n SINGLE FRONTAL VIEW OF THE CHEST: Internal jugular venous catheter with the\n tip most likely at the brachiocephalic internal jugular junction, endotracheal\n tube with the tip about 5 cm above the carina and the left subclavian\n intravenous catheter with the tip at the mid-to-distal SVC are stable. Low\n lung volumes limit evaluation of the lungs. Bilateral reticular opacities\n are increased. Smal bilaterl pleural effusions and lower lobe atelectasis are\n unchanged. Heart is mildly enlarged. The aorta is tortuous.\n\n IMPRESSION:\n 1. Worsening pulmonary edema.\n 2. Stable small bilateral pleural effusions and lower lobe atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-10-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111114,
"text": " 11:44 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ET tube\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with intubation\n REASON FOR THIS EXAMINATION:\n ET tube\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post intubation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, an endotracheal tube has\n been inserted. The tip of the tube projects 5 cm above the carina. Also new\n are a nasogastric tube and a left-sided subclavian access line. The tip of\n the line projects over the inflow tract of the right atrium, the line could be\n pulled back by 1-2 cm.\n\n Unchanged cardiomegaly, unchanged low lung volumes. No evidence of\n pneumothorax, a right lateral linear hyperlucency is caused by a skinfold.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-10-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1111380,
"text": " 3:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with respiratory distress\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory distress, evaluation for 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 bilateral parenchymal opacities show a\n mild tendency to progress, notably the left retrocardiac atelectasis is\n slightly denser than on the previous image. Unchanged size of the cardiac\n silhouette.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-10-24 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1111200,
"text": " 8:02 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? pulled back L subclavian line position\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with UGIB and ARF\n REASON FOR THIS EXAMINATION:\n ? pulled back L subclavian line position\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Subclavian line re-positioned.\n\n FINDINGS: In comparison with the earlier study of this date, the left\n subclavian catheter has been pulled back to the mid portion of the SVC.\n Otherwise, little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2174-10-24 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1111190,
"text": " 6:28 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Line placement\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old man with UGIB and renal failure\n REASON FOR THIS EXAMINATION:\n Line placement\n ______________________________________________________________________________\n WET READ: RSRc MON 7:55 PM\n New R IJ line terminates in lower SVC. Unchanged cardiomegaly, low lung\n volumes. Slightly increased basilar atelectasis. 7:50 p .\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 6:50 P.M. \n\n HISTORY: Upper GI bleed and renal failure. Check line placement.\n\n IMPRESSION: AP chest compared to at 9:40 and 11:50 a.m.:\n\n Tip of the new right internal jugular line projects over the mid SVC. Left\n subclavian line ends in the upper right atrium as before, unchanged. There is\n no pneumothorax. Pulmonary and mediastinal vascular congestion persists and\n mild pulmonary edema is new. There may be small bilateral pleural effusions.\n Moderate cardiomegaly is unchanged. There is no focal pulmonary abnormality\n to suggest pneumonia. ET tube in standard placement.\n\n Severe distention of the stomach with air and fluid is probably a new\n development.\n\n Dr. was paged.\n\n\n"
}
] |
24,573 | 102,522 | The patient was admitted to the Medical Service. The patient was a 55 year-old male who was admitted to the Medical Service for prehydration prior to angio for claudication. The patient went for cardiac catheterization on . Dr. attending and the patient was noted to have three vessel disease. For more details please see procedure note. Cardiac Surgery was consulted on . The patient was evaluated by Dr. and deemed appropriate for coronary artery bypass surgery. After undergoing the appropriate preoperative workup the patient went to the Operating Room on for coronary artery bypass graft times four, left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to right coronary artery to the posterior descending coronary artery, saphenous vein graft to the obtuse marginal. For more detailed account please see operative report. The patient was transferred to the CSRU on a Dobutamine and Neo IV. Chest x-ray postoperatively was notable for a left lower lobe collapse. The patient was extubated early on postoperative day number one. In addition, on postoperative day number one the patient required one unit of packed red blood cells. Of note on postoperative day number two the patient had a creatinine of 2.8, which rose from 2.0. The Renal Service was consulted and they recommended holding diuresis with Lasix, transfusing to a hematocrit above 30 and avoiding other nephrotoxic agents. In addition they recommended keeping systolic blood pressure over 130. On the patient remained on pressors with neo-synephrine intravenously. Insulin drip was also restarted at this time. On the patient was transfused 2 units of packed red blood cells for a low urine output. The patient's renal status was worsening at this time with creatinine of 2.5 to 3 range. In addition, on this day the mediastinal chest tube was discontinued. The patient continued to have left persistent left lower collapse. On the patient was transfused 1 unit of packed red blood cells. The patient was off pressors. On the patient had a bronchoscopy, which revealed a mild tracheal malacia otherwise within normal limits. The patient also at this time was noted to have a rise in white blood cell count, so was placed on Levofloxacin. White blood cell count rose to 24. On the patient was found to have an alkaline phosphatase of greater then 1000. Right upper quadrant ultrasound was done, which showed some dilation. General Surgery Dr. was consulted and the patient was monitored with expectant management. The patient was eventually transferred to the floor on . The patient continued to have left lower lobe collapse on chest x-ray. Creatinine was stable in the 2 to 2.5 range. White blood cell count was persistently high between 20 and 25,000. Liver function tests were steady decreasing and the patient's abdominal examination was benign. The patient was also noted to have some erythema at the superior pole of the sternotomy wound with minimal drainage, which improved over the course of his floor stay. On Infectious Disease was consulted and they recommended placing the patient on Vancomycin. He was placed on 1 gram q 24 hours. Over the next several days the patient's white blood cell count steadily decreased to the current discharge white blood cell count of 11. In addition, the patient was intermittently diuresed. In addition, the patient received intermittent doses of Kayexalate for a potassium level between 5 and 6. The patient continued to improve clinically on the Vancomycin. Infectious Disease recommended discharge with PICC line and intravenous Vancomycin for three weeks. On the day of discharge the patient's white blood cell count was stable at 11. The patient's creatinine had decreased to 1.8. The patient was replaced on po Lasix, however, on only 40 mg b.i.d. instead of his usual home dose of 100. The patient's ace inhibitor and continued to be held to be started at the discretion of his primary care physician. patient continued to have left lower lobe collapse, however, pulmonary is recommending no intervention at this time. The patient is clinically stable. | EPISODES OF ^ HR/BP RESOLVED W/ IV LOPRESSOR. MEDICATED C/ PERCOCET AND MSO4. EKG WNL. pt currently recieving 1 unit prbc for hct of ~ 28.resp: LS clear upper lobes, lll very dim and rll with crackles. ADEQUATE DIURESIS.ENDO~DAILY DOSE OF LANTUS, ALSO TX W/ SPECIFIC DAILY DOSES.SEE FLOW SHEET.A/P~COMPROMISED RESP STATUS. Tol cl liqs. pp by doppler. CA RELACEMENT X 1. -sputum production.gi/gu: +bs. CPT, INS & NEBS PER RESP TX.PRODUCTIVE COUGH. SEE FLOW SHEET FOR AM LABS.RESP: LS CLEAR WITH DIM BASES L>R. H/H stable.P: consult Renal. amb in w/minimal assist. DOBUTAMINE AND NEO BEING WEANED. TMAX 99.0. NPO FOR BRONCH TODAY. RX WITH 3/4 AMP D50, BS 85 AT 0400.GI: ABD SOFT, + BOWEL SOUNDS. random vanco level 6.7. pt afebrileendo: BS 118 this am. CXR. sbp 100-140. tolerated prbc w/o difficulty. encouraged to cdb/use is. BS 52 AT 2400, PT ASYMPTOMATIC. ON LANTUS REGIMEN. tolerating po's. LUNGS INITALLY RHONCHI W/ EXP WHEEZE ON RIGHT. CPT done. CXR done this amgi/gu: pt with + bs. LOW U/O CRI.PLAN: WEAN NEO AND DOBUTAMINE OFF AS TOLERATED. encouraged to cdb & use is. Vanco level drawn, pending.Heme: H/H: 28.5/9.6; plts 304.P: Cont vigorous bronchial hygeine; nebs prn /wheezing. FSBS Q2H WHILE NPO, RX LOW BS WITH D50. ?CHECK ABG IN AM. +bs. LUNGS CLEAR RUL, DIMINISHED WITH CRACKLES RLL, BRONCHIAL BBS LUL, DIMINISHED LLL. Med x 2 w/ percocet 2. MONITOR BS. OOB, cont vigorous bronchial hygeine. gen consulted. pt using IS . CONT W/ AGGRESSIVE REHAB. +pp bilat.resp: lungs clear but diminshed in bases. VENOUS PH 7.29. +pp bilat.resp: lungs clear but diminished in bases. BUN/Cr: 65/3.1, worsening.MS/derm: remains anasarcic. MIDNOC 76. BUN/Cr=54/2.9. monitor uop. us=dialated. CURRENT BS PENDING.GU/RENAL: UO HAS IMPROVED OVN. POS PAL PEDAL PULSES BILAT.RESP~3L NP. fs per protocol. SBP 90-120'S. CI>2 SVO2 >60. need spec for ucx.endo: lantus given per order. pt aware that a sputum spec is need for cx. R LUNG DIMINISHED BASE, CLEAR APICES. GU: GOOD DIURESIS, PRESENTLY SLOWING. Continued patchy atelectasis at the right base. Atelectasis/consolidation left base and small bilateral pleural effusions. BS COURSE TO CLEAR UPPER, SX FOR SCANT. IMPRESSION: Stable left lower lobe collapse/consolidation with small left pleural effusion. NP of cont'd low BS. IMPRESSION: Stable appearance of left lower lobe collapse/consolidation and small left pleural effusion. Pt given 2U PRBC for low u/o and low BP. Overall left ventricular systolic functionis moderately depressed.LV WALL MOTION: The following resting regional left ventricular wall motionabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -hypokinetic; basal inferior - hypokinetic; mid inferior - hypokinetic; midinferolateral - hypokinetic; septal apex - hypokinetic; inferior apex -hypokinetic; lateral apex - hypokinetic;RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation.MITRAL VALVE: Mild to moderate (+) mitral regurgitation is seen.TRICUSPID VALVE: Physiologic tricuspid regurgitation is seen.PERICARDIUM: There is no pericardial effusion.Conclusions:The left atrium is mildly dilated. DSG WITH SMALL SANGIUNOUS DRAINAGE NOTED. DP RIGHT, PT LEFT. cpt done. 02 VIA N/C DECREASED TO 2L.CV: NSR WITHOUT ECTOPY. attempted to wean neo->unable d/t sbp<90. Left ventricular wall thicknesses arenormal. A right central line is noted with tip in the upper SVC. AMBULATE AT LEAST QID. wean neo as tolerates. BUN 68/CREAT 2.4. Small right pleural effusion. Po dilaudid x2 and one time dose of sq dialudid with effect.CV: SR, no ectopy. 2) Left lower lobe collapse/consolidation and a small left effusion are demonstrated. A-LINE DC'D. Respiratory Care:Pt. RESPIRATORY CARE: PT. A SINGLE AP SEMI-UPRIGHT VIEW: Comparison study . ValveHeight: (in) 65Weight (lb): 148BSA (m2): 1.74 m2BP (mm Hg): 170/80HR (bpm): 103Status: OutpatientDate/Time: at 11:00Test: TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. PA AND LATERAL CHEST: The appearance is unchanged with bilateral pleural effusions, left greater than right, and continued left lower lobe collapse. There is priorinferior myocardial infarction.TRACINBG #2 IMPRESSION: 1) Bilateral pleural effusions and left lower lobe atelectasis, likely postoperative in etiology. Compared to theprevious tracing of there is interim inferior wall myocardialinfarction. Mediastinal and left chest tubes in situ. Prior inferior myocardial infarction. Prior inferior myocardial infarction. Rule out myocardial infarction as compared to theprevious tracing of . Incidental note is made of a right pleural effusion. There is mild vascular engorgement and perihilar haziness. FINDINGS: There are small bilateral pleural effusions and there is left lower lobe collapse. Sinus rhythmProbable inferior infarct, age indeterminateDiffuse ST-T wave changes with modest ST elevation - cannot exclude in partischemia and/or pericarditisClinical correlation is suggestedSince previous tracing of , further ST-T wave changes present A 0.018 guide wire was advanced under fluoroscopy into the superior vena cava. 2:07 AM CHEST (PORTABLE AP) Clip # Reason: Please assess for acute pulm edema. The endotracheal tube is in the right main bronchus. 2) Right pleural effusion. There is vascular engorgement and diffuse perihilar haziness. REASON FOR THIS EXAMINATION: assess L pleural effusion FINAL REPORT HISTORY: Assess left pleural effusion post CABG. Sinus tachycardia. Sinus tachycardia. Sinus rhythmInferior infarct, age indeterminateDiffuse ST-T wave abnormalities with ST elevation - consider pericarditis or inpart ischemiaClinical correlation is suggestedSince previous tracing of , further ST-T wave changes present There remains dense opacification in the left retrocardiac region as well as a moderate to large left pleural effusion. | 45 | [
{
"category": "Nursing/other",
"chartdate": "2126-03-13 00:00:00.000",
"description": "Report",
"row_id": 1581500,
"text": "NEURO~A&OX3. FC. MAE. OOB TO CHAIR AND AMB IN UNIT W/ PT, WELL. MED W/ DILAUDID 2 MG Q 4 HRS FOR DISCOMFORT. EFFECTIVE. FAMILY VISITING.\n\nCARDIAC~ W/ HTN~HR~100, BP~160'/170. GIVEN 5 MG OF IV LOPRESSOR GIVEN @ THAT TIME. EFFECTIVE. REPEAT EPISODE AGAIN AT 1430. REPEAT DOSE OF 5 MG OF IV LOPRESSOR. CURRENTLY SR IN 80'S BP~ 119/60. ELECTROLYTES REPLACED. POS PAL PEDAL PULSES BILAT.\n\nRESP~3L NP. LUNGS INITALLY RHONCHI W/ EXP WHEEZE ON RIGHT. RHONCHI & DIMINISHED ON LEFT. CPT, INS & NEBS PER RESP TX.PRODUCTIVE COUGH. FREQ COUGHS UP SM AMTS OF THIN YELLOW/WHITE SECRETIONS.\n\nGI/GU~ FOOD AND FLUIDS WELL. ADEQUATE DIURESIS.\n\nENDO~DAILY DOSE OF LANTUS, ALSO TX W/ SPECIFIC DAILY DOSES.SEE FLOW SHEET.\n\nA/P~COMPROMISED RESP STATUS. PUL CONSULT TODAY PLAN TO BRONCH PT TOMORROW AM. CONT W/ AGGRESSIVE REHAB. HOLD BREAKFAST. EPISODES OF ^ HR/BP RESOLVED W/ IV LOPRESSOR.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-14 00:00:00.000",
"description": "Report",
"row_id": 1581501,
"text": "NEURO: ALERT AND ORIENTED TO TIME PLACE AND EVENTS. MAE, FOLLOWS COMMANDS. COOPERATIVE, SMILES A LOT. DILAUDID 2MG PO X 2 FOR PAIN.\n\nPULM: 02 AT 2L WITH SATS > 94%, P02 75, COMPENSATED. LUNGS CLEAR RUL, DIMINISHED WITH CRACKLES RLL, BRONCHIAL BBS LUL, DIMINISHED LLL. Q2H BILATERAL CHEST PT WITH COUGHING AND DEEP BREATHING. USING IS TO 500-750CC. NPO SINCE 2400 FOR SCHEDULED BEDSIDE BRONCH TODAY. AFEBRILE.\n\nCV: SINUS TACH AND HYPERTENSIVE AT ONSET OF SHIFT. LOPRESSOR 25MG INCREASED TO 50MG PO BID WITH EFFECT, SBP DOWN TO 90, HR 78 WHEN ASLEEP. A&V WIRES SECURED. CA RELACEMENT X 1. PALPABLE PEDAL PULSES.\n\nSKIN: MULTIPLE SKIN TEARS OVER ABDOMEN, ARMS, LEGS FROM TAPE. STERNAL INCISION SLIGHTLY PINK, NO DRAINAGE.\n\nENDO: SSRI COVERAGE FOR QID BS. BS 52 AT 2400, PT ASYMPTOMATIC. RX WITH 3/4 AMP D50, BS 85 AT 0400.\n\nGI: ABD SOFT, + BOWEL SOUNDS. NO BM. NPO SINCE 2400 FOR BRONCH AT 1100.\n\nGU: FOLEY TO CD DRAINING CLOUDY AMBER COLORED URINE. UO 25 CC/HR X 3 HOURS, MD AWARE. TO GIVE LASIX 20MG IF UO REMAINS LOW. NOT GIVEN AS UO > 30 CC/HR SINCEAND HX CRI.\n\nSOCIAL: NO PHONE CALLS. FRIEND .\n\n\nPLAN: CONTINUE AGGRESSIVE PULM HYGIENE WITH Q2H CHEST PT. NPO FOR BRONCH TODAY. INCREASE ACTIVITY. FSBS Q2H WHILE NPO, RX LOW BS WITH D50. ADJUST SCHEDULED AM INSULIN DOSE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-12 00:00:00.000",
"description": "Report",
"row_id": 1581497,
"text": "7am-12 update\nneuro: pt alert and orienated x3. MAE and able to follow commands.\n\nCv: pt remains nsr, no ectopy noted. HR 80-90's. BP 100-110's/40-50's. MAP 60's. pt with 2 a wires and 2 v wires -> insulated and secured to chest. pp by doppler. pt currently recieving 1 unit prbc for hct of ~ 28.\n\nresp: LS clear upper lobes, lll very dim and rll with crackles. pr denies sob. pt remains on 4 L nc, o2 sats 95-98%. pt using IS . CPT done. pt with strong non productive cough. CXR done this am\n\ngi/gu: pt with + bs. no stool. foley draining amber urine with sediment. UO 30-60 cc/hr. BUN and creatinine 65/3.1 (up from yesterday)\n\nid: WBC's 13.8 this am. random vanco level 6.7. pt afebrile\n\nendo: BS 118 this am. pt given 20 unit lantus sc as ordered with breakfast.\n\nactivity/comfort: pt c/o pain. treated with 2 percocet -> pt continued to have pain 1 hr after percocets. pt given 2 mg morphine iv (in addition to percocets). plan to change pain med to diluadid. pt ambualted with 2 person assist.\n\nplan: pulm toliet, pain control, monitor renal status, increase activity as tolerated, monitor lytes/wbc's\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-12 00:00:00.000",
"description": "Report",
"row_id": 1581498,
"text": "shift update:\n\nneuro: a&o x3. mae. in chair->amb w/assist of 1->back to bed. c/o pain medicated w/dilaudid 4mg at 1400. at 1600 pt c/o severe pain np aware dilaudid 4mg given effect pending.\n\ncardiac: nsr-st. hr 80-100. no vea. sbp 100-140. tolerated prbc w/o difficulty. +pp bilat.\n\nresp: lungs clear but diminshed in bases. left more diminshed than right. sat's>94% on 4lnc. encouraged to cdb/use is. abg's acceptable.\n\ngi/gu: abd soft non tender. +bs. tolerating po's. uop 35-60cc/hr.\n\nendo: fs tx'd w/ssri.\n\nsocial: family & friends into visit. pt requesting to call wife & children. friend to assist pt w/call this pm.\n\nplan: pain management. cont cardiac rehab. pulmonary toilet. monitor uop. fs per protocol. encourage mobility.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-13 00:00:00.000",
"description": "Report",
"row_id": 1581499,
"text": "7P-7A\n\nNEURO: ALERT AND ORIENTED. MAE AND FOLLOWS COMMANDS. PLEASANT AND COOPERATIVE.\n\nCV: NSR, OCCASIONAL PVC NOTED. SBP 90-120'S. STARTED ON PO LOPRESSOR THIS PM. PAPABLE PEDAL PULSES. TEMP PACER WIRES SECURED. SEE FLOW SHEET FOR AM LABS.\n\nRESP: LS CLEAR WITH DIM BASES L>R. EXPECTORING MOD AMOUNTS OF BLOOD TINGED SPUTUMN. O2 SATS>92% ON 2L NC. SEE FLOW SHEET FOR ABG.\n\nENDO: NO SSRI COVERAGE NEEDED.\n\nGI/GU: BS+4. DIURESING MIN AMOUNTS OF CLEAR AMBER COLORED URINE. LASIX DC'D ON PREVIOUS SHIFT, ELEVATED CREAT. NO BM THIS SHIFT. TOLERATING DIET.\n\nPAIN/COMFORT: FREQUENT REPOSITIONING. FREQUENT C/O PAIN TO NECK AREA. HEAT PACK APPLIED AND PAIN MEDS GIVEN WITH MIN RELIEF.\n\nSOCIAL: FRIEND INTO VISIT, PHONE CALLED MADE TO OUT OF COUNTRY FAMILY.\n\nPLAN: MONITOR UO. PAIN MANAGEMENT. AGGRESSIVE PULM TOILETING. MONITOR LABS. INCREASE DIET AND ACTIVITY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-11 00:00:00.000",
"description": "Report",
"row_id": 1581494,
"text": "RN Progress note\nneuro: AAO x 3; no focal deficits. Med x 2 w/ percocet for sternal pain w/ coughing\n\nCV: NSR, ST, AEA during resp distres. CVP 17 initially, down to 10 after lasix.\n\nPulm: rhonchorous through anterior fields, clear w/ cough. Diminished left field to half, then crackles to apex. Resp distress 0200 requiring FiO2 to 100%, lasix 40mg. CXR showed left lung atelectasis, CHF. EKG WNL. ABG's wnl after diuresis 300cc. O2 weaned to 40%. Good CDB effort, non-productive.\n\nGI: abd soft, non-tender; hypo BS. Tol cl liqs. No BM.\n\nGU: marginal UOP until lasis. BUN/CR: 64/3.2\n\nMS/derm: leg wounds C/D. Sternum stable, wound C/D. Left meds CT stab wound open, weeping small s/s.\n\nLabs: calcium repleted. H/H stable.\n\nP: consult Renal. ?natrecor to off load in setting of renal failure, low EF. OOB, cont vigorous bronchial hygeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-11 00:00:00.000",
"description": "Report",
"row_id": 1581495,
"text": "0700-1900\nEvents\nc/o of chest pain non radiating with mild SOB ? 12 lead EKG done ST elvation noted and CT team team aware cardiac sent/ morphine 2mg IV given with relief of pain/ percocet given q4 hour with relief neuro anxious at times mild barrier understands english well other RN in to translate in spanish pt aware of postop activity and pulm toilet/ CV MP SR no vea genralized edema and scrotal edema noted/\nLS left crackles at bases with bronchial BS upper lobes/ right dim clear upper lobes O2 weaned to 3 L NP sao2 96%/ taking in po well\n\nPlan-cont to adv activity, pulm toilet, ?need for more lasix continue to monitor u/o and I/O, ?need to start lopressor tomorrow, please see flow sheet\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-12 00:00:00.000",
"description": "Report",
"row_id": 1581496,
"text": "RN progress note\nneuro: AAO x 3; remains very anxious @ times. Cont w/ c/o \"lots\" of chest pain , mostly after vigorous coughing. Med x 2 w/ percocet 2. Slept well in long spells.\n\nCV: NSR, rare AEA, 70-100. SBP 90's-130.\n\nPulm: early eve resp distres w/ sats to 90, wheezing throughout. Congested cough prod thick yellow secretions. Neb rx, lasix 20mg IV, brief increased FiO2: pt back to baseline w/i 1 hour. Cont w/ intermittent EE wheeze -ax, right post; absent LLL sounds, consolidated to percussion. Chest P/T, postural drainage q2-3 hours; left lung down results in dyspnea, lower sats. ABG's on 4L/NP: 7.34/44/88/-\n\nGI: abd soft, non-tender. BS hypo; no BM. Tol cl liqs.\n\nGU: F/C UOP marginal w/ poor diuretic response from laix 20mg @ 2100. BUN/Cr: 65/3.1, worsening.\n\nMS/derm: remains anasarcic. Healing tape burns on chest. Sternum stable; chest & leg wounds C/D.\n\nEndo: no extra insulin needed.\n\nID: afebrile; WBC 13.8. Vanco level drawn, pending.\n\nHeme: H/H: 28.5/9.6; plts 304.\n\nP: Cont vigorous bronchial hygeine; nebs prn /wheezing. ?cont lasix in setting of worsening RF. OOB, cont increased activity as tol. CXR. ? start lopressor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-15 00:00:00.000",
"description": "Report",
"row_id": 1581505,
"text": "shift update:\n\nneuro: a&o x3. mae. follow commands. oob->chair. amb in w/minimal assist. dilaudid given po for pain.\n\ncardiac: nsr. no vea. hr 80-90's. sbp 100-140's w/pain & activity. sbp~100 this am 25mg lopressor given instead of 50mg np. epi wires secure. ?d/c epi wires. +pp bilat.\n\nresp: lungs clear but diminished in bases. lll more dimished than rll. sat's>93% on 2l nc. encouraged to cdb & use is. pt aware that a sputum spec is need for cx. -sputum production.\n\ngi/gu: +bs. tolerating diet. pt was npo for gallbladder us this afternoon. us=dialated. alk phos>1000. gen consulted. foley d/c'd at 0830. dtv. need spec for ucx.\n\nendo: lantus given per order. no ssri coverage needed.\n\nsocial: brother & sister in-law into visit. a few friends also this afternoon.\n\nplan: gen consult. pulmonary toilet. transfer to 2 when bed available. pain management.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-07 00:00:00.000",
"description": "Report",
"row_id": 1581485,
"text": "Neuro: pt alert oriented, following all commands.\nResp: pt weaned and extubated without difficulty. O2 sats 100% on 40% open face tent changed to np 4l. chest tubes patent draining moderate amount of serous snaguinous drainage. no air leak detected.\nC/V: vss with good SvO@ 70's CO of Dobutamine on at 5mcg/kg/min decreased to 3mcg/kg/min At 5am. pt given 1 amp of sodium bicarb last night prior to extubation for a metabolic acidosis with correction. Neo started at 0.25 mcg for MAP <60.\ngi: OGT removed with extubation pt c/o nausea after turning treated with Reglan with relief.\nEndo: Insulin drip off for blood sugar of 69 blood sugars remain in the 80's\nGU: Urine output drifted down to 20 cc/hr given 250cc bolus of lr with improvement.\nSkin: dsg D&I.\nPain: good pain relief with morphine 4mg sc every 3-4hours.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-07 00:00:00.000",
"description": "Report",
"row_id": 1581486,
"text": "FOCUS: STATUS UPDATE\nPT HAVING PAIN ISSUES AT CHANGE OF SHIFT. MEDICATED C/ PERCOCET AND MSO4. IMPROVED. LANTUS STARTED AS PT STARTED HAVING PO INTAKE. NEUOLOGICALLY INTACT. C/ LOWER EXTREMITY NEUROPATHY. DOBUTAMINE AND NEO BEING WEANED. CI>2 SVO2 >60. LOW U/O CRI.\nPLAN: WEAN NEO AND DOBUTAMINE OFF AS TOLERATED. INCREASE LEVEL OF ACTIVITY. MONITOR BS. CONTINUE C/ CURRENT PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-08 00:00:00.000",
"description": "Report",
"row_id": 1581489,
"text": "Neuro-c/o of pain med with percocet with relief/ pt primary spanish states understands english MAEW OOB to chair marhc in place\n\nCV-MP SR no VEA CSM cool LE edema x4 extrem noted doppler pulses DP CT remain drg minimal amt sero/sang neo titrated for MAP>60 1u PRBC given for volume and HCT of 26.4\n\nResp-brochial BS at bases Ldim>right CPT/CDB/and ICS well O2 6l NP cont pulm toilet\n\nGI-Lantus dose increased to 20u/covered with reg insulin SS renal diabetic diet taking in well\n\nGU-postive urine cx plan to changed foley cath/ u/o down lasix 100mg IV given with some response Cr 2.8 (baseline 2.2) renal fellow into evaluate pt continue to monitor fluid balance and K\n\nPlan-neo for MAP>60 monitor K and I/O assess need for fluids vs lasix ?ABX monitor T please see flow sheet\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-09 00:00:00.000",
"description": "Report",
"row_id": 1581490,
"text": "CSRU UPDATE\nNEURO: INTACT. DENIES PAIN. MAE.\nCV: NSR, NO ECTOPY. TMAX 99.0. CONT ON NEO AT 1MCG/KG/MN TO KEEP MAP>60. WEIGHT 75.9KGS TODAY.\nPULM: LS BRONCHIAL RIGHT UPPER LOBES, DECREASED BUT CLEAR ON LEFT. USING IS. CT CHAMBER CHANGED. STILL DRAINING SEROUS FLUID. 2LNC SATS 99%. STRONG COUGH.\nGI: BENIGN. INSULIN GTT OFF. ON LANTUS REGIMEN. BS LOW OF 60 WHEN INSULIN GTT STOPPED. BS TRENDING UPWARDS. MIDNOC 76. CURRENT BS PENDING.\nGU/RENAL: UO HAS IMPROVED OVN. VENOUS PH 7.29. NO ARTERIAL LINE. ?CHECK ABG IN AM. BUN/CREAT PENDING. STARTED ON ALUMINUM HYDROXIDE. PLEASE GIVE WITH MEALS TO MAXIMIZE PHOSPHATE BINDING.\nPLAN: ATTEMPT TO WEAN NEO. INCREASE ACTIVITY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-09 00:00:00.000",
"description": "Report",
"row_id": 1581491,
"text": "FULL CODE Universal Precautions\nAllergies: Cefepime\n\n\nNeuro: AAOx3, MAEx4. OOB to chair w/ assistance.\n\nCV: Remains on neo at .5mcg/kg/min. Attempted to wean to off, but MAP <60 (57). Currently BP=110/120/40-50s, and even back on .5mcg of neo will dip to 96/. HR=80s, NSR, no ectopy. Weak periph pulses, extrems warm, no edema. 2 middle CT d/c'd this am and pleural CT remains - serosang drainage (70cc since 9am for pleural tube alone).\n\nResp: 2l n/p w/ 02sat 96%, drops to hi 80s when on r/a. C/DB done w/ dry cough, using IS to 750. Lungs - bronchial in right fields anteriorly, but clear post, diminshed in L fields w/ crackles in the lest base this afternoon.\n\nGI/GU: Abd soft, +BS, no BM. TAking liquids well, but not much solid. Foley cath w/ clear yellow urine which was 70-100cc/hr prior to 11am. Since then, u/o has dropped off to 20-30cc/hr. Dr. aware and pt was seen by renal this am. BUN/Cr=54/2.9. Renal d/c'd scheduled lasix and assessed by renal again this afternoon and they do not want to give lasix and eill continue to monitor pt. Pt also noted to have crackles in R bases this afternoon). He is taking quite a bit fluids/mouth and is +600cc since 12am.\n\nPain: Med this am w/ MS04 by night nurse discomfort and pt then required additional percocet for CT removal. He was able to move well and get in and out of bed w/o pain. Med again at 3pm w/ percocet 2 tabs w/ good effect.\n\nSkin: incisions/dressings intact. CT sites intact. Buttocks/back intact.\n\nID: Afebrile, altho WBC=22. Not on antibx.\n\nAccess: RIJ CL.\n\nLabs: FS at 1200 = 258. Lantus was not given in am (usually it's given in pm). Lantus was given at 12pm and will be given in am as this is when the pt usually takes it.\n\nPlan: Monitor fluid status, resp status. Adm pain med prn for comfort. Monitor BP and attempt to wean neo off. Monitor CT/drainage. Monitor blood sugars.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-10 00:00:00.000",
"description": "Report",
"row_id": 1581492,
"text": " B:\n\nNeuro: alert and oriented x3, mae, oob to chair, following commands correctly.\n\nCardiac: nsr no ectopy, neo for bp, palpible pedial pulses, skin warm dry and intact, a-febrile, + 1 edema in extremities.\n\nResp: crackles in bases bilat, on 3 liters nc satting at 99%, is coughing and deep breathing and using i/s, no leak in ct system draining scant serosang.\n\nSkin: chest with steri strips is cdi, bilat legs with dsds that are cdi, ct dsds cdi.\n\nGi/Gu: tolerating po's good bowel sounds, abd soft round and nontender, is on riss, making around 20 cc/hr of u/o.\n\nPlan: wean neo, monitor u/o, monitor blood sugars, increase activity.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-10 00:00:00.000",
"description": "Report",
"row_id": 1581493,
"text": "CSRU Nursing Progress Note\nNeuro: Pt A&O x3. Pt OOB for multiple hours. Pt c/o dizziness and overall chest pain, pt tx with percocet that dropped pts BP. Pt feels very poor today. Pt able to stand with minimal assistance.\n\nCardiac: Pt in SR/ST HR 80-100 no ectopy. BP 91-134/34-58. PTs BP dropped s/p percocet. Pt given 2U PRBC for low u/o and low BP. Some, but minimal effect on either. Pt on and off Neo all day only at .1mcg/k/min. Pt currently off.\n\nResp: Pt on 2L NC with O2 sat 96-97% BS clear in upper airway bilaterally rales in bases and greatly decreased in LLL. Pt had CT DC'd today. Pt need much encouragement with IS! Pt able to cough well, non-productive however.\n\nGI: Pt has poor appetite, hypoactive BS, -BM.\n\nGU: PT has f/c with poor u/o, pt recieved blood. Pt painting an increasing renal failure picture, lytes and creatnine. Pt remains edematous throughout.\n\nEndo: No coverage needed via RISS.\n\nAccess: Pt has R IJ trauma TL. Kept in place due to BP issues and blood.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-07 00:00:00.000",
"description": "Report",
"row_id": 1581487,
"text": "PROB: CABG\n\nCV: SR NO ECTOPY NOTED. CT DRAINING S/S DRAINAGE. DOBUTMAINE WEANED TO OFF, TOLERATED WELL. NEO TITRATED TO KEEP SBP>100. CO/CI GOOD. CCO D/CD. MEDICATED FOR PAIN WITH PERCOCET WITH FAIR EFFECT, MSO 2MG WITH IMPROVED EFFECT.\n\nRESP: LUNGS CLEAR. O2 SATS ADEQUATE.\n\nGU: K CLIMBING. 250 NS BOLUS GIVEN WITH REPEAT K <5.0. UOP MARGINAL GIVEN LASIX WITH POOR EFFECT.\n\nGI: APPETITE POOR. STARTING TO TAKE LIQUIDS. NO C/O N/V.\n\nNEURO: ALERT AND ORIENTED X3.\n\nENDO: BLOOD SUGARS PER FLOW SHEET. INSULIN DRIP RESTARTED, PRESENTLY OFF.\n\nASSESSMENT: RENAL STATUS TENUOUS\n\nPLAN: CONT.\nMONITOR LYTES/BS/ABGS\nMONITOR UOP\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-08 00:00:00.000",
"description": "Report",
"row_id": 1581488,
"text": "shift update:\n\nneuro: a&o x3. mae. able to turn in bed w/minimal assist. c/o pain medicated w/percocet 2 tabs w/good effect.\n\ncardiac: nsr. no vea. attempted to wean neo->unable d/t sbp<90. neo currently at 0.25mcg/kg/min. k+ 5.6->team aware. tmax 100.3->wbc 24 this am. ct w/mod amt ss drainage.\n\nresp: lungs clear. lll diminished. sat's92-98% on 4l nc. pt encouraged to cdb & use is. abg=>po2 69-80 team aware. abg pending. cpt done. -sputum.\n\ngi/gu: tolerating sips of h2o. uop minimal. poor effect from lasix.\nbun/creat ^ 40's/2.8. team aware.\n\nendo: bs tx'd w/ssri per protocol.\n\nsocial: friend into visit last evening.\n\nplan: pain management. wean neo as tolerates. aggressive pulmonary toilet. advance diet as tolerates. bs per protocol. monitor uop.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-14 00:00:00.000",
"description": "Report",
"row_id": 1581502,
"text": "Nursing note\nNeuro: A+O x3, spekaing fluent spanish with another RN. Understands most English. Fooolws commands. Pain excalating with movement, i.e. back to bed. Po dilaudid x2 and one time dose of sq dialudid with effect.\nCV: SR, no ectopy. SBP 130-180s with pain. NP. OOB to chair most of AM, assisted back to bed with minimal assist. Periph line replaced secodnary to redness at old site.\nRESP:LS coarse to clear. LL lung sounds absent. Bronch scheduled for 5p. o2 sat 95-98% on 3lNC. IS done with encouragement. CPT q4. no sputum.\nGI: Abd soft,nt,nd. +BS, No BM. No n/v. complaints of \"hungry\", NPO for bronch.\nGU:foley patent cloudy urine with some sediment. urine cx pending.\nENDO: BS remains <100. Lantus given as scheduled. NP of cont'd low BS.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-14 00:00:00.000",
"description": "Report",
"row_id": 1581503,
"text": "Respiratory Care:\n\nPt. had a bronkoscopy this PM due to white out on L.\nthere were no plugs but the airways are very collapsable with just normal resps. A sample was obtained and sent for C+S and GM ST.\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-15 00:00:00.000",
"description": "Report",
"row_id": 1581504,
"text": "NEURO: ALERT AND ORIENTED TO TIME, PLACE AND EVENTS. MAE, FOLLOWS COMMANDS. \"I FEEL GOOD.\" DILAUDID 2MG PO X 2 FOR PAIN.\n\nPULM: L LUNG BRONCHIAL, DIMINISHED BASE. R LUNG DIMINISHED BASE, CLEAR APICES. Q2H BILATERAL CHEST PT, GOOD COUGH EFFORT AND USE OF IS TO 500CC. WBC UP TO 24K. AFEBRILE. SATS > 95%, PO2 ON 3L 79 AT AND 126 AT 0400. 02 VIA N/C DECREASED TO 2L.\n\nCV: NSR WITHOUT ECTOPY. MAP > 110 BEFORE LOPRESSOR GIVEN AT , DOWN TO 70'S 2H AFTER LOPRESSOR. LOW MAP OF 55 WITH SBP 85 WHEN ASLEEP. R RADIAL A-LINE DAMPENED, UNABLE TO ASPIRATE BLD, ASPIRATING AIR. A-LINE DC'D. 2 GMS CA GLUC IV X 1.\n\nSKIN: MULTIPLE SKIN TEARS OVER BODY FROM TAPE. STERNAL INCISION WITH STERI-STRIPS, INCISION ERYTHEMIC, NO DRAINAGE. LEVOFLOXIN 250 PO STARTED AT . WBC RISING TO 24K.\n\nENDO: SSRI COVERAGE. 2200 BS 172, RX WITH 4 UNITS. 4AM BS 71, CRANAPPLE JUCE GIVEN.\n\nGI: + BS. + FLATUS, NO BM. COLACE AS ORDERED.\n\nGU: FOLEY TO CD DRAINING AMBER COLORED URINE WITH LARGE AMTS DK BROWN SEDIMENT. IRRIGATED WITH 30CC STERILE H20 WITH 30CC RETURN. BUN 68/CREAT 2.4. HX CRI.\n\nSOCIAL: FRIEND .\n\nPLAN: CONTINUE BILATERAL CHEST PT Q2H WITH COUGH,DB AND IS USE. OOB TO CHAIR MOST OF TIME. AMBULATE AT LEAST QID. ? NEED FOR NEW A-LINE TO MONITOR PULM STATUS.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-06 00:00:00.000",
"description": "Report",
"row_id": 1581483,
"text": "RESPIRATORY CARE: PT. IS S/P CABG TODAY.\nFROM OR TO CSRU. 7.5 ORAL ETT @ 24 LIP.\nINITIAL VENTILATOR SETTINGS WERE SIMV\n12/700/1.0/5/5. PT. PROBABLY TO BE\nWEANED AND EXTUBATED LATER.\n\n , RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2126-03-06 00:00:00.000",
"description": "Report",
"row_id": 1581484,
"text": "ALTERED CARDIAC STATUS\nO: CARDIAC:SR 80-90'S WITH ISOLATED PVC'S NOTED. SBP 100-110'S TRANSIENT NEO REQUIRED PRESENTLY OFF. CI >2.13 , SVO2 50'S RECIEVED 2300 LR, REPEAT HCT 28.6 THEREFORE RECIEVED 1UP WITH SVO2 60-70'S. DSG WITH SMALL SANGIUNOUS DRAINAGE NOTED. FEET WARM TO TOUCH. DP RIGHT, PT LEFT. CT DRAINING MINIMAL AMOUNTS 270 ML DUMP WITH TURN VERY SEROUSY. TOTAL CT DRAINAGE 700ML. LYTES NL. DOBUTAMINE INCREASED TO 5 MCQ @ 1800.\n RESP: PRESENTLY ON CPAP 12/5 TO WEAN TO EXTUBATE. O2 SATS >99%. BS COURSE TO CLEAR UPPER, SX FOR SCANT. + CT LEAK. RR 20'S.\n NEURO: REVERSED AND PROPOFOL OFF , AWOKE CALM, FOLLOWING COMMANDS, MAE, PUPILS = INITIALLY SLUGGISH PRESENTLY BRISK.\n GI: OGT + PLACEMENT, DRAINING 100 ML GREEN BILIOUS DRAINAGE. ABD SOFT NONTENDER, ABSENT BOWEL SOUNDS.\n GU: GOOD DIURESIS, PRESENTLY SLOWING. CREAT PREOP 2.2 POST 1.6\n ENDO: INSULIN GTT\n ID: VANCO\n PAIN: MSO4 2 MG X3\n SOCIAL: BROTHER AND FAMILY INOT VISIT.\nA: DECREASED SVO2 RESPONDED TO INCREASED DOBUTAMINE TO 5 MCQ FROM 3 MCQ + IUPC, WEANING PRESENTLY, CALM.\nP: MONITOR COMFORT, HR AND RYTHYM, SBP, SVO2 ,CI, CT DRAINAGE, DSGS, PP, RESP STATUS WEAN TO EXTUBATE, NEURO STATUS, I+O, LABS, IF EXTUBATED SOON WEAN DOBUTAMINE AT 0500 PER DR. .\n"
},
{
"category": "Echo",
"chartdate": "2126-02-27 00:00:00.000",
"description": "Report",
"row_id": 60737,
"text": "PATIENT/TEST INFORMATION:\nIndication: Evaluation wall motion. Valve\nHeight: (in) 65\nWeight (lb): 148\nBSA (m2): 1.74 m2\nBP (mm Hg): 170/80\nHR (bpm): 103\nStatus: Outpatient\nDate/Time: at 11:00\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 mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis moderately depressed.\n\nLV WALL MOTION: The following resting regional left ventricular wall motion\nabnormalities are seen: basal inferoseptal - hypokinetic; mid inferoseptal -\nhypokinetic; basal inferior - hypokinetic; mid inferior - hypokinetic; mid\ninferolateral - hypokinetic; septal apex - hypokinetic; inferior apex -\nhypokinetic; lateral 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) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: Mild to moderate (+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: Physiologic tricuspid regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is moderately depressed. Resting regional wall motion\nabnormalities include inferior, inferolateral and inferoseptal hypokinesis.\nRight ventricular chamber size and free wall motion are normal. The aortic\nvalve leaflets (3) appear structurally normal with good leaflet excursion and\nno aortic regurgitation. Mild to moderate (+) mitral regurgitation is seen.\nThere is no pericardial effusion.\n\nCompared with the findings of the prior report (tape unavailable for review)\nof , the LV function has decreased while the MR is less.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 819868,
"text": " 8:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess infiltrates\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o CAD s/p cabg x4\n\n REASON FOR THIS EXAMINATION:\n assess infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease status post CABG.\n\n VIEWS: An erect AP view compared with upright AP view from .\n\n FINDINGS: The patient is status post median sternotomy and CABG. There is\n persistent left lower lobe collapse/consolidation with small left pleural\n effusion. Mild patchy atelectasis is also present at the right base. The\n cardiac and mediastinal contours remain stable. The pulmonary vascularity is\n within normal limits. No pneumothorax is identified.\n\n IMPRESSION: Stable appearance of left lower lobe collapse/consolidation and\n small left pleural effusion. Continued patchy atelectasis at the right base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 819694,
"text": " 2:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: +\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o CAD s/p cabg x4\n\n REASON FOR THIS EXAMINATION:\n s/p d/c ct x1\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: S/P CABG and removal of chest tubes.\n\n The left chest tube has been removed. There is no evidence of pneumothorax.\n There is obscuration of the left hemidiaphragm and evidence of an air\n bronchogram behind the heart suggesting a left lower lobe consolidation.\n Blunting of the left costophrenic angle is present. This is also present on\n the right indicating bilateral effusions.\n\n IMPRESSION: No pneumothorax. Left lower lobe consolidation. Bilateral\n effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 819722,
"text": " 4:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o chf\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o CAD s/p cabg x4\n\n REASON FOR THIS EXAMINATION:\n r/o chf\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: CAD, s/p CABG surgery. r/o chf.\n\n A SINGLE AP SEMI-UPRIGHT VIEW: Comparison study .\n\n There is again evidence of a recent CABG surgery and there is also persistent\n left lower lobe collapse/consolidation and a small left pleural effusion on\n the left side. The left diaphragm is elevated. The right lung shows some\n minor atelectatic changes in the basal segments of the right lower lobe. A\n small effusion is also present on the right side. A right central line is\n noted with tip in the upper SVC. Two extremely thin lines extend upwards from\n the lower portions of the stomach and over the left hemithorax. Their nature\n is uncertain. Clinical correlation would help.\n\n IMPRESSION:\n 1) S/P CABG surgery.\n\n 2) Left lower lobe collapse/consolidation and a small left effusion are\n demonstrated. A trace effusion is also present on the right side.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 819390,
"text": " 10:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/L sided collapse on previous CXR-please evaluate\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o CAD s/p cabg x4\n\n REASON FOR THIS EXAMINATION:\n s/p CABG w/L sided collapse on previous CXR-please evaluate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left-sided lung collapse on prior chest x-ray.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT PORTABLE CHEST: There is improved aeration in the left lung\n in the upper lobe. There is persistent left lower lobe collapse. Chest tubes\n and mediastinal drains are unchanged. A PA catheter terminates with its tip\n in the main pulmonary artery. There is effusion on the right. The right lung\n is grossly clear. There is no pneumothorax.\n\n IMPRESSION: Improving aeration in the left lung, but with persistent left\n lower lobe collapse.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 819477,
"text": " 6:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/decreased BS-r/o effusion\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o CAD s/p cabg x4\n\n REASON FOR THIS EXAMINATION:\n s/p CABG w/decreased BS-r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: CABG.\n\n S/P CABG. Cordis catheter overlies upper SVC. Mediastinal and both chest tubes\n in situ. No pneumothorax. There is opacity at the left base obscuring the left\n hemidiaphragm likely due to a combination of left pleural effusion and\n atelectasis/consolidation in left lower lobe. Linear atelectasis is present in\n the left mid zone. Small right pleural effusion.\n\n IMPRESSION: No pneumothorax. Atelectasis/consolidation left base and small\n bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 819982,
"text": " 9:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess lll collapse\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o CAD s/p cabg x4\n\n REASON FOR THIS EXAMINATION:\n assess lll collapse\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: S/P CABG.\n\n SEMI-UPRIGHT AP VIEW is compared with ap view from .\n\n FINDINGS: Patient is s/p median sternotomy and CABG. The cardiac and\n mediastinal contours remain stable. Persistent left lower lobe\n collapse/consolidation as well as probable atelectasis of the inferior segment\n of the lingula. A small left pleural effusion is also present. The pulmonary\n vascularity is within normal limits. The right lung remains grossly clear.\n No pneumothorax is identified.\n\n IMPRESSION: Stable left lower lobe collapse/consolidation with small left\n pleural effusion. Probable collapse inferior segment of lingula.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 818976,
"text": " 2:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for acute pulm edema.\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o CAD with severe 3VD awaiting CABG now with acute SOB,\n diaphoresis and ST-depressions\n REASON FOR THIS EXAMINATION:\n Please assess for acute pulm edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: SOB and diaphoresis.\n\n PORTABLE AP CHEST: Comparison is made to previous films from .\n\n The heart is mildly enlarged. There is vascular engorgement and diffuse\n perihilar haziness. Small pleural effusions are present bilaterally. As\n compared to the recent study, the degree of CHF is slightly worsened. However,\n areas of previously noted bibasilar confluent opacification, previously\n attributated atelectasis have improved significantly.\n\n IMPRESSION: CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 819308,
"text": " 4:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: postop film\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with h/o CAD s/p cabg x4\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM.\n\n History of CABG.\n\n Status post CABG. The endotracheal tube is in the right main bronchus. The\n Swan-Ganz catheter is in the right main pulmonary artery. Mediastinal and\n left chest tubes in situ. No pneumothorax. There is total opacity of the\n left hemithorax with a shift of the heart to the left consistent with collapse\n of left lung and probable associated layering left pleural effusion.\n\n IMPRESSION: Endotracheal tube is in right main bronchus and there is collapse\n of the left lung and probable associated left pleural effusion. The heart is\n shifted to the left (even allowing for rotation). No pneumothorax.\n (Findings discussed with by telephone.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-14 00:00:00.000",
"description": "CT CHEST W/O CONTRAST",
"row_id": 820114,
"text": "\n CT CHEST W/O CONTRAST Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with s/p CABG\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post CABG. Abnormal chest x-ray. Evaluate for pneumonia.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n TECHNICAL NOTE: Patient has difficulty following breathing instructions.\n\n FINDINGS: There are small bilateral pleural effusions and there is left lower\n lobe collapse. Superimposed infection cannot be excluded. The mid and upper\n lung zones are grossly clear allowing for respiratory motion artifact. There\n is borderline malacia in the bronchi and distal trachea, though this is not a\n dedicated tracheal study. Epicardial pacing leads are noted and the patient\n is post-CABG. There is cardiomegaly. There is a small amount of fluid in the\n paracardium and anterior mediastinum, not unexpected this recently postop. The\n imaged portions of the upper abdomen reveal a distended gallbladder and no\n other significant findings. The bones are unremarkable with satisfactory\n appearing sternotomy.\n\n IMPRESSION:\n 1) Bilateral pleural effusions and left lower lobe atelectasis, likely\n postoperative in etiology. A superimposed infection at the left base is not\n entirely excluded.\n 2) Distended gallbladder without secondary signs of inflammation. If the\n patient has unexplained infectious symptoms, targeted ultrasound of the\n gallbladder can be considered.\n 3) Once the patient recovers from this hospitalization, and if there is a\n history of chronic cough or recurrent pulmonary infection, a dedicated trachea\n CT could be performed as an outpatient to better establish the presence or\n absence of tracheobronchomalacia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-15 00:00:00.000",
"description": "ABDOMEN U.S. (COMPLETE STUDY)",
"row_id": 820221,
"text": " 1:50 PM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: DISTENDED GB SEEN ON CT, RULE OUT CHOLECYSTITS\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old man with dilated gallbladder and rising WBC\n REASON FOR THIS EXAMINATION:\n r/o cholecystitis\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increased white blood count.\n\n FINDINGS:\n\n The liver is normal in size and echogenicity without focal mass. The portal\n vein is patent with proper direction of flow. No intra or extrahepatic\n biliary ductal dilatation.\n\n The gallbladder demonstrates normal wall thickeness without pericholecystic\n fluid or calculus.\n\n The right kidney measures 12.2 cm in length while the left kidney measures\n 12.0 cm in length. No hydronephrosis bilaterally.\n\n The spleen is normal in size and echogenicity. The pancreas is normal in\n echogenicity.\n\n Incidental note is made of a right pleural effusion.\n\n IMPRESSION:\n\n 1) No son evidence of acute cholecystitis.\n\n 2) Right pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-21 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 820892,
"text": " 2:40 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC for home IV antibiotics. IV nurse attempted and failed\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\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 55 year old man with\n REASON FOR THIS EXAMINATION:\n PICC for home IV antibiotics. IV nurse attempted and failed on the floor.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY/INDICATION: A 55-year-old man for PICC line placement for home IV\n antibiotics.\n\n PROCEDURE: The procedure was performed by Drs. (the attending\n radiologist) and .\n\n The left upper arm was prepped and draped in sterile fashion. Since no\n suitable superficial veins were present, ultrasound was used for localization\n of a suitable vein. The basilic vein was patent and compressible. After\n local anesthesia with 2 cc of 1% Lidocaine, the basilic vein was entered under\n ultrasonographic guidance with a 21-gauge needle. A 0.018 guide wire was\n advanced under fluoroscopy into the superior vena cava. Based on the markers\n of the guide wire, it was demonstrated that a length of 37 cm would be\n suitable. The PICC line was trimmed to length and advanced over a 4-French\n Introducer sheath under fluoroscopic guidance into the superior vena cava. The\n sheath was removed. The catheter was flushed. A final chest x-ray was\n obtained. The film demonstrates the tip to be in the superior vena cava just\n above the atrium. The line is ready for use. A Stat- Lock was applied and\n the line was hep-locked.\n\n IMPRESSION: Successful placement of a 37 cm total length 4-French single-\n lumen PICC line with its tip in the superior vena cava, ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 820741,
"text": " 10:47 AM\n CHEST (PA & LAT) Clip # \n Reason: assess L pleural effusion\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55M POD 11 s/p CABG.\n\n REASON FOR THIS EXAMINATION:\n assess L pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Assess left pleural effusion post CABG.\n\n COMPARISON: .\n\n PA AND LATERAL CHEST: The appearance is unchanged with bilateral pleural\n effusions, left greater than right, and continued left lower lobe collapse.\n There is a slight decrease in the degree of congestive heart failure.\n\n IMPRESSION: Slight decrease in CHF with persistent effusions and left lower\n lobe collapse.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-18 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 820490,
"text": " 11:00 AM\n CHEST (PA & LAT) Clip # \n Reason: s/p CABG c high WBC\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55M POD 11 s/p CABG.\n\n REASON FOR THIS EXAMINATION:\n s/p CABG c high WBC\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Elevated white blood cell count. Status post coronary\n artery bypass surgery.\n\n Comparison is made to chest radiograph.\n\n The patient is status post median sternotomy and coronary bypass surgery.\n Allowing for patient rotation, cardiac and mediastinal contours are stable and\n are postoperative. There is mild vascular engorgement and perihilar haziness.\n There remains dense opacification in the left retrocardiac region as well as\n a moderate to large left pleural effusion. A small right pleural effusion is\n also present and appears unchanged. No pneumothorax is identified.\n\n IMPRESSION:\n\n 1) Moderate to large left pleural effusion, stable. Persistent adjacent left\n retrocardiac opacity, which may be related to either atelectasis or pneumonia.\n 2) Mild congestive heart failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2126-03-17 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 820397,
"text": " 2:15 PM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate for pneumona/CHF.\n Admitting Diagnosis: CLAUDICATION\\AA RUNOFFS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55M POD 11 s/p CABG.\n REASON FOR THIS EXAMINATION:\n Evaluate for pneumona/CHF.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 14:15:\n\n INDICATION: Post-op CABG.\n\n COMPARISON: .\n\n FINDINGS: Compared to the prior study there is substantial accumulation of\n left pleural fluid increased from prior. A small amount of right pleural\n fluid is seen tracking up laterally. The pulmonary vascular markings are\n within normal limits. Note that the left hemidiaphragm is obscured indicating\n air space disease at the left base - atelectasis vs. pneumonia. Upper lungs\n are clear. Cardiac and mediastinal contours are unchanged.\n\n IMPRESSION:\n\n Enlarging left pleural effusion. Persistent air space disease at the left\n base.\n\n"
},
{
"category": "ECG",
"chartdate": "2126-03-19 00:00:00.000",
"description": "Report",
"row_id": 109407,
"text": "Sinus rhythm. Inferior myocardial infarction probably old. Since the previous\ntracing of there may be no significant change but baseline artifact on\nprevious tracing makes comparison difficult.\n\n"
},
{
"category": "ECG",
"chartdate": "2126-03-11 00:00:00.000",
"description": "Report",
"row_id": 109408,
"text": "Sinus rhythm. Prior inferior myocardial infarction. There is wandering\nbaseline. Non-specific lateral ST-T wave flattening. Compared to the previous\ntracing of slight ST segment elevation persist without diagnostic\ninterim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2126-03-07 00:00:00.000",
"description": "Report",
"row_id": 109409,
"text": "Sinus rhythm\nInferior infarct, age indeterminate\nDiffuse ST-T wave abnormalities with ST elevation - consider pericarditis or in\npart ischemia\nClinical correlation is suggested\nSince previous tracing of , further ST-T wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2126-03-06 00:00:00.000",
"description": "Report",
"row_id": 109410,
"text": "Sinus rhythm\nProbable inferior infarct, age indeterminate\nDiffuse ST-T wave changes with modest ST elevation - cannot exclude in part\nischemia and/or pericarditis\nClinical correlation is suggested\nSince previous tracing of , further ST-T wave changes present\n\n"
},
{
"category": "ECG",
"chartdate": "2126-03-04 00:00:00.000",
"description": "Report",
"row_id": 109411,
"text": "Sinus rhythm with slowing of the rate as compared to the previous tracing\nof . In addition, the ischemic appearing ST segment abnormalities in\nleads V3-V6 have resolved without diagnostic interim change. There is prior\ninferior myocardial infarction.\nTRACINBG #2\n\n"
},
{
"category": "ECG",
"chartdate": "2126-03-04 00:00:00.000",
"description": "Report",
"row_id": 109412,
"text": "Sinus tachycardia. Non-specific ST-T wave flattening in the limb leads. There\nare ST segment depressions in leads V3-V6 that is downsloping in leads V4-V6\nconsistent with acute lateral ischemic process in the context of left\nventricular hypertrophy. Rule out myocardial infarction as compared to the\nprevious tracing of . Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2126-03-01 00:00:00.000",
"description": "Report",
"row_id": 109413,
"text": "Sinus tachycardia. Prior inferior myocardial infarction. Compared to the\nprevious tracing of there is interim inferior wall myocardial\ninfarction. Clinical correlation is suggested.\n\n"
}
] |
6,996 | 104,941 | In the Medical Intensive Care Unit, the patient's hypotension responded well to boluses of intravenous fluid. The following day he was ready for transfer to the floor. The patient did well on the floor tolerating a regular diet by his second day on the floor. He had an abdominal CT scan to rule out pancreatic phlegmon and had no abdominal tenderness. His lipase and amylase trended steadily downward. In addition, his blood urea nitrogen and creatinine returned toward their baseline values with a creatinine on the day of discharge being 2.1. The patient was discharged in stable condition. He will follow-up with Doctor one week after discharge. | First degree A-V delay.Intraventricular conduction delay. Ventricular premature beats. T wave inversions in leads I and aVL, withT wave inversions and ST segment depressions in leads V4-V6 possibly consistentwith ongoing anterolateral ischemia. Sinus rhythm. | 1 | [
{
"category": "ECG",
"chartdate": "2129-01-22 00:00:00.000",
"description": "Report",
"row_id": 148181,
"text": "Sinus rhythm. Ventricular premature beats. First degree A-V delay.\nIntraventricular conduction delay. T wave inversions in leads I and aVL, with\nT wave inversions and ST segment depressions in leads V4-V6 possibly consistent\nwith ongoing anterolateral ischemia. Clinical correlation is suggested.\nCompared to the previous tracing of the changes are new.\n\n"
}
] |
20,981 | 152,367 | Patient was transferred from Hospital to the ER with a small bowel obstruction. She was admitted to the SICU because she is a C5 quadriplegic and is on chronic ventilator support at night. Her small bowel obstruction was managed non-operatively with IV hydration, an NG tube, and keeping the patient NPO. A CT on demonstrated contrast throughout the small bowel suggesting a partial SBO. In the SICU she initially had high NG tube and she was unable to tolerate NG tube clamping trails. Her output decreased on and her NGT was removed. It was replaced however on due to nausea, abd pain. She did pass stool x3 on but continued to have high NG output. On she was started on total parenteral nutrition due to the fact she remained NPO. Her NGT output varied and she was started on tube feeds via the NGT on because the patient was reporting being hungry. On her NG output was markedly decreased and the NG was removed. She was then started on sips of liquid diet which she tolerated. She was transitioned to a regular diet on and tolerated it without any further N/V or abd pain. Her PO intake was adequate and the TPN was stopped on . In addition to the SBO she was transfused 2 units of blood on for anemia and a follow up hematocrit demonstrated an adequate response. While in the unit she was ventilated at night according to her regular home settings. She also had wound care consisting of dressing changes to a sacral and buttock pressure ulcer. She also came in with a chronic left hip wound with osteomyelitis. While in hospital she was continued on IV nafcillin for the osteomyelitis and had wound vacuum changes every Monday Wednesday and Friday. On she was discharged home with a PICC line and IV Nafcillin. She was discharged with the same ventilator settings and wound care protocol that she came in to the hospital with. She was instructed to follow up with Dr. in 2 weeks and she was given prescriptions for home health care. She was also provided instructions to call her Dr. for any recurrence of symptoms of nausea, vomiting or abdominal pain. | Dense left retrocardiac opacity, likely a combination of atelectasis and effusion appear unchanged. Similar left basilar opacity with bilateral effusions. NGT clamped and residuals checked q 4hours. CT PELVIS WITH CONTRAST: A small amount of free fluid is noted within the pelvis. Resp Care,Pt. Nursing Note 7p-7a:Afebrile. CT ABDOMEN WITHOUT CONTRAST: Exam is somewhat compromised by patient arm positioning. Respiratory CarePt remains trached (#7.0 TTS). Lungs clear with diminished bases; on and off of ventilator and suctioned frequently by RT and given breathing treatments as needed by RT as well. A right-sided PICC line terminates in the upper superior vena cava. Nasogastric tube terminates below the diaphragm, and left subclavian catheter terminates in superior vena cava. CHEST, SEMI-UPRIGHT AP: Comparison is made to . There is cardiomegaly and bilateral pleural effusions with obscuration of the left hemidiaphragm likely due to a combination of left pleural effusion and atelectasis in the left lower lobe unchanged since the prior film of . TECHNIQUE: Non-contrast axial images of the abdomen and pelvis were obtained with multiplanar reformatted images. INDICATION: Nasogastric tube position. NGT continues with lg outputs and replaced with LR cc:cc. Question small-bowel obstruction. Persistent retained contrast within a dilated right renal collecting system extending down to the neobladder. Lung sounds were course to clear t/o. Cardiac silhouette remains enlarged. HR NSR to ST 103 with pain/anxiety only. Pleural thickening along the right lateral lower chest is likewise unchanged. There is slight rotation of the tracheostomy, compared to earlier studies. EKG done and lytes sent. NGT clamped; residual checked q6hr. Trach care performed. Trach capped this AM. NGT to suction this a.m. repleting cc per cc with LR. ABDOMEN SOFT, NGT RESIDUALS HIGH THIS AM. Dr. notified. CC:CC REPLETION RESTARTED, CVP APPROX . CPT done. NGT placement verified by CXR. Check NGT residuals q6hr. Nebs given. Plan to trach in am. Dilaudid 2mg IV given with +effect. on vent o/n. ABDOMEN SOFT, NGT TO CONTINUOUS SUCTION @ BEGINNING OF SHIFT. Xopenex HHH given via mouthpiece PRN. Lytes repleted as indicated SS. Resp CarePt had a exsullflator tx and placed on vent. + BS x4 abd soft nt/nd. TPN with lipids @ 63cc/hr. SBP 80s-170s based on pt comfort level/ procedures ie suctioning. Abdomen softly distended with +bowel sounds. Hct 19.1; 2units PRBC ordered. Replete lytes as needed. pain medicated x1 w/ dilaudid 2mg iv w/ good releif. NGT output replaced cc:cc with NS q6hr. TRACH CAPPED AND PATIENT TOLERATING NASAL CANNULA (BASELINE). afebrile. Afebrile. AFEBRILE. Needs assistance using Yankauer suction. Transfuse 2units PRBC for Hct 19.1; monitor Hct closely. NPNPlease see carevue for further details.alert oriented x3 speech clear. Replace NGT output cc:cc with NS q6hr. MD aware. vss, pt alert and able to voice needs. VAC dressing changed today by MD. Left hip VAC dsg with small amount serosang drainage. HR 80s-100s (NSR/sinus tach; rare PVCs and occassional PACs). bs 120; taking mod amounts of po fluid. TPN with lipids infusing via central line. Bbs coarse to clear after suct. Lungs clear to coarse and suctioning with expectorator by RT. Exsullflator treatment done by RT and nebs administered a/o. SBP 90s-130s.RESP: LS clear/diminished. Given Dilaudid/Ativan with effect. Coccyx dressing c/d/i. Off vent most of day and nasal cannula off with good sats. Continues on Nafcillin and Erythromycin. Resp CarePt placed on vent after exsulfator tx. Tx'd with dilaudid with + result.CV: NSR with some PVCs. +BS hypoactive. Tmax 98.8.Skin: wound vac drsg hip area w serous drng.allevyn to buttocks.Bilat heel dsrg changed.Rt heel dry eschar->wound gel.Lt heel dry.A/P: Pulm toilet-> off vent during w np O2 as needed.Wound care.? DID MOVE BOWELS FROM BELOW AFTER DULCULOX SUPP. RESP. Nebs given. Resp CarePt placed on vent. speech clear when off vent and trach is capped. Chest PT by RT. NGT clamped. Nursing Note 7a-7p:Nursing Assessment:Afebrile. trach in am. Nebs given once. Respiratory care:63 y.o. Coccyx dressing changed with aquacel ag packing and allevyn over. Afebrile. Will go on the vent to-noc to rest. TREATMENTS GIVEN AS ORDERED. Abdomen soft and hypoactive bowel sounds. Abd soft, + BS. Will continue routine of having trachd during day, if tolerable. Frequent t&p.advance diet as indicated. on SIMV&PS overnight. monitor bowel status. NSR 70s SBP 110-130s. c/o abd. ShE was ready for the day atfer that and did the Vacuum Tx.x 3 more by the RT and some PM CPT. Plan to cap trach and place on nasl canulla in Am. NGT discontinued by Dr. . SOME ECTOPY THIS AM, K/MG REPLACED. Resp Care,Pt. Resp Care,Pt. L-GLUTEAL DECUB DSG/SACRAL DSG CHANGED BY CARE RN. Lungs coarse to clear, suctioned by RT. placed on SIMV overnoc, vent dependent. placed on SIMV overnoc, vent dependent. R-HIP VAC PATENT, DRNG SEROUS FLUID. LEFT HEAL DSG. CONT ICU PLAN OF CARE. Respiratory care:Pt W/xopenex x 2 today and had In-Exsuf. transfuse for hct. VAC CHANGE. Trach wnl. CV: Remains NSR-NST, occational PAC's noted. AFEBRILE, PALP PP. xopenex neb given once. bowel obstruction REASON FOR THIS EXAMINATION: ?interval change FINAL REPORT One supine radiograph of the abdomen was obtained. Coccyx with dsd, abraision. WITH AQUCEL DSD. CHECK AND REPLACE LYTES AS ORDERED. GI: Abd soft, NT, pos bs. Nursing Note 7a-7p:Nursing Assessment:Afebrile. L gluteal with dsd, packed, changed previously in day. Requiring dilaudid q3h for lt hip pain and prn ativan q6h. UpdateO: See carevue for specifics. Sats while trach capped prior to return to vent adeq, altho pt tiring just prior to return to simv mode on vent wslt tachypnea and tachycardia prior to being placed on vent for noc. Pt remained on vent d/t other issues at present w hypotension/tachypnea aft pain med. In-exsufflator x 1, xopenex x 1. Plan: Cont to monitor for n/v. SKIN/ CARE, ? | 61 | [
{
"category": "Radiology",
"chartdate": "2119-08-02 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 966169,
"text": " 1:07 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Assess line placement, pneumothorax\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with c5 fracture, bowel obstruction\n\n REASON FOR THIS EXAMINATION:\n Assess line placement, pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: C5 fracture and bowel obstruction. Assess line placement.\n\n CHEST, AP PORTABLE: There is a new left subclavian central venous catheter\n terminating in the lower superior vena cava. There is no pneumothorax.\n Otherwise, there has been no significant change since an earlier film of the\n same day.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-08-02 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 966228,
"text": " 5:59 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Follow up Ct See passage of contrast no IV Contrat, no requi\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with SBO\n REASON FOR THIS EXAMINATION:\n Follow up Ct See passage of contrast no IV Contrat, no requiered po contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Small-bowel obstruction, to evaluate for passage of contrast.\n\n COMPARISON: CT abdomen and pelvis from outside facility dated .\n\n TECHNIQUE: Non-contrast axial images of the abdomen and pelvis were obtained\n with multiplanar reformatted images.\n\n CT ABDOMEN WITHOUT CONTRAST: Exam is somewhat compromised by patient arm\n positioning. Bilateral right greater than left pleural effusions and collapse\n of the right lower lobe is noted at the lung bases. There is no evidence of\n pericardial effusion though the heart appears shifted into the left\n hemithorax.\n\n Non-contrast evaluation of the liver, spleen, pancreas and adrenal glands are\n limited but unremarkable. Layering high density within the gallbladder likely\n represents vicarious excretion of previously administered contrast. Persistent\n contrast within the right renal collecting system is noted with hydronephrosis\n and hydroureter extending down to the neobladder. The caliber of the right\n ureter demonstrates no short interval change. Multiple small hypoattenuating\n renal lesions are noted bilaterally and are too small to fully characterize.\n There is no evidence of left-sided hydronephrosis.\n\n The persistent diffusely dilated loops of small bowel demonstrate overall\n slight decreased in caliber compared to a day prior. Contrast is present\n within all loops of small bowel though it has been diluted secondary to\n enteric fluid likely suggesting a component of slow transit through the small\n bowel. Contrast is also noted throughout the colon down to the rectum. Stool\n and air are noted in the post-surgical proximal colon, distal colon, and\n rectum. The transverse colon appears collapsed. An NG tube courses into the\n stomach pointing towards the pylorus. Moderate intra-abdominal free fluid is\n located perihepatically and perisplenically, tracking amongst loops of small\n bowel and extending into the paracolic gutters. Overall, the amount of free\n fluid is perhaps slightly decreased compared to a day prior with persistent\n anasarcsa. No free air or pathologically enlarged lymph nodes are seen. There\n is no evidence of portal air or pneumatosis.\n\n CT PELVIS WITH CONTRAST: A small amount of free fluid is noted within the\n pelvis. Patient's neobladder demonstrates no short interval change with a\n suprapubic Foley catheter present and a small amount of intravesicular air.\n There is diverticulosis without evidence of diverticulitis.\n\n (Over)\n\n 5:59 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: Follow up Ct See passage of contrast no IV Contrat, no requi\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n BONES AND SOFT TISSUES: A moderately large right ischial ulcer and large left\n hip ulcer are again observed. There is diffuse osteopenia and muscular\n atrophy. Osseous deformity of the proximal hips bilaterally with marked\n heterotopic bone formation is unchnaged from recent prior. Heterotopic bone\n formation also involves the lumbar spine.\n\n IMPRESSION:\n 1. Diffusely dilated small bowel, overall decreased in caliber compared to a\n day prior with contrast present throughout the small bowel and colon,\n suggesting partial obstruction. There is no free air. Moderate free fluid is\n seen as described.\n 2. Persistent retained contrast within a dilated right renal collecting\n system extending down to the neobladder. Multiple small bilateral\n hypoattenuating renal lesions are too small to fully characterize.\n 3. Bilateral right greater than left pleural effusions and collapse of the\n right lower lobe.\n 4. Pelvic soft tissue ulceration and osseous deformity as described.\n 5. Diverticulosis without diverticulitis.\n 6. Anasarca.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-08-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 966090,
"text": " 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SBP, confirm PICC line placement\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with\n REASON FOR THIS EXAMINATION:\n SBP, confirm PICC line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 63-year-old woman with spontaneous bacterial peritonitis.\n Question PICC line placement.\n\n CHEST, AP UPRIGHT: Comparison is made to . A right-sided PICC line\n terminates in the upper superior vena cava. The patient is status post\n tracheostomy. A nasogastric tube enters the stomach, and passes inferior to\n the lower edge of the film, its tip not visualized. Residual contrast is\n present in the stomach. A dilated segment of small bowel is visualized in the\n left upper quadrant, but not fully characterized.\n\n The heart is enlarged, but unchanged. Mediastinal contours are similar. There\n is also similar non-specific left basilar opacity with bilateral effusions.\n Pleural thickening along the right lateral lower chest is likewise unchanged.\n Old left second and third rib fractures are noted.\n\n IMPRESSION: Satisfactory positioning of the PICC line. Similar left basilar\n opacity with bilateral effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-08-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 966631,
"text": " 7:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p NGT\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with c5 fracture, bowel obstruction s/p resiting of\n central line\n REASON FOR THIS EXAMINATION:\n s/p NGT\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST OF \n\n COMPARISON: .\n\n INDICATION: Nasogastric tube position.\n\n Nasogastric tube terminates below the diaphragm, and left subclavian catheter\n terminates in superior vena cava. Tracheostomy tube is in standard position.\n Cardiac silhouette remains enlarged. Recently reported left perihilar opacity\n has resolved, and there has also been improved aeration within the right lower\n lobe with improving effusion and atelectasis. Dense left retrocardiac\n opacity, likely a combination of atelectasis and effusion appear unchanged.\n Lung volumes remain increased suggestive of underlying emphysema.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-08-03 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 966356,
"text": " 12:06 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Assess for line placement\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with c5 fracture, bowel obstruction s/p resiting of central\n line\n REASON FOR THIS EXAMINATION:\n Assess for line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of cervical spine fracture with tracheostomy and CV line placement.\n\n Tracheostomy tube is 5 cm above the carina. Left subclavian CV line has tip\n located in distal SVC. NG tube is in body of stomach with distal end not\n included on film. Tip of right PICC line not clearly localized on this film\n due to overlying chest leads on the chest wall. There is cardiomegaly and\n bilateral pleural effusions with obscuration of the left hemidiaphragm likely\n due to a combination of left pleural effusion and atelectasis in the left\n lower lobe unchanged since the prior film of . There is a left\n perihilar opacity, new since the prior film, possibly due to atelectasis or\n evolving consolidation and which can be reevaluated on followup film.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-08-06 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 966766,
"text": " 12:30 PM\n PORTABLE ABDOMEN Clip # \n Reason: SBO? bowel gas pattern\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with high NGT output\n REASON FOR THIS EXAMINATION:\n SBO? bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN \n\n INDICATION: High nasogastric tube output. Question small-bowel obstruction.\n\n Examination is limited as it does not include the entirety of the abdomen,\n with exclusion of the superior and lateral portions.\n\n A relative paucity of gas is present in the abdomen with diffuse haziness and\n apparent bulging of the flanks, likely due to ascites, which has been\n documented on recent abdominal CT of four days earlier. There are no dilated\n loops of bowel to suggest an obstructive pattern, but correlative upright view\n may be helpful for more complete assessment. Surgical clips are present in\n the right lower quadrant. Unusual appearance of the right hip is noted with\n extensive heterotopic ossification and adjacent deformity. These areas were\n also evaluated on the recent CT examination.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2119-08-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 967817,
"text": " 11:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o consolidation\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with c5 fracture, bowel obstruction chronic vent\n REASON FOR THIS EXAMINATION:\n r/o consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 63-year-old woman with cervical spine fracture and bowel\n obstruction, on chronic ventilation. Question consolidation.\n\n CHEST, SEMI-UPRIGHT AP: Comparison is made to . The patient is\n status post tracheostomy. There is slight rotation of the tracheostomy,\n compared to earlier studies. This appearance can be seen with slight\n misalignment of deep and superficial incisions for tracheostomy insertion. A\n left subclavian central venous catheter terminates in the distal superior vena\n cava.\n\n Collapse of the left lower lobe is chronic, with mild leftward shift of\n mediastinum. Bilateral pleural effusions are also similar. Otherwise, there\n is similar hyperexpansion of the lungs, compatible with emphysema, as well as\n similar mild pulmonary venous congestion. The heart appears enlarged, but\n unchanged.\n\n IMPRESSION: Little significant change in cardiomegaly, bilateral pleural\n effusions and persistent extensive left lower lobe atelectasis.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-07 00:00:00.000",
"description": "Report",
"row_id": 1537733,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nPt is alert and orientated. Quadrapledgic requiring frequent assistance. Afebrile. Lungs clear with diminished bases; on and off of ventilator and suctioned frequently by RT and given breathing treatments as needed by RT as well. NGT continues with lg outputs and replaced with LR cc:cc. IVF decreased so that IVF + TPN equal 100cc/hr. Ducolax supp given this morning with BM x 2 to follow. HR NSR-ST with some pvc's. KCL given this morning for k 3.7; has been low frequently this admit and will continue to monitor for hypokalemia. BP labile sbp 80s-170s. Pain managed with dilauidid and ativan for anxiety with good effect. Please refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-07 00:00:00.000",
"description": "Report",
"row_id": 1537734,
"text": "BS CTAB; no change with nebs. Exsufflator x 2 with pt coughing up copious amounts of pale yellow - thick mucus. Briefly went back on vent during day but most of the time on nasal cannula 2-3 L. Will rest again on SIMV tonight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-08 00:00:00.000",
"description": "Report",
"row_id": 1537735,
"text": "Resp Care,\nPt. has trach capped during day, O2 3L. Given xopenex x 1 and inexsuffilator. C&R thick yellow sputum. Placed on SIMV overnoc per home vent settings. Slept thru noc. RSBI not done due to vent dependency. Plan cap trach during day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-09 00:00:00.000",
"description": "Report",
"row_id": 1537739,
"text": "Nursing Note 7p-7a:\nAfebrile. Slept on and off tonight: Med with dilaudid and ativan with good effect per pt requests. HR NSR to ST 103 with pain/anxiety only. SBP 80s-150s. UO adequate still with sediments. Lungs are clear to coarse and resting on vent tonight. Abdomen is soft and bowel sounds present. Ducolax supp given with no results thus far tonight. NGT clamped and residuals checked q 4hours. Residuals of 510 taken out at midnight and MD notified. Left clamped and rechecked at 4 am for 135. Will leave ngt clamped and continue to check residuals: >200cc will reattach ngt to lcws. Please refer to carevue for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-09 00:00:00.000",
"description": "Report",
"row_id": 1537740,
"text": "Respiraotry Care:\nPatient placed on ventilatory support at the beginning of the shift and remained so all night. NO xopenex or insuffillator Rx's given.\nNo abg results this am.\n\nRSBI = 79 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-09 00:00:00.000",
"description": "Report",
"row_id": 1537741,
"text": "Respiratory Care\nPt remains trached (#7.0 TTS). Pt remained on vent until noon and then capped. Pt has remained capped since. Lung sounds were course to clear t/o. Pt was able to expectorate sm thk yellow secretions w/the assist of the inexsuffilator. Pt received x2 of xopenex. Trach site remains stable no redness/swelling/pain. Care plan is to continue noc vent support, ? of PSV rather then SIMV, and continue to cap trach during the day. Will continue to follow pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-08 00:00:00.000",
"description": "Report",
"row_id": 1537736,
"text": "nursing note\nPt remians alert, mouthing words when on vent. Dilaudid for pain with effect. NGT clamped with minimal residuals, denies nausea. abd soft,nd. vac intact. Suprapubic catheter draining around entrance site, question secondary to severe sediment back up in foley, foley drained and no further leakage.\n\nPLAN:cont to monitor NGT residuals. Vac to be changed. dilaudid for pain, ativan for anxiety. trach collar thorughout day.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-08 00:00:00.000",
"description": "Report",
"row_id": 1537737,
"text": "BS CTAB. Xopenex neb x 1 without change. Exsufflator administered x 4 with pt coughing up large amounts thick pale yellow sputum. Also tracheal suction x 2 (pt's request) for mod to large amounts thick yellow mucus. Rested on vent x 1 hr for increased WOB. Rest overnight on vent starting @ hr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-08 00:00:00.000",
"description": "Report",
"row_id": 1537738,
"text": "NURSING NOTE\nASSESSMENT:\n PATIENT ORIENTED AND APPROPRIATE. GIVEN DILAUDID FOR NECK & HIP PAIN PER PATIENT. REQUIRED ATIVAN ONCE WITH FAIR EFFECT. HEART RATE 90-120 SINUS TACH. AFEBRILE. SBP RANGING 80-140'S, DEPENDING ON PATIENT'S COMFORT. CVP ~ 10, MAKING ADEQUATE URINE VIA SUPRAPUBIC TUBE (LEAKING AROUND SITE).\n LUNG SOUNDS MOSTLY CLEAR. PATIENT SUCTIONED BY RESP THERAPY, SEE RT NOTE). OFF VENT MOST OF THE DAY (REQUIRED VENT ASSISTANCE X 1 FOR 1-2 HOURS). RESP RATE 14-20'S, BREATHING UNLABORED OFF VENT. SP02 90'S WITH NASAL CANNULA.\n ABDOMEN SOFT, TPN FOR NUTRITION. BLOOD GLUCOSE WITHIN NORMAL RANGE. NGT CLAMPED AND RESIDUALS CHECKED EVERY 4 HOURS. RESIDUALS < 50 CC BROWN BILE. PATIENT COMPLAINING OF SLIGHT NAUSEA IN AFTERNOON, RESOLVED WITHOUT INTERVENTION. SEE FLOWSHEET FOR SKIN ASSESSMENT AND CARE.\nPLAN:\n NGT TO REMAIN IN PLACE UNTIL TOMORROW, CONTINUE WITH RESIDUAL CHECKS EVERY 4 HOURS. CONTINUE WITH SKIN CARE. PROVIDE SUPPORT TO PATIENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-09 00:00:00.000",
"description": "Report",
"row_id": 1537742,
"text": "NURSING NOTE\nASSESSMENT:\n PATIENT ORIENTED AND APPROPRIATE, GIVEN ATIVAN FOR ANXIETY PER PATIENT'S REQUEST. PATIENT ALSO COMPLAINING OF NECK & HIP PAIN, MEDICATED WITH DILAUDID AND POSITIVE EFFECT. HEART RATE 100-120'S SINUS TACH & SBP RANGING 90-160'S. AFEBRILE. MAKING ADEQUATE HOURLY URINE (SUPRAPUBIC TUBE). PATIENT ON VENT FOR APPROX 2 HOURS IN AM, OTHERWISE TOLERATING NASAL CANNULA. SEE RESP NOTE FOR ALL DETAILS. LUNG SOUNDS CLEAR. ABDOMEN SOFT, NGT RESIDUALS HIGH THIS AM. NGT TO LOW CONT SUCTION AND DRAINING APPROX 400 CC EVERY 3-4 HOURS. DR. AWARE AND SPOKE WITH PATIENT AND HUSBAND. DISCUSSED POSSIBLE NEED FOR OR IN NEXT COUPLE OF DAYS. CC:CC REPLETION RESTARTED, CVP APPROX . SEE FLOWSHEET FOR ALL SKIN CARE.\nPLAN:\n CONTINUE WITH FLUID REPLETION EVERY 6 HOURS. VENT ASSISTANCE OVERNIGHT. PROVIDE SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-10 00:00:00.000",
"description": "Report",
"row_id": 1537743,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt oriented x3. Clear speech when tracheostomy capped. Mouths words when vented overnight; easy to understand. Follows commands; moves BUE in bed. Per pt, she does not have sensation on BUE and BLE. Cooperative with care. Pt very anxious at beginning of shift. Per pt request, lorazepam 1.5 mg IV given with +effect. Pt able to sleep most of the night. Able to use call button on side of bed. Afebrile. HR 80s-100s (NSR/sinus tach; rare PVCs and occassional PACs). Potassium, magnesium, and calcium repleted. NBP 90s-130s/40s-90s. SBP increased to 150s during bedbath. CVP 5-9. LR @ 37cc/hr. TPN with lipids @ 63cc/hr. PICC line and central line patent. Lungs clear, coarse at times. Pt suctioned for large amount thick, secretions. Strong cough and able to expectorate sputum. Needs assistance using Yankauer suction. Mouth care performed per VAP prevention protocol. CPT done. Trach care performed. Rested on SIMV overnight. SIMV 50%, Vt 550 x10, PEEP 8, PS 8. Abdomen softly distended with +bowel sounds. NPO. NGT to low continuous suction with large amount bilious drainage. NGT output replaced cc:cc with NS q6hr. NO BM overnight. Pt refused bisacodyl PR. FS q6hr with regular insulin sliding scale. Suprapubic catheter intact with yellow urine; +sediments. UO 35-180cc/hr. DSD to bilateral heels changed x1; see CareVue for measurements of pressure ulcers on heels. Waffle boots on BLE. Allevyn dsg to coccyx and buttocks intact. Left hip with VAC dsg intact; small amount serosang drainage. Pt c/o left hip pain. Medicated with dilaudid 2mg IV with +effect. Pt on -Air bed. RN discussed importance of turning/changing position q2hr to prevent skin breakdown, but pt refused to turn at times.\n Plan: Monitor VS, I's and O's, labs. Replete lytes as needed. Monitor neuro and respiratory status. Place pt on nasal cannula during the day and cap tracheostomy as tolerated. Change dsg to coccyx/ buttocks/bilat heels qdaily. Monitor output from VAC dsg. Replace NGT output cc:cc with NS q6hr. Update pt and family on plan of care. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-10 00:00:00.000",
"description": "Report",
"row_id": 1537744,
"text": "Respiratory Care:\nPt came off vent to a red cap (W/water out of cuff) at about 0800.\nUsed the In-Ex-sufflator with the RT then with her husband\nagain. 1 Xopenex neb. removed a mod. to lg amount of light yellow secretions. She has been sleeping on and off and is to go all day on cap.Remains quite conversive when on cap and is very helpfull with her therapy... See CareVue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-15 00:00:00.000",
"description": "Report",
"row_id": 1537765,
"text": "npn 0700-1300;\n\nneuro; very pleasant and co-operative,aoox3 quad who has some upper limb movement.cooperative with care placed on trach and cap uses insufflator and placed on 2l n/c. tolerated well sats 92-96%.coughing\nmod amounts thick tan secretions .\n\ncvs tmax 97 po nsr 90-111 bp 90-122/70.\ngu; foley draining mod amounts of yellow urine with lots of sediments\ngi;took mod amount of house diet. belly distended but soft and pt states that belly is much smallerthan previous small amount soft soft liquid stoolx1. bs 120; taking mod amounts of po fluid.\n dsd changed wounds unchanged,\npt discharged home with husband and vna.at 1300\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-05 00:00:00.000",
"description": "Report",
"row_id": 1537726,
"text": "vss, pt alert and able to voice needs. tol. sips of liq.\nno bm this shift.\nurine via suprapubic cloudy yellow 20-30cc/hr. cvp 4-5\npt slept in short naps-requesting ativan for sleep and dilaudid for pain w/ good relief.\nk+3.3 repleted w/ 40meq iv\nremains on vent o/n-suctioned q3hrs for mod. thick sputum.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-05 00:00:00.000",
"description": "Report",
"row_id": 1537727,
"text": "NPN\nPlease see carevue for further details\nPt c/o abd pain, + nausea and vomiting at beginning of shift. abd firm, tender. NGT placed - large amounts of brownish drainage all shift. Dr. notified. NGT placement verified by CXR. Dilaudid for pain with good relief. Alert, oriented x3. On vent until mid morning. using in-exsufflator for suctioning. BLSC, diminished at bases. sats 96-98 on 2l n.c. Abdomen currently soft, nontender. BM x3 this shift. Foley draining amber cloudy urine marginal amounts. Coccyx dressing changed, frequent turn and position. afebrile. Hypotensive to the 70s this shift. Given LR bolus with good effect. Continue to closely monitor bowel status, NGT drainage, hemodynamics, skin integrity, respiratory status, provide comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-10 00:00:00.000",
"description": "Report",
"row_id": 1537745,
"text": "NURSING NOTE\nASSESSMENT:\n PATIENT ORIENTED AND APPROPRIATE. GIVEN DILAUDID APPROX EVERY 4 HOURS FOR HIP & NECK PAIN, + EFFECT. REQUIRED ONE DOSE ATIVAN FOR ANXIETY. HEART RATE ~ 100 SINUS TACH, SBP RANGING 90-160'S. MAKING ADEQUATE URINE OUTPUT (SUPRAPUBIC TUBE). LUNG SOUNDS CLEAR. SEE RESP NOTE FOR ALL DETAILS. TRACH CAPPED AND PATIENT TOLERATING NASAL CANNULA (BASELINE). ABDOMEN SOFT, NGT TO CONTINUOUS SUCTION @ BEGINNING OF SHIFT. DR. SPOKE WITH PATIENT ABOUT CLAMPING TRIALS FOR ANOTHER 24 HRS AND NEED FOR SURGERY IF ATTEMPT FAILS. MINIMAL RESIDUALS SO FAR, CHECKING EVERY 6 HOURS. TPN INFUSING, NO INSULIN REQUIRED. SEE FLOWSHEET FOR SKIN ASSESSMENT & DETAILS.\nPLAN:\n VAC DRESSING CHANGE TOMORROW AM. ? OR THIS WEEKEND. CONTINUE TO PROVIDE SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-11 00:00:00.000",
"description": "Report",
"row_id": 1537746,
"text": "Resp Care\nPt capped removed and placed on vent @ the start of shift. Suctioned for mod amt of thick yellow secretion. sating in the high 90s. Plan to trach in am. Will continue to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-11 00:00:00.000",
"description": "Report",
"row_id": 1537747,
"text": "Nursing Progress Note:\nPlease refer to CareVue for details.\n Pt easily arousable to voice when asleep. Oriented x3. Mouthing words. Clear speech when tracheostomy capped. Follows commands. Moves BUE in bed. Pleasant and cooperative with care. Tmax 99.8. HR 70s-100s (NSR/sinus tach). At 2200, pt with frequent PACs; Dr. notified. EKG done and lytes sent. Potassium and magnesium repleted. Rare PACs noted after lytes repleted. NBP 90s-140s/50s-80. At 0600, SBP 60-70s (Dr. aware). 1unit PRBC hung at 0600; no IVB ordered at this time. Hct 19.1; 2units PRBC ordered. Dr. called pt's husband to discuss blood transfusion over the phone. Blood consent obtained from husband; this RN witnessed discussion. Blood consent form placed in chart. CVP 4-8. No edema noted. Lungs clear. Pt with strong cough; expectorated large amount thick, secretions. Pt rested on SIMV overnight. No c/o shortness of breath. O2 sat WNL. Abdomen soft with hypoactive BS. TPN with lipids infusing via central line. NGT clamped; residual checked q6hr. Residuals: 10cc @ and 85cc @ 0200. No c/o nausea. BS 152; no insulin coverage needed per sliding scale. Pt on -Air mattress. Waffle boots on BLE. DSD on BLE heels changed. Allevyn on coccyx/buttock intact. Left hip VAC dsg with small amount serosang drainage. VAC dsg due to be changed today. Pt c/o left hip and neck pain. Dilaudid 2mg IV given with +effect. Lorazepam 1mg IV x2 given for anxiety with +effect. husband called; RN updated pt's husband on pt's condition and on plan of care. Husband will visit this AM.\n Plan: Monitor VS, I's and O's, labs. Transfuse 2units PRBC for Hct 19.1; monitor Hct closely. Offer pain med as needed. VAC dsg to be changed today. Change coccyx/buttock/heels dsg qdaily. Check NGT residuals q6hr. Update pt and husband on plan of care; provide emotional support. Continue ICU care and treatment.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-11 00:00:00.000",
"description": "Report",
"row_id": 1537748,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nAfebrile for shift. Medicated with Dilaudid and ativan prn with good effect. Hct 19 this morning and given 2 units prbcs with resulting hct 27.1. Hypotensive prior to blood , however no issues this shift. SBP 80s-170s based on pt comfort level/ procedures ie suctioning. HR NSR to ST 120s with suctioning and turning but 80s-90s when resting with rare PACs. UO adequate. Lungs are clear throughout and suctioned by RT with expectorator machine. Per RT sputum becoming thick yellow in moderate amounts. Off Vent most of shift. Abdomen is soft with hypoactive bowel sounds. No c/o n/v. NGT Remains clamped with residual checks q 6 hours. 250cc and then only 5 cc output from ngt. MD aware. Ducolox supp given with no effect so far. Wound care done: sacral wound with aquacel ag strip packing and allevyn covering. Wound care nurse in after dressing change and would like to be present for Monday's dressing changes to evaluate wounds. VAC dressing changed today by MD. Emotional support. Pt discouraged and tearful this morning; mood improving throughout the day. Plan: Cont to monitor ngt outputs/ replete lytes in am if necessary/ wound care/ monitor hct. Please refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-11 00:00:00.000",
"description": "Report",
"row_id": 1537749,
"text": "Respiratory Care:\npt off vent and \"red capped\" @ about 0800. Had a Xopenex neb and was In-Exsufflated with removal of Lg amount of pale yellow thick secretions, after which she settled in and was comfortable for most of the time. Seen two additional times and her husband did a couple of\n while he was here. In total 3 In-Ex's, 2 xopenex Rx's, 1 CPT\nWill remain capped til sleep time when she will go on the vent for the noc. See CareVue for additional info.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-12 00:00:00.000",
"description": "Report",
"row_id": 1537750,
"text": "Resp Care\nPt had a exsullflator tx and placed on vent. Suctioend for mod amt of yellow secretions. Nebs given. Sating in the high 90s. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-03 00:00:00.000",
"description": "Report",
"row_id": 1537720,
"text": "Respiratory Therapy\n\nPt remains trached w/ TTS, taken off ventilator this AM and trach cuff deflated/capped. In-Exsufflator used multiple times t/o shift, pt expectorating moderate amounts of creamy pale yellow secretions via trach w/ small amounts of frothy oral secretions. Wearing 3L/M nasal cannula O2 w/ SpO2 92%-94%. Xopenex HHH given via mouthpiece PRN. Will continue to follow per airway protocol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-06 00:00:00.000",
"description": "Report",
"row_id": 1537728,
"text": "vss. cvp 2-4. c/o abd. pain medicated x1 w/ dilaudid 2mg iv w/ good releif. ativan 1mg iv given for sleep x2.\nabd. soft. +bs. no bm this shift. ngt w/ lgre output brown bilious.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-06 00:00:00.000",
"description": "Report",
"row_id": 1537729,
"text": "resp care - Pt is trached with #7 water cuff. Trach capped this AM. 0.63mg Xopenex given twice today. BLBS were mostly clear, some scattered wheezes on L.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-06 00:00:00.000",
"description": "Report",
"row_id": 1537730,
"text": "NPN\nPlease see carevue for further details.\nalert oriented x3 speech clear. on vent o/n. BLS clear, diminished at bases. using in-exsufflator as cough assist with good effect. + BS x4 abd soft nt/nd. NGT to suction this a.m. repleting cc per cc with LR. Clamping trial this afternoon. Will retry this evening d/t high residuals. denies pain, abd distension or cramping. TPN started this evening. Foley draining amber cloudy urine, marginal amounts. No BM this shift though suppository given. Skin and wound dsgs intact. NSR 70s BP 90-140s. Lytes repleted as indicated SS. SSRI a/o. Dilaudid and Ativan given for pain and anxiety. Continue to closely monitor bowel status, NGT output, skin integrity, respiratory status. provide comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-07 00:00:00.000",
"description": "Report",
"row_id": 1537731,
"text": "Respiratory Care:\nPatient received on inexsuffilator Rx and was able to expectorate a large yellow, mucoidal sputum. Received xopenex Rx by RN prior to the treatment. Placed on ventilatory support (SIMV/PSV) as ordered for the night (see CareVue). Slept most of the night, requiring little intervention. Stated she did not need the xopenex at this time.\n\nRSBI = 53 on 0-PEEP and 5 cm PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-07 00:00:00.000",
"description": "Report",
"row_id": 1537732,
"text": "vss. slept well during noc. on vent o/n-suctioned thick yellow sputum\nq3hrs. c/o abd. pain medicatd w/ dilaudid x2 and ativan for sleep/anxiety.\nngt output less than day before-replacing cc for cc w/ lr q6hrs. cvp 2-4\nbm x2-thin mocous grey mod. amt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-04 00:00:00.000",
"description": "Report",
"row_id": 1537721,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: patient C 5 quadriplegic from MVC many years back,moving the upper extrimities only,alert & oriented,pERL,pleasant & cooperative with care.c/o abd pain,dilaudid ,& ativan with good effect.able to communicate with mouthing words.\n\nCV: NSR,HR in 70's rare pvc's,SBP 97-128.denies CP or discomfort,CVP 3-4,IVF via CVL,one port saved for TPN.++pp.\n\nResp: Was on NC with 3L O2 when tracheostomy caped,connected to vent at 2100 as patient requested.SIMV/Ps mode.lS clear & diminished at bases,weak cough,sxn thick secretion.spitting out lot of saliva .tracheostomy care not done as patient refused.\n\nGI: NPO,abd soft,hypoactive BS,BMx1,NGt still with large out put.\n\nGU: Suprapubic cath intact with cloudy urine adq amt.\n\nID: afebrile,on anbx.\n\nEndo: Bld sug q6h,on SSRI.\n\nAct: turned & position changed,dressing intact on coccyx, & both heels,vac dressing from lt femur intact.\n\nPlan: cont monitoring,pulm hygiene.wound care.support to patient,wean off vent\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-04 00:00:00.000",
"description": "Report",
"row_id": 1537722,
"text": "Resp Care\nPt placed on vent @ 2100, pt suctioned for mod amt of yellow secretions. Fio2 and peep increased due to low sats.Nebs given. Plan to cap trach and place on nasl canulla in Am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-04 00:00:00.000",
"description": "Report",
"row_id": 1537723,
"text": "NPN\nPlease see carevue for further details\nAlert, oriented x3. speech clear when off vent and trach is capped. jerky movements of BUE, poor fine motor. Quadriplegic for many years. BLSCTA diminished at bases. Uses in-exsuffulator for thick tan secretions. sats 98-100 on 2l n.c during the day. on SIMV&PS overnight. NSR 70s SBP 110-130s. On Kinair bed, waffle boots, Heparin SQ. + BS x4 abd soft nontender nondistended. medicated for abd pain with Dilaudid with good effect. NGT clamped for four hours this a.m wiht only 100 residual. no complaints of nausea or abd discomfort while clamped. NGT discontinued by Dr. . Suprapubic cath draining cloudy yellow urine adq amounts. VAC dressing changed by Dr. draining small amounts of serosang drainage. Heel dsgs changed. Coccyx dressing c/d/i. Sacral area reddened. Frequent t&p.\nadvance diet as indicated. provide comfort and support. monitor bowel status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-04 00:00:00.000",
"description": "Report",
"row_id": 1537724,
"text": "pt remained off vent without difficulty, required inexuff numerous times for thick secretions. plan to continue with same resp tx\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-05 00:00:00.000",
"description": "Report",
"row_id": 1537725,
"text": "Resp Care\nPt placed on vent after exsulfator tx. Nebs given. Suctioned for large amt of thick yellow secretions. No changes made. Will continue routine of having trachd during day, if tolerable. Sats in the high 90s. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-12 00:00:00.000",
"description": "Report",
"row_id": 1537752,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nAfebrile. Pain managed with dilaudid q 3 hours and ativan prn for anxiety. Lungs clear to coarse and suctioning with expectorator by RT. Chest PT by RT. Off vent most of day and nasal cannula off with good sats. Residuals remained low and MD d/c'd. Pt may have sips and advance to clears however pt is tentative to take sips and has only had sips today. TOlerated well. Abdomen soft and hypoactive bowel sounds. Refused ducolax supp this morning d/t stooling over night, however was willing to have it this afternoon. No results so far. Coccyx dressing changed with aquacel ag packing and allevyn over. Mod amount yellow drg and some scant serous drg on old dressing. Pt is very optimistic about coming out and in good spirits . Husband in to visit this afternoon.\nPlease refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-12 00:00:00.000",
"description": "Report",
"row_id": 1537753,
"text": "RESPIRATORY CARE:\nPt went on \"red cap\" @ about 0800 and very soon after had a xopenex followed by In -Ex-Sufflator tx productine of a LARGE very dark brown plug and then more of her usual thick yellow secrtion. ShE was ready for the day atfer that and did the Vacuum Tx.x 3 more by the RT and some PM CPT. I Think she is an excellent candidate for \"The Vest\"\nand would benefit from further investigation. Raises significant amount of thick yellow secretions over the day. Will go on the vent to-noc to rest.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-13 00:00:00.000",
"description": "Report",
"row_id": 1537754,
"text": "Resp Care\nPt placed on vent. Suctioned for mod amt of yellow secretions. Nebs given once. trach in am. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-13 00:00:00.000",
"description": "Report",
"row_id": 1537755,
"text": "Update\nO: See carevue for specifics.\nCV: sr w 1 episode of 4 beat run vt (self terminating)lytes pending.Sbp stable\nResp: on np w trach capped until bedtime at 2130 back on vent simv mode tv 550 rr 10 peep 8 ps8. Bbs coarse to clear after suct. for thick yellow sputum.\nGi: hypoactive bowel snds, no n/v. tol sips h2o.sm mucusy results\nGu: suprapubic tube w cloudy yellow urine, irrig for sm amts sediment.\n\nHeme/Id: am labs pending. Tmax 98.8.\n\nSkin: wound vac drsg hip area w serous drng.allevyn to buttocks.Bilat heel dsrg changed.Rt heel dry eschar->wound gel.Lt heel dry.\n\nA/P: Pulm toilet-> off vent during w np O2 as needed.Wound care.? adv diet today.Recheck labs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-03 00:00:00.000",
"description": "Report",
"row_id": 1537718,
"text": "nursing progress note\nSee Carevue for specifics\n\nTMAX: 98.8\n\nNEURO: A & O x 3, pleasant, appropriate, follows all commands. Gross motor movement in UEs, no movement in LEs. Frequent complaints of pain in L hip. Tx'd with dilaudid with + result.\n\nCV: NSR with some PVCs. HR elevated to 120s late in shift. ? anxiety vs. respiratory issues. MD notified, 1 mg ativan given with mediocre result. Latest K 3.3, being repleted with 20 mEq. SBP 90s-130s.\n\nRESP: LS clear/diminished. On SIMV overnoc, trache collar during the day. See RT note for details.\n\nGI: NPO, NGT to LCS and draining large amounts of brown fluid. Abd soft, + BS. 500 cc LR replacement bolus given.\n\nGU: Supra-pubic catheter draining yellow sedimented urine. Output low. MD aware.\n\nSKIN: Pressure sore on coccyx dsg changed to aquacel per patient request. L heal wound open to air. R heal wound dressing intact. Hip wound vac dsg intact.\n\nPLAN: Monitor frequently for pain & comfort. Communicate with patient re: results of CT scan and plan of care. Coordinate wound care consult.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-03 00:00:00.000",
"description": "Report",
"row_id": 1537719,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENT\nNEURO--C5 QUAD FOR MANY YEARS. UPPER EXTREMITY MOVEMENT ONLY. ALERT AND ORIENTED. VERY INVOLVED IN HER CARE.\nCV--SOME EPISODES OF HYPOTENSION AFTER SEDATION GIVEN, USUALLY LASTING AROUND 10 MINUTES.\nGU--SUPRAPUBIC TUBE INTACT, DRAINING CLOUDY CONCENTRATED URINE. MOISTURE BARRIER CREAM APPLIED AROUND TUBE\nGI--STILL CONCERNED FOR SIGNIFICANT BOWEL OBSTRUCTION. DID MOVE BOWELS FROM BELOW AFTER DULCULOX SUPP. GIVEN--OLD COFFEE GROUND STOOL. STILL PUTTING OUT LARGE AMOUNT OF NGT DRAINAGE. PRIMARY TEAM AWARE, PATIENT TOLD SHE IS STILL NOT OUT OF THE FOR NEEDING A SURGICAL INTERVENTION. WILL KEEP PATIENT NPO, HOPING BOWELS WILL OPEN UP.\nHAS TLC, ONE PORT HAS BEEN SAVED FOR TPN.\nENDO--NO ISSUES.\nRESP--OFF VENT ALL DAY. RESP. TREATMENTS GIVEN AS ORDERED. SUCTIONED WITH OWN MACHINE. CPT DONE Q 4 HRS.\nID--ON NAFICILLIN FOR LONG TERM TREATMENT OF OSTEO. OF LEFT HIP.\nSKIN--WOUND VAC INTACT ON LEFT HIP, CHANGED YESTERDAY . SKIN CARE CONSULTED FOR L/R HEALS AND BUTT.\nFOR HEALS--WOUND GEL/ADAPTIC/GAUZE WRAP.\nBUTT--WOUND GEL WITH ALLEVYN DSG.\nLOWER BUTT--AQUACEL CELL ROPE PACKING WITH TEGAERM COVERING.\nPLAN: CONTINUE TO MONITOR FOR \"OPENING UP \" OF BOWELS, NO EVIDENCE OF THAT SO FAR.\nCHECK LYTES AND REPLACE AS ORDERED.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-12 00:00:00.000",
"description": "Report",
"row_id": 1537751,
"text": "Nursing Progress Note 11p-7a\nSee Carevue for specifics\n\nNeurologically intact. Able to mouth words to communicate effectively. Anxious at times. Reports pain in back/hip. Given Dilaudid/Ativan with effect. BP 130's/70's. CVP 5-10. LS clear. Suctioned periodically for thick yellow secretions. Exsullflator treatment done by RT and nebs administered a/o. Strong productive cough for thin secretions suctioned with Yankauer. +BS hypoactive. Abd soft. No stool. NGT clamped. Residual checks q 6 hours-see carevue. Continues on TPN for nutritional support. Afebrile. Continues on Nafcillin and Erythromycin. Suprapubic tube patent draining cloudy yellow urine with sediment. Hct stable 27. Awaiting other lab results.\nPlan: Continue monitor NGT residuals q 6 hours-team hoping for conservative management of SBO, continue monitor hemodynamics, resp status, follow labs and treat as necessary. Continue provide emotional support and comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-02 00:00:00.000",
"description": "Report",
"row_id": 1537713,
"text": "Respiratory care:\n63 y.o. F admitted with nausea, vomiting and abdominal pain. Patient with a PMH: C5 quadraplegic s/p MVC s/p trached with TTS #7. Patient is vent dependent at night. Her trach was inflated with 10c Sterile H20 and patient was placed on vent. Please see respiratory section of carevue for further data.\nPlan: Continue vent @ night. Trach cappped during the day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-02 00:00:00.000",
"description": "Report",
"row_id": 1537714,
"text": "NEURO; A&OX3, PT IS QUADRIPLEGIC, ABLE TO MOVE ARMS SLIGHTLY, SPEECH IS CLEAR, IS ANXIOUS AND TEARFUL AT ONE POINT,\n\nCARDIOVASCULAR; HR 90'S-LOW 100'S, SR-ST, SYS BP 120-90'S, PT HAS PERIPHERAL LINE IN FOOT, PIC LINE RT ANTECUB,\n\nRESPIR; LUNGS CLEAR, PT HAS TRACH, USES PASSE MUIR VALVE DURING DAY AND USES N/C AT 3L/MIN, IS ON VENT OVERNOC,\n\nGI; NG TUBE TO LCSX, SMALL AMT BILIOUS DGE\n\nGU; SUPRAPUBIC TUBE IN PLACE, APPROX 500CC URINE ON ARRIVAL\n\nWOUND; BLACKISH-RED BROKEN AREA LEFT HEEL,APPROX 2-3 CM, NO DGE, DSD ON RT HEEL, OPEN AREA COCCYX, APPROX 2 CM, NEEDS WOUND CARE CONSULT\n\nPLAN; KEEP PT COMFORTABLE, OFFER EMOTIONAL SUPPORT,WILL NEED BETTER ACCESS FOR MEDS, ? A LINE FOR LAB DRAWS, PT IS EXTREMELY DIFFICULT TO OBTAIN LAB DRAWS\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-02 00:00:00.000",
"description": "Report",
"row_id": 1537715,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\nNEURO--AWAKE, ALERT AND VERY PLEASANT. C5 QUAD FOR MANY YEARS AND WELL AWARE OF WHAT SHE CAN/CAN'T DO.\nCV--VS PER FLOW SHEET. SOME ECTOPY THIS AM, K/MG REPLACED. BLOOD PRESSURE AROUND 90/. RECEIVING LR A 150CC HR AS WELL AS BOLUSES TO KEEP UP WITH NGT LOSSES. LEFT SUBCLAVIAN TLC PLACED WITH ULTRASOUND GUIDANCE AT BEDSIDE, CXRAY +PLACEMENT.\nGU--CLOUDY URINE THROUGH SUPRAPUBLC CATH.\nGI-->1000CC NGT OUTPUT TODAY. SLOW PREP THIS PM FOR ABD. CT. SCAN. DIFFUSE TENDERNESS THROUGHOUT ABD.,PAIN MANAGED WELL WITH 1 MG DILAUDID. HYPERACTIVE BOWEL SOUNDS HEARD.\nSKIN--LEFT HIM VAC DGS. CHANGED BY TEAM WITH GOOD HEALING AND IMPROVED GRANULATION. LEFT HEAL DSG. WITH AQUCEL DSD. WILL PLACE ON KINAIR BED AFTER CT SCAN.\nPLAN: NPO. CHECK AND REPLACE LYTES AS ORDERED. CT SCAN. ?OR INTERVENTION CALL HO WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-02 00:00:00.000",
"description": "Report",
"row_id": 1537716,
"text": "Respiratory Care\n\n Pt off the vent and capped all day. xopenex neb given once. Inexsuflator done with each sx'ing sx'd for mod thick creamy yellow. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-03 00:00:00.000",
"description": "Report",
"row_id": 1537717,
"text": "Resp Care\nPt given a round of exsulflator treament, expectotrated mod amt yellow secretions. Pt placed on vent for the night, stable throughout. No changes made. Will continue with current routine ( trached capped and on Nasal cannula) during day. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-13 00:00:00.000",
"description": "Report",
"row_id": 1537756,
"text": "Nursing Note 7a-7p:\nNursing Assessment:\n\nAfebrile. A+O. Requiring pain meds q 3 hours and ativan prn. Lungs coarse to clear, suctioned by RT. Off vent for day and on and off o2 per request of patient. Adequate sats on room air. Abdomen soft. One extra large liquid brown BM and ducolax supp held this morning per pt request. MD started on reg diet and had a little bit of dinner; so far tolerating well. Tolerated sips no greater then 60cc /hr prior. Bowel sounds present. Plan: Cont to monitor for n/v. If continues to tolerate pos ?d/c to home in a few days. OOB to chair tommorrow with , pt's husband will bring in her wheelchair and cushion from home. Wound care nurse to look at wounds tommorrow; dressings changed by nursing today.\nPlease refer to carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-13 00:00:00.000",
"description": "Report",
"row_id": 1537757,
"text": "Respiratory care:\nPt W/xopenex x 2 today and had In-Exsuf. x 3 productive of large amounts of thick yellow secretions..She w/o any O2 all day with an\nO2 sat of 98-100%..husband in to see her and also used the In-Ex with her.. No further respiratory issues.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-14 00:00:00.000",
"description": "Report",
"row_id": 1537758,
"text": "Resp Care,\nPt. placed on SIMV overnoc, vent dependent. Capped during day. Suctioned small amount yellow sputum. In-exsufflator x 1, xopenex x 1. RSBI not done due to vent dependency. See carevue, plan cap during day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-14 00:00:00.000",
"description": "Report",
"row_id": 1537759,
"text": "Update\nO: See carevue for specifics. Placed on vent by 2100. Sats while trach capped prior to return to vent adeq, altho pt tiring just prior to return to simv mode on vent wslt tachypnea and tachycardia prior to being placed on vent for noc. Requiring dilaudid q3h for lt hip pain and prn ativan q6h. Some episodes of hypotension overnight w pain med. This a.m. pt becoming very anxious upon awakening asking to be taken off vent and to receive pain med-> sinus tachy to 120 at time w some ^ wob despite vent-> resp therapy in to use exsufflator & suct for thick yellow secretions. Pt remained on vent d/t other issues at present w hypotension/tachypnea aft pain med. Update to HO re: hypotension despite lower dose of narcotics given-> 500cc lr bolus ordered and mgso4 2gms given for mg+ 1.4 and freq pac's.Hct 22 this am, no active signs of bldg.Tol po liqs in sm amts, no stools overnight.\n\nA/P: fld bolus for low bp-> additnl pain med when bp stabilizes. ? Consult pain service for pain mngmnt issues. ? transfuse for hct. Rx lytes as ordered.Wound drsgs to be changed by wound care nurse today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-14 00:00:00.000",
"description": "Report",
"row_id": 1537760,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n PT A&O X3, DILAUDID GIVEN FOR C/O HIP PAIN W/RELIEF. ATIVAN GIVEN AS ORDERED. HR 90S-110S, ST/NSR, FEW PVC'S. SBP 90S-140S, PT BECAME HYPOTENSIVE TO 80S SYS AFTER DILAUDID ADMIN, INCREASED TO 90S-100S SYS W/500CC LR BOLUS. AFEBRILE, PALP PP. LUNGS CLEAR TO COARSE, ON VENT BRIEFLY THIS AM FOR REST PER PT REQUEST, O2 SATS 92-100%, RR 10S-20S. PT W/SOME RESP DISTRESS, TACHYPNEIC/TACHYCARDIC, RESOLVED FOLLOWING VIGOROUS SUCTIONING FOR LGE AMT THICK, YELLOW SECRETIONS. CPT DONE BY RN/HUSBAND AS . ABD S/NT, PO'S WELL, NO N/V, LGE LIQUID STOOL X1. SUPRA-PUBIC FOLEY DRNG>=50CC/HR SEDIMENTARY URINE. FOUND TO BE LEAKING THIS EVE, DR. & DSG CHANGED. R-HIP VAC PATENT, DRNG SEROUS FLUID. L-GLUTEAL DECUB DSG/SACRAL DSG CHANGED BY CARE RN. LEFT HEEL W/SM AMT BREAKDOWN, NO DRNG, WAFFLE BOOTS ON, LEFT OTA. NO NEW AREAS OF BREAKDOWN NOTED. HUSBAND IN TO VISIT BRIEFLY, VERY SUPPORTIVE.\n\nPLAN: CONT HEMODYNAMIC MONITORING, PULM TOILETING/FREQUENT SUCTIONING. PAIN MGMT, REPLETE LYTES. SKIN/ CARE, ? VAC CHANGE. CONT ICU PLAN OF CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-14 00:00:00.000",
"description": "Report",
"row_id": 1537761,
"text": "BS coarse crackles; Xopenex x 1 without change. Exsufflator x 6. Coughing copoious amounts thick yellow sputum. On vent x 30\" per pt's request after desat to 88. Recovered with gentle ambuing. Back on vent overnight.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-15 00:00:00.000",
"description": "Report",
"row_id": 1537762,
"text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt A&Ox3, follows all commands, moves upper extremities, full assist with ADL's, PERLA. Pt anxious at times, Ativan prn with pos effect. Dilaudid prn pain with pos effect.\n\n Resp: LS coarse bilat throughout. Suctioned prn, but able to cough & raise most of secretions on own, thick /yellow secretions. Placed on vent to rest over night, well. Maintaining o2 sat > 97%. Trach wnl.\n\n CV: Remains NSR-NST, occational PAC's noted. labs pnd. PICC difficult to draw labs from, positional. Denies CP. VSS, but became hypotensive to 80's when in deep sleep, resolves without intervention, MD aware. Palp pedal pulses.\n\n GI: Abd soft, NT, pos bs. po's, no bm this shift.\n\n GU: Suprapubic tube clogged, leaking from site, flushed and aspirated for lg amount of sediment, now patent. Adequate amounts of yellow urine with mod amounts of sediment noted.\n\n Skin: bilat heels pink, waffel boots. Airbed in use. L gluteal with dsd, packed, changed previously in day. Coccyx with dsd, abraision. L hip Vac dsg changed by plastics MD, draining small amounts of serous drainage.\n\n Plan: Pain management, encourage po's, pulm toileting, diligent skin care, provide pt and family with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-15 00:00:00.000",
"description": "Report",
"row_id": 1537763,
"text": "Resp Care,\nPt. placed on SIMV overnoc, vent dependent. Inexsufflator x 3 this shift, C&R moderate amount thick yellow sputum. Plan cap trach during day.\n"
},
{
"category": "Nursing/other",
"chartdate": "2119-08-15 00:00:00.000",
"description": "Report",
"row_id": 1537764,
"text": "Respiratory Care\nPatient taken from mechanical ventilator and placed on nasal cannula at 3 liters per minute. Inexsuffilator used times three cycles/twice followed by neb with unit dose of xoponex neb treatment. Patient was able to cough up small to moderate amounts of thick secreations. Treatment time at 0800.\n"
},
{
"category": "Radiology",
"chartdate": "2119-08-08 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 966964,
"text": " 5:25 AM\n PORTABLE ABDOMEN Clip # \n Reason: ?interval change\n Admitting Diagnosis: SMALL BOWEL OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman, C5 quad, trach, with ? bowel obstruction\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n One supine radiograph of the abdomen was obtained.\n\n INDICATION: 63-year-old woman with abdominal distention.\n\n Comparison is made to the prior study done on .\n\n There is relative paucity of abdominal gas. A small amount of gas is noted\n within the small bowel. No supine evidence of intra-abdominal air is noted.\n\n The visualized portion of the left lung base demonstrates opacification\n unchanged compared to the recent CT. There is also severe hypertrophic change\n of the lumbar spine consistent with diagnosis of DISH.\n\n IMPRESSION:\n 1. Relatively gasless abdomen unchanged compared to the prior study. This\n appearance might be suggestive of multiple fluid-filled loops of bowel. No\n free intra-abdominal air is noted.\n 2. The visualized portion of the lung bases demonstrates bilateral pleural\n effusion, more prominent on the left side.\n\n\n\n"
}
] |
8,196 | 130,974 | 70 y/o M with PMHx of DM, CRI, CAD, PVD s/p b/l BKA who was initially admitted on for NSTEMI and CHF that was later felt to be due to demand ischemia from CHF rather than plaque rupture. While on the floor was refusing lab draws and echocardiogram to assess resolution of NSTEMI. His hospital course was then complicated by 2 embolic strokes on (R parietal and L frontal lesion) which caused him to become aphasic and develop R sided weakness. He did not receive any thrombolysis, and coumadin was held as felt risk on anticoagulation outwayed the benefits. He has ESRD but not getting dialysis yet as making urine, has a working fistula on R arm. On he was intubated and transfered to the ICU for Urosepsis. He was treated with Meropenem, extubated, and transfered out of the ICU and back to the medical floor. While in the ICU a double lumen PICC was placed. . On the medical floor a PEG tube was placed and dispo planning was in process until AM when he was found to be grunting and coughing. At that time Lasix was given for fluid overload and enzymes were cycled. His EKG showed suggestion of anterior STEMI with no reciprocal changes, cardiology evaluated this and felt it was most likely a NSTEMI. They felt that no further intervention was warented. His troponin bumped to 1.49 and then 2.75 without an increase in his MB fraction. He was started on Heparin for anticoagulation. . At 6:30 AM on a trigger was called for hypoxia and tachypnia. Per the vitals sheet her O2 sat had dropped at 4:30AM to 80s however he was due for transfusion which was started and respiratory status worsened. The blood transfusion was stopped and he was placed on 100% on shovel mask with sats recorded at 86%, he was then placed on NRB with sats up to 97%. He was given 100mg Lasix and 500mg Diurel. He was then transfered to for management of pulmonary edema. . On the evening of he again developed acute respiratory failure. He was intubated. A family meeting was held , and the decision was made to make the patient DNR, and to not pursue any further escalation of care (no pressors, no dialysis). A seconde family meeting was held on , and the decision was made to make the patient comfort measures only. He was extubated in the evening of . He died at 0600 on . His son, , was contact at the time of death. | There is prominence of ventricles and sulci compatible with age appropriate volume loss, which is unchanged. The right PICC line was repositioned with its tip now terminating at least 1 cm below the cavoatrial junction at the level of eighth thoracic vertebra. Intracranial flow voids are maintained. The left retrocardiac opacity is unchanged and most likely represents atelactasis. The NG tube tip terminates proximal at the cavoatrial junction with the sidehole situated in the mid esophagus. IMPRESSION: AP chest compared to through 21: Left lower lobe atelectasis persists. There are periventricular white matter hypodensities, most consistent with chronic microvascular ischemic changes. Again, unchanged periventricular white matter hypodensities consistent with chronic microvascular infarction. The, on previous examination, , identified basal densities including pleural effusion and parenchymal infiltrates have normalized. TECHNIQUE: A non-contrast head CT was performed. Tip of the right PIC line is partially obscured, but passes at least as far as the upper SVC. Bilateral pleural effusions persist. FINDINGS: Compared with , the ETT has been removed. TECHNIQUE: Non-contrast head CT. Also the sideport has reached below the diaphragm. There has been significant interval reexpansion of the retrocardiac atelectasis. Old bilateral cerebellar infarcts are seen. The cardiac silhouette is within normal limits. More wedge-like region of hypodensity in the region of the right parietal lobe is felt to represent a subacute infarct. IMPRESSION: Subacute infarct in the right parietal lobe. IMPRESSION: Interval intubation as above. Trachea is midline. Mild ethmoid sinus mucosal thickening is noted. There is a right-sided PICC line with its tip unchanged in position from the prior examination and likely in the mid SVC. Cardiac, mediastinal, and hilar contours are probably unchanged. Mild (1+) aortic regurgitation is seen. Thereis a minimally increased gradient consistent with minimal aortic valvestenosis. ]TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.Indeterminate PA systolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Rule out intracranial hemorrhage. Lung sounds clear/diminished bilaterally. There is severe symmetric left ventricular hypertrophy.The left ventricular cavity size is normal. Specifically, the left frontal-temporal and right temporal-parietal infarcts are redemonstrated, without evidence of hemorrhagic transformation. Remains afebrile.CV: HR 60's to 70's, SR w/ no appreciable ectopy noted. ?PFO.Height: (in) 68Weight (lb): 185BSA (m2): 1.98 m2BP (mm Hg): 165/60HR (bpm): 77Status: InpatientDate/Time: at 11:30Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: SalineTechnical Quality: AdequateINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Mild LA enlargement.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Severe symmetric LVH. Right PIC catheter passes as far as the upper SVC. A small right pleural effusion has decreased in the interim. Renal may opt for dialysis later today.Resp: Lungs clear w/deminished sounds at bases. Minimally increasedgradient c/w minimal AS. Moderate mitral annularcalcification. Focal calcifications inaortic root.AORTIC VALVE: Moderately thickened aortic valve leaflets. Opening eyes spontaneously, though appears calm and relaxed t/o shift w/ no diaphoresis, acute change in VS, grimacing or other s/s pain noted t/o shift. The right-sided PICC tip projects at the level of mid SVC. clear anteriorly with minimal secreations.Plan:DNR with possibly transition to CMO, no rsbi done. Sacral decub cleansed per protocol. breaths over set rate.Bs:ess. Sats 100%.GU/GI: TF remains off r/t heme/resp instability, abd soft/nt/nd, +BS. Vanco/zosyn administered.Reiview of Systems:Neuro: Lightly sedated on fent, opens eyes to stimulation, unable to track or follow commands, no movement x 4 extremities.CV: NSR w/ occasional ventricular ectopy, Levoped gtt titrated to maintain MAP >60, ABP 100-110's systolic. Does not appear to move RUE, moves RLE and LLE.ID: Afeb at present. Moves lower exts w/ nail bed pressure to uper exts. Foley in place w/ low uo. Resp CarePt. Resp CarePt. Continue fentanyl gtt as ordered w/ priority on comfort. Sent off for C-Diff culture. no further desat.gi/gu: abd soft, nt, +bs, ngt . TF's stopped during resp distress episode. no evidence of discomfort.cv: hr ranging 60s-90s sr with one run of unsustained vtach. BBS CTA to slightly diminshed L base. Right upper arm has a PICC line and BLE a BP was undetectable. Sinus rhythmBorderline first degree AV delayLeft atrial abnormalityLeft ventricular hypertrophy with ST-T abnormalitiesSince previous tracing of the same date, sinus tachycardia absent Tolerated well however respirations became in-effective/tachypneic/ HR decreased. Clinical correlation is suggested.Since the previous tracing of sinus tachycardia is absent and theST-T wave changes are less prominent.TRACING #3 NTG restarted ~ after being shut off for hypotension, currently infusing at 6gtts/hr, .56 mcg/kg/hr. remains DNR. Stable Spo2.CV: HR 66-68-SR w/ no ecopty noted. Left atrial abnormality. Received 1LR in am.ID: Tmax 100.1 oral. BUN 118 and creat 5.1. REMAINS ON FENTANYL 300MIC/HR. PEARL.CV: BP 130-170's/ HR 80's NSR. Urine cldy.GI/METABOLIC: NPO. Butt bag in place.GU: UO adequate via foley. Vanco/Zosyn given as ordered. MPM 0700-1500;EVENTS; WEANED LEVO AND MAINTAINED SBP THAN 100.PROPOFOL OFF AT 0830 VERY SLOW TO AWAKEN BEGINNING TO GRIMACE WITH WITH NOXIOUS STIMULI SOME MOVEMENT OF OF HEAD WITHDRAWS TO PAINFUL STIMULI IN LT ARMINSULIN GTT OFF AT 1130 AFTER BEING GIVEN LANTUS 5UNITS S/C AT 1130 AM.PICC PLACED IN RT ARM. 500 and rate 18.ett secure at 22cm with #8.0. alarms set. continues on iv meropenem/vanco. Borderline first degree A-V block. Not following commands, pt speaks only.RESP: ETT 22 lip, ventilated on CMV for metabolic acidosis- current settings .50/500/14/5, RR 26-28, SPO2 100%. Fistula has strong bruit.ID: afebrile on meropenum and vanco. Small to mod amts thick tan bloody secretions suctioned Q3hr. ABG IMPROVED, PT NOW BREATHING A FEW BREATHS ABOVE SET RATE, IS NOW SYNCHRONOUS WITH THE . BS occ. Levophed at 0.3-0.5mcg/kg/min, ABP 95-130s/40s, goal MAP>60. CONTINUES TO HAVE LOOSE STOOL VIA FIB. MICU/SICU NPN ICU day #3Events: successfully extubated this AMS/O:Neuro: pt is lethargic, retracts to painful stimuli only, PERRL sluggish 4mm, nonpurposeful movements of LUE, no verbal communicationPulm: extubated, SpO2 93-98% RA, LS coarse with scattered rhonchi, nonproductive coughCV: HR 67-89 SR with occasional PVC's, BP 138-182/35-51, please see flowsheet for dataInteg: C/W/D/IGI/GU: abd soft, NT/ND, BS present, hiccoughs, NGT in place, TF retarted at 10cc/h, Foley in place draining adequate amts yellow urine with yeastAccess: right radial art line day #3, right cephalic PICC day #2A:high risk for injury, trauma r/t immobility, altered mental statusrisk for infection r/t indwelling catheter, invasive lineshigh risk for aspiratation r/t altered mental statusP:conintinue to monitor hemodynamic/respiratory status, aspiration precautions, slowly advance TF, speech and swallow eval, PT consult, continue post acute care planning | 77 | [
{
"category": "Radiology",
"chartdate": "2105-06-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962055,
"text": " 5:13 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate tube and line placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke who needs picc line for iv\n access,heparin and antibiotics.\n REASON FOR THIS EXAMINATION:\n evaluate tube and line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old man with embolic stroke. Please evaluate PICC line.\n\n Comparison is made to the prior study done one hour earlier.\n\n FINDINGS: The endotracheal tube is in satisfactory position. The NG tube\n side port is projecting below the diaphragm. Right-sided PICC line tip is\n projecting at the level of the cavo- atrial junction.\n\n The heart, mediastinal and hilar contours are normal. The lungs are clear\n with no pleural effusion or pneumothorax. Mild retrocardiac opacity might be\n present, which is unchanged compared to prior study.\n\n IMPRESSION:\n 1. Proper position of the lines with recent PICC line projecting at level of\n cavo-atrial junction.\n 2. The left retrocardiac opacity is unchanged and most likely\n represents atelactasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-29 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 962036,
"text": " 2:51 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Pt had r sided picc line repositioned and needs new cxry to\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke who needs picc line for iv\n access,heparin and antibiotics.\n REASON FOR THIS EXAMINATION:\n Pt had r sided picc line repositioned and needs new cxry to confirm tip\n placement,please page at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of PICC line placement.\n\n The right PICC line was repositioned with its tip now terminating at least 1\n cm below the cavoatrial junction at the level of eighth thoracic vertebra. The\n NG tube tip is still terminating to proximal at the gastroesophageal junction.\n The ETT tube position is also unchanged, 6.3 cm above the carina with neck\n in partly flexed position, and might be advanced 2 cm for more standard\n positioning. The left retrocardiac consolidation has been slightly improved.\n These findings were discussed with the IV nurse at the time of dictation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961785,
"text": " 11:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke now with fever, tachypnea\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, edema\n ______________________________________________________________________________\n FINAL REPORT\n `HISTORY: End-stage renal disease for stroke now with fever and tachypnea.\n\n COMPARISON: .\n\n PORTABLE CHEST RADIOGRAPH: The heart size is within normal limits. The\n mediastinal and hilar contours are normal in appearance. The lungs are clear\n without focal consolidations or pleural effusions. There is an NG tube with\n its tip in the stomach in satisfactory position.\n\n IMPRESSION: No pneumonia or CHF.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 961018,
"text": " 1:30 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for intracranial hemorrhage\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man previously on plavix, heparin, concern for acute stroke given\n MS change, inability to speak, RUE weakness\n REASON FOR THIS EXAMINATION:\n evaluate for intracranial hemorrhage\n CONTRAINDICATIONS for IV CONTRAST:\n end stage renal disease not on HD\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Plavix. Fall. Mental status changes. Inability to speak. Right\n upper extremity weakness.\n\n TECHNIQUE: A non-contrast head CT was performed.\n\n FINDINGS: There is no intracranial hemorrhage. There is no midline shift,\n mass effect or hydrocephalus. There are periventricular white matter\n hypodensities, most consistent with chronic microvascular ischemic changes.\n More wedge-like region of hypodensity in the region of the right parietal lobe\n is felt to represent a subacute infarct. A small, more subtle area of\n hypodensity is noted in the left frontal lobe. This could represent a more\n acute infarct. Dr. was contact with these findings at the time of\n dictation. MRI is recommended if further evaluation is clinically warranted.\n\n There is no intracranial hemorrhage.\n\n No fractures are noted.\n\n IMPRESSION:\n\n Subacute infarct in the right parietal lobe. There is also a subtle hypodense\n region in the posterior left frontal lobe, which could be better evaluated at\n that time also, as it may indicate an early infarct.\n\n Dr. was contact with these findings at the time of dictation.\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 960454,
"text": " 5:34 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Repeat, prior film was expatory.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD presents with acute SOB.\n\n REASON FOR THIS EXAMINATION:\n Repeat, prior film was expatory.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 70-year-old man with diabetes and end-stage renal disease, with\n acute shortness of breath.\n\n CHEST, UPRIGHT: Correlation to earlier films of the same day. There is\n persistent asymmetric edema and bilateral effusions. The possibility of\n pneumonia in the left lower lobe or marked atelectasis is also possible. More\n focal right lower lobe opacity is also concerning for pneumonia.\n\n IMPRESSION: Bibasilar opacities concerning for pneumonia. Also effusions and\n mild pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961937,
"text": " 4:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval lines, tubes, infiltrates\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke now with fever, s/p code with\n hypotension and hypoxia and intubated now s/p NGT re-advancement\n REASON FOR THIS EXAMINATION:\n eval lines, tubes, infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:40 A.M., .\n\n HISTORY: Embolic stroke with fever, hypotension and hypoxia. Readvance\n tubes.\n\n IMPRESSION: AP chest compared to through 20:\n\n Lungs clear. Heart size normal. ET tube in standard placement. Nasogastric\n tube ends above the gastroesophageal junction would need to be advanced at\n least 10 cm to move all the side ports into the stomach. No pneumothorax or\n pleural effusion. Heart size normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-22 00:00:00.000",
"description": "MR HEAD W/O CONTRAST",
"row_id": 961061,
"text": " 6:12 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: evaluate for stroke, specifically left MCA distribution\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with end stage renal disease, coronary artery disease,\n peripheral vascular disease, concern for left MCA stroke given inability to\n speak, RUE weakness\n REASON FOR THIS EXAMINATION:\n evaluate for stroke, specifically left MCA distribution\n ______________________________________________________________________________\n FINAL REPORT\n ROUTINE MRI OF THE BRAIN WITHOUT GADOLINIUM. ROUTINE MRA USING 3D TIME-OF-\n FLIGHT TECHNIQUE.\n\n HISTORY: End-stage renal disease, coronary artery disease with focal\n neurological symptoms, concern for left MCA stroke.\n\n Comparison is made with previous CT from the same day and previous MRI from\n .\n\n FINDINGS:\n\n The study is markedly motion degraded. There are extensive small vessel\n ischemic sequelae in the subcortical and periventricular white matter.\n\n There are foci of acute ischemia in the right parietal and left frontal lobes.\n Old bilateral cerebellar infarcts are seen. There is small vessel ischemic\n sequela and lacunes in the pons. Intracranial flow voids are maintained.\n\n There is mucosal thickening in the right ethmoid sinus.\n\n There is prominence of ventricles and sulci compatible with age appropriate\n volume loss, which is unchanged.\n\n The MRA is nondiagnostic. On the source images of the MRA, no large\n discontinuity of flow is seen.\n\n IMPRESSION:\n\n Acute infarctions in the right parietal and left frontal lobes.\n\n MRA is nondiagnostic.\n\n The results were conveyed to the CCC dashboard at the time of resident\n interpretation with which I concur.\n\n (Over)\n\n 6:12 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: evaluate for stroke, specifically left MCA distribution\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961860,
"text": " 6:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumonia\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke now with fever, tachypnea and\n increasing 02 req\n REASON FOR THIS EXAMINATION:\n eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, , AT 07:07 HOURS.\n\n HISTORY: Multiple medical problems with fever and tachypnea.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: Motion degrades the diagnostic quality of the current examination.\n No gross consolidation or superimposed edema is noted. Nasogastric tube is\n evident stable in course and position. There may be a small left pleural\n effusion. No pneumothorax is definitely identified.\n\n IMPRESSION: Marginal quality secondary to respiratory motion. No gross\n consolidation seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961867,
"text": " 9:18 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: STAT CXR-interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke now with fever, tachypnea and\n increasing 02 req- apnic breathing\n REASON FOR THIS EXAMINATION:\n STAT CXR-interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST AT 10:07 A.M.\n\n HISTORY: Apneic breathing.\n\n COMPARISON: Multiple priors, the most recent dated earlier the same day.\n\n FINDINGS: The patient has been intubated in the interval, and the\n endotracheal tube distal tip is approximately 6 cm from the carina.\n Nasogastric tube again remains in place. Again there is minimal blurring of\n the hemidiaphragms due to respiratory motion, although much improved\n visualization of lung parenchyma is present on the current exam. Overall, the\n lungs are clear. There is no consolidation or superimposed edema. The\n mediastinum is unremarkable. The cardiac silhouette is within normal limits.\n No effusion or pneumothorax is seen.\n\n IMPRESSION: Interval intubation as above. For optimal placement, consider\n advancing endotracheal tube 2 cm.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-29 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 962023,
"text": " 1:28 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please check picc tip position. 46cm v-cath picc. please pag\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke now with fever, s/p code with\n hypotension and hypoxia and intubated now s/p NGT re-advancement\n REASON FOR THIS EXAMINATION:\n please check picc tip position. 46cm v-cath picc. please page beeper #\n with wet read asap. thanks.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of PICC line placement.\n\n Portable AP chest radiograph was reviewed. The right PICC line continues into\n the right internal jugular vein, going up with its tip terminating above the\n upper limit of the chest film most likely within the skull. The ET tube tip\n is 6 cm above the carina but given the flexion of the neck, might be advanced\n for at least 2 cm. The NG tube tip terminates proximal at the cavoatrial\n junction with the sidehole situated in the mid esophagus. The left\n retrocardiac consolidation is grossly unchanged. No sizeable pleural effusion\n is identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-28 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 961891,
"text": " 1:28 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please re-evaluate for new strokes.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with recent b/l strokes, now with altered mental status, now\n s/p code.\n REASON FOR THIS EXAMINATION:\n Please re-evaluate for new strokes.\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent bilateral strokes with altered mental status post code.\n\n COMPARISON: , CT and MR.\n\n TECHNIQUE: Non-contrast axial CT images of the head were obtained at 5-mm\n section thickness.\n\n NON-CONTRAST CT HEAD: No hemorrhage, shift of normally midline structures is\n apparent. Evolving right posterior parietal and left frontal infarcts are\n observed. Again, unchanged periventricular white matter hypodensities\n consistent with chronic microvascular infarction. Mild ethmoid sinus mucosal\n thickening is noted. Mastoid air cells appear well aerated.\n\n IMPRESSION:\n 1. No evidence of hemorrhage.\n 2. Evolving right parietal and left frontal infarcts.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 960451,
"text": " 5:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please eval for infiltrate vs CHF.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD presents with acute SOB.\n REASON FOR THIS EXAMINATION:\n Please eval for infiltrate vs CHF.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 70-year-old man with end-stage renal disease and shortness of\n breath.\n\n CHEST, UPRIGHT AP VIEW: Comparison is made to prior films. These include\n .\n\n The heart is enlarged. There is marked pulmonary edema, with a predilection\n for the right side, as well as moderately large pleural effusions. There is\n no pneumothorax.\n\n Repeat radiography following appropriate diuresis recommended to assess for\n underlying infection.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 961512,
"text": " 1:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for NG tube placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke s/p NG tube placement\n REASON FOR THIS EXAMINATION:\n evaluate for NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, AP PORTABLE SINGLE VIEW\n\n INDICATION: Diabetes, end-stage renal disease, and peripheral vessel disease,\n status post embolic stroke and NG tube placement. Evaluate tube position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n semi-upright position and is analyzed in direct comparison with a similar\n study dated . During the interval, an NG tube has been placed,\n seen to reach far below the diaphragm pointing to the left within the fundus\n of the stomach. Also the sideport has reached below the diaphragm. No\n complication has occurred during the procedure. The lungs remain clear. The,\n on previous examination, , identified basal densities including\n pleural effusion and parenchymal infiltrates have normalized.\n\n IMPRESSION: Uncomplicated placement of NG tube.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962083,
"text": " 6:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated patient\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke who needs picc line for iv\n access,heparin and antibiotics.\n REASON FOR THIS EXAMINATION:\n intubated patient\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:31 A.M. \n\n HISTORY: Embolic stroke. PICC line.\n\n IMPRESSION: AP chest compared to through 21:\n\n Left lower lobe atelectasis persists. Tip of the right PIC line is partially\n obscured, but passes at least as far as the upper SVC.\n\n Tip of the ET tube at the upper margin of the clavicles is at least 6 cm from\n the carina, with the chin partially flexed. This is 3 cm above optimal\n placement. NG tube passes below the diaphragm and out of view. Lungs grossly\n clear. Heart size normal. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-06-23 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 961136,
"text": " 9:16 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: STROKE, CHF\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70M h/o PVD, DM, CAD presented with decompensated CHF and demand ischemia, now\n with concern for CVA\n REASON FOR THIS EXAMINATION:\n eval for carotid disease\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID SERIES COMPLETE.\n\n REASON: Stroke.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal\n plaque is identified.\n\n On the right, peak systolic velocities are 100, 112, 109 in the ICA, CCA, ECA\n respectively. The ICA/CCA ratio is 0.9. This is consistent with less than\n 40% stenosis.\n\n On the left, peak systolic velocities are 90, 99, 106 in the ICA, CCA, and ECA\n respectively. The ICA/CCA ratio is 0.9. This is consistent with less than\n 40% stenosis. Antegrade flow in both vertebral arteries.\n\n Although there are no elevated velocities in the carotid artery, both sides\n show diminished diastolic flow, especially on the left. This may be\n consistent with intracranial carotid disease.\n\n IMPRESSION: Minimal plaque with bilateral less than 40% cervical internal\n carotid artery stenosis. However, waveforms as described above may indicate\n more distal intracranial carotid disease. Clinical correlation and potential\n further evaluation is warranted.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962248,
"text": " 7:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Presence of worsening airspace disease post intubation\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke who needs picc line for iv\n access,heparin and antibiotics.\n REASON FOR THIS EXAMINATION:\n Presence of worsening airspace disease post intubation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST, 7:08 A.M, 5:23.\n\n INDICATION: Worsening airspace disease post-intubation.\n\n FINDINGS: Compared with , the ETT has been removed. The tip of the\n NGT projects at the mid stomach level with its proximal sidehole near the GE\n junction. The tip of the right arm PICC line projects at the mid SVC level.\n\n There has been significant interval reexpansion of the retrocardiac\n atelectasis.\n\n Allowing for some respiratory motion, the lungs are otherwise grossly clear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962772,
"text": " 1:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate Dopoff tube\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke s/p NG Dopoff\n placement.\n REASON FOR THIS EXAMINATION:\n evaluate Dopoff tube\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:23 P.M., \n\n HISTORY: End-stage renal and pulmonary vascular disease. Check Dobbhoff tube\n placement.\n\n IMPRESSION: Feeding tube ends with the weighted tip traversing the\n gastroesophageal junction. Side ports are in the esophagus. Heart size\n normal. Lungs clear. No pneumothorax or mediastinal widening. Tip of the\n right PIC catheter projects over the junction of the brachiocephalic veins. No\n pneumothorax or pleural effusion. Healed fractures, posterior left middle\n ribs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 963046,
"text": " 10:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PLEASE GET LOW XRAY TO INCLUDE ABDOMEN FOR ASSESSMENT OF DOB\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CVA w/ Dobhoff in place\n REASON FOR THIS EXAMINATION:\n PLEASE GET LOW XRAY TO INCLUDE ABDOMEN FOR ASSESSMENT OF DOBHOFF PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 10:02 A.M. \n\n INDICATION: Dobbhoff tube placement.\n\n FINDINGS: Compared with , the Dobbhoff tube has advanced from the\n level of the mid to the distal stomach.\n\n Motion artifact precludes evaluation of the lung fields.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-03 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 962561,
"text": " 12:42 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess for ICH or other pathology\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with recent massive CVA now with fever and altered mental\n status, ? ICH\n REASON FOR THIS EXAMINATION:\n please assess for ICH or other pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of recent massive stroke, now with fever and altered\n mental status, ? intracranial hemorrhage.\n\n COMPARISON: CT scans dated and and MRI dated .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Study is limited by motion. The areas of infarction in the left\n frontal and right parietal lobes are slightly more hypodense compared to the\n previous study, consistent with continued evolution of infarction. The\n ventricles are stable in size and configuration. There is no evidence of\n acute intracranial hemorrhage. There is opacification of right posterior\n ethmoid air cells, also noted on the previous CT scan.\n\n IMPRESSION: Continued evolution of left frontal and right parietal\n infarction, with no evidence of hemorrhage.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 963764,
"text": " 7:13 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: question of flash pulm edema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CVA w/ hypoxia and cough query pulmonary oedema\n\n REASON FOR THIS EXAMINATION:\n question of flash pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cough.\n\n A single portable radiograph of the chest demonstrates a similar\n cardiomediastinal contour to that seen on the chest radiograph obtained\n thirteen hours prior. Again noted is increased airspace opacity involving\n both lungs, worse on the right than the left and unchanged. Right-sided PICC\n line is unchanged. Bilateral pleural effusions persist. Trachea is midline.\n No pneumothorax. Radiopaque tubing and surgical staples project over the\n epigastrium. The appearance of the lungs is unchanged compared with .\n\n IMPRESSION:\n\n Persistent CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-07 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 963142,
"text": " 8:08 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P CVA WITH INCREASING SOMNOLENCE. ? BLEED.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CVA with increasing somnolence\n REASON FOR THIS EXAMINATION:\n r/o bleed, assess prior noted evolving stroke\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n WET READ: DSsd WED 2:29 AM\n No bleed or other acute process. No significant interval change. \n 02:30, .\n ______________________________________________________________________________\n FINAL REPORT\n CT SCAN OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST\n\n HISTORY: Status post CVA with increasing somnolence. Rule out intracranial\n hemorrhage.\n\n TECHNIQUE: Non-contrast head CT scan.\n\n PRELIMINARY REPORT: \"No bleed or other acute process. No significant\n interval change.\" This report was issued by Dr. at 2:30 a.m.,\n on .\n\n PRIOR REPORT: \"Continued evolution of left frontal and right parietal\n infarction, with no evidence of hemorrhage\", reported by Drs. and \n on .\n\n FINDINGS: There has been no definite interval change in the appearance of the\n brain compared to the prior study. Specifically, the left frontal-temporal\n and right temporal-parietal infarcts are redemonstrated, without evidence of\n hemorrhagic transformation. There is no other new intracranial abnormality\n discerned. There is continued demonstration of focal opacification by soft\n tissue density of the most posterior right ethmoid sinus air cell, with a\n slight amount of marginal sclerosis suggesting that the abnormality could be a\n reflection of chronic inflammatory sinus disease in this locale.\n\n CONCLUSION: No evidence of hemorrhagic transformation of previously\n identified infarcts, as noted above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962556,
"text": " 12:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxic, please assess for pna, aspiration\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke who needs picc line for\n iv access,heparin and antibiotics.\n REASON FOR THIS EXAMINATION:\n hypoxic, please assess for pna, aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia.\n\n CHEST, ONE VIEW: Comparison with examination of same day, 18:39 p.m. Motion\n blurs this image. The nasogastric tube is seen with its tip in the stomach.\n A pad terminates over the left hemithorax. PICC tip is not well\n identified, but can be seen coursing in the mid superior vena cava. The lungs\n appear clear on this limited examination. Cardiac, mediastinal, and hilar\n contours are probably unchanged. No pneumothorax is identified.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 963813,
"text": " 9:06 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: new OGT, please check placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CVA w/ hypoxia and cough, pulmonary edema, now s/p\n intubation\n REASON FOR THIS EXAMINATION:\n new OGT, please check placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CVA status post ET tube placement.\n\n CHEST, ONE VIEW: Comparison with exam of same day, 1:22 a.m. A new orogastric\n tube terminates in the fundus. Lungs appear better aerated, and pulmonary\n edema is less marked. The remainder of the exam is unchanged.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 963938,
"text": " 5:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess lines/tubes/lung fields\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CVA w/ hypoxia and cough, pulmonary edema, now\n s/p intubation\n REASON FOR THIS EXAMINATION:\n assess lines/tubes/lung fields\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:32 A.M. ON \n\n HISTORY: CVA, hypoxia, and cough.\n\n IMPRESSION: AP chest compared to through 4:\n\n Mild pulmonary edema has returned accompanied by increased small bilateral\n pleural effusions. Heart size is normal and there is no appreciable\n mediastinal vascular engorgement. Opacification at the base of the left lung\n is probably atelectasis, improved since . ET tube is in standard\n placement. Nasogastric tube loops in the stomach and passes out of view.\n Right PIC catheter passes as far as the upper SVC. No pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962548,
"text": " 7:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: location of tip of picc line\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke who needs picc line for\n iv access,heparin and antibiotics.\n REASON FOR THIS EXAMINATION:\n location of tip of picc line\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old man with recent PICC placement.\n\n Comparison is made to the prior study done on .\n\n The heart, mediastinal and hilar contours are normal. The lungs are clear.\n The right-sided PICC tip projects at the level of mid SVC. The NG tube side\n port projects at the level of the diaphragm.\n\n IMPRESSION:\n 1. Proper position of the right-sided PICC, with its tip projecting at the\n level of mid SVC.\n 2. Stable radiographs of the chest with no evidence of acute cardiopulmonary\n process.\n 3. NG tube side-port projects at the level of the GE junction, and needs to be\n advanced.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-08 00:00:00.000",
"description": "US ABD LIMIT, SINGLE ORGAN",
"row_id": 963188,
"text": " 8:38 AM\n US ABD LIMIT, SINGLE ORGAN Clip # \n Reason: please do RUQ u/s to assess GB and liver for evidence of , h\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with elevated LFTs and rising wbc\n REASON FOR THIS EXAMINATION:\n please do RUQ u/s to assess GB and liver for evidence of\n hepatitis/cholecystitis/vascular occlusion\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL ULTRASOUND LIMITED.\n\n INDICATION: 70-year-old man with elevated LFTs and rising white blood cell\n count. Assess gallbladder and liver for evidence of hepatitis, cholecystitis,\n and vascular occlusion.\n\n RIGHT UPPER QUADRANT ULTRASOUND: Comparison is made to a prior examination of\n . The examination is limited as the patient is not able to follow\n breathing instructions. The echotexture of the liver is coarse. No focal\n lesions are seen. The gallbladder is unremarkable. There is no wall\n thickening. No stones are seen. The gallbladder is not distended. The\n common bile duct is normal at 3 mm. Normal flow is identified in the hepatic\n veins and the portal vein. A Doppler of the hepatic artery could not be\n obtained as the patient could not follow breathing instructions.\n\n IMPRESSION: Somewhat limited examination as described above. No evidence for\n cholecystitis. Patent portal vein and hepatic veins. Hepatic artery could\n not be evaluated as described above.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962675,
"text": " 5:19 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate Dopoff NG placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke s/p NG Dopoff\n placement.\n REASON FOR THIS EXAMINATION:\n evaluate Dopoff NG placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate NGT placement in 70-year-old man with end-stage renal\n disease status post embolic stroke.\n\n Comparison is made to prior chest radiograph dated .\n\n UPRIGHT PORTABLE CHEST RADIOGRAPH\n\n FINDINGS:\n\n A nasogastric tube is coiled within the gastric fundus. Limited examination\n of the lungs appears unremarkable. A right-sided PICC catheter is seen\n coursing through the right axilla.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-09 00:00:00.000",
"description": "PERC PLCMT GASTROMY TUBE",
"row_id": 963356,
"text": " 10:41 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: please place GJ tube for continuous tube feeds and medicatio\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: OPTIRAY Amt: 30\n ********************************* CPT Codes ********************************\n * PERC PLCMT GASTROMY TUBE PERC PLCMT GASTROSOTMY TUBE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 yo M s/p NSTEMI, acute CVA, and urosepsis w/ resulting poor mental\n status/aspiration - NPO\n REASON FOR THIS EXAMINATION:\n please place GJ tube for continuous tube feeds and medication administration\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n\n\n\n This is a 70-year-old gentleman who is status post non-ST-segment elevation\n myocardial infarction with an acute CVA and urosepsis. The patient is aphasic\n and cannot swallow. He is unable to tolerate a nasogastric tube for long-term\n therefore the request was made to place a gastrojejunostomy tube.\n\n Informed consent was obtained from the wife. The patient was brought to the\n interventional suite and the abdomen prepped. The nasogastric tube was\n insufflated with air and three punctures were made for tie tacks to secure the\n stomach to the internal abdominal wall. The stomach was then entered and a\n guidewire passed into the ampullary area followed by an Omni Sos catheter to\n access the pyloric canal. The wire was passed into the duodenum past the\n ligament of Treitz over which a 14-French was passed through a peel-\n away sheath. The pigtail was coiled in the duodenum in excellent position.\n There was no immediate complication.\n\n MODERATE SEDATION was provided by administering divided doses of 50 mcg of\n Fentanyl and 1 mg of Versed throughout the intraservice time of 30 minutes\n during which the patient's hemodynamic parameters were continuously monitored.\n\n CONCLUSION: Status post gastrojejunostomy with tip of the feeding tube distal\n to the ligament of Treitz.\n\n\n\n\n\n (Over)\n\n 10:41 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: please place GJ tube for continuous tube feeds and medicatio\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Contrast: OPTIRAY Amt: 30\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 963704,
"text": " 6:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: query pulmonary oedema\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CVA w/ hypoxia and cough query pulmonary oedema\n\n REASON FOR THIS EXAMINATION:\n query pulmonary oedema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cough.\n\n Single portable radiograph of the chest is submitted. The right lateral\n hemithorax is excluded from the imaged field of view. Right-sided PICC line\n is unchanged. Surgical staples and radiopaque tubing again project over the\n epigastrium. There are small bilateral pleural effusions. Assessment of the\n pulmonary parenchyma is limited by respiratory motion, but increased airspace\n opacity persists. Trachea is midline. There is no pneumothorax.\n\n IMPRESSION:\n\n Limited examination.\n\n Persistent CHF, unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 962869,
"text": " 5:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval Dopoff placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 YO M with dm, ESRD, PVD, s/p embolic stroke s/p NG Dopoff\n placement.\n REASON FOR THIS EXAMINATION:\n eval Dopoff placement\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Dobbhoff placement.\n\n A single AP view of the chest was obtained at 17:10 hours and compared\n with the prior radiograph performed the prior day. The Dobbhoff tube has been\n advanced and its tip now projects over the expected location of the gastric\n body. Minimal subsegmental atelectasis seen at the left base. There is a\n right-sided PICC line with its tip unchanged in position from the prior\n examination and likely in the mid SVC.\n\n IMPRESSION:\n\n Further advancement of Dobbhoff tube with the tip in the gastric body. It\n still needs to be advanced for optimal placement.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 963781,
"text": " 2:15 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ETT placement, s/p adjustment\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CVA w/ hypoxia and cough, pulmonary edema, now s/p\n intubation\n REASON FOR THIS EXAMINATION:\n ETT placement, s/p adjustment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ET tube replacement.\n\n CHEST, TWO VIEWS: Comparison with examination of 45 minutes earlier.\n Endotracheal tube remains in position. Remainder of the examination is\n unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-02 00:00:00.000",
"description": "L UNILAT UP EXT VEINS US LEFT",
"row_id": 962479,
"text": " 10:42 AM\n UNILAT UP EXT VEINS US LEFT Clip # \n Reason: please evaluate LUE for clot in fistula or DVT\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with ESRD, with recent acute embolic CVA, with maturing LUE\n fistula and LUE swelling.\n REASON FOR THIS EXAMINATION:\n please evaluate LUE for clot in fistula or DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent acute embolic stroke. Please evaluate left upper\n extremity and fistula.\n\n COMPARISON: .\n\n FINDINGS: Limited evaluation of the left upper extremity and fistula was\n performed only for the evaluation of clot. Grayscale and color Doppler images\n of the left internal jugular, subclavian, axillary, and brachial veins were\n performed as was as images of the fistula. The left basilic vein was not well\n identified. Allowing for the fistula, compressibility, flow and augmentation\n are within normal limits. No intraluminal thrombus is identified.\n\n IMPRESSION: Left basilic vein not seen. No evidence of left upper extremity\n thrombus or thrombus within the fistula.\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 963779,
"text": " 1:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ETT placement, interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CVA w/ hypoxia and cough, pulmonary edema, now s/p\n intubation\n REASON FOR THIS EXAMINATION:\n ETT placement, interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CVA, intubated.\n\n CHEST, ONE VIEW: Comparison with , 18:19 p.m. New endotracheal\n tube terminates approximately 6.0 cm above the carina. Right PICC is\n unchanged in position. Lungs appear better aerated, which may be due in part\n to positive pressure ventilation. Pulmonary edema has decreased slightly. A\n small right pleural effusion has decreased in the interim. Extensive left\n lower lobe atelectasis, with slight leftward mediastinal shift is slightly\n worse than the last exam.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2105-07-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 963659,
"text": " 9:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o new infiltrate\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p CVA w/ hypoxia and cough\n REASON FOR THIS EXAMINATION:\n r/o new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:46 \n\n HISTORY: CVA, hypoxia and cough.\n\n IMPRESSION: AP chest compared to and 29:\n\n Pulmonary vascular and mediastinal vascular congestion have developed\n suggesting perihilar opacification in the right lung is more likely edema than\n pneumonia. Heart size is top normal though increased since . Tip of\n the right PIC catheter projects over the upper SVC. New tubing projects over\n the upper abdomen but cannot be localized on this view alone. Dr. and I\n discussed these findings by telephone at the time of dictation.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2105-06-23 00:00:00.000",
"description": "Report",
"row_id": 70170,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. ? Thrombus. ?PFO.\nHeight: (in) 68\nWeight (lb): 185\nBSA (m2): 1.98 m2\nBP (mm Hg): 165/60\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 11:30\nTest: Portable 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: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size. Overall normal\nLVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root.\n\nAORTIC VALVE: Moderately thickened aortic valve leaflets. Minimally increased\ngradient c/w minimal AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular\ncalcification. No MR. [Due to acoustic shadowing, the severity of MR may be\nsignificantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest. Patient was unable to cooperate with\nmaneuvers.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast at rest (cannot\ndefinitively exclude). There is severe symmetric left ventricular hypertrophy.\nThe left ventricular cavity size is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets are moderately thickened. There\nis a minimally increased gradient consistent with minimal aortic valve\nstenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets\nare mildly thickened. No mitral regurgitation is seen. [Due to acoustic\nshadowing, the severity of mitral regurgitation may be significantly\nUNDERestimated.] There is no pericardial effusion.\n\nNo cardiac source of embolus identified (cannot definitively exclude).\n\nCompared with the prior study (images reviewed) of , there is no\ndefinite change.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-13 00:00:00.000",
"description": "Report",
"row_id": 1371166,
"text": "Respiratory Care: pt recieved intubated and vented on AC. No changes done today. Lung sounds clear/diminished bilaterally. Suctioned for small thick yellow secretions.Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-14 00:00:00.000",
"description": "Report",
"row_id": 1371168,
"text": "Shift Note: 1900-0700\nNeuro: Pt remains intubated and sedated on fentanyl gtt at 75mcg/hr. Moves LE w/ nail bed pressure to UE. Opening eyes spontaneously, though appears calm and relaxed t/o shift w/ no diaphoresis, acute change in VS, grimacing or other s/s pain noted t/o shift. Appears comfortable.\n\nResp: Vented AC 500/8 X 18 FiO2 40%. Snx occasionally for scant amount thick white secretions. SpO2 remains 99-100%. BBS clear to diminished at bases. Remains afebrile.\n\nCV: HR 60's to 70's, SR w/ no appreciable ectopy noted. BP remains stable off levophed and dopamine. Also remains off nitro gtt. Continues on heparin gtt initially at 550 units/hr though 1000 unit bolus given and rate increased to 800 units/hr per SS for PTT result 37.6 at 0200. Repeat PTT entered for 0800. Pt remains free of s/s active bleeding t/o shift.\n\nFEN: Continues w/ TF nutren renal at 30ml/hr increasing to goal rate 40ml/hr as ordered. DSD over large unstagable pressure sore to coccyx per report. Dsng remains intact and pt remains w/o BM so far this shift. Will send am labs. FSBS have remained stable 60's to 70's. Pt ordered for fixed doses of regular insulin qhr w/ insulin glargine qpm. 9 units glargine given at 1800 per report. All regular insulin held this shift and TF increased as pt tolerates. Will continue to monitor for s/s hypoglycemia. Pt is not a dialysis candidate at this time per renal progress note.\n\nSocial: Per report family mtg took place yesterday w/ team, nursing and ethics. Decision made for pt to be DNR and orders written. Also plan for no further escalation in care. Pressors will not be restarted as stated in orders. Though son ready for comfort measures, wife needs more time. Possible transition to CMO over next several days though priority at this time remains comfort.\n\nPlan: Continue to monitor VS and labs as ordered. Priority on comfort. Continue fentanyl gtt as ordered and titrate as necessary. Continue support for family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-13 00:00:00.000",
"description": "Report",
"row_id": 1371167,
"text": "NPN\n\nNeuro: Pt sometimes found with his eyes open, does not appear to track, at times he is lethargic, remains on a fent gtt, this has not been increased and remains at 75 mcg/hr.\n\nCV: Conts on the hep gtt at 700 units/hr, last PTT was 39.5 and his rate was not increased because he has repeatedly needed to have his gtt rate decreased or stopped on the same rate. His BP has been stable 110-120s, off of pressures and NTG gtt, his BP has not been high enough to tolerate the lopressor.\n\nResp: Remains vented, no changes were made on the , LS coarse.\n\nGI: TF were restarted at 10cc/hr with a goal rate of 40cc/hr, babnanaflakes cont, he has not had any stool this shift.\n\nGU: His urine remains light in color, u/o has been 20-40cc/hr, no further diuretics have been given. Renal saw him today and said that he is not a cadidate for dialysis.\n\nSkin: He remains on a kinair matress for his unstagable decube. it conts to have some areas of blackened skin as well as red raw area that tend to bleed. Conts with the skin care oint and turning.\n\nSoc: His wife and son were in this morning, they were told that he was not doing very well overall, a family meeting occured with ethics, an interpreter, MICU attending, nursing and his wife and son. It was decided that comfort would be our primary goal, that we would not escalate care, would not add back pressures, his son was ready to withdraw the but his wife was not and asked for a little more time. He is now DNR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-14 00:00:00.000",
"description": "Report",
"row_id": 1371169,
"text": "Resp Care\nPt. remains intubated w/o change this shift. No abgs drawn.\nBs: clear equal bilat. secreations minimal.\nPlan:Family meeting yesterday,made DNR however not made CMO as of yet.Continue current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-12 00:00:00.000",
"description": "Report",
"row_id": 1371161,
"text": "Nursing Admission Note:\n70y.o. portuguese speaking male transferred from 11R today for increased resp distress, new NSTEMI, possible intubation.\n\nPMH: CAD, CVA, IDDM, MI, PVD s/p bilateral BKA, ESRD with left AV fistula in place but has not received dialysis as yet, This admission has had CVA and MI already. Pt has PEG in place. Pt also has PICC right upper extremity\n\nAllergies: NKA\n\nPt has had increased Resp distress noted in past 24hrs while on 11R and CPK/troponins indicated new NSTEMI. CXR showed worsening pulmonary edema and possible aspiration PNA. Pt's urine output low and he has not responded well to lasix/diuril doses on floor. Transfers to MICU for possible intubation/possible dialysis. Cardiology does not have any intervention to offer him at this time. He transfers to MICU on heparin drip at 910u/hr and NTG drip at 3 drops.\n\nArrives moaning in bed slightly distressed resp status. Good sat on 100% NRB. Weaning down at present. He has large sacral decubitus ulcer which is black and unstagable. Kinaire bed ordered. Family aware of transfer.\n\nNeuro: Pt non-verbal at baseline. Stiff to move in bed. Moans at times.\n\nCV: BP 110-120/50. HR 90's NSR with APC's. Labs sent are pnd. Initial PTT was 101 so heparing drip dropped to 700u/hr and repeat PTT needs to be drawn at 5PM. Getting BP in lower right arm. NTG on. Pt received 100mg lasix and 500mg IV diuril prior to transfer to MICU and will hopefully respond to this. Renal may opt for dialysis later today.\n\nResp: Lungs clear w/deminished sounds at bases. RR 24-36 ABG pnd.\n\nGI: Has PEG in place and is having diarrhea. Pt is getting banana flakes via PEG TID. Tube feeds full strength renal goal is 40cc/hr.\n\nGU: Foley in place draining small amts yellow urine with sediment.\n\nID: afebrile on transfer.\n\nSkin: Needs Kinaire bed. Has large sacral decubitus. Needs to be seen by skin care/wound nurse.\n\nSocial: Pt's family is Portuguese speaking. Son is proxy \n\nAccess: PICC in right upper extemity is double lumen. Working well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-14 00:00:00.000",
"description": "Report",
"row_id": 1371170,
"text": "neuro: pupils equal at 2-3 mm slugish to nonreactive, pt oens eyes to voice stim but no tracking, pos coreal reflex. rt side flacid upper extrem seems to move both stumps upon stimulation. no movement or reaction to nail bed press. no grimacing with movement. fentanyl gtt maintained at 75 mcg /hr\n\nresp: remains on cmv with 40%, tv 500 rate 18, MV 8.6 . not suctioned this shift. lung snds clear upper and diminished at basess\n\ncard: nsr 65-80's bp 112=130 sys, no ectopy. heparing gtt with ptt 52 at 0900 and will check at 1500 and if in range will be able to hold at dose of 800 units/hr. rt stump with lg pressure hematoms and poss site for skin breakdown. need to protect rt stump with pillow.\n\nfen: flushed G/J tube and hooked tube feeds to that and gave meds via peg. could d/c oral gastric tube and will be better to prevent asp. tube feeds at goal and consulted nutrition and should be feeding continously. endo: glucose 200 and given standing and coverage SSI today.\n\nskin: monitor rt stump for poss breakdown. skin care nurse consulted.\nordered no double guard to buttocks and lg pressure ulcer. wash after each bm and apply critic -aid clear skin oint after rubbing it in hand, to total ulcer area. no dressing\n\nsocial :no visitors today.\n\nplan: family has made him dnr. no pressors, goal will be for comfort with no further escalation of care. may extubate and make cmo in next 24-48 hr but no definate process in place ast this time\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-14 00:00:00.000",
"description": "Report",
"row_id": 1371171,
"text": "Resp Care\nPt remains intubated. Current settins: A/C 500 x 18 8P 40%. No current ABG's. Still waiting for family decision. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-15 00:00:00.000",
"description": "Report",
"row_id": 1371172,
"text": "Shift Note: 1900-0700\nNeuro: Remains intubated and sedated on fentanyl drip. Opening eyes spontaneously or to voice at times, though not tracking RN in room. Moves bilat lower extremities w/ nail bed pressure to upper extremities. Pupils 3mm and non-reactive to light. Pt appears calm and relaxed, no diaphoresis, acute change in VS, grimacing or other s/s pain t/o shift. Occasionally moves LE. No spontaneous movement noted to upper extremities. Pt appears comfortable t/o shift.\n\nResp: Continues AC 500/8 X 18 FiO2 40% - no spontaneous resp noted. Snx X 1 for scant thick white secretions. BBS CTA to slightly diminshed L base. SpO2 remains 95-98%.\n\nCV: Hr remains 60's to 70's, SR w/ no appreciable ectopy. BP remains stable. Continues on heparin gtt at 800 units/hr. PTT has been therapeutic X 2 sets. Am labs pnd. Pt remains free of s/s active bleeding.\n\nFEN: Continues TF nutren renal at goal rate of 40ml/hr through PEG. Ok to use PEG per team and OGT removed. FSBS covered w/ fixed dose regular insulin and SS humalog insulin as ordered. UOP decreasing w/ worsening renal function. Pt is not a dialysis candidate per renal progress note. Am labs pnd. Generalized edema increasing. Abd soft, non-tender w/ BS present. No BM this shift and banana flakes have been held.\n\nSkin: Large pressure sore to coccyx w/ necrotic area and tissue sloughing. Difficult to stage. Areas of wound base red w/ granulation tissue. Scant s/s drainage noted. Using foam cleanser and barrier ointment as well as citiric aid ointment per wound care recommendations.\n\nSocial: No contact from family this shift.\n\nPlan: Continue to monitor VS and labs as ordered. Continue wound care tx as recommended, air bed, frequent repositioning and other skin care measures. Continue fentanyl gtt as ordered w/ priority on comfort. Pt is DNR w/ plan for possible transition to CMO in next 24hr as per family meeting . Anticipate 2nd family meeting. Support for family ongoing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-15 00:00:00.000",
"description": "Report",
"row_id": 1371173,
"text": "Resp Care\nPt. remains on same ventilator settings x3 days, with no abgs.Occ. breaths over set rate.\nBs:ess. clear anteriorly with minimal secreations.\nPlan:DNR with possibly transition to CMO, no rsbi done.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-15 00:00:00.000",
"description": "Report",
"row_id": 1371174,
"text": "rsp care - Pt remains intubated and on full support. No changes made this shift. Pt suctioned frquently for small amounts of thick, white secretions. BLBS were coarse t/o. Continued resp support planned.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-15 00:00:00.000",
"description": "Report",
"row_id": 1371175,
"text": "MICU nursing progress note:\n\n Please see flowsheet for more details\n\nNeuro: Opens eyes sponts. at times and to voice, but lacks tracking. Moves lower exts w/ nail bed pressure to uper exts. Pupils remain 3mm and NR. Fentanyl gtt at 75mcg/hr. No signs/symptoms of pain/discomfort.\n\nResp: Remains orally intubated on AC x 18/500/8/40%. No spont resp. noted. Suctioning for small amt of thick whitish secretions. BBS CTA. Stable Spo2.\n\nCV: HR 66-68-SR w/ no ecopty noted. T. max. 99.0. ABP 114/40 - 126/46. Increasing generalized body edema noted. Continues on heparin gtt at 800 units/hr w/ therapeutic PTT.\n\nGI/GU: + BS noted. Abd is soft, nt, nd. On TF (nutren renal FS) goal rate of 40cc/hr via PEG. No BM for my shift. Foley in place w/ low uo. Pt. is not a dialysis candidate per renal notes.\n\nSKIN: Coccyx area w/ stage II pressure ulcer --wound care RN consulted and recommended barrier cream application.\n\nSOCIAL: Family meeting this afternoon to decide continuing further treatment vs CMO/withdrawal of care. No decision at present.\n\nPlan: Monitor per protocol. Cont. wound tx as recommended, air bed. Cont. fenantyl gt as ordered. Pt. remains DNR. Provide support to family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-12 00:00:00.000",
"description": "Report",
"row_id": 1371162,
"text": "MICU NPN Addendum to admit note:\nStill awaiting arrival of Kinaire bed to unit. Renalk has come by and decision to use lasix/diuris tonight and hold of dialysis for now. UO ranging 40-60/hr. need another large lasix dose followed by diuril this evening.\n\nBP 100-120/50 HR 80's after getting dose of lopressor 50mg PO. His dose ordered is 100mg but since BP boarderline I gave him only 50mg and BP dropped from 110-90's. The rest of the dose of lopressor held. Continue on NTG drip increased to 6gtt. Heparin drip rate dropped to 700u/hr at 11AM. Please send repeat labs at 5PM along with his PM labs ordered.\n\nABG on 40% cool neb was 75/20/7.50 showing a combined resp alkalosis and metabolic acidosis. FIO2 increased to 70% CN and will watch closely. RR continues to be 30's.\n\nTeam is watching his temp curse as his WBC has climbed up to 22.3 today. Pt is ordered for echo to check for endocarditis. No antibiotics for now.\n\nPlan: Continue diuresis. Follow resp status, he still looks tenuous and may need intubation if family wants to continue aggressive care. Follow temp closely and notify team of any spike. Please send PM labs as ordered. Follow PTT Q6hr while on heparin.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-12 00:00:00.000",
"description": "Report",
"row_id": 1371163,
"text": "MICU NPN 1500-2300\n Pt is a 70 yo male, who arrived in the MICU earlier in the day after having respiratory distress on the floor.\n\nReview of systems:\n\nResp: Received pt on 100% CN with RR in the low 20's. LS were course, NT sxn'd ~1600, for thick tan secretions. Approx 1845, pt having increasing resp distress after a drop in BP required the NTG to be turned off. LS coarse with scattered rales at that time. Ordered and received 100mg IV lasix followed by 500 mg IV Diuril. Fair urine response. Placed on masked ventilation, with noted improvement.\n\nCV: CPK's resent at 1900, increased to 1462 with MB 23. HR has been in the 70's-90's, 100's with distress. Difficulty with monitoring BP acurately. Had been monitoring BP on right wrist, becoming bypotensive to the 70's/, Rechecked in the left arm: 125/, unable to con't monitoring BP in this extremity due to A-V fistula. Right upper arm has a PICC line and BLE a BP was undetectable. Team notified, and A-line placed for continued monitoring. NTG restarted ~ after being shut off for hypotension, currently infusing at 6gtts/hr, .56 mcg/kg/hr. Heparin infusing at 700units/hr. PTT checked ~51, no changes made.\n\nGU: Fair response to the lasix and diuril. Amts recorded in carevue. Foley intact, draining clear yellow urine.\n\nGI: +BS, 3 stools this shift. Sent off for C-Diff culture. TF's stopped during resp distress episode. Con'ts off during masked ventilation. Will need to reassess later prior to restarting. Had been infusing at 20cc/hr. Goal is 40cc/hr.\n\nSkin: BUE edema. Sacral decub cleansed per protocol. Awaiting skin care consult tomorrow. Incontinent of stool times 3. Difficult to keep area clean. Checked and turned frequently.\n\nSocial: No contact from family this shift.\n\nNeuro: Pt responds to tactile stimuli, but does not visually track. He will squeeze left hand, but not on command. Does not appear to move RUE, moves RLE and LLE.\n\nID: Afeb at present. No antibiotic coverage at this time. Sputum and stool sent this shift.\n\nLines: new A-line in right radial, PICC in RUE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-13 00:00:00.000",
"description": "Report",
"row_id": 1371164,
"text": "M/SICU ICU day 2 (2300 -0700)\n\nEvents: Recieved pt from previous shift @ 2300, VS @ the time of transfer were as follows ABP 123/43, RR 35, Sat 100%, on Non invasive mask ventilation (NIMV). @ ~ 2345 pts respirations became agonal RR dropped from mid 30's to low 20's, sats trended down to low 90's, became bradycardic and hypotensive to high 70's systolic. ABG @ this time was 7.29/37/157, family was notified of the change in condition and reaffirmed the desire for pt to remain full code.\n\nRecieved 1 amp Na bicarb, emergently intubated w/ succ's/etomodate. Follow up ABG 7.49/27/300 on the following settings AC 100% 600x 20 PEEP 8. L Femoral TLCL placed, levophed and dopamine gtts initiated. Vanco/zosyn administered.\n\nReiview of Systems:\n\nNeuro: Lightly sedated on fent, opens eyes to stimulation, unable to track or follow commands, no movement x 4 extremities.\n\nCV: NSR w/ occasional ventricular ectopy, Levoped gtt titrated to maintain MAP >60, ABP 100-110's systolic. Afebrile. Please refer to flow sheet for objective data.\n\nResp: Intubated 25cm @ lip, size 8.0 ett, current settings 50% 500x 18 PEEP 8. ABG on these settings pending @ this time. LS coarse upper lobes, crackles lower. Sats 100%.\n\nGU/GI: TF remains off r/t heme/resp instability, abd soft/nt/nd, +BS. Recieved 100mg IVP lasix w/ only 80 cc output, clear yellow, U/O since emergent intubation <30cc/hr.\n\nAccess: R DL PICC, L femoral TLCL (all ports flush appropriately, only brown draws). R radial A-line.\n\nPlan: Family meeting to be held this AM to discuss Code Status and then re-evaluate goals/plan of care. Cont. to monitor/maintain heme/resp status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-13 00:00:00.000",
"description": "Report",
"row_id": 1371165,
"text": "Resp Care\nPt. placed on NIV for increased WOB/high Fio2 requirement. Tolerated well however respirations became in-effective/tachypneic/ HR decreased. Intubated.\nabgs:chronic metabolic acidosis with resp. compensation. Oxygenation improved t/o shift.\nBs:clear uppers with bibasilar crackles.\nPlan: Cont. current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-01 00:00:00.000",
"description": "Report",
"row_id": 1371159,
"text": " nsg note: 19:00-7:00\nthis is a 70 y.o. male adm with NSTEMI/CHF who has had two embolic strokes this admission. He was found unresponsive on while on a regular floor with temp 102.3 and required transfer to ICU intubated on pressors. pt transferred to 4 from SICU due to bed availability as pt is a MICU pt. pt off sedation since 8:30 (was on propofol). has also been off levophed since am of . extubated .\n\nneuro: alert most of shift with eyes open but not tracking. nonverbal. inconsistently squeezes with l hand, moves le's. no movement of rue. perrla 3mm sluggish to brisk. no evidence of discomfort.\n\ncv: hr ranging 60s-90s sr with one run of unsustained vtach. otherwise, no ectopy. bp ranging 140s-190s/40s-50s. pt given iv lopressor 5mg when sbp 190s without effect. given 10mg iv hydralazine x2 with some effect. started on norvasc 5mg pngt with good effect with sbp in 140s-160s.\n\nresp: lungs with rhonchi t/o. sp02 91% at beginning of shift with pt coughing but not able to get sputum up requiring nts for moderate amts thick tan secretions with sat up to mid 90s. pt placed on 50% cool neb scoop mask with sat mid to upper 90s. also given cpt. no further desat.\n\ngi/gu: abd soft, nt, +bs, ngt . feed stopped at beginning of shift when desated. free h20 also held. foley draining yellow urine with sediment with adequate amts.\n\nskin: warm, dry and intact.\n\nsocial: portuguese speaking pt. family was visiting yesterday. has a wife and son. son is spokesperson and speaks english well.\n\nplan: continue to monitor mental status, continue metoprolol, hydralazine and norvasc and hold per parameters. keep map > or equal to 70 (currently 80s). maintain aspiration precautions, cpt, cool neb, suction prn, swallow eval-may need peg in near future. pt consult.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-01 00:00:00.000",
"description": "Report",
"row_id": 1371160,
"text": "Neuro: alert followsto commands intermittently when spoken with creol language, purpose movements, L arm normal in strength, lift and holds LLE, no movement R extremeties. puplis equally reactive, grimacing to pain, given tylenol 650 mgs per NGT; pateint able to sleep intermittently\n\nCV: hydralazine 10mg IV given x 1 for SBP >180's, on lopressor and norvasc SBP goal 140's-160's MAP < 90 ( see careview for details ) SR without ectopy; edema both hands noted.\n\nRespi: cough out moderate amount of tan colored secretions, lung sounds rhonchorous, sats >95% at room air\n\nGI: tube feeds restarted at 10cc/hr no residuals, free water q6hrs continued. tubefeeds dc'd at 1600 consistently hiccups. bowel sounds present, incontinent bag intact with brown liquid stool. plan for PEG insertion.\n\nGU: -200cc for LOS BUN and crea rising, renal following patient. Renal attending talked with family about dialysis where they consented however no dialysis is needed at this moment per renal.\n\nID: on contact precaution for Klebsiella growing urine and sputum, afebrile continues on meropenem 500mg q24hrs\n\nAccess: Aline and double lumen PICC R arm; AV fistula \n\nSocial: patient's wife stayed for visit, needs interpreter. team reviewed advance directive again with wife, full code.\n"
},
{
"category": "ECG",
"chartdate": "2105-06-30 00:00:00.000",
"description": "Report",
"row_id": 155604,
"text": "Sinus rhythm\nLVH with secondary repolarization abnormality\nAnterolateral ST-T changes are probably due to ventricular hypertrophy\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2105-06-29 00:00:00.000",
"description": "Report",
"row_id": 155605,
"text": "Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy. ST-T wave\nabnormalities - cannot exclude ischemia. Clinical correlation is suggested.\nSince the previous tracing of sinus tachycardia is absent and the\nST-T wave changes are less prominent.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2105-06-28 00:00:00.000",
"description": "Report",
"row_id": 155606,
"text": "Sinus tachycardia. Left atrial abnormality. Left ventricular hypertrophy.\nST-T wave abnormalities - cannot exclude ischemia. Clinical correlation is\nsuggested. Since the previous tracing earlier this date sinus tachycardia is\npresent and ST-T wave abnormalities are more prominent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2105-06-28 00:00:00.000",
"description": "Report",
"row_id": 155607,
"text": "Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy. ST-T wave\nabnormalities - cannot exclude ischemia. Clinical correlation is suggested.\nSince the previous tracing of the rate is faster and ST-T wave changes\nappear slightly more prominent.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2105-07-12 00:00:00.000",
"description": "Report",
"row_id": 155601,
"text": "Sinus rhythm\nBorderline first degree AV delay\nLeft atrial abnormality\nLeft ventricular hypertrophy with ST-T abnormalities\nSince previous tracing of the same date, sinus tachycardia absent\n\n"
},
{
"category": "ECG",
"chartdate": "2105-07-12 00:00:00.000",
"description": "Report",
"row_id": 155602,
"text": "Sinus tachycardia\nBorderline first degree AV delay\nLeft atrial abnormality\nLeft ventricular hypertrophy with ST-T abnormalities\nSince previous tracing of , sinus tachycardia present\n\n"
},
{
"category": "ECG",
"chartdate": "2105-07-11 00:00:00.000",
"description": "Report",
"row_id": 155603,
"text": "Sinus rhythm\nBorderline first degree A-V delay\nLeft atrial abnormality\nLeft ventricular hypertrophy with ST-T abnormalities\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2105-06-22 00:00:00.000",
"description": "Report",
"row_id": 155836,
"text": "Sinus rhythm\nProbable left atrial abnormality\nLeft ventricular hypertrophy with ST-T abnormalities\nPossible left anterior fascicular block\nSince previous tracing of , axis appears more leftward\n\n"
},
{
"category": "ECG",
"chartdate": "2105-06-19 00:00:00.000",
"description": "Report",
"row_id": 155837,
"text": "Normal sinus rhythm. Left ventricular hypertrophy with secondary ST-T wave\nabnormalities. No change from tracing #1.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2105-06-18 00:00:00.000",
"description": "Report",
"row_id": 155838,
"text": "Normal sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy with\nsecondary ST-T awve abnormalities. Compared to the previous tracing of \nno diagnostic interim change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2105-06-18 00:00:00.000",
"description": "Report",
"row_id": 155839,
"text": "Normal sinus rhythm, rate 82. Borderline first degree A-V block. Borderline\nleft atrial abnormality. Left ventricular hypertrophy. Non-specific lateral\nrepolarization changes consistent with left ventricular hypertrophy and/or\nischemia. Cannot exclude old septal infarction. Compared to the previous\ntracing of lateral ST segment depression is more marked and R wavse\nhave disappeared in leads VI-V2 consistent with interval septal myocardial\ninfarction (though unlikely).\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-06-29 00:00:00.000",
"description": "Report",
"row_id": 1371151,
"text": "NPN (SEE CAREVUE FOR SPECIFICS)\nAT BEGINNING OF THE SHIFT, PT BREATHING IN 30'S ON AC, ABG SHOWING ALKALOSIS WITH PCO2 OF 24. PT APPEARING UNCOMFORTABLE, GRIMACING WHEN MOVED. HR 110-115, SINUS TACH, HYPOTENSIVE WITH LEVO TITRATED UP TO .4 MCGS/KG/MIN. DR. PAGED, DECISION MADE TO INCREASE PROPOFOL, FENTANYL PRN ORDERED FOR PAIN WITH EXCELLENT EFFECT. ABG IMPROVED, PT NOW BREATHING A FEW BREATHS ABOVE SET RATE, IS NOW SYNCHRONOUS WITH THE . BP CONTINUED TO DROP WITH INCREASED SEDATION, HR REMAINED 115-120 DESPITE 50MCGS OF FENTANYL. 1 LITER OF LR GIVEN OVER AN HOUR WITH EXCELLENT EFFECT, HR CURRENTLY 80'S, NSR, BP STABLE WITH MAP ABOVE 60 AND ABLE TO TITRATE LEVO DOWN TO .2-.3 MCGS. RESIDENT SUGGESTING ADDITIONAL FLUID IF PT BECOMES ABOVE 110.\nNO SPONTANEOUS MOVEMENT AT THIS TIME, NOW THAT PT IS MORE STABLE ON THE , DO DAILY WAKE UP THIS MORNING TO FULLY ASSESS NEURO STATUS. LUNGS CLEAR, O2 SAT 100%. ABD SOFT, + BS. CONTINUES TO HAVE LOOSE STOOL VIA FIB. LOW GRADE TEMPS, AWAITING CULTURE RESULTS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-06-29 00:00:00.000",
"description": "Report",
"row_id": 1371152,
"text": "Respiratory Care\n\n Pt continues on full ventilatory support. No changes made. B/S ess clear. Will continue to follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-06-29 00:00:00.000",
"description": "Report",
"row_id": 1371153,
"text": "MPM 0700-1500;\nEVENTS; WEANED LEVO AND MAINTAINED SBP THAN 100.\nPROPOFOL OFF AT 0830 VERY SLOW TO AWAKEN BEGINNING TO GRIMACE WITH WITH NOXIOUS STIMULI SOME MOVEMENT OF OF HEAD WITHDRAWS TO PAINFUL STIMULI IN LT ARM\nINSULIN GTT OFF AT 1130 AFTER BEING GIVEN LANTUS 5UNITS S/C AT 1130 AM.\nPICC PLACED IN RT ARM. CXR DONE AWAITING READ.\nNEURO ;OFF PROPOFOL AT 0830; DOES NOT OPEM EYES MOTHING TO VCOMMAND MN MOVEMENT OF LOWER LIMBS ON BED NO MOVEMENT OF RT ARM WITHDRAWS TO NAILBED PRESS ON LT ARM.\n\nRESP; LUNGS CLEAR DIMINISHED AT BASES CHANGED TO CPAP WITH PS 5 PEEP 5 ABG WITH PCO2 25-26. TEAM AWARE. SUCTIONED FOR MOD AMOUNT OF YELLOW SECRETIONS.Q3 SATS 97-100% RR 22-28 TV 360-400 WITH REPEAT ABG PENDING.\n\nCVS; TMAX 100.1 PO NSR 75-83 ISO PACS NOTED BP 125-131/36 . LEVO OFF BY 1030 BP MAINTAINED.\n\nGU; PASSING 30-40 MLS/HR 100 MLS/HR LR/D5% CONTINUES.\n\nGI; BELLY SOFT HYPOACTIVE BS LOOSE BROWN STOOL VIA RECTAL BAG C-DIFF SENT.\n\nENDO; GIVEN GLARGINE 5 UNITS S/C AT 1130 AND INSULIN DRIP TURNED OFF AT 1330 BS 97-126.\n\nSOC; FAMILY INTO VISIT NO ONE SPEAKING ENGLISH AT THIS POINT.\n\nA/P; MONITOR CHECK RSBI THIS AFTERNOON CONTINUE WITH NEURO OBS.\nFOLLOW UP ON CULTURES AFTER PICC PLACEMENT IS CONFIRMED D/C FEM LINE. PREPARE FOR TRANSFER TO 4.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-06-29 00:00:00.000",
"description": "Report",
"row_id": 1371154,
"text": "resp. care\npt. transfered from via resp. therapist, nurse, emt's. continued on cpap/ps 5/5 and 40% with tidal vols. 500 and rate 18.\nett secure at 22cm with #8.0. alarms set. plan to continue\n for a/w protection until pt. wakes up.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-06-28 00:00:00.000",
"description": "Report",
"row_id": 1371149,
"text": "Resp Care\nPt found unresponsive on F3, intubated and trans to unit. Continues on CMV, traveled for head ct without incident. Plan to continue with current tx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-06-28 00:00:00.000",
"description": "Report",
"row_id": 1371150,
"text": "FOCUSED NURSING NOTE\nPlease see carevue flowsheet for furhter details\n\nNEURO:Intubated, propofol gtt for therapeutic ventilation and comfort. PERRL, 2-3mm. Moves all extremities (BKA) weakly when propofol lightened, strong cough/gag. Not following commands, pt speaks only.\n\nRESP: ETT 22 lip, ventilated on CMV for metabolic acidosis- current settings .50/500/14/5, RR 26-28, SPO2 100%. Lungs coarse right lobe, clear on left. Suctioned for thick/yellow secretions, ?aspiration prior to transfer. copious oral secretions as well-\n\nHEMODYNAMICS: Unresponsive, tachy and hypotensive trigger on 3. Dopmaine/levo gtts to sustain SBP>90. Dopamine titrated off by 1500 (pt became tachycardic just prior to successful wean- EKG confirms ST). Levophed at 0.3-0.5mcg/kg/min, ABP 95-130s/40s, goal MAP>60. u.o. 20-30ml/hr. s/p 1500ml D5W w/ 1amp NaHCO3 to correct met acidosis/hypernatremia. Received 1LR in am.\n\nID: Tmax 100.1 oral. Pancx, loose brown stool with very foul odor- Cdiff pending. Vanco/Zosyn given as ordered. Urine cldy.\n\nGI/METABOLIC: NPO. NGT in place, intermittent LCS draining light brown fluid. Large amt stool output.Nutrition on hold today. Hyperglycemic to 316, insulin gtt titrated protocol, current glucose 133. K+ 3.1, Ion Ca++ 1.06, Cr 5.1 (5.6) MICU team aware.\n\nSKIN INTEGRITY: Skin intact- fecal bag placed for volume of loose stool. Turn and repostion q2-3hr.\n\nPSYCHOSOCIAL: Multiple family members at bedside, very concerned. Son served as spokesperson for language barrier of wife. Family updated on plan of care by RN and MICU team frequently.\n\nPLAN OF CARE:\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-15 00:00:00.000",
"description": "Report",
"row_id": 1371176,
"text": "addendum:\n\nPt. made CMO at 18:30. Awaiting arrival of priest and plan is to withdrawal care. Pt. to remain on fentanyl gtt. Family at bedside.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-16 00:00:00.000",
"description": "Report",
"row_id": 1371177,
"text": "Resp: pt intubated on a/c 18/500+8/40%. Following family meeting the decision was to make pt cmo and extubate. Pt was extubated @ 2100.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-16 00:00:00.000",
"description": "Report",
"row_id": 1371178,
"text": "NARRATIVE NOTE:\n\nPT IS A CMO AND WAS EXTUBATED LAST EVENING AT 2045. PT HAS REMAINED ON R/A THROUGHOUT THE SHIFT. SAO2 CURRENTLY DROPPING INTO THE MID 70'S. B/P WAS IN THE 130'S AND HAS DECREASED TO THE LOW 90'S WITH THE MAP 45. HR WAS IN THE 80'S AND NOW IS IN TH LOW 50'S. PUPILS HAVE REMAINED NON-REACTIVE ALTHOUGT HE HAS OPENED HIS EYES TO VERBAL STIMULI. FAMILY WAS IN WITH PT LAST EVENING AND LEFT PRIOR TO EXTUBATION. REMAINS ON FENTANYL 300MIC/HR. PLEASE SEE CAREVUE FOR SPECIFICS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-07-16 00:00:00.000",
"description": "Report",
"row_id": 1371179,
"text": "PT EXPIRED AND WAS PRONOUNCED AT 0600. POST MORTUM CARE PROVIDED AND TRANSPORT NOTIFIED. TEAM NOTIFIED SON AND FAMILY DECLINED TO COME IN.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-06-29 00:00:00.000",
"description": "Report",
"row_id": 1371155,
"text": "MICU NPN 5PM-11PM:\nPt is 70y.o. male adm with NSTEMI/CHF who has had two embolic strokes this admission. He was found unresponsive on while on regular floor with temp 102.3 and required transfer to ICU intubated on pressors. Pt transferred to 4 from SICU due to bed availability. Pt is MICU pt. Orders rewritten. Pt is off sedation, propofol off at 0830 today. Levophed has been off as well since early AM. Pt has been slow to wake but opens eyes spontaneously at this point and followed commands to squeeze his wife's hand during her visit. Family is aware of transfer and have been involved and updated.\n\nCultures are growing resistent Klebsiella in urine and sputum. Pt put on isolation precautions as ordered. Antibiotics changed to meropenum/vanco.\n\nNeuro: Awake and alert alt w/ sleeping. Opens eyes to my voice. Moves left arm to midline and reaches for ETT. PEARL.\n\nCV: BP 130-170's/ HR 80's NSR. Skin cool and dry. Labs sent at 7PM are pnd. Calcium repletion will be given.\n\nResp: Remains intubated on PSV 5/5 40%. Small to mod amts thick tan bloody secretions suctioned Q3hr. Sputum sent for culture.\n\nGI: Started on tube feeds at 10cc/hr full str Nutren Renal. Goal is 40cc/hr. Positve bowel sounds heard. Butt bag in place.\n\nGU: UO adequate via foley. BUN 118 and creat 5.1. Pt has left arm fistula in place but has not needed dialysis as of yet. Fistula has strong bruit.\n\nID: afebrile on meropenum and vanco. A dose of vanco is ordered for this evening. WBC 18.0 Vanco level due with AML.\n\nEndo: Pt is on sliding scale insulin coverage QID and gets Lantus QD.\n\nIV: PICC inserted today and I took out the groin line which was in his left groin.\n\nSkin: Pt has bilateral BKA. Skin intact.\n\nSocial: Pt speaks only portuguese. Wife was here with a friend who spoke English very well and helped explain everything to her. son is spokesperson and speaks English well also.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-06-30 00:00:00.000",
"description": "Report",
"row_id": 1371156,
"text": "Respiratory CAre\nPt remains intubated on ventilatory support for airway protection. Tol PSV well all shift. BS occ. coarse clear with sx of thick tan secretions. Oxygenting well. AM RSBI 53. Mentation appears to be improving and plan is to wean to extubation later today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-06-30 00:00:00.000",
"description": "Report",
"row_id": 1371157,
"text": " nsg note: 19:00-7:00\nthis is a 70 y.o. man adm with NSTEMI/CHF who had 2 embolic strokes this admission. he was found unresponsive on while on the regular floor with temp 102.3 and required transfer to sicu intubated on pressors. pt transferred to 4 when bed available as pt a micu pt. pt off sedation since 8:30am yesterday (was on propofol). has also been off levophed since yesterday am too. pt slow to wake but opens eyes to voice. awaiting possible extubation today if awake enough.\n\nneuro: very lethargic at beginning of shift with mental status improving t/o the shift. pt now opens eyes spontaneously, squeezing my hand with his l hand but otherwise not following commands. did grimace once requiring 25mcg fentanyl for pain with good effect. tries to move l hand toward ett when repositioned. bilat wrist restraints maintained for safety.\n\ncv: hr ranging 60s-80s sr with no ectopy noted. sbp ranging 120s-160s. am labs pending with vanco level drawn.\n\nresp: lungs cta and diminshed at bases. suctioned for scant to small amts thick tan secretions. sp02 ranging 99-100% on psv .4, 5ps, 5 peep. RSBI 53.\n\ngi/gu: abd soft, +bs, tolerated tf with no residual. tf stopped at 3am in anticipation of extubation this am md. draining adequate amts clear yellow urine. l arm fistula intact with +bruit, +thrill. fecal bag draining moderate amts brown liquid stool sent for cdiff spec.\n\nid: t max 99.6 po. cultures are growing resistent Klebsiella in urine and sputum. pt maintained on isolation precautions as ordered. continues on iv meropenem/vanco. am vanco level pending.\n\nskin: bilat BKA.\n\nendo: on ss insuin coverage QID.\n\nsocial: speaks only portuguese. has a wife and a son . son is spokesperson and speaks english well.\n\nplan: possible extubation later today if wakes up enough. monitor mental status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2105-06-30 00:00:00.000",
"description": "Report",
"row_id": 1371158,
"text": "MICU/SICU NPN ICU day #3\nEvents: successfully extubated this AM\n\nS/O:\n\nNeuro: pt is lethargic, retracts to painful stimuli only, PERRL sluggish 4mm, nonpurposeful movements of LUE, no verbal communication\n\nPulm: extubated, SpO2 93-98% RA, LS coarse with scattered rhonchi, nonproductive cough\n\nCV: HR 67-89 SR with occasional PVC's, BP 138-182/35-51, please see flowsheet for data\n\nInteg: C/W/D/I\n\nGI/GU: abd soft, NT/ND, BS present, hiccoughs, NGT in place, TF retarted at 10cc/h, Foley in place draining adequate amts yellow urine with yeast\n\nAccess: right radial art line day #3, right cephalic PICC day #2\n\nA:\n\nhigh risk for injury, trauma r/t immobility, altered mental status\nrisk for infection r/t indwelling catheter, invasive lines\nhigh risk for aspiratation r/t altered mental status\n\nP:\n\nconintinue to monitor hemodynamic/respiratory status, aspiration precautions, slowly advance TF, speech and swallow eval, PT consult, continue post acute care planning\n"
}
] |
7,787 | 138,438 | Pt. admitted from the ED after and 18F three way foley had been placed. Pt. was irrigated and several clots were extracted from his bladder. On the floor the pt. was started on IVF and CBI. Pt.s hct was noted to be 25.5 on admission and 2 units of prbcs were transfused on hd 2. Pt. had a questionable rise in temperature in responce to the first unit of blood but pathology determined he was not having a transfusion reaction. So the second unit of blood was hung. A repeat hematocrit (on HD 3) was 23.9 and the cbi irrigant continued to be cranberry juice color - intermittently becoming clear. However, he continued to form clots and a large amount of clots continued to be extracted on HD 3. Because the hematocrit was persistently low 2 units of prbsc were transfused on HD 3 as well as one unit of FFP to restore clotting factors. The pt. was taken to the cysto suite in the afternoon of HD 3 for formal clot evacuation. During the cystoscopy it was discovered that the pt. had a right lateral bladder perforation - presumably from the previous fulguration. The pt. spent an uneventful evening in the ICU for closer monitoring and was started on Cipro. On HD 5 the pt. returned to the floor, having remained afebrile with stable vital signs. On HD6 pt. continued to be afebrile with stable vitals, tolerating POs and pain was well controlled on a po regimen. Pt. was ready for discharge with a foley in place and continuing on antibiotics. Pt. was sent with VNA to visit him to help w/continued foley bag training. | PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. HAS REMAINED AFEBRILE. REMAINS A/A/O AND HAS C/O ABD. ABD. AND HAS BEEN TAKEN OFF AMICOR GTT. REMAINS A FULL CODE AT THIS TIME. Sinus rhythm. HAS BEEN NSB/SR 58-70'S WITH NO NOTED ECTOPY. NO NOTED EDEMA NOTED. BLOOD SUGARS ARE WNL'S WITH NO COVERAGE REQUIRED. REMAINS NEUROLOGICAL INTACT WITH NO NOTED DEFICITS. EXPERIENCED NO ILL EFFECTS. Intraventricular conduction delay with left bundle-branch blockpattern. SKIN INTEGRITY IS INTACT WITH IV'S INTACT, SECURED, AND FUNCTIONING WELL. B/P HAS BEEN RANGING 99-130'/50-60'S. IS SLIGHTLY TENDER TO TOUCH BUT OTHERWISE BENIGN, WITH BOWEL SOUNDS EASILY AUDIBLE. Possible left ventricular hypertrophy. POST PROCEDURE HCT DOWN SLIGHTLY 29.1 FROM 32, TEAM AWARE WITH NO ORDERS. THIS HAS SIGNIFICANTLY LIGHTENED OVER THE PAST SEVERAL HOURS.PT. IS TOLERATING A CLEAR/DIABETIC DIET AND CAN ADVANCE THIS AM. Compared to the previoustracing of the rate has increased and the axis has shifted leftward. PULSES ARE WEAK BUT EASILY PALPABLE. NO STOOL NOTED THIS SHIFT. TOLERATED THIS PROCEDURE WELL AND ONLY CAME TO THE ICU FOR MANAGEMENT WHILE ON AMICAR GTT. FOLEY IN PLACE AND DRAINING AMPLE AMT'S>60CC/HR OF PINKISH TINGED CLEAR URINE. WAS RECEIVED FROM PACU POST CYSTOSCOPY AND EVACUATION OF BLOOD CLOTS. LUNGS ARE CLEAR IN ALL LOBES WITH 100% SATS NOTED ON 2L/MIN VIA NASAL CANNULA. WILL TRANSFER UP TO 12 WHERE A BED HAS BEEN HELD FOR HIM. PAIN ONCE WITH PERCOCET 2 TABS GIVEN WITH DESIRED EFFECTS REACHED WITHIN 45MINS. | 2 | [
{
"category": "Nursing/other",
"chartdate": "2114-12-22 00:00:00.000",
"description": "Report",
"row_id": 1366621,
"text": "PT. REMAINS A/A/O AND HAS C/O ABD. PAIN ONCE WITH PERCOCET 2 TABS GIVEN WITH DESIRED EFFECTS REACHED WITHIN 45MINS. PT. REMAINS NEUROLOGICAL INTACT WITH NO NOTED DEFICITS. PT. HAS REMAINED AFEBRILE. PT. WAS RECEIVED FROM PACU POST CYSTOSCOPY AND EVACUATION OF BLOOD CLOTS. PT. TOLERATED THIS PROCEDURE WELL AND ONLY CAME TO THE ICU FOR MANAGEMENT WHILE ON AMICAR GTT. PT. HAS BEEN NSB/SR 58-70'S WITH NO NOTED ECTOPY. B/P HAS BEEN RANGING 99-130'/50-60'S. PULSES ARE WEAK BUT EASILY PALPABLE. NO NOTED EDEMA NOTED. POST PROCEDURE HCT DOWN SLIGHTLY 29.1 FROM 32, TEAM AWARE WITH NO ORDERS. LUNGS ARE CLEAR IN ALL LOBES WITH 100% SATS NOTED ON 2L/MIN VIA NASAL CANNULA. PT. IS TOLERATING A CLEAR/DIABETIC DIET AND CAN ADVANCE THIS AM. BLOOD SUGARS ARE WNL'S WITH NO COVERAGE REQUIRED. ABD. IS SLIGHTLY TENDER TO TOUCH BUT OTHERWISE BENIGN, WITH BOWEL SOUNDS EASILY AUDIBLE. NO STOOL NOTED THIS SHIFT. SKIN INTEGRITY IS INTACT WITH IV'S INTACT, SECURED, AND FUNCTIONING WELL. FOLEY IN PLACE AND DRAINING AMPLE AMT'S>60CC/HR OF PINKISH TINGED CLEAR URINE. THIS HAS SIGNIFICANTLY LIGHTENED OVER THE PAST SEVERAL HOURS.\nPT. REMAINS A FULL CODE AT THIS TIME. AND HAS BEEN TAKEN OFF AMICOR GTT. PT. EXPERIENCED NO ILL EFFECTS. PT. WILL TRANSFER UP TO 12 WHERE A BED HAS BEEN HELD FOR HIM. PT. IS AWAITING UROLOGY TO MAKE ROUNDS THIS AM PRIOR TO TRANSFER.\n"
},
{
"category": "ECG",
"chartdate": "2114-12-20 00:00:00.000",
"description": "Report",
"row_id": 142879,
"text": "Sinus rhythm. Intraventricular conduction delay with left bundle-branch block\npattern. Possible left ventricular hypertrophy. Compared to the previous\ntracing of the rate has increased and the axis has shifted leftward.\n\n"
}
] |
25,185 | 196,508 | Patient admitted to the trauma service. Orthopedics; Spine Service and Neurosurgery were immediately consulted. Her humeral fracture was treated non surgically; she is being treated with sling and will need to follow up in clinic in 2 weeks for repeat films. Spine service has recommended hard cervical collar immobilization for the next 6 weeks and follow up in the Ortho Spine clinic in weeks. Neurosurgery has recommended Dilantin for a total of 7 days; her last dose will be on . Renal was also consulted because of her ESRD; she will need to follow up with her primary nephrologist after her discharge. Geriatrics service was consulted because of patient's mechanism of injury and have made several recommendations; patient has been started on Calcium and Vit D and will need bone densitometry when in rehab. | T-SICU NPN 0700-1900See carevue for specifics.ROS:Neuro: A+Ox3, MAE's (RUE weaker d/t displaced prox. IMPRESSION: Minimally displaced and rotated fracture of the greater tuberosity. TECHNIQUE: Routine non-contrast head CT. IMPRESSION: Stable appearance to small parafalcine subdural hemorrhage. TECHNIQUE: Non-contrast CT of the head was performed. Pt has R displaced prox. PB's for DVT prophylaxis. TECHNIQUE: Contiguous 2.5 mm axial images were obtained through the right glenohumeral joint without the administration of contrast. peripheral pulses palpable.Resp - Lungs CTA. Left anterior fascicular block. FINDINGS: Comparison with plain film examination dated . Head CT this am unchanged, R shoulder CT currently unread. There is a minimally displaced and partially rotated fracture through the greater tuberosity. Right shoulder, a single AP view shows mildly displaced greater tuberosity fracture. Pt difficult to arouse after, exam unchanged. Peripheral pulses palpable.Resp - Lungs CTA.GI - Tolerating sips overnoc.GU - PD per renal orders. FINDINGS: The normal cervical spinal alignment is maintained. Forehead lac with dry blood tinged drainage, OTA. C-collar on.CV - NSR without ectopy. C-collar on.CV - NSR without ectopy. Mild narrowing of the intervertebral disk space is seen at C6/7. Access: PIV x2 wnl.Resp: LS clear, weak cough. A moderate left-sided subdural hematoma extends along the left frontal bone, along the falx cerebri, and down along the left tentorium cerebelli. There is a moderate glenohumeral joint effusion, with a 2 cm oval shaped more hyperintense fluid collection within the subcoracoid or subscapular recess, compatible with hemarthrosis. Sensation at baseline with neuropathy. The glenohumeral joint articulation is unremarkable, without subluxation or dislocation. CT OF THE HEAD WITHOUT CONTRAST: There is no change to the small parafalcine subdural hemorrhage extending along the posterior falx to the vertex. Faint lac. Neuro exam normal except for baseline neuropathy in extremities x4. Coronal and sagittal reformatted images were obtained. Logroll maintained, c-collar on.Neuro - AAO x3. 3-mm shift of normal midline structures to the right. IMPRESSION: Bilateral acute subdural hemorrhages, left greater than right as described above. A tiny, 2-mm subdural hematoma is also seen along the right falx cerebri. The paranasal sinuses and mastoid air cells are appropriately aerated. The surrounding soft tissue and osseous structures demonstrate a dens fracture. Repeat CT. Contsult PD service re: catheter. Peritoneal fluid sent for cell count,gram stain, and cx by renal RN.Skin; back/buttocks intact. pt with history of MRSA/VRE. FINDINGS: There is a small right-sided subdural hematoma measuring no more than 3 mm in diameter. The surgical neck and lesser tuberosity are intact without fracture. Remainder of the soft tissues is unremarkable. Pedal pulses weak, palpable. PERRL. Sinus rhythm. DR. Screen for rehab placement. RR even and unlabored, denies difficulty breathing.GI: abd soft, NT (dtrs state pt does not experience pain, even with peritonitis), BS hypoactive, no stool. The acromioclavicular joint is intact. Low attenuation within the periventricular white matter is consistent with small vessel ischemic disease. TSICU Nursing Progress NoteNeuro - Pt x3. Peritoneal dialysis started, tol. The septum pellucidum is slightly shifted to the right by 3 mm. Daughters appropriately concerned, updated by Dr. , CM, ortho resident. CT is not as sensitive as MR in defining intrathecal detail. screening for rehab, will need pg 1,2,3 and d/c summary. The biceps tendon is appropriately seated within the bicipital groove. INDICATION: Followup of known subdural hemorrhage. TECHNIQUE: MDCT imaging of the cervical spine was performed without intravenous contrast. PD per renal orders. prn. Cont. Cont. Cont. Cont. humerus fx, placed in sling. Left axis deviation. Lopressor/atenolol dc'd (pt states she hasn't taken atenolol "in a long time"). Fluid clear.Endo - No sliding scale coverage needed.A - Pt with stable neuro exam s/p fall at home.P - Continue serial exams. WET READ VERSION #1 MMBn FRI 12:54 AM Bilateral SDH, left greater than right. Images were reformatted in oblique, coronal, and sagittal planes. pt c/o neck pain. The humeral shaft is anteriorly displaced with relation to humeral head. Assess pain, med. Follows commands consistnetly. well; 1600cc drained, 2000cc 1.5% dextrose (pt states this is her usual amt) currently dwelling. Slight shift of midline to the right. Given Olanzapine for difficulty sleeping, aggitiation. The visualized outline of the thecal sac is unremarkable. Ventricles are stable in size. humerus fx), follows commands consistently. No other or new intracranial hemorrhage identified. Degenerative changes are seen primarily along the facet joints. Tol. Catheter working well. Pupils equal and reactive. Evaluate. to bridge of nose, OTA.Activity: PT to see pt in am. There is no loss of -white matter differentiation. Relatively hypotensive when sleeping deeply. Since there is only one view of the left shoulder, evaluation of lesser and greater tuberosities is limited for an associated fracture. There is no loss of vertebral body height. TSICU Nursing Admit notePt admitted from ED at 0500. At greatest dimension adjacent to the left falx cerebri, this measures 6 mm. NOTE ADDED AT ATTENDING REVIEW: Please note that this is a head CT study, and not adequate to evaluate the odontoid fracture. HISTORY: Trauma. No additional fractures are identified within the skull. Next due at 2200 (2.5%).Endo: BS 80's, no issues.ID: tmax 100.1; no current abx coverage. Coronary vessel calcification is also identified. IMPRESSION: Type II odontoid fracture. No other fractures identified. There is a type II odontoid fracture. There is vascular calcification involving the axillary artery. regular diet, no n/v.GU: PD/renal RN up to see pt this am; spoke with pt's daughters. peritoneal dialysis 4xday as ordered. Skin warm, dry. Daughters very involved in pt's care, agreeable to plan for rehab.A: neuro exam and CT unchanged, hemodynamically stableP: Monitor VS,I/O, labs, neuro checks. C/o neuropathy pain in hands. No additional fractures are seen within the cervical spine. 12:19 AM CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # -59 DISTINCT PROCEDURAL SERVICE Reason: please eval for fx MEDICAL CONDITION: 84 year old woman with fall, BL SDH, type 2 dens fx per OSH, right shoulder pain REASON FOR THIS EXAMINATION: please eval for fx No contraindications for IV contrast WET READ: MMBn FRI 1:59 AM Type II odontoid fracture. | 9 | [
{
"category": "Nursing/other",
"chartdate": "2187-12-14 00:00:00.000",
"description": "Report",
"row_id": 1591065,
"text": "TSICU Nursing Admit note\nPt admitted from ED at 0500. Very pleasant, neurologically intact elderly lady. Neuro exam normal except for baseline neuropathy in extremities x4. pt c/o neck pain. Logroll maintained, c-collar on.\n\nNeuro - AAO x3. PERRL. Moving extremities x4 with good strength. Sensation at baseline with neuropathy. C-collar on.\n\nCV - NSR without ectopy. SBP 120 - 140 by cuff. peripheral pulses palpable.\n\nResp - Lungs CTA. O2 sat > 95% on 2 L NC.\n\nGI - Abdomen soft, NT, ND.\n\nGU - Pt voids 1x per day. No foley. Uses PD with 5 dwells per day. PD catheter came apart in ED with loss of PD fluid into bed.\n\nA - Neurologically intact elderly lady s/p fall with C2 fx and bilateral SDH.\n\nP - Serial exams. Repeat CT. Contsult PD service re: catheter.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-12-14 00:00:00.000",
"description": "Report",
"row_id": 1591066,
"text": "T-SICU NPN 0700-1900\nSee carevue for specifics.\nROS:\nNeuro: A+Ox3, MAE's (RUE weaker d/t displaced prox. humerus fx), follows commands consistently. Pupils equal and reactive. Logroll precautions dc'd, collar changed to J, maintained at all times. Head CT this am unchanged, R shoulder CT currently unread. c/o neck pain this am at 8 on scale 0-10, med. with 2mg morphine with (+) effect, pain down to 3 on scale. Started on tylenol 1000mg q8hrs and motrin 400mg q8hrs for c/o hand pain per geriatrics recs.\nCV: HR 70-80'sSR, BP 80-120's/40-50's. Lopressor/atenolol dc'd (pt states she hasn't taken atenolol \"in a long time\"). Skin warm, dry. Pedal pulses weak, palpable. PB's for DVT prophylaxis. Access: PIV x2 wnl.\nResp: LS clear, weak cough. O2 sats dip to 90 with O2 off while eating, O2sats 95% on 2Lnc. RR even and unlabored, denies difficulty breathing.\nGI: abd soft, NT (dtrs state pt does not experience pain, even with peritonitis), BS hypoactive, no stool. Tol. regular diet, no n/v.\nGU: PD/renal RN up to see pt this am; spoke with pt's daughters. pt with history of MRSA/VRE. Peritoneal dialysis started, tol. well; 1600cc drained, 2000cc 1.5% dextrose (pt states this is her usual amt) currently dwelling. Next due at 2200 (2.5%).\nEndo: BS 80's, no issues.\nID: tmax 100.1; no current abx coverage. Peritoneal fluid sent for cell count,gram stain, and cx by renal RN.\nSkin; back/buttocks intact. Forehead lac with dry blood tinged drainage, OTA. Faint lac. to bridge of nose, OTA.\nActivity: PT to see pt in am. Pt has R displaced prox. humerus fx, placed in sling. Geriatrics following pt, ?carpal tunnel, OT to see pt in am for R wrist cock-up splint. involved and following, spoke with pt's daughters as far as needs/rehab needs.\nPsych/social: pt interacting appropriately. Daughters appropriately concerned, updated by Dr. , CM, ortho resident. Questions answered, support provided. Daughters very involved in pt's care, agreeable to plan for rehab.\nA: neuro exam and CT unchanged, hemodynamically stable\nP: Monitor VS,I/O, labs, neuro checks. Assess pain, med. prn. Cont. pulmonary hygiene/skin care. Cont. peritoneal dialysis 4xday as ordered. Cont. screening for rehab, will need pg 1,2,3 and d/c summary. Cont. ongoing open communication, comfort, and support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2187-12-15 00:00:00.000",
"description": "Report",
"row_id": 1591067,
"text": "TSICU Nursing Progress Note\nNeuro - Pt x3. Follows commands consistnetly. C/o neuropathy pain in hands. Given Olanzapine for difficulty sleeping, aggitiation. Pt difficult to arouse after, exam unchanged. C-collar on.\n\nCV - NSR without ectopy. Relatively hypotensive when sleeping deeply. Peripheral pulses palpable.\n\nResp - Lungs CTA.\n\nGI - Tolerating sips overnoc.\n\nGU - PD per renal orders. Catheter working well. Fluid clear.\n\nEndo - No sliding scale coverage needed.\n\nA - Pt with stable neuro exam s/p fall at home.\n\nP - Continue serial exams. Transfer to floor when neuro checks Q 4 hours. PD per renal orders. Screen for rehab placement.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2187-12-14 00:00:00.000",
"description": "Report",
"row_id": 201780,
"text": "Sinus rhythm. Left axis deviation. Left anterior fascicular block. No previous\ntracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-12-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 889789,
"text": " 10:52 AM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p fall with sdh\n Admitting Diagnosis: SUBDURAL HEMORRHAGE-DENS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with\n REASON FOR THIS EXAMINATION:\n s/p fall with sdh\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: CT head without contrast.\n\n INDICATION: Followup of known subdural hemorrhage.\n\n Comparison is made to the prior study of the same day.\n\n TECHNIQUE: Non-contrast CT of the head was performed.\n\n CT OF THE HEAD WITHOUT CONTRAST: There is no change to the small parafalcine\n subdural hemorrhage extending along the posterior falx to the vertex. No\n other or new intracranial hemorrhage identified. Ventricles are stable in\n size. No evidence of interval major vascular territorial infarction.\n\n IMPRESSION: Stable appearance to small parafalcine subdural hemorrhage. No\n new hemorrhage or mass effect identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-12-14 00:00:00.000",
"description": "B SHOULDER 1 VIEW BILAT",
"row_id": 889739,
"text": " 12:33 AM\n SHOULDER 1 VIEW BILAT Clip # \n Reason: please eval for fx/dislocation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with fall, BL SDH, type 2 dens fx per OSH, right shoulder\n pain\n REASON FOR THIS EXAMINATION:\n please eval for fx/dislocation\n ______________________________________________________________________________\n FINAL REPORT\n EXAM ORDER: Bilateral shoulders.\n\n HISTORY: Trauma.\n\n A single AP view of the left shoulder show 2-part surgical neck fracture of\n the proximal left humerus. There is no apposition of the humeral shaft and\n head fragments. The humeral shaft is anteriorly displaced with relation to\n humeral head. Since there is only one view of the left shoulder, evaluation\n of lesser and greater tuberosities is limited for an associated fracture.\n\n Right shoulder, a single AP view shows mildly displaced greater tuberosity\n fracture. No other fracture is seen on this single view.\n\n\n DR. \n"
},
{
"category": "Radiology",
"chartdate": "2187-12-14 00:00:00.000",
"description": "CT C-SPINE W/O CONTRAST",
"row_id": 889737,
"text": " 12:19 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: please eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with fall, BL SDH, type 2 dens fx per OSH, right shoulder\n pain\n REASON FOR THIS EXAMINATION:\n please eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MMBn FRI 1:59 AM\n Type II odontoid fracture.\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 84-year-old female status post fall. Evaluate.\n\n COMPARISON: None.\n\n TECHNIQUE: MDCT imaging of the cervical spine was performed without\n intravenous contrast. Coronal and sagittal reformatted images were obtained.\n\n FINDINGS:\n The normal cervical spinal alignment is maintained. There is a type II\n odontoid fracture. No additional fractures are seen within the cervical\n spine. Degenerative changes are seen primarily along the facet joints. There\n is no loss of vertebral body height. Mild narrowing of the intervertebral\n disk space is seen at C6/7. CT is not as sensitive as MR in defining\n intrathecal detail. The visualized outline of the thecal sac is unremarkable.\n\n IMPRESSION: Type II odontoid fracture.\n\n NOTE ADDED AT ATTENDING REVIEW: In addition to the fracture across the base of\n the odontoid, there is a coronally oriented fracture through the odontoid.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-12-14 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 889736,
"text": " 12:18 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with fall, BL SDH, type 2 dens fx per OSH, right shoulder\n pain\n REASON FOR THIS EXAMINATION:\n please eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MMBn FRI 1:55 AM\n Bilateral SDH, left greater than right.\n Slight shift of midline to the right.\n WET READ VERSION #1 MMBn FRI 12:54 AM\n Bilateral SDH, left greater than right.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old female status post fall.\n\n COMPARISON: None.\n\n TECHNIQUE: Routine non-contrast head CT.\n\n FINDINGS: There is a small right-sided subdural hematoma measuring no more\n than 3 mm in diameter. A tiny, 2-mm subdural hematoma is also seen along the\n right falx cerebri. A moderate left-sided subdural hematoma extends along the\n left frontal bone, along the falx cerebri, and down along the left tentorium\n cerebelli. At greatest dimension adjacent to the left falx cerebri, this\n measures 6 mm. The septum pellucidum is slightly shifted to the right by 3\n mm. There is no evidence of herniation. There is no loss of -white\n matter differentiation. Low attenuation within the periventricular white\n matter is consistent with small vessel ischemic disease. The surrounding soft\n tissue and osseous structures demonstrate a dens fracture. The paranasal\n sinuses and mastoid air cells are appropriately aerated. No additional\n fractures are identified within the skull.\n\n IMPRESSION: Bilateral acute subdural hemorrhages, left greater than right as\n described above. 3-mm shift of normal midline structures to the right.\n\n\n\n NOTE ADDED AT ATTENDING REVIEW: Please note that this is a head CT study, and\n not adequate to evaluate the odontoid fracture.\n\n"
},
{
"category": "Radiology",
"chartdate": "2187-12-14 00:00:00.000",
"description": "CT UP EXT W/O C",
"row_id": 889790,
"text": " 10:53 AM\n CT UP EXT W/O C; CT RECONSTRUCTION Clip # \n -59 DISTINCT PROCEDURAL SERVICE\n Reason: S/P FALL, EVAL HUMERUS FX\n Admitting Diagnosis: SUBDURAL HEMORRHAGE-DENS FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman s/p fall with right proximal humerus fx\n REASON FOR THIS EXAMINATION:\n please do CT of right shoulder, patient has humerus fx on plain film\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT EXAMINATION OF THE RIGHT SHOULDER:\n\n DATE OF EXAM: .\n\n INDICATION: 84-year-old female status post fall with right proximal humeral\n fracture.\n\n TECHNIQUE: Contiguous 2.5 mm axial images were obtained through the right\n glenohumeral joint without the administration of contrast. Images were\n reformatted in oblique, coronal, and sagittal planes.\n\n FINDINGS: Comparison with plain film examination dated .\n There is a minimally displaced and partially rotated fracture through the\n greater tuberosity. The surgical neck and lesser tuberosity are intact\n without fracture. The glenohumeral joint articulation is unremarkable,\n without subluxation or dislocation. There is a moderate glenohumeral joint\n effusion, with a 2 cm oval shaped more hyperintense fluid collection within\n the subcoracoid or subscapular recess, compatible with hemarthrosis. Remainder\n of the soft tissues is unremarkable. The biceps tendon is appropriately\n seated within the bicipital groove.\n\n There is vascular calcification involving the axillary artery. No displaced\n rib fractures are seen in the area imaged. There is pleural thickening within\n the left lung apex, as well as a focal pleural-based calcification. Coronary\n vessel calcification is also identified.\n\n The acromioclavicular joint is intact.\n\n IMPRESSION: Minimally displaced and rotated fracture of the greater\n tuberosity. No other fractures identified.\n\n\n"
}
] |
10,010 | 199,960 | This is a 53yo woman with h/o Barrett's esophagus and internal/external hemorrhoids who presented with progressive symptomatic bright red blood per rectum x 6 wks and a Hct drop from 28 to 19.7. . 1. Lower GI bleed- The patient was transferred to the MICU and a total of three units of blood was transfused during her hospitalization. She had a colonoscopy that showed large Grade 2 internal hemorrhoids or possible rectal varix with recent stigmata of bleeding. The patient refused an NG lavage and EGD as she had an EGD recently that did not show any signs of PUD or source of bleeding. Therefore, the source of her bleeding was presumed to be her hemorrhoids. The patient Hct had stabilized after the blood transfusions and she was transferred to the floor. A surgical consult was called and the patient underwent a hemorhoidectomy. She was discharge after the procedure as her Hct had been stable for > 48hrs. She was advised to return to the ER if her bleeding recurred. She was also advised to follow up with her surgeon, Dr. upon discharge and to have a CBC checked in one week and sent to her PCP . 2. depression/anxiety: The patient was continued on her home regimen. . 3. h/o ETOH abuse: The patient was continued on antabuse. | TRansfer to floor if no further stools and if hct improves. Almost done with golytely prep. Upon admit to ED hct 19 and given 1 unit prbcs. OOB to commode independently, turns by self. OOB independently. A-V conduction delay. Dr. notified. denies nausea. EKG obtained in unit. Hct stable at 26-27. serial Hcts q6.R: BLSCTA even unlabored. Colonscopy tomm.GU: Voiding with BSC independently.SKIN: c/d/iPAIN: currently denying pain.PLAN: Continue with serial Hcts, monitor hemodynamics and hcts, plan for scope tomorrow and provide comfort and support. Stooled x 2 ?brb. No secretions.NEURO: A&Ox3. HR NSR 60-70s, SBP 90-120 when pt allows it to be taken. NURSING NOTEPLEASE SEE CAREVUE FOR SPECIFICSCV: BP stable. MICU team wrote for Ativan, recieved 1mg with effect. + BS. Refused ng lavage in ED. RR 16-20 02 sats 97-100 though pt removes sat frequently.GI: + BSx4 abd soft nt/nd. Dr. aware that labs have not been drawn yet. NPNplease see carevue for further detailsN: alert and oriented x3, mae well. Independent. Otherwise,no diagnostic interim change. Sinus rhythm. Needs encouragement and support.C: HR 70s BP 100-120s. Continue to monitor pts BM's. Continues to remain NPO per team. Follows commands. hct 16, given one more unit prbcs. ?Transfer to floor. NSR HR 60-80s. Plan: Scope probably today, post hct to follow 3rd unit prbc's. UO clear yellow, voids in commode, refuses foley cath. No bloody stools.RESP: Sat'ing 97-100% RA. pts anxiety level. Please refer to admit note and carevue for further details. Abdomen soft, nontender, no n/v. No ectopy. Calls for assistance.SKIN: Intact. Pt c/o hunger. ?colonoscopy tomorrow. ?colonoscopy tomorrow. Cough/gag intact.GI/ENDO: Abdomen soft, non distended. Bowel sounds present. Systolic NBP 100-120s (mid 90s while sleeping). Nursing Note 7p-7a:Nursing Assessment:Pt is a 53 y.o. HO aware of above, will call with any changes. Also, hemmorhoids noted on exam. IV team notified for restart and to draw labs. No stools yet upon arrival to unit. Lungs clear. Peripheral iv x2 #20 placed with great difficulty d/t poor access in ED. EMotional support. Golytely started this evening- difficulty drinking, needs encouragement. Lungs clear, sats 96-100 % on RA. Pt difficult in ED, refusing interventions, eating despite NPO, and getting up to br and emptying stool without any documentation as to amt. NPN addendumpt began having bowel movements at approx 0500 though not clear, large amounts. Hct up to 25 from admit level of 16. Compared to the previous tracing of the P-R interval has increased and the T waves are less prominent. Also, pt lost IV access and also was unable to draw am labs. No BM or bloody stool. Pt not ordered for blood sugar checks/insluin sliding scale.GU: Voids adequate clear yellow urine via commode. Pt also recieving Seroquel TID and other home meds. Sleeping most of day. Pleasant and cooperative when awake, slightly anxious. female presenting to the ED with c/o prbpr x a few days, +palpations, +DOE on antabuse for ETOH. Checking Hct every 6 hours. Pt admitted to unit alert and orientated, yells when blood pressure cuff inflates that it hurts and often refused the cuff. medicated with .5mg PO ativan given at midnight for + anxiety per pt. Pt has had multiple admits to the hospital with alcohol withdrawals and hemmorrhoids/polyps, +Barrett's, banding for prolapsed hemorrhoids, and uterine fibroids. | 5 | [
{
"category": "Nursing/other",
"chartdate": "2178-03-25 00:00:00.000",
"description": "Report",
"row_id": 1394276,
"text": "NPN\nplease see carevue for further details\nN: alert and oriented x3, mae well. OOB independently. medicated with .5mg PO ativan given at midnight for + anxiety per pt. Needs encouragement and support.\nC: HR 70s BP 100-120s. Hct stable at 26-27. serial Hcts q6.\nR: BLSCTA even unlabored. RR 16-20 02 sats 97-100 though pt removes sat frequently.\nGI: + BSx4 abd soft nt/nd. denies nausea. Golytely started this evening- difficulty drinking, needs encouragement. Colonscopy tomm.\nGU: Voiding with BSC independently.\nSKIN: c/d/i\nPAIN: currently denying pain.\nPLAN: Continue with serial Hcts, monitor hemodynamics and hcts, plan for scope tomorrow and provide comfort and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-03-25 00:00:00.000",
"description": "Report",
"row_id": 1394277,
"text": "NPN addendum\npt began having bowel movements at approx 0500 though not clear, large amounts. Almost done with golytely prep. Dr. notified. Also, pt lost IV access and also was unable to draw am labs. IV team notified for restart and to draw labs. Dr. aware that labs have not been drawn yet. Also, hemmorhoids noted on exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-03-24 00:00:00.000",
"description": "Report",
"row_id": 1394274,
"text": "Nursing Note 7p-7a:\nNursing Assessment:\n\nPt is a 53 y.o. female presenting to the ED with c/o prbpr x a few days, +palpations, +DOE on antabuse for ETOH. Upon admit to ED hct 19 and given 1 unit prbcs. hct 16, given one more unit prbcs. Pt difficult in ED, refusing interventions, eating despite NPO, and getting up to br and emptying stool without any documentation as to amt. Stooled x 2 ?brb. Pt admitted to unit alert and orientated, yells when blood pressure cuff inflates that it hurts and often refused the cuff. Refused ng lavage in ED. EKG obtained in unit. Peripheral iv x2 #20 placed with great difficulty d/t poor access in ED. Pt has had multiple admits to the hospital with alcohol withdrawals and hemmorrhoids/polyps, +Barrett's, banding for prolapsed hemorrhoids, and uterine fibroids. Lungs clear, sats 96-100 % on RA. Abdomen soft, nontender, no n/v. Bowel sounds present. No stools yet upon arrival to unit. HR NSR 60-70s, SBP 90-120 when pt allows it to be taken. UO clear yellow, voids in commode, refuses foley cath. Plan: Scope probably today, post hct to follow 3rd unit prbc's. EMotional support. TRansfer to floor if no further stools and if hct improves. Please refer to admit note and carevue for further details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-03-24 00:00:00.000",
"description": "Report",
"row_id": 1394275,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR SPECIFICS\n\nCV: BP stable. Systolic NBP 100-120s (mid 90s while sleeping). NSR HR 60-80s. No ectopy. Hct up to 25 from admit level of 16. Checking Hct every 6 hours. No bloody stools.\n\nRESP: Sat'ing 97-100% RA. Lungs clear. No secretions.\n\nNEURO: A&Ox3. Sleeping most of day. Pleasant and cooperative when awake, slightly anxious. MICU team wrote for Ativan, recieved 1mg with effect. Pt also recieving Seroquel TID and other home meds. Follows commands. OOB to commode independently, turns by self. Cough/gag intact.\n\nGI/ENDO: Abdomen soft, non distended. + BS. No BM or bloody stool. Pt c/o hunger. Continues to remain NPO per team. ?colonoscopy tomorrow. Pt not ordered for blood sugar checks/insluin sliding scale.\n\nGU: Voids adequate clear yellow urine via commode. Independent. Calls for assistance.\n\nSKIN: Intact. Pt with hemmroids.\n\nSOCIAL: Family called, boyfriend in to visit.\n\nPLAN OF CARE: Continue to monitor Hct, checking every 6 hours. Continue to monitor pts BM's. ?colonoscopy tomorrow. ?Transfer to floor. pts anxiety level. HO aware of above, will call with any changes.\n"
},
{
"category": "ECG",
"chartdate": "2178-03-24 00:00:00.000",
"description": "Report",
"row_id": 300816,
"text": "Sinus rhythm. A-V conduction delay. Compared to the previous tracing of \nthe P-R interval has increased and the T waves are less prominent. Otherwise,\nno diagnostic interim change.\n\n"
}
] |
9,411 | 180,383 | By systems: 1. Respiratory: was intubated shortly after admission to the neonatal intensive care unit. She received 2 doses of Surfactant. She was extubated to continuous positive airway pressure on day of life #2. She continued on the continuous positive airway pressure through day of life #37, . At that time, she transitioned to nasal cannula oxygen. She weaned to room air on , and has remained in room air through discharge. was treated with caffeine for apnea of prematurity. The caffeine was discontinued on . Her last episode of spontaneous apnea and bradycardia occurred on , 10 days prior to discharge. At the time of discharge, she is breathing comfortably in room air with a respiratory rate of 30-60 breaths per minute. Given prolonged need for CPAP and nasal cannula support, overall course is consistent with diagnosis of mild BPD. 2. Cardiovascular: has maintained normal heart rates and blood pressures. A murmur became audible in the second week of life and remained intermittent at the time of discharge. A chest x-ray shows normal heart size and pulmonary blood flow and a 12 lead electrocardiogram was within normal limits. Four limb blood pressures were also within normal limits. At the time of discharge, she has a resting heart rate of 140 to 160 beats per minute with a recent blood pressure of 68/33 mmHg with a mean of 42 mmHg. 3. Fluids, electrolytes and nutrition: was initially NPO and treated with intravenous fluids. A peripherally inserted central catheter was placed. Enteral feeds were started on day of life #4 and gradually advanced to full volume. She was then advanced to a maximum of 30 calories per ounce. Initially she was fed expressed mother's milk but mother ceased pumping and she was later changed to formula. On , she presented with some abdominal distention. An abdominal x-ray was concerning for possible necrotizing enterocolitis. Her brother was also initiating treatment for necrotizing enterocolitis at the same time and she was presumptively treated for necrotizing enterocolitis. She received intravenous Zosyn and clindamycin for 14 days in addition to 14 days of bowel rest. Her feedings were restarted on , and gradually advanced and were well tolerated. At the time of discharge, she is taking Enfamil 24 calories per ounce with a minimum of 120 to 140 cc/kilogram per day. Her discharge weight is 2.47 kilograms with a corresponding length of 47 cm and a head circumference of 32 cm. required treatment for metabolic acidosis in the first week of life with sodium bicarbonate. Otherwise, her electrolytes have been normal during admission. 4. Infectious disease: Due to the unknown etiology of the preterm labor, was evaluated for sepsis upon admission to the neonatal intensive care unit. A complete blood count was within normal limits. She was treated with 48 hours of ampicillin and gentamicin pending culture results which were negative at 48 hours and the antibiotics were discontinued. As previously mentioned, with the concern for necrotizing enterocolitis, she received a 14 day course of Zosyn and clindamycin. Repeat blood culture at that time was no growth. She also had stool cultures sent for Rotavirus and enterovirus which were negative. 5. Gastrointestinal: As previously noted, was treated for presumed necrotizing enterocolitis. She also required treatment for unconjugated hyperbilirubinemia with phototherapy. Her rebound bilirubin on day of life 11 was a total of 2.4/0.3 mg/deciliter. 6. Hematological; is blood type O positive and is Coombs negative. She did receive 1 transfusion of packed red cells on day of life #31. Her hematocrit at that time was 26.9%. She is being discharged home on supplemental iron. Last hematocrit on was 33. 7. Neurology: Head ultrasound was performed on day of life #4 and showed a tiny cyst lateral to the left ventricle. Ultrasound was repeated on , and , showing the same findings. There is not presumed to be any clinical significance to this finding on head ultrasound. 8. Sensory: Audiology hearing screening was performed with automated auditory brainstem responses. passed in both ears. Ophthalmology: Eye exams were performed, without evidence for retinopathy of prematurity. Last exam was performed on , showing immature retinas to zone 3, no retinopathy of prematurity seen. Recommended follow-up in 3 weeks. 9. Psychosocial: The parents have been consistent visitors and are very involved in the baby's care. | LS = and clear, mildintercostal/subcostal retractions baseline. P/Cont with current Rx. lastspell on . P/Cont tomonitor and support G&D.7. Temps stable in servo isolette. Temps now wnl. out.On Zosyn/Clinda. Mild SC retrx. on q8hr shedule. Lytes were 133/4.6/98/23. Cl BS. Cont oncaffeine. Moving all extremities.Fontanelle soft and flat.A: One low temp this AM, now resolved. AGA, 31 wks.P: Cont dev. Resp. TF=160cc/k/day. FEN=O/Remains NPO. A/ Stable on CPAP. Oncaffeine. Oncaffeine. Resp. Lytes and bilipndg. Continue with CPAP. A: Stable on CPAP. LS CTA. Paretning. G&D. Cares clustered.A/ AGA. LS clear andequal. given. will check bili this am. LSC/=. FiO2 RA. AGA. continueto support G/D.5.) Held infnatfor ~1hr. One spell thus farw/ HR to 62; qsr. NICU NSG NOTE#1. I have placed EIP & VNA options in record. A/stable on CPAP. Repogle discontinued.ID: On zoyn/clinda day .DEV: In isolette.IMP: Former 27+ wk twin with presumed NEC, RDS, overall stable. A: Stable on CPAP. P/contwith current Rx. Two QSR-mild bradys as per flowsheet as of this writing. RR 30's-40'swith mild int/sc retractions. Continue to asess. Neonatology-NNP Progress NotePE: Remains on an open warmer, nested, under pt with eye covering on, jaundiece with bruising noted, on 19/5 X14 bbs sl cse=, rrr s1s 2no murmur, pulses 2+=, abd soft, nontender, ua, uvc in place and secure, afso, acitveSee attending note for plan A/stable on CPAP. Cont oncaffeine. Continues on amp/gent. Settles well in between w/pacifier. HCT 26.9, retic 10.0.Plts 603. Plan NPO for now, repeat KUB this am.Repogle to low suction. aspirates. Two bradys this shift; QSR-mod stim. Hct 26.9. HUS . 24hr bili 3.7/0.3, remains ruddy under max intensityneoblu.Continue w/current tx. PND10 infusingvia DLUV. Wt. Bili=O/Cont under mini neoblue. pt. Pt. Pt. Pt. Pt. In isolette.140/4.4/108/21A/P:Cont CPAP. P/contwith current Rx. Refed. Temps stable nested insheepskin in servo isolette. Cont oncaffeine. Start Vit E and Fe. Bili this am 4.9 and 0.3. LSclear. Tone wnl. LS cl/= with IC/SC retxns. ABG 7.28/31/107/15/-10. Continue tomonitor. BP 67/37, 48. TF 130cc/k/dof PND10 @ 8.2cc/hr and IL @ 1.1cc/hr; infusing well via PIVin R. arm. Breath sounds,resprate, and WOB are at baseline. )A/stable on CPAP. Stable temp in isolette. A: Stable on CPAP. Oncaffiene. Cont oncaffeine. in Resp. Check lytes AM. whilesleeping. On CPAP. Abd benign. Abd benign. RR 30-60's stable on CPAP cont to follow. LS clear/=, mild SCR. Mild IC/SC retractions. A/tolerating current regime. A: AGA. Lytes in good range.PN to begin. infant remains npo.infant abd exam benign. 02 as needed to maintain sats. Updated bynursing. Oncaffeine. NPN1900-0700#1Resp. noted and PN adjusted accordingly. HUS due . Repogle to be dcedDay of abx for NEC.COntinue as at present. Abd benign.BS+. Hct/retic due on .2. NEOBLUE STARTED ON PT. Currently pt. MOST RECENTGAS 7.36/37. and well perfused in RA. Rest PN. LSC/=. Wt. P/Cont tomonitor FEN status.4. Will place back on CPAP for now. Abd ebnign. Pt. Pt. G&D=O/Temp stable nested in servo isolette. A/stable on CPAP. I/D=O/cont on Zosyn Q8hrs. REmains NPO on PN-D10/IL. Started on Clindamycin Q8hrstoday. P/Cont tomonitor FEN status. A: WEaned down onflow today. Remains NPO, on PN-D13W/IL. Rec 1st aliquot PRBC's. Smstool x1, guaiac (-). TEMP STABLE. Nospits, min. Abd exam benign as noted on flow sheet. IC/SC retrx. temp cobedding with sib. CBC/diff to be sent in am.P/cont with current Rx. A/stable on CPAP. O/Pt's temp stable. Settleseasily after cares. Updated bynursing. P/Cont. P/Cont. P/Cont. P/Cont. Resp. Mild-mod retractions noted. A: stable on bowel rest P:Cont to follow wt andexam. Abdomen benign.On day of abx for NEC. IC/SC retract'snoted. LAst HCT 3/16-25.9,retic-4.2. BP WNL. LS CTA. One wk. Sincestable. LSC/=. BBS cl/=. REmains on NCO2 flow. Soft murmur noted this am. Abdbenign. A/stable on CPAP. A/stable on CPAP. Cont oncaffeine. LSC and equalwith SC/IC retractions. Day of zosyn. BP WNL. Continue tomonitor. RR 30-60's stable on CPAP cont to follow. RR 30-60's stable on CPAP cont to follow. FIO2 .21. bs clear, rr 40's. Wt. Stable in O2.Monitor.2. Remains NPO. Pt. Pt. Pt. Nostool so far this shift. Abd benign. Abd benign. Plan to continueCPAP, monitor resp. Stable temp in isolette. Right nare breakdown noted. 99.8 after.A/A with cares. P/Cont with current Rx. Remains on Zocyn and oxacilling. Stable temp cobedding with sib. NeonatologyDoing well.Remains on RA. fio2 .21, bs clear, rr 30-60. IVF of PN D10.5 and il infusingvia PIV. Monitor gorwth.Hct 25.9 with retic 4.2 . MildIC/SC retractions noted. P/Cont tomonitor FEN status. Will cont CPAP. RR 40's-70's w/mild baseline sc retractions. Settles well in betweenw/ pacifier. Updatesgiven. FIO2 .21, bs clear, rr 30-60. noted and PN adjusted accordingly. Abxgiven as ordered. Temp stable. oncaffeine. LS clear/=, mild IC/SCretractions. Tolerating efeds at 150 cc/k/d of 26 cal.A bdomen benign. clear/=, mild IC/SC retractions. Plan to support as neeeded. Spell x1tonight thus far, at rest, requiring mild stim. heme). Stable temp in heated isolette. LS CTA. A/ Stable on CPAP. A/stable on CPAP. P/Cont to support G&D.7.Sepsis= O/ Remains on contact precautions. Oncaffeine. FEN=O/ Currently on TF=140cc/kg/d of PND10 via Rhand PIV.Remains NPO. Stable on CPAP cont to follow. Infant remains NPO. BS+. + BS. Abd benign. REMAINS NPO. Remaining 105cc/k/d=PND15 with lipids viapatent/intact PICC. NeonatologyDoign well. P/Cont tomonitor FEN status.4. PICC line for today. Sm spit x1. A/tolerating current regime. Max aspirate3.1cc; benign and refed. G&D=O/Temp stable swaddled in air isolette. PN continues via PIV.Will place oin gravity.Day of ZOsyn/Clinda. Abdomen bengin.All agavge.Temp stable.Continue a sat present HYPOACTIVE BS NOTED. Will repeat HUS in 1 wk. A/stablein NCO2. Toleratign efeds at 150 cc/k/d of 30 cal>A bdomen benign.COntinue a sat present. oncaffeine. On VitE, Fe. BBS clear/=, mild SC/IC retractions. Breath sounds,r esprate, and WOB are at baseline. Stable temp in isolette. Mild IC/SC retractionsnoted. Settles well in between w/pacifier. Sepsis O: Pt. RESP RATE 44-70WIHT MILD SC RETRACTIONS. Heart size and mediastinal contours are within normal limits. Respiratory O: Pt. Fio2 .21-.23. bs clear, rr 50's with mild retractions. Normal ECG. She is onCaffeine. O: Infant remains on TF's of 150cc/k/d of PE30PM. Respiratory CarePt cont on prong CPAP. Again noted is endotracheal tube with its tip located at the thoracic inlet level. Again seen is umbilical artery catheter with its tip located at T6 vertebral body level without significant interval change. Stable appearance of small cystic structure adjacent to the frontal of the left lateral ventricle, as described. IMPRESSION: Normal bowel gas pattern as described above. Interval reposition of umbilical vein catheter with its tip now located in the inferior vena cava. | 301 | [
{
"category": "Nursing/other",
"chartdate": "2179-02-20 00:00:00.000",
"description": "Report",
"row_id": 1810603,
"text": "NPN 1815\n\n\n#1 Resp: Infant remains on nasal cannula O2 of 13cc flow,\nFIO2 100%. Infant trialed out of nc and maintained O2sat\n93-100%, but was replaced d/t spells. Infant had desats w/\nbradys to 80-90% w/ pallor. Infant had 5 brady spells today\nd/t reflux and apnea. Caffeine dose resumed at 5pm. RR\n40-60. Br. snds clear and equal w/ mild IC/SC retractions.\nA: Infant tolerating periods in RA but continues to have\nbrady spells.\nP: Cont to assess readiness to transition off nasal cannula.\nAssess spells.\n#2 F/N: Infant remains on 150cc/kg/d Br. milk30 +\npromod/PE30 + Promod, 35cc q 4 hrs. Infant has small spits\nduring feeds which infuse over 1hr 45mins. Abd full, soft.\nBowel snds active. AG 22cms. Voiding well. Stooled X1 lg\ngreen heme negative. Minimal aspirates. Remains on Vit E and\nFe.\nA: Occ small spits. Requires long infusion time.\nP: Cont to assess for change in toleration of feedings.\n#4 : Mom in at 1645. Held both babies. Brought in\nbreast milk. Mom pumping X2 per day. States she did not know\nto 8X per day. Emphasized need for mom to more\nfrequently. Mom's plan is to provide br. milk for as long as\nshe can. Gave mom written information re: pumping schedule\nand also suggestions to increase milk supply. Supplies\ngiven.\nA: Mom w/ knowledge defecit re: pumping and establishing\nmilk supply.\nP: Encourage frequent pumping and pumping near bedside.\n#5 Dev.: Infant remains on servo heat control w/ a nested\nsheepskin. Infant had one temp of 97.2ax this AM. Placed\nunder heat lamp. Temps now wnl. Alert and active w/ cares.\nSkin intact, no breakdown. Moving all extremities.\nFontanelle soft and flat.\nA: One low temp this AM, now resolved. AGA, 31 wks.\nP: Cont dev. supports.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-21 00:00:00.000",
"description": "Report",
"row_id": 1810604,
"text": "NICU NSG NOTE\n\n\n#1. Resp. O/ Received infant in NC 13cc, 100%. Changed to\nhigh flow blender 200-400cc 21-30% in hopes of decreasing\nspells. Infnat had 8 bradys in 1st 4h of this shift. Placed\nback on Prong CPAP 5 at 2300. FIO2 21-26%. LS clear and\nequal. RR 50-60's. Infant has had no bradys thus far since\ngoing on CPAP. A/ Improved spells since CPAP. Stable. P/\nCont to monitor resp status closely. Monitor spells.\n\n#2. FEN. O/ Wt up 30g. TF 150cc/k/d BM30 with PM. Receiving\nq4h volumes via gavage over 1h and 45 mins for hx spits.\nInfant has had 2 spits thus far. Abd soft and round. Voiding\nqdiaper. No stool. 1-3cc nonbilious asps. No loops. A/\nTolerating feeds. P/ Cont to monitor for feeding\nintolerances.\n\n#4. Parenting. No contact with family thus far this shift.\n\n#5. G&D. O/ Awake and alert with cares. Sleeping quietly in\nbetween. Temps stable in servo isolette. Cares clustered. A/\nAGA. P/ Cont to support developmental needs of infant.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-06 00:00:00.000",
"description": "Report",
"row_id": 1810519,
"text": "Respiratory Care\nPt received on nasal prong CPAP +6cm's with the fio2 21%. Pt's resp rates 30's to 50's, on caffine. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-07 00:00:00.000",
"description": "Report",
"row_id": 1810520,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 6 FiO2 21-25%. Suctioned nares for sm amt of white secretions. Breath sounds are clear. Six bradys so far tonight. Baby is on caffeine. RR 30-50's cont to monitor respiratory status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-07 00:00:00.000",
"description": "Report",
"row_id": 1810521,
"text": "NPN 1900-0700\n\n\n1. Resp: Infant remains on prong CPAP 6. FiO2 range has\nbeen 21-25%. RR=40-60's. Baseline SCR/ICR. Has had 6\nspells thus far tonight (9 in 24hrs). See flowsheet for\ndetails. On caffeine.\n\n2. FEN: WT=1075gms (up 35gms). TF=160cc/k/day. Infant is\ncurrently receiving enteral feeds of BM20 at 60cc/k/day. PN\nD10 and IL are infusing at 100cc/k/day via PICC. Infant had\n2.7cc asp before 0030 feeding. Asp was refed and after 30\",\nasp was 1.7cc. Infant was then fed. No spits. Abd girth =\n19cm. Abd is slightly full, but soft with active bs. Had 1\nsmall green heme neg stool. U/O for past 24hrs was\n2.5cc/k/hr. D/S = 133. Lytes were 133/4.6/98/23. Plan is\nto continue advancing enteral feeds by 10cc/k/ as tol.\n\n3. : No contact this shift.\n\n4. G&D: is alert and active with cares. Sleeps well\nbetween cares. Uses pacifier at times to comfort self.\nTemps stable nested in sheepskin in servo isolette. AFSF.\nAGA.\n\n5. Hyperbili: Todays bili was 5.7/0.3.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-07 00:00:00.000",
"description": "Report",
"row_id": 1810522,
"text": "Neonatology Attending Note\nDay 9, PMA 29 1\nCPAP6, 21-25%. Cl BS. RR30-70s. On caffeine. 9 A&Bs past 24h. HR 160-180s. BP 78/35, 47. Bili 5.7. Wt 1075, up 35 gms. TF 160 = 60 enteral + PN/IL. Tol well. Nl voiding and stooling. In isolette.\nd/s 133\n133/4.6/98/23\n\nA/P:\nMaintain CPAP.\nCont feeding adv as tolerated.\nInfant has rec'd 30/k bolus of caffeine and maintenance dose at 8mg/k. This should be adequate, so will cont to monitor AOP on this current dosing.\nRestart photot, follow bili levels.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-21 00:00:00.000",
"description": "Report",
"row_id": 1810605,
"text": "RESPIRATORY CARE NOTE\nBaby #2 received on nasal cannula 200-400cc FiO2 21-30%. Due to increased brady spells baby was placed back on CPAP at 2300 hrs. Placed on bubble CPAP 5 FiO2 21-26%. Breath sounds are clear. RR 50-60's. No brady spells since back on CPAP. Cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-21 00:00:00.000",
"description": "Report",
"row_id": 1810606,
"text": " Physical Exam\nPE: , AFOF, nasal CPAP prongs in place, nares intact, breath sounds clear/equal with mild retracting, no murmur, abd soft, full, + bowel sounds, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-21 00:00:00.000",
"description": "Report",
"row_id": 1810607,
"text": "Neonatology Attending\n\nDOL 23 PMA 31 1/7 weeks\n\nCPAP replaced last night due to spells. Currently on CPAP 5 21-23%. R 30s-70s. 11 A/B. On caffeine. Spells decreased back on CPAP.\n\nMurmur present. Tachycardic secondary to caffeine. BP 53/44 mean 47\n\nOn 150 ml/kg/d BM/PE 30 with promod q 4 pg over 80 min. Occ spit. Voiding. Stooling. Wt 1420 grams (up 30).\n\n in and up to date.\n\nA: Stable. Still requiring CPAP secondary to spells. Feeding and growing.\n\nP: Monitor\n Continue CPAP\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-21 00:00:00.000",
"description": "Report",
"row_id": 1810608,
"text": "Respiratory Therapy\nBaby remains on CPAP of 5, RA. RR 40-50. LS CTA. On caffeine with 4 spells as of this note. Plan to continue with CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-07 00:00:00.000",
"description": "Report",
"row_id": 1810692,
"text": "Neonatology Attending\nDOL 37 / PMA 33-1/7 weeks\n\nOn CPAP 6 cm H2O in room air with no distress. On caffeine with no cardiorespiratory events.\n\nIntermittent murmur. BP 80/51 (58).\n\nOn zosyn and clinda .\n\nWt 1805 (+20) on TFI 140 cc/kg/day PN-D10W/IL. Remains NPO for NEC. Abd distended overnight but benign. Voiding 3.1 cc/kg/day. No stools since NPO.\n\nTemp stable in off isolette.\n\nA&P\n27-6/7 week GA twin with respiratory and feeding immaturity, presumptive NEC\n-Will trial off CPAP today\n-No other changes in management as detailed above\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-07 00:00:00.000",
"description": "Report",
"row_id": 1810693,
"text": "NICU nursing note\n\n\n1. Resp=O/Received in prong CPAP of 6, FIO2 21%. Trialed\noff CPAP at 1300. No spells so far this shift. Cont on\ncaffeine. (Please refer to flowsheet for resp assessment.)\nA/trialing off CPAP. P/Cont to monitor for ^spells/WOB.\n\n2. FEN=O/Remains NPO. TF cont at 140cc/k/d of PND10 with\nlipids via patent/intact PIC. Abd full otherwise benign.\n(Please refer to flowsheet for assessment.) Voiding. No\nstool so far this shift. A/NPO r/t NEC. P/Cont to monitor\nFEN status. Send lytes and triglyceride on am.\n\n4. =O/No contact with so far this shift.\nDue in to visit at 1600. P/Cont to support and educate\n.\n\n5. G&D=O/Temp stable swaddled on sheepskin in off isolette.\nWill place in open crib cobedding with twin after \nhold at 1600. Alert and active with cares. Sleeping well\nin between. MAe. Font S/F. A/alt in G&D. P/Cont to\nmonitor and support G&D.\n\n7. I/D=O/Now day 7:14 day course of Zosyn and day 7:7 day\ncourse of Clindamycin. Clinda to be d/c'd once day 7\ncompleted. P/Cont with current Rx.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Report",
"row_id": 1810475,
"text": "NPN\n\n\n#1 Remains on Nasal Prong CPAP, decreased from 6 to 5 this\nAM. Fio2 21%, brady x 1 after irritable episode/crying. Sao2\nhigh 90's, rr 30-70's.On caffeine. LS = and clear, mild\nintercostal/subcostal retractions baseline. Con't to assess.\n\n#2 TF increased to 120cc/k/d, started enteral feeds at\n10cc/k/d w/no plan to increase at this time. Tolerating OG\ngavage feeds, abdominal exam unchanged, hypoactive->active\nbowel sounds. Is voiding, no stool so far. DUV con't to\ninfuse D10PN, D/S 108. Con't to assess toleration.\n\n#3 Amp and gent d/c'd, blood culture neg, respiratory status\nstable, infant active and tolerating feeds. Con't to\nmonitor.\n\n#4 No parental contact so far this shift but visited\nw/siblings last evening.\n\n#5 No murmur, tolerating CPAP 5 in 21%, tolerating feeds so\nfar, active and alert w/handling, monitoring bili. DOL #2,\ncon't to assess closely.\n\n#6 Bili this AM 3.7, to recheck in AM w/lytes.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-05 00:00:00.000",
"description": "Report",
"row_id": 1810678,
"text": "NPN 1900-0700\n\n\nResp: Remains on prong CPAP 6cm. FIO2 remains 21% throughout\nshift. RR=30-60. LS clear/=. O2 sats>97%. Oral airway sxn'd\nx2 for sn->mod cloudy secretions. Mild SC retrx. No A's or\nB's thus far. On caffeine. P: Continue to monitor closely.\n\nFEN: Weight= 1780g, down 10g. Remains NPO for Medical NEC.\nTF=140cc/kg/day of PND10 w/ IL infusing well via non-central\nPICC. Abdomen exam benign(+BS, No loops). AG stable=24cm.\nRepogle to gravity remains in place and is drained 0.8cc of\nbenign clear fluid for 12hrs. Pt. voiding 3.3cc for 24hrs\nand has not stooled. Still needs stool spec's sent for Rota-\nvirus and Enterovirus. P: COntinue NPO/monitor FEN status.\n\nDEN: Remains swaddled w/sheepskin in Air mode isolette. (Had\nbeen in off isolette yesterday but temp low after being out\non warmer for extended time for PICC placement). Temp stable\nand able to wean heat settings, currently on minimal heat.\nA&A w/cares and sleeps/settles well bwtn. Brings hands to\nface for comfort and sucks well on binki. AFSF. MAE =.\nBehaviors AGA. CGA= 326/7 wks, remains NPO for tx of NEC. P:\nContinue to monitor and promote optimal G&D.\n\nSepsis: Now Day of tx for medical NEC. Recieving Zosyn\nas ordered. No s/s of sepsis. P: Continue to monitor.\n\n: Mom called 2200; updates given by this RN. \nare planning to come for eve cares tomorrow (). P:\nContinue to update, educate and support NICU family.\n\nsee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-05 00:00:00.000",
"description": "Report",
"row_id": 1810679,
"text": "Respiratory Care Note\nInfant remains on NCPAP +6, 21% - RR's 30's-50's, BS clear - on caffeine, no spells thus far this shift - continue to monitor, mod cloudy secretions po.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-05 00:00:00.000",
"description": "Report",
"row_id": 1810680,
"text": "Neonatology\nRemains on CPAP. Comfortable appearing. Leave on CPAP over weekend.\n\nWt 1780 down 10. Remains NPO for NEC. Abdomen benign. PICC placed last night and is in peripheral position. TF at 140 via PN. out.\n\nOn Zosyn/Clinda. Will plan to continue Clinda for 1 week.\n\nCOntinue a sat prtesent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-05 00:00:00.000",
"description": "Report",
"row_id": 1810681,
"text": "7a-7p\n\n\n1.) RESP: infant remains on cpap 6. fio2 continues at 21%.\nRR20s-50s. LSCL/=. mild sc retractions. no increase WOB.\ncontinues on caffeine. no spells thus far this shift. last\nspell on . CV no murmur heard HR 120s-140s. bp 71/41/52.\ncontinue to monitor resp status.\n\n2.) FEN: npo TF 140CC/KG/DAY of PND10 and IL. infusing well\nvia non-central picc line. site right arm no edema gd csm.\nabd round sl full soft active bs. no loops. no stool thus\nfar this shift. plan to send spec when infant stools. AG\n=24CM. infant pulled out repogal tube and ogt inserted to\nasp air and .8cc cl fluid refed. team aware dc'd repogal and\nok to leave ogt in. continue to support FEN.\n\n4.) : no contact thus far this shift.\n\n5.)G/D: Infant swaddled on sheepskin in air isolette. temps\nstable. A/A with care sleeps well inbetween. AGA. AFSF.\ncontinue to support G/D.\n\n7.) SEPSIS: infant is day5 of 14 on zocyn and clindamycin.\nfor medical nec. on q8hr shedule. continue to watch for s/sx\nof infection.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-05 00:00:00.000",
"description": "Report",
"row_id": 1810682,
"text": " Physical Exam\nSleepy with exam. AFOF with good tone. Breath sounds clear and equal on CAPA with good transmission to the bases and slight retractions. No audible murmur, well perfused and with normal pulses. Abdomen soft and rounded with good BS, no HSM or masses. NOrmal GU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-21 00:00:00.000",
"description": "Report",
"row_id": 1810609,
"text": "NPN 1800\n\n\n#1Resp: remains on CPAP of 5cms, FIO2 21%. Infant had\n4 spells today; HR 60-62, mild stim X2. Remains on caffeine.\nBr. snds clear and equal, RR 40-50. O2sat 93-99%.\nA: Less spells since starting CPAP.\nP: Cont CPAP, assess spells.\n#2 F/N: TF 150cc/kg/d, 36cc q 4 hrs br. milk 30+ Promod/PE30\n+ promod. Gavage fed over 1 hr 45mins. Abd full, soft. Bowel\nsnds active. Voiding, no stool this shift. AG 22.5-23cms.\nAspirates minimal. No spits.\nA: Tolerating breast milk today.\nP: Cont to assess for s/s of feeding intolerance.\n#4 : Family in at 1630. Mom trying to increase #\npumps per day. Mom took home; she is sending\nback the Medela Lactina to Medical. Mom changed\nthe diaper and took the baby's temp.\nA: learning to care for premature infants.\nP: Cont parent teaching.\n#5 Dev.:Infant remains on servo heat control w/i a nested\nsheepskin. Position changed q 4 hrs. Awake and alert w/ some\nirritability during cares. Quiets when lights dimmed and\nrepositioned on abd.\nA: AGA, 31 wks corrected.\nP: Cont dev. supports.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-22 00:00:00.000",
"description": "Report",
"row_id": 1810610,
"text": "NICU NSG NOTE\n\n\n#1. Resp. O/ conts on Prong CPAP 5 in 21%. LS clear and\nequal. RR 40-50's. IC/SubC retrx. Brady x1 thus far. On\ncaffeine. A/ Stable on CPAP. P/ Cont to monitor resp status\nclosely. Monitor for spells.\n\n#2. FEN. O/ Wt up 50g. TF 150cc/k/d BM30 with PM/PE30 with\nPM. Receiving q4h volumes via gavage over 90 mins. Abd soft\nand round. Voiding and stooling. Spit x1. 0.5-2cc asps. AG\n23cm. A/ Tolerating feeds. P/ Cont to monitor for feeding\nintolerances. Daily wts.\n\n#4. Paretning. Mom called x1 and was updated over phone.\n\n#5. G&D. O/ AWake and alert with cares .Temps stable in\nservo isolette. MAE. Nested on sheepskin. Cares clustered.\nA/ AGA. P/ Cont to support developmental needs of infant.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-05 00:00:00.000",
"description": "Report",
"row_id": 1810683,
"text": "Respiratory Care Note\nBaby Girl remains on +6 prong CPAP, FiO2 .21 this shift. BS clear. RR 20-40's. On caffeine. No documented spells thus far this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-06 00:00:00.000",
"description": "Report",
"row_id": 1810684,
"text": "NPN/1900-0700\n\n\n#1 RESP: Infant remains on prong cpap 6, FiO2 21%. RR\n30-50's. LSC/=. Mild sc retractions. One spell thus far\nw/ HR to 62; qsr. On caffeine. Stable. Cont. to monitor.\n#2 FEN: Wt 1785, ^5gms. NPO. TF=140cc/k/d of PND10 and IL\nthru picc. Abd. soft, full. Girth=24.5cm. Voiding; no\nstools. Needs rotavirus and enterovirus cx sent when passes\nstool. Cont. to monitor.\n#4 : visiting at bedside this evening.\nUpdated by nursing. Mom . with cares. Held infnat\nfor ~1hr. Very loving and involved. Cont. to support\nparental needs.\n#5 DEVELOPMENT: Temps wnl swaddled in low air mode isolette.\nActive and alert w/ cares; sleeps well b/t. Loves pacifier\nwhen offered. AFOF. AGA. Support developmental needs.\n#7 SEPSIS: Day of Zosyn and Clindamycin for medical\nnec.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-06 00:00:00.000",
"description": "Report",
"row_id": 1810685,
"text": "Respiratory Care Note\nInfant remains on NCPAP +6, 21% -BS clear, RR's 20's-50's, on caffeine, 1 QSR spell noted, prongs out - continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Report",
"row_id": 1810476,
"text": "Respiratory Therapy\nBaby was weaned to CPAP of 5 today. FiO2 RA. RR 40-70. LS CTA. On caffeine with 1 spell. Continue with CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Report",
"row_id": 1810477,
"text": "NPN Addendum: Mom and dad in to visit and were updated at bedside. Mom may be discharged on or , and was informed that we'd like to have a Family Meeting prior to her going home. Will finalize plan/time tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Report",
"row_id": 1810478,
"text": "Neonatology NP Note\nPE\nnested under phototherapy\nAFOF\nmild subcostal/intercostal retractions on CPAP, lungs clear/=, slightly diminished breath sounds at bases\nRRR, no murmur, pink and wellperfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\nUVC in place\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Report",
"row_id": 1810479,
"text": "NPN 1900-0700\n\n3 SEPSIS\n\n1. Infant continues on prong CPAP5, fiO2 21%. rr50-70's,\nLS cl/=, mild sc/ic retrx. 2 brady's overnight, QSR. On\ncaffiene.\nCOntinue to monitor resp status.\n\n2. Current wt 983gms (-87). tf 120/k. ent feeds of BM20\n@10/k, PND10/IL @110/k infusing via DLUV. Lytes and bili\npndg. Belly soft/flat, no loops, active BS. No spits.\nASp's ranging from 2-3cc, NNP aware, advised to continue\nfeeding based on benign belly exam/no stool since birth.\nu/o 2.4cc/k/hr. DS88.\nCOntinue to monitor feeding tolerance, I+O.\n\n3. 48hr r/o complete, bloodwork neg. Problem resolved.\n\n4. Mom called last eve, given update. Invested .\nContinue to support and update regularly.\n\n5. Temp stable on servo warmer. Alert/active w/cares, sucks\non paci. Bruising still evident on viarious areas of\ninfant's body. PKU sent.\nContinue to support needs.\n\n6. Remains under neoblu, bili pndg.\nCotninue w/current tx.\n\nREVISIONS TO PATHWAY:\n\n 3 SEPSIS; d/c'd\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Report",
"row_id": 1810480,
"text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21%. On Caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Report",
"row_id": 1810481,
"text": "Case Management Note\nChart has been reviewed and events noted. I have placed EIP & VNA options in record. I will cont to follow and assist w/any d'c planning needs along with team & family inputs\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Report",
"row_id": 1810559,
"text": "Respiratory care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 25-30%. BS clear. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Report",
"row_id": 1810560,
"text": "Nursing Progress Note\n\n\n#1. O: Infant remains on prong CPAP 5 in 25-30%. RR\n20's-50's. Breath sounds are clear and equal. IC/SC\nretractions noted. Infant had 6 spells in last 24hrs. On\ncaffeine. A: Stable on CPAP. P: Continue to monitor.\n\n#2. O: Infant remains on TF's of 150cc/k/d of BM pg fed over\n1 hour. No spits. Minimal aspirates. AG stable. Abd soft and\nround with active bowel sounds. No loops. Voiding qs. No\nstools. WGt is up 5gms tonight to 1210gms. A: Tolerating\nfeeds. P: Continue to monitor feeding tolerance.\n\n#4. O: in this evening. Mom changed diaper and took\ntemp. Dad kangaroo'd x1hr. Asking appropriate questions.\nPictures taken. A: Involved loving . P: Continue to\ninform and support.\n\n#5. O: Infant remains in servo control isolette with stable\ntemp. She is alert and active with cares. MAEW. A: AGA P:\nContinue to assess and support developmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-03 00:00:00.000",
"description": "Report",
"row_id": 1810494,
"text": "npn 7p-7a\n\n\n1.) RESP: infant remains on nasal prong cpap 5. in 21% FIO2.\nno desats. 5 bradys this shift thus far qsr. RR=30s-50s.\nlscl/= mild ic/sc retractions. o2 sats >95%. on caffeine\ndaily. continue to monitor resp progress.\n\n2.) FEN: current weight .975gms up 19gms. TF 150cc/kg/day.\nenteral BM 10cc/kg or 2cc q4. held for asp3cc and 2.6cc.\nrefed asp. 140cc/kg/day of PND10 VIA DLUVC. abd soft no\nloops noted. AG stable. no stool thus far. uop=1.8cc/kg/hr\nfor past 8 hours. plan to check lytes this am. continue to\nsupport FEN.\n\n3.) : no contact this shift.\n\n4.) G/D: infant nested on sheepskin on a warmer. A/A with\ncares settles well inbetween. temp 99.1-99.8 warmer turned\ndown .1 degree. head us scheduled for this friday. continue\nto support G/D.\n\n5.) HYPERBILI: infant on mini neo blue phototherapy. eye\nshields on. will check bili this am. continue to monitor and\nassess.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-03 00:00:00.000",
"description": "Report",
"row_id": 1810495,
"text": "Respiratory Care\nBaby continues on prong CPAP 5, 21%. BS clear. RR mostly 30's-50's with IC/SCR. Five spells as per flowsheet as of this writing. On caffeine. Will cont CPAP, follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-03 00:00:00.000",
"description": "Report",
"row_id": 1810496,
"text": "npn add:\ntodays cbg result for 4am are as follows: 7.25/39/48/18/-9.\nnnp aware no changes made.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-03 00:00:00.000",
"description": "Report",
"row_id": 1810497,
"text": "Neonatology NP Note\nPE\nnested on radiant warmer\nAFOF\nmild subcostal/intercostal retractions on CPAP, lungs with slightly diminished air entry in bases, clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, hypoactive bowel sounds\nUVC in place\nactive with good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-03 00:00:00.000",
"description": "Report",
"row_id": 1810498,
"text": "Neonatology Attending Progress Note\n\nNow day of life 5, CA 4\nOn 5cm of CPAP and in RA.\nRR 30-60s. CBG - 7.25/39\nOn caffeine.\n13 episodes of apnea/bradycardia in the past 24 hours - all very mild\n\nCVS - HR 150-180 BP 64/25 39\n\nWt. 975gm up 19 on 150ml/kg/d of TF - feedings held yesterday - now getting 10ml/kg/d of MM PN/IL 140ml/kg\nUO 2.0ml/kg/hr DS 99\nPassing meconium.\n\nLytes 137 5.4 107 13\n\nBili 4.1 on phototherapy\n\nFamily meeting yesterday with both .\n\nAssessment/plan:\nBaby with 14% weight loss and dehydration with metabolic acidosis.\nWill treat with NaHCO3 replacement.\nFluids increased to 160ml/kg/d today.\nWill follow lytes closely.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-03 00:00:00.000",
"description": "Report",
"row_id": 1810501,
"text": "Respiratory Care\nPt received on +5cm's of nasal prong CPAP with the fio2 21%. Pt's resp rates 30's to 60's on caffine. Pt have quick self resolved spells. Pt's CPAP inceased from 5cm's to 6cm's. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-04 00:00:00.000",
"description": "Report",
"row_id": 1810502,
"text": "NPN\n\n\n#1 Resp;\no; Remains on 21% prong cpap 6 cm.RR 30-40, Lungs cl=. Brady\nX2\nA: Pot for spells P: Cont to monitor\n\n#2 FEN:\no: Remains on 10cc/k/ BM . DLUVC infusing D85 and IL Abd\nsoft, hypoactive BS,No spits. voided 3.6cc/k/h\nglycerine supp. given. small mec\nA: tol feeds at present\nP: Cont to monitor for feeding intol\n\n#4 :\nno contact this shift\n\n\n#5 dev:\no; Temps stable in open warmer, nested in sheepskin\nMAE,AFSOF\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-04 00:00:00.000",
"description": "Report",
"row_id": 1810503,
"text": "Respiratory Care\nBaby continues on prong CPAP 6, 21%. BS clear. RR 40's-50's with mild retractions. Two QSR-mild bradys as per flowsheet as of this writing. On caffeine. Will cont CPAP, follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-04 00:00:00.000",
"description": "Report",
"row_id": 1810504,
"text": "Neonatology Attending\n\nNow day of life 6, CA 5/7 weeks.\nOn CPAP of 6 and in RA.\nRR 40-60s\n2 episodes of apnea/bradycardia in the past 24 hours.\nCVS - HR 150-170s BP 71/35 48\n\nWt. 1kg up 25gm on 160ml/kg/d of TF - enteral feedings - 10ml/kg/d of MM 150ml/kg/d of PN/IL\nUO - 3.6ml/kg/hr - passing meconium\n\nLytes 131 4.5 100 19\n\nBili 4.0/0.3\n\nHct 44.9%\n\nAssessment/plan:\nBaby doing very well with only minimal vent support required.\nWill continue with gradual advancement of feedings as tolerated.\nWill maximize Na HCO3 intake via PN.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-04 00:00:00.000",
"description": "Report",
"row_id": 1810505,
"text": "Respiratory Care\nPt received on nasal prong CPAP +6cm's with the fio2 21%. Pt's resp rates 40's to 60's, on caffine. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-06 00:00:00.000",
"description": "Report",
"row_id": 1810686,
"text": "Neonatology\nDOL #36, CGA 33 wks.\n\nCVR: Remains on CPAP 6 cm, 21%, RR 30-50, clear. On caffeine, one spell. Hemodynamically stable, intermittent murmur.\n\nFEN: Wt 1785, up 5 grams. NPO, TF 140 cc/kg/day, PN D10/IL, non-central PICC. Abdomen benign. Voiding, no stool. Repogle discontinued.\n\nID: On zoyn/clinda day .\n\nDEV: In isolette.\n\nIMP: Former 27+ wk twin with presumed NEC, RDS, overall stable. Comfortable on CPAP. Abdomen benign on treatment.\n\nPLANS:\n- Continue CPAP, consider trial off next week.\n- Continue NPO, PN.\n- Continue zosyn/clinda.\n- Monitor abdominal exam.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-06 00:00:00.000",
"description": "Report",
"row_id": 1810687,
"text": "Respiratory Care Note\nBaby Girl remains on +6 prong CPAP, FiO2 .21 this shift. BS clear. RR 20-60's. On caffeine. No bradys noted thus far this shift. Changed to larger prongs today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-06 00:00:00.000",
"description": "Report",
"row_id": 1810688,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont on bubble prong CPAP of 6, FIO2 21%. No\nspells or desats this shift. Cont on caffeine. (Please\nrefer to flowsheet for resp assessments.) A/stable on CPAP.\nP/Cont to monitor for resp distress.\n\n2. FEN=O/Remains NPO. TF cont at 140cc/k/d of PND10 with\nlipids via patent/intact PICC. Abd full but otherwise\nbenign. in to assess at 1500 r/t fullness. Ngtube\ndropped and 25-30cc air aspirated. (Please refer to\nflowsheet for assessment.) No spits. U/o=3.8cc/k/hr for\nthis shift. No stool. A/NPO r/t NEC. P/Cont to monitor\nFEN status.\n\n4. =O/Mom called x1. Updated by this nurse.\n will be in to visit tomorrow. P/Cont to support and\neducate .\n\n5. G&D=O/Temp stable swaddled on sheepskin in air isolette.\nAlert and active with cares. Sleeping well in between.\nMAE. Font S/F. Sucking on pacifier. A/alt in G&D. P/Cont\nto monitor and support G&d.\n\n7. I/D=O/Cont on Zosyn and Clindamycin, now day 6. P/cont\nwith current Rx. Clindamycin to be d/c'd after day 7.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Report",
"row_id": 1810468,
"text": "NPN (con't)\n#6 Bili 2.9/0.2 at 12 hrs. Remains under neoblue light w/eye and genital protection in place. Plan to check bili again at 24 hrs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Report",
"row_id": 1810469,
"text": "Neonatology-NNP Progress Note\nPE: Remains on an open warmer, nested, under pt with eye covering on, jaundiece with bruising noted, on 19/5 X14 bbs sl cse=, rrr s1s 2no murmur, pulses 2+=, abd soft, nontender, ua, uvc in place and secure, afso, acitve\n\nSee attending note for plan\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Report",
"row_id": 1810470,
"text": "NPN Addendum:\nBlood gas drawn after infant placed on CPAP:7.36/33/73/19/-5. No further changes made, infant remains in RA w/sao2's mid 90's, RR 40-70's. UAC infusion stopped and line will be removed by NNP. DUV now infusing D10PN at 100cc/k/d, D/S this afternoon 129. U/O:3.3 cc/k/hr, no stool, 24 hr lytes and bili pending. Parents in to visit (along with twins siblings, and were updated. Grandmother also visited. Will con't to update/support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Report",
"row_id": 1810561,
"text": "Neonatology Attending Progress Note\nNow day of life 15, CA weeks.\nOn FIO2 of 25-32% on CPAP of 5 RR 40-60s\n5 episodes of apnea/bradycardia in the past 24 hours.\n\nCVS - HR - 150-170s BP 72/40 48\n\nWt. 1220gm up 5gm on 150ml/kg/d of MM or PE20\nFeedings well tolerated - more spitting noted with PE.\nNormal urine and stool output.\n\nHUS - FU this week no change\n\nAssessment/plan:\nVery nice progress.\nWill continue with current management.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Report",
"row_id": 1810562,
"text": "Neonatology Attending Progress Note\nAddendum - PE\n\nBaby is , sleeping during exam\nAF soft and flat.\nLungs clear and equal.\nCVS - no murmur, perfusion good\nAbd - soft with normal bowel sounds\nNeuro - tone/position good\nSkin clear\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Report",
"row_id": 1810563,
"text": "Respiratory Care Note\nBaby Girl remains on +5 prong CPAP, FiO2 .21-.33 this shift. BS clear. RR 20-50's. On caffeine. No spells thus far this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-13 00:00:00.000",
"description": "Report",
"row_id": 1810564,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont on prong CPAP of 5, FIO2 21-33%. No spells\nthis shift. Cont on caffeine. (Please refer to flowsheet\nfor resp assessments.) A/stable on CPAP. P/Cont to monitor\nfor resp distress.\n\n2. FEN=O/TF cont at 150cc/k/d of now BM/PE22 gavaged over\n80min. Abd benign. (Please refer to flowsheet for\nassessments.) Sm spit x1. Voiding. No stool this shift.\nA/tolerating current regime. P/Cont to monitor FEN status.\nSend lytes am.\n\n4. =O/Mom called x1. Updated by this nurse. Will\nbe in to visit tomorrow. P/Cont to support and educate\n.\n\n5. G&D=O/Temp stable nested on sheepskin in servo isolette.\nAlert and active with cares. Sleeping well between feeds.\nMAE. Font S/F. A/alt in G&D. P/Cont to monitor and\nsupport G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-28 00:00:00.000",
"description": "Report",
"row_id": 1810648,
"text": "NPN 7a-7p\n\n\n1) infant received on NC 400cc flow in 21% fio2. Infant had\n3 brady's requiring some stim . Infant placed on prong cpap\n6 and now requiring 21-26% O2. 3 bradys thus far while on\ncpap. BS clear. RR 40-60's with mod i/c s/c retractions.\nLess retracting while on cpap. REamins on caffeine. Nasally\nsx infant for bloody secretions. at 9am. Continue to asess.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-28 00:00:00.000",
"description": "Report",
"row_id": 1810649,
"text": "NPN cont'd 7a-7p\n\n\n2) TF 150cc/kg/day. tolertating feeds of BM/PE 28 with pm\ngavaged over 1 hour 2o min. Abdomen softly full. No spits.\nmax asp 2cc. old blood flecks in 2pm asp. Most likely r/t\nnasal sx at 10am ( with bloody nasal secretions). aware.\nNo spits. AG stable. No stool thus far today. continue to\nclosely asess.\n4) mother called this evening . Update given. Mom will be\ninto visit for the 8 & 9pm cares. Mom asking lots of\nquestions. she requested to speak with the md this evening.\ncontinue to support and keep them well informed.\n5) infant alert and active with cares. sleeping well between\nnested in sheepskin .Temps stable in servo isolette. Loves\npacifier. Head u/s to be done tomorrow. continue to support\ndev.needs.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-28 00:00:00.000",
"description": "Report",
"row_id": 1810650,
"text": "Neonatal NP- Note\n\nAsked by RN to evalaute this infant for abd distention.\n\nAbd full, tense and non-tender. Active bowel sounds. Foul smelling stool, guiac negative. Infant active with exam.\n\nKUB obtained, reviewed with Dr. , concerns for possible NEC. Infant made NPO with antibiotics. Discussed with mother and Dr. also spoke with mom.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Report",
"row_id": 1810482,
"text": "Neonatology Attending Progress Note\n\nNow day of life 3, CA 2/7 weeks.\nOn CPAP of 5 and in RA.\nRR 30-60s.\napproximately 5-6 episodes of apnea/bradycardia in the past 24 hours.\nHR - 160-170 BP 75/43 54\n\nWt. 983gm down 87gm\nOn TF of 120ml/kg/d - PN- IL\nMM 10ml/kg/d\nNormal urine output - given glycerine with resulting large meconium.\n\nDS 88\nLytes 143 4.4 113 15\n\nBili 5.4/0.4 on phototherapy\n\nAssessment/plan:\nVery nice progress overall for this ELBW infant.\nWill continue with support with CPAP.\nWill monitor feeding tolerance closely.\nWill set up family meeting in the next 2 days.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Report",
"row_id": 1810577,
"text": "NPN 0700-1900\n\n\nResp: Remains on prong CPAP 5cm. FiO2=21% throughout shift.\nRR=20-50. Lungs clear/=. IC/SC retractions. O2sat>93%.\nRemains on caffiene. No spells in 36hrs. P: Continue to\nmonitor pt for apnea and bradycardia.\n\nFEN: TF remain 150cc/kg/day. Cals increased today to BM26 or\nPE26. Needs 32cc Q4hrs. PG fed over 90 minutes and tolerated\nwell this shift. No spits. Minimal aspirates. Abdomen exam\nbenign, active BS, AG=21-22cm. Voiding/trace stools. Remains\non Iron and vitamin E. P: Continue to monitor FEN status.\n\nDEV: Remains nested on sheepskin, in servo isolette, with\nfirm boundaries to keep settled. Temp is stable. is\nA&A with her cares and sleeps bwtn, wakes occ but settles w/\nbinki or hand containment. AFSF. MAE equally. Brings hands\nto face to comfort self and will suck on binki intermittent-\nly. Will need f/u HUS at 30 days old. P: Continue to promote\noptimal growth and development of infant.\n\n: No contact thus far this shift. P: Continue to\nupdate and support NICU family.\n\nsee flowsheet for details.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Report",
"row_id": 1810578,
"text": "NPN 1900-0700\n\n\n#1: O: Infant remains on CPAP of 5, 21% FiO2. RR 30's-40's\nwith mild int/sc retractions. LS c/=, no spells. Infant\ncontinues on caffeine. A: Stable on CPAP. P: Continue to\nmonitor.\n\n#2: O: Current weight 1275g (+10g). TF 150cc/kg/day of\nbm/pe26, 32cc q4 hours gavaged over 90min. Abdomen benign,\ninfant is voiding and stooling, stools heme negative.\nMinimal aspirates, no spits. Girth stable at 21-21.5cm. A:\nTolerating feeds. P: Continue with current feeding plan.\n\n#4: O: No contact so far this shift.\n\n#5: O: Temp stable in servo isolette. Infant is alert and\nactive with cares. Brings hands to face for comfort and\nsucks pacifier when offered. Remains nested in sheepskin. A:\nAGA. P: Continue to support growth and development.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Report",
"row_id": 1810579,
"text": "Respiratory Care\nBaby continues on prong CPAP 5, 21%. BS clear. Nares sxn x1 for mod amt white sec. RR mostly 20's-50's with baseline retractions. No spells recorded as of this writing. On caffeine. Will follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Report",
"row_id": 1810580,
"text": "Neonatology\nRemains on CPAP. Low Fio2. Comfortable appearing. Few spells on caffeine.\n\nWt 1275 up 10. TF at 150 of 26 cal. promod to be added. ABdomen benign. Tolereating gavage with few non-bilious spits.\n\nContinue a sat present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Report",
"row_id": 1810581,
"text": "NPN 0700-1900\n\n\n#1Resp: Pt. remains on prong CPAP 5, FiO2 21%. RR 30-50's,\nsats > 96%. No spells or desats so far this shift. Cont on\ncaffeine. Lungs clear & equal w/ IC/SCR. P: cont to\nmonitor resp status.\n\n#2FEN: TF 150cc/kg/d of PE 26/BM 26 w/ promod started\ntoday. Feeds gavaged over 90min but increased to 100min d/t\nlg spit at 9am. Pt. seems to tolerate feeds better when\nprone. Abd soft & full, +BS. Soft transient loops noted at\n1pm cares. AG stable. Pt. voiding & stooling, guiac neg.\nMin aspirates. P: Cont to monitor for feeding intolerances.\n\n#4Parents: no contact from family so far this shift.\n\n#5DEV: Temps stable nested in sheepskin in servo isolette.\nPt. awake & alert for cares. Settles well in between w/\npacifier. MAE. AFSF. P: Cont to support dev needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-04 00:00:00.000",
"description": "Report",
"row_id": 1810506,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont in prong CPAP of 6, FIO2 21%. Spell x2 this\nshift. Cont on caffeine. (Please refer to flowsheet for\nresp assessments.) A/stable on CPAP. P/Cont to monitor for\nresp distress.\n\n2. FEN=O/TF cont at 160cc/k/d. Enteral feeds increased to\n20cc/k/d of BM20. Remaining 140cc/k/d=PND10 with lipids via\npatent/intact DLUVC. Abd benign. (Please refer to\nflowsheet for assessments.) No spits. U/o=2.3cc/k/hr for\n12 hours. Mec stool x1. A/alt in FEN. P/Cont with current\nregime and monitor FEN status. Send lytes and bili am.\n\n4. =O/Mom, dad, and siblings in to visit. Updated\nby this nurse. A/loving, appropriate and actively involved\nfamily. P/cont to support and educate .\n\n5. G&D=O/Temp stable nested on sheepskin on warmer. Alert\nand active with cares. Sleeping well between feeds. MAE.\nFont S/F. HUS . A/alt in G&d. P/Cont to monitor and\nsupport G&D.\n\n6. Bili=O/Cont under mini neoblue. Next bili to be sent\n am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-04 00:00:00.000",
"description": "Report",
"row_id": 1810507,
"text": "Procedure Note: P-CVL\nIndication: long-term IV access\n\nSigned parental consent in chart. Procedural Time Out observed.\n\n#1.9 BD catheter shortened to 12cm and inserted to 11 cm mark via introducer in right arm vein, catheter drew and flushed easily. Secured with sterile occlusive dressing. Aseptic technique with betadine/alcohol skin prep. Chest x-ray showed tip in neck. Catheter pulled back 2 cm and sterile occlusive dressing re-applied. Repeat x-ray shows tip in SVC. Infant tolerated procedure well, no complications.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-18 00:00:00.000",
"description": "Report",
"row_id": 1810590,
"text": "NPN 1900-0700\n\n\nRESP: Remains on prong CPAP 5, 21%. LS clear/=, mild SC\nretractions. Continues on caffeine, no spells thus far.\n\nFEN: Tolerating full enteral feeds well, no spits, minimal\naspirates. Abdomen soft/round, slightly full at times, good\nbs, girth stable, voiding, no stool thus far. Continues on\nvitamin E & Iron.\n\n: No contact thus far.\n\nG/D: Temp stable nested in sheepskin in servo isolette. A&A\nw/cares, sleeps well in between.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-18 00:00:00.000",
"description": "Report",
"row_id": 1810591,
"text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21%. BS clear. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-18 00:00:00.000",
"description": "Report",
"row_id": 1810592,
"text": "Social Work:\n\nMet very briefly with mom on Tuesday. Please see sw note in brother's chart. I remain available prn for support to this family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-18 00:00:00.000",
"description": "Report",
"row_id": 1810593,
"text": "Neonatology\nDoing well. REmains on CPAP. Spells not problem. trial off cpap today., Caffeine held for tachycradia tlast night.\n\nWt 1335 up 60. Tolerating feeds at 150 cc/k/d of 28 cal> Will increase to 30 cal.A bdomen benign.\n\nTemp stable.\n\nContinue a sat present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-18 00:00:00.000",
"description": "Report",
"row_id": 1810594,
"text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in isolette, on NP CPAP\nSkin: warm and dry; color ; well-perfused\nHEENT: anterior fontanel open, level; sutures opposed; symmetric facial features\nChest: breath sounds clear/=; well-aerated; minimal retractions\nCV: RRR without murmur; normal S1 S2; pulses +2\nAbd: soft; no masses; + bowel sounds; umbilicus healed\nExtr: moving all equally\nNeuro: symmetric tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Report",
"row_id": 1810471,
"text": "Respiratory Care\nPt received on IMV, rate of 18, pressures of 18/5 with the fio2 21%. Pt's resp rates 30's to 50's. Pt weaned down on vent settings with good ABG's. Pt extubated and placed on nasal prong CPAP, plan is to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Report",
"row_id": 1810472,
"text": "Respiratory Care Note\nPt. continues on 6cmh2O of nasal prong CPAP and 21%. BS clear. pt. on Caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Report",
"row_id": 1810473,
"text": "NPN 1900-0700\n\n\n1. Infant continues on prong CPAP6, fiO2 21%. RR30-70's, LS\ncl/=, ic/sc rtx though appears comfortable. No spells, on\ncaffiene.\nContinue to monitor resp status.\n\n2. Current wt 1070gms (-60). tf100/k, NPO. PND10 infusing\nvia DLUV. UAC removed by NNP w/o complication. DS 124.\nBelly soft, active BS, well perfused. Good diuresis o/n, no\nstool since birth. 24hr lytes 139/3.9/110/17.\nContinue to monitor I+O, wt trends, electrolye status.\n\n3. Continues on amp/gent. BC ntd. CBC benign.\nContinue to administer antibx as ordered.\n\n4. no contact from overnight.\n\n5. Temp 97.1ax--infant had voided outside of diaper and was\nlying on wet blanket underneath. Blanket changed and\nwarming lights applied; temp resolved. Otherwise stable\ntmeps. Fiesty/active w/cares, settled b/w. Nested on\nsheepskin. Significant edema/molding noted on infant's\nhead--NNP notified and infant examined. Advised to monitor.\nContinue to support needs.\n\n6. 24hr bili 3.7/0.3, remains ruddy under max intensity\nneoblu.\nContinue w/current tx.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-31 00:00:00.000",
"description": "Report",
"row_id": 1810474,
"text": "Neonatology Attending Note\nDOL# 2, CGA 28 wk\n\nExtubated Saturday, in CPAP 6, RA\nRR 20-70s\nOn Caffeine, 2 spells in 24 hrs\nGood sats\n\nP 140-150s\nMBP 40\n\nWt 1070 (down 60)\nOn TF 100 cc/kg, NPO\nUVC in place, on PN\nD-stick 124\n\nHypoactive BS\nUO 3.7 cc/kg/hr\n\nBili 3.7/0.3\nOn NeoBlue\n\nOn Amp and Gent\n\nA/P:\nPremature infant with RDS\nRESP: Try to wean CPAP to 5cm\nCV: Stable\nFEN: Increase TF to 120 cc/kg and start enteral feeds at 10 cc/kg. Recheck lytes in am\nGI: Continue on current phototherapy\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Report",
"row_id": 1810553,
"text": "NPN 1900-0700\n\n\nResp: Remains on nasal prong CPAP of 5. FiO2= 27-37% thus\nfar this shift. RR=40-60. IC/SC retractions. LS clear/=.\nPink. Remains on caffeine. One spell thus far this shift,\nsee flowsheet. P: continue to monitor pt for A's and B's.\n\nFEN: Weight=1205g, up 15g. TF at 150cc/kg/day BM20/PE20.\nNeeds 30cc Q4hrs PG fed over 1 hr for spits. (At FF since\n1700 last shift). Tolerating well. Two very small spits.\nMin. aspirates. Abdomen exam benign. Active BS. AG stable.\nVoiding well; trace stool. P: continue to monitor.\n\nDEV: Temp stable nested on sheepskin in Servo Isolette.\nAlert/active w/ cares and slightly irritable w/cares and at\ntimes bwtn cares but settles well w/ contaiment and flexed\npositioning. Like Pacifier. Brings hands to face to comfort\nherself. Fonts soft/flat. MAE equally. Repeat HUS due .\nP: continue to monitor and promote optimal G&D.\n\n: No contact from thus far this shift. P:\nUpdate, educate and support NICU family.\n\nPlease refer to flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Report",
"row_id": 1810554,
"text": "Respiratory Care\nBaby continues on prong CPAP 5, 26-37% 02. BS clear. RR 30's-60's. One mild stim A&B as of this writing. On caffeine. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-01 00:00:00.000",
"description": "Report",
"row_id": 1810651,
"text": "NPN 1900-0700\n\n\n#1Resp. Pt. received on prong bubble CPAP of 6 and remains\non same. FiO2 21-26%. RR 40-60, LS clear and equal, mild\nITC/SC retractions present. On caffeine, one brady, moderate\nstim. and increased O2 to resolve.Plan to continue CPAP,\ncontinue caffeine.\n\n#2FEN. Wt. 1725gms, up 35gms. NPO. TF of 130cc/k/day,\nreceiving D10 with lytes via PIV. Dstick 78. Pt. NPO all\nshift after noted to have firm distended abd at 2100, girth\n27cm, active bowel sounds,examined by , KUB done. Repogle\nplaced to low continuous suction and abd. appears less\ndistended. Pt. had guaic negative stool. Lytes obtained\n136/5.3/102/25. Plan NPO for now, repeat KUB this am.\nRepogle to low suction. Monitor I/O, dstick, abd. exam.\n\n#4Parents. Mom here for evening cares, updated by and\nattending. Mom called x1 for update. Plan to continue to\nupdate and support .\n\n#5Dev. Nested on sheepskin in servo control isolette. Temp.\nstable. Alert, active with cares, settles well between\ncares. MAE. AFF. Plan to support dev. needs. HUS to be done.\n\n#6Potential sepsis. CBC and BC done, WBC 18 with 47 polys, 2\nbands. HCT 26.9, retic 10.0.Plts 603. BC pending. BP 78/40,\nMAP52. Pt. started on zosyn q 8 hrs. Plan to monitor for\nsigns of sepsis, continue antibiotics.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-01 00:00:00.000",
"description": "Report",
"row_id": 1810652,
"text": "Respiratory Care\nBaby continues on prong CPAP 6 with 02 req 21-26%. BS clear. RR 30's-60's. Serial KUBs: +pneumotosis reported on film @ 0430. On caffeine, abx. Hct 26.9. Two bradys this shift; QSR-mod stim. Will cont to follow closely, support as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-12 00:00:00.000",
"description": "Report",
"row_id": 1810716,
"text": "Neonatology Attending Progress Note:\nDOL #42\nPMA 33 6/7 weeks\nremains in 200cc flow (decreased yesterday). 25-21% FiO2\nclear/equal, RR=40-60's, no spells, on caffeine\nsoft intermittent murmur, HR=130-160's, BP mean=56\nday # zosyn\n1985g (inc 30g), TF=140cc/kg/d PN D12.5. NPO, central PICL\nvoiding\nstools heme negative yesterday\nImp/Plan: premie infant with medical NEC, intermittent murmur, mild apnea of prematurity, residual lung disease, stable\n--recheck KUB prior to starting feedings\n--recheck lytes\n--monitor oxygen saturations, wean oxygen as tolerated\n--continue antibiotics until Sunday and then if KUB o.k, start feedings\n--continue rest of present management\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-12 00:00:00.000",
"description": "Report",
"row_id": 1810717,
"text": " Physical Exam\nPE: , AFOF, breath sounds clear/equal with mild retracitng, no murmur, well perfused, abd soft, non distended, + bowel sounds, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-12 00:00:00.000",
"description": "Report",
"row_id": 1810718,
"text": "NICU nursing note\n\n\n1. Resp=O/Received in NCO2 FIO2 21% 200cc/min flow. RA\ntrial started at 1500. No spells or desats. Cont on\ncaffeine. (Please refer to flowsheet for resp assessments.)\nA/stable in room air. P/Cont to monitor for resp distress.\n\n2. FEN=O/Remains NPO. TF cont at 140cc/k/d of PND12.5 with\nlipids via patent/intact PICC. Abd benign. (Please refer\nto flowsheet for assessments.) No spits. Voiding. No\nstool this shift. A/NPO r/t NEC. P/Cont to monitor FEN\nstatus. Send lytes am.\n\n4. =O/Mom called x1. Updated by this nurse. P/Cont\nto support and educate .\n\n5. G&D=O/Temp stable swaddled cobedding in open crib.\n and active with cares. Sleeping well in between.\nMAE. Font S/F. A/alt in G&D. P/Cont to monitor and\nsupport G&D.\n\n7. I/D=O/Cont on Zosyn, now day 12:14 day course. P/cont\nwith current Rx.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Report",
"row_id": 1810483,
"text": "NICU Nursing Progress Note\n\nRemains in prong CPAP 5 cms in room air. Breath sounds,resp\nrate, and WOB are at baseline. Suctioned nasal secretions\nX1. Infant has had 5 spells so far this shift consisting of\nbradycardia without desat and requiring mild stim to\nresolve. Remains on caffeine.\nNo murmur appreciated. Infant is ruddy and bruised. VSS.\nRemains under Neoblue mini phototherapy with eyes covered.\nTF increased to 140cc/kg. Enteral feeds remain at 10cc/kg\ndue to some large non-bilious aspirates overnight and this\nmorning. Abd exam benign, however, there is no stool\ndocumented since birth. Glycerin supp given with large\nmeconium results. DUVC infusing PN ans IL without\ndifficulty. Voiding qs.\nRemains on open warmer on servo control with stable temp.\nActive and alert with cares. Tone wnl. Nested prone with\nextremities flexed. Infant sucks vigorously on pacifier.\nMom called for update and progress report given.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Report",
"row_id": 1810484,
"text": "Social Work\nPlease see sw note in twin brother's chart.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Report",
"row_id": 1810485,
"text": "Respiratory Care\nPt received on nasal prong CPAP +5cm's with the fio2 21%. Pt's resp rates 40's to 60's, on caffine. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Report",
"row_id": 1810486,
"text": "NNP Physical Exam\nPE: pink, AFOf, sutures override, CPAP prongs in place, nares intact, breath sounds clear/equal with mild retracting, good air entry, no murmur, normal pulses and perfusion, abd soft, + bowel sounds, active, irritable, good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-01 00:00:00.000",
"description": "Report",
"row_id": 1810487,
"text": "Rehab/OT\n\nInfant seen, care plan posted at the bedside. Met with mother in her room to discuss OT and care plan recommendations. Mom receptive to information. Please refer to care plan posted at the bedside for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-02 00:00:00.000",
"description": "Report",
"row_id": 1810488,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 5 FIO2 21%. Breath sounds are clear. Three brady's so far tonight. Baby is on caffeine. RR 30-50's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Report",
"row_id": 1810565,
"text": "NPN 1900-0700\n\n\n1. Resp: Infant remains on prong CPAP 5. FiO2 range has\nbeen 23-25%. RR=40-80's. Mild SCR/ICR at baseline. LS\nclear. Has had 2 spells thus far tonight. (2 in 24hrs).\nOn caffeine.\n\n2. FEN: WT=1245gms (up 35gms). TF=150cc/k/day BM22.\nGavaged 31cc over 1hr and 20\". Max asp = 5.0cc partially\ndigested bm. Refed. No spits. Abd girth = 20-21.5cm. Abd\nis round and soft with active bs. V&S with each diaper\nchange. D/S at 0100 was 85. Lytes were 140/4.4/108/21.\n\n3. : No contact this shift.\n\n4. G&D: is alert and active with cares.\nAppropriately irritable at times. Temps stable nested in\nsheepskin in servo isolette. AFSF. AGA.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Report",
"row_id": 1810566,
"text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 23-27%. BS clear. On Caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Report",
"row_id": 1810567,
"text": "Neonatology Attending Note\nDay 16, PMA 30 1\n\nCPAP5, 21-27%. RR30-60s. On caffeine. +SOft murmur. HR 150-170s. . BP 67/37, 48. Wt 1245, up 35. TF 150 BM/PE22. Tol well. Nl voiding and stooling. In isolette.\n\n140/4.4/108/21\n\nA/P:\nCont CPAP. Monitor AOP on caffeine. Inc cals to 24. Start Vit E and Fe.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-02 00:00:00.000",
"description": "Report",
"row_id": 1810489,
"text": "NPN:\n\nRESP: Prong CPAP 5cm, 21% 02. Sats 98-100%. RR=40-60s with SC/IC retraction. BBS =/clear. A&B x 1 thus far tonight -> stim; x 6 over past 24 h. Remains on Caffeine.\n\nCV: No murmur. HR=150-170. BP=62/43 (50). Color ruddy pink w/good perfusion.\n\nFEN: Wt=956g (- 27g). TF=140cc/kg/d. Enteral feeds @ 10cc/k g/d (2cc BM q 4 h via gavage). PN(D-10) and IL @ 130cc/kg/d via DUV. Enteral fdg held x 1 due to soft abd loops. Abd continues to be soft, pink, soft loops, active bs ; NNP examined baby. U/O=1.7cc/kg/h over 24-h period yesterday; voiding qs tonight. No stool since yesterday. Dx=162. Elec: 141/ 5.1/ 113/ 14. Trig=86.\n\nBILI: NeoBlue- mini. Bili 4.9/ 0.3/ 4.6 (down from 5.4).\n\nG&D: CGA=28 wk. Temp stable on servo-controlled warmer. Active and alert w/cares. Nested in sheepakin and resting well. Abrasion lower lip; no s/s inflammation.\n\nSOCIAL: No contact w/. Family meeting to be arranged w/i the next two days.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-02 00:00:00.000",
"description": "Report",
"row_id": 1810490,
"text": "CORRECTION TO ABOVE NOTE:\n\nRESP: A&B x 2 thus far tonight -> stim; x 10 over past 24 h.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-02 00:00:00.000",
"description": "Report",
"row_id": 1810491,
"text": "Neonatology Attending Progress Note\n\nNow day of life 4, CA 3/7 weeks.\nOn CPAP of 5 and in RA.\nRR 30-50s on caffeine.\nCVS - HR 150-170s BP 62/43 50\n10 episodes of apnea/bradycardia in the past 24 hours.\nOn caffeine.\n\nWt. 956gm down 27gm on 140ml/kg/d of TF - feedings MM 10ml/kg/d and 130ml/kg/d of PN - feedings well tolerated thus far.\nNormal urine 1.7ml/kg/d and stool output.\nDS 162\nLytes 141 5.1 113 14\nTG 86\n\nBili 4.9 on phototherapy\n\nAssessment/plan:\nBaby continues to require support with CPAP.\nWill check ABG and repeat lytes as well as urine pH to bettter evaluate her acid base status.\nWill continue with trophic feedings of 10ml/kg/d.\nFamily meeting to be scheduled for today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-02 00:00:00.000",
"description": "Report",
"row_id": 1810492,
"text": "Respiratory Care\nPt cont on prong CPAP. FIO2 .21. BS clear, rr 30-50. On caffeine. No spells noted thus far this shift. ABG 7.28/31/107/15/-10. bicarb given. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-02 00:00:00.000",
"description": "Report",
"row_id": 1810493,
"text": "NPN 7a-7p\n\n\n1) infant remains on prong cpap 5 in 21% FIO2. No desats. 7\nbrady's needing some stim. RR 30-60's with mild i/c s/c\nretractions. remains on caffeine. continue to asess.\n2) TF increased to 150cc/kg/day. Enterals remain at 10cc/kg.\n BM gavaged every 4 hours. asp .6-4cc. WIthheld last fed due\nto nonbilious 4cc asp. ( refed asp) Abdomen softly full with\ni/m loops. AG stable. No stool. u/o 2.2cc/kg/hour. Art gas\ndone and 7.28. 31. 107. 15 . and -10 . Bicarb given at 1330.\nWill recheck lytes in the am. No plan to increase feedings.\n4) in to visit with sibling. Family meeting held\ntoday . update given and reviewed what to expect. Mom dc'd\ntoday. Reviewed nicu routine. Mom has not held infant . SHe\nhopes to hold on Thurs when she returns. continue to support\nand keep them well informed.\n5) Infant alert and active with cares. very irritable\nbetween cares. infant nested in sheepskin with boundaries.\nTemps stable on a warmer. Head u/s Friday. continue to\nasess.\n6) infant remains on mini neo blue phototherapy. eye shades\nin place. Bili this am 4.9 and 0.3. Plan to recheck in the\nam.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-02 00:00:00.000",
"description": "Report",
"row_id": 1810659,
"text": "NPN 7p-7a\n\n\nRESP: Infant remains in prong CPAP of 6; FiO2 21%. RR\n20-60's. LS cl/= with IC/SC retxns. On caffeine. Spell x2\nthis shift. Infant stable on CPAP with decrease spells.\nContinue to support resp. needs and monitor for spells.\n\nFEN: Infant remains NPO. CW 1740 (up 15g). TF 130cc/k/d\nof PND10 @ 8.2cc/hr and IL @ 1.1cc/hr; infusing well via PIV\nin R. arm. PICC planned for wed. HL in L. leg for blood\ntransfusion; without incident. ABd. soft, active BS, no\nloops. Girth 24.5-25cm. No spits. Repogle to continuous\nLWS; 5cc of clear secretions with very few blood flecks. DS\n75. Lytes this am 140, 4.2, 107, 21 with triglyceride of\n47. 12hr UO= 2.6cc/k/hr. No stool this shift. KUB (x2)\nshows improvement. Infant is NPO with IVF; gaining weight.\nContinue to monitor abdomen and provide nutrition via IVF.\n\n: Mom and dad in for . Mom updated by this RN;\nboth asking appropriate questions. Spoke with \nH. about infant's condition. Mom held infant for about 1hr.\nCalled later for update. Continue to update and support as\nneeded.\n\nDEV: Infant nested on sheepskin in servo isolette;\nincreased to 36.4 for temp of 97.7ax. Alert and active with\ncares. Not able to sleep too much this shift d/t blood\ntransfusions and KUB's. Irritable at times. Sucks on\npacifier for comfort. MAE. Continue to support growth and\ndevelopment.\n\nSEPSIS: Infant is on zosyn and clindamycin Q8hrs. CBC with\ndif sent (pls check laboratory for further info). Infant\nwas transfused with 1st alaquot of PRBC for a total of 17cc;\n2nd alaquot (17cc) currently transfusing. Infant needs\nstool sent for enterovirus and rotovirus when she stools.\nInfant not showing any overt s/s of sepsis. Continue to\nmonitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-02 00:00:00.000",
"description": "Report",
"row_id": 1810660,
"text": "7 SEPSIS\n\nREVISIONS TO PATHWAY:\n\n 7 SEPSIS; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-02 00:00:00.000",
"description": "Report",
"row_id": 1810661,
"text": "Neonatology\nRemains on CPAP 6, low fio2. Comfortable apeparing. Spells not problem. to leave on CPAp till next week.\n\nWt 1740 up 15. NPO at present for 14 day course. Abdomen remains slightly distended but soft. in place. Small amounts of drainage. Will leave in place for today and consider to gravity in am. Lytes in good range.\n\nTransfused with PRBCs overnight.\n\nOn Zosyn/clinda for NEC. Plan 14 day course. BC negative.\nPICC cobnsent to be obtained.\n\nTeam spoke with last night at bedside.\nCOntinue a sat present.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-02 00:00:00.000",
"description": "Report",
"row_id": 1810662,
"text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral; infant in isolette, on NP CPAP; sump to wall suction\nSkin: warm and dry; color \nHEENT: anterior fontanel open, level; sutures opposed;\nChest: breath sounds clear/=, minimal retractions\nCV: RRR, no murmur; normal S1 S2; pulses +2\nABd: soft; no masses; + bowel sounds; non-tender, non-distended; umbilicus healed\nGU: normal preterm female\nExt: moving all\nNeuro: + suck; + grasps; easily roused to drowsy state\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-18 00:00:00.000",
"description": "Report",
"row_id": 1810595,
"text": "NICU nursing note\n\n\n1. Resp=O/Received in prong CPAP of 5, FIO2 21%. Trialed\noff CPAP at 1300. Presently in NCO2 FIO2 30% 400cc/min\nflow. Spell x5 so far this shift (4 since trialing off\nCPAP). Cont on caffeine. (Please refer to flowsheet for\nresp assessment and details of bradys.) A/trialing off\nCPAP. P/Cont to monitor for resp distress or ^spells.\n\n2. FEN=O/TF cont at 150cc/k/d of now BM/PE30PM gavaged over\n90min. Abd benign. (Please refer to flowsheet for\nassessments.) Sm spit x2. Voiding/stooling, heme (-).\nCont on vit E and iron. A/tolerating current regime.\nP/Cont to monitor FEN status.\n\n4. =O/Mom called x1. Updated by this nurse. Will\nbe in to visit with dad at 1600. A/loving, appropriate and\nactively involved . P/Cont to support and educate\n.\n\n5. G&D=O/Temp stable nested on sheepskin in servo isolette.\nAlert and active with cares. Sleeping well between feeds.\nMAE. Font S/F. A/alt in G&D. P/Cont to monitor and\nsupport G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-19 00:00:00.000",
"description": "Report",
"row_id": 1810596,
"text": "NPN 1900-0700\n\n\nRESP: Remains in NC 100% 25-75cc. LS clear/=, mild SCR. Has\nhad 1 spell thus far this shift.\n\nFEN: Tolerating full enteral feeds well, no spits, minimal\naspirates. Abdomen soft/round, good bs, girth stable,\nvoiding, no stool thus far. On vitamin E & Iron.\n\n: Mom called x1. Updated by this RN, asking\nappropriate questions. Plans to call again on days.\n\nG/D: Received infant nested in servo isolette. Swaddled and\nplaced on air mode at first cares. Temp remains stable. A&A\nw/cares, sleeps well in between. Soothes well with pacifier.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-03 00:00:00.000",
"description": "Report",
"row_id": 1810669,
"text": "0700- NPN\n\n\nRESP: Remains on Prong CPAP of 6, FiO2 21%. RR 20's-50's.\nLS clear/=. Mild IC/SC retractions. No A/B spells or\ndesats. On Caffeine. P: Cont to monitor.\n\nID: Today is day 3 of 14 day course of treatment with\nZosyn/Clindamycin for medical NEC. P: Cont to monitor.\n\nFEN: TF=140cc/kg/d. Pt is NPO, receiving D10PN and IL via\nPIV. D-stick=83. Abdomen soft, round, , no loops,\ngirth stable. Voiding, no stool. P: Cont to monitor.\n\nDEV: Temps stable, pt is now swaddled in air mode isolette.\nAlert/active with cares. Sleeps between Q 6 hour cares.\nSucks pacifier and brings hands to face for comfort.\nFontanels soft/flat. AGA. P: Cont to support growth and\ndevelopment.\n\nSOCIAL: No contact from yet this shift. P: Cont to\nsupport/educate .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-03 00:00:00.000",
"description": "Report",
"row_id": 1810670,
"text": "Respiratory Care Note\nBaby Girl remains on +6 prong CPAP, FiO2 .21 this shift. BS clear. RR 20-50's. On caffeine. No bradys noted thus far this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-04 00:00:00.000",
"description": "Report",
"row_id": 1810671,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on bubble CPAP 6 via Prongs FiO2 21%. No bradys so far tonight. Baby is on caffeine. Breath sounds are clear. RR 30-60's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Report",
"row_id": 1810555,
"text": "Neonatology\nDoing well. REmains in low fio2. On CPAP. NO spells. Comfortable apeparing.\n\nWt 1205 up 15. having some non-bilious apsirates. full voluems today. Abdomen bengin. Will plan on advancing cals in am.\n\nHUS shwo germinal matrix cyst.\n\nContinue as at present.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Report",
"row_id": 1810556,
"text": "Neonatology NP Note\nPE\nnested in isolette\nAFOF, sutures approximatd\nmild subcostal/intercostal retractions on CPAP, lungs clear/=\nRRR, very soft systolic murmur at LSB, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Report",
"row_id": 1810557,
"text": "NPN 0700-1900\n\n#1 Alt. in Resp. Function\nO: Remains on prong CPAP 5cm, mainly in 21% with sats 88-95 and occasional sat drifts to mid 80's. Occasionally needs increased 02 (23-30%) for brief periods. RR 30's-60's with mild IC/SC retractions. On caffiene. One spell today, QSR.\nA: Occasional spells and sat drifts on prong CPAP, minimal 02 need\nP: Continue with present resp. plan. 02 as needed to maintain sats. Document all spells.\n\n#2 Alt. in Nutrition\nO: TF=150cc/kg=30cc PE20 (no breastmilk available) Q 4 hrs. Abd. is round. soft with + BS, occasional soft loops. Girth stable at 23cm. Small spits X 2. 3-6cc partially digested formula residuals. Voiding and passing seedy guaiac - stools.\nA: Tolerating feeds with some aspirates and spits\nP: Close observation and monitoring for feeding tolerance. Advance cals tomorrow if tolerating feeds well. Check lytes AM. Follow daily wts.\n\n#4 Alt. in Parenting\nO: Mom called X 1. Updated. Plans to visit tonight at .\nA: Involved mom\nP: informed and support.\n\n#5 Alt. in Developmant\nO: Temps 98.1-98.6 in servo isolette, nested in sheepskin with boundaries in place. Position changed Q 4 hrs. Stresses with cares, but settles easily with containment. Not interested in pacifier. Occasional spells. All gavage. HUS done today.\nA: Appropriate for GA\nP: Continue to support developmental needs. F/U HUS at 30 days.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-12 00:00:00.000",
"description": "Report",
"row_id": 1810558,
"text": "Respiratory Care\nPt received on nasal prong CPAP +5cm's with the fio2 21 to 26%. Pt's resp rates 30's to 60's. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-27 00:00:00.000",
"description": "Report",
"row_id": 1810642,
"text": "Attending Note\nDay of life 29 PMA 32\nin nasal cannula 21% 400 cc of flow 10 spells in the previous 24 hours clustered together all either mild stim or QSR large amounts of thick nasal secretions\non caffeine\nsoft murmur HR 160-180 BP 75/39 mean 51\nlast hct 25.9 retic 4.2 on \n1655 up 35 grams on 150 cc/kg/day of BM or PE 28 cal/oz with promod\nmin spits pg over 1 hour 20 min\n\nImp-in stable condition\nwill monitor work of breathing\nwill not begin nasal drops now\nwill monitor spells\nwill increase the iron dose because of her anemia\nwill recheck hct on Monday\nnutrition on Monday\nHUS on Monday\nwill get consent for Hep B\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-13 00:00:00.000",
"description": "Report",
"row_id": 1810719,
"text": "npn 1900-0700\n\n\n1: resp\nremains in ra. infant has had three spells this shift. while\nsleeping. please see flow sheet for further details.\nfollowing third spell infant suctioned for large thick\nyellowish/old blood tinged secretions. no further spells\nafter suctioning. lung sounds clear and equal. mild\nsubcostal retractions. rr 30-60's. continues on caffeine.\ncontinue to monitor for changes in resp status.\n\n2: fen\ncurrent weight 2045gms up 60. total fluids remain at\n140cc/kilo/day of pn d13 with lipids. infant remains npo.\ninfant abd exam benign. abd soft with no loops. voiding, no\nstool thus far this shift. no spits. lytes sent this shift\npending. girth stable. dstick 104. continue with current\nplan of care.\n\n4: \nmom called x's 1. updated by this rn. loving and involved.\nasking appropriate questions. continue to support \nneeds.\n\n5: dev\ntemps stable in an oac. cobedded with brother. swaddled on a\nsheepskin. and active with cares. sleeps well\ninbetween. brings hands to face. sucks vigorously on\npacifier. aga. continue to monitor for developmental\nmilestones.\n\n7: sepsis\ninfant remains on zosyn for 14 day treatment. no signs and\nsymptoms of infection noted. today day 13/14 day course.\ncontinue to monitor for changes.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Report",
"row_id": 1810568,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont on prong CPAP of 5 (changed to bubble at\n0900), FIO2 21%. No spell so far this shift. Cont on\ncaffeine. (Please refer to flowsheet for resp assessment.)\nA/stable on CPAP. P/Cont to monitor for resp distress.\n\n2. FEN=O/TF cont at 150cc/k/d of now BM/PE24 gavaged over\n80min. Abd benign. (Please refer to flowsheet for\nassessments.) No spits. Voiding/stooling. Started on vitE\nand iron. A/tolerating current regime. P/Cont to monitor\nFEN status. Send bili am.\n\n4. =O/No contact with so far this shift.\nDue in to visit at 1600.\n\n5. G&D=O/Temp stable nested on sheepskin in servo isolette.\nAlert and active with cares. Sleeping well between feeds.\nMAE. Font S/F. A/alt in G&D. P/Cont to monitor and\nsupport G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Report",
"row_id": 1810569,
"text": "Respiratory Care Note\nBaby Girl remains on +5 prong CPAP, FiO2 .21 t/o shift. BS clear. RR in the 30's. On caffeine. No bradys noted this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-14 00:00:00.000",
"description": "Report",
"row_id": 1810570,
"text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. She is , well perfused, no murmur auscultated. She is comfortable on CPaP of 5, fio2 21-27%. Breath sounds clear and equal. She is tolerating full volume feeds. Abd soft, active bowel sounds, voiding and stooling. Stable temp in isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-01 00:00:00.000",
"description": "Report",
"row_id": 1810653,
"text": "Neonatology\nBack on CPAP yesterday for increased spells. COmfortabel apeparing this am with resolution of spells.\n\nWt up 35. NPO since last night. Abdomen is less distended this am. No BS noted. Soft. Non-tender to my exam. Lytes in good range.\nPN to begin. WIll need PICC for 14 day course of NPO for NEC.\n\nKUB this am shows area of ? pneumotosis in RLQ. Will repeat later this am. Viral cx of stool to be done.\n\nHct 26.9. Given concern over abdomen will transfuse with PRBCs to optimize gut perfusion.\n\nHUS shows resolution of germinal matrix hemorrhage.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Report",
"row_id": 1810571,
"text": "Nursing Progress Note\n\n\n#1. O: Infant remains on prong bubble CPAP 5 in 21%\novernight. RR 20's-50's. Breath sounds are clear and equal.\nMIld IC/SC retractions noted. No spells thus far tonight. On\ncaffiene. A: Stable on CPAP. P: Continue to monitor.\n\n#2. O: Infant remains on TF's of 150cc/k/d of BM24. No\nspits. Minimal aspirates. AG stable. Abd soft and round with\nactive bowel sounds. No loops. Voiding qs. Med yellow stool,\nneg heme. Wgt is up 20gms tonight to 1265gms. A: Tolerating\nfeeds. P: Continue to monitor feeding tolerance.\n\n#4. No contact from family thus far tonight.\n\n#5. O: Infant remains in servo control isolette with stable\ntemp. (warm x1 = probe loose) She is alert and active with\ncares. MAEW. A: AGA. P: Continue to assess and support\ndevelopmental needs.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Report",
"row_id": 1810572,
"text": "Respiratory Care Note\npt. continues on 5cmH2O of nasal prong CPAP and 21%. BS clear. on Caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Report",
"row_id": 1810573,
"text": "Neonatology\nDoing well. Remains on CPAP. Comfortable apeparing.\nNo spells.\n\nWt 1265 up 20. Tolerating feeds at 150 cc/k/d. Abdomen benign.\nTolerating gavage at 150 cc/k/d of 24 cal. Will increase to 26 cal.\n\n\nBili in 3.9 range.\n\nContinue as at present.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Report",
"row_id": 1810574,
"text": "Clinical Nutrition:\nO:\n~30 week CGA BG on DOL 17.\nWT: 1265g(+20)(25-50th %ile); BWT: 1130g. Average wt gain over past week ~16g/kg/day.\nHC: 26cm(~10th %ile); last: 25.5cm\nLN: 40cm(25-50th %ile); last: 36cm\nMeds include Fe & Vit.E\nLabs noted.\nNutrition: 150cc/kg/day as BM/PE 26(No Promod); pg over 90mins d/t hx spits. Projected intake for next 24hrs ~150cc/kg/day, providing ~130kcal/kg/day & ~3.2-3.3g pro/kg/day.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds over extended feeding times w/o GI problems; pg fed. Labs noted & within acceptable range. Current feeds & supps meeting recs for kcal/pro/vits/mins. Growth is meeting recs for WT/HC gains. LN gain is exceeding recs of ~1cm/wk. Will monitor long-term trends. Will cont. to follow w/ team & participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Report",
"row_id": 1810575,
"text": "NP NOTE\nPlease refer to attending note for deatls of evaluation and plan.\n\nPE: small preterm infant on prong CPAP, well perfused, motlles with exam\nAFOF sutures approxmated, eyes clear, nares intact, og in place, MMMP\nChest is clear, eqaul bs, faior excursion mild SCR\nCV: RRR, no murmur, sinus bradycardia with prong off recovers quickly\nAbd: soft full wotyh active bs\nGU: immature female\nEXT: lean\nneuro: symmetric tone, active\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-15 00:00:00.000",
"description": "Report",
"row_id": 1810576,
"text": "Respiratory Care Note\nBaby Girl remains on +5 prong CPAP, FiO2 .21 this shift. BS clear. RR 20-60's. On caffeine. No documented spells thus far this shift.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-01 00:00:00.000",
"description": "Report",
"row_id": 1810655,
"text": " PHysical Exam\nPE: pale , AFOF, nasal CPAP in place, nares intact, breath sounds clear/equal with minimal retracting, no murmur, normal pulses and perfusion, abd distended, firm, seems tender, bowel sounds present, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-01 00:00:00.000",
"description": "Report",
"row_id": 1810656,
"text": "Respiratory Care\nPt received on nasal prong CPAP +6cm's with the fio2 21%. Pt's resp rates 20's to 50's. Plan is to follow on CPAP wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-15 00:00:00.000",
"description": "Report",
"row_id": 1810728,
"text": "CLinical Nutrition\nO:\n~34 wk CGA BG on DOL 45.\nWT: 2140 g (+85)(~25th to 50th %Ile) birth wt: 1130 g. Average wt gain over past wk ~22 g/kg/day.\nHC: 30.5 cm (~25th %Ile); last: 28.5 cm\nLN: 42 cm (~10th to 25th %Ile); last: 42.5 cm\n noted\nNutrition: 140 cc/kg/day TF. NPO, but plan to start feeds today @ 20 cc/kg/day BM 20. Remainder of fluids as PN via central PICC line; projected intake for next 24 hrs from PN ~97 kcal/kg/day , ~3.5 g pro/kg/day and ~2.9 g fat/kg/day. From EN: ~13 kcal/kg/day, ~0.4 g pro/kg/day and ~0.8 g fat/kg/day. GIR from PN ~11 mg/kg/min.\nGI: ABdomen benign. KUB benign.\n\nA/Goals:\nTolerating PN with good BS control. Plan to start feeds today and monitor closely for tolerance. noted and PN adjusted accordingly. CUrrent PN + EN meeting recs for kcals/pro/fat and vits. FUll mineral recs will not be met until feeds reach initial goal. Growth is exceeding recommended ~15 to 20 g/kg/day for wt gain and ~0.5 to 1 cm/kg/day for HC gain; represents catch up growth. LN shows loss of 0.5 cm over past wk; question accuracy of measurement. WIll follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-15 00:00:00.000",
"description": "Report",
"row_id": 1810729,
"text": "NP NOTE\nPE: grwoing preterm infant nestled in open crib with twin. AFOF, sutures approximated, ng in place, MMMP\nPale , well perfues in RA.\nChest is symmetric with clear and equal bs\nCV: RRR, no murmur, pulses=2=\nAbd:soft active bs\nGU: immature\nEXT: PICC intactright arm\nNeuro: active, flexed posture with bundleing, symmetric reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-15 00:00:00.000",
"description": "Report",
"row_id": 1810730,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont in room air. No spells or desats this\nshift. Cont on caffeine. (Please refer to flowsheet for\nreps assessments.) A/stable in room air. P/Cont to monitor\nfor resp distress.\n\n2. FEN=O/TF cont at 140cc/k/d. Enteral feeds started today\nat 20cc/k/d of BM/PE20. Remaining 120cc/k/d=PND15 with\nlipids via patent/intact PICC. Abd benign. (Please refer\nto flowsheet for assessments.) No spits. Voiding. No\nstool this shift. A/feeds restarted at 1600. P/Cont to\nmonitor FEN status.\n\n4. =O/Mom and dad in to visit at 1700. Updated by\nthis nurse and Attending. Mom gave baby first bottle.\nA/loving, appropriate and actively involved family. P/Cont\nto support and educate .\n\n5. G&D=O/Temp stable swaddled cobedding in open crib.\n and active with cares. Sleeping well in between.\nMAE. Font S/F. A/alt in g&D. P/Cont to monitor and\nsupport G&d.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-04 00:00:00.000",
"description": "Report",
"row_id": 1810672,
"text": "NPN/1900-0700\n\n\n#1 RESP: Infant remains on prong cpap 6, Fio2 21%. RR\n30-50's. LSC/=. Mild retractions. No spells. On\ncaffeine. Stable. Cont. to monitor.\n#2 FEN: Wt 1790, ^ 40gms. NPO. TF=140cc/k/d of PND10 and\nIL thru piv. Abd. soft, round. Girth=24cm. Voiding 2cc/k\nthis shift. No stools. Plan on attempting picc today.\nObtain sample for rotavirus and enterovirus when stools.\n#4 : visiting during evening. Updated by\nnursing. Independ. with cares; dad held infant for ~1hr.\nVery loving and involved. No further contact this shift.\nCont to support parental needs.\n#5 DEVELOPMENT: Swaddled in off isolette; temps warm\n99-100ax. Active/alert w/ cares; sleeping well b/t. Sucks\non pacifier when offered. AFOF. MAE. Support\ndevelopmental needs.\n#7 SEPSIS: Day of Zosyn and Clindamycin for medical\nnec.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-04 00:00:00.000",
"description": "Report",
"row_id": 1810673,
"text": "NeonatologyOn CPAP. Comfortable. Low FIo2.\n\nWT 1790 up 40 NPO at present. Abd ebnign. Peripheral IV access has become difficult. Will attempt to place PICC today. Repogle to be dced\n\nDay of abx for NEC.\n\nCOntinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-17 00:00:00.000",
"description": "Report",
"row_id": 1810735,
"text": "NPN 1900-0700\n\n\n1. RESP: Pt remains in RA with RR 30-50s' and sats >92%.\nLung sounds are clear. Mild retractions. No spells noted\nso far this shift.\n\n2. F&N: TF remain at 140cc/k/d. Feeds were advanced to\n50cc/k/d of BM20. IVF of PND15 with IL infusing well via\nPICC. She bottled her whole feed well at 2430. Abd benign.\nBS+. A/G stable. No spits noted. Max asp was 2.4cc of\nnonbilious, partially digested breast milk. U/O 1.9cc/k/h.\nNo stool noted so far this shift. Weight gain 40 grams.\n\n4. PAR: Mom called for update X1. She plans on calling\ntomorrow after noon and coming in to visit tomorrow.\n\n5. DEV: is active and during her cares. Temp\nstable swaddled in open crib with her twin brother. She\nputs her hands to her face and sucks on her pacifier at\ntimes.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-17 00:00:00.000",
"description": "Report",
"row_id": 1810736,
"text": "Neonatology\nDOL #47, CGA 34 wks.\n\nCVR: Continues in RA, overall comfortable, mild intermittent retractions. No spells, off caffeine. Hemodynamically stable.\n\nFEN: Wt 2195, up 40 grams. TF 140 cc/kg/day, enteral feeds at 50 cc/kg/day, BM20, all PO thus far. Rest PN. Abdomen soft, voiding/. Dstik 89.\n\nDEV: Cobedding in open crib.\n\nIMP: Former 27 wk infant with hx RDS, NEC, overall stable. Tolerating gradual advancement of enteral feeds.\n\nPLANS:\n- Continue as at present.\n- Monitor for spells.\n- Advance enteral feeds gradually.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-17 00:00:00.000",
"description": "Report",
"row_id": 1810737,
"text": "NP NOTE\nPE: grwoing preterm infant neslted in open crib. and well perfused in RA. AFOF sutures approximated, eyes and lcear, ng in place, mucousy spit during exam. MMMP\nChest is clear, equal bs\nCV: RRR, no murmur, pulses=2=\nAbd: soft active bs, NTND\nGU: MAE,WWP\nNeuro: symmetric tone and relfexes.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Report",
"row_id": 1810463,
"text": "#1 PT INTUBATED AND SURFED X2. LS ARE IMPROVING, CLEAR TO\nCOARSE WITH GOOD AERATION. FI02 MOSTLY 35-40%. MOST RECENT\nGAS 7.36/37. PT WEANED TO 20/5 R=18 WITH RECENT GAS RESULTS.\nPLAN FOR REPEAT GAS IN A.M.. RR 30-60.\n#2 TF 80CC/KG. D10 AND STARTER PN INFUSING WELL VIA DUV.\n1/2NS WITH HEPARIN INFUSING WELL VIA UAC. DSTIX 120/103.\nVOIDING, HAS NOT STOOLED. ABD SOFT AND FLAT, NON AUDIBLE BS\nAT THIS TIME.\n#3 PT STARTED ON AMP AND GENT. MEDS GIVEN AS ORDERED.\n#4 MOM AND DAD TO SEE PTS. NNP UPDATED PARENTS AT BEDSIDE.\n#5 TEMPS ARE STABLE NESTED ON SERVO WARMER. ALERT. RESPONDS\nTO CARES. SETTLES WELL.\n#6 NO MURMER NOTED AT THIS TIME. PT RUDDY WITH BRUISING ALL\nOVER. NEOBLUE STARTED ON PT. BILI TO BE DONE AT 12HR OF\nLIFE. NS BOLUS GIVEN X2 FOR MAPS <30. BP MAPS INCREASED TO\nLOW 30'S. DELAYED CAP REFILL.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Report",
"row_id": 1810464,
"text": "1 RESP\n2 FEN\n3 SEPSIS\n4 PARENTS\n5 DEV\n\nREVISIONS TO PATHWAY:\n\n 1 RESP; added\n Start date: \n 2 FEN; added\n Start date: \n 3 SEPSIS; added\n Start date: \n 4 PARENTS; added\n Start date: \n 5 DEV; added\n Start date: \n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Report",
"row_id": 1810465,
"text": "Respiratory Care Note\nPt. is a 27 wk'er twin # 2 born via C/S. Pt. was transferred to NICU and intubated with a 2.5 ett taped at 7.25. Pt. was treated with 4.5 cc's of Survanta at 2100/0300. Initial settings were 25/5 R 25. Currently pt. is on 18/5 R 18. Last gas was on 20/5 R 18 and was 7.29/44/62/22/-4. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-27 00:00:00.000",
"description": "Report",
"row_id": 1810643,
"text": "NPN (0700-1900)\n\n\n1. Resp: Remains in NC02 21-25% 400cc flow. LS clear after\nsuctioning X1 for mod thick blood tinged secretions.\nBreathing pattern is comfortable overall. Mild-mod IC/SC\nretractions, RR 40's-60's. On caffeine, 10 spells in 12\nhours...all qsr with the exception of one mild stim with\nincrease in 02. Will monitor closely for increased WOB\nand/or increased severity of spells. Hct/retic due on .\n\n2. F/N: Tolerating 150cc/kg/d of BM28 w/promod well over 1\nhr 20 min on . No spits, minimal aspirates. Glycerin\nsupp given X1 for straining and full belly at 1730 with\nlarge g- results. Abd otherwise benign. Nut due on\n.\n\n4. : Mom and grandmother in for scrapbooking class,\nbut could not stay for feeding. Visited at bedside with\nbabies for a while and will be in tomorrow to hold.\n\n5. Dev: Alert and active with cares. Servo temp increased\nslightly at last care time for temp of 97.6. HUS due .\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-28 00:00:00.000",
"description": "Report",
"row_id": 1810644,
"text": "NPN1900-0700\n\n\n#1Resp. Pt in O2 via NC, 400cc, 21-25%. RR 40-60s, LS clear\nand equal, ITC/ SC retractions present. Remains on caffeine.\nPt. has had 3 bradys tonight, mainly QSR. Plan to continue\nO2, monitor resp. status.\n\n#2FEN. Wt. 1690gms, up 35gms. On TF of 150cc/k/day\nofBM28/PE28PM, 42cc q4hrs gavaged over 1hr, 20 minutes. No\nspits, minimal aspirates. Abd. full, active bowel sounds, no\nnoted loops. Girth25-25.5cm. Voiding with each care. No\nstool. Plan to monitor for tolerance of feeds.\n\n#4Parents. Mom called x2, updated. Plan to continue to\nupdate and support .\n\n#5Dev. Pt. nested on sheepskin in servo control isolette.\nTEmp. stable. Alert and active with cares, settles well\nbetween cares. MAE. AFF. Plan to support dev. needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-28 00:00:00.000",
"description": "Report",
"row_id": 1810645,
"text": "Neonatology\nRemains in RA. Moderate number of spells. Intermittetn retratcing. Will place back on CPAP for now. Monitor spells.\n\nWt 1690 up 95. Tolerating feeds at 150 cc/k/d. Abdomen benign.\n\nHUS for Monday.\n\nContinue as at present.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-28 00:00:00.000",
"description": "Report",
"row_id": 1810646,
"text": " Physical Exam\nAwake and alert. AFOF with good tone. Breath sounds clear and equal on CPAP with good transmission to the bases. No audible murmur, well perfused with normal pulses. Abdomen soft and rounded with active BS, no HSM or masses.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-28 00:00:00.000",
"description": "Report",
"row_id": 1810647,
"text": "Respiratory Therapy\nBaby was placed back on CPAP today for increasing spells. On +6, RA. RR 40-60. LS CTA. Suctioned nares for small yellow-BT. On caffeine with continued spells on CPAP. Plan to continue with CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-11 00:00:00.000",
"description": "Report",
"row_id": 1810712,
"text": "Neonatology Attending\nDOL 41 / PMA 33-5/7 weeks\n\nIn NC 400 cc/min of 21-25% FiO2. Two bradycardias in 24 hours, on caffeine.\n\nIntermittent murmur. BP 88/33 (55).\n\nOn day zosyn.\n\nWt (+35) on TFI 140 cc/kg/day. REmains NPO on PN-D10/IL. Abd full yesterday but soft this morning. Voiding 2.6 cc/kg/hr and stooling normally (guiac negative). D-stick 98\n\nA&P\n27-6/7 week GA infant with CLD, feeding and respiratory immaturity, presumptive NEC\n-Continue bowel rest and antibiotic coverage through 14 days then cautious reintroduction of feeds\n-Continue to wean oxygen as tolerated\n-Follow murmur clinically given intermittent\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-01 00:00:00.000",
"description": "Report",
"row_id": 1810654,
"text": "Clinical Nutrition\nO:\n~32 wk CGA BG on DOL 31.\nWT: 1725 g (+35)(~50th %Ile); birth wt: 1130 g. Average wt gain over past wk ~21 g/kg/day.\nHC: 28 cm (~10th to 25th %Ile); last: 27 cm\nLN: 42 cm (~25th to 50th %Ile); last: 40.5 cm\n noted\nNutrition: 130 cc/kg/day TF. NPO due to NEC. D10 w/ lytes infusing via PIV. Plan to change to PN tonight; projected intake for next 24hrs from PN ~83 kcal/kg/day, ~3.4 g pro/kg/day and ~3.1 g fat/kg/day. GIR from PN ~7.9 mg/kg/min.\nGI: Abdomen benign, full and soft. + bowel sounds. Decreased abdominal girth since yesterday when made NPO due to abdominal distention and pneumotosis noted on KUB. Repogle to LCS draining 1 cc of clear fluid.\n\nA/Goals:\nTolerating IVF w/ good BS control; plan to change to PN tonight. NPO day 1 of 14 for NEC. noted and PN adjusted accordingly. Nutrition drawn prior to infant being made NPO and were within acceptable range. Tonight's PN will meet recs for pro/fat and vits. FUll mineral and kcals recs are not being met due to limitations of PIV access. Plan is to place central PICC within next few days to optimize nutrition. Growth is meeting recs for HC gain. WT gain and LN gain are exceeding recommended ~15 to 20 g/kg/day for wt gain and ~1 cm/wk for LN gain, but overall trends on both growth charts is acceptable. WIll continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-13 00:00:00.000",
"description": "Report",
"row_id": 1810720,
"text": "Neonatology Attending\nAddendeum - Physical Examination\nHEENT AFSF\nCHEST no retractions; good bs bilat; no adventitious sounds\nCVS well-perfused; RRR; femoral pulses normal; S1s2 normal; short SEM ULSB radiating to back\nABD soft, non-distended; no organomegaly; bs active\nCNS active, , resp to stim; tone AGA and symm; MAE symm; suck/root/gag intact\nINTEG normal\nMSK normal insp/palp/ROM all ext\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-13 00:00:00.000",
"description": "Report",
"row_id": 1810721,
"text": "Neonatology Attending\nDOL 43 / PMA 34 weeks\n\nTransitioned to room air yesterday, currently in room air with no distress. Four bradycardias in 24 hours (several related to upper airway secretions). On caffeine.\n\nIntermittent murmur. BP 66/25 (38).\n\nOn day 13/14 of zosyn.\n\nWt 2045 (+60) on TFI 140 cc/kg/day. Remains NPO, on PN-D13W/IL. D-stick 104. Abd benign. Voiding normally 3.7 cc/kg/hr. Lytes 138/5/104/22.\n\nTemp stable in open crib\n\nA&P\n27-6/7 week GA infant with respiratory immaturity, NEC nearing completion of 2-week course of bowel rest\n-Continue to await maturation of respiratory drive\n-Monitor murmur clinically\n-Complete 14-day course of bowel rest and antibiotic coverage as of tomorrow, then obtain radiograph and start trophic feeds on Monday if radiographically reassuring\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-01 00:00:00.000",
"description": "Report",
"row_id": 1810657,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont in prong CPAP of 6, FIO2 21%. No spells.\nCont on caffeine. (Please refer to flowsheet for\nassessments.) A/stable on CPAP. P/Cont to monitor for resp\ndistress.\n\n2. FEN=O/Remains NPO. Conts with serial KUB's-last KUB\ndone at 1700. TF cont at 130cc/k/d of PND10 with lipids via\npatent/intact PIV Rhand. Abd benign. Repoggle to LCS\ndrained 4cc clear fluid with flecks of old blood. No spits.\n(Please refer to flowsheet for assessments.) Voiding. No\nstool. A/NPO r/t NEC. P/cont to monitor FEN status. Send\nlytes, triglyceride and CBC with diff am. Send spec\nfor enterovirus and rotovirus with next stool.\n\n4. =O/Mom called x2. Updated by this nurse .\nWill be in to visit at . P/Cont to support and educate\n.\n\n5. G&D=O/Temp stable nested in servo isolette. Alert and\nactive with cares. Sleeping well in between. MAE. Font\nS/F. HUS done this am. A/alt in G&D. P/cont to monitor\nand support G&D.\n\n6. I/D=O/cont on Zosyn Q8hrs. Started on Clindamycin Q8hrs\ntoday. Day 1:14day course. CBC/diff to be sent in am.\nP/cont with current Rx.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-02 00:00:00.000",
"description": "Report",
"row_id": 1810658,
"text": "Respiratory Care\nBaby continues on prong CPAP 6, 21%. BS clear. RR 30's-60's with baseline retractions. 2 QSR bradys recorded as of this writing. On caffeine. Rec 1st aliquot PRBC's. Will cont CPAP, follow closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-14 00:00:00.000",
"description": "Report",
"row_id": 1810724,
"text": "Neo Attending\nDay 44 34 1/7gm PMa\n\nrr %, on caffeine, no spells.\nmean bp 39, vs stable\n\nWt 2055 gm, up 10 gm\n140 cc/kg/day pn d13\nag wnl, uop and stool wnl. abd wnl.\nday 14 / 14 zocyn. KUB . feeds .\n\nAssessment: completing NEC Rx.\nPlan: as noted above.\n\nPt is stable. Evaluated and discussed with team.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-14 00:00:00.000",
"description": "Report",
"row_id": 1810725,
"text": "Nursing Progress Note\n\n\nResp: Infant is in r/a sating 95-100%, no spells. Cont to\nmonitor.\n\nFEN: TF 140cc/kg/d PN D10 and IL are infusing through\ncentral PICC without icident. Voiding 4.5cc/kg/hr. No\nstools. Abd exam benign as noted on flow sheet. KUB\nobtained, resluts pending. Plan to cont to monitor abd\nexam.\n\nDev: Temp stable swaddled co-bedding in crib. Infant is\n and active with cares. Acitve with cares. Plan to\ncont to support dev needs.\n\nSepsis: Cont on Zocin as ordered. Day 14/14. No overt s/s\nsepsis. Will cont ot monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-15 00:00:00.000",
"description": "Report",
"row_id": 1810726,
"text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN RA WITH 02 SATS >90%. NOTED ONE BRIEF BRADYCARDIC EPISODE AND NO DESATS SO FAR TONIGHT. BS CL&= WITH NO INCREASE IN WORK OF BREATHING. NOTED MILD GENERALIZED EDEMA. REMAINS ON CAFFEINE PO. BP 71/35-46. COLOR AND WELL PERFUSED.\n\nFEN: WEIGHT UP 85GMS TO 2140GMS TONIGHT. TOTAL FLUIDS MAINTAINED AT 140CC/KG/D OF PN13% & IL VIA CENTRAL PICC. ABD SOFT, WITH STABLE GIRTH AND +BS. VOIDING 3CC/KG/D AND STOOING, HEME -. REMAINS NPO, KUB WNL AND FEEDS SCHEDULED TO RESUME TODAY.\n\nDEV: ACTIVE AND WITH INTERVENTIONS AND SLEEPING QUIETLY BETWEEN CARES. TEMP STABLE. SUCKING VIGOROUSLY ON PACIFIER.\n\nSOCIAL: MOM CALLED FOR UPDATE X1.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-17 00:00:00.000",
"description": "Report",
"row_id": 1810738,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont in room air. Spell x1 so far this shift.\n(Please refer to flowsheet for resp assessments and details\nof brady.) A/stable in room air. P/Cont to monitor for\nresp distress.\n\n2. FEN=O/TF cont at 140cc/k/d. Enteral feeds presently at\n65cc/k/d of BM20 po/pg. Remaining 75cc/k/d=PND15 with\nlipids via patent/intact PICC. Abd benign. (Please refer\nto flowsheet for assessments.) Mod spit x1. Voiding. Sm\nstool x1, guaiac (-). A/advancing on feeds. P/Cont to\nmonitor FEN status. Cont to advance feeds by 15cc/k/d \nas tol.\n\n4. =O/Mom called x1. Updated by this nurse. Will\nbe in to visit at . P/Cont to support and educate\n.\n\n5. G&D=O/Temp stable swaddled cobedding in open crib.\n and active with cares. Sleeping well between feeds.\nMAE. Font S/F. A/alt in G&D. P/cont to monitor and\nsupport G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Report",
"row_id": 1810466,
"text": "Attending Note\nDay of life 1 PMA 28 0/1\ns/p surf X2\nSIMV 18/5 rate 16 FiO2 21-25% blood gas this am ABG 7.30/42/65/21/-5 and weaned to current setting RR 26-28\nHR 160-170's BP mean 32 no pressors\nweigth 1130 grams NPO on 80 cc/kg/day getting starter PN and D 10 W\nUAC with 1/2 NS\nruddy and bruised on neo blue phototherapy\nblood out 2.3 cc\nvoiding but not stooling\nNa 138 K 4.5 Cl 110 CO2 19 (12 hours of life)\nbili 2.9/0.2\non amp/gent\n\nIMP-stable making good progress\nRESP-will consider extubation later today. Will consider caffeine prior to extubation\nID-will have amp/gent 48 hours\nNEURO-will plan for a head US for next Friday\nwill d/c UAC later today\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Report",
"row_id": 1810467,
"text": "NPN\n\n\n#1 ABG drawn: 7.30/42/65/21/-5; rate decreased to 16 from\n18. Current vent settings: 21% r16 18/5. RR mid 20's 50's.\nSao2 >94%, no brady's or desat's. LS = and slightly coarse,\nimproved after sx'd for small->mod returns. No plans for 3rd\nsurfactant dose at this time. To obtain blood gas later on,\nconsidering removing UAC if resp remains stable.\n\n#2 TF at 80cc/k/d, remains NPO, no bowel sounds audible,\nbelly soft and pink, no stool. Voiding well. UAC and DUV\n(D10) infusing, D/S:172. 12 hr lytes drawn, unremarkable.\nTotal blood out ~2.3cc's. Will check labs again at 24 hrs,\ncon't to monitor.\n\n#3 On amp and gent, planning 48hr rule-out. CBC w/diff on\nadmission unremarkable, resp stable. Con't to assess\nclosely, blood culture pending.\n\n#4 No parental contact so far this shift but parents visited\nlast evening. Con't to support.\n\n#5 On servo-warmer, cluster-care observed, maintaining temp,\nrests comfortably b/t cares, active w/handling. Bruising\nevident on torso and rt extremities, including leg/foot.\nPlanning for 7 day HUS. Con't present interventions.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-10 00:00:00.000",
"description": "Report",
"row_id": 1810546,
"text": " Physical Exam\nPE: pink, AFOF, nasal CPAP prongs in place, nasal septum, breath sounds clear/equal with mild retracting, no murmur, normal pulses and perfusion, abd soft, full, non tender, + bowel sounds, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Report",
"row_id": 1810547,
"text": "NPN 1900-0700\nCorrection to above NPN:\nInfant was recieved on and remains on nasal prong CPAP of 5cm. (not 6).\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Report",
"row_id": 1810548,
"text": "NPN 1900-0700\n\n\nResp: Remains on nasal prong CPAP 6. FiO2=22-27% this shift,\n(increased w/cares). RR= 40-60. IC/SC retrx. Remains on\ncaffeine. One spell thus far this shift w/sleep (see flow-\nsheet). P: COntinue to monitor for A's and B's.\n\nFEN: Weight=1190g, up 15g. TF 160cc/kg/day. D10 w/NA+ & K+\npresently at 30cc/kg/day =1.5cc/hr infusing well via non-\ncentral PICC. Dstik=75. Enterals presently at 130cc/kg of\nBM20= 26cc Qhrs. PG fed over 45 min; tolerated well. No\nspits, min. residuals. Abdomen exam is benign, AG stable,\nActive BS. Voiding well/stooling heme(-). Plan is to advance\nfeeds by 10cc/kg at 0430 and 1630. P: continue to\nadvance per orders; assess infant and support FEN needs.\n\nDEV: Remains nested on sheepskin in servo mode isolette.\nTemo stable. A&A w/ her cares and sleeps well bwtn cares.\nBrings hands to face and sucks on pacifier when offered.\nAFSF. MAE. Respeat HUS planned for . P: Continue to\nsupport and promote optimal G&D.\n\n: No contact from thus far this shift. P:\nUpdate, educate and support NICU family.\n\nsee flowsheet for details.\n\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-11 00:00:00.000",
"description": "Report",
"row_id": 1810713,
"text": "Nursing Progress Notes\n\n\n#1 O: Baby remains in nasal cannula oxygen but weaned to\n200cc flow, 21%. Breath sounds clear and equal, mild\nretractions, no spells to time of report. A: WEaned down on\nflow today. P: Continue to monitor and wean as tolerated.\n#2 O: Total fluids 140cc/kg/day of D10.5PN and IL. IV fluids\ninfusing via central PICC line. Peripheral IV removed after\nantibiotics as it was slightly red. BAby remains NPO.\nAbdomen soft, bowel sounds active, no loops, girth stable.\nBaby gagging on orogastric tube this morning, no output form\ntube this am either. Baby pulled out tube this afternoon\nand tube was left out after discussing with . Baby\nvoiding and guiac negative stool. A: REmains NPO.\nP: Continue to monitor intake and output and complete 14 day\nNPO plan.\n#5 O: Temp stable in open crib while cobedding with\nsibbling. Baby is and active with cares and sleeps\nwell between cares. She takes her pacifier eagerly when\noffered. A: Appropriate for age. P: Continue to support\ndevelopment.\n#7 O: Baby remains on IV antibiotics. A: Day 11 of 14\ntoday. P: Continue with IV antbiotics.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-11 00:00:00.000",
"description": "Report",
"row_id": 1810714,
"text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. She is , well perfused, no murmur auscultated. She is comfortable in NCO2, breath sounds clear and equal. She remains NPO. PN/IL infusing via intact right arm PICc line. Abd soft, soft bowel sounds, voiding, no stool overnight. OG tube pulled out by baby today. temp cobedding with sib. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-12 00:00:00.000",
"description": "Report",
"row_id": 1810715,
"text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN NASAL CANNULA 200CC FLOW IN 25% FI02. BS CL&= WITH MILD RETRACTIONS AND NO INCREASE IN WORK OF BREATHING. NO A&B'S OR DESATS NOTED TONIGHT. COLOR AND WELL PERFUSED. BP WNL. AUDIBLE MURMER X1.\n\nID: DAY OF ZOCYN VIA CENTRAL PICC. REMAINS NPO.\n\nFEN: WEIGHT UP 20GMS TO 1985GMS. TOTAL FLUIDS MAINTAINED AT 140CC/KG/D OF PN 12.5 & IL. URINE OUTPUT 3.2CC/KG/HR. NO STOOL TONIGHT. ABD SOFT, WITH STABLE GIRTH AND +BS.\n\nDEV: TEMP STABLE CO-BEDDING. ACTIVE AND WITH INTERVENTIONS AND SLEEPING QUIETLY BETWEEN CARES.\n\nSOCIAL: IN AND INDEPENDENT WITH CARES. HELD BOTH INFANTS FOR LONG PERIOD. MOM SIGNED IMMUNIZATION CONSENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-13 00:00:00.000",
"description": "Report",
"row_id": 1810722,
"text": "NPN 7a-7p\n\n\n#1: remains in RA, sating >/= 92%. RR stable.\nBreathing comfortably with mild SC retractions. No ^'ed WOB\nnoted. Did have brady spell today- see flowsheet for\ndetails. Conts on Caffiene as ordered. Also noted to hover\nin sats of 70's at one time requiring BBO2 to recover. Since\nstable. BBS cl/=. A: stable in RA with occ drifts P:Cont\nto monitor and provide support as needed.\n\n#2: TF: 140cc/k/d. NPO. Conts on PND13 & IL infusing via\npatent PICC. Abd soft, +, no loops. AG stable. Voiding\nqs. Stooled x1- heme negative. Few small clear mucus spits\nnoted. A: stable on bowel rest P:Cont to follow wt and\nexam. KUB tomorrow.\n\n#4: Mom called several times, updates given. Mom had\nplanned to visit, but at last phone call was not sure if she\ncould make it in today. Mom did speak with Dr. . A:\nInvolved parent, eager to have infant home P:Cont to\nsupport and educate.\n\n#5: Temps stable while swaddled in an open crib. Infant is\nco-bedding with her brother. MAE. Fonts soft/flat. Settles\neasily after cares. Will suck on pacifier intermittently.\nA:AGA P:Cont to support dev needs.\n\n#7: Day 13/14 of Zosyn. Temps stable. Infant with\nappropriate behavior. A: stable P:Cont with antibiotics as\nordered. Monitor for s&s of infection.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-14 00:00:00.000",
"description": "Report",
"row_id": 1810723,
"text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN RA WITH 02 SATS >90%. NO A&B'S OR DESATS NOTED SO FAR TONIGHT. BS CL&= WITH MILD RETRACTIONS AND NO INCREASE IN WORK OF BREATHING. SOFT MURMER AUDIBLE. COLOR AND WELL PERFUSED. CONTINUES WITH MILD GENERALIZED EDEMA. BP WNL.\n\nFEN: WEIGHT UP 10GMS TO 2055GMS TONIGHT. REMAINS NPO WITH CENTRAL PICC INFUSING PN13% & IL AT 140CC/KG/D. ABD SOFT, WITH STABLE GIRTH AND +BS. NO EMESIS NOTED. NO STOOL TONIGHT. VOIDING 2CC/KG/HR.\n\nDEV: TEMP STABLE CO-BEDDING AND SWADDLED WITH BROTHER. AND ACTIVE WITH INTERVENTIONS AND SLEEPING QUIETLY BETWEEN CARES.\n\nID: DAY 14/14 OF ZOCYN.\n\nSOCIAL: MOM X3 FOR UPDATE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-15 00:00:00.000",
"description": "Report",
"row_id": 1810727,
"text": "Neonatology\nDOL #45, CGA 34 wks.\n\nCVR: Continues in RA, comfortable. On caffeine, 1 spell in 24 hrs. Hemodynamically stable, intermittent murmur reported.\n\nFEN: Wt 2140, up 85 grams. TF 140 cc/kg/day, PN. NPO. Voiding/.\n\nGI: KUB yesterday normal.\n\nID: Completed 14 days of abx yesterday.\n\nDEV: In crib.\n\nIMP: Former 27 wk twin with RDS, mild evolving CLD, hx NEC. Doing well with reassuring exam and KUB following treatment.\n\nPLANS:\n- Continue monitoring resp status.\n- Continue caffeine for now.\n- Start enteral feeds today 20 cc/kg/day, monitor tolerance.\n- Due for optho next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Report",
"row_id": 1810549,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 5 FiO2 22-27%. Suctioned nares for sm amt of yellow secretions. Breath sounds are clear. One spell so far tonight. Baby is on caffeine. RR 40-60's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Report",
"row_id": 1810550,
"text": "Neonatology\nDOing well. REmains on CPAP. Tolerated change from 6 to 5 yesterday. Comfortable apeparing. Intermittent spells continue. Soft murmur noted this am. Will evaluate clincially.\n\nWt 1190 up 15. Tolerating feeds at 140 cc/k/d of. IV to be dced later today. PICC to be dced. Abdomen benign. Lytes to be checked over weekend.\n\nContinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Report",
"row_id": 1810551,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont on prong CPAP of 5, FIO2 22-31%. No spells\nthis shift. Cont on caffeine. (Please refer to flowsheet\nfor resp assessments.) A/stable on CPAP. P/Cont to monitor\nfor resp distress.\n\n2. FEN=O/TF decreased to 150cc/k/d. Due to advance to full\nfeeds of BM/PE20 at 1630. Feeds gavaged over 45min. Abd\nbenign. (Please refer to flowsheet for assessments.) Sm\nspit x1. Voiding (u/o=2.9cc/k/hr for 8hrs), stooling, heme\n(-). A/tolerating current regime. P/cont to monitor FEN\nstatus. PIC to be removed by at 1630. Lytes to be sent\n am.\n\n4. =O/No contact with so far this shift.\n\n5. G&D=O/Temp stable nested on sheepskin in servo isolette.\nAlert and active with cares. Sleeping well between feeds.\nMAE. Font S/F. A/alt in G&D. P/Cont to monitor and\nsupport G&D. Repeat HUS tomorrow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-11 00:00:00.000",
"description": "Report",
"row_id": 1810552,
"text": "Respiratory Care\nPt received on nasal prong CPAP +5cm's with the fio2 22 to 30%. Pt's resp rates 40's to 50's. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-26 00:00:00.000",
"description": "Report",
"row_id": 1810637,
"text": " Physical Exam\nAwake and alert. AFOF with good tone and activity. Breath sounds clear and equal with slight retractions on CPAP. No audible murmur, well perfused with normal pulses. Abdomen soft and rounded with active BS, no HSM or masses. Normal GU.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-26 00:00:00.000",
"description": "Report",
"row_id": 1810638,
"text": "NPN 0700-1900\n\n\nRESP: Rec'd infant on Prong CPAP-5cm, 21%. Breath sounds\nare clear and equal w/ mild intercostal/subcostal\nretractions. RR 50-60's. Infant has had 2 bradys this\nmorning, on CPAP. COnts on Caffeine as ordered.\n Trialing off CPAP, as of 1300. In NCO2, 400cc, 50-30%.\nInfant has had 2 bradys since coming off CPAP, one w/ apnea.\nWill closely monitor for increase in spells and increase in\nWOB.\n\nF&N: TF-150cc/kg/d of BM/PE28 w/ promod. Tolerating feeds\nover 1hr, 20min w/o spits. MAx aspirate=.4cc. ABd is full\nbut soft w/ active bowel sounds and no oops. Ag 23-25cm.\nVoiding well. No stool this shift.\nA/P: Cont to follow weight. Assess tolerance to feeds.\n\n: No contact from yet this shift.\n\nDEV: Mild periorbital edema noted, bilaterally. Temp is\nstable in servo-controlled isolette. 30day HUS scheduled for\nMOnday- . Infant is pale-- HCt and retic to be\nchecked on MOnday ( w/ nutrition ). LAst HCT 3/16-25.9,\nretic-4.2. Infant is alert and active w/ cares.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-26 00:00:00.000",
"description": "Report",
"row_id": 1810639,
"text": "Respiratory Therapy\nBaby was taken off CPAP today and now is on 400cc NC 0.30-0.50. RR 30-60. Small yellow secretions. LS CTA. On caffeine with 3 spells as of this note-2 off CPAP. Plan to continue with NC as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-01-30 00:00:00.000",
"description": "Report",
"row_id": 1810462,
"text": "Neonatal NP-Procedure Note\n\nProcedure: UA/UVC placement\nIndication: continuous BP monitoring, vascular access and nutritional needs\n\nTime out observed. Infant restrained and umbi prep'd for procedure. Infant monitored continuously throughout procedure. #5 fr double lumen UVC placed without difficulty to premeasured distance of 9cm and secured. #5 fr single lumen UAC placed without difficulty to premeasured distance of 14 cm and secured.\n\nXray revealed UA/UVC -6, lines pulled back 1cm each. Awaiting repeat Xray to confirm position.\n\nInfant tolerated procedure well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-27 00:00:00.000",
"description": "Report",
"row_id": 1810640,
"text": "Nursing NICU Note\n\n\n1. Resp. O/Pt in NC FiO2 21%, 400ml/min flow. Please refer\nto flowsheet. Mild-mod retractions noted. Sxn'd twice from\nnares and mouth (once by this nurse and once by RT). RT\nasked to examine pt r/t spells noted this shift. RT in to\nsee pt. See flowsheet for A/B. Occasional drifts in\nsaturations noted into the 80s (all QSR). A/Requires NC\nflow. Occasional spells noted. P/Cont. to monitor for s/s of\nresp distress and need for additional resp support. Cont. to\nmonitor for A/B and intervene as pt needs.\n\n\n2. F/N. O/TF remain at 150ml/kg/day of BM28PM/PE28PM pngt\nover 1 hour and 45 min. PLeases refer to flowsheet for\nexaminations of pt from this shift. Full soft abd. Voiding.\nPassing flatus. No stool passed this shift. A/Appears to be\ntolerating present feeding regimen. P/Cont. to monitor for\ns/s of feeding intolerance.\n\n4. . O/Mother and father in last night. \nupdated on pt's status and plan of care. Mother held infant.\nA/ are updated on pt's status and care. P/Cont. to\nsupport and educate .\n\n\n5. Dev. O/Pt's temp stable. Pt's air controled isolette\nadjusted X1. Awake and alert with cares and sleeping well in\nbetween. A/Alt. in G/D. P/Cont. to support pt's growth and\ndev. needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-27 00:00:00.000",
"description": "Report",
"row_id": 1810641,
"text": " Physical Exam\nPE: pale , AFOF, nasal cannula in place, breath sounds clear/equal with mild retracting, soft murmur, abd soft, + bowel sounds, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-10 00:00:00.000",
"description": "Report",
"row_id": 1810706,
"text": "NPN/1900-0700\n\n\n#1 RESP: Infant remains in 400cc flow NC, 21-25% fio2. RR\n30-40's. LSC/=. SC retractions. Has had 3 bradys thus\nfar; see flowsheet. On caffeine. Stable. Cont. to\nmonitor.\n#2 FEN: Wt , ^80gms. NPO. TF=140cc/k/d of PND10.5 and\nIL thru piv. Abd. soft, full. Girth=27cm. Voiding 2.3cc/k\nthis shift; no stools. Stable. Cont. to monitor.\n#4 : visiting during evening. Updated by\nnursing. Mom . with cares. Held infant for ~1hr.\nVery loving and involved. Cont. to support parental needs.\n#5 DEVELOPMENT: Swaddled in oac; cobedding with brother.\nTemps wnl. Active/alert; sleeping well over noc. MAE.\nAGA. Support developmental needs.\n#7 SEPSIS: Day of Zosyn for medical nec and day of\noxacillin for phlebitic picc site.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-10 00:00:00.000",
"description": "Report",
"row_id": 1810707,
"text": "Neonatology\nDOing well. REmains on NCO2 flow. Low FIo2. Comfortable apeparing. Intermittent spells not problem\n\nWt up 80. NPO at present for NEC. Abdomen benign.\n\nOn day of abx for NEC. BC remains negative.\nStool virus testing pending. Oxacillin for Arm sweeling at site of PICC to be dced. BC remains neagtive. WIll attempt to replace PICC. Exam improved. No evidence of infection.\n\nContinue a sat present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-10 00:00:00.000",
"description": "Report",
"row_id": 1810708,
"text": " PHysical Exam\nPE: , AFOF, breath sunds clear/equal with mild retracting, sof murmur, abd soft, non distended, non tender, active bowel sounds, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-10 00:00:00.000",
"description": "Report",
"row_id": 1810540,
"text": "NPN 1900-0700\n\n\nResp: Infant remains on nasal prong CPAP 6cm. FiO2 req= 26-\n30% this shift(40%x1 w/kangaroo). RR=30-60. IC/SC retract's\nnoted. Lungs clear/=. Sxn'd oral/nares x1 this shift, for\nmed spit up. Remains on caffeine. 3 spells thus far this\nshift, 2 were during Kangaroo care. (See flowsheet). P:\nContinue to monitor infant for A's and B's.\n\nFEN: Weight=1175g, +10g. TF=160cc/kg/day. PND10 infusing\nwell via non central PICC at 50cc/kg/day= 2.4cc/hr. D/S=76\nthis shift. Enterals at 110cc/kg BM20/PE20=21cc Q4hrs.\nABdomen is full, soft, no loops, active BS. AG=21.5-22.5.\nMax aspirate of 2.2cc shown to and discarded for\n?slightly mucous appearance. Two small spits after 0100\nfeeding. Infant re-positioned prone to improve digestion, no\nspits since. Voiding well/Passing heme(-) stools. Plan is to\nadvance feeds by 10cc/kg at 0500 and 1700. P: Continue\nto monitor and support nutritional needs of infant.\n\nDEV: Remains prone, nested on sheepskin in servo isolette.\nTemp stable. A&A w/cares and sleeps well bwtn. Brings hands\nto face to comfort self. Not interested in pacifier at this\ntime. AFSF. MAE equally. One wk. HUS showed small cyst, to\nbe repeated on . P: Continue to promote optimal G&D.\n\nHyperbili: Problem resolved at of yesterday, .\n\n: See NPN for ,boy 1 for this shift for a\ndetailed description.\n\nsee flowsheet for details\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-10 00:00:00.000",
"description": "Report",
"row_id": 1810541,
"text": "6 Hyperbili\n\nREVISIONS TO PATHWAY:\n\n 6 Hyperbili; resolved\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-10 00:00:00.000",
"description": "Report",
"row_id": 1810542,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 6 FiO2 26-30%. Suctioned nares for sm amt of cloudy secretions. Breath sounds are clear. Three spells so far tonight. Baby is on caffeine. RR 30-60's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-10 00:00:00.000",
"description": "Report",
"row_id": 1810543,
"text": "Neonatology\nDoing well. Remains on CPAP. Comfortable apeparing. NO murmur. Intermittent spells.\n\nWt 1175 up 10. Tolerating feeds at 120 cc/k out of 160./ ABdomemn bengin. feeds adv w/o difficulty.\n\nRebound bili to be done in next day.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-10 00:00:00.000",
"description": "Report",
"row_id": 1810544,
"text": "NICU nursing note\n\n\n1. Resp=O/Presently on prong CPAP of 5 (decreased from 6 at\n1000), FIO2 24-30%. Spell x1 so far today. Cont on\ncaffeine. (Please refer to flowsheet for resp assessments,\nsxning, and details of brady.) A/stable on CPAP of 5.\nP/Cont to monitor for resp distress.\n\n2. FEN=O/TF cont at 160cc/k/d. Enteral feeds presently at\n120cc/k/d of BM20 gavaged over 45min. Remaining\n40cc/k/d=PND10 via patent/intact PIC. Abd benign. (Please\nrefer to flowsheet for assessments and dstick.) No spits.\nU/o=4.2cc/k/hr for 8hrs. Stooling. A/advancing on feeds.\nP/Cont to monitor FEN status. Enteral feeds due to advance\nto 130cc/k/d at 1700. PND10 to be d/c'd at 1800 and D10\nwith 5NaCl and 1 KCl to be hung in its place.\n\n4. =O/No contact with so far this shift.\n\n5. G&D=O/Temp stable nested on sheepskin in servo isolette.\nAlert and active with cares. Sleeping well between feeds.\nMAE. Font S/F. A/alt in G&d. P/Cont to monitor and\nsupport G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-10 00:00:00.000",
"description": "Report",
"row_id": 1810545,
"text": "Respiratory Care\nPt weaned from +6cm H2O to +5cm H2O prong CPAP today. Fio2 .26-.30. bs clear, rr 50's. On caffeine. 1 spell noted thus far this shift. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-10 00:00:00.000",
"description": "Report",
"row_id": 1810709,
"text": "NPN DAYS\n\n\n1. Remains in NCO2 400cc flow at 21-25%. LS clear. RR\n40-60's. On caffeine. 1 spell thus far today. Stable in O2.\nMonitor.\n\n2. NPO. TF at 140cc/kg of PN/lipids as ordered. DS stable.\nNew PIV placed. Voiding, no stool. AG stable. Abdomen soft.\nActive bowel sounds. Monitor.\n\n4. Mother called this am and updated. Asking appropriate\nquestions. Involved parent.\n\n5. Temp stable in open crib. Cobedding with sibling. Active\nand alert with cares. Likes pacifier. AGA.\n\n7. Continues on abx as ordered. Day of zosyn. Monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-11 00:00:00.000",
"description": "Report",
"row_id": 1810710,
"text": "Procedure Note: P-CVL\nIndication: long-term IV access.\n\nSigned parental consent in chart. Procedural time-out observed.\n\n#1.9 Fe. BD catheter shortened to 13 cm and advanced to 13 cm mark via introducer in left arm vein. Draws and flushes easily. Aseptic technique with betadine/alcohol skin prep. Secured with sterile occlusive dressing. X-ray showed tip in right atrium. Catheter withdrawn to 11.5 cm mark and sterile occlusive dressing re-applied. Repeat x-ray shows tip in SVC. Infant tolerated procedure well, no complications.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-11 00:00:00.000",
"description": "Report",
"row_id": 1810711,
"text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS IN 21-25% FI02 AT 400CC FLOW VIA NASAL CANNULA. BS CL&= WITH MILD RETRACTIONS AND NO INCREASE IN WORK OF BREATHING. COLOR AND WELL PERFUSED WITH MILD GENERALIZED EDEMA. BP WNL. NO A&B'S OR DESATS NOTED SO FAR TONIGHT.\n\nFEN: WEIGHT UP 35GMS TO 1955GMS TONIGHT. TOTAL FLUIDS MAINTAINED AT 140CC/KG/D OF PN10.5% & IL VIA NEWLY PLACED PICC LINE IN LEFT ARM. NO BLEEDING AT NEW INSERTION SITE. VOIDING 2.6CC/KG/HR. ABD SOFT, WITH STABLE GIRTH AND +BS. PASSED LG GREEN STOOL, HEME -. STOMACH DECOMPRESSED WITH OG TUBE.\n\nDEV: TEMP STABLE CO-BEDDING IN CRIB. ACTIVE AND ALERT WITH INTERVENTIONS.\n\nSOCIAL: MOM CALLED FOR UPDATE\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-25 00:00:00.000",
"description": "Report",
"row_id": 1810631,
"text": "Clinical Nutrition\nO:\n~31 wk CGA BG on DOL 27.\nWT: 1590 g (+75)(~25th to 50th %Ile); birth wt: 1130 g. Average wt gain over past wk ~23 g/kg/day.\nHC: 27 cm (~10th %Ile); last: 26 cm\nLN: 40.5 cm (~25th to 50th %Ile); last: 40 cm\nMEds include Fe and Vit E\n not due yet\nNutrition: 150 cc/kg/day BM/PE 28 w/ promod, all pg over 80 min feeds due to hx of spits. Feeds just decreased today; projected intake for next 24 hrs ~140 kcal/kg/day and ~4 to 4.4 g pro/kg/day.\nGI: ABdomen benign.\n\nA/Goals:\nTolerating feeds over extended feeding times without GI problems. not due yet. Current feeds + supps meeting recs for kcals/pro/vits and mins. Growth is meeting recs for HC gain. WT gain is exceeding recommended ~15 to 20 g/kg/day; represents catch up growth. 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"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-25 00:00:00.000",
"description": "Report",
"row_id": 1810632,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont in bubble prong CPAP of 5, FIO2 21%. Spell\nx1 so far this shift. Cont on caffeine. (Please refer to\nflowsheet for resp assessment.) A/stable on CPAP. P/Cont\nto monitor for resp distress.\n\n2. FEN=O/TF cont at 150cc/k/d of now BM/PE28PM gavaged over\n80min. Abd full, otherwise benign. (Please refer to\nflowsheet for assessments.) No spits so far. Voiding. No\nstool so far this shift. Cont on vit e and iron.\nA/tolerating current regime. P/cont to monitor FEN status.\n\n4. =O/No contact with so far this shift.\n\n5. G&D=O/Temp stable nested on sheepskin in servo isolette.\nAlert and active with cares. Sleeping well between feeds.\nMAE. Font S/F. A/alt in G&D. P/Cont to monitor and\nsupport G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-25 00:00:00.000",
"description": "Report",
"row_id": 1810633,
"text": "Respiratory Care\nPt cont on CPAP. FIO2 .21. bs clear, rr 40's. caffeine. 2 spell noted thus far this shift. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-26 00:00:00.000",
"description": "Report",
"row_id": 1810634,
"text": "NPN 1900-0700\n\n\n#1Resp. Pt. remains on prong CPAP of 5, fiO2 21%. RR 30s to\n60s, LS clear and equal, mild ITC/ SC retractions present.\nOn caffeine, no spells so far tonight. Plan to continue\nCPAP, monitor resp. status.\n\n#2FEN. Wt. 1620gms, up 30gms. On TF of 150cc/k/day of\nBM28/PE28PM, 41cc gavaged over 1hr, 20 minutes. No spits,\nminimal aspirates. Abd round, , active bowel sounds, no\nnoted loops. Girth 25cm. Voiding and passing green guaic\nnegative stool. On vitamin E and iron. Plan to monitor for\ntolerance of feeds.\n\n#4Parents. No contact.\n\n#5Dev. Pt. nested on sheepskin in servo control isolette.\nTEmp. stable. Alert, active with cares, settles well between\ncares. MAE. AFF. Plan to continue to support dev. needs.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-26 00:00:00.000",
"description": "Report",
"row_id": 1810635,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 5 FIO2 21%. Breath sounds are clear. No spells so far tonight. Baby is on caffeine. Breath sounds are clear. RR 30-60's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-26 00:00:00.000",
"description": "Report",
"row_id": 1810636,
"text": "Neonatoilogy\nDoing well. REmains on CPAP. Comfortable apeparing. Low FIo2. Intermittent spells on caffeine. WIll trial on NCO2 today and monitor tolerance.\n\nWt up 30. Tolerating feeds at 150 cc/k/d of 28 cal. Abdomen benign.\n\nHct 25.9 with retic 4\n\nCOntinue a sat present.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-09 00:00:00.000",
"description": "Report",
"row_id": 1810536,
"text": "NPN 2300-0730\n\n\n1. Prong CPAP 6, FiO2 21-25%. RR 40-50's. LSC and equal\nwith SC/IC retractions. On caffeine. No spells thus far\nthis shift. Continue to monitor resp status, monitor for\nspells.\n\n2. Weight 1165gms, up 45gms. TF 160cc/kg/day, working up\non enteral feeds. Enteral feeds currently at 100cc/kg/day,\nBM 20. Increasing by 10cc/kg/day at 430am, 430pm. IVF\nPN D10 at 60cc/kg/day infusing via PICC line. Belly soft,\n+BS, no loops, no spits, min aspirates. DS- 87. 24 hour\nu/o 2cc/kg/hr. Continue to monitor tolerance to feeds,\nincrease as tolerated.\n\n4. NO contact with thus far this shift.\n\n5. TEmp stable in servo isolette, nested in sheepskin.\nAlert and active with cares, settles well between cares.\nContinue to promote growth and development.\n\n6. Infant remains under single phototherapy, eye shields in\nplace. Bili drawn this AM- results pending. Continue to\nmonitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-09 00:00:00.000",
"description": "Report",
"row_id": 1810537,
"text": "Neonatology Attending Progress Note\n\nNow day of life 11, CA 3/7 weeks.\nOn CPAP of 6 and in 21-23% FIO@\nRR 30-70s\nOn caffeine.\n5 episodes of mild apne\nHR 150-170s BP 59/28 39\n\nWt. 1165 up 45gm on 160ml/kg/d of MM\nFeedings advancing - up to 100ml/kg/d of MM\nRest of fluids with PN/IL DS 74\nNormal urine and stool output.\n\nBili - on phototherapy 2.4\n\nAssessment/plan:\nSteady progress continues.\nWill advance feedings 10ml/kg as tolerated.\nPhototherapy dc'ed.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-09 00:00:00.000",
"description": "Report",
"row_id": 1810538,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont on prong CPAP of 6, FIO2 26-30%. No spells\nso far this shift. Cont on caffeine. (Refer to flowsheet\nfor resp assessments.) A/stable on CPAP. P/Cont to monitor\nfor resp distress.\n\n2. FEN=O/TF cont at 160cc/k/d. Enteral feeds presently at\n100cc/k/d of BM20 gavaged over 30min. Remaining\n60cc/k/d=PND10 via patent/intact PIC. Abd benign. (Please\nrefer to flowsheet for assessment and dstick.) No spits.\nVoiding/stooling. A/advancing on feeds. P/cont to monitor\nFEN status and cont to advance enteral feeds by 10cc/k/d \nas tol.\n\n4. =O/No contact with so far this shift.\n\n5. G&D=O/Temp stable nested on sheepskin in servo isolette.\nAlert and active with cares. Sleeping well between feeds.\nMAE. Font S/F. A/alt in G&D. P/Cont to monitor and\nsupport G&D.\n\n6. Bili=O/Phototx shut off at 1300 per team orders.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-09 00:00:00.000",
"description": "Report",
"row_id": 1810539,
"text": "Respiratory Care Note\nBaby Girl remains on +6 prong CPAP, FiO2 .26-.36 this shift. BS clear. RR 30-60's. On caffeine. No bradys noted this shift as of this writing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-24 00:00:00.000",
"description": "Report",
"row_id": 1810625,
"text": "NP NOTE\nPE:small growing preterm infant neslted in isolette, pale , mottles with exam. Comfortable on prong CPAP.\nAFOF sutres aproximated, eyes clear, nares patent, og in place, MMMP\nChest is symmetric with fair exchange\nCV: RRR, no murmur, pulses+2=\nAbd: soft active bs, NTND\nGU: immature female\nEXT:, \nNeuro: flexed posture with boundaries, active with good tone.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-09 00:00:00.000",
"description": "Report",
"row_id": 1810702,
"text": "NPN 1900-0700\n\n\nResp: Remains on NC 400cc flow, remains in 21% Fio2. LS cl/=\nO2 sats>91%. RR 20-60. One brady d/t apnea, was QSR, thus\nfar. see flowsheet. P: Continue to monitor for A's and B's.\n\nFEN: Weight=1815 g, +25g. Remains NPO. TF 140cc/k/d PND10.5\nw/IL infusing well via PIV left foot, site soft. Abdomen\nremains full and slightly distended at 2130. +BS, no loops,\nAG stable at 26.5cm. Instructed by team to check abdomen for\nair w/OGT w/cares if continued to appear distended-and it\ndid so, 15cc AIR obtained/removed; OGT removed, pt tolerated\nwell. Abd. remains full but is now soft once air removed.\nExam is otherwise benign. Voiding well; Stooled heme(-),\nStool spec's sent to lab as ordered. P: Continue to monitor\nFEN status and support nutritional needs of pt.\n\nDEV: Remains cobedding w/brother, swaddled with hat and\nsheepskin. Maintaining stable temps. is A&A w/ her\ncares and sleeps soundly bwtn with binki. Brings hands to\nface to face for comfort. AFSF. MAE. Eye exam was done\nyesterday. P: Continue to monitor and support G&D.\n\n: For family assessment, see NPN for Twin #1().\n\nSepsis: Pt. now Day of tx for ? of NEC. (Did not have\npnuemotosis on KUB). Recieving Zosyn as ordered. Pt. A&A w/\ncares and afebrile. No s/s of sepsis at this time. P:\nContinue 14 day course of Abx; Monitor for sepsis.\n\nsee flowsheet for details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-09 00:00:00.000",
"description": "Report",
"row_id": 1810703,
"text": "Neonatology\nDoing well. REmains in NCO2 400 cc flow. Low fIo2. Intermittent spells. Comfortable apeparing.\n\nWt 1840 up 25. NPO at present. Abdomen softly distended this am. Will follow. If persistent will check KUB.\n\nRotavirus pending\n\nAbx day for NEC. On oxacillin for 48 h course given phelibitic PICC site yetserday. Line removed and site improved this am. Will consider need for replacement of PICC after BC negative at 48 hours.\n\nContinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-09 00:00:00.000",
"description": "Report",
"row_id": 1810704,
"text": "Neonatology - PRogress Note\n\nInfant is active with good tone. AFOF. She is , well perfused, no murmur auscultated. She is comfortable on NCO2, Breath sounds clear and equal. She remains NPO. Abd soft, active bowel sounds, voding 3.3 cc/kg/day, no recent stool. PIV intact. Right arm at insertion site of PICC line without redness signs of phlebitis. Remains on Zocyn and oxacilling. Stable temp cobedding with sib. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-09 00:00:00.000",
"description": "Report",
"row_id": 1810705,
"text": "NPN 7a-7p\n\n\n1) infant remains in NC 400cc flow in 21-23% FIO2. BSclear.\nRR 40-60's with mild s/c retractions. No brady's thus far .\nremains on caffeine. continue to asess.\n2) NPO . TF 140cc/kg/day. IVF of PN D10.5 and il infusing\nvia PIV. Abdomen softly full. ag stable. No stool. Voiding\n3cc/k/hour. Continue to asess.\n4) mom called and update given. she plans to visit tonight.\ncontinue to support.\n5) infant alert and active with cares. sleeping well between\nnested and swaddled. temps stable. loves pacifier. Continue\nto support dev needs.\n7) Day 9 of 14 of zosyn for medical nec. Also on oxacillin\nfor 48 hours for phlebitic pic. Site in Right arm no\nredness. Blood cx neg to date.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-08 00:00:00.000",
"description": "Report",
"row_id": 1810529,
"text": "npn 7a-7p\n\n\n1.) RESP: infant remains on prong c-pap 6. fio2 25-35%. rr\n50s-7os. lscl/=. mild ic/sc retractions. no increase work of\nbreathing. no spells thus far this shift. cv no murmur sl\njaundice. well perfused bp 52/22/33. continue to monitor\nresp/cv status.\n\n2.) FEN: TF continue at 160cc/kg/day. infant recieving bm20\n8occ/kg. advance 10cc/kg due at 4pm. pn10% via picc line\nand IL at currently at 80cc/kg. abd soft no stool thus far\nthis shift. uop 2.4cc/kg/hr for 8hrs. continue to monitor\nand support FEN.\n\n3.) : no contact this shift.\n\n4.G/D: infant nested on sheepskin in servo controlled\nisolette. temp 99.5-100.3 adjusted skin probe. 99.8 after.\nA/A with cares. sleeps well inbetween. continue to monitor\nG/D.\n\n5.) HYPERBILI: infant under single phototherapy. eye shields\nin place. sl jaundice. check for rebound bili in am.\ncontinue to monitor for s/sx.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-08 00:00:00.000",
"description": "Report",
"row_id": 1810530,
"text": "Clinical Nutrition:\nO:\n~29 week CGA BG on DOL 10.\nWT: 1120g(+45)(25-50th %ile); BWT: 1130g. WT is down ~0.9% from BWT.\nHC: 25.5cm( %ile); HC @ Birth: 26.5cm\nLN: 36cm( %ile); LN @ Birth: 37.5cm\nLabs noted.\nNutrition: 160cc/kg/day. EN BM 20. PN infusing via non-central PICC. Projected intake for next 24hrs from PN ~31kcal/kg/day & ~1.8g pro/kg/day; from EN BM 20 @ 90cc/kg/day, providing ~60kcal/kg/day, ~0.9g pro/kg/day & ~3.4g fat/kg/day. Glucose infusion rate from PN ~4.9mg/kg/min.\nGI: Abd benign.\n\nA/Goals:\nTolerating feeds w/o GI problems; pg fed. Tolerating PN with good BG. Labs noted & PN adjusted accordingly. Current feeds & PN meeting recs for pro/kg/day but not fully for kcal/vits/mins until @ full feeds @ 24kcal/oz. Growth is not meeting recs for all parameters; feeds advancing as tolerated. Will cont. to follow w/ team & participate in nutrition plans.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-08 00:00:00.000",
"description": "Report",
"row_id": 1810531,
"text": "Respiratory Care\nPt cont on prong CPAP. Fio2 .30. bs clear, rr 40-60. On caffeine. 3 brady spells noted thus far this shift. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-08 00:00:00.000",
"description": "Report",
"row_id": 1810532,
"text": "NPN Addendum:\nDiscussed 5 brady's w/ for this shift. Fio2 remains in 25-35% range. No increased WOB. Is active and pink. Will con't to monitor status for S&S of infection, feeding intolerance, and increased resp distress.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-08 00:00:00.000",
"description": "Report",
"row_id": 1810533,
"text": "Neonatology NP Note\nPE\nnested in isolette\nAFOF\nmild subcostal/intercostal retractions on CPAP, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-08 00:00:00.000",
"description": "Report",
"row_id": 1810534,
"text": "NPN (1900-2300)\nRight hand puffy below entry site of PICC line. Seen by , , and thought to be due to decreased venous return when arm is completely flexed at the elbow. Infant positioned on left side with right arm extended and slightly elevated. Hand is pink and well perfused. There is already a visible improvement in swelling since 2100 when arm repositioned. Will continue to try to position infant to best optimize venous return of right arm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-09 00:00:00.000",
"description": "Report",
"row_id": 1810535,
"text": "Respiratory Care\nBaby continues on prong CPAP 6 with 02 req 33-> 21% this shift. BS clear. RR 30's-70's. No spells recorded as of this writing. On caffeine. Will cont CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-24 00:00:00.000",
"description": "Report",
"row_id": 1810626,
"text": "Nursing Progress Note\n\n\n#1 O: bubble cpap 5cms FiO2 21%; lungs clear/equal, color\n. RR 40's-70's w/mild baseline sc retractions. Caffeine\nas ordered, bradys x2 this shift w/ mild desats w/pg feeds.\nA: occ bradys P: maintain cpap for now.\n#2 O: TF 150cc/k/d BM30/PE30 w/PM; all feeds pg over\n1h30mins for spits. min asp and spit x1 today. abd round,\nsoft, active bowel sounds, stool x1 and vdg qdiaper.\nVit E/ferinsol as ordered. A: tol feeds P: present care.\n#4 O: mom called for update, will visit tonight.\n#5 O: temp stable on servo, heated isolette. sleepy w/cares.\nsettles easily.P: cont to assess and support developmentally\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-25 00:00:00.000",
"description": "Report",
"row_id": 1810627,
"text": "Nursing Progress Note:\n\n\n#1 Resp: O: Infant remains on NP CPAP of 5, 21% FiO2. O2\nsats w/in limits w/out drifting. LS cl/= bilaterally. Mild\nIC/SC retractions noted. Spells x2 tonight thus far\n(x5/24hrs). A: Infant breathing comfortably w/ resp.\nsupport. P: Continue to support infant's resp. needs.\n\n#2 FEN: O: Current weight = 1.590kg (+75g). Total fluids\nremain @ 150cc/kg/day; BM/PE 30 w/ pm. Q 4hr feedings, PG,\ngavaged over 1hr 20min. Minimal aspirates, no spits.\nInfant's abdomen is soft, +BS, no loops. Voiding, no stool.\nContinues on vit. E and iron. A: Tolerating feedings well.\nP: Continue to support infant's nutritional needs.\n\n#4 : O: Mom and Dad in for cares. are\nindependant w/ cares. Dad kangaroo' for about 1hr. A:\n seem loving, comfortable caring for infants. Asking\nappropriate questions. P: Continue to update, support and\nteach .\n\n#5 DEV: O: Infant remains nested on sheepskin in a servo\nisolette. Maintaining stable temps. Infant sleeps well\nbetween cares. Wakes w/ cares and remains A/A throughout.\nMAE. AFSF. Right nare breakdown noted. Duoderm replaced to\ninfant's nose. A: AGA. P: Continue to support infant's\ndevelopmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-25 00:00:00.000",
"description": "Report",
"row_id": 1810628,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on bubble CPAP 5 via Prongs FiO2 21%. Breath sounds are clear. Two brady spells so far tonight. Baby is on caffeine. RR 40-60's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-25 00:00:00.000",
"description": "Report",
"row_id": 1810629,
"text": "NeonatologyDoing well.\nRemains on RA. No spells. Comfortable apeparing.\n\nWt 1590 Tolerating feeds well. TF at1 50 cc/k/d of 30 cal.\nWill decrease to 28 cc/k/d. Monitor gorwth.\n\nHct 25.9 with retic 4.2 . Will rcehecek in one week.\n\nContinue a sat present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-25 00:00:00.000",
"description": "Report",
"row_id": 1810630,
"text": "NeonatologyDoing well.\nComfortable on exam. active. Skin w/o leisons. Good air movement on CPAP. Neuro non-focal and age appropriate.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-03 00:00:00.000",
"description": "Report",
"row_id": 1810499,
"text": "CLinical Nutrition\nO:\n27 wk gestational age BG, AGA, now on DOL 5.\nBirth wt: 1130 g (~50th %Ile); current wt: 975 g (+19)(down ~14% from birth wt)\nHC at birth: 26.5 cm (~50th %Ile)\nLN at birth: 37.5 cm (~50th %Ile)\nLabs noted\nNutrition: 160 cc/kg/day TF. Feeds started on DOL 3; currently @ 10 cc/kg/day BM 20; no plan for further advancement at this time. PN started on DOL 0 via DUVC; lipids added on DOL 2. Remainder of fluids as PN; projected intake for next 24hrs from PN ~82 kcal/kg/day, ~3.5 g pro/kg/day and ~3 g fat/kg/day. From EN: ~7 kcal/kg/day, ~0.1 g pro/kg/day and ~0.4 g fat/kg/day. GIR from PN ~7.9 mg/kg/min.\nGI: ABdomen benign. Infant w/ aspirates > volume of feed overnight, so feeds held, but now resumed. No stool x past 2 days, but has passed meconium.\n\nA/Goals:\nTolerating PN with good BS control now after some transient hyperglycemia yesterday to 162. Was not tolerating feeds yesterday w/ large aspirate; will retry trophic feeds today and monitor carefully for tolerance. Labs noted and PN adjusted accordingly. Initial goal for PN is ~90 to 110 kcal/kg/day, ~3 to 3.5 g pro/kg/day and ~3 g fat/kg/day. PN being advanced as per protocol and tolerance. When able to advance EN feeds, initial goal is ~150 cc/kg/day PE/BM 24, providing ~120 kcal/kg/day and ~3.2 to 3.6 g pro/kg/day. Expect PN to taper as EN feeds advance towards initial goal. Further increases in feeds as per growth and tolerance. Appropriate to add Fe and Vit E supps when feeds reach initial goal. Growth goals after initial diuresis are ~15 to 20 g/kg/day for wt gain, ~0.5 to 1 cm/wk for HC gain,and ~1 cm/wk for LN gain. Will follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-03 00:00:00.000",
"description": "Report",
"row_id": 1810500,
"text": "NICU nursing note\n\n\n1. Resp=O/Presently on prong CPAP of 6 (received in CPAP of\n5, ^'d r/t spells overnight.) FIO2 21%. No spells or\ndesats so far today. (Please refer to flowsheet for resp\nassessments.) Na Bicarb (2meg) given at 1130. A/alt in\nresp status. P/Cont to monitor for resp distress.\n\n2. FEN=O/TF increased to 160cc/k/d. Enteral feeds remain\nat 10cc/k/d of BM20. Remaining 150cc/k/d=PND10 with lipids\nvia patent/intact DLUVC. Abd benign. (Please refer to\nflowsheet for assessments.) No spits. U/o=2.1cc/k/hr for\n8hrs. No stool so far this shift. A/alt in FEN. P/Cont to\nmonitor FEN status. Feeding advancement on hold. Send\nlytes/bili am.\n\n4. =O/No contact with so far this shift.\n\n5. G&D=O/Temp stable nested on sheepskin on open warmer.\nAlert and active with cares. Sleeping well in between.\nMAE. Font S/F. A/alt in G&D. P/Cont to monitor and\nsupport G&D.\n\n6. Bili=O/Cont under mini neoblue. Next bili to be sent\n am. P/Cont with current Rx.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Report",
"row_id": 1810582,
"text": "Neonatology - Progress Note\n\nInfant is active with good tone. AFOF. She is , well perfused, no murmur auscultated. She is active with good tone. AFOF. She is , well perfused, no murmur auscultated. She is comfortable on CPAP, low fio2. Breath sounds clear and equal. She is tolerating enteral feeds, abd soft, active bowel sounds, voiding and stooling. Stable temp in isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-16 00:00:00.000",
"description": "Report",
"row_id": 1810583,
"text": "Respiratory Care\nPt cont on prong CPAP. fio2 .21, bs clear, rr 30-60. On caffeine. No spells noted. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-07 00:00:00.000",
"description": "Report",
"row_id": 1810523,
"text": "NPN\n\n\n#1 Resp: remains on prong CPAP +6 FiO2 25-28%. Sats 90-96%\nwith RR 40-60s. clear/=, mild IC/SC retractions. on\ncaffeine. 2 spells so far this shift. cont to closely\nmonitor.\n\n#2 FEN: infant remains on TF 160cc/kg/d. IV fluids PN/IL\n@100cc/kg via PICC. Enteral intake Br20 @60cc/kg NG Q4h.\nplan to increase feeds by 10cc/kg this afternoon.\ntolerating feeds, abd full, soft, +BS, voiding, stools heme\nnegative. cont to closely monitor and advance as tolerated.\n\n#4 : No parental contact so far this shift. \nplan to visit this afternoon.\n\n#5 Dev: infant remains nested in isolette with stable temps.\nactive, alert, AGA. cont to provide dev support.\n\n#6 Bili: PT restarted this afternoon. infant sl jaundiced,\nvoiding and stooling. plan to draw bili on . cont to\nclosely follow.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-07 00:00:00.000",
"description": "Report",
"row_id": 1810524,
"text": "Respiratory Therapy\nBaby remains on CPAP of 6, 0.25-0.28. RR 30-70. LS CTA. On caffeine with 3 spells so far. Plan to continue with CPAP as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-07 00:00:00.000",
"description": "Report",
"row_id": 1810525,
"text": "Neonatology NP Note\nPe\nnested in isolette\nAFOF, sutures approximated\nmild subcostal/intercostal retractions on CPAP, lungs clear/=\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\nPICC insertion with occlusive dressing, no erythema or edema at site\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-08 00:00:00.000",
"description": "Report",
"row_id": 1810526,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Nasal Prong CPAP 6 FiO2 25-29%. Suctioned nares for sm amt of cloudy secretions. Breath sounds are clear. One A & B so far tonight. Baby is on caffeine. Occasional sat drifts. RR 40-80's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-23 00:00:00.000",
"description": "Report",
"row_id": 1810618,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont in bubble prong CPAP of 5, FIO2 21%. No\nspells so far this shift. Cont on caffeine. (Please refer\nto flowsheet for resp assessments.) A/stable on CPAP.\nP/Cont to monitor for resp distress.\n\n2. FEN=O/TF cont at 150cc/k/d of BM/PE30PM gavaged over\n90min. Abd benign. (Please refer to flowsheet for\nassessments.) No spits. Voiding/stooling, heme (-). Cont\non vit E and iron. A/tolerating current regime. P/Cont to\nmonitor FEN status.\n\n4. =O/Mom called x1. Updated by this nurse. Will\nbe in to visit tomorrow. P/Cont to support and educate\n.\n\n5. G&D=O/Temp stable nested on sheepskin in servo isolette.\nAlert and active with cares. Sleeping well between feeds.\nMAE. Font S/F. A/alt in G&D. P/cont to monitor and\nsupport G&D.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-23 00:00:00.000",
"description": "Report",
"row_id": 1810619,
"text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. She is , well perfused, no murmur auscultated. She is comfortable on prong CPAP. Breath sounds clear and equal. She is tolerating enteral feeds. Abd soft, active bowel sounds, voiding and stooling. Stable temp in heated isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-23 00:00:00.000",
"description": "Report",
"row_id": 1810620,
"text": "Respiratory Care\nPt cont on prong CPAP. FIO2 .21, bs clear, rr 30-60. On caffeine. No spells noted thus far this shift. Plan to support as neeeded. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-24 00:00:00.000",
"description": "Report",
"row_id": 1810621,
"text": "Nursing Progress Note:\n\n\n#1 Resp: O: Infant remains on NP CPAP of 5, 21% FiO2. O2\nsats w/in limits. LS cl/= bilaterally. Mils IC/SC\nretractions noted. Infant continues on caffeine. Spell x1\ntonight thus far, at rest, requiring mild stim. A: Infant\nbreathing comfortably w/ resp. support. P: Continue to\nsupport infant's resp. needs.\n\n#2 FEN: O: Current weight = 1.515kg (+15g). Total fluids\nremain @ 150cc/kg/day; BM/PE 30 w/ pm. Q 4hr feedings,\ngavaged over 1hr 20min. Max aspirate = 2.6cc. No spits.\nInfant's abdomen is soft, +BS, no loops. Infant is voiding,\nstooling (neg. heme). Girth stable @ 23cm. Continues on vit.\nE and iron. A: Infant tolerating feedings well. P: Continue\nto support infant's nutritional needs.\n\n#4 : O: No contact from . P: Continue to\nupdate, support and teach .\n\n#5 DEV: O: Infant remains nested on sheepskin in a covered\nservo isolette. Maintaining stable temps. Infant sleeps well\nbetween cares. Wakes w/ cares and remains quietly A/A\nthroughout. MAE. AFSF. A: AGA. P: Continue to support\ninfant's developmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-24 00:00:00.000",
"description": "Report",
"row_id": 1810622,
"text": "Respiratory Care\nBaby continues on prong CPAP 5, 21%. BS clear. RR 30's-50's with baseline retractions. 2 mild stim A's&B's as of this writing. On caffeine. Will cont CPAP, monitor closely.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-24 00:00:00.000",
"description": "Report",
"row_id": 1810623,
"text": "Neoantology\nDOing well. REmains ion CPAP. Comfortable appeairng. Intermittent\nWill continue on CPAP.\n\nWt 1515 up 15. Abdomen benign. Tolerating feeds at 150 cc/k/d.\n\nHUS for Monday.\n\nHct and retic to be chcekd.\n\nContinue a sat present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-24 00:00:00.000",
"description": "Report",
"row_id": 1810624,
"text": "Respiratory Care\nPt cont on prong CPAP. Fio2 .21, bs clear, rr 40-50. On caffeine. 2 spells noted this shift. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-08 00:00:00.000",
"description": "Report",
"row_id": 1810699,
"text": "Clinical Nutrition\nO:\n~33 wk CGA BG on DOL 38.\nWT: 1815 g (+10)(~25th to 50th %Ile); birth wt: 1130 g. Average wt gain over past wk ~7 g/kg/day.\nHC: 28.5 cm (~10th %Ile);last: 28 cm\nLN: 42.5 cm (~25th %Ile); last: 42 cm\n noted\nNutrition: 140 cc/kg/day TF. NPO for NEC, day 8 of 14. PN infusing via non central PICC line; projected intake for next 24hrs from PN ~88 kcal/kg/day, ~3.5 g pro/kg/day and ~2.9 g fat/kg/day. GIR from PN ~9.2 mg/kg/min.\nGI: Abdomen benign.\n\nA/Goals:\nTolerating PN with good BS control. noted and PN adjusted accordingly. Remains NPO for NEC. Current PN meeting recs for pro/fat and vits. NOt meeting recs for kcals of ~90 to 110 kcal/kg/day or minerals due to limitations of non central IV access. Optimizing nutrition as much as possible given IV access. Growth is meeting recs for HC gain. WT gain and LN gain are not meeting recommended ~15 to 20 g/kg/day for wt gain and ~1 cm/wk for LN gain. Overall trends on both HC and LN growth charts over past 4 wks are acceptable, however; will follow long term trends. Will continue to follow w/ team and participate in nutrition plans.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-08 00:00:00.000",
"description": "Report",
"row_id": 1810700,
"text": "NPN 0700-1900\n\n\n#1Resp: Pt. remains on NCO2 400cc/min, FiO2 21%. RR\n30-50's, sats > 94%. Pt. had one spell d/t apnea w/ QSR.\nPt. continues on caffeine. Lungs clear & equal w/ mild SCR.\nP: cont to monitor resp status.\n\n#2FEN: Pt. remains NPO on TF 140cc/kg/d of PND11/IL\ninfusing well through PIV. R PICC line in arm noted to be\nred & puffy. in to assess & decision made to d/c this\nam. PICC line site remains puffy & red. Abd soft & full,\n+BS, no loops. AG stable. UOP= 3.5cc/kg/hr for 12hrs. No\nstool so far this shift. P: cont to monitor FEN.\n\n#4Parents: Mom called X 2 asking approp questions. Updates\ngiven. P: cont to support & update.\n\n#5DEV: Temp borderline at 3pm cares swaddled in OAC,\ncobedding. Warming lights placed & pt. quickly warmed to\n98.1. Pt. alert & active w/ cares. Settles well in between\nw/ pacifier. MAE. AFSF. Eye exam done this afternoon.\nEyes immature, zone 2 bilaterally w/ f/u in 2wks. P: cont\nto support dev needs.\n\n#7Sepsis: Pt. continues on zosyn, now day 8 of 14. Abx\ngiven as ordered. P: Cont to monitor.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-08 00:00:00.000",
"description": "Report",
"row_id": 1810701,
"text": "NPN 0700-1900\nAddendum to above note:\nR arm PICC site remains reddened & firm when palpated. Oxacillan ordered . Blood cultures sent as well. Also, abdomen appeared distended & slightly firm at 1800. OGT placed & removed 50cc of air. Abd appeared distended but less firm after air removal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-17 00:00:00.000",
"description": "Report",
"row_id": 1810584,
"text": "NPN 1900-0700\n\n\nRESP: Remains in prong CPAP 5, 21%. LS clear/=, mild IC/SC\nretractions. Continues on caffeine, no spells thus far this\nshift.\n\nFEN: Tolerating full enteral feeds well, no spits, minimal\naspirates. Abdomen soft/round, good bs, girth stable,\nvoiding, no stool thus far. Continues on vitamin E & Iron.\n\n: No contact thus far this shift.\n\nG/D: Temp stable nested in sheepskin in servo isolette. A&A\nw/cares, sleeps well in between. Likes to sleep on her\nbelly.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-17 00:00:00.000",
"description": "Report",
"row_id": 1810585,
"text": "Respiratory care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21%. BS clear. On Caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-17 00:00:00.000",
"description": "Report",
"row_id": 1810586,
"text": "Neonatology\nRemains on CPAP. Comfortable appearing. Spells not problem\n dcerease caffeine dose slightly given relative tachycardia.\n\nWt 1275 unchanged. Tolerating efeds at 150 cc/k/d of 26 cal.A bdomen benign. All gavage. WIll increase to 28 cal.\n\nContinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-17 00:00:00.000",
"description": "Report",
"row_id": 1810587,
"text": " PHysical Exam\nPE: , AFOF, nasal prong CPAP in place, nasal septum intact, old bloody secretions from left nare, breath sounds clear/equal with mild retracting, soft murmur best heard on back, abd soft, full, + bowel sounds, active with age appropriate tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-17 00:00:00.000",
"description": "Report",
"row_id": 1810588,
"text": "NPN 0700-1900\n\n\nResp: Remains on prong CPAP 5cm. FiO2 remains 21%. RR=40-60.\nO2 sats>93%. IC/SC retractions, No incr. WOB. Lungs clear\nbilaterally. Remains on caffeine, dose decreased this shift.\nNo A's or B's >24hrs. P: Continue to monitor resp status.\n\nFEN: TF=150cc/kg/day BM/PE 28w/promod (cals incr. today) =\n32cc Q4hrs. PG fed over 90 min. for hx of spits. No spits.\nMAx aspirate= 1cc benign/refed. Abdomen exam benign. Active\nBS. AG 22-23cm. Remains on Vitamin E and Iron. P: continue\nto monitor and support nutritional needs of infant.\n\nDEV: Remains nested on sheepskin in servo mode isolette. HOB\nelevated slightly. Repositioned Q4hrs. Temp stable. A&A w/\nher cares and sleeps well bwtn when prone w/ firm boundaries\nBrings hands to face to comfort herself and able to suck on\npacifier when offered. AFSF. MAE equally. F/U HUS to be done\nat 30 days for unchanged small cyst. P: Continue to promote\noptimal G&D and monitor for DEV milestones.\n\n: No contact from this shift. P: Continue to\nupdate and support NICU family.\n\nsee flowsheet for further details.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-17 00:00:00.000",
"description": "Report",
"row_id": 1810589,
"text": "Respiratory Care\nPt received on nasal prong CPAP +5cm's with the fio2 21%. Pt's resp rates 50's to 60's, on caffine. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-16 00:00:00.000",
"description": "Report",
"row_id": 1810731,
"text": "NPN 1900-0700\n\n\n1. RESP: Pt remains in RA with RR 30-60's and sats >96%.\nLung sounds are clear. Mild baseline retractions noted.\nOne spell noted so far this shift. She is on caffeine.\n\n2. F&N: TF remain at 140cc/k/d. Feeds are at 20cc/k/d of\nBM20. IVF PND15 with IL infusing well via central PICC.\nAbd benign. BS+. A/G stable. No spits noted. Max asp was\n1.4cc of nonbilious, partially digested breast milk. U/O\n3.7cc/k/h. No stool noted so far this shift. Weight gain\n15 grams.\n\n4. PAR: No contact from so far this shift.\n\n5. DEV: is active and during her cares. Temp\nstable swaddled in open crib, cobedding with her twin\nbrother. She puts her hands to her face and sucks on her\npacifier.\n\n7. : Abx have been d/c'ed and infant has no S&S of\nsepsis. Will D/C problem.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-16 00:00:00.000",
"description": "Report",
"row_id": 1810732,
"text": "Neonatology\nDOL #46, CGA 34 wks.\n\nCVR: Remains in RA, clear and equal. One spell in 24 hrs, on caffeine. Hemodynamically stable, soft murmur.\n\nFEN: Wt 2155, up 15. TF 140 cc/kg/day, enteral feeds at 20 cc/kg/day, rest PN via central PICC. Tolerating trophic feeds thus far. Voiding/.\n\nDEV: In open crib.\n\nIMP: Former 27 wk twin with hx RDS, NEC, doing well. Stable in RA. Minimal apnea of prematurity. Tolerating trophic feeds.\n\nPLANS:\n- Monitor resp status.\n- D/C caffeine.\n- Advance enteral feeds, monitor tolerance.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-16 00:00:00.000",
"description": "Report",
"row_id": 1810733,
"text": " Physical Exam\nAsleep. AFOF with good tone. Breath sounds clear and equal on room air with slight retractions. No audible murmur, well perfused with normal pulses. Abdomen soft and rounded with active BS, no HSM or masses.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-16 00:00:00.000",
"description": "Report",
"row_id": 1810734,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont in room air. No spells or desats this\nshift. Caffeine d/c'd today. (Please refer to flowsheet\nfor resp assessments.) A/stable in room air. P/Cont to\nmonitor for resp distress.\n\n2. FEN=O/TF cont at 140cc/k/d. Enteral feeds presently at\n35cc/k/d of BM20. Remaining 105cc/k/d=PND15 with lipids via\npatent/intact PICC. Abd benign. (Please refer to flowsheet\nfor assessments.) No spits. Voiding. No stool this shift.\nA/advancing on feeds. P/Cont to monitor FEN status. Cont\nto advance enteral feeds by 15cc/k/d as tol.\n\n4. =O/Mom called x1. Updated by this nurse. Will\nvisit tomorrow. P/Cont to support and educate .\n\n5. G&D=O/Temp stable swaddled cobedding in open crib.\n and active with cares. Sleeping well between feeds.\nMAE. Font S/F. A/alt in G&D. P/Cont to monitor and\nsupport G&D.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-08 00:00:00.000",
"description": "Report",
"row_id": 1810527,
"text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS ON PRONG CPAP OF 6 IN 25-30% FI02 TONIGHT. 2 A&B'S SO FAR TONIGHT AND OCCAS. QUICK DESATS NOTED. BS CL&= MILD RETRACTIONS AND NO INCREASE IN WORK OF BREATHING. SX'D X1. COLOR PINK/JAUNDICE AND WELL PERFUSED. NO AUDIBLE MURMER. BP 66/32-45.\n\nFEN: WEIGHT UP 45GMS TO 1120GMS TONIGHT. TOTAL FLUIDS MAINTAINED AT 160CC/KG/D. D-STICK 113. PN10% & IL INFUSING VIA PICC AT 80CC/KG/D. ENTERAL FEEDS ADVANCED TO 80CC/KG/D OF BM20CAL. ABD SOFT, PALE & FULL WITH STABLE GIRTH AMD +BS. HEME - STOOL X2. NO EMESIS AND 5CC MAX RESIDUAL OF PARTIALLY DIGESTED BM. VOIDING 3.2CC/KG/HR.\n\nSOCIAL: NO CONTACT WITH FAMILY TONIGHT.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-08 00:00:00.000",
"description": "Report",
"row_id": 1810528,
"text": "Neonatology Attending\nNow day of life 10 CA 2/7 weeks.\n\nOn CPAP of 6 and in 25-30% FIO2\nRR 40-80s\nOn caffeine, 5 episodes of apnea/bradycardia in the past 24 hours.\nHR 150-170s BP 52/22 33\n\nWt. 1120 up 45gm on 160ml/kg/d of TF - enteral feedings up to 80ml/kg/d\nFeedings well tolerated thus far.\nNormal urine and stool output.\nDS 113\n\nBili - 5.7 on phototherapy\n\nAssessment/plan:\nBaby continues to do very nicely overall.\nWill continue with current management with slow advancement of feedings as tolerated.\nFU HUS this week.\nFU bili tomorrow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-22 00:00:00.000",
"description": "Report",
"row_id": 1810611,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on bubble CPAP 5 via prongs FiO2 21%. Breath sounds are clear. One brady so far tonight. Baby is on caffeine. RR 40-50's. Stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-22 00:00:00.000",
"description": "Report",
"row_id": 1810612,
"text": "Neonatology\nDoign well. REamins on CPAP after trial in cannula earlier inw eekend.\nWill plan to leave on for rest of week. Intermittent spells.\n\nWt 1470 up 50. Tolerating feeds at 150 cc/k/d of 30 cal.A bdomen benign.\n\nTemp stable\n\nCOntinue as at present.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-22 00:00:00.000",
"description": "Report",
"row_id": 1810613,
"text": "Neonatology NP Note\nPE\nswaddled in isolette\nAFOF, sutures approximated\nmild subcostal/intercostal retractions on CPAP, lungs clear/=\nRRR, no murmur, and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-22 00:00:00.000",
"description": "Report",
"row_id": 1810614,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont in bubble prong CPAP of 5, FIO2 21%. No\nspells so far this shift. (Refer to flowsheet for resp\nassessments.) A/stable on CPAP. P/Cont to monitor for resp\ndistress.\n\n2. FEN=O/TF cont at 150cc/k/d of BM/PE30PM gavaged over 90\nmin. Abd full but benign. (Please refer to flowsheet for\nassessments.) Sm spit x1. Voiding/trace stool. Cont on\nvit E and iron. A/tolerating current regime. P/Cont to\nmonitor FEN status.\n\n4. =O/Mom called x1. Updated by this nurse. Will\nbe in to visit later today. P/Cont to support and educate\n.\n\n5. G&D=O/Temp stable nested on sheepskin in servo isolette.\nAlert and active with cares. Sleeping well between feeds.\nMAE. Font S/F. A/alt in g&d. P/Cont to monitor and\nsupport G&D.\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-07 00:00:00.000",
"description": "Report",
"row_id": 1810694,
"text": " On-Call\nPlease see Dr. note for overall summary and plan.\n\nPhysical Exam\nGeneral: infant in isolette, on nasal cannula O2; P-CVL intact right arm with old blood under dressing\nSkin: warm and dry; color ; hemangioma on right forearm; right arm with firm area near P-CVL insertion site, ? old venupuncture site; no erythema\nHEENT: anterior fontanel open, level; sutures opposed; bilateral peri-orbital edema\nChest: breath sounds clear/=, well-aerated; mild intercostal retractions\nCV: soft; systolic murmur left sternal border; normal S1 S2; pulses +2\nAbd: distended, non-tender; no bowel loops visible/palpable; no masses; active bowel sounds; + flaatus; umbilicus healed\nGU; normal female\nExt: moving all\nNeuro: appropriate tone and reflexes\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-07 00:00:00.000",
"description": "Report",
"row_id": 1810695,
"text": "Respiratory Care Note\nInfant received on NCPAP +6, 21% - BS clear, x1 spell - taken off CPAP ~1230 - placed in 400cc NC - on caffeine, continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-08 00:00:00.000",
"description": "Report",
"row_id": 1810696,
"text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS OFF PRONG CPAP SINCE 1300 YESTERDAY. TOLERATING 400CC FLOW OF 21% FI02 VIA NASAL CANNULA. BS CL&= WITH MILD RETRACTIONS AND NO INCREASE IN WORK OF BREATHING OVER NIGHT. NO A&B'S AND ONLY OCCAS QUICK DESAT NOTED. REMAINS ON CAFFEINE. COLOR AND WELL PERFUSED. BP 58/25-37.\n\nID: DAY OF ZOCYN. ACTIVE AND ALERT WITH INTERVENTIONS. TEMP STABLE CO-BEDDING IN OPEN CRIB.\n\nFEN: WEIGHT UP 10GMS TO 1815GMS TONIGHT. REMAINS NPO. TOTAL FLUIDS OF PN11% & IL INFUSING AT 140CC/KG/D. LYTES/TRIGLYCERIDES PNDING THIS AM. VOIDING 2.5CC/KG/HR. NO STOOL. ABD SOFT, FULL WITH STABLE GIRTH AND +BS. PASSING GAS.\n\nSOCIAL: IN LAST NIGHT AND THRILLED WITH PROGRESS OF THEIR TWINS. INDEPENDENT WITH CARES. HELD INFANT FOR > 1 HOUR AND TOOK MANY PHOTOS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-08 00:00:00.000",
"description": "Report",
"row_id": 1810697,
"text": "Neonatology\nDOing well. On NCO2 since yesterday and is tolerating well. No spells.\n\nWt 1815 up 10. NPO for 14 day course. Abdomen benign. PN content to be titrated\n\nCo-bedding with stable temp.\n\nEye exam for today.\n\nOn abx for 14 day course. Rotavirus to be sent.\n\nCOntinue a sat present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-08 00:00:00.000",
"description": "Report",
"row_id": 1810698,
"text": "Neonatology NP Note\nPE\nswaddled in open crib, cobedding with twin\nAFOF, sagital sutures slighlty split\nmild subcostal retractions in NCO2, lungs clear/= with good air entry\nRRR, no murmur, and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nactive with good tone\nPICC insertion site and above to shoulder with erythema and ropey feeling of vein-> line removed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-02 00:00:00.000",
"description": "Report",
"row_id": 1810663,
"text": "NICU nursing note\n\n\n1.Resp= O/ Cont on bubble CPAP of 6, FiO2 21%. No bradys or\ndesats. (please see flowsheet for details of assessments.)\nCont on Caffeine. A/ Stable on CPAP. P/ Cont to monitor for\nresp distress.\n\n2. FEN=O/ Currently on TF=140cc/kg/d of PND10 via Rhand PIV.\nRemains NPO. Abd soft, no loops. + BS. AG stable. Voiding,\nno stools so far this shift. No spits. to LCS with\n1cc clear drainage. (please see flowsheet for details of\nassessments.) A/ NPO r/t NEC. P/ Cont to monitor FEN status.\nPlease obtain stool sample for enterovirus and rotovirus\nwith next stool.\n\n4 = O/ Mom called x2, updated by this RN. P/ Cont to\nsupport and educate.\n\n5 G&D= O/ Temp stable nested in servo isolette. alert and\nactive, sleeping between cares. MAE. AFOF. A/ALt in G&D. P/\nCont to support G&D.\n\n7.Sepsis= O/ Remains on contact precautions. Cont on Zosyn\nand Clindamycin, now day 2 of 14. P/ Cont to monitor for\ns/sx infection.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-02 00:00:00.000",
"description": "Report",
"row_id": 1810664,
"text": "Respiratory Care Note\nBaby Girl remains on +6 prong CPAP, FiO2 .21 this shift. BS clear. RR 30-60's. On caffeine. No bradys noted today as of this writing.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-03 00:00:00.000",
"description": "Report",
"row_id": 1810665,
"text": "NPN 7p-7a\n\n\nRESP: Infant remains on bubble prong CPAP of 6; FiO2 21%.\nLS cl/= with IC/SC retxns. RR 20-50's. Sats 96-99%. On\ncaffeine. No spells this shift. Infant stable on CPAP;\nbreathing comfortably. Continue to support resp. needs and\nmonitor for spells.\n\nFEN: CW 1750; up 10g. Infant remains NPO. TF 140cc/k/d of\nPND10 @ 9cc/hr and IL @ 1.1cc/hr infusing via PIV in R.\nfoot; without incident. PICC line for today. Abd. soft,\nactive BS, no loops. Girth 24.5-25cm. Repogle to cont LWS;\ndraining clear fluid. KUB done tonight - improving; no\npneumotosis or free air. 24hr UO = 3.5cc/k/hr; no stool.\nInfant gaining weight, KUB improving. Plan to send stool\nfor rotovirus and enterovirus.\n\n: No contact from . Continue to support and\nupdate as needed.\n\nDEV: Infant nested on sheepskin in servo isolette. Temps\nstable. Alert and active with cares. MAE. Sucks on\npacifier. Waking occ. in between cares. Continue to\nsupport growth and development.\n\nSEPSIS: Infant continues on day of zosyn and\nclindamycin Q8hrs. Infant showing no overt s/s of\ninfection. Continue with antibiotics and monitor for\nsepsis.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-03 00:00:00.000",
"description": "Report",
"row_id": 1810666,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on bubble CPAP 6 FiO2 21%. Breath sounds are clear. No spells so far tonight. Baby is on caffeine. RR 20-50's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-03 00:00:00.000",
"description": "Report",
"row_id": 1810667,
"text": " Physical Exam\nPE: , puffy face and eyes, AFOF, nasal prong CPAP in place, nares intact, breath sounds clear/equal with mild retracting, no murmlur, abdf soft, non distended, non tender, active bowel sounds, active with good tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-03 00:00:00.000",
"description": "Report",
"row_id": 1810668,
"text": "Neonatology\nDoing well. Remains on CPAP. Low Fio2. Comfortable apeparing.\nSpells not problemtic.\n\nWt 1750 up 10. NPO for 14 day course. PN continues via PIV.\nWill place oin gravity.\n\nDay of ZOsyn/Clinda. PICVC to be attempted this afternoon.\nKUB Ok this am.\n\nCOntinue as at present.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-05 00:00:00.000",
"description": "Report",
"row_id": 1810513,
"text": "NICU Nursing Progress Note\n\nRemains in Prong CPAP 6cms in room air. Breath sounds,r esp\nrate, and WOB are at baseline. 4 spells noted today. Remains\non caffeine.\nPhototherapy d/c'd at 1400. Will check bili in am.\nAdvancing enteral feeds by 10cc/kg . At present infant is\nreceiving 30cc/kg/day BM by gavage. Abd exam benign. Voiding\nand passing green stool. DUVC d/c'd at 1900 by .\nPICC line pulled back 1 cm by and Chest Xray\nobtained. PN and IL infusing via non-central PICC.\nInfant remains in servo isolette with stable temp. Active\nand alert with cares. HUS done today revealing a small cyst\nnear ventricle. Will repeat HUS in 1 wk. Dr. spoke\nwith to update them. Mom kangaroo'd infant for 45\nmins and infant returned to for spells. \nplan to visit again tomorrow and Sunday.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-06 00:00:00.000",
"description": "Report",
"row_id": 1810514,
"text": "RESPIRATORY CARE NOTE\nBaby #2 remains on Prong CPAP 6 FiO2 21%. Suctioned nares for sm amt of white secretions. Breath sounds are clear. Two bradys so far tonight. Baby is on caffeine. RR 30-50's stable on CPAP cont to follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-06 00:00:00.000",
"description": "Report",
"row_id": 1810515,
"text": "NPN 1900-0700\n\n\n1. Resp: Infant remains on prong CPAP 6 in 21% fiO2. O2\nsats = 96-97%. RR=30-40's. Mild SCR/ICR. LS clear. Has\nhad 2 spells thus far tonight. (6 in past 24hrs). See\nflowsheet for details. On caffeine.\n\n2. FEN: WT=1040gms (up 15gms). TF=160cc/k/day. Currently\nreceiving enteral feeds of BM20 at 30cc/k/day. IVF is PN\nD10 and IL infusing via PICC at 130cc/k/day. Max asp =\n1.8cc partially digested bm. No spits. Abd girth =\n18-19cm. U/O for past 12hrs is 2.7cc/k/hr. Passed 1 trace\ngreen stool. Abd is soft and round with active bs and no\nloops.\n\n3. : No contact tonight.\n\n4. G&D: is alert and active with cares. Sleeps well\nbetween cares. Uses pacifier to comfort self. Temps stable\nnested in sheepskin in servo mode isolette. AFSF. AGA.\n\n5. Hyperbili: Phototx d/c'd yesterday at 1400. Will check\nrebound in am.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-06 00:00:00.000",
"description": "Report",
"row_id": 1810516,
"text": " PHysical Exam\nPE: pinkk jaundiced, AFOF, CPAP prongs in place, nares intact, breath sounds clear/equal with mild intercostal retracting, fair air entry, no murmur, normal pulses and perfusion, abd soft, full, intermittent soft bowel sounds, active with age appropriate tone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-06 00:00:00.000",
"description": "Report",
"row_id": 1810517,
"text": "Neo Attending\nDay 8 now 29 wk\nRespr CPAP 6 cm, FiO2 21%, on caffeine. rr 30-50s.\nsm secretions. 7 spells (apnea)/ 24 hrs. on caffeine. half self-resolved/ others mild stimulation.\nCV: no murmur. 150-170s. BP 51/25, mean 35\nOff photoRx. Bili 3.4 on photoRx. 4.4/0.5 rebound.\nwt 1040, up 15 gm\n160 cc/kg/day\nPIQ pn/il. bm 20 cc/kg/day advancing 10 cc/kg .\nuop and stool wnl. glu screen wnl.\nabd wnl\nlytes: 133, 6.2 (hemolyzed).\nisolette temp stable.\nHUS: small cyst L ventricle. follow.\nrepeat state screen.\n\nInfant not ready to wean from CPAP.\nContinue with current regimen, increase feeds.\nMonitor CVR.\nbili repeat in a.m.\nSocial servoce involved.\n\nPt evaluated and discussed with team.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-06 00:00:00.000",
"description": "Report",
"row_id": 1810518,
"text": "NPN\n\n\n#1 Resp: infant remains on prong CPAP +6 RA. RR 30-60s with\nSats 94-100%. BBS clear/=, mild SC/IC retractions. on\ncaffeine. 2 spells so far this shift. cont to closely\nmonitor.\n\n#2 FEN: infant remains on TF 160cc/kg/d. PN/IL@120cc/kg via\nPICC. Enteral feeds Br20 @40cc/kg NG. plan to advance\nenteral feeds by 10cc/kg at 1600. tolerating feeds, abd\nfull, soft, +BS. voiding, stool X2 heme negative. no spits.\ncont to closely monitor.\n\n#4 : No parental contact so far this shift, \nplan to visit at some point today.\n\n#5 Dev: infant remains nested in servo isolette. active,\nalert, irritable at times. cont to provide dev support.\n\n#6 Bili: remains OFF PT. infant sl jaundiced, plan to draw\nBili in AM. cont to closely follow.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-23 00:00:00.000",
"description": "Report",
"row_id": 1810615,
"text": "NPN 7p-7a\n\n\nRESP: Infant remains on bubble CPAP of 5; FiO2 21% (27%\nwhen being held). LS cl/= with IC/SC retxns. RR 30-50's.\nOn caffeine. Spell x1; HR 62, 78% - requiring mod. stim and\nincrease in O2. Infant stable on CPAP of 5. Continue to\nprovide respiratory support and monitor for A's and B's.\n\nFEN: CW 1500 (up 30g). TF 150cc/k/d of BM/PE30 with promod\n= 38cc Q4hrs; gavaged over 1hr30min. Abd. full, soft,\nactive bs, no loops. Girth 24cm. Spit x1. Max aspirate\n3.1cc; benign and refed. Voiding, trace stool x1. On Vit\nE, Fe. Infant tolerating feeds and gaining weight.\nContinue to monitor for feeding intolerance.\n\n: Mom and dad in @ . Mom took temp and changed\ndiaper. Held infant. Both asking appropriate questions;\nupdated by this RN. Loving and involved. Continue to\nsupport and update as needed.\n\nDEV: Infant nested on sheepskin in servo isolette; weaned\nx1 for temp of 99.6ax. Alert and active with cares. More\nfeisty than her brother. Sucks on pacifier. MAE. Resting\nwell in between cares. Continue to support growth and\ndevelopment.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-23 00:00:00.000",
"description": "Report",
"row_id": 1810616,
"text": "Respiratory Care Note\nPt. continues on 5cmH2O of nasal prong CPAP and 21%. BS clear. On Caffeine. To follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-23 00:00:00.000",
"description": "Report",
"row_id": 1810617,
"text": "Neonatology\nDoign well. On CPAP. Intermitettn spells Comfortable appearing.\n\nWt 1500 up 30 TF at 150 of 30 cal. Abdomen bengin.\nAll agavge.\n\nTemp stable.\n\nContinue a sat present\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-06 00:00:00.000",
"description": "Report",
"row_id": 1810689,
"text": "Neonatology NP Note\nPE\nswaddled in isolette\nAFOF, sagital sutures split\nmild subcostal retractions on CPAP, decreased air entry when CPAP removed briefly during exam, lungs clear/=\nRRR, l/Vl SEM at LUSb, and well perfused\nabdomen soft, nontender and nondistended, active bowel sounds\nPICC insertion site with occlusive dressing, no erythema or edema\nactive with good tone\n1 cm x 0.5 cm erythematous area on right forearm, blanches, not indurated ? evolving hemangioma\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-07 00:00:00.000",
"description": "Report",
"row_id": 1810690,
"text": "Respiratory Care\nBaby 3 2 remains on cpap 6 21%.RR 20-50's.BS clear throughout.No spells documented thus far this shift,on caffeine.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-07 00:00:00.000",
"description": "Report",
"row_id": 1810691,
"text": "NURSING PROGRESS NOTE\n\nRESP/CV: REMAINS ON PRONG CPAP OF 6 IN RA ALL NIGHT. BS CL&= WITH MINIMAL WORK OF BREATHING AND NO A&B'S OR DESATS. REMAINS ON CAFFEINE AS ORDERED. COLOR AND WELL PERFUSED. BP WNL. SOFT MURMER AUDIBLE.\n\nID: REMAINS ON IV ANTIBIOTICS AS ORDERED, DAY . TEMP STABLE IN OFF ISOLETTE. ACTIVE AND ALERT WITH INTERVENTIONS.\n\nFEN: WEIGHT UP 20GMS TO 1805GMS TONIGHT. TOTAL FLUIDS MAINTAINED AT 140CC/KG/D OF PN10% & IL. REMAINS NPO. ABD SOFT ROUND AND WITH NO LOOPS AND STABLE GIRTH. HYPOACTIVE BS NOTED. NO STOOL. URINE OUTPUT 3.1CC/KG/HR.\n\nSOCIAL: NO CONTACT WITH FAMILY TONIGHT. PLAN TO VISIT TODAY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-05 00:00:00.000",
"description": "Report",
"row_id": 1810512,
"text": "Neonatology NP Note\nPE\nnested on radiant warmer\nAFOF\nmild subcostal/intercostal retractions on CPAP, lungs clear/= but diminished at at bases\nRRR, no murmur, pink and well perfused\nabdomen soft, nontender and nondistended active bowel sounds\nactive with good tone\n\nPICC line across midline at level of clavicle, pulled back 1 cm so that 5 cm markers outside of skin, line secured with occlusive dressing no erythema or edema at site, repeat chest xray shows tip of catheter at midline at level of clavicle\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-19 00:00:00.000",
"description": "Report",
"row_id": 1810597,
"text": "Neonatology\nDoing well. Remains in NCo2. Intermittent spells. Comfortable apeparing.\nNo spells today so far. Caffeine being held for tachycardia.\n\nWt 1350 up 15. Toleratign efeds at 150 cc/k/d of 30 cal>A bdomen benign.\n\nCOntinue a sat present. Will monitor for need to return to CPAp.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-19 00:00:00.000",
"description": "Report",
"row_id": 1810598,
"text": "NICU nursing note\n\n\n1. Resp=O/Cont in NCO2 FIO2 100% 25cc/min flow. Spell x1\nso far today. Caffeine cont on hold per team order.\n(Please refer to flowsheet for resp assessments.) A/stable\nin NCO2. P/Cont to monitor for resp distress and/or ^# of\nspells.\n\n2. FEN=O/TF cont at 150cc/k/d of BM/PE30PM gavaged over\n1hr45min. Abd benign. (Please refer to flowsheet for\nassessments.) Spit x1. Voiding. No stool so far this\nshift. Cont on vit E and iron. a/tolerating current\nregime. P/Cont to monitor FEN status.\n\n4. =O/Mom called x1. Updated by this nurse. P/Cont\nto support and educate .\n\n5. G&D=O/Temp stable swaddled in air isolette. Alert and\nactive with cares. Sleeping well between feeds. MAE. Font\nS/F. A/alt in G&D. P/Cont to monitor and support G&D.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-19 00:00:00.000",
"description": "Report",
"row_id": 1810599,
"text": "NP NOTE\nPE: small grwoing preterm infant neslted in isolette, pale , well perfused on nasal canula.\n AFOF sutures approximated, eyes clear, ng in place, MMMP\nChest is symmetric with fair exchange, equal bs\nCV: RRR, no murmur, pulses+2=\nAbd: soft, full with active bs\nGU: immature female\nETX: , \nNeuro: active with good tone.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-20 00:00:00.000",
"description": "Report",
"row_id": 1810600,
"text": "Nursing Progress Note\n\n\n#1. O: Infant remains on NC O2 in 100% 25cc's. RR 30's-60's.\nBreath sounds are clear and equal. Mild IC/SC retractions\nnoted. Infant has had 2 spells thus far tonight (=5x24hrs)\nA: Stable in NC P: Continue to monitor resp status.\n\n#2. O: Infant remains on TF's of 150cc/k/d of PE30PM. PG fed\nover 1hr 45min. No spits. Minimal aspirates. AG stable. Abd\nsoft and round with active bowel sounds. No loops. Voiding\nqs. No stools thus far tonight. Wgt is up 40gms tonight to\n1390gms. A: Tolerating feeds. P: Continue to monitor feeding\ntolerance.\n\n#4. No contact thus far from .\n\n#5. O: Received infant dressed and swaddled in air isolette.\nTemp 99.8 despite weening on days. Infant placed back on\nservo control with good results. Alert and active with\ncares. MAEW. A: AGA. P: Continue to assess and support\ndevelopmental needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-20 00:00:00.000",
"description": "Report",
"row_id": 1810601,
"text": "Neonatology Attending Note\nDOL# 22, CGA 31 wk\n\nOn NC 13-25 cc\nRR 30-60s\nMild retractions\n5 spells in 24 hrs\nOn caffeine, but doses held for tachycardia\n\nP 160-170s\nMBP 43\n\nWt 1390 (up 40 gm)\nTF 150 cc/kg PE30+PM\nFrequent spits\n\nVoiding and stooling\nOn Vit E and Fe\n\nIn isolette\n\nA/P:\nRESP: Continue on NC, wean as tolerated. Monitor spells. Restart caffeine.\nCV: Stable BPs\nFEN: Continue current nutritional regimen\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-18 00:00:00.000",
"description": "Report",
"row_id": 1810739,
"text": "1900-0700 NPN\n\n\n#1RESPIRATORY\nO:REMAINS IN RA WITH SATS >95%. BS CLEAR. RESP RATE 44-70\nWIHT MILD SC RETRACTIONS. NO SPELLS THUS FAR\nA:STABLE\nP:CONTINUE TO MONITOR RESP STATUS\n\n#2F/E/N\nO:TF AT 140CC/KG. BABY ADVANCED TO 80CC/KG ENTERALLY BM 29CC\nQ4HR PO/PG AND IVF D15PN AND IL AT 60CC/KG. BABY BOTTLING\n20-23CC OVERNIGHT, REMAINDERS GAVAGE. ABDOMEN SOFT, FULLW\nITH GOOD BS. NO SPITS AND 0.4-7CC NONBILIOUS ASPIRATES. AG\n26.5-27CM. WT UP 40 GM. MILD GENERALIZED PUFFINESS\nA:TOLERATING FEEDS WELL\nP:CONTINUE TO MONITOR TOLERANCE TO FEEDS, ADVANCE 15CC/KG\n AS TOLERATED\n\n#4PARENTING\nSEE SIBLINGS CHART\n\n#5G&D\nO:IN OAC WITH STABLE TEMPERATURE, WITH SISTER.\nACTIVE/MAE WITH CARES; SLEEPING WELL BETWEEN. FONTANEL SOFT\nAND FLAT; SUTURES SMOOTH. BOTTLINGS SLOW BUT WELL\nCOORDINATED.\nA:AGA, LEARNING TO PO\nP:CONTINUE TO SUPPORT AND MONITOR\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-18 00:00:00.000",
"description": "Report",
"row_id": 1810740,
"text": "Neonatology\nDOL #48, CGA 34 wks.\n\nCVR: Remains in RA, RR 40-70s, O2sats > 97%. Overall comfortable, mild intermittent retractions. 1 spell, off caffeine. Hemodynamically stable, soft murmur reported.\n\nFEN: Wt 2245 grams, up 40 grams. TF 140 cc/kg/day, enteral feeds at 80 cc/kg/day, BM 20, feeds PO/PG. Rest PN at 60 cc/kg/day. Abdomen full, soft, small aspirates. Voiding, . Dstik 90.\n\nDEV: in open crib.\n\nIMP: Former 27 wk twin with hx RDS, NEC, overall stable. Appears to be tolerating gradual advancement of enteral feeds.\n\nPLANS:\n- Continue as at present.\n- Continue advancing enteral feeds as able.\n- Optho next week.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-18 00:00:00.000",
"description": "Report",
"row_id": 1810741,
"text": "NPN 0700-1900\n\n\n#1Resp: Pt. remains in RA, RR 30-70's, sats > 93%. No\nspells or desats so far this shift. Lungs clear & equal w/\nmild SCR. P: cont to monitor resp status.\n\n#2FEN: TF 140cc/kg/d of PN/IL & enteral feeds of BM 20.\nPND15/IL @ 45cc/kg infusing well through PICC. BM 20 @\n95cc/kg PO/PG Q 4hrs. Pt. took 19cc when bottled at 1230.\nAdvancing feeds 15cc/kg per orders. Tolerating feeds\nwell, no spits, min asp. Abd soft & full, +BS, no loops.\nAG stable. Pt. voiding & , guiac neg. P: cont to\nmonitor FEN & advance feeds as tolerated.\n\n#4Parents: Mom called today asking approp questions.\nUpdates given. Mom may be in for 8pm cares. P: cont to\nsupport & update.\n\n#5DEV: Temps stable swaddled in OAC, cobedding w/ brother.\nPt. awake & for cares. Settles well in between w/\npacifier. MAE. AFSF. P: cont to support dev needs.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-05 00:00:00.000",
"description": "Report",
"row_id": 1810508,
"text": "NPN 1900-0700\n\n\n1. Resp: Infant remains on prong CPAP 6 in 21%. O2 sats =\n96-100%. RR=40-50's. Mild SCR/ICR. LS clear. Has had 3\nspells thus far this shift. (5 in 24hrs). See flowsheet\nfor details. On caffeine.\n\n2. FEN: WT=1025gms (up 25gms). TF=160cc/k/day. Currently\nreceiving enteral feeds of BM20 at 20cc/k/day = 4cc q4h. PN\nD10 and IL are infusing via DLUVC at 140cc/k/day. PICC was\nplaced at and has D10W with 1/2 U hep/cc infusing. Min\nasp/no spits. Abd girth = 17-17.5cm. Abd is soft and round\nwith active bs. Had 1 lg mec stool at . Voiding with\neach diaper change. Will check lytes and d/s at 0400.\n\n3. : No contact this shift.\n\n4. G&D: Infant is alert and active with cares. Uses\npacifier to comfort self. Temps stable nested in sheepskin\nin servo mode isolette. HUS to be done today. AFSF. AGA.\n\n5. Hyperbili: Infant remains under single phototx with eye\nshields in place. Will check bili at 0400.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-05 00:00:00.000",
"description": "Report",
"row_id": 1810509,
"text": "Respiratory Care Note\nInfant remains on NCPAP +6, 21% - BS mostly clear, mild retractions, RR's 40's-50's, small cloudy secretions - On caffeine, 3 documented spells thus far this shift - continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-05 00:00:00.000",
"description": "Report",
"row_id": 1810510,
"text": "Neonatology Attending Progress Note\n\nNow day of life 7, Ca 6/7 weeks.\nOn CPAP of 6 and in RA.\nRR 40-60s on caffeine.\n6 episodes of apnea/bradycardia in the past 24 hours.\nHR 160s BP 64/35 46\n\nWt. 1025gm up 25gm on 160ml/kg/d Feedings - 20ml/kg/d of MM well tolerated, 140ml/kg/d of PN/IL.\nNormal urine and stool output.\n\nBili - 3.4 on phototherapy\n\nHUS - no , left periventricular cyst noted\n\nLytes 132 4.2 100 18\n\nAssessment/plan:\nBaby overall doing well on CPAP of 6.\nWill continue to monitor for apnea of prematurity.\nFU bili tomorrow.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-05 00:00:00.000",
"description": "Report",
"row_id": 1810511,
"text": "Respiratory Care\nPt cont on prong CPAP. Fio2 .21-.23. bs clear, rr 50's with mild retractions. on caffeine. No spells noted thus far this shift. Plan to support as needed. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-02-20 00:00:00.000",
"description": "Report",
"row_id": 1810602,
"text": "Neonatology- Progress Note\n\nPE: remains in her isolette, nested in nasal cannula O2, bbs cl=, rrr s1s2 no murmur, well perfused,abd soft, nontender, V&S, afso, sutures approximated, active\n\nSee attending note for plan\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-04 00:00:00.000",
"description": "Report",
"row_id": 1810674,
"text": "Nursing NICU Note\n\n\n#1. Respiratory O: Pt. remains on Prong CPAP 6, FIO2 21%.\n RR ~30-60's, no increase work of breathing noted. LS\nclear/=. No A&B's noted this shift thus far. She is on\nCaffeine. A: Pt. remains stable on Prong CPAP 6. P:\nContinue to monitor respiratory status. Monitor for A&B's.\n\n#2. FEN O: Pt. remains NPO. TF 140cc/kg/d of IV D10W\nw/2MeqNa +1MeqKCl w/.5 Unit Heparin/cc =10.4cc/hr is\ninfuseing via a new R.arm PICC (non-central) without\ndifficulty. Abdomen is , soft, hypo-active bs, no\nloops/ Abdominal girth is ~23.5cm. She is voiding well, no\nstool passed this shift thus far. A: Pt. is tolerateing\ncurrent nutritional plan. P: Continue w/ current feeding\nplan. Monitor for s/s of intolerance. Plan to restart\nPN/IL tonight.\n\n#4. O: Mom called this am and was updated on pt's\ncurrent status and daily plan of care. Mom active and\ninvolved, asking appropriate questions. A: Family is\nloving and involved. P: Continue to update, support and\neducate.\n\n#5. Growth/Development O: Pt. is now in a low air\nisolette, temps stable. She is alert and active w/cares,\nsleeps well in between. Fontanelle soft/flat. She uses her\npacifier well for comfort. A: AGA P: Continue to provide\nenvironment appropriate for growth and development.\n\n#7. Sepsis O: Pt. is on Day #4of 14 days IV Clinda+Zosyn.\n She is alert, active and appropriate, temps stable.\nAbdomen stable. A: Potential for sepsis. P: Continue to\nmonitor for s/s of infection.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-04 00:00:00.000",
"description": "Report",
"row_id": 1810675,
"text": "Respiratory Care\nPt received on nasal prong CPAP +6cm's with the fio2 21%. Pt's resp rates 30's to 50's. Plan is to follow on CPAP.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-04 00:00:00.000",
"description": "Report",
"row_id": 1810676,
"text": "Neonatology - Progress Note\n\n is active with good tone. AFOF. She is , well perfused, no murmur auscultated. She is comfortable on nasal prong CPAP, fio2 21%. Breath sounds clear and equal. She remains NPO. Abd soft, hypoactive bowel sounds, voiding, no stool overnight. Peripheral IV out, new PICC line inserted (see note below). Stable temp in isolette. Please refer to neonatology attending note for detailed plan.\n"
},
{
"category": "Nursing/other",
"chartdate": "2179-03-04 00:00:00.000",
"description": "Report",
"row_id": 1810677,
"text": "Neonatology - Procedure Note\n\nProcedure: PiCC line placement\nIndication: Infant with NEC. Need for extended IV access for IV nutrition\n\nParental consent in medical record. Patient ID confirmed. Infant prepped in sterile fashion. Introducer inserted in right antecubital vein. PICC line advanced to 8 cms (total line length 13cms). Good blood return and flushes easily. Line secured with tegaderm dsg. CXR shows line ending at the shoulder (non-central). Procedure tolerated well by infant.\n"
},
{
"category": "ECG",
"chartdate": "2179-03-26 00:00:00.000",
"description": "Report",
"row_id": 204387,
"text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-05 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 901995,
"text": " 7:02 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: RULE OUT INTRACRANIAL HEMORRHAGE OR OTHER ABNORMALITY\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant BORN AT 27 6/7 WEEKS GESTATION\n REASON FOR THIS EXAMINATION:\n RULE OUT INTRACRANIAL HEMORRHAGE OR OTHER ABNORMALITY\n ______________________________________________________________________________\n FINAL REPORT\n TITLE: PORTABLE HEAD ULTRASOUND.\n\n DATE OF EXAMINATION: .\n\n TIME: 08:17\n\n CLINICAL HISTORY: The patient is a 27-weeker infant who is here for evaluation\n of intracranial hemorrhage.\n\n COMPARISON: There is no prior examination available for comparison.\n\n FINDINGS: There is an approximately 0.2 cm x 0.8 cm x 0.3 cm round cystic\n structure located just lateral to the frontal of left lateral ventricle.\n Otherwise, the remaining brain is normal in appearance without evidence of\n germinal matrix, intraparenchymal or intraventricular hemorrhage. The\n ventricles are within normal limits and symmetric. No evidence of ventricular\n dilatation is seen. No abnormal extra-axial fluid collection is noted.\n\n IMPRESSION: A small cystic structure located just lateral to the frontal \n of left lateral ventricle as described above. Otherwise, unremarkable portable\n head ultrasound examination.\n\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-12 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 902943,
"text": " 7:25 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANTPREVIOUS FINDINGS OF SMALL CUST ASSESS FOR IVH\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27 6/7 weeks, now 12 do with previous findings of small cyst\n lateral to Left ventricle\n REASON FOR THIS EXAMINATION:\n r/o IVH\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Premature infant, now 12 days of life, with a prior study\n showing a small cyst adjacent to the left lateral ventricle. Followup.\n\n FINDINGS: Cranial ultrasound was performed from the anterior fontanelle and\n mastoid foramen. Comparison is made to the previous study dated .\n\n The brain parenchyma remains normal in echogenicity and morphology. The\n pattern of sulcation is appropriate for the patient's degree of prematurity.\n\n The ventricles are normal in size and there is no evidence of intraparenchymal\n or intraventricular hemorrhage.\n\n Again seen is a tiny cystic structure just lateral to the frontal of the\n left lateral ventricle. The structure is similar in size and appearance when\n compared to the previous study, measuring 1 x 0.3 x 0.2 cm. Today's study\n suggests cystic structure may be located in the superior portion of the left\n caudate head and it is of uncertain significance.\n\n There are no other abnormalities seen. The extra-axial fluid spaces are\n normal.\n\n IMPRESSION:\n 1. No evidence of intraventricular or intraparenchymal hemorrhage.\n 2. Stable appearance of small cystic structure adjacent to the left lateral\n ventricle, perhaps in the left caudate head. The significance of this finding\n is unclear.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-04 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 901960,
"text": " 8:41 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: CONFIRM P-CVL TIP POSITION\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with P-CVL ORIGINATING RIGHT ARM\n REASON FOR THIS EXAMINATION:\n CONFIRM P-CVL TIP POSITION\n ______________________________________________________________________________\n FINAL REPORT\n TITLE: PORTABLE CHEST, ONE VIEW.\n\n CLINICAL HISTORY: Infant who is here for evaluation of right subclavian\n central venous line catheter placement.\n\n COMPARISON: Comparison is made to prior examination dated , time\n 17:19.\n\n FINDINGS: In the interim, interval placement of right subclavian central\n venous line with its tip located towards the right internal jugular vein is\n seen. In the interim, interval improvement of aeration is noted in both lungs\n without focal consolidation, pleural effusion, or pneumothorax. Heart size\n and mediastinal contours are within normal limits. Again, noted is an\n umbilical vein catheter with its tip located in the inferior vena cava at T10\n to T11 vertebral body level. Interval removal of umbilical artery catheter is\n seen. The visualized upper abdomen is unremarkable. Nasogastric tube with its\n tip located in the stomach is seen.\n\n IMPRESSION: Interval placement of right subclavian central venous line with\n its tip located in the right internal jugular vein. The clinician taking care\n of this patient was notified with findings at the time of dictation.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-01-29 00:00:00.000",
"description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT",
"row_id": 901256,
"text": " 10:29 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: check tube & line placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with ETT, UAC/UVC.\n REASON FOR THIS EXAMINATION:\n check tube & line placement\n ______________________________________________________________________________\n FINAL REPORT\n There are no comparisons.\n\n FINDINGS: The endotracheal tube has tip at the thoracic inlet. The UAC has\n tip at the T5 level. The UVC has tip in the right atrium. The abdominal\n bowel gas pattern is normal. The heart size is normal. Fine granular opacity\n throughout the lungs is consistent with hyaline membrane disease.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-01-30 00:00:00.000",
"description": "P BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT",
"row_id": 901314,
"text": " 5:00 PM\n BABYGRAM CHEST & ABD (TOGETHER ONE FILM) PORT Clip # \n Reason: evaluate placement of uvc\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with ETT, UAC/UVC.\n REASON FOR THIS EXAMINATION:\n evaluate placement of uvc\n ______________________________________________________________________________\n FINAL REPORT\n TITLE: PORTABLE BABYGRAM.\n\n DATE OF EXAMINATION: , time 17:19.\n\n CLINICAL HISTORY: Infant who is here for evaluation of umbilical vein catheter\n placement.\n\n COMPARISON: Comparison is made to prior examination dated , time\n 22:59.\n\n FINDINGS: Interval reposition of umbilical vein catheter with its tip located\n in the IVC at T8 vertebral body level is seen. Again seen is umbilical artery\n catheter with its tip located at T6 vertebral body level without significant\n interval change. Again noted is diffuse opacities in both lungs, most likely\n representing surfactant deficiency syndrome. No focal consolidation, pleural\n effusion or pneumothorax is seen. Heart size and mediastinal contours are\n within normal limits. Again noted is endotracheal tube with its tip located\n at the thoracic inlet level. Bowel gas pattern is nonobstructive without\n evidence of pneumatosis, portal venous gas, or dilated small bowel loops. The\n visualized osseous structures are normal in appearance.\n\n IMPRESSION:\n\n 1. Endotracheal tube with its tip located at the level of thoracic inlet.\n\n 2. Interval reposition of umbilical vein catheter with its tip now located in\n the inferior vena cava.\n\n 3. Nonobstructive bowel gas pattern.\n\n 4. The findings were discussed with the clinician taking care of this patient\n at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-01 00:00:00.000",
"description": "P BABYGRAM AP ABD ONLY PORT",
"row_id": 905204,
"text": " 4:50 AM\n BABYGRAM AP ABD ONLY PORT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: PLEASE DO AT 0400\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with abd distention\n REASON FOR THIS EXAMINATION:\n PLEASE DO AT 0400\n ______________________________________________________________________________\n FINAL REPORT\n A BABYGRAM TAKEN PORTABLY ON AT 4:53 A.M. AND COMPARED TO AT\n 2134 HOURS.\n\n FINDINGS: Air is seen in the mildly dilated loops of bowel. There is a foamy\n pattern in a vertically oriented loop of bowel against the right flank that is\n suspicious for possible intramural air. This region should be watched closely\n on future films for necrotizing enterocolitis. On this supine film there is\n no evidence of free air.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-28 00:00:00.000",
"description": "P BABYGRAM AP ABD ONLY PORT",
"row_id": 905183,
"text": " 9:18 PM\n BABYGRAM AP ABD ONLY PORT Clip # \n Reason: bowel gas pattern\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with abd distention\n REASON FOR THIS EXAMINATION:\n bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM TAKEN PORTABLY AT 2134 HOURS AND COMPARED TO AT 1638\n HOURS.\n\n FINDINGS: Multiple moderately dilated air-filled loops of bowel fill the\n abdomen. On this single supine film, there is no evidence for free or\n intramural air. Nasogastric catheter overlies the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-02 00:00:00.000",
"description": "P BABYGRAM AP ABD ONLY PORT",
"row_id": 905392,
"text": " 3:55 AM\n BABYGRAM AP ABD ONLY PORT Clip # \n Reason: PLEASE DO AT 0400, , follow bowel gas pattern\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with NEC\n REASON FOR THIS EXAMINATION:\n PLEASE DO AT 0400\n\n follow bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE BABYGRAM AT 4:12 P.M.\n\n HISTORY: Followup necrotizing enterocolitis.\n\n FINDINGS: The comparison exam is 11:30 p.m.\n\n Foamy-appearing bowel in the right abdomen is no longer present. Bowel gas\n pattern is now unremarkable, with no distended loops.\n\n Lung volumes are lower than previously. This brings out mild grayish\n bilateral opacification, consistent with chronic lung disease. Heart size is\n normal.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-01 00:00:00.000",
"description": "P BABYGRAM ABD WITH DECUB (74020) PORT",
"row_id": 905268,
"text": " 11:16 AM\n BABYGRAM ABD WITH DECUB () PORT Clip # \n Reason: evauate bowel gas pattern, r/o free air\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with abd distention, NEC\n REASON FOR THIS EXAMINATION:\n evauate bowel gas pattern, r/o free air\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM AT 11:34 A.M.\n\n HISTORY: Necrotizing enterocolitis.\n\n FINDINGS: Comparison exam is 4:53 a.m.\n\n Again seen is bubbly pattern of lucency in the right abdomen. This certainly\n could represent intramural air. There is no evidence for free intraperitoneal\n air on the supine or decubitus views. No portal venous gas.\n\n There is a feeding tube in the stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-01 00:00:00.000",
"description": "NEONATAL HEAD PORTABLE",
"row_id": 905221,
"text": " 7:39 AM\n NEONATAL HEAD PORTABLE Clip # \n Reason: PREMATURE INFANT ASSESS FOR PVL\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant born at 27 6/7 weeks, now 1 month old with previous findings of small\n cyst lateral to Left ventricle\n REASON FOR THIS EXAMINATION:\n r/o pvl\n ______________________________________________________________________________\n FINAL REPORT\n NEONATAL PORTABLE HEAD ULTRASOUND\n\n HISTORY: Premature infant twin born at 27 and 6/7th weeks, now one-month-old\n with previous finding of small cyst lateral to the left ventricle.\n\n Examination of the cranium through the anterior fontanelle and the left\n mastoid foramen demonstrates the previously identified left white matter cyst\n adjacent to the frontal of the left lateral ventricle. This cyst has not\n changed in size or appearance. This type of cyst is uncommon but is seen in\n this location and is well described in the pediatric literature. The\n significance of this finding is unclear, but in most instances is of no\n clinical significance. These types of cysts have been identified in fetuses\n and in newborns and usually do not change in appearance over time. The\n remainder of the brain appears normal, without evidence of intracranial\n hemorrhage or other structural abnormality.\n\n IMPRESSION:\n 1. No evidence of intraventricular or intraparenchymal hemorrhage.\n 2. Stable appearance of small cystic structure adjacent to the frontal \n of the left lateral ventricle, as described. The appearance of this cyst is\n consistent with cysts that are described in the pediatric literature which\n does not change over time and are of uncertain, if any, clinical significance.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-04 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 905833,
"text": " 12:26 PM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: S/p PICC placement.\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with above\n REASON FOR THIS EXAMINATION:\n S/p PICC placement.\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM PORTABLE VIEW OF THE CHEST AND UPPER ABDOMEN.\n\n CLINICAL HISTORY: Four-week-old infant, check line placement.\n\n Comparison is made with the previous chest radiograph from . There\n has been interval placement of a right axillary approach long line with the\n tip likely at the junction of the axillary and subclavian veins. The\n nasogastric tube tip is in the stomach. The lungs are clear bilaterally.\n There is no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-01 00:00:00.000",
"description": "BABYGRAM AP ABD ONLY",
"row_id": 905341,
"text": " 4:50 PM\n BABYGRAM AP ABD ONLY; -59 DISTINCT PROCEDURAL SERVICE Clip # \n -77 BY DIFFERENT PHYSICIAN\n : evaluate bowel gas pattern\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with NEC\n REASON FOR THIS EXAMINATION:\n evaluate bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM PORTABLE ON AT 5 O'CLOCK P.M.\n\n HISTORY: Neck watch.\n\n Comparison is 11:34 a.m.\n\n There is air throughout nondistended bowel. The appearance of lucencies\n within the right abdomen has improved though there is some persistence. No\n portal venous gas. No evidence of free air.\n\n The lungs are clear. Heart size is normal. The feeding tube extends into the\n stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-01 00:00:00.000",
"description": "P BABYGRAM AP ABD ONLY PORT",
"row_id": 905380,
"text": " 11:16 PM\n BABYGRAM AP ABD ONLY PORT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n -76 BY SAME PHYSICIAN\n : follow bowel gas pattern\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with NEC\n REASON FOR THIS EXAMINATION:\n follow bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM PORTABLE AT 2330 HOURS\n\n HISTORY: Neck watch.\n\n FINDINGS: The comparison exam is 5 o'clock p.m.\n\n Further improvement in the appearance of the right-sided bowel, with no new\n areas of suspicion. No evidence for portal venous gas or free air.\n\n Lungs remain clear. Heart size is normal. There is a feeding tube extending\n into the stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-03 00:00:00.000",
"description": "P BABYGRAM AP ABD ONLY PORT",
"row_id": 905549,
"text": " 1:56 AM\n BABYGRAM AP ABD ONLY PORT Clip # \n Reason: EVALUATE BOWEL GAS PATTERN\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant ABDOMINAL DISTENSION\n REASON FOR THIS EXAMINATION:\n EVALUATE BOWEL GAS PATTERN\n ______________________________________________________________________________\n FINAL REPORT\n Examination of the abdomen performed on the at 2:19 a.m.\n\n Comparison is made with an exam performed on . There has been\n little change. Nasogastric tube reaches the stomach. There is mild diffuse\n distention of large and small bowel. No specific signs of necrotizing\n enterocolitis are apparent.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-04 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 901965,
"text": " 9:05 PM\n BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # \n Reason: CONFIRM P-CVL TIP POSITION\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with P-CVL PULLED BACK 2 CM\n REASON FOR THIS EXAMINATION:\n CONFIRM P-CVL TIP POSITION\n ______________________________________________________________________________\n FINAL REPORT\n TITLE: PORTABLE CHEST, ONE VIEW.\n\n CLINICAL HISTORY: Evaluation of right subclavian central venous line catheter\n placement.\n\n COMPARISON: Comparison is made to prior examination dated , time\n 20:41.\n\n FINDINGS: This study is markedly limited due to the technique. Previously\n noted right subclavian central venous line is projecting over the patient's\n lower neck. The tip of the central venous line is not clearly visualized for\n evaluation.\n\n IMPRESSION: Markedly limited study due to the technique. The tip of the\n newly placed right subclavian central venous line cannot be completely\n visualized for full evaluation. Findings were discussed with the clinician\n taking care of this patient. Repeat study will be performed for further\n evaluation.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-14 00:00:00.000",
"description": "BABYGRAM AP ABD ONLY",
"row_id": 907153,
"text": " 1:46 PM\n BABYGRAM AP ABD ONLY Clip # \n Reason: evaluate bowel gas pattern\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant s/p 14 days bowel rest for medical NEC\n REASON FOR THIS EXAMINATION:\n evaluate bowel gas pattern\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE AP ABDOMEN, , 12:51 HOURS\n\n CLINICAL HISTORY: Premature infant following 2 weeks of bowel rest for\n medical necrotizing enterocolitis.\n\n Normal bowel gas pattern. No evidence of focal ileus, bowel wall thickening\n or pneumatosis intestinalis identified. No free peritoneal air is identified.\n\n IMPRESSION: Normal bowel gas pattern as described above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-05 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 902024,
"text": " 10:03 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: PICC line placement\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with PICC line\n REASON FOR THIS EXAMINATION:\n PICC line placement\n ______________________________________________________________________________\n FINAL REPORT\n The tip of the right PICC line is probably in the proximal portion of the\n internal jugular vein. There is an NG tube with its tip in the stomach and an\n umbilical venous catheter with its tip overlying the liver at the level of\n T9-10. Heart size is normal. There is a moderate ground glass appearance of\n the lung parenchyma bilaterally in keeping with RDS. Heart size is normal.\n\n IMPRESSION: Tip of the right PICC line is superomedial to the medial aspect\n of the right clavicle, probably within the proximal internal jugular vein.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-11 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 906724,
"text": " 1:05 AM\n BABYGRAM (CHEST ONLY); -76 BY SAME PHYSICIAN # \n Reason: CONFIRM P-CVL TIP POSTITION AFTER WITHDRAWING LINE 1.5 CM\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with P-CVL ORIGINATING LEFT ARM\n REASON FOR THIS EXAMINATION:\n CONFIRM P-CVL TIP POSTITION AFTER WITHDRAWING LINE 1.5 CM\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM CHEST ONLY AT 1:15 A.M.\n\n HISTORY: Confirm central venous line tip position. Originating in the left\n arm.\n\n FINDINGS: Comparison is made to the examination performed at 12:47 a.m. The\n left arm vascular catheter has been pulled back and its tip now projects over\n the expected position of the left brachial cephalic vessel. The nasogastric\n tube is in a similar position projecting over left upper lobe. The lung\n volumes are lower, and there is more patchy, multifocal atelectasis. The\n heart and mediastinal contours are normal. A pleural effusion is not seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-03-11 00:00:00.000",
"description": "BABYGRAM (CHEST ONLY)",
"row_id": 906722,
"text": " 12:46 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: CONFIRM P-CVL TIP POSITION\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with P-CVL ORIGINATING LEFT ARM\n REASON FOR THIS EXAMINATION:\n CONFIRM P-CVL TIP POSITION\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM, CHEST ONLY, AT 12:47 A.M.\n\n HISTORY: Confirm central venous line tip position. Originating in left arm.\n\n FINDINGS: Comparison is made to the chest radiograph of . The right\n PICC has been removed. There is a new left PICC, and its tip projects over\n the expected position of the junction between the right atrium and superior\n vena cava. The nasogastric tube is again noted to project over the gastric\n bubble. The lung volumes are lower, and there is more patchy multifocal\n atelectasis bilaterally. The heart and mediastinal contours are unchanged. A\n pleural effusion is not seen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2179-02-05 00:00:00.000",
"description": "P BABYGRAM (CHEST ONLY) PORT",
"row_id": 902092,
"text": " 4:25 PM\n BABYGRAM (CHEST ONLY) PORT; -76 BY SAME PHYSICIAN # \n Reason: evaluate for placement of picc after being pulled back 1 cm\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with prematurity]\n REASON FOR THIS EXAMINATION:\n evaluate for placement of picc after being pulled back 1 cm\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 16:38 HOURS.\n\n HISTORY: Premature infant. Assess PICC line placement.\n\n FINDINGS: A supine portable chest radiograph is compared to the immediately\n preceding film obtained earlier in the day at 10:06 hours. The tip of the\n right PICC line has been pulled back and now lies medial to the lateral aspect\n of the right first rib, presumably within the right subclavian vein. There is\n an NG tube with its distal tip in the stomach and an umbilical venous catheter\n with its tip overlying the liver at the level of T10. Heart size is normal.\n There is a mild ground-glass appearance of the lung parenchyma bilaterally in\n keeping with RDS. There has been no significant change in lung aeration\n compared to the prior study.\n\n IMPRESSION: The tip of the PICC line now appears to lie in the right\n subclavian vein as described above.\n\n\n"
}
] |
17,385 | 153,275 | A/P: 51 to male with hematochezia and recent h/o UGIB likely from duodenal/gastric ulcers. HCT 11.7 and hypotensive to 80s on presentation with good response to volume repletiong with IVFs and blood. Currently hemodynamically stable in MICU. 1. GIB Pt received 10 units of prbcs Grade II esophagitis in the gastro-esophageal junction Ulcers in the antrum, pre-pyloric region and pylorus Ulcers in the stomach body and fundus Ulcers in the duodenal bulb Friability, granularity, erythema and nodularity in the bulb and post bulbar duodenum 2. Hepatomegaly- Had negative hep serologies and RUQ U/S w/ fatty infiltration, mild ascitis. INR 1.2 Alb in 2s at OSH. No varices on EGD. Clubbing and hyponatremia suggest liver dx. ? ETOH hepatitis vs NASH - recheck hep serologies, albumin - follow LFTs 3. Ischemic Fingertips- improving per patient. Ddx includes ? A-line but doesn't seem like he had a recent line per exam, dopamine, hepC/cryo but cryoglobulins neg at OSH, plastics followed pt Nitroglycerin topically, lidocaine tp and bacitracin Pt to see plastics on 4. ETOH- CIWA scale but denies drinking since left last night. Serum ETOH negative. - IV MVI, folate, thimaine - check magnesium and replete prn - Encourage abstinence 7. PPX- 'boots, PPI 8. wife at cell 9. T/L/D- NGT d/ced prior to EGD, Right IJ placed - need to pull back 2 cm, foley 10. Full Code Dispo At Dc pt to follow up with Dr. on , Hand Clinic on and lab check on | Pt with mild orthostatic hypotension--transfers supervised. abd soft, hypoactive BS's. Rt Central line remains patent and dressing intact.GI/GU: Abd soft. CV: Low grade temps with tmax 99.6. extremities cool, pulses diminished. GU: Foley d/c'd per pt request. BP stable. no cough noted.NEURO- MAE. 0600 hct 26--2 u prbc infused without s/sx reaction. RBC's infusing at a moderate pace thru peripheral IV. The mitral valve appears structurally normal with trivial mitralregurgitation. Pt tollerating clear liquids well. GU: Pt voiding without issue. Mg, Ca, and K repleted this am. BP down, 80-100's systolic. Plan to c/o pt to floor if hct stable. Pt voiding without difficulty. Pt in NSR rat 80's, low 100's with exertion. There is an anterior space which mostlikely represents a fat pad, though a loculated anterior pericardial effusioncannot be excluded.Conclusion: No cardiac source of embolism seen. f/u hct 28.7--slightly bump than expected. Abd softly distended. PATIENT/TEST INFORMATION:Indication: Source of embolism.Height: (in) 74Weight (lb): 190BSA (m2): 2.13 m2BP (mm Hg): 127/63HR (bpm): 76Status: InpatientDate/Time: at 18:30Test: Portable TTE (Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left ventricular cavitysize is normal. had recurrance of BRBPR, to ED w/ hct of 11.7. poor access. The leftventricular cavity size is normal. Amber/clear. Sats 96-99% on RA.CV: Hemodynamically stable. Pulm: No issues. no further boluses yet d/t poor IV access. NGT to LCS. hx of ETOH abuse. Pt on RA, non productive cough. + flatus. serial hct's. Right ventricular chamber size and free wall motion are normal.4.The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic regurgitation. BS present. BP stable but did drop slightly when pt standing to 89/36. HR, NSR 76-97. The left atrium is normal in size.2. transferred to MICU A w/ 1 unit of RBC's and 1 18g IV. CV: Low grade temps. Tmax 101.1.ROS-CV- NSR, HR 80-100's. Pulm: Lungs CTA. No c/o nausea, one episode of 150 cc melena this am. dropping hct. No active s/s bleeding noted. Left ventricular wall thicknesses are normal. one 18g IV intact.SOCIAL- recently married. BP 95-126/44-71. Lungs CTA. Overall left ventricular systolic functionis normal (LVEF>55%).RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.AORTIC VALVE: The aortic valve leaflets (3) appear structurally normal withgood leaflet excursion and no aortic regurgitation. MICU NPN 0700-1390 Neuro: Pt alert and oriented, pleasant and cooperative. Skin: NTP to ischemic fingers and covered with DSD. NiBP as mentioned above. GI: Pt continues to be NPO in setting of ? Hct stable X 3--1600 hct pending. Hct stable X 3 at 30. Liver US with patent portal vein. Overall left ventricular systolic function is normal(LVEF>55%).3. There is an anterior spacewhich most likely represents a fat pad, though a loculated anteriorpericardial effusion cannot be excluded.Conclusions:1. MICU NPN 0700-: Pt scoped today--no s/sx of active bleeding, multiple healed ulcers. Transfusion reaction work up completed after reaction early this am. NPN 7p-7aevents:pt rc'd a total of 6units PRBC's, serial Hcts, endoscopy overnocneuro: A&Ox3, MAE's, appropriate on unit, follows commands and able to make needs known; CIWA total zero overnoc; pt reports pain in R index finger treated with topical lidocaine with good effectcv: HR 70-90's, NSR with rare PVC's, NBP 90-110/40-50's; rc'd a total of 6 units PRBC's overnoc, Hct 27 (22) and Hgb 9.4, Serial Hct's q4, next due at 7am; Mg 1.3, K 4.0, Na 135; NS (w/ MVI, thiamine and folic acid) infusing at 125cc/hr for 1L; +pp; EKG obtained; plan to continue infusing for low Hct's; pneumo boots on for DVT prophylacisresp: RR 14-20 and Sats 97-100% on 4L via NC, LS clear in upper lobes with some faint crackles in bilateral lower lobesgi: NPO, +bs/flatus, Abd soft/NT/ND, no stool overnoc; NGT dc'd prior to endoscopy which initially showed several ulcers but no active bleeding currently; protonix gu: u/o 100-200cc/hr, light yellow and clear; BUN 18 and Creat 0.4id: Tmax 100.0, no current ABX therapy, WBC 7.3integ: R index finger purple and painful (pt reports he did not have this before last adm to OSH but it was present when he was dc'd), treated with lidocaine and covered with DSD, continue to monitor; Bilateral feet appear sloughing and heels covered with duoderm, continue to monitorsocial: pt is newly married and spouse appears very supportive and invested, social work consult ordered as additional support; per team, pt must abstain from drinking or smoking to prevent further recurrences or further damage; per pt's spouse, he has been told this before but will not listen (may need psych RN consult) Urine is amber/clear. Mg 1.6. Pt in NSR rate 80's, low 100's when exerting himself. pt states topical lidocaine helps, awaiting orders. Non tender. Mg=1.7--repleted with 2 g magnesium IV. Diet advanced to clear liquids. X 1 void of 375 cc. Central line placement insitu. Hct remained stable. Sats 100%. Sats 100%. No ectopy noted. recieved 2 liters NS in ED. lethargic. EGD there showed duodenal ulcers. Addendum: 7p-7apt had ~200cc melena this am, 7am Hct pending hct 11.1, to be repeated after 4 th unit. K 3.8. Pt has 4 u available in BB. Sinus rhythmNormal ECGNo previous tracing for comparison Pt not orthostatic. No masses or vegetationsare seen on the aortic valve.MITRAL VALVE: The mitral valve appears structurally normal with trivial mitralregurgitation. See carevue for all objective data.Neuro: AA&Ox3. Morphine given in 4mg increments appeared to work best. Morphine prn for digit pain. Fingers on R hand purple, from unknown origin, ?embolic vs vasculitis.RESP- 100% on 4 liters NC. Plan to follow q 4 hct overnight and transfuse if necessary. CXR per team showed no infiltrates. Urine yellow and clear.Skin: Nitropaste and DSD applied to right indes and middle finger as ordered. | 9 | [
{
"category": "Echo",
"chartdate": "2137-06-28 00:00:00.000",
"description": "Report",
"row_id": 100018,
"text": "PATIENT/TEST INFORMATION:\nIndication: Source of embolism.\nHeight: (in) 74\nWeight (lb): 190\nBSA (m2): 2.13 m2\nBP (mm Hg): 127/63\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 18:30\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thicknesses are normal. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation. No masses or vegetations\nare seen on the aortic valve.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation. No mass or vegetation is seen on the mitral valve.\n\nPERICARDIUM: There is no pericardial effusion. There is an anterior space\nwhich most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nConclusions:\n1. The left atrium is normal in size.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nsize is normal. Overall left ventricular systolic function is normal\n(LVEF>55%).\n3. Right ventricular chamber size and free wall motion are normal.\n4.The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. No masses or vegetations are seen on\nthe aortic valve.\n5. The mitral valve appears structurally normal with trivial mitral\nregurgitation. No mass or vegetation is seen on the mitral valve.\n6. There is no pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nConclusion: No cardiac source of embolism seen.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2137-06-27 00:00:00.000",
"description": "Report",
"row_id": 283599,
"text": "Sinus rhythm\nNormal ECG\nNo previous tracing for comparison\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-06-27 00:00:00.000",
"description": "Report",
"row_id": 1490071,
"text": "Nursing Admission Note 1800-1900\nPt to MICU A from ED. had previously been at x about 2 weeks for pna (requiring intubation and ventilatory support), and GIB. EGD there showed duodenal ulcers. Pt dc'ed himself AMA from there a few days ago. had recurrance of BRBPR, to ED w/ hct of 11.7. poor access. transferred to MICU A w/ 1 unit of RBC's and 1 18g IV. Central line placement insitu. pt to recieve 4 units RBC's, currently on 2nd. BP down, 80-100's systolic. recieved 2 liters NS in ED. no further boluses yet d/t poor IV access. Tmax 101.1.\n\nROS-\n\nCV- NSR, HR 80-100's. NiBP as mentioned above. hct 11.1, to be repeated after 4 th unit. RBC's infusing at a moderate pace thru peripheral IV. extremities cool, pulses diminished. Fingers on R hand purple, from unknown origin, ?embolic vs vasculitis.\n\nRESP- 100% on 4 liters NC. fine crackles in bases. CXR per team showed no infiltrates. no cough noted.\n\nNEURO- MAE. surprisingly alert and oriented. lethargic. c/o pain in R fingers. pt states topical lidocaine helps, awaiting orders. hx of ETOH abuse. recent dx of renal failure and liver \"problems\". pt states that his last drink was several weeks ago and he did not drink during his time at home.\n\nGI/GU- foley draining adeq u/o. NGT to LCS, bloody to bilious drainage. no stool since arrival. abd soft, hypoactive BS's. pt needs to recieved IV protonix and erythromycin when central line is placed.\n\nSKIN- skin red and peeling off of feet, unknown origin. R finders purple.\n\nACCESS- attempting to place dual lumen (2 x 14g's) central line. one 18g IV intact.\n\nSOCIAL- recently married. lives w/ wife. Wife is pt's spokesperson.\n\nPLAN- EGD today once Central line is placed. needs erythromycin IV also probable IVF's. NGT to LCS. serial hct's. to recieve additional 2 units RBC's. frequent support/ encouragement. Will need pan cultures when line placed (urine sent).\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-06-28 00:00:00.000",
"description": "Report",
"row_id": 1490072,
"text": "NPN 7p-7a\n\nevents:pt rc'd a total of 6units PRBC's, serial Hcts, endoscopy overnoc\n\nneuro: A&Ox3, MAE's, appropriate on unit, follows commands and able to make needs known; CIWA total zero overnoc; pt reports pain in R index finger treated with topical lidocaine with good effect\n\ncv: HR 70-90's, NSR with rare PVC's, NBP 90-110/40-50's; rc'd a total of 6 units PRBC's overnoc, Hct 27 (22) and Hgb 9.4, Serial Hct's q4, next due at 7am; Mg 1.3, K 4.0, Na 135; NS (w/ MVI, thiamine and folic acid) infusing at 125cc/hr for 1L; +pp; EKG obtained; plan to continue infusing for low Hct's; pneumo boots on for DVT prophylacis\n\nresp: RR 14-20 and Sats 97-100% on 4L via NC, LS clear in upper lobes with some faint crackles in bilateral lower lobes\n\ngi: NPO, +bs/flatus, Abd soft/NT/ND, no stool overnoc; NGT dc'd prior to endoscopy which initially showed several ulcers but no active bleeding currently; protonix \n\ngu: u/o 100-200cc/hr, light yellow and clear; BUN 18 and Creat 0.4\n\nid: Tmax 100.0, no current ABX therapy, WBC 7.3\n\ninteg: R index finger purple and painful (pt reports he did not have this before last adm to OSH but it was present when he was dc'd), treated with lidocaine and covered with DSD, continue to monitor; Bilateral feet appear sloughing and heels covered with duoderm, continue to monitor\n\nsocial: pt is newly married and spouse appears very supportive and invested, social work consult ordered as additional support; per team, pt must abstain from drinking or smoking to prevent further recurrences or further damage; per pt's spouse, he has been told this before but will not listen (may need psych RN consult)\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-06-28 00:00:00.000",
"description": "Report",
"row_id": 1490073,
"text": "Addendum: 7p-7a\n\npt had ~200cc melena this am, 7am Hct pending\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-06-28 00:00:00.000",
"description": "Report",
"row_id": 1490074,
"text": "MICU NPN 0700-1390\n Neuro: Pt alert and oriented, pleasant and cooperative. Able to stand/pivot to chair without issue. Pt with mild orthostatic hypotension--transfers supervised. Pt c/o severe pain from R index and middle fingers--areas blistered with black tips. Morphine 2 mg IV X 3 for pain control with + result.\n\n CV: Low grade temps with tmax 99.6. Pt in NSR rate 80's, low 100's when exerting himself. BP stable but did drop slightly when pt standing to 89/36. 0600 hct 26--2 u prbc infused without s/sx reaction. f/u hct 28.7--slightly bump than expected. Plan to follow q 4 hct overnight and transfuse if necessary. 2 u blood available and ready in blood bank. Lytes from this afternoon--K+ 3.9--repleted with 20 meq kcl IV. Mg=1.7--repleted with 2 g magnesium IV.\n\n Pulm: Lungs CTA. Pt on RA with congested sounding cough, but no sputum produced. Sats 100%.\n\n GI: Pt continues to be NPO in setting of ? dropping hct. No c/o nausea, one episode of 150 cc melena this am. Liver US with patent portal vein.\n\n GU: Foley d/c'd per pt request. X 1 void of 375 cc. Amber/clear.\n\n Skin: Fingers as stated above. VERY painful. NTP applied per order to help improve vasodilation. Vascular following.\n\n Family: Pts wife at bedside for most of the day. Very helpful with personal care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-06-30 00:00:00.000",
"description": "Report",
"row_id": 1490077,
"text": "MICU NPN 7pm-7am\n\nPt continued to have right index and middle finger pain which was treated with morphine. Hct remained stable. No active s/s bleeding noted. See carevue for all objective data.\n\nNeuro: AA&Ox3. Pleasant and cooperative. Dozed intermittently throughout the night. Pt c/o severe right index and finger pain. Morphine given in 4mg increments appeared to work best. Pt reported a decrease in pain although still reported it as high # after morphine but tolerable.\n\nResp: LS CTA. Sats 96-99% on RA.\n\nCV: Hemodynamically stable. HR, NSR 76-97. No ectopy noted. BP 95-126/44-71. Hct stable throughout the night 28-29%. K 3.8. Mg 1.6. Rt Central line remains patent and dressing intact.\n\nGI/GU: Abd soft. Non tender. BS present. NO stool this shift. Pt voiding without difficulty. Urine yellow and clear.\n\nSkin: Nitropaste and DSD applied to right indes and middle finger as ordered. Pt did remove the dressing @ 22:00 with c/o \"burning\" Pt encouraged to leave dressings on when changed in am.\n\nDispo: ? calling out to floor later today. Full Code\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-06-29 00:00:00.000",
"description": "Report",
"row_id": 1490075,
"text": "NPN 7p-7a\n\npt passed >1L melena, became hypotensive, episode of rigors after transfusion, rc'd 2 units of blood; please see careview for objective data\n\nneuro: A&Ox3, pt appears very preoccupied and sad with the news of possibly loosing one finger or some of a few pieces of fingers; pt c/o pain and rc'd 2-4mg of morphine for the pain; pt rc'd 1mg ativan and slept through the night\n\ncv: HR 80-120's, NSR without ectopy, NBP 100-140's/40-80's, Hct of 26 received two units of PRBC's, 5am Hct pending, next due at 9a; pt rc'd 2l NS boluses for SBP's<95; CVP transduced at 4\n\nresp: RR 13-22, SATs 95-100%, +non-productive cough, LS clear except faint expiratory wheeze in LUL\n\ngi: pt continues npo, +bs/flatus, passed > 1L melena, liquid, within one hour; ABD soft/distended, pt reported abd increasingly tender overnight\n\ngu: pt voids in urinal, 350cc q3-4 hr\n\nid: Tmax 102 rectally, rigors (as well as tachycardia and hypotension) after blood transfusion completed, blood cx sent and Coombs and haptoglobin ordered; no currentl ABC treatmetn\n\ninteg: index and middle fingers on R hand dusky/ with small black areas, Vascular team consulted, covered with nitro-paste and dsd, pt need reminders not to touch other parts of body with paste; both feet with large areas sloughing off, dermatology consulted, will continue to monitor\n\nsocial: wife in early in evening and will return in am\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2137-06-29 00:00:00.000",
"description": "Report",
"row_id": 1490076,
"text": "MICU NPN 0700-:\n\n Pt scoped today--no s/sx of active bleeding, multiple healed ulcers. Diet advanced to clear liquids. Hct stable X 3--1600 hct pending. Plan to c/o pt to floor if hct stable.\n\n Neuro: alert and oriented X 3, pleasant and cooperative. Able to transfer from bed to chair many times during the day with supervision only. Pt c/o pain from ischemic index and middle fingers--treated with 2 mg IV morphine X 2 during day with + result.\n\n CV: Low grade temps. Transfusion reaction work up completed after reaction early this am. Pt to recieve tylenol as premedication in future. Pt in NSR rat 80's, low 100's with exertion. BP stable. Pt not orthostatic. Mg, Ca, and K repleted this am.\n\n Pulm: No issues. Pt on RA, non productive cough. Sats 100%. Lungs CTA.\n\n GI: Pt having several episodes of melena this am. + flatus. Abd softly distended. Endoscopy without issue--pt recieved 100 mcg fentanyl and 3 mg versed for procedure per GI attending. Pt tollerating clear liquids well. Hct stable X 3 at 30. Pt has 4 u available in BB.\n\n GU: Pt voiding without issue. Urine is amber/clear.\n\n Skin: NTP to ischemic fingers and covered with DSD. Moisturizers to sloughing skin on feet. Morphine prn for digit pain.\n"
}
] |
91,296 | 166,313 | The patient was admitted on for IV heparin, pre-op testing and a CT scan of the chest. Underwent surgery with Dr. on . Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Extubated in the early AM of POD #1. Transferred to the postop floor on POD #3 to begin increasing her activity level. Chest tubes and pacing wires removed per protocol. Gently diuresed toward her preop weight. The EP service was consulted for rhythm issues postoperatively. She was found to be in an atrial tachycardia with variable block - rate 90's-150's. Beta blockers were titrated up for better rate control. After extensive discussions with Dr and Dr and it was determined she would be continuing the Multaq and cutting her digoxin dose in half and having a cardioversion in the next month as outpatient in with primary cardiologist, Dr. . Due to scheduling issues, it was determined she would contact Dr. to be set up with a Holter monitor as an outpatient, as well. Due to a white blood cell count in the 13-15 range, a urine culture with >100,000 organisms/milliliter of Staphylococcus (coagulate negative) and a newly placed mechanical valve, it was determined that she would receive IV Vancomycin until urinary tract infection could be ruled out. Follow up urine culture was mixed bacterial flora and Vancomycin was stopped after a 3 day course. She subsequently underwent a straight catherization for a noncontaiminated urine culture and urinalysis. Culture was pending at the time of this summary but urinalysis revealed moderate bacteria. Bactrim was started and to continue until final urine culture is known. Ms did have a supratherapuetic INR which was treated with Vitamin K. Her INR was therapeutic at the time of discharge (3.0) and she was instructed to resume her home dose of 2.5 mg of Coumadin with a INR goal of 2.5-3.5 for a mechanical valve and atrial fibrillation. She was cleared for discharge to home with VNA on POD #9. At the time of discharge, she was tolerating a full oral diet (appetite marginal) her incisions were healing well and she was ambulating without difficulty. She was started on iron before discharge for a hematocrit in the 25 range (stable.) First blood draw for INR on Monday with results to be called to Dr. as per discharge instructions. Target INR 2.5-3.5 for mechanical valve. | Physiologic(normal) PR.PERICARDIUM: Very small pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. CHEST, AP: Moderate cardiomegaly persists, post-median sternotomy with mitral valve replacement. Cts patent for minimal sero-sang drainage. The left atrial appendage emptying velocity isdepressed (<0.2m/s). Interstitial edema and small right effusion. There is a residual right IJ Cordis. A right venous introduction sheath has been removed. No TEE relatedcomplications.Conclusions:Pre-bypass:The left atrium is markedly dilated. Mild spontaneous echo contrast is present in theleft atrial appendage. Normal interatrial septum. Resp: Intubated. Right axis deviation.Non-specific ST-T wave changes. Severe valvular MS(MVA <1.0cm2). Soft with hypoactive BS. Soft with hypoactive BS. Aspirin EC . HISTORY: Patient with new left-sided PICC line. NoASD by 2D or color Doppler.LEFT VENTRICLE: Low normal LVEF.RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Normal aortic valve leaflets (3). Metoclopramide . Stable substantial enlargement of the cardiac silhouette with mild residual opacification at the left base. Pt encouraged to C&DB. Pt encouraged to C&DB. Right axis deviation.Delayed R wave progression. Prior inferior myocardialinfarction. Slow atrial flutter with variable conduction block. Neo stopped and IV NTG started to keep S b/p less than 120. Depressed LAA emptyingvelocity (<0.2m/s) No thrombus in the LAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. There is severe valvular mitral stenosis (area = 1.0cm2).Mild (1+) mitral regurgitation is seen. Mild spontaneous echo contrast is seen inthe body of the left atrium. HR-A-fib/A-flutter 60s-80s with SBP-90s-120s per cuff/a-line. HR-A-fib/A-flutter 60s-80s with SBP-90s-120s per cuff/a-line. Resolving left lower lobe atelectasis and effusion. Mild spontaneous echo contrast in the LAA. Monitor HR and BP and beta block as tolerated. Monitor HR and BP and beta block as tolerated. Since the previous tracingof regular wide complex tachy-arrhythmia is now absent.TRACING #2 Cardiac: CCO swan in place. +DP and PT pulses palpable. +DP and PT pulses palpable. IV NEO infusing upon admission. Atrial flutter with slow ventricular response. F POD # 3 from maze, MVR (mechanical) PMH: ^lipids, afib/flutter, non-. IMPRESSION: Persistent left lower lobe atelectasis and small effusion. Simvastatin . small left pleural effusion persists. PATIENT/TEST INFORMATION:Indication: Mitral valve disease.Height: (in) 61Weight (lb): 123BSA (m2): 1.54 m2BP (mm Hg): 124/81HR (bpm): 45Status: InpatientDate/Time: at 14:31Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Marked LA enlargement. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements Assessment:57F s/p MVr (), maze Valve replacement, mitral mechanical (MVR) Assessment: Neurologically intact but lethagic,fatigued.transfers well with 1 assist.remains in afib/flutter with vrr 90-110. digoxin,multaq resumed,lopressor increased for rate control.coumadin started,plan to bridge to heparin on pod # 3.wires & chest tubes removed .poor appetite,bouts of nausea. FINDINGS: Cardiomediastinal contours are stable in appearance in the postoperative setting. Weaned off NTG gtt. Weaned off NTG gtt. Weaned off NTG gtt. Weaned off NTG gtt. Weaned off NTG gtt. Weaned off NTG gtt. Metoclopramide . Pericardial effusions after ablations, s/p pericardiocentesis. Aspirin EC . A/C with Coumadin started. A/C with Coumadin started. Received with bp syst 80s. Metoprolol Tartrate . HR-A-fib/A-flutter 60s-80s with SBP-90s-120s per cuff/a-line. EP consulted per RH for AFlutter. EP consulted per RH for AFlutter. Encouareg DB&C,IS. Encouareg DB&C,IS. Milk of Magnesia Ondansetron . Valve replacement, mitral mechanical (MVR) Assessment: Lethargic but a & o x 3,aflutter/fib 70s. EP consulted per RH for . A/C with Coumadin. Morphine Sulfate 19. Morphine Sulfate 19. Morphine Sulfate 19. Vancomycin 24. Vancomycin 24. Vancomycin 24. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements Assessment:57F s/p MVr (), maze Valve replacement, mitral mechanical (MVR) Assessment: Neurologically intact but lethagic,fatigued.transfers well with 1 assist.remains in afib/flutter with vrr 90-120s. Glucagon . Milk of Magnesia 18. Milk of Magnesia 18. Milk of Magnesia 18. Metoprolol Tartrate 16. Metoprolol Tartrate 16. Metoprolol Tartrate 16. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements Events: Heparin POD 3 if not anticoagulated PWs/CTs DC'd.Coumadin 5mg.AFlutter, EP consulted. Metoclopramide 17. Metoclopramide 17. Metoclopramide 17. Ranitidine 22. Ranitidine 22. Ranitidine 22. Aspirin EC 5. Aspirin EC 5. Aspirin EC 5. REASON FOR THIS EXAMINATION: r/o PTX/Effusion WET READ: MBue FRI 7:51 PM ET TUBE 3.6CM ABOVE CARINA. Simvastatin . Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor, Wean off NTG gtt. Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor, Wean off NTG gtt. Furosemide . Pt encouraged to C&DB. Furosemide 11. Furosemide 11. Furosemide 11. Calcium Gluconate . : Extubated. NGT TERM IN STOMACH WITH SIDEHOLE JUST DISTAL TO GE JUNCTION. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements Assessment:57F s/p MVr (), maze Chief complaint: PMHx: Current medications: Acetaminophen 4. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements Assessment:57F s/p MVr (), maze Chief complaint: PMHx: Current medications: Acetaminophen 4. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements Assessment:57F s/p MVr (), maze Chief complaint: PMHx: Current medications: Acetaminophen 4. Digoxin 8. Digoxin 8. Digoxin 8. Simvastatin 23. Simvastatin 23. Simvastatin 23. Docusate Sodium 9. Docusate Sodium 9. Docusate Sodium 9. Stable anemia, HCT=29.6, PLTs=82. Platelets down-HITT pending. Pain controlled with percocet & toradol. gentle diuresis Gastrointestinal / Abdomen: bowel regimen, prophylaxis Nutrition: ADAT Renal: Foley, Adequate UO, BUN/CR= 14/1.1, gentle diuresis Hematology: A/C with Coumadin for Mechanical Valve & Aflutter. | 37 | [
{
"category": "Radiology",
"chartdate": "2162-04-24 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1130889,
"text": " 4:28 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for effusion/hemothorax\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT W/ CONCOMITANT MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman s/p mvr/maze\n REASON FOR THIS EXAMINATION:\n eval for effusion/hemothorax\n ______________________________________________________________________________\n FINAL REPORT\n TWO-VIEW CHEST, \n\n COMPARISON: Study of .\n\n INDICATION: Status post mitral valve surgery.\n\n FINDINGS: Cardiomediastinal contours are stable in appearance in the\n postoperative setting. Left basilar atelectasis has nearly resolved in the\n interval, and a small left pleural effusion has also decreased in size. Note\n is made of mild interstitial pulmonary edema and an apparent small right\n pleural effusion.\n\n IMPRESSION:\n 1. Resolving left lower lobe atelectasis and effusion.\n 2. Interstitial edema and small right effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-04-21 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1130305,
"text": " 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for effusion\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT W/ CONCOMITANT MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with s/p MVR maze\n REASON FOR THIS EXAMINATION:\n evaluate for effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 57-year-old female post-MVR.\n\n COMPARISON: .\n\n CHEST, AP: Moderate cardiomegaly persists, post-median sternotomy with mitral\n valve replacement. Lung volumes are low, with increased left lower lobe\n atelectasis. A small left pleural effusion is unchanged. A left PICC again\n terminates at the cavoatrial junction. A right venous introduction sheath has\n been removed. There is no pneumothorax.\n\n IMPRESSION: Persistent left lower lobe atelectasis and small effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-04-20 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1130140,
"text": " 8:17 AM\n PORTABLE ABDOMEN Clip # \n Reason: r/o obstruction\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT W/ CONCOMITANT MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with s/p maze and mvr\n REASON FOR THIS EXAMINATION:\n r/o obstruction\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post MVR. Rule out obstruction.\n\n COMPARISON: No prior.\n\n SUPINE ABDOMEN: Bowel gas pattern is no obstructing with air seen in\n non-dilated loops of small and large bowel. There is no free intraperitoneal\n air in this supine and lateral decubitus study. Multiple mediastinal wires\n appear intact.\n\n IMPRESSION: No evidence of bowel obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-04-22 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1130611,
"text": " 5:36 PM\n CHEST (PA & LAT) Clip # \n Reason: interval chnage-? effusion\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT W/ CONCOMITANT MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with MVR\n REASON FOR THIS EXAMINATION:\n interval chnage-? effusion\n ______________________________________________________________________________\n WET READ: 6:43 PM\n little change from previous study. small left pleural effusion persists.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: MVR.\n\n FINDINGS: In comparison with the study of , there is litte change.\n Central catheter remains in place. Stable substantial enlargement of the\n cardiac silhouette with mild residual opacification at the left base.\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-04-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1129793,
"text": " 3:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PTX\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT W/ CONCOMITANT MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman s/p MVR/MAZE\n REASON FOR THIS EXAMINATION:\n PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST.\n\n HISTORY: 57-year-old woman status post mitral valve replacement.\n\n FINDINGS: Comparison is made to previous study from .\n\n Since the prior study, there has been removal of the Swan-Ganz catheter,\n feeding tube, mediastinal drains, and endotracheal tube. There is a residual\n right IJ Cordis. The cardiac silhouette is enlarged but unchanged. The\n mediastinal silhouette is somewhat prominent when compared to the previous\n study; however, this may be due to the technique and poor inspiratory effort.\n There is some streaky density at the left base which is likely due to\n atelectasis. No pneumothoraces are identified.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-04-18 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1129880,
"text": " 2:40 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Pt. had a left sided picc line placed,42cm and needs tip con\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT W/ CONCOMITANT MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with PICC who needs it for antibx and heparin.\n REASON FOR THIS EXAMINATION:\n Pt. had a left sided picc line placed,42cm and needs tip confirmation please\n page at with wet read,thanks.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: Patient with new left-sided PICC line.\n\n FINDINGS: Comparison is made to previous study from .\n\n The distal tip of the left-sided PICC line is at the cavoatrial junction\n appropriately sited. There are no pneumothoraces. There is a small left-\n sided pleural effusion. The faint left retrocardiac opacity has improved\n slightly since the prior study. Cardiomegaly is unchanged.\n\n\n\n\n\n"
},
{
"category": "Echo",
"chartdate": "2162-04-16 00:00:00.000",
"description": "Report",
"row_id": 90467,
"text": "PATIENT/TEST INFORMATION:\nIndication: Mitral valve disease.\nHeight: (in) 61\nWeight (lb): 123\nBSA (m2): 1.54 m2\nBP (mm Hg): 124/81\nHR (bpm): 45\nStatus: Inpatient\nDate/Time: at 14:31\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Marked LA enlargement. Mild spontaneous echo contrast in the body\nof the LA. Mild spontaneous echo contrast in the LAA. Depressed LAA emptying\nvelocity (<0.2m/s) No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Low normal LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Characteristic rheumatic deformity of the mitral valve leaflets\nwith fused commissures and tethering of leaflet motion. Severe valvular MS\n(MVA <1.0cm2). Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic\n(normal) PR.\n\nPERICARDIUM: Very small 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. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\n\nConclusions:\nPre-bypass:\nThe left atrium is markedly dilated. Mild spontaneous echo contrast is seen in\nthe body of the left atrium. Mild spontaneous echo contrast is present in the\nleft atrial appendage. The left atrial appendage emptying velocity is\ndepressed (<0.2m/s). No thrombus is seen in the left atrial appendage. No\natrial septal defect is seen by 2D or color Doppler. Overall left ventricular\nsystolic function is low normal (LVEF 50-55%). Right ventricular chamber size\nand free wall motion are normal. The ascending, transverse and descending\nthoracic aorta are normal in diameter and free of atherosclerotic plaque. The\naortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The mitral valve shows characteristic\nrheumatic deformity. There is severe valvular mitral stenosis (area = 1.0cm2).\nMild (1+) mitral regurgitation is seen. There is a very small pericardial\neffusion.\n\nPost-bypass:\nThe patient is receiving no inotropic support post-CPB. There is a well-seated\nmechanical bileaflet prosthesis in the mitral position with good leaflet\nexcursion. There is no paravalvular regurgitation. There are small\ntransvalvular regurgitation jets consistent with \"washing jets.\" The mean\ntransvalvular pressure gradient is 4 mm Hg with a cardiac output of 2.5 L/min.\nBiventricular systolic function is preserved and all other findings are\nconsistent with pre-bypass findings. The aorta is intact post-decannulation.\nAll findings were communicated to the surgeon intraoperatively.\n\nPRELIMINARY REPORT developed by a Cardiology Fellow. Not reviewed/approved by\nthe Attending Echo Physician.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2162-04-23 00:00:00.000",
"description": "Report",
"row_id": 232168,
"text": "Slow atrial flutter with variable conduction block. Right axis deviation.\nNon-specific ST-T wave changes. Compared to the previous tracing of the\nrate has decreased.\n\n"
},
{
"category": "ECG",
"chartdate": "2162-04-21 00:00:00.000",
"description": "Report",
"row_id": 232169,
"text": "Regular tachycardia of uncertain mechanism but may be accelerated junctional\nrhythm. Rightward axis. Low QRS voltage. Diffuse ST-T wave abnormalities.\nFindings are non-specific but clinical correlation is suggested. Since the\nprevious tracing of ventricular response is now regular and faster.\n\n"
},
{
"category": "ECG",
"chartdate": "2162-04-20 00:00:00.000",
"description": "Report",
"row_id": 232170,
"text": "Probable atrial fibrillation. Low QRS voltage. Right axis deviation.\nDelayed R wave progression. ST-T wave abnormalities. Findings are\nnon-specific. Clinical correlation is suggested. Since the previous tracing\nof regular wide complex tachy-arrhythmia is now absent.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2162-04-16 00:00:00.000",
"description": "Report",
"row_id": 232171,
"text": "Wide complex tachycardia of uncertain mechanism but may be atrial tachycardia\nor \"slow\" flutter with 2:1 response and left bundle-branch block/left axis\ndeviation configuration. Since the previous tracing of findings as\noutlined are now present.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2162-04-13 00:00:00.000",
"description": "Report",
"row_id": 232172,
"text": "Atrial flutter with slow ventricular response. Prior inferior myocardial\ninfarction. Possible prior anteroseptal myocardial infarction. Lateral\nST-T wave changes may be due to myocardial ischemia. Low voltage in the\nprecordial leads. No previous tracing available for comparison.\n\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-18 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 735381,
"text": "Ejection Fraction:40\n Hemoglobin A1c:5.5\n Pre-Op Weight:124 lbs 56.25 kgs\n Baseline Creatinine:1.0\n PMH: ^lipids, afib/flutter, non-. cardiomyopathy, severe MR\n : Levoxyl 137mcg', Coumadin 2.5mg'-LD , Simvastatin 80mg',\n Metoprolol 50''. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements\n Assessment:57F s/p MVr (), maze \n Valve replacement, mitral mechanical (MVR)\n Assessment:\n Neurologically intact but lethagic,fatigued.transfers well with 1\n assist.remains in afib/flutter with vrr 90-110. digoxin,multaq\n resumed,lopressor increased for rate control.coumadin started,plan to\n bridge to heparin on pod # 3.wires & chest tubes removed .poor\n appetite,bouts of nausea.\n Action:\n Response:\n Nausea improved with reglan & zofran.\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 735668,
"text": " MVR 927/29 on-y mechanical) Maze, LAA ligation, easy\n intubation, left atrium very large per anesthesia\n Valve replacement, mitral mechanical (MVR)\n Assessment:\n Neuro: Intact, MAE very weak and slightly lethargic, no energy,\n CV: Rate controlled AF 80-90\ns with no ectopy, did not receive morning\n dose of lopressor due to BP of low 80\ns, BP 90-low 100\ns, weak palpable\n pedal pulses\n Resp: 3 liters NC, LSCTA, strong congested/productive cough with thick\n dark tanish sputum\n GI: +BS, +flatus, no difficulty swallowing, poor appetite, no nausea\n GU: Patent foley draining adequate amounts of clear yellow urine\n Endo: BS covered by personal RISS\n Pain: incisional pain\n Action:\n Neuro: OOB\nchair\n CV: Receives dronderone as ordered, HIT screening obtained\n Resp: Weaned from the O2, CDB and IS encouraged, decent amount of\n sputum with coughs\n GI: Good breakfast ordered and eating encouraged\n Endo: Receives Lantus fixed dose at 8am, BS ACHS\n Pain: Adequate relief with Tylenol\n Response:\n Neuro: 1 assist with moves and turning, steady on her feet\n CV: Remains in AF 80-90\ns, no ectopy\n Resp: Room air sats 93%, no respiratory distress\n GI: No difficulty swallowing, eating encouraged, patient slightly\n nauseas, with no vomiting, zofran given\n Endo: BS well controlled\n Plan:\n Continue to monitor and transfer to the floor\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735267,
"text": "Valve replacement, mitral mechanical (MVR)\n Assessment:\n Pt sleepy throughout shift but easily arousable and oriented x3. MAE\n and follows all commands.\n HR-A-fib/A-flutter 60\ns-80\ns with SBP-90\ns-120\ns per cuff/a-line. AM\n labs sent. +DP and PT pulses palpable.\n LS-CTA/Dim at bases on 2LO2 NC with sats >95%. Pt encouraged to C&DB.\n Abd. Soft with hypoactive BS. No c/o N/V at this time.\n Foley intact draining good amounts of clear, yellow urine.\n BS\ns checked and covered per CVICU protocol.\n Action:\n Pt washed in evening, turned and repositioned throughout shift.\n Pt continues on beta blocker and diuresed making good urine throughout\n shift.\n AM labs- K-4.1, mag.-2, Hct-29, and platelets down from 110 to 82.\n Response:\n No further changes in assessment at this time.\n Plan:\n Continue to assess neuro status.\n Monitor HR and BP and beta block as tolerated.\n Increase activity and diet as tolerated. Monitor BS\ns and administer\n insulin per CVICU protocol.\n Pulmonary toilet.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain .\n Action:\n Pt given 1 percocet in evening and toradol during night for pain during\n movement and C&DB.\n Response:\n Pt resting comfortably with eyes closed at this time.\n Plan:\n Continue to assess pain level and administer pain meds prn.\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735313,
"text": "Valve replacement, mitral mechanical (MVR)\n Assessment:\n Pt sleepy throughout shift but easily arousable and oriented x3. MAE\n and follows all commands.\n HR-A-fib/A-flutter 60\ns-80\ns with SBP-90\ns-120\ns per cuff/a-line. AM\n labs sent. +DP and PT pulses palpable.\n LS-CTA/Dim at bases on 2LO2 NC with sats >95%. Pt encouraged to C&DB.\n Abd. Soft with hypoactive BS. No c/o N/V at this time.\n Foley intact draining good amounts of clear, yellow urine.\n BS\ns checked and covered per CVICU protocol.\n Action:\n Pt washed in evening, turned and repositioned throughout shift.\n Pt continues on beta blocker and diuresed making good urine throughout\n shift.\n AM labs- K-4.1, mag.-2, Hct-29, and platelets 82.\n Response:\n No further changes in assessment at this time.\n Plan:\n Continue to assess neuro status.\n Monitor HR and BP and beta block as tolerated.\n Increase activity and diet as tolerated. Monitor BS\ns and administer\n insulin per CVICU protocol.\n Pulmonary toilet.\n UOP decreasing in am. Continue to diurese and monitor.\n Transfer to 6.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain .\n Action:\n Pt given 1 percocet in evening and toradol during night for pain during\n movement and C&DB.\n Response:\n Pt resting comfortably with eyes closed at this time.\n Plan:\n Continue to assess pain level and administer pain meds prn.\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-16 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 734957,
"text": "Valve replacement, mitral mechanical (MVR)/maze\n Assessment:\n Neuro: Admitted from operating room sedated on IV Propofol.\n Cardiac: CCO swan in place. IV NEO infusing upon admission. Pacer-AV\n pacing. Ct\ns patent for minimal sero-sang drainage. RT PT\n only.\n Resp: Intubated. Chest sounds diminished in bases.\n OG: OG in place.\n GU: Foley in place, patent for clear yellow\n Endo: Glucose above 120\n Pain: Appears comfortable per vital signs.\n Family: Husband and daughter in to see patient\n Action:\n Neuro: Reversals given, woke, MAE, Following commands\n Cardiac: CCO swan calibrated. CO/CI acceptable. Pacer tested- A wires\n do not sense/capture-reported from operating room. V\nS sense/capture.\n Patient own heart rate faster than pacer set. Total 2 liters RL given\n for elevated heart rate and dropping SVO2. Pacer set at 60. Neo stopped\n and IV NTG started to keep S b/p less than 120. Feet wrapped with warm\n blankets\n Resp: Reversals given\n OG: Placement checked, patent for bilious, small amt bldy, quickly\n change to bilious.-ranitidine given\n Endo: Insulin gtt started.\n Pain: With reversals patient nods yes to pain, medicated with IV\n morphine\n Family: All questions answered, explained to family plan.\n Response:\n Cardiac: Heart rate now AF in the 80\ns. Bilateral pulses\n Plan:\n Neuro: Reorient as needed.\n Cardiac: Monitor hemodynamics, repleate lab work as needed,\n Resp: Wean to extubated\n GI: Pull with extubation, increase diet as tolerated\n GU: Monitor urine output\n Endo: Follow insulin protocol\n Pain: Medicate as needed, see care plan\n Family: Answer all questions. Husband plans to visit again on \n"
},
{
"category": "Nursing",
"chartdate": "2162-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735655,
"text": " MVR 927/29 on-y mechanical) Maze, LAA ligation, easy\n intubation, left atrium very large per anesthesia\n Valve replacement, mitral mechanical (MVR)\n Assessment:\n Neuro: Intact, MAE very weak and slightly lethargic, no energy,\n CV: Rate controlled AF 80-90\ns with no ectopy, did not receive morning\n dose of lopressor due to BP of low 80\ns, BP 90-low 100\ns, weak palpable\n pedal pulses\n Resp: 3 liters NC, LSCTA, strong congested/productive cough with thick\n dark tanish sputum\n GI: +BS, +flatus, no difficulty swallowing, poor appetite, no nausea\n GU: Patent foley draining adequate amounts of clear yellow urine\n Endo: BS covered by personal RISS\n Pain: incisional pain\n Action:\n Neuro: OOB\nchair\n CV: Receives dronderone as ordered, HIT screening obtained\n Resp: Weaned from the O2, CDB and IS encouraged, decent amount of\n sputum with coughs\n GI: Good breakfast ordered and eating encouraged\n Endo: Receives Lantus fixed dose at 8am, BS ACHS\n Pain: Adequate relief with Tylenol\n Response:\n Neuro: 1 assist with moves and turning, steady on her feet\n CV: Remains in AF 80-90\ns, no ectopy\n Resp: Room air sats 93%, no respiratory distress\n GI: No difficulty swallowing, eating encouraged, patient slightly\n nauseas, with no vomiting, zofran given\n Endo: BS well controlled\n Plan:\n Continue to monitor and transfer to the floor\n"
},
{
"category": "General",
"chartdate": "2162-04-19 00:00:00.000",
"description": "Generic Note",
"row_id": 735632,
"text": "CVICU\n HPI:\n 57 y.o. F POD # 3 from maze, MVR (mechanical)\n PMH: ^lipids, afib/flutter, non-. cardiomyopathy, severe MR\n : Levoxyl 137mcg', Coumadin 2.5mg'-LD , Simvastatin 80mg',\n Metoprolol 50''. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements\n Events:\n Heparin POD 3 if not anticoagulated\n PWs/CTs DC'd.Coumadin 5mg.AFlutter, EP consulted.*F6 in AM\n Assessment:57F s/p MVR (mechanical)/ maze \n Current medications:\n Acetaminophen . Aspirin EC . Calcium Gluconate . Dextrose 50% .\n Dextrose 50% Digoxin . Docusate Sodium . Dronedarone . Furosemide .\n Glucagon . Heparin Flush (10 units/ml) Insulin . Magnesium Sulfate .\n Metoprolol Tartrate . Metoclopramide . Milk of Magnesia Ondansetron .\n Potassium Chloride Ranitidine . Simvastatin . Warfarin\n 24 Hour Events:\n PICC LINE - START 02:08 PM\n CORDIS/INTRODUCER - STOP 04:06 PM\n Post operative day:\n POD 3- MVR(mech)/MAZE\n Allergies:\n Penicillins\n Anaphylaxis;\n Erythromycin Base\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:10 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 07:53 AM\n Furosemide (Lasix) - 08:00 AM\n Other medications:\n Flowsheet Data as of 11:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.5\nC (97.7\n HR: 91 (65 - 111) bpm\n BP: 96/43(55) {74/23(37) - 111/65(70)} mmHg\n RR: 17 (11 - 22) insp/min\n SPO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 59 kg (admission): 55.5 kg\n Height: 61 Inch\n Total In:\n 536 mL\n 144 mL\n PO:\n 180 mL\n Tube feeding:\n IV Fluid:\n 356 mL\n 144 mL\n Blood products:\n Total out:\n 1,880 mL\n 900 mL\n Urine:\n 1,880 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,344 mL\n -756 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 94%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, fatigued\n HEENT: PERRL\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 77 K/uL\n 8.8 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 20 mg/dL\n 103 mEq/L\n 137 mEq/L\n 25.5 %\n 16.9 K/uL\n [image002.jpg]\n 12:45 AM\n 01:05 AM\n 02:21 AM\n 04:00 AM\n 04:03 AM\n 04:42 AM\n 05:48 AM\n 12:23 PM\n 01:30 AM\n 03:52 AM\n WBC\n 16.0\n 16.4\n 16.9\n Hct\n 30.8\n 27.4\n 32.1\n 29.6\n 25.5\n Plt\n 110\n 82\n 77\n Creatinine\n 1.1\n 1.0\n 0.9\n TCO2\n 24\n 22\n 24\n 22\n Glucose\n 82\n 121\n 113\n 100\n 97\n 85\n 129\n 110\n 115\n Other labs: PT / PTT / INR:15.9/26.6/1.4, Fibrinogen:147 mg/dL, Lactic\n Acid:3.0 mmol/L, Ca:7.8 mg/dL, Mg:1.7 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), VALVE REPLACEMENT, MITRAL\n MECHANICAL (MVR)\n Assessment and Plan: 57 y.o. F POD # 3 from maze, MVR (mechanical)\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Full anticoagulation, Multaq, HD stable\n Pulmonary: IS. OOB\n chair\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Regular diet\n Renal: Foley, adequate urine output\n Hematology: Stable anemia, thrombocytopenia. HIT pending\n Endocrine: RISS with adequate glucose control. Goal BG < 150\n Infectious Disease: No evidence of infection\n Lines / Tubes / Drains: Foley\n Fluids: KVO\n Consults: P.T.\n ICU Care\n lycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:08 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 20 min\n"
},
{
"category": "Physician ",
"chartdate": "2162-04-19 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 735612,
"text": "CVICU\n HPI:\n HD7 POD 3-maze, MVR (mechanical)\n Ejection Fraction:40\n Hemoglobin A1c:5.5\n Pre-Op Weight:124 lbs 56.25 kgs\n Baseline Creatinine:1.0\n PMH: ^lipids, afib/flutter, non-. cardiomyopathy, severe MR\n : Levoxyl 137mcg', Coumadin 2.5mg'-LD , Simvastatin 80mg',\n Metoprolol 50''. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements\n Events:\n Heparin POD 3 if not anticoagulated\n PWs/CTs DC'd.Coumadin 5mg.AFlutter, EP consulted.*F6 in AM\n Assessment:57F s/p MVR (mechanical)/ maze \n Current medications:\n Acetaminophen . Aspirin EC . Calcium Gluconate . Dextrose 50% .\n Dextrose 50% Digoxin . Docusate Sodium . Dronedarone . Furosemide .\n Glucagon . Heparin Flush (10 units/ml) Insulin . Magnesium Sulfate .\n Metoprolol Tartrate . Metoclopramide . Milk of Magnesia Ondansetron .\n Potassium Chloride Ranitidine . Simvastatin . Warfarin\n 24 Hour Events:\n PICC LINE - START 02:08 PM\n CORDIS/INTRODUCER - STOP 04:06 PM\n Post operative day:\n POD 3- MVR(mech)/MAZE\n Allergies:\n Penicillins\n Anaphylaxis;\n Erythromycin Base\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:10 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 07:53 AM\n Furosemide (Lasix) - 08:00 AM\n Other medications:\n Flowsheet Data as of 11:41 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.5\nC (97.7\n HR: 91 (65 - 111) bpm\n BP: 96/43(55) {74/23(37) - 111/65(70)} mmHg\n RR: 17 (11 - 22) insp/min\n SPO2: 94%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 59 kg (admission): 55.5 kg\n Height: 61 Inch\n Total In:\n 536 mL\n 144 mL\n PO:\n 180 mL\n Tube feeding:\n IV Fluid:\n 356 mL\n 144 mL\n Blood products:\n Total out:\n 1,880 mL\n 900 mL\n Urine:\n 1,880 mL\n 900 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,344 mL\n -756 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 94%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress, fatigued\n HEENT: PERRL\n Cardiovascular: (Rhythm: No(t) Regular, Irregular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 77 K/uL\n 8.8 g/dL\n 115 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.2 mEq/L\n 20 mg/dL\n 103 mEq/L\n 137 mEq/L\n 25.5 %\n 16.9 K/uL\n [image002.jpg]\n 12:45 AM\n 01:05 AM\n 02:21 AM\n 04:00 AM\n 04:03 AM\n 04:42 AM\n 05:48 AM\n 12:23 PM\n 01:30 AM\n 03:52 AM\n WBC\n 16.0\n 16.4\n 16.9\n Hct\n 30.8\n 27.4\n 32.1\n 29.6\n 25.5\n Plt\n 110\n 82\n 77\n Creatinine\n 1.1\n 1.0\n 0.9\n TCO2\n 24\n 22\n 24\n 22\n Glucose\n 82\n 121\n 113\n 100\n 97\n 85\n 129\n 110\n 115\n Other labs: PT / PTT / INR:15.9/26.6/1.4, Fibrinogen:147 mg/dL, Lactic\n Acid:3.0 mmol/L, Ca:7.8 mg/dL, Mg:1.7 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), VALVE REPLACEMENT, MITRAL\n MECHANICAL (MVR)\n Assessment and Plan: Stable but fatigued. . Platelets down-HITT\n pending. Heparin after results known to be negative.To floor\n Neurologic: Neuro checks Q: 4 hr, Pain controlled\n Cardiovascular: Aspirin, Full anticoagulation, Multaq\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet\n Renal: Foley\n Hematology:\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Fluids:\n Consults: P.T.\n ICU Care\n lycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 02:08 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition:\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735426,
"text": "Ejection Fraction:40\n Hemoglobin A1c:5.5\n Pre-Op Weight:124 lbs 56.25 kgs\n Baseline Creatinine:1.0\n PMH: ^lipids, afib/flutter, non-. cardiomyopathy, severe MR\n : Levoxyl 137mcg', Coumadin 2.5mg'-LD , Simvastatin 80mg',\n Metoprolol 50''. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements\n Assessment:57F s/p MVr (), maze \n Valve replacement, mitral mechanical (MVR)\n Assessment:\n Neurologically intact but lethagic,fatigued.transfers well with 1\n assist.remains in afib/flutter with vrr 90-120\ns. digoxin,multaq\n resumed,lopressor increased for rate control.coumadin started,plan to\n bridge to heparin on pod # 3 until inr becomes therapeutic..wires &\n chest tubes removed .picc placed for access/blood drawing.poor\n appetite,bouts of nausea. Pain controlled with percocet & toradol.\n Action:\n Antiemetics added,lopressor increased,picc placed\n Response:\n Nausea improved with reglan & zofran. Vrr now < 100.\n Plan:\n Pathway for mechanical mvr\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735502,
"text": "Valve replacement, mitral mechanical (MVR)\n Assessment:\n Lethargic but a & o x 3,aflutter/fib 70\ns. Received with bp syst 80\n Eventual increase to 90\ns but Metropolol held at 2200. decreased\n breathsounds . C and DB with IS q3-4hour over night.\n Action:\n Narcotics dc\nd due to lethargy and med x 1 with Tylenol for discomfort.\n ,anticoagulation begun and received Coumadin yesterday,. Borderline\n low uop except when lasix given.\n Response:\n Good uop post lasix. Adequate pain control on Tylenol.\n Plan:\n Pulmonary toilet,monitor inr & dose Coumadin accordingly,pathway\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 735605,
"text": " MVR 927/29 on-y mechanical) Maze, LAA ligation, easy\n intubation, left atrium very large per anesthesia\n Valve replacement, mitral mechanical (MVR)\n Assessment:\n Neuro: Intact, MAE very weak and slightly lethargic, no energy,\n CV: Rate controlled AF 80-90\ns with no ectopy, did not receive morning\n dose of lopressor due to BP of low 80\ns, BP 90-low 100\ns, weak palpable\n pedal pulses\n Resp: 3 liters NC, LSCTA, strong congested/productive cough with thick\n dark tanish sputum\n GI: +BS, +flatus, no difficulty swallowing, poor appetite, no nausea\n GU: Patent foley draining adequate amounts of clear yellow urine\n Endo: BS covered by personal RISS\n Pain: incisional pain\n Action:\n Neuro: OOB\nchair\n CV: Receives dronderone as ordered\n Resp: Weaned from the O2, CDB and IS encouraged, decent amount of\n sputum with coughs\n GI: Good breakfast ordered and eating encouraged\n GU: Foley discontinued at ####\n Endo: Receives Lantus fixed dose at 8am, BS ACHS\n Pain: Adequate relief with Tylenol\n Response:\n Neuro: 1 assist with moves and turning, steady on her feet\n CV: Remains in AF 80-90\ns, no ectopy\n Resp: Room air sats 93%, no respiratory distress\n GI: No difficulty swallowing, eating encouraged, patient slightly\n nauseas, with no vomiting, zofran given\n GU: DTV @ ####\n Endo: BS well controlled\n Plan:\n Continue to monitor and transfer to the floor\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 735606,
"text": " MVR 927/29 on-y mechanical) Maze, LAA ligation, easy\n intubation, left atrium very large per anesthesia\n Valve replacement, mitral mechanical (MVR)\n Assessment:\n Neuro: Intact, MAE very weak and slightly lethargic, no energy,\n CV: Rate controlled AF 80-90\ns with no ectopy, did not receive morning\n dose of lopressor due to BP of low 80\ns, BP 90-low 100\ns, weak palpable\n pedal pulses\n Resp: 3 liters NC, LSCTA, strong congested/productive cough with thick\n dark tanish sputum\n GI: +BS, +flatus, no difficulty swallowing, poor appetite, no nausea\n GU: Patent foley draining adequate amounts of clear yellow urine\n Endo: BS covered by personal RISS\n Pain: incisional pain\n Action:\n Neuro: OOB\nchair\n CV: Receives dronderone as ordered, HIT screening obtained\n Resp: Weaned from the O2, CDB and IS encouraged, decent amount of\n sputum with coughs\n GI: Good breakfast ordered and eating encouraged\n GU: Foley discontinued at ####\n Endo: Receives Lantus fixed dose at 8am, BS ACHS\n Pain: Adequate relief with Tylenol\n Response:\n Neuro: 1 assist with moves and turning, steady on her feet\n CV: Remains in AF 80-90\ns, no ectopy\n Resp: Room air sats 93%, no respiratory distress\n GI: No difficulty swallowing, eating encouraged, patient slightly\n nauseas, with no vomiting, zofran given\n GU: DTV @ ####\n Endo: BS well controlled\n Plan:\n Continue to monitor and transfer to the floor\n"
},
{
"category": "Physician ",
"chartdate": "2162-04-18 00:00:00.000",
"description": "Generic Note",
"row_id": 735416,
"text": "TITLE:\n CVICU\n HPI:\n HD6 POD 2-MVR(Mechanical)/MAZE\n Ejection Fraction:40\n Hemoglobin A1c:5.5\n Pre-Op Weight:124 lbs 56.25 kgs\n Baseline Creatinine:1.0\n PMH: ^lipids, afib/flutter, non-. cardiomyopathy, severe MR\n : Levoxyl 137mcg', Coumadin 2.5mg'-LD , Simvastatin 80mg',\n Metoprolol 50''. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements\n Assessment:57F s/p MVr (), maze \n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 4. Aspirin EC 5. Calcium Gluconate 6. Dextrose 50% 7.\n Digoxin\n 8. Docusate Sodium 9. Dronedarone 10. Furosemide 11. Insulin 12.\n Ketorolac 13. Ketorolac 14. Magnesium Sulfate\n 15. Metoprolol Tartrate 16. Metoclopramide 17. Milk of Magnesia 18.\n Morphine Sulfate 19. Oxycodone-Acetaminophen\n 20. Potassium Chloride 21. Ranitidine 22. Simvastatin 23. Vancomycin\n 24. Warfarin 25. Warfarin\n 24 Hour Events:\n: Aflutter. HD stable. EP consulted. A/C with Coumadin\n started.\n : Extubated. Weaned off NTG gtt. HD stable in AFlutter.\n CORDIS/INTRODUCER - START 06:01 PM\n CCO PAC - START 06:01 PM\n ARTERIAL LINE - START 06:01 PM\n OR RECEIVED - At 06:01 PM\n INVASIVE VENTILATION - START 06:01 PM\n NASAL SWAB - At 06:10 PM\n EKG - At 07:50 PM\n Post operative day:\n POD#2 s/p MVR (mechanical), MAZE4/9/10\n Allergies:\n Penicillins\n Anaphylaxis;\n Erythromycin Base\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 07:54 AM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 09:43 PM\n Furosemide (Lasix) - 08:53 AM\n Morphine Sulfate - 08:53 AM\n Ranitidine (Prophylaxis) - 08:59 AM\n Other medications:\n Flowsheet Data as of 04:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 88 (77 - 125) bpm\n BP: 97/70(81) {97/65(79) - 146/108(115)} mmHg\n RR: 14 (6 - 23) insp/min\n SPO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 66.6 kg (admission): 55.5 kg\n Height: 61 Inch\n CVP: 13 (11 - 19) mmHg\n PAP: (29 mmHg) / (21 mmHg)\n CO/CI (Fick): (3.8 L/min) / (2.5 L/min/m2)\n CO/CI (CCO): (3.4 L/min) / (2.3 L/min/m2)\n SvO2: 60%\n Mixed Venous O2% sat: 67 - 67\n Total In:\n 6,827 mL\n 2,942 mL\n PO:\n 60 mL\n Tube feeding:\n IV Fluid:\n 6,227 mL\n 2,007 mL\n Blood products:\n 600 mL\n 875 mL\n Total out:\n 1,014 mL\n 2,765 mL\n Urine:\n 125 mL\n 2,495 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 5,813 mL\n 178 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 362 (362 - 362) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 58\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n SPO2: 95%\n ABG: 7.40/34/127/22/-2\n Ve: 6.4 L/min\n PaO2 / FiO2: 254\n Physical Examination\n Labs / Radiology\n 82 K/uL\n g/dL\n 110 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 17 mg/dL\n 106 mEq/L\n 139mEq/L\n 29.6 %\n 16.4 K/uL\n [image002.jpg]\n 06:30 PM\n 12:00 AM\n 12:45 AM\n 01:05 AM\n 02:21 AM\n 04:00 AM\n 04:03 AM\n 04:42 AM\n 05:48 AM\n 12:23 PM\n WBC\n 16.0\n Hct\n 30.8\n 27.4\n 32.1\n Plt\n 110\n Creatinine\n 1.1\n TCO2\n 24\n 24\n 22\n 24\n 22\n Glucose\n 136\n 98\n 82\n 121\n 113\n 100\n 97\n 85\n 129\n Other labs: PT / PTT / INR:13.7/25.6/1.2, Fibrinogen:147 mg/dL, Lactic\n Acid:3.0 mmol/L, Mg:1.7 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), VALVE REPLACEMENT, MITRAL\n MECHANICAL (MVR)\n Assessment and Plan: POD#1 s/p MVR (mechanical), MAZE4/9/10\n :\n Extubated. Weaned off NTG gtt. HD stable in AFlutter.\n:\n Aflutter. HD stable. EP consulted. A/C with Coumadin started.\n Neurologic: Neuro checks Q: 4 hr, PCT/Torodol prn pain. OOB->chair.\n Cardiovascular: Aspirin, Statins, Optimize B-Blocker, Multaq and Dig\n for rate control atrial flutter/fib. EP consulted per RH for . A/C with\n Coumadin. Heparin gtt not until pod#3\n Pulmonary: IS, OOB->chair. Encourage DB&C,IS. gentle diuresis\n Gastrointestinal / Abdomen: bowel regimen, prophylaxis\n Nutrition: ADAT\n Renal: Foley, Adequate UO, BUN/CR= 17/1.0, gentle diuresis\n Hematology: A/C with Coumadin for Mechanical Valve & Aflutter. Stable\n anemia, HCT=29.6, PLTs=82.\n Endocrine: RISS, Lantus (R)\n Infectious Disease: No issues. Periop ABX\n Lines / Tubes / Drains:\n Wounds: Dry dressings\n Imaging:\n Fluids:\n Consults: CT surgery, P.T., EP dept\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Arterial Line - 06:01 PM\n Cordis/Introducer - 06:01 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Tx F6\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 735708,
"text": " MVR 927/29 on-y mechanical) Maze, LAA ligation, easy\n intubation, left atrium very large per anesthesia\n Valve replacement, mitral mechanical (MVR)\n Assessment:\n Neuro: Intact, MAE very weak and slightly lethargic, no energy,\n CV: Rate controlled AF 80-90\ns with no ectopy, did not receive morning\n dose of lopressor due to BP of low 80\ns, BP 90-low 100\ns, weak palpable\n pedal pulses\n Resp: 3 liters NC, LSCTA, strong congested/productive cough with thick\n dark tanish sputum\n GI: +BS, +flatus, no difficulty swallowing, poor appetite, no nausea\n GU: Patent foley draining adequate amounts of clear yellow urine\n Endo: BS covered by personal RISS\n Pain: incisional pain\n Action:\n Neuro: OOB\nchair\n CV: Receives dronderone as ordered, HIT screening obtained\n Resp: Weaned from the O2, CDB and IS encouraged, decent amount of\n sputum with coughs\n GI: Good breakfast ordered and eating encouraged\n Endo: Receives Lantus fixed dose at 8am, BS ACHS\n Pain: Adequate relief with Tylenol\n Response:\n Neuro: 1 assist with moves and turning, steady on her feet\n CV: Remains in AF 80-90\ns, no ectopy\n Resp: Room air sats 93%, no respiratory distress\n GI: No difficulty swallowing, eating encouraged, patient slightly\n nauseas, with no vomiting, zofran given\n Endo: BS well controlled\n Plan:\n Continue to monitor and transfer to the floor\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 735710,
"text": " MVR 927/29 on-y mechanical) Maze, LAA ligation, easy\n intubation, left atrium very large per anesthesia\n Valve replacement, mitral mechanical (MVR)\n Assessment:\n Neuro: Intact, MAE very weak and slightly lethargic, no energy,\n CV: Rate controlled AF 80-90\ns with no ectopy, did not receive morning\n dose of lopressor due to BP of low 80\ns, BP 90-low 100\ns, weak palpable\n pedal pulses\n Resp: 3 liters NC, LSCTA, strong congested/productive cough with thick\n dark tanish sputum\n GI: +BS, +flatus, no difficulty swallowing, poor appetite, no nausea\n GU: Patent foley draining adequate amounts of clear yellow urine\n Endo: BS covered by personal RISS\n Pain: incisional pain\n Action:\n Neuro: OOB\nchair\n CV: Receives dronderone as ordered, HIT screening obtained\n Resp: Weaned from the O2, CDB and IS encouraged, decent amount of\n sputum with coughs\n GI: Good breakfast ordered and eating encouraged\n Endo: Receives Lantus fixed dose at 8am, BS ACHS\n Pain: Adequate relief with Tylenol\n Response:\n Neuro: 1 assist with moves and turning, steady on her feet\n CV: Remains in AF 80-90\ns, no ectopy\n Resp: Room air sats 93%, no respiratory distress\n GI: No difficulty swallowing, eating encouraged, patient slightly\n nauseas, with no vomiting, zofran given\n Endo: BS well controlled\n Plan:\n Continue to monitor and transfer to the floor\n Demographics\n Attending MD:\n C.\n Admit diagnosis:\n MITRAL VALVE DISORDER MITRAL VALVE REPLACEMENT W/ CONCOMITA\n Code status:\n Full code\n Height:\n 61 Inch\n Admission weight:\n 55.5 kg\n Daily weight:\n 59 kg\n Allergies/Reactions:\n Penicillins\n Anaphylaxis;\n Erythromycin Base\n Nausea/Vomiting\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: Arrhythmias\n Additional history: Rheumatic fever, Hyperlipidemia, Nonischemic\n cardiomyopathy, Atrial flutter s/p failed ablations and failed several\n antiarrhymatic agents including flecainaide, Amio., and Multag DCCV\n (reverted to AF in 10 min). Pericardial effusions after ablations, s/p\n pericardiocentesis. Mitral Stenosis/Mitral regurgitation,\n hypothyroidism, Depression.\n S/p tonsillectomy, Lap chole, Total abdominal hysterectomy.(+) \n Father with MI in 40's- died of CHF age 79, ETOH-prior alcholic-sober\n since \n Surgery / Procedure and date: MVR 927/29 on-y mechanical)\n Maze, LAA ligation. easy intubation. bypass time 149 minutes, cross\n clamp time- 84 minutes. 3400 crystalloid, 600 cell ,\n urien-825.left atrium very large per anesthesia\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:114\n D:46\n Temperature:\n 99\n Arterial BP:\n S:109\n D:60\n Respiratory rate:\n 19 insp/min\n Heart Rate:\n 96 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n None\n O2 saturation:\n 99% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 144 mL\n 24h total out:\n 1,865 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 03:52 AM\n Potassium:\n 4.2 mEq/L\n 03:52 AM\n Chloride:\n 103 mEq/L\n 03:52 AM\n CO2:\n 28 mEq/L\n 03:52 AM\n BUN:\n 20 mg/dL\n 03:52 AM\n Creatinine:\n 0.9 mg/dL\n 03:52 AM\n Glucose:\n 115 mg/dL\n 03:52 AM\n Hematocrit:\n 25.5 %\n 03:52 AM\n Finger Stick Glucose:\n 103\n 05:00 PM\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: cvicu a\n Transferred to: 6\n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735544,
"text": "Valve replacement, mitral mechanical (MVR)\n Assessment:\n Lethargic but a & o x 3, easily arousable.aflutter/fib 70\ns. Received\n with bp syst 80\ns. Eventual increase to 90\ns but Metropolol held at\n 2200 and again at 0600. decreased breathsounds . C and DB with IS\n q3-4hour over night. Sat is maintained in high 90\ns on 2lnp. Productive\n cough. Mobilizing secretions.\n Action:\n Narcotics dc\nd due to lethargy and med x 1 with Tylenol for\n discomfort. ,anticoagulation begun and received Coumadin yesterday,\n (inr increased this am). Borderline low uop except when lasix given.\n Response:\n Good uop post lasix. Adequate pain control on Tylenol.\n Plan:\n Pulmonary toilet,monitor inr & dose Coumadin accordingly, pathway. Hct\n drop this am (29-25)\n? Transfuse. Monitor BP for dosing of metropolol.\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-19 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 735579,
"text": " MVR 927/29 on-y mechanical) Maze, LAA ligation, easy\n intubation, left atrium very large per anesthesia\n Valve replacement, mitral mechanical (MVR)\n Assessment:\n Neuro: Intact, MAE very weak and slightly lethargic, no energy,\n CV: Rate controlled AF 80-90\ns with no ectopy, did not receive morning\n dose of lopressor due to BP of low 80\ns, BP 90-low 100\ns, weak palpable\n pedal pulses\n Resp: 3 liters NC, LSCTA, strong congested/productive cough with thick\n dark tanish sputum\n GI: +BS, +flatus, no difficulty swallowing, poor appetite, no nausea\n GU: Patent foley draining adequate amounts of clear yellow urine\n Endo: BS covered by personal RISS\n Pain: incisional pain\n Action:\n Neuro: OOB\nchair\n CV: Receives dronderone as ordered\n Resp: Weaned from the O2, CDB and IS encouraged, decent amount of\n sputum with coughs\n GI: Good breakfast ordered and eating encouraged\n GU: Foley discontinued at ####\n Endo: Receives Lantus fixed dose at 8am, BS ACHS\n Pain: Adequate relief with Tylenol\n Response:\n Neuro: 1 assist with moves and turning, steady on her feet\n CV: Remains in AF 80-90\ns, no ectopy\n Resp: Room air sats 93%, no respiratory distress\n GI: No difficulty swallowing, eating encouraged\n GU: DTV @ ####\n Endo: BS well controlled\n Plan:\n Continue to monitor and transfer to the floor\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735002,
"text": "57 year old female with known mitral valve stenosis/regurgitation ,\n ^lipids, atrial fib/flutter s/p multi failed interventions and drug\n therapies, nonischemic cardiomyopathy. Ef 40%.pmh rheumatic fever,\n pericardial effusions after ablations/p pericardiocentesis,\n hypothyroidism, depression, prior alcoholic history sober since \n Valve replacement, mitral mechanical (MVR)\n Assessment:\n Aflutter with ventricular response 110\ns,sbp requiring ntg to keep map\n <90, pads 20\ns, cvp high teens, ci>2. warm and dry, dopp pp, hct 30, .\n uo <30 ml/hr. min ct drainage. Neuro intact\n Action:\n 1 L ns , 250 albumin x2, ntg at .5 , md aware of uo, extubated at\n 0250 to open face tent , morphine 4 mg sc x 1,\n Response:\n Continues in aflutter, map <90, ci>2, uo >30, morphine with good\n effect,\n Plan:\n Monitor comfort, hr and rythym? lopressor, sbp-wean ntg as tolerated,\n pads, ci, ct drainage, dsgs, pp, resp status-pulm toilet, neuro status,\n i+o-uo, labs pending. As per orders.\n"
},
{
"category": "Physician ",
"chartdate": "2162-04-18 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 735359,
"text": "CVICU\n HPI:\n HD5 POD 1-maze, MVr ()\n Ejection Fraction:40\n Hemoglobin A1c:5.5\n Pre-Op Weight:124 lbs 56.25 kgs\n Baseline Creatinine:1.0\n PMH: ^lipids, afib/flutter, non-. cardiomyopathy, severe MR\n : Levoxyl 137mcg', Coumadin 2.5mg'-LD , Simvastatin 80mg',\n Metoprolol 50''. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements\n Assessment:57F s/p MVr (), maze \n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 4. Aspirin EC 5. Calcium Gluconate 6. Dextrose 50% 7.\n Digoxin\n 8. Docusate Sodium 9. Dronedarone 10. Furosemide 11. Insulin 12.\n Ketorolac 13. Ketorolac 14. Magnesium Sulfate\n 15. Metoprolol Tartrate 16. Metoclopramide 17. Milk of Magnesia 18.\n Morphine Sulfate 19. Oxycodone-Acetaminophen\n 20. Potassium Chloride 21. Ranitidine 22. Simvastatin 23. Vancomycin\n 24. Warfarin 25. Warfarin\n 24 Hour Events:\n : Extubated. Weaned off NTG gtt. HD stable in AFlutter.\n CORDIS/INTRODUCER - START 06:01 PM\n CCO PAC - START 06:01 PM\n ARTERIAL LINE - START 06:01 PM\n OR RECEIVED - At 06:01 PM\n INVASIVE VENTILATION - START 06:01 PM\n NASAL SWAB - At 06:10 PM\n EKG - At 07:50 PM\n Post operative day:\n POD#1 s/p MVR (mechanical), MAZE4/9/10\n Allergies:\n Penicillins\n Anaphylaxis;\n Erythromycin Base\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 07:54 AM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 09:43 PM\n Furosemide (Lasix) - 08:53 AM\n Morphine Sulfate - 08:53 AM\n Ranitidine (Prophylaxis) - 08:59 AM\n Other medications:\n Flowsheet Data as of 04:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 88 (77 - 125) bpm\n BP: 97/70(81) {97/65(79) - 146/108(115)} mmHg\n RR: 14 (6 - 23) insp/min\n SPO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 66.6 kg (admission): 55.5 kg\n Height: 61 Inch\n CVP: 13 (11 - 19) mmHg\n PAP: (29 mmHg) / (21 mmHg)\n CO/CI (Fick): (3.8 L/min) / (2.5 L/min/m2)\n CO/CI (CCO): (3.4 L/min) / (2.3 L/min/m2)\n SvO2: 60%\n Mixed Venous O2% sat: 67 - 67\n Total In:\n 6,827 mL\n 2,942 mL\n PO:\n 60 mL\n Tube feeding:\n IV Fluid:\n 6,227 mL\n 2,007 mL\n Blood products:\n 600 mL\n 875 mL\n Total out:\n 1,014 mL\n 2,765 mL\n Urine:\n 125 mL\n 2,495 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 5,813 mL\n 178 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 362 (362 - 362) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 58\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n SPO2: 95%\n ABG: 7.40/34/127/22/-2\n Ve: 6.4 L/min\n PaO2 / FiO2: 254\n Physical Examination\n Labs / Radiology\n 110 K/uL\n 9.8 g/dL\n 129 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 114 mEq/L\n 142 mEq/L\n 32.1 %\n 16.0 K/uL\n [image002.jpg]\n 06:30 PM\n 12:00 AM\n 12:45 AM\n 01:05 AM\n 02:21 AM\n 04:00 AM\n 04:03 AM\n 04:42 AM\n 05:48 AM\n 12:23 PM\n WBC\n 16.0\n Hct\n 30.8\n 27.4\n 32.1\n Plt\n 110\n Creatinine\n 1.1\n TCO2\n 24\n 24\n 22\n 24\n 22\n Glucose\n 136\n 98\n 82\n 121\n 113\n 100\n 97\n 85\n 129\n Other labs: PT / PTT / INR:13.7/25.6/1.2, Fibrinogen:147 mg/dL, Lactic\n Acid:3.0 mmol/L, Mg:1.7 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), VALVE REPLACEMENT, MITRAL\n MECHANICAL (MVR)\n Assessment and Plan: POD#1 s/p MVR (mechanical), MAZE4/9/10\n :\n Extubated. Weaned off NTG gtt. HD stable in AFlutter.\n Neurologic: Neuro checks Q: 4 hr, PCT/Torodol prn pain. OOB->chair.\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor,\n Wean off NTG gtt. Optimize B-Blocker, Resumed Multaq and Dig for rate\n control atrial flutter. EP consulted per RH for AFlutter. A/C to start\n tonight with Coumadin. Heparin gtt not until pod#3\n Pulmonary: IS, OOB->chair. Encouareg DB&C,IS. gentle diuresis\n Gastrointestinal / Abdomen: bowel regimen, prophylaxis\n Nutrition: ADAT\n Renal: Foley, Adequate UO, BUN/CR= 14/1.1, gentle diuresis\n Hematology: A/C with Coumadin for Mechanical Valve & Aflutter. Stable\n anemia, HCT=27.4, PLTs=110. Tx 1uPRBC\n Endocrine: RISS, Lantus (R)\n Infectious Disease: No issues. Periop ABX\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today, post-pull CXR\n Fluids:\n Consults: CT surgery, P.T., EP dept\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Arterial Line - 06:01 PM\n Cordis/Introducer - 06:01 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , 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: 10:40 AM ------\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735073,
"text": "57 year old female with known mitral valve stenosis/regurgitation ,\n ^lipids, atrial fib/flutter s/p multi failed interventions and drug\n therapies, nonischemic cardiomyopathy. Ef 40%.pmh rheumatic fever,\n pericardial effusions after ablations/p pericardiocentesis,\n hypothyroidism, depression, prior alcoholic history sober since \n Valve replacement, mitral mechanical (MVR)\n Assessment:\n Aflutter with ventricular response 110\ns,sbp requiring ntg to keep map\n <90, pads 20\ns, cvp high teens, ci>2. warm and dry, dopp pp, hct 30, .\n uo <30 ml/hr. min ct drainage. Neuro intact\n Action:\n 1 L ns , 250 albumin x2, ntg at .5 , md aware of uo, extubated at\n 0250 to open face tent , morphine 4 mg sc x 1, 2.5 mg iv lopressor x 2\n Response:\n Continues in aflutter, map <90, ci>2, uo >30, morphine with good\n effect, after iv lopressor af 80\ns however returned to aflutter/st\n shortly after\n Plan:\n Monitor comfort, hr and rythym?po lopressor, sbp-wean ntg as tolerated,\n pads, ci, ct drainage, dsgs, pp, resp status-pulm toilet, neuro status,\n i+o-uo, labs pending. As per orders.\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-18 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735271,
"text": "Valve replacement, mitral mechanical (MVR)\n Assessment:\n Pt sleepy throughout shift but easily arousable and oriented x3. MAE\n and follows all commands.\n HR-A-fib/A-flutter 60\ns-80\ns with SBP-90\ns-120\ns per cuff/a-line. AM\n labs sent. +DP and PT pulses palpable.\n LS-CTA/Dim at bases on 2LO2 NC with sats >95%. Pt encouraged to C&DB.\n Abd. Soft with hypoactive BS. No c/o N/V at this time.\n Foley intact draining good amounts of clear, yellow urine.\n BS\ns checked and covered per CVICU protocol.\n Action:\n Pt washed in evening, turned and repositioned throughout shift.\n Pt continues on beta blocker and diuresed making good urine throughout\n shift.\n AM labs- K-4.1, mag.-2, Hct-29, and platelets 82.\n Response:\n No further changes in assessment at this time.\n Plan:\n Continue to assess neuro status.\n Monitor HR and BP and beta block as tolerated.\n Increase activity and diet as tolerated. Monitor BS\ns and administer\n insulin per CVICU protocol.\n Pulmonary toilet.\n Transfer to 6.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o incisional pain .\n Action:\n Pt given 1 percocet in evening and toradol during night for pain during\n movement and C&DB.\n Response:\n Pt resting comfortably with eyes closed at this time.\n Plan:\n Continue to assess pain level and administer pain meds prn.\n"
},
{
"category": "Physician ",
"chartdate": "2162-04-17 00:00:00.000",
"description": "ICU Note - CVI",
"row_id": 735174,
"text": "CVICU\n HPI:\n HD5 POD 1-maze, MVr ()\n Ejection Fraction:40\n Hemoglobin A1c:5.5\n Pre-Op Weight:124 lbs 56.25 kgs\n Baseline Creatinine:1.0\n PMH: ^lipids, afib/flutter, non-. cardiomyopathy, severe MR\n : Levoxyl 137mcg', Coumadin 2.5mg'-LD , Simvastatin 80mg',\n Metoprolol 50''. Multaq 400mg'', Digoxin 0.25mg', Vit E supplements\n Assessment:57F s/p MVr (), maze \n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 4. Aspirin EC 5. Calcium Gluconate 6. Dextrose 50% 7.\n Digoxin\n 8. Docusate Sodium 9. Dronedarone 10. Furosemide 11. Insulin 12.\n Ketorolac 13. Ketorolac 14. Magnesium Sulfate\n 15. Metoprolol Tartrate 16. Metoclopramide 17. Milk of Magnesia 18.\n Morphine Sulfate 19. Oxycodone-Acetaminophen\n 20. Potassium Chloride 21. Ranitidine 22. Simvastatin 23. Vancomycin\n 24. Warfarin 25. Warfarin\n 24 Hour Events:\n : Extubated. Weaned off NTG gtt. HD stable in AFlutter.\n CORDIS/INTRODUCER - START 06:01 PM\n CCO PAC - START 06:01 PM\n ARTERIAL LINE - START 06:01 PM\n OR RECEIVED - At 06:01 PM\n INVASIVE VENTILATION - START 06:01 PM\n NASAL SWAB - At 06:10 PM\n EKG - At 07:50 PM\n Post operative day:\n POD#1 s/p MVR (mechanical), MAZE4/9/10\n Allergies:\n Penicillins\n Anaphylaxis;\n Erythromycin Base\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 07:54 AM\n Infusions:\n Other ICU medications:\n Insulin - Regular - 09:43 PM\n Furosemide (Lasix) - 08:53 AM\n Morphine Sulfate - 08:53 AM\n Ranitidine (Prophylaxis) - 08:59 AM\n Other medications:\n Flowsheet Data as of 04:13 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 88 (77 - 125) bpm\n BP: 97/70(81) {97/65(79) - 146/108(115)} mmHg\n RR: 14 (6 - 23) insp/min\n SPO2: 95%\n Heart rhythm: AF (Atrial Fibrillation)\n Wgt (current): 66.6 kg (admission): 55.5 kg\n Height: 61 Inch\n CVP: 13 (11 - 19) mmHg\n PAP: (29 mmHg) / (21 mmHg)\n CO/CI (Fick): (3.8 L/min) / (2.5 L/min/m2)\n CO/CI (CCO): (3.4 L/min) / (2.3 L/min/m2)\n SvO2: 60%\n Mixed Venous O2% sat: 67 - 67\n Total In:\n 6,827 mL\n 2,942 mL\n PO:\n 60 mL\n Tube feeding:\n IV Fluid:\n 6,227 mL\n 2,007 mL\n Blood products:\n 600 mL\n 875 mL\n Total out:\n 1,014 mL\n 2,765 mL\n Urine:\n 125 mL\n 2,495 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 5,813 mL\n 178 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 362 (362 - 362) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 58\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n SPO2: 95%\n ABG: 7.40/34/127/22/-2\n Ve: 6.4 L/min\n PaO2 / FiO2: 254\n Physical Examination\n Labs / Radiology\n 110 K/uL\n 9.8 g/dL\n 129 mg/dL\n 1.1 mg/dL\n 22 mEq/L\n 4.5 mEq/L\n 14 mg/dL\n 114 mEq/L\n 142 mEq/L\n 32.1 %\n 16.0 K/uL\n [image002.jpg]\n 06:30 PM\n 12:00 AM\n 12:45 AM\n 01:05 AM\n 02:21 AM\n 04:00 AM\n 04:03 AM\n 04:42 AM\n 05:48 AM\n 12:23 PM\n WBC\n 16.0\n Hct\n 30.8\n 27.4\n 32.1\n Plt\n 110\n Creatinine\n 1.1\n TCO2\n 24\n 24\n 22\n 24\n 22\n Glucose\n 136\n 98\n 82\n 121\n 113\n 100\n 97\n 85\n 129\n Other labs: PT / PTT / INR:13.7/25.6/1.2, Fibrinogen:147 mg/dL, Lactic\n Acid:3.0 mmol/L, Mg:1.7 mg/dL\n Assessment and Plan\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN), VALVE REPLACEMENT, MITRAL\n MECHANICAL (MVR)\n Assessment and Plan: POD#1 s/p MVR (mechanical), MAZE4/9/10\n :\n Extubated. Weaned off NTG gtt. HD stable in AFlutter.\n Neurologic: Neuro checks Q: 4 hr, PCT/Torodol prn pain. OOB->chair.\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor,\n Wean off NTG gtt. Optimize B-Blocker, Resumed Multaq and Dig for rate\n control atrial flutter. EP consulted per RH for AFlutter. A/C to start\n tonight with Coumadin. Heparin gtt not until pod#3\n Pulmonary: IS, OOB->chair. Encouareg DB&C,IS. gentle diuresis\n Gastrointestinal / Abdomen: bowel regimen, prophylaxis\n Nutrition: ADAT\n Renal: Foley, Adequate UO, BUN/CR= 14/1.1, gentle diuresis\n Hematology: A/C with Coumadin for Mechanical Valve & Aflutter. Stable\n anemia, HCT=27.4, PLTs=110. Tx 1uPRBC\n Endocrine: RISS, Lantus (R)\n Infectious Disease: No issues. Periop ABX\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today, post-pull CXR\n Fluids:\n Consults: CT surgery, P.T., EP dept\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n Arterial Line - 06:01 PM\n Cordis/Introducer - 06:01 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin (R))\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n"
},
{
"category": "Nursing",
"chartdate": "2162-04-17 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 735181,
"text": "Valve replacement, mitral mechanical (MVR)\n Assessment:\n Lethargic but a & o x 3,aflutter/fib 120\ns with stable bp,decreased\n breathsounds with bibasilar crackles,scant chest tube drainage.\n Action:\n Narcotics transitioned to toradol for pain control,anticoagulation\n begun,lopressor & multaq added for rate control,magnesium given as\n recorded,compression sleeves applied,prbc x 1,chest tubes & pacing\n wires removed pre Coumadin.\n Response:\n Rate now < 100 with stable hemodynamics,diuresing with lasix\n Plan:\n Pulmonary toilet,monitor inr & dose Coumadin accordingly,pathway\n"
},
{
"category": "Radiology",
"chartdate": "2162-04-16 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1129715,
"text": " 6:41 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r/o PTX/Effusion\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT W/ CONCOMITANT MAZE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman s/p MVR/MAZE/LAA ligation. Please at \n with abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion\n ______________________________________________________________________________\n WET READ: MBue FRI 7:51 PM\n ET TUBE 3.6CM ABOVE CARINA. RT SWAN GANZ CATHETER TERM PROXIMAL RT PULMONARY\n ARTERY. NGT TERM IN STOMACH WITH SIDEHOLE JUST DISTAL TO GE JUNCTION. MS DRAIN\n IN PLACE. MILD CARDIOMEGALY. NO FOCAL PULMONARY OPACITIES. BLUNTING LEFT CPA.\n ______________________________________________________________________________\n FINAL REPORT\n\n AP CHEST\n\n HISTORY: 57-year-old woman with mitral valve placement. Evaluate for\n pneumothorax.\n\n FINDINGS: There is a Swan-Ganz catheter with the distal lead tip in the\n proximal right pulmonary artery. The endotracheal tube and nasogastric tube\n are perfectly sited. There is a mitral valve replacement. The cardiac\n silhouette and mediastinum is grossly within normal limits. Lungs are grossly\n clear.\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2162-04-13 00:00:00.000",
"description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY",
"row_id": 1129183,
"text": " 5:24 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY Clip # \n Reason: Cardiac CTA w/PVI Protocol ** ** to readPre-op MVR/\n Admitting Diagnosis: MITRAL VALVE DISORDER\\MITRAL VALVE REPLACEMENT W/ CONCOMITANT MAZE\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 57 year old woman with severely symptomatic atrial fibrillation and at least\n moderate mitral valvular disease including stenosis and regurgitation\n REASON FOR THIS EXAMINATION:\n Cardiac CTA w/PVI Protocol ** ** to readPre-op MVR/MAZE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MBue TUE 10:03 PM\n NO PE OR ACUTE PROCESS. CARDIOMEGALY WITH MARKED ENLARGEMENT OF LEFT ATRIUM.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 57-year-old female with severely symptomatic Afib.\n\n STUDY: Cardiac CTA; images were acquired in a perspective gated fashion at\n 75% of the RR interval one heartbeat.\n\n FINDINGS: The coronary arteries arise from the normal expected origins.\n Overall, the coronary arteries appear small but patent. The heart itself is\n enlarged. The left atrium is noted to be enlarged measuring 55 x 89 mm in the\n axial plane (3; 36) and 77 x 68 in the sagittal plane (400; 38). No clot is\n seen in the left atrial appendage.\n\n The pulmonary arteries show no filling defect down to the subsegmental level.\n\n The ascending aorta is mildly enlarged measuring 37 x 32 mm (3; 20). Small\n aortopulmonary lymph nodes are noted, although none meet pathologic size\n criteria.\n\n The left pulmonary veins share a common trunk whose cross-sectional area is 16\n x 31 mm. This common trunk then quickly bifurcates to an upper branch\n measuring 8 x 10 mm in cross-sectional area and a lower branch measuring 11 x\n 16 mm in cross-sectional area. The right superior pulmonary vein measures 19\n x 15 mm in cross-sectional area. The right superior-mid pulmonary vein\n measures 6 x 10 mm in cross-sectional area.\n\n Although this exam is not tailored for subdiaphragmatic evaluation, no acute\n intra-abdominal abnormality is noted.\n\n IMPRESSION: Cardiomegaly with enlarged left atrium; pulmonary veins as\n described above.\n\n"
}
] |
8,654 | 131,701 | The patient was admitted to the preoperative holding area on . He underwent aortobifemoral bypass with bilateral femoral popliteal bypasses with Dacron. He tolerated the procedure well. He was transferred to the PACU in stable condition. He remained afebrile, hemodynamically stable. Blood gases were 7.33, 37, 150, 20 minus 5. He was on an SIMV of 50%, 700 x10 with 5 of PEEP. His MV was 70%. The patient continued to do well. He had a faintly palpable right PT with triphasic dopplerable signal on the right and triphasic dopplerable PT on the left. The patient was transferred to the SICU for continued care and respiratory support. He was followed by the acute pain service and analgesic control with an epidural. Postoperative day 1, the patient had no overnight events. He did require fluid bolusing and nitroglycerin for afterload reduction. His postoperative hematocrit was 31.6. BUN, creatinine and potassium remained stable. The patient was extubated. Epidural was continued. Postoperative day 2, his hematocrit was 27.0. His troponin was less than 0.3. He remained hemodynamically stable. He had been extubated. His Lopressor was increased for afterload reduction. He received 1 unit of packed red blood cells with Lasix and he was transferred to the VICU for continued monitoring and care. His epidural infusion was augmented to 10 mg for analgesic control. Postoperative day 4, he continued to do well with a low grade temperature though of 100.4??????. Hematocrit remained stable at 27.2. BUN and creatinine were stable at 14 and 1.0. Epidural was discontinued and he was converted to oral analgesics. He was begun on a regular diet. DICTATION ENDS ABRUPTLY , M.D. Dictated By: MEDQUIST36 D: 11:10 T: 11:20 JOB#: | K NOT REPLETED PER VASCULAR AT THIS TIME D/T RISING CREAT.HEME: HCT STABLE.ENDO: BS 120ID: AFEBRILE. CLEAR.GI: ABD SOFTLY DISTENDED WITH +BS. K REPLETED.HEME: 1UPRBC GIVEN. CO>4 with index>2.RESP: L/S CLEAR AND DIMINISHED AT BASES. CONTS ON EPIDURAL OF DILAUDID 10MEQ/ML AND BUPIVACAINE 0.1% WITH EFFECT. SBP 170-190 NTG GTT RESTARTED AND TITRATED TO KEEP SBP<160. K low @ 3.4 but now orders to replete. L/S CLEAR AND DIMINISHED AT BASES. SICU NURSING NOTE 7A-530PREVIEW OF SYSTEMSNEURO: PROPOFOL OFF. EPIDURAL RATE AT 6CC/HR.CV: HR 70 SR WITH OCC PVCS. Minimal secretionsRENAL: Cr bumped to 1.5GI: abdomen firm, bilious drainage from ngENDO: no insulin requiredHeme: hct 27ID: kefzol completedSKIN: sternal wound to begin w-d dsg. NTG GTT CONTS TO KEEP SBP<160. There is slight increase in the bronchopulmonary markings suggesting congestive failure. NGT DRAINING MOD AMT OF BILIOUS MATERIAL. SX FOR SCANT. IMPRESSION: Mild worsening congestive failure. CONTS TO BE ACIDOTIC WITH BE-7. ABD INCISION WITH STAPLES INTACT. RECHECK HCT THIS EVENING.ENDO: BS 107-116ID: AFEBRILE.SKIN: W>D DSG TO STERNAL INCISION CHANGED AND DRAINING SMALL AMT OF GREEN DRAINAGE. Slight continued metabolic acidosis. PROPOFOL PLACED BACK ON AT LOW TO HELP PT ETT UNTIL AM. PA 30'S/10'S CVP 4-5. T/SICU Nursing Progress NOteS:O: Neuro: has effective epidural infusing. LASIX 10MG IV X1 AS ORDERED. Awakens easily, follows commandsCVS: on ntg to keep SBP <160. NTG TO KEEP SBP<160. Consider also left ventricular hypertrophy.Since the previous tracing of ST-T wave changes are less prominent. Dilaudid 0.5mg X 1 for c/o abdominal pain. TX FOR T/SICU FOR FURTHER VENT MANAGEMENT AND EXTUBATION IN AM.REVIEW OF SYSTEMSNEURO: PROPOFOL TURNED OFF AFTER ARRIVAL. Sinus rhythm. NGT DRAINING MOD AMTS OF BILIOUS MATERIALS. NPOGU: U/O ADEQUATE. Patchy opacity at the left base probably representing atelectasis. Status post CABG. PRESENTLY AT 1.25MEQ/KG/MIN. PA WNL. WEDGE 12 WITH CO/CI WNL.RESP: EXTUBATED AT 820AM AND WELL. COUGH WITH THICK YELLOW.GI: ABD SOFTLY DISTENDED WITH HYPOACTIVE BS. CONTS ON EPIDURAL FOR PAIN WITH DILAUDID 0.5MG IV FOR BREAKTHROUGH PAIN X1. CREAT ELEVATED TO 1.2 FROM 0.7 YESTERDAY. ?increasing lopressor to wean ntg off. Baseline artifact. EPIDURAL CATH IN CORRECT PLACEMENT AT 15 AT SKIN. Other skin intact.PeripheraLLY: feet warming, pulses present per doppler, slight mottling of toes and bottoms of feetA: stable, progressing well s/o aortobifemP: extubate today...begin activity progression. Tip of Swan-Ganz catheter overlies proximal right main pulmonary artery. The cardiomediastinal contours are unchanged. PT SPEND 24HRS IN PACU C/B POOR CARDIAC FUNCTION D/T CARDIAC HISTORY AND RESP ACIDOSIS. NURSING NOTE 1645- PT ADMITTED FROM PACU S/P AORTOFEM BPG AND BILAT FEMPOP BYPASS WITH VEIN. LAST DOSE OF CEFAZOLIN GIVEN AS ORDERED.SKIN: INCISIONS WITH DSG INTACT.SOCIAL: NO CONTACT WITH FAMILY THIS SHIFT.A: S/P AORTOFEM BPGP: KEEP ON PS OVER NIGHT, AND EXTUBATE IN AM. The ET tube, feeding tube and Swan-Ganz catheter are appropriately positioned. Endotracheal tube is approximately 4 cm above carina. Low dose propofol for comfort. SATS 94-96% ON 4L. URINE LOOK MORE DILUTE. CONTS TO BE NPO.GU: U/O LOW INITIALLY BUT HAS INCREASED IN LAST HOUR. Extensive ST-T changes with prolongedQTc interval - may be due to myocardial ischemia and/or metabolic/drug effect.Clinical correlation is suggested. BILAT LEG INCISIONS WITH STAPLES DRAINING SMALL>MOD AMT OF SEROSANG.SOCIAL: DAUGHTERS CALLED AND UPDATED ON STATUS VIA PHONE BY THIS RN.A: S/P AORTOFEM BPGP: TRANSFER TO VICU. A single view of the chest is compared to a previous study performed yesterday. PAIN SERVICE UP TO SEE PT AND ORDERED TO INCREASE EPIDURAL RATE TO 12CC/HR FOR 1HR WHICH WAS DONE AND NOW EPIDURAL AT 8CC/HR.CV: HR 70-80 SR WITH PAC AND PVC'S. WEDGE 17. There is a patchy opacity in the left base. VENT CHANGED TO PS 5/5. There are sternal wires overlying the cardiac silhouette. Other abdominal and leg sites without significant drainage, dsg removed by surgery this am. CONT TO MONITOR RENAL STATUS. AOX3 AND FOLLOWING ALL COMMANDS. LOPRESSOR INCREASED TO 10MG Q6. Receiving lopressor 5 mg q 6 hours. ? CO adequate.RESP; on all night, tolerated well. Follow renal status and cr closely avoiding any other insults to kidneys. No pneumothorax. STRONG PROD. 12:45 PM CHEST (PORTABLE AP) Clip # Reason: sat drop MEDICAL CONDITION: 56 year old man with REASON FOR THIS EXAMINATION: sat drop FINAL REPORT HISTORY: Decreased saturation. ALL TEAMS AWARE AND WILL CONT TO MONITOR. PT OPENS EYES SPONTANEOUSLY AND FOLLOWING ALL COMMANDS WITH ALL EXTREMETIES. There is no pneumothorax. 5:08 PM CHEST (PORTABLE AP) Clip # Reason: s/p central line, swan MEDICAL CONDITION: 56 year old man with REASON FOR THIS EXAMINATION: s/p central line, swan FINAL REPORT HISTORY: Placement of Swan-Ganz catheter. NO STOOL OR FLATUS. | 6 | [
{
"category": "Radiology",
"chartdate": "2132-06-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 765942,
"text": " 12:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: sat drop\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with\n\n REASON FOR THIS EXAMINATION:\n sat drop\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Decreased saturation.\n\n A single view of the chest is compared to a previous study performed\n yesterday.\n\n The ET tube, feeding tube and Swan-Ganz catheter are appropriately positioned.\n There are sternal wires overlying the cardiac silhouette. The\n cardiomediastinal contours are unchanged. There is a patchy opacity in the\n left base. There is slight increase in the bronchopulmonary markings\n suggesting congestive failure. There is no pneumothorax.\n\n IMPRESSION:\n\n Mild worsening congestive failure.\n\n Patchy opacity at the left base probably representing atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2132-06-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 765875,
"text": " 5:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p central line, swan\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with\n REASON FOR THIS EXAMINATION:\n s/p central line, swan\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Placement of Swan-Ganz catheter.\n\n Tip of Swan-Ganz catheter overlies proximal right main pulmonary artery. No\n pneumothorax. Endotracheal tube is approximately 4 cm above carina. Status\n post CABG.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-26 00:00:00.000",
"description": "Report",
"row_id": 1677784,
"text": "NURSING NOTE 1645-\n PT ADMITTED FROM PACU S/P AORTOFEM BPG AND BILAT FEMPOP BYPASS WITH VEIN. PT SPEND 24HRS IN PACU C/B POOR CARDIAC FUNCTION D/T CARDIAC HISTORY AND RESP ACIDOSIS. TX FOR T/SICU FOR FURTHER VENT MANAGEMENT AND EXTUBATION IN AM.\n\nREVIEW OF SYSTEMS\n\nNEURO: PROPOFOL TURNED OFF AFTER ARRIVAL. PT OPENS EYES SPONTANEOUSLY AND FOLLOWING ALL COMMANDS WITH ALL EXTREMETIES. PROPOFOL PLACED BACK ON AT LOW TO HELP PT ETT UNTIL AM. CONTS ON EPIDURAL OF DILAUDID 10MEQ/ML AND BUPIVACAINE 0.1% WITH EFFECT. EPIDURAL CATH IN CORRECT PLACEMENT AT 15 AT SKIN. EPIDURAL RATE AT 6CC/HR.\n\nCV: HR 70 SR WITH OCC PVCS. SBP 170-190 NTG GTT RESTARTED AND TITRATED TO KEEP SBP<160. PRESENTLY AT 1.25MEQ/KG/MIN. PA 30'S/10'S CVP 4-5. WEDGE 17. CO>4 with index>2.\n\nRESP: L/S CLEAR AND DIMINISHED AT BASES. VENT CHANGED TO PS 5/5. CONTS TO BE ACIDOTIC WITH BE-7. ALL TEAMS AWARE AND WILL CONT TO MONITOR. SX FOR SCANT. CLEAR.\n\nGI: ABD SOFTLY DISTENDED WITH +BS. NGT DRAINING MOD AMTS OF BILIOUS MATERIALS. NO STOOL OR FLATUS. CONTS TO BE NPO.\n\nGU: U/O LOW INITIALLY BUT HAS INCREASED IN LAST HOUR. URINE LOOK MORE DILUTE. CREAT ELEVATED TO 1.2 FROM 0.7 YESTERDAY. K NOT REPLETED PER VASCULAR AT THIS TIME D/T RISING CREAT.\n\nHEME: HCT STABLE.\n\nENDO: BS 120\n\nID: AFEBRILE. LAST DOSE OF CEFAZOLIN GIVEN AS ORDERED.\n\nSKIN: INCISIONS WITH DSG INTACT.\n\nSOCIAL: NO CONTACT WITH FAMILY THIS SHIFT.\n\nA: S/P AORTOFEM BPG\nP: KEEP ON PS OVER NIGHT, AND EXTUBATE IN AM. NTG TO KEEP SBP<160. CONT TO MONITOR RENAL STATUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-27 00:00:00.000",
"description": "Report",
"row_id": 1677785,
"text": "T/SICU Nursing Progress NOte\nS:\nO: Neuro: has effective epidural infusing. Dilaudid 0.5mg X 1 for c/o abdominal pain. Low dose propofol for comfort. Awakens easily, follows commands\nCVS: on ntg to keep SBP <160. Receiving lopressor 5 mg q 6 hours. K low @ 3.4 but now orders to replete. CO adequate.\nRESP; on all night, tolerated well. Slight continued metabolic acidosis. Minimal secretions\nRENAL: Cr bumped to 1.5\nGI: abdomen firm, bilious drainage from ng\nENDO: no insulin required\nHeme: hct 27\nID: kefzol completed\nSKIN: sternal wound to begin w-d dsg. Other abdominal and leg sites without significant drainage, dsg removed by surgery this am. Other skin intact.\nPeripheraLLY: feet warming, pulses present per doppler, slight mottling of toes and bottoms of feet\nA: stable, progressing well s/o aortobifem\nP: extubate today...begin activity progression. ??increasing\n lopressor to wean ntg off. Follow renal status and cr closely avoiding any other insults to kidneys.\n"
},
{
"category": "Nursing/other",
"chartdate": "2132-06-27 00:00:00.000",
"description": "Report",
"row_id": 1677786,
"text": "SICU NURSING NOTE 7A-530P\nREVIEW OF SYSTEMS\n\nNEURO: PROPOFOL OFF. AOX3 AND FOLLOWING ALL COMMANDS. CONTS ON EPIDURAL FOR PAIN WITH DILAUDID 0.5MG IV FOR BREAKTHROUGH PAIN X1. PAIN SERVICE UP TO SEE PT AND ORDERED TO INCREASE EPIDURAL RATE TO 12CC/HR FOR 1HR WHICH WAS DONE AND NOW EPIDURAL AT 8CC/HR.\n\nCV: HR 70-80 SR WITH PAC AND PVC'S. NTG GTT CONTS TO KEEP SBP<160. LOPRESSOR INCREASED TO 10MG Q6. PA WNL. WEDGE 12 WITH CO/CI WNL.\n\nRESP: EXTUBATED AT 820AM AND WELL. L/S CLEAR AND DIMINISHED AT BASES. SATS 94-96% ON 4L. STRONG PROD. COUGH WITH THICK YELLOW.\n\nGI: ABD SOFTLY DISTENDED WITH HYPOACTIVE BS. NGT DRAINING MOD AMT OF BILIOUS MATERIAL. NO STOOL OR FLATUS. NPO\n\nGU: U/O ADEQUATE. LASIX 10MG IV X1 AS ORDERED. K REPLETED.\n\nHEME: 1UPRBC GIVEN. RECHECK HCT THIS EVENING.\n\nENDO: BS 107-116\n\nID: AFEBRILE.\n\nSKIN: W>D DSG TO STERNAL INCISION CHANGED AND DRAINING SMALL AMT OF GREEN DRAINAGE. ABD INCISION WITH STAPLES INTACT. BILAT LEG INCISIONS WITH STAPLES DRAINING SMALL>MOD AMT OF SEROSANG.\n\nSOCIAL: DAUGHTERS CALLED AND UPDATED ON STATUS VIA PHONE BY THIS RN.\n\nA: S/P AORTOFEM BPG\nP: TRANSFER TO VICU.\n"
},
{
"category": "ECG",
"chartdate": "2132-06-25 00:00:00.000",
"description": "Report",
"row_id": 174284,
"text": "Baseline artifact. Sinus rhythm. Extensive ST-T changes with prolonged\nQTc interval - may be due to myocardial ischemia and/or metabolic/drug effect.\nClinical correlation is suggested. Consider also left ventricular hypertrophy.\nSince the previous tracing of ST-T wave changes are less prominent.\n\n"
}
] |
79,962 | 138,182 | Patient was admitted for a right submandibular abscess. She was preoped, consented, and underwent a right neck I/D on . Please Dr. operative note for details. She tolerated the procedure well and was transferred to the SICU intubated. She was continued on unasyn. She returned to the OR the following day for teeth extraction. Please see Dr. operative note for details. Again she tolerated the procedure well and was transferred to the SICU intubated without events. She was successfully extubated that evening. Patient was started on nasal irrigations. Her home medications were continued. Physical therapy was consulted to improve strength and mobility. She was anemic with a HCT in the low 20s. Her hematologist, Dr. , was contact. was alreeady aware of her blood smear findings suggestive of myelodysplasia and did not request any further workup or management during this hospital stay. On POD3 she was given 2uPRBCs with lasix and was transferred to the floor. Her hematocrit appropriately bumped to 28 and was stable in the high 20s prior to discharge. Her penrose drain was slowly backed out and removed on POD4. Culture sensitivities returned on POD4, showing MRSA. An ID consult was obtained at that time, recommending switching from unasyn to vancomycin and flagyl. A PICC was successfully placed on POD5. A vancomycin trough level was low at 9.6. We subsequently increased her dosing frequency from QD to . Another vanco trough should be checked prior to 3rd dose of new dosing regimen. Her first dose at interval was on at 0800. She is to receive IV vancomycin until (time of f/u in clinic). On POD7 she was transferred to a rehab facility in good condition. Please note that she will need to be set up for weekly lab draws (CBC, BUN/Cr, ALT/AST) to be faxed to ( clinic). | Pneumococcal Vac Polyvalent 12. Sodium Chloride 0.9% Flush 24 Hour Events: FEVER - 103.0F - 12:00 AM : admitted to SICU from OR s/p drainage, left intubated, to OR tomorrow with Dr . need to clarify dose with family/PCP : Extubate today, (Ventilator mode: CPAP + PS), intubated/sedated. Gastrointestinal / Abdomen: NPO for now; h/o colon CA, has open wound in abd, will watch, cx if issues Nutrition: NPO Renal: Foley, Adequate UO, h/o renal failure, follow creat esp as pt got contrast, currently stable. Pneumococcal Vac Polyvalent 13. Current medications: 24 Hour Events: OR SENT - At 08:15 AM teeth extraction OR RECEIVED - At 09:15 AM INVASIVE VENTILATION - STOP 01:59 PM pt arrived from OR intubated EXTUBATION - At 02:46 PM Post operative day: POD#1 - s/p extrtaction right infected tooth HD #3, POD#2(submandibular abscess)/ POD1 (teeth extract) Allergies: No Known Drug Allergies Last dose of Antibiotics: Ampicillin - 06:14 AM Ampicillin/Sulbactam (Unasyn) - 12:07 AM Infusions: Other ICU medications: Famotidine (Pepcid) - 06:09 PM Heparin Sodium (Prophylaxis) - 10:15 PM Other medications: Flowsheet Data as of 05:47 AM Vital signs Hemodynamic monitoring Fluid balance 24 hours Since a.m. Tmax: 37.2C (99 T current: 36.6C (97.9 HR: 83 (71 - 92) bpm BP: 135/62(80) {85/39(47) - 136/71(80)} mmHg RR: 16 (14 - 26) insp/min SPO2: 100% Heart rhythm: SR (Sinus Rhythm) Total In: 3,181 mL 340 mL PO: 290 mL 240 mL Tube feeding: IV Fluid: 2,641 mL 100 mL Blood products: 250 mL Total out: 1,140 mL 300 mL Urine: 1,095 mL 300 mL NG: Stool: Drains: Balance: 2,041 mL 40 mL Respiratory support O2 Delivery Device: Nasal cannula Ventilator mode: CPAP/PSV Vt (Set): 500 (500 - 500) mL Vt (Spontaneous): 400 (400 - 790) mL PS : 5 cmH2O RR (Set): 14 RR (Spontaneous): 18 PEEP: 5 cmH2O FiO2: 40% PIP: 11 cmH2O SPO2: 100% ABG: ///25/ Ve: 9.7 L/min Physical Examination General Appearance: No acute distress HEENT: PERRL Cardiovascular: (Rhythm: Regular) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA bilateral : ), (Sternum: Stable ) Abdominal: Soft, Non-distended, Non-tender Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present) Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse - Dorsalis pedis: Present), (Pulse - Posterior tibial: Present) Skin: (Incision: Clean / Dry / Intact) Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities Labs / Radiology 93 K/uL 6.4 g/dL 90 mg/dL 0.9 mg/dL 25 mEq/L 3.3 mEq/L 13 mg/dL 107 mEq/L 137 mEq/L 20.2 % 7.0 K/uL [image002.jpg] 01:52 AM 03:13 AM 06:17 PM 02:50 AM 04:35 AM 10:16 AM 08:38 PM 01:27 AM WBC 10.6 7.2 5.6 7.9 7.0 Hct 22.8 25.0 21.7 21.2 21.2 19.6 20.2 Plt 116 118 103 92 93 Creatinine 1.0 1.0 1.1 0.9 TCO2 25 Glucose 150 85 123 90 Other labs: PT / PTT / INR:16.7/35.3/1.5, Lactic Acid:1.0 mmol/L, Ca:7.1 mg/dL, Mg:1.7 mg/dL, PO4:2.6 mg/dL Assessment and Plan CELLULITIS, .H/O PROBLEM - ENTER DESCRIPTION IN COMMENTS Assessment and Plan: 84 yo F p/w right neck swelling who is s/p submandibular abscess drainage and subsequent teeth extraction Neurologic: fentanyl prn for pain, not using Cardiovascular: will restart home PO lopressor dose Pulmonary: extubated without any difficulties, nasal cannula as needed Gastrointestinal / Abdomen: off H2B Nutrition: Regular diet Renal: Foley, Adequate UO, Cr stable Hematology: h/o anemia req transfusions. (Ventilator mode: CPAP + PS), intubated/sedated. Dilaudid pca if extubation. Renal: Foley, Adequate UO, h/o renal failure, follow creat esp as pt got contrast, currently stable. is POD 1 s/p maxillofacial abcess I&D. Tylenol given PR. Tylenol given PR. .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Pt intubated for OR at start of shift. admitted to breathing uncomfortably on PSV, placed back on CMV by RT. given fentanyl boluses for sedation and propofol gtt titrated to and stable BP. Pneumococcal Vac Polyvalent 12. .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: PT came from OR intubated, neck with swelling, tongue and mouth is with swelling Action: Pt on vent AC mode, ABG WNL. Ampicillin-Sulbactam 4. Metoprolol Tartrate 11. Response: LS clear, O2 sat 97-99% Plan: Wean extubate as tolerates .H/O Problem - Description In Comments Assessment: Swelling neck rt side, s/p I & D in the OR. IVfluids as ordered @80ml/hr Response: sedated on propofol and awake MAE wanting ETT out off propofol. IVfluids as ordered @80ml/hr Response: sedated on propofol and awake MAE wanting ETT out off propofol. She was treated with IV unasyn and transferred to . She was treated with IV unasyn and transferred to . wean from vent, Gastrointestinal / Abdomen: NPO for now; h/o colon CA, has open wound in abd, will watch, cx if issues Nutrition: place dobhoff. .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway Clearance, Cough) Assessment: Action: Response: Plan: .H/O Problem - Description In Comments Assessment: Action: Response: Plan: Cellulitis Assessment: neck remains mildly swollen afebrile Action: penrose drains to gravity, ampicillin a/o normal saline nasal wash Response: cont to drain serosang from penrose drains cellulits improving able to raise secretions Plan: cont ampicllin a/o penrose drains to gravity per ENT follow low HCTborderline per patient (takes procrit and iron at home) await wound care recs for abd dressing need to clarify dose with family/PCP : hold extubation until OMF/ ENT plan. She went to an OSH ED today where CT with contrast of the neck showed fluid collection in the submandibular space. | 22 | [
{
"category": "Radiology",
"chartdate": "2137-12-04 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1054086,
"text": ", A. ENT CC6A 1:06 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: repeat xray of picc tip since repositioned.\n Admitting Diagnosis: FACIAL CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with\n REASON FOR THIS EXAMINATION:\n repeat xray of picc tip since repositioned.\n ______________________________________________________________________________\n PFI REPORT\n Right PICC tip now in the mid SVC.\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-04 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 1054067,
"text": " 11:29 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: repeat of picc tip. wire pulled out, looking for picc to dro\n Admitting Diagnosis: FACIAL CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with\n REASON FOR THIS EXAMINATION:\n repeat of picc tip. wire pulled out, looking for picc to drop into SVC.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with right PICC. Assess PICC placement.\n\n COMPARISON: Chest radiographs done approximately 2 hours prior.\n\n TECHNIQUE: Portable AP view of the chest.\n\n FINDINGS: The right-sided PICC tip now makes a hairpin turn at the upper SVC\n with the tip doubled back on itself, approximately 4.5 cm from the turn. The\n remainder of the exam is unchanged.\n\n These findings were discussed with , IV nurse, at the time of review on\n .\n\n"
},
{
"category": "Radiology",
"chartdate": "2137-12-04 00:00:00.000",
"description": "BY SAME PHYSICIAN",
"row_id": 1054085,
"text": " 1:06 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: repeat xray of picc tip since repositioned.\n Admitting Diagnosis: FACIAL CELLULITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with\n REASON FOR THIS EXAMINATION:\n repeat xray of picc tip since repositioned.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKSd WED 8:42 PM\n Right PICC tip now in the mid SVC.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with repositioning of PICC tip.\n\n COMPARISON: Multiple chest x-rays, most recently done 2 hours prior.\n\n TECHNIQUE: Portable AP view of the chest.\n\n FINDINGS: The right PICC tip now appears to be at the mid SVC. The remainder\n of the exam is unchanged since prior. Findings were discussed with ,\n IV nurse at the time of review.\n\n"
},
{
"category": "ECG",
"chartdate": "2137-11-29 00:00:00.000",
"description": "Report",
"row_id": 242823,
"text": "Sinus tachycardia with premature atrial complexes. Normal axis and intervals.\nSmall Q waves are present in leads II, III and aVF which are probably\nnon-pathologic. No previous tracing available for comparison.\n\n"
},
{
"category": "Physician ",
"chartdate": "2137-12-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 651594,
"text": "SICU\n HPI:\n 84 yo F p/w right neck swelling who is s/p submandibular abscess\n drainage and subsequent teeth extraction\n Chief complaint:\n right neck swelling\n PMHx:\n CHF, hypothyroidism, Colon Ca, GERD, COPD, PNA, Renal\n failure, vascular disease, abdominal aortic aneurysm (pt informs\n that last year it was ~4cm), iron deficiency anemia.\n Current medications:\n 24 Hour Events:\n OR SENT - At 08:15 AM\n teeth extraction\n OR RECEIVED - At 09:15 AM\n INVASIVE VENTILATION - STOP 01:59 PM\n pt arrived from OR intubated\n EXTUBATION - At 02:46 PM\n Post operative day:\n POD#1 - s/p extrtaction right infected tooth\n HD #3, POD#2(submandibular abscess)/ POD1 (teeth extract)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 06:14 AM\n Ampicillin/Sulbactam (Unasyn) - 12:07 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 06:09 PM\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Other medications:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 36.6\nC (97.9\n HR: 83 (71 - 92) bpm\n BP: 135/62(80) {85/39(47) - 136/71(80)} mmHg\n RR: 16 (14 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,181 mL\n 340 mL\n PO:\n 290 mL\n 240 mL\n Tube feeding:\n IV Fluid:\n 2,641 mL\n 100 mL\n Blood products:\n 250 mL\n Total out:\n 1,140 mL\n 300 mL\n Urine:\n 1,095 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,041 mL\n 40 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 400 (400 - 790) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///25/\n Ve: 9.7 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 : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 93 K/uL\n 6.4 g/dL\n 90 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 107 mEq/L\n 137 mEq/L\n 20.2 %\n 7.0 K/uL\n [image002.jpg]\n 01:52 AM\n 03:13 AM\n 06:17 PM\n 02:50 AM\n 04:35 AM\n 10:16 AM\n 08:38 PM\n 01:27 AM\n WBC\n 10.6\n 7.2\n 5.6\n 7.9\n 7.0\n Hct\n 22.8\n 25.0\n 21.7\n 21.2\n 21.2\n 19.6\n 20.2\n Plt\n 116\n 118\n 103\n 92\n 93\n Creatinine\n 1.0\n 1.0\n 1.1\n 0.9\n TCO2\n 25\n Glucose\n 150\n 85\n 123\n 90\n Other labs: PT / PTT / INR:16.7/35.3/1.5, Lactic Acid:1.0 mmol/L,\n Ca:7.1 mg/dL, Mg:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n CELLULITIS, .H/O PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 84 yo F p/w right neck swelling who is s/p\n submandibular abscess drainage and subsequent teeth extraction\n Neurologic: fentanyl prn for pain\n Cardiovascular: will restart home PO lopressor dose\n Pulmonary: extubated without any difficulties\n Gastrointestinal / Abdomen: off H2B\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, Cr stable\n Hematology: h/o anemia req transfusions. HCT borderline 20-21.\n Asymptomatic. No CP/SOB/Abd pain/dizziness; t/c transfuse\n Endocrine: RISS; d/w pt re synthroid dose\n Infectious Disease: s/p submandibular abscess drainage and removal\n ?infected tooth) - on unasyn. f/u Cxs sensitivities\n Lines / Tubes / Drains: PIV, Foley\n Wounds: c/d/i\n Imaging:\n Fluids: KVO\n Consults: ENT, P.T., OMFS\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:36 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 32 minutes\n"
},
{
"category": "Respiratory ",
"chartdate": "2137-11-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 651318,
"text": "Airway\n location:\n Reason:\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: 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 claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1545\n none\n"
},
{
"category": "Nursing",
"chartdate": "2137-12-02 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 651670,
"text": "Neck Abcess\n Assessment:\n pt alert and oriented x 3\n o2 sat 97% room air\n no sob or resp distress\n lungs clear\n rsr\n afebrile\n hct 20\n bp stable\n tol reg diet\n one loose bm\n foley dc\n skin intact\n neck dsg with two penrose drains and sutures\n denies pain\n Action:\n one unit prbc\n oob chair\n eating\n swallowing intact\n neck dsg to be changed by ent this afternoon\n Response:\n pt sitting in chair comfortably without complaints\n pt ambulated well with one assist\n neck dsg intact\n blood infusing\n Plan:\n transfer to cc6\n second unit of prbc to be transfused on when pt on floor\n"
},
{
"category": "Nursing",
"chartdate": "2137-12-02 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 651671,
"text": "Neck Abcess\n Assessment:\n pt alert and oriented x 3\n o2 sat 97% room air\n no sob or resp distress\n lungs clear\n rsr\n afebrile\n hct 20\n bp stable\n tol reg diet\n one loose bm\n foley dc\n skin intact\n neck dsg with two penrose drains and sutures\n denies pain\n Action:\n one unit prbc\n oob chair\n eating\n swallowing intact\n neck dsg to be changed by ent this afternoon\n Response:\n pt sitting in chair comfortably without complaints\n pt ambulated well with one assist\n neck dsg intact\n blood infusing\n Plan:\n transfer to cc6\n second unit of prbc to be transfused on when pt on floor\n ------ Protected Section ------\n Demographics\n Attending MD:\n A.\n Admit diagnosis:\n FACIAL CELLULITIS\n Code status:\n Height:\n Admission weight:\n 58 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: COPD, Renal Failure\n CV-PMH:\n Additional history: CHF,Colon Ca,GERD,Vascular disease,abdominal aortic\n aneurysm,iron deficiency anemia.\n Recent resection for colon CA with subsequent infection that required\n washout. Recent VAC therapy. Son reports pt. had MRSA in wound.\n Surgery / Procedure and date: : I & D of neck abscess rt side\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:121\n D:54\n Temperature:\n 97.3\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 100 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 40% %\n 24h total in:\n 1,583 mL\n 24h total out:\n 1,090 mL\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 01:27 AM\n Potassium:\n 3.3 mEq/L\n 01:27 AM\n Chloride:\n 107 mEq/L\n 01:27 AM\n CO2:\n 25 mEq/L\n 01:27 AM\n BUN:\n 13 mg/dL\n 01:27 AM\n Creatinine:\n 0.9 mg/dL\n 01:27 AM\n Glucose:\n 90 mg/dL\n 01:27 AM\n Hematocrit:\n 20.2 %\n 01:27 AM\n Finger Stick Glucose:\n 118\n 10:00 AM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Amount: sent with pt\n Cards: sent with pt\n / Credit cards sent home with:\n Jewelry: one metal ring\n Transferred from: sicu a\n Transferred to: cc622\n Date & time of Transfer: 12:00 AM\n ------ Protected Section Addendum Entered By: , RN\n on: 12:37 ------\n"
},
{
"category": "Physician ",
"chartdate": "2137-12-02 00:00:00.000",
"description": "Intensivist Note",
"row_id": 651628,
"text": "SICU\n HPI:\n 84 yo F p/w right neck swelling who is s/p submandibular abscess\n drainage and subsequent teeth extraction\n Chief complaint:\n right neck swelling\n PMHx:\n CHF, hypothyroidism, Colon Ca, GERD, COPD, PNA, Renal\n failure, vascular disease, abdominal aortic aneurysm (pt informs\n that last year it was ~4cm), iron deficiency anemia.\n Current medications:\n 24 Hour Events:\n OR SENT - At 08:15 AM\n teeth extraction\n OR RECEIVED - At 09:15 AM\n INVASIVE VENTILATION - STOP 01:59 PM\n pt arrived from OR intubated\n EXTUBATION - At 02:46 PM\n Post operative day:\n POD#1 - s/p extrtaction right infected tooth\n HD #3, POD#2(submandibular abscess)/ POD1 (teeth extract)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 06:14 AM\n Ampicillin/Sulbactam (Unasyn) - 12:07 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 06:09 PM\n Heparin Sodium (Prophylaxis) - 10:15 PM\n Other medications:\n Flowsheet Data as of 05:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (99\n T current: 36.6\nC (97.9\n HR: 83 (71 - 92) bpm\n BP: 135/62(80) {85/39(47) - 136/71(80)} mmHg\n RR: 16 (14 - 26) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,181 mL\n 340 mL\n PO:\n 290 mL\n 240 mL\n Tube feeding:\n IV Fluid:\n 2,641 mL\n 100 mL\n Blood products:\n 250 mL\n Total out:\n 1,140 mL\n 300 mL\n Urine:\n 1,095 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 2,041 mL\n 40 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 400 (400 - 790) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 18\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///25/\n Ve: 9.7 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 : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 93 K/uL\n 6.4 g/dL\n 90 mg/dL\n 0.9 mg/dL\n 25 mEq/L\n 3.3 mEq/L\n 13 mg/dL\n 107 mEq/L\n 137 mEq/L\n 20.2 %\n 7.0 K/uL\n [image002.jpg]\n 01:52 AM\n 03:13 AM\n 06:17 PM\n 02:50 AM\n 04:35 AM\n 10:16 AM\n 08:38 PM\n 01:27 AM\n WBC\n 10.6\n 7.2\n 5.6\n 7.9\n 7.0\n Hct\n 22.8\n 25.0\n 21.7\n 21.2\n 21.2\n 19.6\n 20.2\n Plt\n 116\n 118\n 103\n 92\n 93\n Creatinine\n 1.0\n 1.0\n 1.1\n 0.9\n TCO2\n 25\n Glucose\n 150\n 85\n 123\n 90\n Other labs: PT / PTT / INR:16.7/35.3/1.5, Lactic Acid:1.0 mmol/L,\n Ca:7.1 mg/dL, Mg:1.7 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n CELLULITIS, .H/O PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Assessment and Plan: 84 yo F p/w right neck swelling who is s/p\n submandibular abscess drainage and subsequent teeth extraction\n Neurologic: fentanyl prn for pain, not using\n Cardiovascular: will restart home PO lopressor dose\n Pulmonary: extubated without any difficulties, nasal cannula as needed\n Gastrointestinal / Abdomen: off H2B\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, Cr stable\n Hematology: h/o anemia req transfusions. HCT borderline 20-21.\n Asymptomatic. No CP/SOB/Abd pain/dizziness; transfuse one unit prbc\n Endocrine: RISS; home synthroid dose\n Infectious Disease: s/p submandibular abscess drainage, unasyn. f/u Cxs\n sensitivities\n Lines / Tubes / Drains: PIV, Foley\n Wounds: wet to dry\n Imaging: none\n Fluids: KVO\n Consults: ENT, P.T., OMFS\n Billing Diagnosis: Respiratory Insufficiency post-op\n ICU Care\n Nutrition:\n Comments: regular diet\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:36 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: floor\n Total time spent: 32 minutes\n"
},
{
"category": "Physician ",
"chartdate": "2137-12-01 00:00:00.000",
"description": "Intensivist Note",
"row_id": 651446,
"text": "SICU\n HPI:\n 84 yo F with 1 week of right neck swelling that has spread\n toward right side of face. She has had right gum tenderness\n around her right lower tooth (only lower right tooth left), and\n has long history of odontogenic disease. Her PCP has treated her\n with oral ciprofloxacin . She went to an OSH ED\n today where CT with constrast of the neck showed fluid collection\n in the submandibular space. She was treated with IV unasyn and\n transferred to . She has trismus, but no respiratory\n distress or desaturation or stridor. Her floor of mouth is\n edematous espcially on the right side, but soft. Went for drainage of\n abscess, left intubated because of concern for postop airway compromise\n (swelling).\n Chief complaint:\n continued pharyngeal swelling\n PMHx:\n PMH:CHF, hypothyroidism, Colon Ca, GERD, COPD, PNA, Renal\n failure, vascular disease, abdominal aortic aneurysm (pt informs\n that last year it was ~4cm), iron deficiency anemia.\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL D5NS 3. Acetaminophen 4.\n Ampicillin-Sulbactam 5. Calcium Gluconate\n 6. Famotidine 7. Fentanyl Citrate 8. Heparin 9. Influenza Virus Vaccine\n 10. Insulin 11. Metoprolol Tartrate\n 12. Pneumococcal Vac Polyvalent 13. Propofol 14. Sodium Chloride 0.9%\n Flush\n 24 Hour Events:\n FEVER - 103.0\nF - 12:00 AM\n : admitted to SICU from OR s/p drainage, left intubated, to OR\n tomorrow with Dr \n .\n Post operative day:\n POD#0 - s/p extrtaction right infected tooth\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Ampicillin - 06:14 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 01:00 PM\n Fentanyl - 05:00 AM\n Famotidine (Pepcid) - 07:53 AM\n Other medications:\n Flowsheet Data as of 10:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.4\nC (103\n T current: 37.1\nC (98.8\n HR: 82 (67 - 112) bpm\n BP: 89/41(52) {87/39(52) - 150/69(88)} mmHg\n RR: 15 (9 - 19) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 3,133 mL\n 1,480 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,133 mL\n 1,480 mL\n Blood products:\n Total out:\n 2,125 mL\n 495 mL\n Urine:\n 1,775 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,008 mL\n 985 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: Standby\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 19 cmH2O\n Plateau: 14 cmH2O\n Compliance: 55.6 cmH2O/mL\n SPO2: 100%\n ABG: ///23/\n Ve: 8 L/min\n Physical Examination\n General Appearance: No acute distress, Cachectic\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, No(t) Distended\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli, Noxious stimuli), Moves\n all extremities\n Labs / Radiology\n 92 K/uL\n 6.9 g/dL\n 123 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 3.5 mEq/L\n 15 mg/dL\n 108 mEq/L\n 138 mEq/L\n 21.2 %\n 7.9 K/uL\n [image002.jpg]\n 01:52 AM\n 03:13 AM\n 06:17 PM\n 02:50 AM\n 04:35 AM\n WBC\n 10.6\n 7.2\n 5.6\n 7.9\n Hct\n 22.8\n 25.0\n 21.7\n 21.2\n Plt\n 116\n 118\n 103\n 92\n Creatinine\n 1.0\n 1.0\n 1.1\n TCO2\n 25\n Glucose\n 150\n 85\n 123\n Other labs: PT / PTT / INR:15.9/27.1/1.4, Lactic Acid:1.0 mmol/L,\n Ca:7.6 mg/dL, Mg:1.9 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), .H/O PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n Assessment and Plan: 84 yo F with 1 week of right neck swelling that\n has spread\n toward right side of face. She has had right gum tenderness\n around her right lower tooth (only lower right tooth left), and\n has long history of odontogenic disease. Her PCP has treated her\n with oral ciprofloxacin . She went to an OSH ED\n today where CT with constrast of the neck showed fluid collection\n in the submandibular space. She was treated with IV unasyn and\n transferred to . She has trismus, but no respiratory\n distress or desaturation or stridor. Her floor of mouth is\n edematous espcially on the right side, but soft. Went for drainage of\n abscess, left intubated because of concern for postop airway compromise\n (swelling).\n Neurologic: Neuro checks Q: 4 hr, sedation with propofol, fentanyl prn\n for pain\n Cardiovascular: hemodynamically stable, on home lopressor, will give IV\n until extubated and taking po's. need to clarify dose with family/PCP\n : (Ventilator mode: CPAP + PS)\n Gastrointestinal / Abdomen: GI: NPO for now\n Nutrition: NPO\n Renal: Foley, Adequate UO, Will use colloid for additional\n resuscitation.\n Hematology: Serial Hct, Will continue to follow due to recent hct drop\n without evidence of hemodilution\n Endocrine: RISS\n Infectious Disease: Check cultures\n Lines / Tubes / Drains: Foley, ETT\n Wounds: Dry dressings\n Imaging: CXR today, to assess tracheal deviation or pneumomeds\n Fluids: D5 1/2 NS\n Consults: ENT\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:36 AM\n 20 Gauge - 01:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n"
},
{
"category": "Physician ",
"chartdate": "2137-11-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 651187,
"text": "SICU\n HPI:\n 84 yo F with 1 week of right neck swelling that has spread toward right\n side of face. She has had right gum tenderness around her right lower\n tooth (only lower right tooth left), and has long history of\n odontogenic disease. Her PCP has treated her with oral ciprofloxacin\n . She went to an OSH ED today where CT with constrast of\n the neck showed fluid collection in the submandibular space. She was\n treated with IV unasyn and\n transferred to . She has trismus, but no respiratory distress or\n desaturation or stridor. Her floor of mouth is\n edematous espcially on the right side, but soft. Went for drainage of\n abscess, left intubated because of concern for postop airway compromise\n (swelling).\n Chief complaint:\n submandibular abscess\n PMHx:\n CHF, hypothyroidism, Colon Ca, GERD, COPD, PNA, Renal failure, vascular\n disease, abdominal aortic aneurysm (pt informs that last year it was\n ~4cm), iron deficiency anemia\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL D5NS 3. Ampicillin-Sulbactam\n 4. Calcium Gluconate 5. Famotidine\n 6. Fentanyl Citrate 7. Heparin 8. Influenza Virus Vaccine 9. Insulin\n 10. Metoprolol Tartrate 11. Pneumococcal Vac Polyvalent\n 12. Propofol 13. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:30 AM\n pt arrived from OR intubated\n - admitted to SICU\n Post operative day:\n POD #1\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 92 (92 - 102) bpm\n BP: 97/54(64) {97/54(64) - 142/82(97)} mmHg\n RR: 19 (14 - 19) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 702 mL\n PO:\n Tube feeding:\n IV Fluid:\n 702 mL\n Blood products:\n Total out:\n 0 mL\n 460 mL\n Urine:\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 242 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): 4\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 21 cmH2O\n Plateau: 15 cmH2O\n SPO2: 100%\n ABG: 7.41/38/488/23/0\n Ve: 8.7 L/min\n PaO2 / FiO2: 1,220\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, open\n wound in abd, covered in dry gauze\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n 116 K/uL\n 7.3 g/dL\n 150 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 16 mg/dL\n 100 mEq/L\n 131 mEq/L\n 22.8 %\n 10.6 K/uL\n [image002.jpg]\n 01:52 AM\n 03:13 AM\n WBC\n 10.6\n Hct\n 22.8\n Plt\n 116\n Creatinine\n 1.0\n TCO2\n 25\n Glucose\n 150\n Other labs: PT / PTT / INR:16.9/26.5/1.5, Lactic Acid:1.0 mmol/L,\n Ca:7.7 mg/dL, Mg:1.8 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), .H/O PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n Assessment and Plan: 84 yo F with submandibular abscess s/p drainage,\n left intubated due to concern for airway compromise\n Neurologic: sedation with propofol, fentanyl prn for pain\n Cardiovascular: Beta-blocker, hemodynamically stable, on home\n lopressor, will give IV until extubated and taking po's. need to\n clarify dose with family/PCP\n : Extubate today, (Ventilator mode: CPAP + PS),\n intubated/sedated. wean from vent, extubate when possible.\n Gastrointestinal / Abdomen: NPO for now; h/o colon CA, has open wound\n in abd, will watch, cx if issues\n Nutrition: NPO\n Renal: Foley, Adequate UO, h/o renal failure, follow creat esp as pt\n got contrast, currently stable. Na 131, will follow while on IVF\n (change to D5NS)\n Hematology: Hct 25.8 at OSH, now 22.8, no indications for transfusion\n but will f/u Hct, has stable coagulopathy INR 1.5, will follow\n Endocrine: RISS\n Infectious Disease: submandibular abscess (likely from infected tooth)\n - s/p drainage. on unasyn. OMFS consulted, will see pt after extubated,\n ?take to OR for tooth extraction - want a new head CT\n Lines / Tubes / Drains: Foley, ETT, PIV\n Wounds: Dry dressings\n Imaging: ?CT head soon per OMFS\n Fluids: D5NS\n Consults: ENT, OMFS\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:36 AM\n 20 Gauge - 01:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: 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": "2137-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651192,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n .H/O Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2137-12-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651416,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n remains intubated for airway protection due to facial swelling.\n Propofol between 40-60mcg/kg temp spike to 103 now 99, WBC and HCT\n 21.7\n Action:\n propofol titrated to BP and intermittent doses of IV fentanyl given.\n Tylenol given PR. IVfluids as ordered @80ml/hr\n Response:\n sedated on propofol and awake MAE wanting ETT out off propofol.\n Plan:\n to OR for teeth extraction , needs consent signed\n"
},
{
"category": "Nursing",
"chartdate": "2137-12-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651417,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n remains intubated for airway protection due to facial swelling.\n Propofol between 40-60mcg/kg temp spike to 103 now 99, WBC 7.9 and HCT\n 21.7\n Action:\n propofol titrated to BP and intermittent doses of IV fentanyl given.\n Tylenol given PR. IVfluids as ordered @80ml/hr\n Response:\n sedated on propofol and awake MAE wanting ETT out off propofol.\n Plan:\n to OR for teeth extraction , needs consent signed\n"
},
{
"category": "Physician ",
"chartdate": "2137-11-30 00:00:00.000",
"description": "Intensivist Note",
"row_id": 651273,
"text": "SICU\n HPI:\n 84 yo F with 1 week of right neck swelling that has spread toward right\n side of face. She has had right gum tenderness around her right lower\n tooth (only lower right tooth left), and has long history of\n odontogenic disease. Her PCP has treated her with oral ciprofloxacin\n . She went to an OSH ED today where CT with constrast of\n the neck showed fluid collection in the submandibular space. She was\n treated with IV unasyn and\n transferred to . She has trismus, but no respiratory distress or\n desaturation or stridor. Her floor of mouth is\n edematous espcially on the right side, but soft. Went for drainage of\n abscess, left intubated because of concern for postop airway compromise\n (swelling).\n Chief complaint:\n submandibular abscess\n PMHx:\n CHF, hypothyroidism, Colon Ca, GERD, COPD, PNA, Renal failure, vascular\n disease, abdominal aortic aneurysm (pt informs that last year it was\n ~4cm), iron deficiency anemia\n Current medications:\n 1. 2. 20 mEq Potassium Chloride / 1000 mL D5NS 3. Ampicillin-Sulbactam\n 4. Calcium Gluconate 5. Famotidine\n 6. Fentanyl Citrate 7. Heparin 8. Influenza Virus Vaccine 9. Insulin\n 10. Metoprolol Tartrate 11. Pneumococcal Vac Polyvalent\n 12. Propofol 13. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:30 AM\n pt arrived from OR intubated\n - admitted to SICU\n Post operative day:\n POD #1\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 50 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:09 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.4\nC (97.5\n T current: 36.4\nC (97.5\n HR: 92 (92 - 102) bpm\n BP: 97/54(64) {97/54(64) - 142/82(97)} mmHg\n RR: 19 (14 - 19) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 702 mL\n PO:\n Tube feeding:\n IV Fluid:\n 702 mL\n Blood products:\n Total out:\n 0 mL\n 460 mL\n Urine:\n 110 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 242 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): 4\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 63\n PIP: 21 cmH2O\n Plateau: 15 cmH2O\n SPO2: 100%\n ABG: 7.41/38/488/23/0\n Ve: 8.7 L/min\n PaO2 / FiO2: 1,220\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, open\n wound in abd, covered in dry gauze\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Sedated\n Labs / Radiology\n 116 K/uL\n 7.3 g/dL\n 150 mg/dL\n 1.0 mg/dL\n 23 mEq/L\n 4.3 mEq/L\n 16 mg/dL\n 100 mEq/L\n 131 mEq/L\n 22.8 %\n 10.6 K/uL\n [image002.jpg]\n 01:52 AM\n 03:13 AM\n WBC\n 10.6\n Hct\n 22.8\n Plt\n 116\n Creatinine\n 1.0\n TCO2\n 25\n Glucose\n 150\n Other labs: PT / PTT / INR:16.9/26.5/1.5, Lactic Acid:1.0 mmol/L,\n Ca:7.7 mg/dL, Mg:1.8 mg/dL, PO4:5.0 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), .H/O PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n Assessment and Plan: 84 yo F with submandibular abscess s/p drainage,\n left intubated due to concern for airway compromise\n Neurologic: cont propofol, fentanyl prn for pain. Dilaudid pca if\n extubation.\n Cardiovascular: Beta-blocker, hemodynamically stable, on home\n lopressor, will give IV until extubated and taking po's. need to\n clarify dose with family/PCP\n : hold extubation until OMF/ ENT plan. (Ventilator mode: CPAP\n + PS), intubated/sedated. wean from vent,\n Gastrointestinal / Abdomen: NPO for now; h/o colon CA, has open wound\n in abd, will watch, cx if issues\n Nutrition: place dobhoff.\n Renal: Foley, Adequate UO, h/o renal failure, follow creat esp as pt\n got contrast, currently stable. Na 131, will follow while on IVF\n (change to D5NS)\n Hematology: Hct 25.8 at OSH, now 22.8, no indications for transfusion\n but will f/u Hct, has stable coagulopathy INR 1.5, will follow\n Endocrine: RISS\n Infectious Disease: submandibular abscess (likely from infected tooth)\n - s/p drainage. on unasyn. OMFS/ENT surgical plan pending prior to\n extubation.\n Lines / Tubes / Drains: Foley, ETT, PIV\n Wounds: Dry dressings\n Imaging: ?CT Neck per OMFS\n Fluids: D5NS\n Consults: ENT, OMFS\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 01:36 AM\n 20 Gauge - 01:37 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: 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": "2137-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651199,
"text": "84 yo F with 1 week of right neck swelling that has spread toward right\n side of face. She has had right gum tenderness around her right lower\n tooth (only lower right tooth left), and has long history of\n odontogenic disease. Her PCP has treated her with oral ciprofloxacin\n starting . She went to an OSH ED today where CT with contrast of\n the neck showed fluid collection in the submandibular space. She was\n treated with IV unasyn and\n transferred to . She has trismus, but no respiratory distress or\n desaturation or stridor. Her floor of mouth is\n edematous especially on the right side, but soft. Went for drainage of\n abscess, left intubated because of concern for postop airway compromise\n (swelling).\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n PT came from OR intubated, neck with swelling, tongue and mouth is\n with swelling\n Action:\n Pt on vent AC mode, ABG WNL. Fio2 down to 40% after ABG.\n Response:\n LS clear, O2 sat 97-99%\n Plan:\n Wean extubate as tolerates\n .H/O Problem - Description In Comments\n Assessment:\n Swelling neck rt side, s/p I & D in the OR.\n Action:\n Dressing intact & Dry, 2 pin rose drain per report from the OR\n Response:\n intact dressing.\n Plan:\n Cont monitoring, dressing change by ENT team.\n .H/O Problem - Description In Comments\n Assessment:\n Open wound on the abd with very foul smelling dressing with greenish\n drainage ( h/o colon cancer)\n Action:\n Dressing changed, wound looks pink, clean and dry\n Response:\n wound looks clean.\n Plan:\n Dressing , wound care nurse involvement\n"
},
{
"category": "Nursing",
"chartdate": "2137-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651601,
"text": "Cellulitis\n Assessment:\n neck remains mildly swollen, erythema over left portion of incision\n afebrile\n Action:\n penrose drains to gravity,\n ampicillin a/o\n normal saline nasal wash\n Response:\n cont to drain serosang from penrose drains\n cellulits improving\n able to raise secretions\n Plan:\n cont ampicillin a/o\n penrose drains to gravity per ENT\n follow low HCT\nborderline per patient (takes procrit and iron at home)\n await wound care recs for abd dressing\n"
},
{
"category": "Respiratory ",
"chartdate": "2137-11-30 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 651181,
"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: OR\n Reason: Elective\n Tube Type\n ETT:\n Position: 19 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 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 Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed;\n Comments: Just arrived from OR\n"
},
{
"category": "Respiratory ",
"chartdate": "2137-12-01 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 651406,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 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 / Scant\n Comments/Plan\n No changes made overnight, remains intubated and vent supported. Pt to\n go to OR today, maintain vent support.\n 06:12\n"
},
{
"category": "Nursing",
"chartdate": "2137-11-30 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651324,
"text": "Inability to protect airway\n Assessment:\n Pt. is POD 1 s/p maxillofacial abcess I&D. Pt. remains intubated for\n airway protection per ENT team. Right jaw is firm to hard. Site\n remains wrapped in DSD with small amts serosang. output via penrose\n drains. Pt. denies pain via nodding. VSS.\n Action:\n Pt. transported to CT this afternoon for maxillofacial CT. Vent weaned\n to PSV this a.m. Pt. given fentanyl boluses for sedation and propofol\n gtt titrated to and stable BP. Pt. cont\ns on unasyn.\n Response:\n Airway patent. Cuff leak present. Pt. admitted to breathing\n uncomfortably on PSV, placed back on CMV by RT. Slight decrease in\n hardness of right jaw this eve.\n Plan:\n OFM specialists to remove abcessed tooth tomorrow. Then plan to\n extubate.\n"
},
{
"category": "Nursing",
"chartdate": "2137-12-01 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651498,
"text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt intubated for OR at start of shift. Sent to OR for teeth extraction.\n , pt stable on CPAP. LSCTA. +cough/gag. Able to lift head/neck\n off bed. Neck incision site with sutures cdi and 2 patent penrose\n drains (surrounding skin erythemous). Teeth extraction sites in\n bilateral lower jaw with sutures cdi.\n Action:\n Extubated pt.\n Response:\n Pt successfully extubated. LSCTA. O2 sats >93% on room air.\n Plan:\n Continue to monitor respiratory status. d/c to floor.\n"
},
{
"category": "Nursing",
"chartdate": "2137-12-02 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 651552,
"text": "Cellulitis\n Assessment:\n neck remains mildly swollen\n afebrile\n Action:\n penrose drains to gravity,\n ampicillin a/o\n normal saline nasal wash\n Response:\n cont to drain serosang from penrose drains\n cellulits improving\n able to raise secretions\n Plan:\n cont ampicllin a/o\n penrose drains to gravity per ENT\n follow low HCT\nborderline per patient (takes procrit and iron at home)\n await wound care recs for abd dressing\n"
}
] |
2,743 | 150,517 | 1. Hypotension: The patient presented to her primary care physician with hypotension, systolic blood pressure in the 80s in the Emergency Department. Sepsis protocol was initiated due to her blood pressure and her lactic acid. Her hypotension responded nicely to aggressive fluid repletion also to stress dosed steroids and continuation of her DDAVP for diabetes insipidus. By the time she arrived in the Intensive Care Unit her blood pressure was already stable and she was doing much better. This was felt likely to be a combination of prerenal volume depletion perhaps in the setting of urosepsis from her urinary tract infection. The patient was stable after essentially 48 hours to be transferred to the floor at which point her blood pressure was no longer an issue. 2. Urinary tract infection: The patient had a positive urinalysis on admission and was started on Ceftriaxone, Flagyl. Her urine culture grew back a pan sensitive Klebsiella pneumonia urinary tract infection. The patient's Flagyl was discontinued and she was continued on a Ceftriaxone for this urinary tract infection. She completed a seven day course of Ceftriaxone and at the time of discharge was afebrile and had no white blood cell count. 3. Hypernatremia: The patient presented with a sodium of 151. She was likely hypernatremic due to her diabetes insipidus and inability to replete free water on her own due to the vomiting she had been experiencing prior to admission. In the Emergency Department she had also received normal saline, but was of course urinating out dilute free water, thus increasing her sodium. Initial treatment was of her volume with normal saline intravenous fluids. Her hypernatremia was treated with D5, her estimated free water deficit was 3 liters. D5 was then changed over to D5 half normal saline. Her DDAVP was also restarted. With the DDAVP given every day her sodium was as low as 134. In the end the DDAVP was titrated to once per day and she was also continued on her Lasix during this time. The feeling was that with the DDAVP the patient now having access to free water and standing Lasix that she would be able to maintain normal sodium. 4. Renal: The patient presented with an elevated creatinine. This was felt due to dehydration of a prerenal nature. It corrected from a high of 1.6 down to her baseline of 1.1. She also had a metabolic acidosis on admission, which was likely again due to vomiting and maybe wit a little bit of lacticacidosis from decreased perfusion in the setting of her dehydration. This also corrected once she was fluid repleted. 5. Chest pain: The patient did complain of some chest pain on admission, which resolved spontaneously. She had no new electrocardiogram changes and had a PMIBI back in that was unremarkable and showed an EF of 60%. She was continued on her aspirin and enzymes were cycled and she ruled out for an myocardial infarction. Her beta-blocker was restarted as tolerated. 6. Neurosarcoid: The patient was continue stress dosed steroids and at discharge had been tapered down to Prednisone 20 mg per day. 7. Panhypopituitarism: The patient was maintained on her Levothyroxine. 8. Diabetes type 2: The patient's Metformin was held for borderline creatinine and in the context of her acute illness she was maintained on regular insulin sliding scale. 9. Hematology: The patient's hematocrit decreased from admission of 40 to 29 at discharge. Much of this was felt due to fluid repletion though workup of her baseline anemia would be warranted. | Iv fluid cont at kvo with am na pending.Resp- Lungs clear. EKG FROM EPISODE NOTED ABOVE UNCHANGED WITH TWAVE INVERSIONS. MORE INTERACTIVE THIS MORNING.CARDIAC: ARRIVED TACHY 100'S AND RANGE 99-118 SR/ST WITH NO ECTOPY. The appendix is nondilated nda filled with contrast. ON CEFTRIAXONE FOR UTI.SKIN: SMALL ABRASION TO UPPER BACK.ACCESS: RIJ PRESEP CATH. EKG DONE AND SX'S RESOLVED SPONTANEOUSLY WITHOUT INTERVENTION. Uo minimal 5-10cc q2hrs. Since the previous tracing of sinus tachycardia and further ST-T wave changes are present. The pulmonary vasculature is within normal limits. The rectum is within normal limits. There is interval placement of a right IJ central venous line, with the tip terminating in the right atrium. Contrast reaches the distal colon indicating no evidence of obstruction. DENIES SOB.GI/GU: ABD OBESE, SOFT WITH +BS. Given 40meq kcl iv and 22meq with k-phos. CK WAS FLAT. OCCASIOANL DRY NONPRODUCTIVE COUGH. D/C sepsis protocol. to take po meds without difficulty. + CONTINUES TO BE AN ISSUE 151, STARTED ON D5W @100CC/HR BUT AM NA+ 157. AM FS 258 GIVEN 6UNITS REGULAR.ID: TMAX 98.4 WBC 8.9 NOW 11.6. The cardiomediastinal and hilar contours are stable. An atrophic, postmenopausal uterus and adnexa are unremarkable. BP 126-163/64-82. Sats 99-100% on ra. TOOK MEDS WITHOUT DIFFICULTY. SVO2 CATH IN WITH #'S 66-75. IMPRESSION: No cause for the patient's abdominal pain identified. NO COMPLAINTS OF NAUSEA. HCT STABLE @34.RESP: NO CURRENT ISSUES. CRE IMPROVING NOW 1.1. CT OF THE ABDOMEN WITH CONTRAST: The visualized portions of the lung bases are clear. REASON FOR THIS EXAMINATION: r/o abscess. STARTED ON 12.5MG LOPRESSOR THIS AM. There are several small aortocaval lymph nodes, none of which are pathologic in size. There is no interval change in the position of a left central venous line with the tip in the lower SVC. C/O OF SSCP. NPNNeuro: Pt is alert, talkative, OOB to chair, able to do her ADLs.CV: VSS, conts on lopressor, Mg of 1.6 was replaced with 3 gms.Resp: LS clear, 02 SATs in the high 90s on RAGI: States that she did have abd pain last night but none today. The liver is normal in contour and attenuation with no evidence for hepatic mass or biliary ductal dilitation. LSC ON RA WITH RR 12-21 AND SATS 98-100%. The gallbladder, pancreas, spleen, adrenal glands, and kidneys are normal in appearance. SMICU nsg progress note Pt alert and orientedx3 verbalizing without problem. Left ventricular hypertrophy with ST-T wave changes.Clinical correlation is suggested. There are bilateral low lung volumes. MD CAME TO EXAMINE AND PT. Tall inferior P waves - possible rightatrial abnormality. Evaluate for intrabdominal abscess. Sinus tachycardia. Stating she feels much better. No change. Also noted is a left subclavian central line, with the tip terminating at the junction of the distal SVC and the right atrium. She conts on her IV abx. IMPRESSION: No evidence of heart failure or pneumonia. The lungs are clear and there are no pleural effusions or pneumothoraces. U/O 330-650CC/HR DI. If she does have a BM the team would like it to be sent for cdif.GU: Her u/o decreased to <10cc/hr, she was given her DDAVP this morning, she was started on NS at 125/hr x 1000cc. Taking po's without difficulty.Endocrine- Fs 98-153 on varing doses insulin gtt (see care-vuePlan- Cont to follow lytes. PORTABLE AP CHEST: The study is notable for low lung volumes. Sleeping off and on thoughout night.Cardiac- Bp and hr stable. She was given DDAVP nasaly and her u/o has decresaed significantly through the day and is now 40cc/hr. No contraindications for IV contrast FINAL REPORT INDICATION: A 54-year-old female with sarcoid, fever, and abdominal pain. REFORMATTED IMAGING: Images reformatted in the coronal plane were essential in evaluating the patient's right lower quadrant and large and small bowel and demonstrate no abnormal dilatation or wall thickening. URINE IS CLEAR. IMPRESSION: The distal tip of the right IJ central venous line is in the right atrium and could be pulled back 5 cm for optimal positioning. Baseline artifact. Pt c/o being hungery. There are several subcentimeter low attenuation lesions within the right kidney which are too small to characterize but likely represent simple renal cysts. INITIAL CVP ~9, RECEIVED 500CC FB WITH CVP ^. BLOOD CX'S PENDING. Nonionic contrast was used due to patient renal dysfunction. Na this am at 11 was 148, gluc 521, she was stated on an insulin gtt and it is down to the 200 range.CV: She was hypertensive today to the 170s-180s, it has decreased to the 150s, HR 80s, her lopressor was increased to 25mg . LINE WAS PULLED BACK 5CM BY MD. REASON FOR THIS EXAMINATION: r/o PNA FINAL REPORT INDICATION: Fever. MOVNG ALL EXTREMITIES. LSC PORTACATH.SOCIAL/DISPO: FULL CODE. There is no focal consolidation or pleural effusion. ?transfer to floor in am. Repeat k pending. 11:19 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 100CC NON IONIC CONTRAST; CT RECONSTRUCTION Reason: FEVER,ABDOMEN PAIN,SARCOID.R/O ABSCESS Admitting Diagnosis: ABDOMINAL PAIN;FEVER Field of view: 48 Contrast: VISAPAQUE Amt: 100 MEDICAL CONDITION: 54 year old woman with sarcoid, fever and abd pain. By noon time she was very sommulent though she she could be aroused and was oriented when she could stay awake long enough to answer the questions. Asking freq for water. K back at 2.8. | 8 | [
{
"category": "Radiology",
"chartdate": "2128-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 814183,
"text": " 6:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p RIJ\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with HX OF SARCOIDOSIS with fever.\n\n REASON FOR THIS EXAMINATION:\n s/p RIJ\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sarcoidosis with fever.\n\n CHEST AP PORTABLE: Comparison is made to the prior study obtained two hours\n earlier. There are bilateral low lung volumes. There is interval placement\n of a right IJ central venous line, with the tip terminating in the right\n atrium. There is no evidence of pneumothorax. Also noted is a left\n subclavian central line, with the tip terminating at the junction of the\n distal SVC and the right atrium. There is no focal consolidation or pleural\n effusion.\n\n IMPRESSION: The distal tip of the right IJ central venous line is in the\n right atrium and could be pulled back 5 cm for optimal positioning.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-02-04 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 814194,
"text": " 11:19 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 100CC NON IONIC CONTRAST; CT RECONSTRUCTION\n Reason: FEVER,ABDOMEN PAIN,SARCOID.R/O ABSCESS\n Admitting Diagnosis: ABDOMINAL PAIN;FEVER\n Field of view: 48 Contrast: VISAPAQUE Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with sarcoid, fever and abd pain. Cr. 1.6.\n REASON FOR THIS EXAMINATION:\n r/o abscess.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 54-year-old female with sarcoid, fever, and abdominal pain.\n Evaluate for intrabdominal abscess.\n\n TECHNIQUE: CT imaging of the abdomen and pelvis after the intravenous\n administration of 100 cc of Isopaque. Nonionic contrast was used due to\n patient renal dysfunction.\n\n CT OF THE ABDOMEN WITH CONTRAST: The visualized portions of the lung bases are\n clear. The liver is normal in contour and attenuation with no evidence for\n hepatic mass or biliary ductal dilitation. The gallbladder, pancreas, spleen,\n adrenal glands, and kidneys are normal in appearance. There are several\n subcentimeter low attenuation lesions within the right kidney which are too\n small to characterize but likely represent simple renal cysts. There is no\n evidence of renal mass, stone, or hydronephrosis. There are several small\n aortocaval lymph nodes, none of which are pathologic in size. There is no\n evidence of mesenteric lymphadenopathy. No free fluid or free air is\n identified within the abdomen or pelvis.\n\n CT OF THE PELVIS WITH CONTRAST: The urinary bladder is collapsed with a Foley\n catheter in place. An atrophic, postmenopausal uterus and adnexa are\n unremarkable. The rectum is within normal limits. There is no evidence of\n , thickening, or abdnormal dilitation within large or small\n bowel. Contrast reaches the distal colon indicating no evidence of\n obstruction. The appendix is nondilated nda filled with contrast. There is\n degenerative change within the lumbar spine.\n\n REFORMATTED IMAGING: Images reformatted in the coronal plane were essential in\n evaluating the patient's right lower quadrant and large and small bowel and\n demonstrate no abnormal dilatation or wall thickening.\n\n IMPRESSION: No cause for the patient's abdominal pain identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2128-02-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 814177,
"text": " 4:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with HX OF SARCOIDOSIS with fever.\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever.\n\n COMPARISON: .\n\n PORTABLE AP CHEST: The study is notable for low lung volumes. The\n cardiomediastinal and hilar contours are stable. The lungs are clear and\n there are no pleural effusions or pneumothoraces. There is no evidence of\n mediastinal lymph adenopathy. The pulmonary vasculature is within normal\n limits. There is no interval change in the position of a left central venous\n line with the tip in the lower SVC.\n\n IMPRESSION: No evidence of heart failure or pneumonia. No change.\n\n"
},
{
"category": "ECG",
"chartdate": "2128-02-04 00:00:00.000",
"description": "Report",
"row_id": 111988,
"text": "Baseline artifact. Sinus tachycardia. Tall inferior P waves - possible right\natrial abnormality. Left ventricular hypertrophy with ST-T wave changes.\nClinical correlation is suggested. Since the previous tracing of \nsinus tachycardia and further ST-T wave changes are present.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-02-05 00:00:00.000",
"description": "Report",
"row_id": 1297833,
"text": "NPN\n\nNeuro: She was a little difficult to arouse this morning, she was oriented and able to follow commands, asking for food to eat and something to drink. By noon time she was very sommulent though she she could be aroused and was oriented when she could stay awake long enough to answer the questions. She is easier to wake this afternoon but quickly falls back to sleep and states that she is tired. PERL, conts to be oriented. Na this am at 11 was 148, gluc 521, she was stated on an insulin gtt and it is down to the 200 range.\n\nCV: She was hypertensive today to the 170s-180s, it has decreased to the 150s, HR 80s, her lopressor was increased to 25mg . Her CVP is ~ 10.\n\nResp: LS clear, 02 SAT high 90s on RA, her conts SV02 has been 77-84.\n\nGI: Sm amount of stool, she c/o abd pain with palpation but also states that she is hungry; she ate toast and juice for breakfast and then had water.\n\nGU: She was having a brisk diuresis this morning ~ 650cc/hr at a high. She was given DDAVP nasaly and her u/o has decresaed significantly through the day and is now 40cc/hr. She was initially being given D5W at a rate equal to her u/o plus 100cc, this has since been changed to KVO.\n\nEndo: Her BS was 521 at noon, she was started on an insulin gtt, given a 10 unit bolus initially and had a max rate on 9 units/hr - she is presently at 5 units/hr.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-02-06 00:00:00.000",
"description": "Report",
"row_id": 1297834,
"text": "SMICU nsg progress note\n Pt alert and orientedx3 verbalizing without problem. to take po meds without difficulty. Stating she feels much better. Sleeping off and on thoughout night.\nCardiac- Bp and hr stable. Uo minimal 5-10cc q2hrs. K back at 2.8. Given 40meq kcl iv and 22meq with k-phos. Repeat k pending. Iv fluid cont at kvo with am na pending.\nResp- Lungs clear. Sats 99-100% on ra.\n Pt c/o being hungery. Asking freq for water. Taking po's without difficulty.\nEndocrine- Fs 98-153 on varing doses insulin gtt (see care-vue\nPlan- Cont to follow lytes. D/C sepsis protocol. ?transfer to floor in am.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-02-06 00:00:00.000",
"description": "Report",
"row_id": 1297835,
"text": "NPN\n\nNeuro: Pt is alert, talkative, OOB to chair, able to do her ADLs.\n\nCV: VSS, conts on lopressor, Mg of 1.6 was replaced with 3 gms.\n\nResp: LS clear, 02 SATs in the high 90s on RA\n\nGI: States that she did have abd pain last night but none today. She ate breakfast and lunch; good appitite. If she does have a BM the team would like it to be sent for cdif.\n\nGU: Her u/o decreased to <10cc/hr, she was given her DDAVP this morning, she was started on NS at 125/hr x 1000cc. Her u/o has increased this afternoon to ~ 20-30cc/hr. She has been drinking water in lg quantities today.\n\nEndo: Her insulin gtt was d/ced and she is now on SS insulin, no plans to start her glucophage at present due to her elevated amylase and elevated creat.\n\nID: T 96, her WBC was 20 this morning - this has been atributed to her high does of steroids. She conts on her IV abx.\n"
},
{
"category": "Nursing/other",
"chartdate": "2128-02-05 00:00:00.000",
"description": "Report",
"row_id": 1297832,
"text": "MICU NPN 7P-7A\nRECEIVED VIA AMBULANCE FROM ED @0130.\n\nNEURO: PATIENT ALERT AND ORIENTED X3. FOLLOWING COMMANDS AND ANSWERING QUESTIONS APPROPIATELY. MOVNG ALL EXTREMITIES. INITIALLY C/O BACK PAIN WHICH SHE STATED WAS FROM PAST SHINGLES EXPOSURE AND NECK PAIN FROM CENTRAL LINE. MD CAME TO EXAMINE AND PT. TEARY AND SLIGHTLY ANXIOUS. C/O OF SSCP. EKG DONE AND SX'S RESOLVED SPONTANEOUSLY WITHOUT INTERVENTION. AFTER INITIAL ASSESSMENT PATIENT SLEEPING SOUNDLY BUT AROUSED EASILY TO VOICE/STIMULI BUT WOULD FALL BACK ASLEEP IN MID SENTENCE. MORE INTERACTIVE THIS MORNING.\n\nCARDIAC: ARRIVED TACHY 100'S AND RANGE 99-118 SR/ST WITH NO ECTOPY. STARTED ON 12.5MG LOPRESSOR THIS AM. BP 126-163/64-82. INITIAL CVP ~9, RECEIVED 500CC FB WITH CVP ^. SVO2 CATH IN WITH #'S 66-75. LINE WAS PULLED BACK 5CM BY MD. + CONTINUES TO BE AN ISSUE 151, STARTED ON D5W @100CC/HR BUT AM NA+ 157. MD AWARE AND WILL INCREASE IVF TO 250CC/HR. CHLORIDE ALSO INCREASING. CK WAS FLAT. EKG FROM EPISODE NOTED ABOVE UNCHANGED WITH TWAVE INVERSIONS. PEDAL PULSES PRESENT. HCT STABLE @34.\n\nRESP: NO CURRENT ISSUES. LSC ON RA WITH RR 12-21 AND SATS 98-100%. OCCASIOANL DRY NONPRODUCTIVE COUGH. DENIES SOB.\n\nGI/GU: ABD OBESE, SOFT WITH +BS. NPO. NO COMPLAINTS OF NAUSEA. TOOK MEDS WITHOUT DIFFICULTY. NO STOOL. U/O 330-650CC/HR DI. CRE IMPROVING NOW 1.1. URINE IS CLEAR. AM FS 258 GIVEN 6UNITS REGULAR.\n\nID: TMAX 98.4 WBC 8.9 NOW 11.6. BLOOD CX'S PENDING. ON CEFTRIAXONE FOR UTI.\n\nSKIN: SMALL ABRASION TO UPPER BACK.\n\nACCESS: RIJ PRESEP CATH. LSC PORTACATH.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY.\n"
}
] |
76,134 | 199,200 | 40 year old Caucasian male with a past medical history of morbid obesity, steroid dependent psoriatic arthritis, insulin dependent type II diabetes mellitus, obstructive sleep apnea on CPAP and multiple recent admissions for a left lower extremity wound/cellulitis s/p wound VAC presenting from a rehabilitation facility with episodes of shortness of breath, hypoxemia and palpitations. #HYPOXEMIA: Mr. hospital course was most notable for normal oxygen saturations during the vast majority of his hospitalization. There was significant concern regarding the accuracy of the pulse ox because of the patient's dactylitis, and significant interstitial edema. His intermittent episodes of hypoxemia were initially concerning for expanding or new pulmonary emboli due to their acute onset, association with tachycardia and reports of pre-syncopal symptoms. The patient had also been subtherapeutic on warfarin prior to admission. The pulmonary service was consulted and felt that pulmonary emboli were unlikely the cause of the hypoxemic episodes given their sub-occlusive nature and stable appearance on CT. Flash pulmonary edema was considered because of the patient's report of a 28 lb weight gain prior to admission, association of the episodes with ambulation/tahcycardia and non-specific CT scan findings potentially consistent with edema. The patient was diuresed, with IV and PO furosemide, from an admission weight of 386 lbs to 366 lbs at discharge. Fluids and sodium were restricted. No direct association between diuresis and the episdoes of hypoxemia was noted; however the patient did not experience additional episodes of hypoxemia during the last 12 days of his admission when he was closer to his dry weight. The patient had a poor quality, but nevertheless essentially normal echocardiogram and no definitive evidence of pulmonary edema on any chest imaging. The patient's severe sleep apnea likely contributed to several episodes of hypoxemia. He was placed on CPAP at night with occasional supplemental O2. During the day shift however he was noted to fall asleep occasionally without the CPAP in place. | Otherwise, withinnormal limits and no longer having frequent ventricular ectopic beats intrigeminy and quadrigeminy compared to previous tracing of .TRACING #1 Sinus rhythm with one ventricular premature beat seen. Sinus rhythm with occasional ventricular premature beats. Sinus rhythm with monomorphic ventricular premature beats. Ventricular premature beats have normal axis andleft bundle-branch block morphology. Indeterminate PAsystolic pressure.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: There is an anterior space which most likely represents a fatpad, though a loculated anterior pericardial effusion cannot be excluded.GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Since the previous tracing ventricularpremature beat is no longer seen. No AR.MITRAL VALVE: Normal mitral valve leaflets with trivial MR.TRICUSPID VALVE: Tricuspid valve not well visualized. Since the previous tracing of the ventricular premature beats have the same morphology, ventricular prematurebeat couplet is no longer seen. Right ventricular function. Normal biventricular cavity sizes withpreserved global biventricular systolic function.Compared with the prior study (images reviewed) of , the findings aresimilar. Frequent unifocal ventricular premature beats in eithera bigeminal or a trigeminal pattern. Diffuse non-specificST-T wave abnormalities. Compared to the previous tracing frequent ventricularectopy is present. Conducted complexesof borderline low voltage. The mitral valveappears structurally normal with trivial mitral regurgitation. Sinus rhythm and frequent ventricular ectopy. Suboptimal technical quality, a focal LV wall motionabnormality cannot be fully excluded.RIGHT VENTRICLE: Normal RV chamber size.AORTA: Normal aortic diameter at the sinus level. Right ventricular chamber size isgrossly normal with good free wall motion (only seen in parasternal long axisorientation). Low precordial lead voltage.Compared to the previous tracing of the rate has slowed. Sinus rhythm. Sinus rhythm. Sinus rhythm with frequent unifocal ventricular ectopy. Compared to theprevious tracing of no change except for the single premature beat.TRACING #1 Otherwise, nodiagnostic interim change. Normal ascending aortadiameter.AORTIC VALVE: Normal aortic valve leaflets (?#). Premature ventricular contractions aremore frequent compared to early tracing of . Sinus tachycardia. Otherwise, no significantchange.TRACING #2 Borderline low voltage. The aortic valve leaflets (?#) appear structurally normal withgood leaflet excursion. Pulmonary embolus.Height: (in) 73Weight (lb): 400BSA (m2): 2.89 m2BP (mm Hg): 126/89HR (bpm): 60Status: InpatientDate/Time: at 10:31Test: TTE (Focused views)Doppler: Limited Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolicfunction (LVEF>55%). Due to suboptimal technical quality, a focal wall motionabnormality cannot be fully excluded. There is an anterior spacewhich most likely represents a prominent fat pad.IMPRESSION: Suboptimal image quality. Pulmonary hypertension. Compared to tracing #1 nosignificant change except for a faster rate.TRACING #2 The pulmonaryartery systolic pressure could not be determined. Otherwise, normal tracing. Congestive heart failure. Sinus tachycardia with frequent monomorphic ventricular premature beats.Compared to the previous tracing of the rate is increased. PATIENT/TEST INFORMATION:Indication: Left ventricular function. The prior study was also technically suboptimal. Clinical correlation is suggested.TRACING #1 Clinical correlation is suggested.TRACING #2 Otherfindings are similar. Suboptimalimage quality - body habitus.Conclusions:Left ventricular wall thickness, cavity size, and global systolic function arenormal (LVEF>55%). The other findings are similar. | 10 | [
{
"category": "Echo",
"chartdate": "2204-09-18 00:00:00.000",
"description": "Report",
"row_id": 70233,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Pulmonary hypertension. Right ventricular function. Congestive heart failure. Pulmonary embolus.\nHeight: (in) 73\nWeight (lb): 400\nBSA (m2): 2.89 m2\nBP (mm Hg): 126/89\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:31\nTest: TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: Normal RV chamber size.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\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 - body habitus.\n\nConclusions:\nLeft ventricular wall thickness, cavity size, and global systolic function are\nnormal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Right ventricular chamber size is\ngrossly normal with good free wall motion (only seen in parasternal long axis\norientation). The aortic valve leaflets (?#) appear structurally normal with\ngood leaflet excursion. No aortic regurgitation is seen. The mitral valve\nappears structurally normal with trivial mitral regurgitation. The pulmonary\nartery systolic pressure could not be determined. There is an anterior space\nwhich most likely represents a prominent fat pad.\n\nIMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with\npreserved global biventricular systolic function.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar. The prior study was also technically suboptimal.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2204-10-03 00:00:00.000",
"description": "Report",
"row_id": 156572,
"text": "Sinus rhythm and frequent ventricular ectopy. Low precordial lead voltage.\nCompared to the previous tracing of the rate has slowed. Otherwise, no\ndiagnostic interim change.\n\n"
},
{
"category": "ECG",
"chartdate": "2204-09-28 00:00:00.000",
"description": "Report",
"row_id": 156573,
"text": "Sinus tachycardia with frequent monomorphic ventricular premature beats.\nCompared to the previous tracing of the rate is increased. Other\nfindings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2204-09-22 00:00:00.000",
"description": "Report",
"row_id": 156574,
"text": "Sinus rhythm with frequent unifocal ventricular ectopy. Diffuse non-specific\nST-T wave abnormalities. Compared to the previous tracing frequent ventricular\nectopy is present. The other findings are similar.\n\n"
},
{
"category": "ECG",
"chartdate": "2204-09-20 00:00:00.000",
"description": "Report",
"row_id": 156575,
"text": "Sinus tachycardia. Otherwise, normal tracing. Compared to tracing #1 no\nsignificant change except for a faster rate.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2204-09-20 00:00:00.000",
"description": "Report",
"row_id": 156576,
"text": "Sinus rhythm with one ventricular premature beat seen. Compared to the\nprevious tracing of no change except for the single premature beat.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2204-09-18 00:00:00.000",
"description": "Report",
"row_id": 156577,
"text": "Sinus rhythm. Borderline low voltage. Since the previous tracing ventricular\npremature beat is no longer seen. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2204-09-17 00:00:00.000",
"description": "Report",
"row_id": 156578,
"text": "Sinus rhythm with monomorphic ventricular premature beats. Conducted complexes\nof borderline low voltage. Ventricular premature beats have normal axis and\nleft bundle-branch block morphology. Since the previous tracing of \nthe ventricular premature beats have the same morphology, ventricular premature\nbeat couplet is no longer seen. Clinical correlation is suggested.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2204-09-17 00:00:00.000",
"description": "Report",
"row_id": 156579,
"text": "Sinus rhythm. Frequent unifocal ventricular premature beats in either\na bigeminal or a trigeminal pattern. Premature ventricular contractions are\nmore frequent compared to early tracing of . Otherwise, no significant\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2204-09-16 00:00:00.000",
"description": "Report",
"row_id": 156825,
"text": "Sinus rhythm with occasional ventricular premature beats. Otherwise, within\nnormal limits and no longer having frequent ventricular ectopic beats in\ntrigeminy and quadrigeminy compared to previous tracing of .\nTRACING #1\n\n"
}
] |
81,229 | 194,995 | 62 y/o M with dilated cardiomyopathy admitted for initiation of dofetilide, complicated by torsades, no s/p pacer/ICD placement. . # RHYTHM: He was admitted for inpatient monitoring during the initiation of dofetilide. He was initiated on dofetilide 500mcg Q12hours with EKG 2 hours after each dose, and magnesium oxide 400mg twice daily. Patient had torsades the morning of in the setting of a prolonged QT interval and worsening bradycardia. He was emergently cardioverted, but the rhythm recurred two more times. He was given IV magnesium sulfate, and taken for pacer/ICD placement. The insertion of the pacer was without incident and he was kept overnight in the CCU. No further dofetilide was given and it should simply wash out of his system. He is now paced at 80bpm and had no further arrhythmias on telemetry. Given his history of MRSA and penicillin allergy, he got one day of vancomycin and two days of clindamycin for prophylaxis after pacer placement. He was discharged back on all of his home medications, including warfarin with a goal INR of . . # PUMP: He has a history of dilated cardiomyopathy (EF15%), but appeared euvolemic throughout his stay. He was continued on his home doses of lasix, aldactone, lisinopril. The atenolol was held in the setting of bradycardia, but restarted once he was being paced. Medications on Admission: ALLERGIES: Amiodarone: pulmonary toxicity Sulfa: Rash Tetracycline: Rash PCN: Rash Erythromycin: Rash --------------- --------------- --------------- --------------- Active Medication list as of : Medications - Prescription ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth daily BUPROPION HCL - (Prescribed by Other Provider) - 150 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth daily CAPTOPRIL - (Prescribed by Other Provider) - 12.5 mg Tablet - 1 Tablet(s) by mouth three times a day DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1 Tablet(s) by mouth once a day DOXAZOSIN - (Prescribed by Other Provider) - 1 mg Tablet - Take one Tablet(s) by mouth every day/bedtime FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) - 110 mcg/Actuation Aerosol - 1 puff inhaled twice a day FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1.5 Tablet(s) by mouth twice a day GABAPENTIN [NEURONTIN] - 600 mg Tablet - 2 Tablet(s) by mouth 3 times daily IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol - 1-2 puffs(s) inhaled four times daily as needed for shortness of breath LANSOPRAZOLE [PREVACID SOLUTAB] - 30 mg Tablet,Rapid Dissolve, DR - 1 Tablet(s) by mouth dissolve in mouth 30 min ac LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime daily METOCLOPRAMIDE - (Prescribed by Other Provider) - 5 mg Tablet - tab in am Tablet(s) by mouth 1 day Last dose was prior to dofetilide initation RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth hs SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day SPIRONOLACTONE [ALDACTONE] - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once a day WARFARIN - (Prescribed by Other Provider) - 4 mg Tablet - 1 Tablet(s) by mouth daily dosing is INR dependent/quest in /followed by dr . Also has 1mg, 2mg, 3mg, and 6mg tablets as needed for dose adjustments. Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth prn for headache OXYGEN-AIR DELIVERY SYSTEMS - Device - 2 L/min by nasal cannula nocturnally SENNOSIDES [SENOKOT] - (Prescribed by Other Provider) - 8.6 mg Tablet - 2 Tablet(s) by mouth once a day Discharge Medications: 1. Atenolol 50 mg Tablet : One (1) Tablet PO DAILY (Daily). 2. Bupropion HCl 150 mg Tablet Sustained Release : One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 3. Captopril 12.5 mg Tablet : One (1) Tablet PO TID (3 times a day). 4. Digoxin 125 mcg Tablet : One (1) Tablet PO DAILY (Daily). 5. Doxazosin 1 mg Tablet : One (1) Tablet PO HS (at bedtime). 6. Fluticasone 110 mcg/Actuation Aerosol : One (1) Puff Inhalation (2 times a day). 7. Furosemide 20 mg Tablet : Three (3) Tablet PO BID (2 times a day). 8. Gabapentin 400 mg Capsule : Three (3) Capsule PO TID (3 times a day). 9. Ipratropium Bromide 17 mcg/Actuation Aerosol : Two (2) Puff Inhalation QID PRN () as needed for wheezing/dyspnea. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR : One (1) Tablet,Rapid Dissolve, DR twice a day. 11. Lorazepam 0.5 mg Tablet : One (1) Tablet PO at bedtime. 12. Ranitidine HCl 150 mg Tablet : One (1) Tablet PO HS (at bedtime). 13. Simvastatin 20 mg Tablet : One (1) Tablet PO once a day. 14. Spironolactone 25 mg Tablet : One (1) Tablet PO DAILY (Daily). 15. Warfarin 2 mg Tablet : Two (2) Tablet PO Once Daily at 4 PM. 16. Senna 8.6 mg Tablet : Two (2) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: atrial fibrillation Chronic systolic heart failure torsades de point ventricular fibrillation GERD chronic renal insufficiency depression Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Worked with PT, able to walk stairs without difficulty. Discharge Instructions: You were admitted because we wanted to start you on dofetilide for control of your atrial fibrillation. While you were here, your heart went into a dangerous rhythm, and you had to be shocked and go to the intensive care unit. You had a cardiac defibrillator implantated that also works as a pacemaker, and you are now safe to go home. . No changes were made to your medications. Please take all of your medications as you were prior to admission. . You have heart failure and will accumulate fluid if you are not careful. Please weigh yourself every morning and call your doctor if your weight goes up more than 3 lbs. Please drink less than 1.5 liters of fluid per day. . You have an appointment in the device clinic to make sure your pacemaker is functioning properly. That is Thursday, at 9:30am. . Your most recent INR was 2.7, meaning that you are therapeutic. Please call Dr. office Monday morning at to tell them your INR and ask when it should be tested next. Followup Instructions: Provider: CLINIC Phone: Date/Time: 9:30 Provider: , M.D. Phone: Date/Time: 3:00 Provider: . /DR. Phone: Date/Time: 1:30 Completed by:[**2195-2-22** | # GI Medications/GERD/Constipation - continue ranitidine - hold metoclopramide given ? # GI Medications/GERD/Constipation - continue ranitidine - hold metoclopramide given ? # GI Medications/GERD/Constipation - continue ranitidine - hold metoclopramide given ? # Atrial Fibrillation: Continue coumadin. Assessment and Plan 62 y/o M with dilated cardiomyopathy a/w torsades in setting of prolonged QT interval during dofetilide initiation. Assessment and Plan 62 y/o M with dilated cardiomyopathy a/w torsades in setting of prolonged QT interval during dofetilide initiation. ASSESSMENT AND PLAN 62 y/o M with dilated cardiomyopathy a/w torsades in setting of prolonged QT interval during dofetilide initiation. Medications on Transfer (reconciled with home medications and consistent except reglan on hold) -dofetilide -vanco/clinda post procedure . Assessment and Plan ATRIAL FIBRILLATION (AFIB) - will hold on any anti-arrthymics for now. Assessment and Plan ATRIAL FIBRILLATION (AFIB) - will hold on any anti-arrthymics for now. He is now s/p ICD/pacer placement and admitted to CCU for observation- stable hemodynamics, no further VT noted. He is now s/p ICD/pacer placement and admitted to CCU for observation- stable hemodynamics, no further VT noted. He is now s/p ICD/pacer placement and admitted to CCU for observation- stable hemodynamics, no further VT noted. He is now s/p ICD/pacer placement and admitted to CCU for observation- stable hemodynamics, no further VT noted. Held doxazosin dose. Held doxazosin dose. EKG on arrival: HR 80 bpm atrial pacing, inferior q-waves, QTc 469. He is now s/p ICd placement and admitted to CCU for observation- stable hemodynamics, no further VT noted. Chief Complaint: 62 y/o M with dilated cardiomyopathy a/w torsades in setting of prolonged QT interval during dofetilide initiation. Chief Complaint: 62 y/o M with dilated cardiomyopathy a/w torsades in setting of prolonged QT interval during dofetilide initiation. # CORONARIES: - continue statin therapy . Action: Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. Action: Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. Action: Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. -atrial flutter s/p ablation -atrial fibrillation prev controlled on amio (stopped in amio lung toxicity) 3. - device interrogation ok, check CXR (PA/LAT) today. - device interrogation ok, check CXR (PA/LAT) today. # torsades de pointes - prolonged QT in setting of dofetilide initiation. # torsades de pointes - prolonged QT in setting of dofetilide initiation. Vancomycin post procedure xs 1 Followed by clindamycin. Chief Complaint: CHIEF COMPLAINT: Admission for Dofetilide initiation Reason for ICU Admission: Torsades HPI: HISTORY OF PRESENTING ILLNESS: This is a 62 y.o. The second with two electrode enforcements representing the ICD terminates in a position compatible with the apical portion of the right ventricle. Compared to the previous tracing of no diagnosticinterim change.TRACING #1 Compared to the previous tracing of there is nochange.TRACING #1 Compared to tracing #1 no diagnostic interim change.TRACING #2 The patient has recently undergone implantation of a left-sided permanent pacer seen in anterior axillary position. One of these is terminating in a position compatible with the right atrial appendage. Probable inferior myocardial infarction of indeterminate age.ST-T wave changes that are non-specific. FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. Compared to tracing #3 no diagnosticinterim change.TRACING #4 The ICD device is again in place with leads in the region of the right atrial appendage and apex of the right ventricle. Possible old inferior myocardial infarction. Intraventricular conduction delay with left bundle-branchblock pattern and QRS duration of 140 milliseconds. Comparison is made with the next previous available chest examination of . Possible old anterior wallmyocardial infarction. Compared to tracing #1 there is no significant diagnosticchange.TRACING #2 Occasional ventricular prematurebeats. FINDINGS: AP single view of the chest has been obtained with patient sitting upright position. Normal sinus rhythm. Normal sinus rhythm. Normal sinus rhythm. Normal sinus rhythm. Sinus bradycardia with sinus arrhythmia. FINDINGS: In comparison with the earlier study of this date, there is little overall change in the appearance of the ICD implant. P-R interval prolongation. Compared to the previous tracingof multiple described abnormalities persist.TRACING #1 Left axisdeviation. Compared to the previous tracingatrial pacing is new.TRACING #2 Sinus bradycardia. Sinus bradycardia. Likely still a candidate for flecainide. Compared to tracing #2 there is no diagnostic interimchange.TRACING #3 FINDINGS: In comparison with the study of , there is little change. 2:59 PM CHEST (PORTABLE AP) Clip # Reason: r/o pneumothorax Admitting Diagnosis: ATRIAL FIBRILLATION MEDICAL CONDITION: 62 year old man post DDD-ICD implant REASON FOR THIS EXAMINATION: r/o pneumothorax PROVISIONAL FINDINGS IMPRESSION (PFI): SP 4:42 PM PFI: Successful pacer implantation, no pneumothorax. Heart size is unchanged and remains within normal limits. No acute cardiopulmonary disease is identified. , H. 2:59 PM CHEST (PORTABLE AP) Clip # Reason: r/o pneumothorax Admitting Diagnosis: ATRIAL FIBRILLATION MEDICAL CONDITION: 62 year old man post DDD-ICD implant REASON FOR THIS EXAMINATION: r/o pneumothorax PFI REPORT PFI: Successful pacer implantation, no pneumothorax. | 26 | [
{
"category": "Physician ",
"chartdate": "2195-02-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 520537,
"text": "Chief Complaint: 62 y/o M with dilated cardiomyopathy a/w torsades in\n setting of prolonged QT interval during dofetilide initiation.\n 24 Hour Events:\n s/p pacemaker placement - some soreness around pocket\n Allergies:\n Penicillins\n Unknown; Hives;\n Tetracyclines\n Hives;\n Sulfa (Sulfonamides)\n Hives;\n Erythromycin Base\n Hives;\n Amiodarone\n pulmonary toxic\n Last dose of Antibiotics:\n Vancomycin - 11:57 PM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:27 PM\n Other medications:\n Changes to medical and 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: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 80 (80 - 80) bpm\n BP: 108/65(74) {78/47(54) - 127/71(80)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 96%\n Heart rhythm: A Paced\n Height: 68 Inch\n Total In:\n 940 mL\n PO:\n 740 mL\n TF:\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,400 mL\n 450 mL\n Urine:\n 1,400 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -460 mL\n -450 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 184 K/uL\n 9.9 g/dL\n 90 mg/dL\n 1.3 mg/dL\n 29 mEq/L\n 4.9 mEq/L\n 27 mg/dL\n 99 mEq/L\n 136 mEq/L\n 34.2 %\n 6.0 K/uL\n [image002.jpg]\n 04:59 PM\n 03:45 AM\n WBC\n 6.0\n Hct\n 29.6\n 34.2\n Plt\n 184\n Cr\n 1.3\n Glucose\n 90\n Other labs: PT / PTT / INR:28.0//2.7, Ca++:8.4 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.7 mg/dL\n Imaging: CXR: AP single view of the chest has been obtained with\n patient sitting\n upright position. Comparison is made with the next previous available\n chest\n examination of . The patient has recently undergone\n implantation of a left-sided permanent pacer seen in anterior axillary\n position. The pacer is connected to a dual electrode system. One of\n these is\n terminating in a position compatible with the right atrial appendage.\n The\n second with two electrode enforcements representing the ICD terminates\n in a\n position compatible with the apical portion of the right ventricle.\n Heart\n size is unchanged and remains within normal limits. No pulmonary\n congestion\n is seen and no pneumothorax can be identified.\n Assessment and Plan\n 62 y/o M with dilated cardiomyopathy a/w torsades in setting of\n prolonged QT interval during dofetilide initiation.\n # torsades de pointes - prolonged QT in setting of dofetilide\n initiation. multiple shocks yesterday. s/p pacemaker placement\n - follow up EP recommendations\n - continue beta blocker\n - paced at 80 bpm\n - replete lytes aggressively\n - d/c dofetilide\n - tele monitoring\n - continue digoxin\n - continue warfarin\n # cardiomyopathy: chronic systolic heart failure. EF 15%. Euvolemic. No\n evidence of myocardial stunning after defibrillation.\n - continue lasix\n - continue spironolactone\n - continue lisinopril\n - continue atenolol\n - I/O, weights\n - fluid restrict\n # atrial fibrillation: s/p pacemaker\n - per above\n # Pulmonary Toxicity/Sleep Apnea/Bronchiectasis: No PFT's available.\n - continue home medicaitons and o/n home O2 therapy.\n - stable for now.\n # GI Medications/GERD/Constipation\n - continue ranitidine\n - hold metoclopramide given ? interaction with dofetilide, may\n reinitiate in the future once dofetilide washed out (clarify with EP\n concern with reglan)\n # BPH: Doxazosin qhs\n # Depression: Continue home buproprion\n ICU Care\n Nutrition:\n Comments: heart healthy diet\n Glycemic Control:\n Lines:\n 20 Gauge - 03:09 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2195-02-19 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 520412,
"text": "Chief Complaint: CHIEF COMPLAINT: Admission for Dofetilide initiation\n Reason for ICU Admission: Torsades\n HPI:\n HISTORY OF PRESENTING ILLNESS: This is a 62 y.o. gentleman with\n dilated cardiomyopathy secondary to chemotherapy and radiation therapy\n for Hodgkin's disease 20 years ago. His cardiomyopathy has been\n complicated by atrial flutter and fibrillation, which at one time\n caused significant clinical heart failure. He underwent successful\n atrial flutter ablation in . His atrial fibrillation was\n initially treated with Dofetilide, however after approximately two and\n half years it was no longer effective. He was then switched to\n Amiodarone, however after approximately 2-3 years he developed\n pulmonary toxicity and it was discontinued in the summer of .\n During the fall of he was primarily in NSR. In \n he contracted the HI NI flu, developed PNA, and was also found to have\n MRSA. He was hospitalized for 3 days. At that time he had recurrent\n PAF. He presently reports daily episodes of PAF and was electively\n admitted for initiation of dofetilide therapy.\n .\n Hospital course complicated by progressive prolonged QT interval with\n dofetilide therapy, and bradycardia. On AM prior to admission to CCU,\n patient developed an episode of torsades on telemtry in setting of QT\n of 490-500ms. Was shocked out of the rhythm, but remained\n bradycardic. Attempts to augment his rate with dopamine and later\n isoproterenol were undertaken with limited success. During this time\n patient was given magnesium sulfate 2grams IV, but had three-four\n further episodes of torsades requiring defibrillation. Patient was\n then taken to the EP lab for emergent pacer/ICD implantation.\n .\n Procedure was uncomplicated and AV Pacer/ICD was implanted.\n He is now transfered to the CCU for management with a heart rate of\n 80bpm, until the dofetilide washes out of his system.\n .\n On arrival to the CCU, patient is mentating well. Denies any chest\n pain, shortness of breath or other complaints. Admits to mild nausea\n and light headedness during the episodes. c/o mild shoulder pain\n following implantation of his device. His baseline exercise tolerance\n is about 1 flight of stairs.\n .\n On review of systems, he denies any prior history of stroke, TIA, deep\n venous thrombosis, pulmonary embolism, myalgias, joint pains, cough,\n hemoptysis, black stools or red stools. He denies recent fevers, chills\n or rigors. He denies exertional buttock or calf pain. All of the other\n review of systems were negative.\n .\n Cardiac review of systems is notable for absence of chest pain, dyspnea\n on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,\n palpitations, syncope or presyncope.\n .\n On arrival to the CCU, intial VS were: T97, HR 80, BP 112/71, RR 15, o2\n 94%\n Allergies:\n Penicillins\n Unknown; Hives;\n Tetracyclines\n Hives;\n Sulfa (Sulfonamides)\n Hives;\n Erythromycin Base\n Hives;\n Amiodarone\n pulmonary toxic\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 Past Medical History:\n 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, ?Hypertension\n 2. CARDIAC HISTORY:\n -Dilated Cardiomyopathy chemo and xrt 20 years ago (EF\n 10-15%) Was treated with adriamycin.\n -atrial flutter s/p ablation \n -atrial fibrillation prev controlled on amio (stopped in \n amio lung toxicity)\n 3. OTHER PAST MEDICAL HISTORY:\n -Hx of Hodgkin's disease , s/p Chemo and XRT\n -Severe GERD\n -Chronic constipation\n -Chronic lung disease with sleep apnea, emphysema and\n bronchiectasis with a history of severe hemoptysis in ,\n currently off of amiodarone; ? amiodarone induced pulmonary\n toxicity\n -History of diverticulitis x2; the last one was five years ago.\n -CRI\n -Dyslipidemia\n -Depression\n -Obstructive Sleep Apnea - uses nasal CPAP at home\n .\n Outpatient Medications:\n ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth daily\n BUPROPION HCL - (Prescribed by Other Provider) - 150 mg Tablet\n Sustained Release 24 hr - 1 Tablet(s) by mouth daily\n CAPTOPRIL - (Prescribed by Other Provider) - 12.5 mg Tablet - 1\n Tablet(s) by mouth three times a day\n DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1\n Tablet(s) by mouth once a day\n DOXAZOSIN - (Prescribed by Other Provider) - 1 mg Tablet - Take\n one Tablet(s) by mouth every day/bedtime\n FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) - 110\n mcg/Actuation Aerosol - 1 puff inhaled twice a day\n FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1.5\n Tablet(s) by mouth twice a day\n GABAPENTIN [NEURONTIN] - 600 mg Tablet - 2 Tablet(s) by mouth 3\n times daily\n IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol -\n 1-2 puffs(s) inhaled four times daily as needed for shortness of\n breath\n LANSOPRAZOLE [PREVACID SOLUTAB] - 30 mg Tablet,Rapid Dissolve, DR\n - 1 Tablet(s) by mouth dissolve in mouth 30 min ac \n LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1\n Tablet(s) by mouth at bedtime daily\n METOCLOPRAMIDE - (Prescribed by Other Provider) - 5 mg Tablet -\n tab in am Tablet(s) by mouth 1 day Last dose was prior\n to dofetilide initation\n RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth hs\n SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1\n Tablet(s) by mouth once a day\n SPIRONOLACTONE [ALDACTONE] - (Prescribed by Other Provider) - 25\n mg Tablet - 1 Tablet(s) by mouth once a day\n WARFARIN - (Prescribed by Other Provider) - 4 mg Tablet - 1\n Tablet(s) by mouth daily dosing is INR dependent/quest in\n /followed by dr . Also has 1mg, 2mg, 3mg, and\n 6mg tablets as needed for dose adjustments.\n Medications - OTC\n ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet -\n 2 Tablet(s) by mouth prn for headache\n OXYGEN-AIR DELIVERY SYSTEMS - Device - 2 L/min by nasal cannula\n nocturnally\n SENNOSIDES [SENOKOT] - (Prescribed by Other Provider) - 8.6 mg\n Tablet - 2 Tablet(s) by mouth once a day\n .\n Allergies: Penicillins / Tetracyclines / Sulfa (Sulfonamides) /\n Erythromycin Base / Amiodarone\n .\n Medications on Transfer\n (reconciled with home medications and consistent except reglan on hold)\n -dofetilide\n -vanco/clinda post procedure\n .\n Father with CAD age 70's. No other family history of early MI,\n arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise\n non-contributory.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Lives in with his wife.\n -Tobacco history: > 25 pack year smoking history but quit in\n when diagnosed with Hodgkin's lymphoma\n -ETOH: denies\n -Illicit drugs: denies\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, Weight loss\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\n Respiratory: No(t) Cough, No(t) Dyspnea\n Neurologic: Numbness / tingling\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Flowsheet Data as of 05:26 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.1\nC (97\n Tcurrent: 36.1\nC (97\n HR: 80 (80 - 80) bpm\n BP: 110/66(74) {104/65(73) - 112/71(80)} mmHg\n RR: 17 (15 - 20) insp/min\n SpO2: 96%\n Heart rhythm: A Paced\n Height: 68 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -300 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t)\n Rub, (Murmur: No(t) Systolic, No(t) Diastolic), Neck with JVP of 10cm\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished), PT\n pulses present b/l\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :\n anteriorly), clear posteriorly\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: No(t) Muscle wasting\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: EKG: from this AM sinus rhythm at 60bpm\n LBBB, poor R-wave progression, and q-waves inferiorly.\n EKG on arrival: HR 80 bpm atrial pacing, inferior q-waves, QTc 469.\n Poor R-wave progression,\n .\n TELEMETRY: polymorphic VT by telemetry from .\n .\n 2D-ECHOCARDIOGRAM: \n 1.The left atrium is elongated.\n 2. Left ventricular wall thicknesses are normal. The left ventricular\n cavity size is top normal/borderline dilated. Overall left ventricular\n systolic function is severely depressed, with severe global\n hypokinesis. [ Intrinsoic LV functiom may be depressed given the\n severity of the degree of MR].\n 3. Right ventricular chamber size is normal. The right ventricular\n function appears normal.\n 4.The aortic valve leaflets (3) appear structurally normal with good\n leaflet excursion and no aortic regurgitation.\n 5.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\n regurgitation is seen.\n 6.The estimated pulmonary artery systolic pressure is normal.\n 7.There is a trivial/physiologic pericardial effusion.\n .\n Exercise MIBI: \n IMPRESSION: Fair functional exercise tolerance limited by exertional\n dyspnea. No anginal symptoms with an uninterpretable ECG. Flat blood\n pressure response to exercise. Nuclear report sent separately.\n .\n IMPRESSION: Moderate fixed inferior wall perfusion defect at the level\n of exercise achieved. Global hypokinesis with LVEF of 27%.\n .\n CARDIAC CATH: n/a\n .\n HEMODYNAMICS: n/a\n .\n LABORATORY DATA:\n Magnesium 2.2\n Potassium 4.1\n Dig 1.2\n INR 2.5\n Baseline Cr 1.2, Hct 35\n (see below for full details).\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n .\n ASSESSMENT AND PLAN\n 62 y/o M with dilated cardiomyopathy a/w torsades in setting of\n prolonged QT interval during dofetilide initiation.\n .\n # CORONARIES:\n - continue statin therapy\n .\n # PUMP: EF 15%, euvolemic. No clinical evidence of myocardial\n stunning after defibrillation.\n - Continue lasix, aldactone, lisinopril\n - Beta-blocker okay now that he is paced.\n - Monitor for e/o volume overload\n - daily weight\n - fluid restrict to 1500ml\n .\n # RHYTHM: Torsades in setting of prolonged QT interval.\n - Paced at 80 bpm\n - Maintain Mg > 2.0 and Potassium > 4.5\n - Repeat Mg/K now\n - Monitor on Tele as per ICU protocol.\n - d/c dofetilide\n - continue other home medications.\n - Vanco x1, clindamycin x48 hours given pcn allergy, MRSA\n .\n # Atrial Fibrillation: Continue coumadin.\n - Paced at 80bpm\n .\n # Pulmonary Toxicity/Sleep Apnea/Bronchiectasis: No PFT's available.\n - continue home medicaitons and o/n home O2 therapy.\n - stable for now.\n .\n # GI Medications/GERD/Constipation\n - continue ranitidine\n - hold metoclopramide given ? interaction with dofetilide, may\n reinitiate in the future once dofetilide washed out (clarify with EP\n concern with reglan)\n .\n # BPH: Doxazosin qhs\n .\n # Depression: Continue home buproprion\n .\n FEN: Low Na diet.\n .\n ACCESS: PIV's x2\n .\n PROPHYLAXIS:\n -DVT ppx with coumadin by INR\n -Pain management with oxycodone/tylenol\n -Bowel regimen with senna/bisacodyl - monitor for constipation with\n oxycodone.\n .\n CODE: Full\n .\n COMM: With patient and family\n .\n DISPO: CCU for now, likely c/o in AM.\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 03:09 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\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"
},
{
"category": "Nursing",
"chartdate": "2195-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 520401,
"text": "Briefly this is a 62 yo M w/ a PMHx of a dilated cardiomyopathy\n secondary to chemotherapy for Hodgkins lymphoma 20 years ago as well as\n atrial fibrillation who was admitted for initiation of Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated and\n he had torsades. Pt medically treated and sent to EP lab for placement\n of ICD. He is now s/p ICd placement and admitted to CCU for\n observation.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2195-02-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 520664,
"text": "This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\n chemotherapy for Hodgkin\ns lymphoma 20 years ago as well as atrial\n fibrillation who was admitted to 3 for initiation of\n Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\n EP lab for placement of ICD.\n He is now s/p ICD/pacer placement and admitted to CCU for observation-\n stable hemodynamics, no further VT noted.\n Atrial fibrillation (Afib)\n Assessment:\n Pt hemodynamically stable s/p ICD/pacer placement for toursades.\n Admitted to CCU for further observation overnite.\n Action:\n Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. ICD\n site at left shoulder D/I- no drainage noted. Arm remains immobilized\n in a sling. Dsg d/i\n Response:\n Pt remains A paced, hemodynamics stable. No further tachy or brady\n arrythmias this shift.\n Plan:\n Bedrest x 24 hrs w sling- increase activity once able. Continue to\n monitor for any arrythmias- or hemodynamic issues. Keep pt aware of\n progress, plan of care.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p incision for ICD current w moderate level of pain at site.\n Action:\n Treating pain w repositioning, pain meds. Received oxycontin total 10\n mg this shift\n Response:\n Pt more comfortable w regular dosing of pain med.\n Plan:\n Continue to make pt comfortable as needed- continue close assessment of\n pain level and treat accordingly. Continue to observe incisional site\n for any change/drainage.\n Demographics\n Attending MD:\n H.\n Admit diagnosis:\n ATRIAL FIBRILLATION\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 84 kg\n Daily weight:\n 84.4 kg\n Allergies/Reactions:\n Penicillins\n Unknown; Hives;\n Tetracyclines\n Hives;\n Sulfa (Sulfonamides)\n Hives;\n Erythromycin Base\n Hives;\n Amiodarone\n pulmonary toxic\n Precautions:\n PMH: COPD\n CV-PMH: Arrhythmias, CHF\n Additional history: h/o cm secondary to Adriamycin for hodgkins\n lymphoma EF 15%\n Depression\n Class III heart failure.\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:98\n D:64\n Temperature:\n 97.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n A Paced\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 480 mL\n 24h total out:\n 1,050 mL\n Pertinent Lab Results:\n Sodium:\n 136 mEq/L\n 03:45 AM\n Potassium:\n 4.9 mEq/L\n 03:45 AM\n Chloride:\n 99 mEq/L\n 03:45 AM\n CO2:\n 29 mEq/L\n 03:45 AM\n BUN:\n 27 mg/dL\n 03:45 AM\n Creatinine:\n 1.3 mg/dL\n 03:45 AM\n Glucose:\n 90 mg/dL\n 03:45 AM\n Hematocrit:\n 34.2 %\n 03:45 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: \n Date & time of Transfer: 12:00 AM\n"
},
{
"category": "Physician ",
"chartdate": "2195-02-19 00:00:00.000",
"description": "Cardiology Fellow Note/ Addendum",
"row_id": 520389,
"text": "TITLE: Cardiology Fellow Note/ Addendum\n Please see residents H and P for full details.\n Briefly this is a 62 yo M w/ a PMHx of a dilated cardiomyopathy\n secondary to chemotherapy for Hodgkins lymphoma 20 years ago as well as\n atrial fibrillation who was admitted for initiation of Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated and\n he had torsades. Pt medically treated and sent to EP lab for placement\n of ICD. He is now s/p ICd placement and admitted to CCU for\n observation.\n Plan:\n -will talk w/ EP regarding treatment of a fib, but will obviously hold\n dofetilide and consider other antiarrhythmic therapy (pt has previously\n failed Amiodarone therapy). Likely still a candidate for flecainide.\n -monitor on tele for residual ventricular tachycardias\n"
},
{
"category": "Nursing",
"chartdate": "2195-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 520450,
"text": "This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\n chemotherapy for Hodgkin\ns lymphoma 20 years ago as well as atrial\n fibrillation who was admitted to 3 for initiation of\n Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\n EP lab for placement of ICD.\n He is now s/p ICd placement and admitted to CCU for observation- stable\n hemodynamics, no further VT noted.\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2195-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 520451,
"text": "This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\n chemotherapy for Hodgkin\ns lymphoma 20 years ago as well as atrial\n fibrillation who was admitted to 3 for initiation of\n Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\n EP lab for placement of ICD.\n He is now s/p ICD/pacer placement and admitted to CCU for observation-\n stable hemodynamics, no further VT noted.\n Atrial fibrillation (Afib)\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": "Physician ",
"chartdate": "2195-02-20 00:00:00.000",
"description": "EP Note",
"row_id": 520658,
"text": "History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: Last 24 hours: Yesterday 11am, pt\n developed TdP requiring shock x 4 initiated by VPC after pause and\n brady. ICD placed yesterday and paced at 80bpm, now decreased to\n 75bpm. Defetilide stopped.\n Medications\n Unchanged\n Physical Exam\n BP: 102 / 53 mmHg\n HR: 75 bpm\n Tmax C last 24 hours: 36.6 C\n Tmax F last 24 hours: 97.9 F\n T current C: 36.6 C\n T current F: 97.8 F\n Previous day:\n Intake: 940 mL\n Output: 1,400 mL\n Fluid balance: -460 mL\n Today:\n Output: 750 mL\n Fluid balance: -750 mL\n Cardiovascular: (Auscultation: RRR)\n Respiratory: (Auscultation: CTA anterior)\n Abdomen: (Palpation: soft)\n Neurological: (Orientation: a&o x 3)\n Other: L chest area ICD implant, tender to touch but no evidence of\n hematoma.\n Labs\n 184\n 9.9\n 90\n 1.3\n 29\n 4.9\n 27\n 99\n 136\n 34.2\n 6.0\n [image002.jpg]\n 04:59 PM\n 03:45 AM\n WBC\n 6.0\n Hgb\n 9.9\n Hct (Serum)\n 29.6\n 34.2\n Plt\n 184\n INR\n 2.7\n Na+\n 136\n K + (Serum)\n 4.6\n 4.9\n Cl\n 99\n HCO3\n 29\n BUN\n 27\n Creatinine\n 1.3\n Glucose\n 90\n ABG: / / / 29 / Values as of 03:45 AM\n Tests\n ECG: (Date: ), 8:20am Apace 75, QT 420ms.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB) - will hold on any anti-arrthymics for\n now. just monitor for now and see if increased atrial pacing will\n prevent him from going into afib.\n VT - TdP from dofetilide s/p ICD yesterday Since he is at increased\n risk with DCM and EF 10-15%, the decision was to implant an ICD instead\n of just a ppm. QT shorted with faster HR.\n - device interrogation ok, check CXR (PA/LAT) today.\n - Device clinic visit 9:30am.\n OK to d/c to tele floor for monitoring.\n ------ Protected Section ------\n I interviewed and examined Mr. . I agree with Dr. \ns H+P,\n A+P.\n ------ Protected Section Addendum Entered By: , MD\n on: 14:29 ------\n"
},
{
"category": "Nursing",
"chartdate": "2195-02-20 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 520492,
"text": "This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\n chemotherapy for Hodgkin\ns lymphoma 20 years ago as well as atrial\n fibrillation who was admitted to 3 for initiation of\n Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\n EP lab for placement of ICD.\n He is now s/p ICD/pacer placement and admitted to CCU for observation-\n stable hemodynamics, no further VT noted.\n Atrial fibrillation (Afib)\n Assessment:\n Pt hemodynamically stable s/p ICD/pacer placement for toursades.\n Admitted to CCU for further observation overnite.\n Action:\n Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. ICD\n site at left shoulder D/I- no drainage noted. Arm remains immobilized\n in a sling. Given evening dose captopril once SBP>100/ . Held doxazosin\n dose.\n Response:\n Pt remains A paced, hemodynamics stable. No further tachy or brady\n arrythmias this shift.\n Plan:\n Bedrest x 24 hrs w sling- increase activity once able. Continue to\n monitor for any arrythmias- or hemodynamic issues. Keep pt aware of\n progress, plan of care. c/o to 3 once medically appropriate.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p incision for ICD current w moderate level of pain at site.\n Action:\n Treating pain w repositioning, pain meds. Received oxycontin 10 mg, 5\n mg , 5mg this shift, as well as Tylenol 650 mg x 2 doses. Also received\n ativan 0.5 qhs( home dose)\n Response:\n Pt more comfortable w regular dosing of pain med. Slept well w ativan.\n When awakened- or moving, developing moderate pain but diminishing w\n medication\n Plan:\n Continue to make pt comfortable as needed- continue close assessment of\n pain level and treat accordingly. Continue to observe incisional site\n for any change/drainage.\n"
},
{
"category": "Physician ",
"chartdate": "2195-02-20 00:00:00.000",
"description": "Physician Resident Progress Note",
"row_id": 520627,
"text": "Chief Complaint: 62 y/o M with dilated cardiomyopathy a/w torsades in\n setting of prolonged QT interval during dofetilide initiation.\n 24 Hour Events:\n s/p pacemaker placement - some soreness around pocket\n Allergies:\n Penicillins\n Unknown; Hives;\n Tetracyclines\n Hives;\n Sulfa (Sulfonamides)\n Hives;\n Erythromycin Base\n Hives;\n Amiodarone\n pulmonary toxic\n Last dose of Antibiotics:\n Vancomycin - 11:57 PM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:27 PM\n Other medications:\n Changes to medical and 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: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 80 (80 - 80) bpm\n BP: 108/65(74) {78/47(54) - 127/71(80)} mmHg\n RR: 16 (13 - 21) insp/min\n SpO2: 96%\n Heart rhythm: A Paced\n Height: 68 Inch\n Total In:\n 940 mL\n PO:\n 740 mL\n TF:\n IVF:\n 200 mL\n Blood products:\n Total out:\n 1,400 mL\n 450 mL\n Urine:\n 1,400 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -460 mL\n -450 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///29/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 184 K/uL\n 9.9 g/dL\n 90 mg/dL\n 1.3 mg/dL\n 29 mEq/L\n 4.9 mEq/L\n 27 mg/dL\n 99 mEq/L\n 136 mEq/L\n 34.2 %\n 6.0 K/uL\n [image002.jpg]\n 04:59 PM\n 03:45 AM\n WBC\n 6.0\n Hct\n 29.6\n 34.2\n Plt\n 184\n Cr\n 1.3\n Glucose\n 90\n Other labs: PT / PTT / INR:28.0//2.7, Ca++:8.4 mg/dL, Mg++:2.7 mg/dL,\n PO4:3.7 mg/dL\n Imaging: CXR: AP single view of the chest has been obtained with\n patient sitting\n upright position. Comparison is made with the next previous available\n chest\n examination of . The patient has recently undergone\n implantation of a left-sided permanent pacer seen in anterior axillary\n position. The pacer is connected to a dual electrode system. One of\n these is\n terminating in a position compatible with the right atrial appendage.\n The\n second with two electrode enforcements representing the ICD terminates\n in a\n position compatible with the apical portion of the right ventricle.\n Heart\n size is unchanged and remains within normal limits. No pulmonary\n congestion\n is seen and no pneumothorax can be identified.\n Assessment and Plan\n 62 y/o M with dilated cardiomyopathy a/w torsades in setting of\n prolonged QT interval during dofetilide initiation.\n # torsades de pointes - prolonged QT in setting of dofetilide\n initiation. multiple shocks yesterday. s/p pacemaker placement\n - follow up EP recommendations\n - continue beta blocker\n - paced at 80 bpm\n - replete lytes aggressively\n - d/c dofetilide\n - tele monitoring\n - continue digoxin\n - continue warfarin\n # cardiomyopathy: chronic systolic heart failure. EF 15%. Euvolemic. No\n evidence of myocardial stunning after defibrillation.\n - continue lasix\n - continue spironolactone\n - continue lisinopril\n - continue atenolol\n - I/O, weights\n - fluid restrict\n # atrial fibrillation: s/p pacemaker\n - per above\n # Pulmonary Toxicity/Sleep Apnea/Bronchiectasis: No PFT's available.\n - continue home medicaitons and o/n home O2 therapy.\n - stable for now.\n # GI Medications/GERD/Constipation\n - continue ranitidine\n - hold metoclopramide given ? interaction with dofetilide, may\n reinitiate in the future once dofetilide washed out (clarify with EP\n concern with reglan)\n # BPH: Doxazosin qhs\n # Depression: Continue home buproprion\n ICU Care\n Nutrition:\n Comments: heart healthy diet\n Glycemic Control:\n Lines:\n 20 Gauge - 03:09 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:Transfer to floor\n"
},
{
"category": "Physician ",
"chartdate": "2195-02-20 00:00:00.000",
"description": "EP Note",
"row_id": 520601,
"text": "History of Present Illness\n Date: \n Subsequent care\n Events / History of present illness: Last 24 hours: Yesterday 11am, pt\n developed TdP requiring shock x 4 initiated by VPC after pause and\n brady. ICD placed yesterday and paced at 80bpm, now decreased to\n 75bpm. Defetilide stopped.\n Medications\n Unchanged\n Physical Exam\n BP: 102 / 53 mmHg\n HR: 75 bpm\n Tmax C last 24 hours: 36.6 C\n Tmax F last 24 hours: 97.9 F\n T current C: 36.6 C\n T current F: 97.8 F\n Previous day:\n Intake: 940 mL\n Output: 1,400 mL\n Fluid balance: -460 mL\n Today:\n Output: 750 mL\n Fluid balance: -750 mL\n Cardiovascular: (Auscultation: RRR)\n Respiratory: (Auscultation: CTA anterior)\n Abdomen: (Palpation: soft)\n Neurological: (Orientation: a&o x 3)\n Other: L chest area ICD implant, tender to touch but no evidence of\n hematoma.\n Labs\n 184\n 9.9\n 90\n 1.3\n 29\n 4.9\n 27\n 99\n 136\n 34.2\n 6.0\n [image002.jpg]\n 04:59 PM\n 03:45 AM\n WBC\n 6.0\n Hgb\n 9.9\n Hct (Serum)\n 29.6\n 34.2\n Plt\n 184\n INR\n 2.7\n Na+\n 136\n K + (Serum)\n 4.6\n 4.9\n Cl\n 99\n HCO3\n 29\n BUN\n 27\n Creatinine\n 1.3\n Glucose\n 90\n ABG: / / / 29 / Values as of 03:45 AM\n Tests\n ECG: (Date: ), 8:20am Apace 75, QT 420ms.\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB) - will hold on any anti-arrthymics for\n now. just monitor for now and see if increased atrial pacing will\n prevent him from going into afib.\n VT - TdP from dofetilide s/p ICD yesterday Since he is at increased\n risk with DCM and EF 10-15%, the decision was to implant an ICD instead\n of just a ppm. QT shorted with faster HR.\n - device interrogation ok, check CXR (PA/LAT) today.\n - Device clinic visit 9:30am.\n OK to d/c to tele floor for monitoring.\n"
},
{
"category": "Nursing",
"chartdate": "2195-02-20 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 520573,
"text": "This is a 62 yo M w/ a PMH of a dilated cardiomyopathy secondary to\n chemotherapy for Hodgkin\ns lymphoma 20 years ago as well as atrial\n fibrillation who was admitted to 3 for initiation of\n Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated\n and he had torsades. Pt was medically treated/shocked x 2 and sent to\n EP lab for placement of ICD.\n He is now s/p ICD/pacer placement and admitted to CCU for observation-\n stable hemodynamics, no further VT noted.\n Atrial fibrillation (Afib)\n Assessment:\n Pt hemodynamically stable s/p ICD/pacer placement for toursades.\n Admitted to CCU for further observation overnite.\n Action:\n Close monitoring of hemodynamics- HR-80 A paced, BP- 101/53-114/60. ICD\n site at left shoulder D/I- no drainage noted. Arm remains immobilized\n in a sling. Given evening dose captopril once SBP>100/ . Held doxazosin\n dose.\n Response:\n Pt remains A paced, hemodynamics stable. No further tachy or brady\n arrythmias this shift.\n Plan:\n Bedrest x 24 hrs w sling- increase activity once able. Continue to\n monitor for any arrythmias- or hemodynamic issues. Keep pt aware of\n progress, plan of care. c/o to 3 once medically appropriate.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt s/p incision for ICD current w moderate level of pain at site.\n Action:\n Treating pain w repositioning, pain meds. Received oxycontin 10 mg, 5\n mg , 5mg this shift, as well as Tylenol 650 mg x 2 doses. Also received\n ativan 0.5 qhs( home dose)\n Response:\n Pt more comfortable w regular dosing of pain med. Slept well w ativan.\n When awakened- or moving, developing moderate pain but diminishing w\n medication\n Plan:\n Continue to make pt comfortable as needed- continue close assessment of\n pain level and treat accordingly. Continue to observe incisional site\n for any change/drainage.\n"
},
{
"category": "Nursing",
"chartdate": "2195-02-19 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 520432,
"text": "Briefly this is a 62 yo M w/ a PMHx of a dilated cardiomyopathy\n secondary to chemotherapy for Hodgkin\ns lymphoma 20 years ago as well\n as atrial fibrillation who was admitted for initiation of Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated and\n he had torsades. Pt medically treated and sent to EP lab for placement\n of ICD. He is now s/p ICd placement and admitted to CCU for\n observation.\n Atrial fibrillation (Afib)\n Assessment:\n Pt received from EP lab s/p placement of ICD/PPM.\n Tele A paced at rate of 80.\n Pacer site is C&D.\n O2 sats 94-96 on room air.\n c/o chest pain at site of pacer.\n Action:\n Dofetilide dc\n To remain on Coumadin.\n Cont to monitor QTC.\n Given Tylenol 650mg po.\n Response:\n Hemodynamically stable A paced.\n Pain improved after Tylenol.\n Plan:\n Check lytes.\n Maintain on bedrest overnite.\n Vancomycin post procedure x\ns 1 Followed by clindamycin.\n"
},
{
"category": "Physician ",
"chartdate": "2195-02-20 00:00:00.000",
"description": "Cardiology Fellow Note/ Addendum",
"row_id": 520569,
"text": "TITLE: Cardiology Fellow Note/ Addendum\n Please see residents H and P for full details.\n Briefly this is a 62 yo M w/ a PMHx of a dilated cardiomyopathy\n secondary to chemotherapy for Hodgkins lymphoma 20 years ago as well as\n atrial fibrillation who was admitted for initiation of Dofetilide.\n While undergoing initiation of Dofetilide therapy his QTc elongated and\n he had torsades. Pt medically treated and sent to EP lab for placement\n of ICD. He is now s/p ICd placement and admitted to CCU for\n observation.\n Plan:\n -will talk w/ EP regarding treatment of a fib, but will obviously hold\n dofetilide and consider other antiarrhythmic therapy (pt has previously\n failed Amiodarone therapy). Likely still a candidate for flecainide.\n -monitor on tele for residual ventricular tachycardias\n ------ Protected Section ------\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n nothing to add\n Physical Examination\n nothing to add\n Medical Decision Making\n nothing to add\n Total time spent on patient care: 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 08:41 ------\n"
},
{
"category": "ECG",
"chartdate": "2195-02-20 00:00:00.000",
"description": "Report",
"row_id": 110243,
"text": "Atrial paced rhythm. Left bundle-branch block. Compared to the previous tracing\natrial pacing is new.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2195-02-19 00:00:00.000",
"description": "Report",
"row_id": 110244,
"text": "Sinus bradycardia. Left bundle-branch block. Occasional ventricular premature\nbeats. Possible old inferior myocardial infarction. Possible old anterior wall\nmyocardial infarction. Compared to the previous tracing of there is no\nchange.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2195-02-19 00:00:00.000",
"description": "Report",
"row_id": 110245,
"text": "Sinus bradycardia. Compared to tracing #1 there is no significant diagnostic\nchange.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2195-02-18 00:00:00.000",
"description": "Report",
"row_id": 110246,
"text": "Sinus bradycardia with sinus arrhythmia. P-R interval prolongation. Left axis\ndeviation. Probable inferior myocardial infarction of indeterminate age.\nST-T wave changes that are non-specific. Compared to the previous tracing\nof multiple described abnormalities persist.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2195-02-18 00:00:00.000",
"description": "Report",
"row_id": 110247,
"text": "Normal sinus rhythm. Marked leftward axis. Compared to tracing #3 no diagnostic\ninterim change.\nTRACING #4\n\n"
},
{
"category": "ECG",
"chartdate": "2195-02-17 00:00:00.000",
"description": "Report",
"row_id": 110248,
"text": "Normal sinus rhythm. Compared to tracing #1 no diagnostic interim change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2195-02-18 00:00:00.000",
"description": "Report",
"row_id": 110295,
"text": "Normal sinus rhythm. Compared to tracing #2 there is no diagnostic interim\nchange.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2195-02-17 00:00:00.000",
"description": "Report",
"row_id": 110296,
"text": "Normal sinus rhythm. Intraventricular conduction delay with left bundle-branch\nblock pattern and QRS duration of 140 milliseconds. Leftward axis at\nminus 50 degrees. Compared to the previous tracing of no diagnostic\ninterim change.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-02-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1122114,
"text": " 7:30 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: Please evaluate for changes\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man s/p ICD\n REASON FOR THIS EXAMINATION:\n Please evaluate for changes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ICD.\n\n FINDINGS: In comparison with the study of , there is little change. The\n ICD device is again in place with leads in the region of the right atrial\n appendage and apex of the right ventricle. No evidence of vascular\n congestion, pleural effusion, or acute pneumonia.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-02-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1122028,
"text": " 2:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man post DDD-ICD implant\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP 4:42 PM\n PFI: Successful pacer implantation, no pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 62-year-old male patient with ICD implant, evaluate for possible\n pneumothorax.\n\n FINDINGS: AP single view of the chest has been obtained with patient sitting\n upright position. Comparison is made with the next previous available chest\n examination of . The patient has recently undergone\n implantation of a left-sided permanent pacer seen in anterior axillary\n position. The pacer is connected to a dual electrode system. One of these is\n terminating in a position compatible with the right atrial appendage. The\n second with two electrode enforcements representing the ICD terminates in a\n position compatible with the apical portion of the right ventricle. Heart\n size is unchanged and remains within normal limits. No pulmonary congestion\n is seen and no pneumothorax can be identified.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-02-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1122029,
"text": ", H. 2:59 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumothorax\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man post DDD-ICD implant\n REASON FOR THIS EXAMINATION:\n r/o pneumothorax\n ______________________________________________________________________________\n PFI REPORT\n PFI: Successful pacer implantation, no pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2195-02-20 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1122151,
"text": " 10:58 AM\n CHEST (PA & LAT) Clip # \n Reason: Leads placement\n Admitting Diagnosis: ATRIAL FIBRILLATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man post DDD-ICD implant\n REASON FOR THIS EXAMINATION:\n Leads placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ICD implant.\n\n FINDINGS: In comparison with the earlier study of this date, there is little\n overall change in the appearance of the ICD implant. No acute cardiopulmonary\n disease is identified.\n\n\n"
}
] |
27,894 | 173,572 | 71M with head and neck cancer, trach/ transferred from an outside hospital with atrial fibrillation with RVR, NSTEMI, acute oliguric renal failure, and acute ischemic hepatitis. . # NSTEMI: Patient has a history of CABG, and had very elevated cardiac enzymes on admission (Trop T 65.48, CKMB 72.1). TTE during this admission shows acute changes, EF from 55-60% on to 25-30%, severely depressed LV systolic function, severe LV global HK in inf, post, lat walls, depressed RV systolic function, 3+MR, 2+TR. EKG shows 2 mm STD V3-V5 which is 0. depression laterally from his old EKGs. CXR shows unchanged pleural effusions and atelectasis. He was maintained on aspirin and metoprolol. He was not started on a statin since he was admitted with acute ischemic hepatitis, and LFTs were still decreasing to normal levels. . # AFIB with rapid ventricular rate: He was in AFIB with rapid ventricular rate, with a pacer for sick sinus/tachy-brady, HR 100-140s, controlled on Metoprolol and Diltiazem. He was not anticoagulated since he has head and neck cancer and had pancytopenia from chemo and radiation. . # Hypoxemic respiratory failure: Likely associated with bilateral pleural effusions, cardiac stunning, and COPD. Patient has a trach and was kept on trach mask for most of the day, with intermittent transition to AC and PS ventilatory support during the night or with decreasing O2 saturation. Patient was diuresed here with lasix gtt, 5-10 mg per hour for pleural effusions, but he was not total body fluid overloaded. Patient has COPD and was placed on albuterol inhalers, spiriva, and advair during admission to be continued. . **As a note, the patient's lasix regimen was added during this admission, and should be titrated up as appropriate to diurese for his bilateral pleural effusions. Currently at the standing dose, he is running even in his fluid goals daily. . # Acute oliguric renal failure: Patient's acute renal failure was prerenal in etiology and associated with a depressed EF and/or post-ischemic ATN, not responsive to fluid boluses. Renal US showed atrophic L kidney unchanged since , no stone, no hydro, no mass. Ulytes consistent with prerenal etiology. Renal failure gradually resolved over admission. . # Acute ischemic hepatitis: Patient had LFTs in the thousands, associated with hepatic congestion from NSTEMI. He showed no signs of cholestasis or obstruction. Tylenol tox screen was negative, hepatitis panel was negative. . # Febrile neutropenia/pancytopenia/L piriform sinus SCC: Patient has head and neck cancer, s/p carboplatin/taxol and XRT, last XRT and chemo . He was neutropenic for only the first day of admission, and was afebrile throughout admission. He is followed as an outpatient by Hem/Onc: , Dr. . He completed a Ceftazidime/Vanco for a 7 day course for neutropenia and coverage in case of pneumonia. He was on neupogen until he was no longer neutropenic. All blood, urine, sputum cultures were negative. His goal Hct was maintained at >28, goal platelets were >30, and these goals were met throughout admission. . # Hypertension: Was unremarkable throughout admission, controlled on Metoprolol and Diltiazem. . # Diabetes mellitus: He was maintained on Lantus 16 qhs and sliding scale. | TUBE FEEDS OF PROBALANCE FULL STRENGHT WERE PLACED ON HOLD. WHEEZE, WHICH RESOLVED WITH TREATMENTS. HAS BEEN SUCTIONED MODERATE AMT'S OF CLEAR/TAN SECRETIONS. Pt placed back on vent. SINCE THIS PROCEDURE PT. MEDS WERE GIVNE VIA PEG. REMAINS A DNR/DNI.PT. RESP RATE IS CONTROLLED AND PT. Standard position of tracheostomy. Referral sent w/pt. Ascites. FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. Lung sounds shightly ronchorus. resting comfort.GI: seen by tam and J-tube site cleared for discharge. SUITE NOTIFIED AND CT ABD. MDIs given per order. MDIs given per order. MICU 7 RN Note 0700-1300refer to Page 2 referral and discharge plan.Awake alert oriented x2 follows commands MAE random equal strenght. EXCRETING MODERATE TO GROSS AMT'S OF SECRETIONS AROUND THE TRACH ITSELF. resident aware pt recieved Ativan 1mg IV x2 w/calming effect.HR 75-130 Afib recieved diltiezem and Lopressor per routine for controlled afib. HAS NKDA.PT. The pacemaker leads terminates in the right ventricle and right atrium. RECEIVED 60MEQ KCL PO, VIA GTUBE AND 40MEQ KCL IV. Progression of CHF findings. Respiratory Care:Pt recieved on trach mask. Received MDI's as ordered. Needed to be placed back on vent d/t desating to high 80s and tachypnea. 12:54 AM CHEST (PORTABLE AP) Clip # Reason: Eval for infiltrates, effusion interval change. THE VANCO IS ON HOLD VANCO THROUGH 63.2. The pancreas and adrenal glands are within normal limits. NPN PA-7P:NEURO: PT IS A/OX2 OR 3. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. GJ tube tip in jejunal loop. IMPRESSION: No short interval change in CHF/fluid overload. There are bilateral substantial pleural effusions layering in semi-erect position with associated bibasilar atelectasis. Purulent drainage noted, avvelyn applied. HAS BEEN AFBRILE.PT. HAS A BOLVONA TRACH. DSD APPLYED.POC: CONT VENT SUPPORT. REMAINS A DNR/DNI.PT. REMAINS A DNR/DNI.PT. HAS TRACH (BOVONA), PT. REMAINS A DNR/DNI AT THIS TIME. FOLLOWS COMMANDSA AND REMAINS AFEBRILE.PT. HIS RR 15-20.CV: A-FIB W/ PVC NOTED, HR 110-82. Cont PSV. Plan is to wean as tolerates in am. HAS NKDA.PT. HAS NKDA.PT. HR 60-130 Afib occass PVC when HR drifts down AV paced. MDI given as per order. PT HAS SECURE AND INTACT PEG TUBE- DRESSING CHANGED. Peripheral pulses 2+ DP/1+DT. Placed back on trach mask @ ~ 0530. was 138. PLACED BACK ON VENT ON PS SETTINGS. K/MG/PHOS AT . Received MDI's as ordered. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. PT. DUODERM ON COCCYX CHANGED THIS SHIFT.PLAN: CONTINUE TO WEAN VENT AS PT WILL TOLERATE. Resp CarePt remaisn trached with #7.0 h20 cuff. GOOD UA OUT PUT NOTED. TO IR TODAY FOR GJ TUBE. REMAINS ON ROUTINE LASIX DOSING.PT. CONTINUES TO DIURESIS >100CC/HR PT. ABLE TO MAE.RESP: LS MIXED BAG. RIGHT GLUTEAL EXHIBITS AREA AS WELL, WITH ALLELYN DRESSING CHANGED, WHICH REMAINS INTACT AT THIS TIME. Received MDI's, suctioned sm amt thick yellow. 'S REMAIN INTACT, PATENT, AND SECURED, WITH IVF OF N/S AT KVO.PLAN IS FOR POSSIBLE TRANSFER TO REHAB FACILITY. AFEBRILE. DUODERM GEL W/ DSD IS TX ORDER. RESP RATE REMAINS CONTROLLED AND PT. sacral edema.Resp: recieved pt on vent CPAP/PS 10/5 40% #7Bovona trache. TODAY HE WENT TO IR. CONTINUE ESMOLOL GTT FOR RATE CONTROL. Coccyx red allevyn dsg reapplied. EXHIBIT GTUBE, SINGLE LUMEN, WHICH HAS DRESSING INTACT. PRESENTLY PT. TRACH CARE PT TOLERATED WELL.CV: S1 AND S2 AS PER AUSCULTATION. Cont. BLBS course, scutioned for sm-mod amt thick aple yellow secrtions, mdi given per order. Had episode of ^RR, though sats remained good. QUESTION TF. WILL GO TO IR TODAY FOR GJ TUBE. SUCTION MODERATE AMOUNT WHITE SECRETYION.YESTARDAY TOLLEARED TRACH COLLAR FOR 4HR.PT NEEDS IP CONSULT FOR POSSIBLE TRACH CHANGES.CV: AS SAYS ABOVE, START ON DILT GTT.REMAIN OB AFIB NO ECTOPY. Areas with purulent drainage, OTA.ID: Remains neutropenic with last WBC 2.3. recieved lasix Lungs clear raled RLL dim L base. Moderate [2+] tricuspid regurgitation isseen. areas on buttox with breakdown noted. Abd soft + BS GT inplace w/gastric leakage. vanco level sent. CXR showed Rt middle lobe pna. EKG done. vanco level wean vent to trach collor mask as tollerates. L/S coarse T/O, bilateral chest expansion noted. Sxned for sm. W/ OUT RESP DISTRESS NOTED. Cuff remains down w/ improved sats.ID: afebrile t-max 98, WBC 7.5 taken off neutropenic precautions. On neutropenic precautions. NOW ON VANCO AND CEFAZIDIME IV.CV: HE IS R/I FOR A NSETMI. ECG showed ST depressions, Troponin I elevated to 65.48. No AS.MITRAL VALVE: Mildly thickened mitral valve leaflets. Resp CareFairly quite shift with pt. Abd tender to palpation. Abd tender to palpation. wean on TM for noc as tol. able to oral sxn self. able to oral sxn self. Left ventricularhypertrophy. Pt lab values showed neutropenia and elevated BUN/Cr. HR control, wean vent. gluteal. TF residuals check q4h with 0.0mls returned. ABLE TO MAE.RESP: HE IS TRACHED. HR 130s, and BP 130s/90s. Last BUN/Cr 83/2.7 respectively.ID: Remains on neutropenic precautions with WBC 2.5. LUNG SOUNDS COURS/RONCHI BILAT. PEG tube patent and secure, residuals checked q4h with 0.0ml returned. Last BUN/Cr, 77/2.7 respectively. Seriel CK/troponin trending down although troponin ^ 3.26 (?renal response). antibx for coverage. ECG showed ST depression, and troponin I elevated to 65.48. trached, on vent. Diff. Arrived to MICU trached and PEGed.Nuero: Pt. Diurese to 1L neg. peripheral pulses 3+ DP/2+ DT. areas of breakdown noted on rt. Last LDH 1182, AST 1552, ALT 2522.Skin: Mult. Resp CarePt was sx Q 2-4hrs, alb / atr MDI Q 4 hrs. BUN 77/2.7. , abx cetazipine, Vanco level 53 Vanco d/c.GU/GI: Foley u/o 20-300cc/hr s/p lasix. currently on Diltiazem PO and Metoprolol Po.neuro: A/ox3, comminication wiht mouth words and writting on board. Atrial fibrillation.Weight (lb): 128BP (mm Hg): 146/12HR (bpm): 103Status: InpatientDate/Time: at 15:37Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. | 45 | [
{
"category": "Radiology",
"chartdate": "2107-10-20 00:00:00.000",
"description": "CT ABDOMEN W/O CONTRAST",
"row_id": 978233,
"text": " 5:12 AM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: please eval for PEG placement.\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n Field of view: 34\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old trached and PEG'd male w/ multiple medical problems including DM,\n COPD, afib, CAD s/p CABG and locally invasive laryngopharyngeal cancer who had\n IR placed GJ tube today, now with extravasation of tube feeds and stool around\n PEG.\n REASON FOR THIS EXAMINATION:\n please eval for PEG placement.\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure\n ______________________________________________________________________________\n WET READ: 5:32 AM\n 1. GJ tube tip in jejunal loop. No dilated bowel. No free intraperitoneal\n air.\n 2. Large bilateral pleural effusions and associated atelectasis.\n 3. Heavy vascular atherosclerotic calcification. Caliber and contour of\n aorta unchanged from .\n 4. Atrohpic left kidney.\n ______________________________________________________________________________\n FINAL REPORT\n\n\n INDICATION: GJ tube position in patient with leaking around tube during\n feeding\n\n COMPARISONS: Torso CT dated .\n\n TECHNIQUE: MDCT images from the lung bases through the mid iliac level were\n obtained with oral contrast only. Lack of intravenous contrast limits\n evaluation of the solid abdominal viscera. Multiplanar reformations were\n essential to interpretation.\n\n LOWER CHEST: Sternotomy wires are present. Cardiac leads are again\n identified, with scattered CABG clips. There are large, simple bilateral\n pleural effusions with adjacent atelectasis. The left effusion appears\n increased when compared to the previous study.\n\n LIVER: Scattered calcifications are compatible with granuloma. The liver is\n otherwise unremarkable. A large splenic calcification is again noted. The\n pancreas and adrenal glands are within normal limits. The left kidney remains\n shrunken. There is no evidence of hydronephrosis. The gallbladder is\n present.\n\n A gastrojejunostomy tube is in appropriate position, entering through the left\n anterior abdominal wall and coursing through the stomach and duodenum into the\n jejunum in the lower abdomen. The proximal coil of the tube is in the second\n portion of the duodenum. There is no evidence of contrast extravasation.\n There are no abnormal fluid collections at the site of entry. There is trace\n (Over)\n\n 5:12 AM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: please eval for PEG placement.\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n Field of view: 34\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n free fluid in the abdomen. There is a stable abdominal aortic aneurysm\n measuring at least 4 cm in greatest dimension, with extensive atheromatous\n calcification. There are scattered surgical clips in the left periaortic\n region. No pathologically enlarged lymph nodes are identified. There is no\n evidence of bowel dilatation. Diffuse stranding of the subcutaneous tissues\n is compatible with anasarca.\n\n OSSEOUS STRUCTURES: There is a stable sclerotic focus in the left iliac bone.\n Multilevel degenerative changes are present in the lumbar spine.\n\n IMPRESSION:\n 1. Appropriate position of a GJ tube, without evidence of oral contrast\n extravasation or abnormal fluid collection.\n 2. Large bilateral pleural effusions.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-10-19 00:00:00.000",
"description": "REPOSITION GASTRIC TUBE INTO DUODENUM",
"row_id": 978077,
"text": " 7:27 AM\n PERC G/J TUBE CHECK Clip # \n Reason: Please change G tube (Foley 14 cath currently) to GJ tube\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n Contrast: OPTIRAY Amt: 25CC\n ********************************* CPT Codes ********************************\n * REPOSITION GASTRIC TUBE INTO D CHANGE PERC TUBE OR CATH W/CON *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with NSTEMI, head and neck cancer, drinks PO liquids by mouth,\n does not eat food by mouth\n REASON FOR THIS EXAMINATION:\n Please change G tube (Foley 14 cath currently) to GJ tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR THE EXAM: 71-year-old male with NSTEMI, head and neck cancer\n with G-tube placed.\n\n RADIOLOGISTS: The procedure was performed by Dr. and Dr. . Dr.\n , the attending radiologist, was present and supervising throughout the\n procedure.\n\n FINDINGS AND TECHNIQUE: Following explanation of the potential risks and\n benefits of the procedure, written informed consent was obtained. The patient\n was placed supine on the angiographic table and abdomen was prepped and draped\n in standard sterile fashion. A timeout was performed to confirm patient\n identity and proposed procedure.\n\n Initial fluoroscopic image demonstrated the presence of Foley catheter in the\n abdomen. A small amount of contrast was injected and demonstrated the balloon\n placed inside of the stomach. A 0.035 wire was advanced into the\n stomach trough the Foley catheter. The present Foley catheter was then\n removed over the wire. A 7- French bright tip sheath was advanced over the\n wire with the tip in the stomach. The wire was removed and a 0.035\n straight Glidewire was advanced. A combination of the 0.035 straight\n Glidewire, 0.035 J-guidewire, 4- French 0.035 Cobra catheter, and 5-\n French Kumpe catheter were used to get access to the jejunum. The wire was\n then exchanged for a 0.035 straight Amplatz, that was advanced into the\n jejunum. The catheter was removed. A 14-French peel-away introducer was\n advanced over the wire into the stomach. 14-French gastrojejunostomy\n catheter was advanced through the peel-away over the wire with the tip placed\n in the proximal jejunum. The wire was removed and the pigtail was formed\n within the duodenum. A small amount of contrast was injected through the tube\n and confirmed the position of the tip of the catheter into the jejunum.\n\n The catheter was secured to the skin. The patient tolerated the procedure\n well and there were no immediate complications.\n\n IMPRESSION: Successful insertion of a 14-French G-J tube with tip in\n the jejunum. The tube is ready for use.\n\n\n (Over)\n\n 7:27 AM\n PERC G/J TUBE CHECK Clip # \n Reason: Please change G tube (Foley 14 cath currently) to GJ tube\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n Contrast: OPTIRAY Amt: 25CC\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-10-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977341,
"text": " 4:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 yo M, h/o of locally invasive laryngopharyngeal CA admitted, trach and PEG\n admitted with hypoxia, MI\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxia.\n\n Portable AP chest radiograph compared to .\n\n The tracheostomy tube is in place. The pacemaker leads terminates in the\n right ventricle and right atrium. There is no change in mild cardiomegaly and\n tortuous and calcified aorta.\n\n The bibasilar consolidations and bilateral right more than left pleural\n effusion are essentially unchanged. There is no evidence of congestive heart\n failure.\n\n IMPRESSION: No significant interval change in bibasilar atelectasis and\n pleural effusion. Standard position of tracheostomy.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-10-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 978048,
"text": " 12:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for infiltrates, effusion interval change.\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 yo M, h/o of locally invasive laryngopharyngeal CA admitted, trach and PEG\n admitted with hypoxia, MI, now with desatting to 80%.\n REASON FOR THIS EXAMINATION:\n Eval for infiltrates, effusion interval change.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Laryngopharyngeal cancer. MI with SOB.\n\n AP bedside chest. The heart is borderline enlarged with satisfactorily\n positioned dual-chamber bipolar pacing leads and previous CABG. Tracheostomy\n tube. There are bilateral substantial pleural effusions layering in\n semi-erect position with associated bibasilar atelectasis. No demonstrable\n PTX. I cannot exclude consolidations in the obscured bases. Appearances are\n unchanged from exam one day ago and little changed from study .\n\n IMPRESSION: No short interval change in CHF/fluid overload.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-10-14 00:00:00.000",
"description": "RENAL U.S.",
"row_id": 977371,
"text": " 8:34 AM\n RENAL U.S. Clip # \n Reason: NEW ONSET RENAL FAILURE, S/P CABG R/O OBSTRUCTION\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: New onset renal failure.\n\n Comparison is made to the prior CT of the abdomen and pelvis performed on , .\n\n The right kidney measures 11 cm. No stone, hydronephrosis or mass is noted\n within the right kidney.\n\n The left kidney measures 7.5 cm. No stone, hydronephrosis or mass is noted\n within the left kidney. The bladder was empty and could not be evaluated.\n\n Small amount of free fluid is noted within within the abdomen.\n\n IMPRESSION:\n 1. Atrophic left kidney (seen on prior CT), which is unchanged since \n . No stone, hydronephrosis or mass is noted within the kidneys.\n\n 2. Ascites.\n\n\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-10-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977507,
"text": " 4:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: SOB\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 yo M, h/o of locally invasive laryngopharyngeal CA admitted, trach and PEG\n admitted with hypoxia, MI\n REASON FOR THIS EXAMINATION:\n SOB\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Laryngeal cancer. Hypoxia.\n\n Tracheostomy tube and permanent pacemaker are unchanged in position.\n Cardiomediastinal contours are stable. Perihilar haziness and peripheral\n interstitial opacities are attributed to interstitial pulmonary edema and has\n slightly worsened. Moderate-sized right effusion has slightly increased as\n well as a small left pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2107-10-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 977956,
"text": " 12:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change.\n Admitting Diagnosis: SQUAMOUS CELL CANCER OF THE HEAD AND NECK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 yo M, h/o of locally invasive laryngopharyngeal CA admitted, trach and PEG\n admitted with hypoxia, MI, please evaluate for interval change.\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: History of locally invasive laryngopharyngeal carcinoma admitted,\n tracheostomy, admitted with hypoxia and MI. Evaluate for interval change.\n\n FINDINGS: AP single view of the chest obtained with patient in semi-upright\n position is analyzed in direct comparison with a similar preceding study dated\n . Tracheostomy, permanent pacer unaltered and stable.\n Previously described diffuse perivascular haze in the pulmonary vasculature\n and bilateral basal densities indicative of pleural effusions have further\n progressed. No new discrete pulmonary parenchymal infiltrates are identified.\n\n IMPRESSION: Stable instrument position. Progression of CHF findings.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-21 00:00:00.000",
"description": "Report",
"row_id": 1626916,
"text": "MICU 7 RN Note 0700-1300\n\nrefer to Page 2 referral and discharge plan.\n\nAwake alert oriented x2 follows commands MAE random equal strenght. denies pain. c/o feeling anxious requests to have valium. resident aware pt recieved Ativan 1mg IV x2 w/calming effect.\n\nHR 75-130 Afib recieved diltiezem and Lopressor per routine for controlled afib. Occas episoded AV paced. BP 100-124/50-75 MAPS>60.\n\nRecieved pt on vent CPAP/PS 12/5 40%, #7.0 Bovona Trache. Wean to TM 50% for 2 hrs became tachypneic RR>40 desat 88%, suctioned via ETT for sm amts thick pale yellow. @ 1015 placed on Vent CPAP/PS 15/5 40%. resting comfort.\n\nGI: seen by tam and J-tube site cleared for discharge. leakage slowed down duoderm drsg site. TF probalance adv to 65cc/hr Goal tol well. Abd soft + BS. sm loose Brown stool x1.\n\nGU: Foley u/o 20-80cc/ht recieved Lasix 40mg Via J-tube\n\nderm: Skin impaired Neck wounds radiation burn healling duoderm gel applied gauze drsg. Avellyn drsg .\n\nSocial: DNR/DNI\n Discharged to rehab @ 1300 by ambulance ACLS. Referral sent w/pt.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-17 00:00:00.000",
"description": "Report",
"row_id": 1626897,
"text": "Respiratory Care:\nPt remains trached and on vent. Was on PSV most of night, but changed to AC mode for 3 hrs for ^RR. Suctioned mod amt of thick white secretions. Received MDI's as ordered. Morning = 74. Plan to go on trach collar again today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-17 00:00:00.000",
"description": "Report",
"row_id": 1626898,
"text": "NPN PA-7P:\n\n\nNEURO: PT IS A/OX2 OR 3. COOP W/CARE. ASKING ABOUT HIS TF. HE IS SWABING HIS BOUTH EVERY 2-3 HOURS. HE IS ABLE TO MOVE ALL EXT.\n\nRESP: TODAY TRACH MASK AT 40%. HE HAS A IN AFFECTIVE COUGH AT TIMES. WHERE HE WILL BRING UP SPUTUM, BUT WILL NOT BE UNABLE TO FORCE THE SPUTUM THROUGHT THE TRACH. HIS TRACH SITE IS A STAGE II. HE HAS DSD OVER THE SITE. AT 1730 HE WENT BACK ON THE VENT RR 38-40, HR 120-125. HIS O2 SAT DROP TO 88-91%. HE WAS PLACED ON CPAP 40%. IMMEDIATELY HIS RR WENT DOWN TO 20-22. LS EXP WHEEZING WHICH RESOLVED W/ HIS INHALERS.\n\nCV:DILT 30MG PP WAS GIVEN ONE HOUR BEFORE THE GTT WAS TURNED OFF. HE WAS GIVEN ONE MORE DOSE OF DILT 30MG AT 1500 2/2 HR UP THE >110. THE DILT WAS CHANGED TO 60MG QID. HE WILL ALSO START LOPRESSOR 12.5MG TONIGHT.\n\nGI/GU: HE IS NPO TODAY. AROUND THE PEG TUBE IS LEAKING THE TF. IP WILL BRONCH HIM TODAY TO LOOK INTO HIS STOMACH TO CHECK THE PLACEMENT OF THE PEG. MEDS WERE GIVNE VIA PEG. LASIX 20MG IV WAS GIVEN. THE GOAL IS 1L NEG. HE HAS PUT OUT 1130 SINCE THE LISIX WAS GIVEN.\n\nI/D: WBC 4.5. THE VANCO IS ON HOLD VANCO THROUGH 63.2. HE WILL CONT ON THE CEFTZ.\n\nPOC: WILL BRONCH HIM TO CHECK PLACEMENT OF PEG TUBE. ATTEMPT TO WEAN HIM FROM THE VENT. GENTLE DIURESIS W/ LASIX. START LOPRESSOR 12.5MG TONIGHT. HE WAS PUT IN FOR A WOUND CONSULT . WILL CONT TO MONITOR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-17 00:00:00.000",
"description": "Report",
"row_id": 1626899,
"text": "Respiratory Care:\nPt recieved trached and vented. Pt weaned to trach mask, pt stayed on TM 7hrs, then pt C/O SOB,RR 36-40, SpO2 97-98%, ? anxiety. Pt placed back on vent. Lung sounds coarse.Suctioned for thick yellow secretions. MDIs given per order. Pt to be bronched by IP. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-17 00:00:00.000",
"description": "Report",
"row_id": 1626900,
"text": "NSG PROGRESS ADDENDUM 1830:\n\nTHE PT HAS A BRONCH TO CHECK THE PLACEMENT OF THE TRACH. THE TRACH IS LOCATED AT THE 4TH CARINA. NO CHANGES WERE MADE.\n\nHE IS TO REMAIN NPO OVER NIGHT OR TO CHECK THE PAG.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-19 00:00:00.000",
"description": "Report",
"row_id": 1626909,
"text": "Respiratory Care:\nPt recieved on trach mask. Needed to be placed back on vent d/t desating to high 80s and tachypnea. Pt currently on PS 15. Lung sounds shightly ronchorus. Suctioned for moderate thick white secretions. MDIs given per order. Pt traveled to and from IR for PEG placement without incident. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-20 00:00:00.000",
"description": "Report",
"row_id": 1626910,
"text": "RESPIRATORY CARE:\n\nPt remained on vent support overnight. Settings PSV 15, CPAP 5. Pt comfortable, NARD. BS's coarse at times, sxing thick white/tan secretions. Administering Albuterol and Atrovent MDI's in line with vent as ordered. See flowsheet for further pt data. Will follow, trache mask trials as tolerated today.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-20 00:00:00.000",
"description": "Report",
"row_id": 1626911,
"text": "PT. REMAINS A DNR/DNI.\n\nPT. HAS NKDA.\n\nPT. HAS REMAINED A/A/O AND COMMUNICATES BY MOUTHING WORDS AND WRITING ON PAD. PT. FOLLOWS ALL COMMANDS AND HAS DENIED ANY PAIN OR DISCOMFORT DURING THIS SHIFT. PT. HGAS REMAINED AFEBRILE THROUGHOUT THIS SHIFT.\n\nPT. HAS BEEN AFIB IN A CONTROLLED RATE, WITHOUT ECTOPY NOTED. H.R. HAS RANGED 70-103. B/P HAS BEEN STABLE AND WNL'S RANGING 110-130'S/70-80'S. PULSE ARE ALL EASILY PALPABLE WITH NO EDEMA NOTED. PT. K WAS 2.9 AT 2200 AND PT. RECEIVED 60MEQ KCL PO, VIA GTUBE AND 40MEQ KCL IV. AM LABS ARE PENDING. PT. HAS BEEN RECEIVING IV LASIX.\n\nLUNGS ARE COARSE AND RHONCHUS THROUGHOUT. PT. AT TIMES HAS EXHIBITED INSP. WHEEZE, WHICH RESOLVED WITH TREATMENTS. RESP RATE IS CONTROLLED AND PT. REMAINS ON VENT VIA TRACH ON 15/5 THROUGHOUT THIS SHIFT, AND SINCE YESTERDAY AFTERNOON WHEN HE HAD GTUBE PLACEMENT PERFORMED IN I.R. PT. IS FOR POSSIBLE WEAN TO TRACH MASK TODAY. PT. HAS BEEN SUCTIONED MODERATE AMT'S OF CLEAR/TAN SECRETIONS. PT. EXHIBITS STRONG COUGH REFLEX. O2 SATS HAVE REMAINED >96%\n\nPT. HAD GTUBE REPLACED YESTERDAY OVER PRE EXISITNG SITE, WHICH HAD BEEN LEAKING. SINCE THIS PROCEDURE PT. HAS CONTINUES TO DRAIN AT THIS SITE, AND BY 0000 PT. WAS NOTED TO BE DRAINING STOOL LOKE MATERIAL FROM AROUND TUBE INSERTION SITE. TEAM MADE AWARE. PT. DENIED ANY PAIN OR DISCOMFORT, REMAINED AFEBRILE. TUBE FEEDS OF PROBALANCE FULL STRENGHT WERE PLACED ON HOLD. I.R. SUITE NOTIFIED AND CT ABD. TO EVALUATE SITUATION WAS PERFORMED THIS MORNING AT 0530. PT. TOLERATED THIS WELL. BLOOD SUGARS HAVE BEEN MONITORED AND HAVE RANGED 67, 134, 61. PT. TREATED WITHOUT DIFFICULTY, PT. DENIED ANY SYMPTOMS. FOLEY CATHETER REMAINS IN PLACE DRAINING MODERATE AMT'S OF CLEAR YELLOW URINE. PT. IS RECEIVING ROUTINE LASIX IV, AND CONTINUES TO DRAIN >100CC/HR.\n\nSKIN EXHIBITS TO NECK WHICH EXHIBITS ALLELYN DRESSING. TRACJH CARE HAS BEEN PERFORMED SEVERAL TIMES WITH PT. EXCRETING MODERATE TO GROSS AMT'S OF SECRETIONS AROUND THE TRACH ITSELF. PT. ALSO HAS ON RIGHT GLUTEAL. BOTH INTACT, SECURED, AND FUNCTIONING WELL, WITH N/S AT KVO.\n\nPLAN IS TO RE EVALUATE GTUBE AND FOLLOW THROUGH ON POSSIBLE LARGE TUBE PLACEMENT. MONITOR RESP STATUS, AND WEAN WHEN APPROPRIATE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-20 00:00:00.000",
"description": "Report",
"row_id": 1626912,
"text": "MICU7 RN Note 0700-1900\n\nEvents: Wean to TM return to PSV, Resumed TF, eval for GT site.\n\nNeuro: awake alert oriented x2, follows commands communicates mouthing word, writing. Pupils 3mm equal react brisk. MAE random equal strength. c/o anxiety @1500 recieved ativan 1mg IV w/ calming effect. S/p care @ 1600 ^ tachypnea/desat ^ anxiety recieved ativan 1mg IVP. Pain Management denies pain @ rest c/o discomfort when providing Neck wound and GT site are.\n\nCV: Recieved Pt rapid Afib HR >125 NPO given Diltiezem 5mg IV HR. HR 60-130 Afib occass PVC when HR drifts down AV paced. recieved Diltiezem 90mg and Lopressor 25mg per parameters. NBP 103-135/55-80 MAPS>60 . IV access 2 NS 10cc/hr. K+ 3.2 repleted KCL40meq/500cc slow infusion K+3.4. Peripheral pulses 2+ DP/1+DT. sacral edema.\n\nResp: recieved pt on vent CPAP/PS 10/5 40% #7Bovona trache. Wean to TM 60% wean to 40% until 1630 return to PSV 12/5. Pt became Increasing ly anxious # 1500 recieved Ativan 1mg w/ sl effect s/p care ^RR>40 ambu and suctioned for sm amt thick yellow recieved Ativan 1mg IVP and returned to PSV. Sats 90-98% TN >350. Lungs coarse DIm L base rales R base. recieved Lasix 20mgI now changed to PO.\n\nGI: abd soft tender GT site Abd CT revealled GT placement ok. GT site leaking sm amt bile. TF restarted @1000. Probalance 25cc/hr adv to goal as tol. Inc loose brown stool x3.\n\nGU: Foley u/o 20-150cc/hr diuresed Lasix 20mg IV.\n\nDerM; Skin impaired Neck/ trach site duoderm gel applied gauze drsg. Coccyx red allevyn dsg reapplied. GT site red bile drangage. duoderm applied for skin protection. Plan to see pt ? need for sutute for closure.\n\nSocial: DNR/DNI, sister called updated on status and plan of care.\n\nPlan: rest on PSV for night.\n consult to evaluate GT wound\n Discharge to rehab \n Refer to page 2 for completion\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-20 00:00:00.000",
"description": "Report",
"row_id": 1626913,
"text": "Respiratory Care:\nPt off to Trach mask @ 0820 till 1721. O2 sat.any where between 98% and 60%. later in the day his RR slowley increasing to 48. Sx'd given MDI's and returned to PSV 12/5 @ 40%...Given ativan just before going back to vent. Now seems much more comfortable. will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-21 00:00:00.000",
"description": "Report",
"row_id": 1626914,
"text": "Resp Care Note:\n\nPt cont trached and on mech vent as per Carevue. Lung sounds coarse suct sm th tan sput. MDI given as per order. Pt in NARD on current vent settings; no vent changes required overnoc. Cont PSV.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-21 00:00:00.000",
"description": "Report",
"row_id": 1626915,
"text": "PT. REMAINS A DNR/DNI.\n\nPT. HAS NKDA.\n\nPT. REMAINS A/A/O AND DENIES ANY PAIN OR DISCOMFORT, DURING THIS SHIFT. PT. FOLLOWS COMMANDSA AND REMAINS AFEBRILE.\n\nPT. REMAINS AFIB IN A CONTROLLED RATE, WITHOUT ECTOPY 80-107. B/P HAS RANGED 115-130/70-90'S. PULSES ARE WEAK, BUT EASILY PALPABLE. NO NOTED EDEMA.\n\nLUNGS ARE COARSE AND DIMINISHED. PT. REMAINS ON VENT AND HAS TOLERATED THIS FINE THROUGHOUT THIS SHIFT. PT. HAS A BOLVONA TRACH. HE HAS BEEN SUCTIONED FOR COPIOUS AMT'S OF CLEAR/TAN SECRETIONS BOTH VIA TRACH AND ORALLY. RESP RATE HAS BEEN WNL'S AND O2 SATS HAVE REMAINED >96%\n\nPT. CONTINUES ON TUBE FEEDS, PRESENTLY AT 45CCHR, WITH GOAL OF 65CC/HR OF PROBALANCE, FULL STRENGTH. ABD. EXHIBIT GTUBE, SINGLE LUMEN, WHICH HAS DRESSING INTACT. INSERTION SITE CONTINUES TO DRAIN SMALL AMT'S OF TUBEFEEDS. NO DARK, FOWL SMELLING DRAINAGE DURING THIS SHIFT. SURGERY CONSULTED AND ASSESSED SITUATION. PLAN TO DISCUSS WHAT TO DO TODAY. BLOOD SUGARS REMAIN WNL'S WITH NO INSULIN COVERAGE GIVEN.\nFOLEY CATHETER INTACT AND DRAINING AMPLE BUT SMALL AMT'S OF CLEAR YELLOW URINE. 60-100CC/HR. PT. REMAINS ON ROUTINE LASIX DOSING.\n\nPT. SKIN EXHIBITS .EXCORIATION TO NECK. ALLELYN DRESSING INTACT AND TRACH CARE PERFORMED. RIGHT GLUTEAL EXHIBITS AREA AS WELL, WITH ALLELYN DRESSING CHANGED, WHICH REMAINS INTACT AT THIS TIME. 'S REMAIN INTACT, PATENT, AND SECURED, WITH IVF OF N/S AT KVO.\n\nPLAN IS FOR POSSIBLE TRANSFER TO REHAB FACILITY. THIS PENDING THE DECISION OF SURGERY ON WHETHER THEY WILL TREAT LEAKAGE AROUND G-TUBE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-19 00:00:00.000",
"description": "Report",
"row_id": 1626906,
"text": "PT. REMAINS A DNR/DNI.\n\nPT. HAS NKDA.\n\nPT. REMAINS A/A/O X2, AND BOTH MOUTHS AND WRITES ON PAD TO COMMUNICATE. PT. HAS DENIED ANY PAIN OIR DISCOMFORT THROUGHOUT THIS SHIFT. PT. HAS BEEN AFBRILE.\n\nPT. HAS REMAINED AFIB IN A CONTROLLED RATE WITH NO BURST IF RVR. PT'S MEDS WERE EVAULATED AND CHANGED YESTERDAY WITH DESIRED EFFECTS REACHED. B/P HAS BEEN STABLE RANGING 100-130'S/60-80'S. PULSE ARE EASILY PALPABLE, WITH NO EDEMA NOTED.\n\nPT. HAS TRACH (BOVONA), PT. REMAINED ON TRACH COLLAR FOR >14HRS. PT. DENIED DISTRESS AND DENIED SOB. BUT O2 SATS DROPPED FROM 97% DOWN TO 88% PT. PLACED BACK ON VENT ON PS SETTINGS. PRESENTLY PT. AS OF 0600 IS BACK ON TRACH MASK AT 50% LUNGS HAVE IMPROVED VIA CHEST XRAY IN COMPARSION FROM YESTERDAY MORNING. LUNG FIELDS ARE CLEAR IN RIGHT UPPER AND COARSE IN RIGHT LOWER, DIMINISHED THROUGHOUT LEFT LUNG. RESP RATE REMAINS CONTROLLED AND PT. DENIES AND SOB. PT. HAS BEEN SUCTIONED FOR COPIOUS MAT'S OF THICK CLEAR TO TANNISH SECRETIONS. PT. CONTINUES TO EXHIBIT STRONG COUGH REFLEX.\n\nPT. CONTINUES TO DIURESIS >100CC/HR PT. RECEIVED LASIX 20MG IV LAST EVENING AND AGAIN 20MG THIS AM. PT. HAS FOLEY CATHETER, CLEAR YELLOW URINE NOTED. NO STOOL NOTED THIS SHIFT. PT. HAS PEG TUBE IN PLACE, WHICH CONTINUES TO LEAK. PT. WILL GO TO IR TODAY FOR GJ TUBE. BLOOD SUGARS HAVE BEEN WNL'S WITH NO COVERAGE REQUIRED DURING THIS SHIFT.\n\nSKIN INTEGRITY EXHIBITS TO RIGHT GLUTEAL, AND ABREASION TO NECK WHICH PT. HAS ALLELYN DRESSING IN PLACE. PIV X2 #18 AND #20 BOTH REMAIN INTACT, SECURED, AND PATENT WITH KVO IVF INFUSING.\n\nPLAN IS TO TAKE PT. TO IR TODAY FOR GJ TUBE. CONTINUE TO MONITOR PULMONARY STATUS, AND AID IN PULMONARY TOILETING. PT. REMAINS A DNR/DNI AT THIS TIME.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-19 00:00:00.000",
"description": "Report",
"row_id": 1626907,
"text": "Resp Care\n\nPt weaning on trach mask until ~ 2400, then accute tachypnea and desaturation which did not rebound to previous level after sxng and bronchodilators by MDI. Pt was then placed o ventialtor on AC mode, then later on PSV. Placed back on trach mask @ ~ 0530. was 138. Pt changed to hi neb due to low saturation on regular neb.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-19 00:00:00.000",
"description": "Report",
"row_id": 1626908,
"text": "NPN 7A-7P:\n\n\nNEURO: HE IS A/OX2. COOP W/ CARE. HE REQUIST TO HAVE ICE CHIPS AND GREEN SWAB AT THE BED SIDE. BUT I NOTED THE PT DRINKING THE WATER, AND COUGHING. HE FOLLOWS COMMANDS CONSISTENTLY. ABLE TO MAE.\n\nRESP: LS MIXED BAG. RONCHE/INS WHEEZING/POPING/DIMINSHED AT THE BASES. THIS AM HE HAS A LARGE AMOUNTS OF CLEAR SPUTUM. HE HAS A IN AFFECTIVE COUGH. HIS O2 SAT DROP DOWN TO 85% W/ RR 38 ON 30% TRACH MASK. LASIX 20MG IV WAS GIVNE. HE PLACED ON TEH VENT CPAP/PS 15/5. HIS RR 15-20.\n\nCV: A-FIB W/ PVC NOTED, HR 110-82. HE IS ON PO DILT AND LOPRESSOR W/ GOOD EFFECT NOTED.\n\nGI/GU: + BS HE DID HAVE SMALL LIGHT BROWN STOOL TODAY. GOOD UA OUT PUT NOTED. TODAY HE WENT TO IR. NEW J TUBE IN PLACE.\n\nSKIN: HE HAS THREE 0.5X0.5 STAGE II ON HIS COCCYX. DRESSING WAS CHANGED TODAY. HE HAS A XRT BURN ON HIS NECK. DUODERM GEL W/ DSD IS TX ORDER. AROUND THE J TUBE SITE THEIR IS YELLOW DRAINAGE IN LARGE AMOUNTS. DSD APPLYED.\n\nPOC: CONT VENT SUPPORT. ATTEMPT TO WEAN TO TRACH MASK. LASIX NOW . QUESTION TF. VANCO LEVEL W/ LABS IN TEH AM. K/MG/PHOS AT .\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-16 00:00:00.000",
"description": "Report",
"row_id": 1626895,
"text": "Micu nurisng note \n\nCv goal today was to titrate esmolol drip off prior to dc of drip hr 95-105 afib, by 1030 am pt restarted on po metoprolol 75 mg, within 30 min drip dc's hr between 100-130 by 4 pm hr back up to 120's pt given po does of metoprolol hr still 115-120 spoke with resident and ? if we need to increase po does of metoprolol, pt recieved 40 kcl this afternoon. pulses faint but palpable, pt oob to chair x4 hrs tol well.\nResp weaned from ac to pressure support to trach collar ( see care view) today pt on trach collar x4 hr tol well lung sounds now course pt was allows small amount of coffee while sitting in chair but noted the secreations which were white this am now are coffe color even though pt was no coughing while drinking I feel pt still asperates liquids and will now only have swabs for mouth, sats 98% pt suctioned q3 -4 for tan secreations. pt still has large amounts of secreations that come around trach, trach area red and still have wound care consult in for rad burn, area fryable, also trach seems to long and ? pt needs different trach and would recomend ip to look at trach. trach care given and skin covered with barrier cream and dsd\nGi tube feeds on hold area leaking lg amount around tube would like to see peg replaced lg amounts of gastric contents that leak area cleaned with soap and water and barrier cream applied will hold feeds for now\nGU pt given lasix this am u.o 150 hr\nid pt hypothermic this afternoon 95.1 now on warming blanket\nendo bs 166 see \nA/P would keep pt npo, hold feeds and have gi look at peg in am\nwould try trach collar this evening and rest on ps tonight \nwound care consult for neck area and ? ip to look at trach\nwould increase po metoprolol for better rate control\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-17 00:00:00.000",
"description": "Report",
"row_id": 1626896,
"text": "1900-0700 RN NOTES MICU\n\nEVENTS:PT START ON DILTAIZEN GTT FOR HR 120-130,TITRATE TO HR 100,OVERNIGHT HR DOWN TO 90-LOW 100 WITH BP STABLE AT 91-100/50'S, CURRENTLLY DILTAIZEM 7MG/HR. METOPROLO PO HELD MD .\n\nNEURO: PT ALERT/OX3, FOLLOWS COMMANDS, /COOPERATIVE WITH CARE.ABLE TO COMMUNICATE WITH MOUTH WORDS AND WRITTNG ON A BOARD.\n\nRESP: RECIVED ON CPAP/PS 40%/PS 15/PEEP 5, OVERNIGHT BECAME INCREASINGLY TIRED AND C/O TROUBLE TO BREATH, PUT ON AC 405/450/RR14.SAT 99%/LS COARSE CLEAR TO SX. SUCTION MODERATE AMOUNT WHITE SECRETYION.YESTARDAY TOLLEARED TRACH COLLAR FOR 4HR.PT NEEDS IP CONSULT FOR POSSIBLE TRACH CHANGES.\n\nCV: AS SAYS ABOVE, START ON DILT GTT.REMAIN OB AFIB NO ECTOPY. PT WITH , TEE SHOWN ACUTE CHANGES EF DOWN TO 25-30% FROM 55-60%.MORNINF LABS PENDING.\n\nGU/GI: FOLEY DRAINGED YELLOW CLEAR URINE, 30-60CC/HR. PT POS 1300CC FOR 24HR. CONT WITH LEAK ON PEG SITE, TF STOOPED, PT NPO. NEEDS GI CONSULT FOR POSSIBLE PEG CHANGES.\n\nSKIN: OPEN AREA STAGE 2 ON COCCYX, ALLEVYN DSD APLLIED. ALSO RED AREA AROUND NECK. PT NEEDS WOUND CARE CONSULT.\n\nID: AFEBRILE, TMAX 97.8, CONT VANCO/CEFTRAZIDIME,\n\nSOCIAL; DNR/DNI, NO CONTACT FROM FAMILY.\n\nPLAN: CONT MONITORING RESP/CARDIO STATUS\n WEAN DILTIAZEM GTT TO KEEP HR LOW 100'S-90.\n PLEASE SEND VANCO LEVEL AT 7-8AM\n IP, GI WOUND CARE CONSULTES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-16 00:00:00.000",
"description": "Report",
"row_id": 1626892,
"text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: ALERT AND ORIENTED X 3- PT ABLE TO COMMUNICATE BY MOUTHING WORDS OR WRITING ON BOARD. PLEASANT. ABLE TO FOLLOW COMMANDS WITHOUT DIFFICULTY. ATTEMPTS TO ASSIST WITH TURNS AND PERSONAL CARE. ENJOYS HIS GINGERALE SWABS. AFEBRILE. PERRLA, 3/BRISK. NO SEIZURE ACTIVITY NOTED.\n\nRR: RECEIVED PT ON CPAP/ HOWEVER, PT BECAME INCREASINGLY TIRED AND TACHYPNIC- FELT LIKE HE WAS \"NOT GETTING ANY AIR\". PT RESTED OVERNIGHT ON AC. HAS DONE VERY WELL. NO FURTHER C/O SOB OR DIFFICULTY BREATHING. BBS= ESSENTIALLY CLEAR TO COARSE THROUGHOUT ALL LUNG FIELDS, NOTED TO BE DIMINISHED TO BASES. BILATERAL CHEST EXPANSION NOTED. SUCTIONING FOR MODERATE AMOUNTS OF YELLOW SPUTUM. PT ABLE TO SELF YANKAUR ORAL SECRETIONS. TRACH CARE PT TOLERATED WELL.\n\nCV: S1 AND S2 AS PER AUSCULTATION. AFIB, HR 80-90'S. RECEIVED PT ON LABETALOL GTT- DC'D AND ESMOLOL GTT INITIATED IN AN ATTEMPT TO PREVENT HYPOTENSION. SBP > OR = TO 90 WITH NO HYPER OR HYPOTENSIVE EPISODES NOTED SINCE STARTING. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PT HAS 2 PIV'S- SECURE AND PATENT. DENIES ANY CHEST PAIN.\n\nGI: ABD IS SOFT, FLAT, NON-DISTENDED. BS X 4 QUADRANTS. PT HAS SECURE AND INTACT PEG TUBE- DRESSING CHANGED. TF AT GOAL- NOTED TO HAVE VERY MINIMAL TO NO GASTRIC RESIDUALS. PT HAD MEDIUM SIZED, BROWN, SOFT STOOL THIS SHIFT. PASSING FLATUS.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. CLEAR, YELLOW URINE NOTED IN ADEQUATE AMOUNTS.\n\nSKIN: FRAGILE SKIN. DUODERM ON COCCYX CHANGED THIS SHIFT.\n\nPLAN: CONTINUE TO WEAN VENT AS PT WILL TOLERATE. CONTINUE ESMOLOL GTT FOR RATE CONTROL. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-16 00:00:00.000",
"description": "Report",
"row_id": 1626893,
"text": "Respiratory Care:\nPt remains trached and on vent. Mode changed to AC to rest overnight, has tolerated well. Received MDI's as ordered. Suctioned lt yellow secretions. Morning = 76. Plan is to wean as tolerates in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-16 00:00:00.000",
"description": "Report",
"row_id": 1626894,
"text": "Resp Care\nPt weaned to psv 5/5 this am then placed on 50% TM for just under 4 hours which he tolerated well satting >95% with rr 20-30. BLBS slightly course, suctioned for sm-mod amt thick white secretions, mdis given per order. Pt placed back on psv at 2pm to allow pt to rest. plan to attempt TM again tomorrow as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-15 00:00:00.000",
"description": "Report",
"row_id": 1626888,
"text": "Nursing Progress Note 1900-0700\n(Continued)\nh care. Purulent drainage noted, avvelyn applied. PEG tube site also with yellow drainage.\n\nEndo: ISS, no coverage this shift, and fixed dose insulin.\n\nPlan: ? consider increasing PO lopressor vs. switching to diltiazem/amiodarone for HR control. Cont. to monitor renal function/ATN. Treat anxiety with lorazepam. CXR showing bilateral effusions. No more fluid boluses. Please see flow sheet as needed for additional information.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-15 00:00:00.000",
"description": "Report",
"row_id": 1626889,
"text": "Respiratory Care:\nPt remains trached with #7 and on vent. No parameter changes made this shift. Received MDI's, suctioned sm amt thick yellow. Had episode of ^RR, though sats remained good. Morning measured = 168.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-15 00:00:00.000",
"description": "Report",
"row_id": 1626890,
"text": "Resp Care\nPt remaisn trached with #7.0 h20 cuff. he was weaned to PSV 15/5 this am and has remained there all shift with volumes 375-550 and rr 18-25, pt has short periods of apnea not exceeding 30 seconds. BLBS course, scutioned for sm-mod amt thick aple yellow secrtions, mdi given per order. plan to remains on psv overnight as tolerated and wean ips tomorrow as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-18 00:00:00.000",
"description": "Report",
"row_id": 1626905,
"text": "MICU7 RN Note 0700-1900\n\nEvents: Wean to TM 50%, Episodes Rapid AFib increased Diltiezem, Increased Lopressor.\n\nNeuro: awake alert oriented x2 follows commands Pupils 3mm equal react brisk, MARE random and to command equal strength. Denies pain . c/o feeling anxious recieved Ativan 1mg IV x2 w/calming effect.\n\nCv: HR 85-120 Afib rare PVC, episodes Rapid afib HR>130-150 assymptomatic Diltizem 60mg increased to 90mg TID and Increased Lopressor to 25mg TID. @ 1600 Rapdid Afib HR>150 recieved lopressor 5mg IVP w/HR 90-110. EKG done. recieved Lasix 20mg for u/o trending down. Seriel CK/troponin trending down although troponin ^ 3.26 (?renal response). peripheral pulses 3+ DP/2+ DT. neg edema.\nK+ 3.2 repleted KCL 40meq/500cc\nIV access : 2PIV #18/#20 NS KVO.\n\nresp: Bovona trach recieved pt vent mode CPAP/PSV 15/5 40%. Rr 18-30 TV >350. Sats 92-97%. @ 1000 wean to Trach collar 50% sats mid 90's. suctioned via trach for sm amt thick pale yellow, lg amt secretions drainage around trach stoma. CXR done routine @ 1600 sats low 90's RR 30-40 tachypneic pt denied Difficulty breathing. recieved lasix Lungs clear raled RLL dim L base. trach cuff down strong cough and able to expectorate mod amt thick yellow secretions. Sat ^ mid 90's. Cuff remains down w/ improved sats.\n\nID: afebrile t-max 98, WBC 7.5 taken off neutropenic precautions. , abx cetazipine, Vanco level 53 Vanco d/c.\n\nGU/GI: Foley u/o 20-300cc/hr s/p lasix. Abd soft + BS GT inplace w/gastric leakage. awaiting GJ tube placement in IR . NPO unable to give TF due to Leakage.\n\nDerM; Skin impaired. Radiation burn neck eval by wound care team, Protectent gel appled, frequent trach dsg changes.\n\nSocial: DNR/DNI. Sister called for update.\n\nPlan: IR for Peg revision GJ tube.\n wean on TM for noc as tol.\n Diurese to 1L neg.\n monitor /control Rapid AFib\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-15 00:00:00.000",
"description": "Report",
"row_id": 1626891,
"text": "Micu nursing note \n\nCV pt remains tacky up to the 130's pt given iv metoprolol 5 mg iv x2 durring the day which would drop hr into the 110-120by 530 pm pt started on a labatolol drip at .5 mg/min which is now at .75mg/min BP 89-117/60-70 hr 98-108 afib, pt troponin 3.3 and house staff felt pt still infacting and needed better rate control\nresp pt switch to ps15/5 tv350-500 rr 10-22, lungs clears sats 100% pt sucitoned for thick sticky pale yellow secreation, pt given trach care x2 pt's neck area pink/rad burn area covered with moisture barrier cream and dsd, ( spoke with heme onc floor this was there recomendation) noted chest x ray increasesize of rt effusion\n\nGi pt continues on tube feeds at 65 hr probalance, residuals 10 cc, no stool\nGU pt given lasix 20 mg at 4 pm pt putting out 150 cc hr\nneuro pt awake and alert\nskin consult placed for wound care\nA/P would continue with labatolol for hr control, follow urine output and if pt u/o falls would consider more lasix tonight, pt needs repeat labs tonight.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-18 00:00:00.000",
"description": "Report",
"row_id": 1626901,
"text": "1900-0700 rn notes micu\n\n71 y.omale with h/o of ETOH abuse,Afib, DM, CAD. s/p CABG, s/p trach/peg, head and neck CA undergoing chemo and transfer from OSH with Afib, ,acute renal failure, hypoxia.TEE shown acute changes EF down to 25-30% form 55-60%.in unit was on Osmolol nad diltaizem gtt for rapid Afib. currently on Diltiazem PO and Metoprolol Po.\n\nneuro: A/ox3, comminication wiht mouth words and writting on board. follows commands, and cooperative with care. given trazodone 25mg and Ambien held. pt c/o anxiety with RR up to high 30's, given Ativan 1mg IV with good effect.\n\nresp: on CPAP/PS 15/peep 5,no vent changes made overnight. LS coarse clear to suction for moderate amount white secretion. sat 98-99%.bronch done yesterday for trach placement no changes made.\n\ncv: HR 80-90's, Afib with occass PVC's, once Hr up to 112-115, given additional dose of Diltiazem 30mg PO with good effect.\n\ngi/gu: foley drainged yellow clear urine 20-30cc/hr MD aware, goal nef 1L,pt neg 1l for 24hr. pt NPO for peg revision possible in OR d/t leak. needs ABD CT prior procedure. abd soft, BS +, no BM.\n\naccess: 2piv pattent.\n\nid: affebrile, vanco held d/t level63, needs level in the morning.cont ceftrazidime.\n\nsocail: DNR, no contact from family.\n\nplan: comt monitoring resp/cardio status\n ABD CT and ?or for peg revesion.\n vanco level\n wean vent to trach collor mask as tollerates.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-18 00:00:00.000",
"description": "Report",
"row_id": 1626902,
"text": "ABD CT canceled, ?OR vs IR. pt had 10 beats of Vtach, bp stable,MD aware. vanco level sent.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-18 00:00:00.000",
"description": "Report",
"row_id": 1626903,
"text": "Resp Care\n\nPt was sx Q 2-4hrs, alb / atr MDI Q 4 hrs. He has a small tach leak which is positional. Pt is very alert and fairly anxious, he was awake almost all night. this morning was ~ 112. No ABG drawn on this shift. Plan is to continue with current level of support as he seems to need the higher level of PSV.\n\n\u0013\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-18 00:00:00.000",
"description": "Report",
"row_id": 1626904,
"text": "Respiratory Care:\nPt recieved trached and vented. Weaned to trach mask with 50% FiO2. Lung sounds clear with few crackles. Suctioned for moderate thick white secretions. MDIs given per order. Plan is to remain on trach collar if possible over noc. Pt will go for PEG placement tomorrow.Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-14 00:00:00.000",
"description": "Report",
"row_id": 1626883,
"text": "Respiratory Care:\n71 Y.O. Male with extensive oncologic HX to neck/throat (arrived with #7 TTS, water filled cuff, trache tube-7cc H20 to seal), here for PNA, and acute neutropenia (on XRT). PMHX: COPD, CAD/CABG. Initiallized on settings per flowsheet. ABG's drawn showing adequate oxygenation with respiratory alkalosis. Awaiting discussion with team regarding possible modality change, or sedation to reduce minute ventilation, also possible increase in FIO2. Pt. awaiting Cardiac Echo today. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-14 00:00:00.000",
"description": "Report",
"row_id": 1626884,
"text": "Nursing Progress Note 1900-0700\nReport received from AM shift. All alarms on monitor and ventilator are functioning properly. Pt's environment secured for safety.\n\nPt is a 71 yo male with a sig. history of afib, PVD, pacemaker, ETOH abuse and 59 pack year smoker, COPD, HTN, DM, CAD s/p CABG, Lt. piriform sinus mass: Squamous cell carcinoma -- radiation treatment, weekly low dose carboplatin/taxol. Pt. was admitted to OSH from rehab on for SOB, chest pain and afib with RVR, O2 dropped to 87%. ECG showed ST depressions, Troponin I elevated to 65.48. CXR revealed cardiomegaly and interstitial pulmonary changes indicative of CHF. Pt. lab values showed neutropenia and elevated BUN/cr. CXR showed Rt middle lobe pna. Arrived to MICU trached and PEGed.\n\nNuero: Pt. alert and oriented when admitted, currently sleeping. Able to mouth words and make needs known. Also able to communicate via pen and paper at bedside. MAE, follows commands consistently. All side rails up for safety.\n\nCV: HR 94-107's afib with rare PVCs noted. BPs 117-139/88-99s, 50mg metoprolol given fore HR control. Feet with mottled looking appearance, but easily palpable pedial pulses and warm to the touch. Denies any chest pain.\n\nRR: Pt. trached, on vent. settings 40%/500/5 PEEP, RR 16. RR 16-24, with sats 97-100%. Sxned for mod. amounts of yellow thick secretions. Pt. able to oral sxn self. Mod. amounts of yellow thick secretions around tracheostomy noted. LS coarse T/O. Bilateral chest expansion noted. Noted teeth missing while performing oral care.\n\nGI/GU: Abd. soft, non-distended. Abd tender to palpation. PEG tube patent and secure, residuals checked q4h with 0.0ml returned. TF started at 25ml/hr, goal rate 65 ml/hr. Pt. received with FIB, draining golden loose stool. Foley catheter is secure and patent draining marginal amounts of clear amber urine. Last BUN/Cr, 77/2.7 respectively. Last LDH 1182, AST 1552, ALT 2522.\n\nSkin: Mult. areas of breakdown noted on rt. gluteal. OTA, pink with no drainage noted. Neck with mult. abrasions and irritation radiation treatment. Areas with purulent drainage, OTA.\n\nID: Remains neutropenic with last WBC 2.3. On neutropenic precautions. Mult. antibx for coverage. Afebrile.\n\nEndo: ISS, and fixed dose insulin for coverage.\n\nPlan: Onc. consult, determine cardiac function; echo tomorrow. HR control, wean vent. as tolerated. Monitor renal function- will administer fluid challenge for decreased UOP.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-14 00:00:00.000",
"description": "Report",
"row_id": 1626885,
"text": "Resp Care\nFairly quite shift with pt. Did try CPAP .40 +5 +10PSV and pt tolerated for approx 2 hrs. Pt told RN despite RR of 30-35 that his breathing was fine and then a short time later he stated he was SOB so pt put back on vent with AC as before. Receiving nebs as ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-14 00:00:00.000",
"description": "Report",
"row_id": 1626886,
"text": "NPN 7P-7A:\n\nTHE PT IS A 71Y/P MALE ADMIT ON W/ DX OF; MI, NEUTROPENIA, SOB. AT THE OSH HIS O2 SAT DROP INTO THE 80'S. HE WAS STARTED CARDIZEM FOR AF AND CHANGED TO LOPRESSOR PO BEFORE TX. . HE HAS A PMH: LEFT PIRIFORM SINUS MASS,TX W/ XRT, TRACH/PEG, DM,HTN,CAD S/P CABGX5, PACER SICK SINUS, AF, COPD,SPONTANEOUS PNEUMOTHORAX S/P CHEST TUBE, COLON CA S/P RESECTION , ESOPHAGEAL STRICTURE, S/P OPEN GASTROSTOMY , S/P TRACH .\nNKDA:\n\nNEURO: HE IS AND MOUTHING WORDS. HE FOLLOWS COMMANDS CONSISTENTLY. ABLE TO MAE.\n\nRESP: HE IS TRACHED. TODAY A ATTEMPT WAS MADE TO CHANGE HIM OVER FROM AC TO CPAP. HE TOLERATED CPAP FOR 15MIN. THAN HE C/O SOB W/ RR UP TO 40'S. BECAME DIAPHERATIC AND FLUSHED. HE WAS CHANGED BACK TO AC NOW HIS RR 20 TO 24 ON 40X450X14 PEEP5. W/ OUT RESP DISTRESS NOTED. LUNG SOUNDS COURS/RONCHI BILAT. SX FOR THICK YELLOW SPUTUM IN MOD AMOUNTS. HE HAS A RIGHT MIDDLE LOBE PNA. NOW ON VANCO AND CEFAZIDIME IV.\n\nCV: HE IS R/I FOR A NSETMI. HIS TROKPI ARE +. HE IS CURRENTLY IN AF W/ HR 98-125. THE LOPRESSOR HAS BEEN INCREASED FORM: LOPRESSOR 50MG TID, TO 75MG TID. WHILE ON CPAP. HIS HR DID INCREASE TO 120-130. A ONE TIME DOSE OF LOPRESSOR 5MG IV WAS GIVEN. HE ALSO DID RECEIVE THE EXTRA 25MG OF LOPRESSOR TO MAKE THE AM DOSE 75MG. DESPITE THE EXTRA LOPRESSOR HIS HR STILL REMAINS FORM 110-125.\n\nGI/GU: HE IS NPO ASPIRATION PRECAUTIONS. HE HAS MISSING THEETH. + BS NO BM. HE HAS A RECTAL BAG IN PLACE. BUN 77/2.7. HE HAS POOR OUT PUT. FLUID CHALLENGE OF 500ML X2 WAS GIVN TODAY. W/ OUT GOOD RESPONSE.\n\nONC: HIS LAST DOSE OF CHEMO WAS ON . HE ALSO HAS A XRT BURN TO THE LEFT SIDE OF HIS NECK. WBC 2.3. HE REMAINS ON NEUTROPENIC PRECAUTIONS.\n\nSKIN: HIS BUTTOCKS HAS MULTIPLE STAGE 2 PINK AREAS. NEW DUODERM WAS APPLYED. HIS PEG TUBE SITE HAS YELLOW DRAINAGE NOTED.\n\nSOCIAL: TODAY HE MADE HIS AND , WHICHE IS HIS BROTHER, AND THE HCP. HE CHANGE THE FULL CODE STATUS TO AND DNR/DNI.\n\nPOC: TO MONITOR CK/TROP, FOR NOW CONT LOPRESSOR. AC OVER NIGHT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2107-10-15 00:00:00.000",
"description": "Report",
"row_id": 1626887,
"text": "Nursing Progress Note 1900-0700\nReport received from AM shift. All alarms on monitor and ventilator are functioning properly. Pt's environment secured for safety.\n\nCode status changed to DNR/DNI\n\nPt. is a 71yo male with a significant history of afib, PVD, pacemaker, ETOH abuse and 59 pack year smoker, COPD, HTN, DM, CAD s/p CABG, Lt. piriform sinus mass: squamous cell carcinoma-- radiation treatment, and weekly low dose carboplantin/taxol. Pt. was admitted to OSH from rehab on for SOB, c/o chest pain, and afib with RVR, O2 dropped to 87%. ECG showed ST depression, and troponin I elevated to 65.48. CXR showed cardiomegally and intersitial pulmonary changes indicative of CHF. Pt lab values showed neutropenia and elevated BUN/Cr. CXR showed right middle lobe PNA. Arrived to MICU trached and PEGed.\n\nEvents: After completing trach care,repositioning and morning , pt c/o feeling \"tight\" and unable to breath. Sxned for mod amounts of thick yellow secretions. RR up in the 40s. HR 130s, and BP 130s/90s. Neb treatment given by respiratory therapy. Given 5mg lopressor IVP x2, for a total of 10mg. Resulting HR 105-115s, BP 120s/80s. Pt appear anxious and RR remained in the high 40s. Pt did not have any episodes of desaturation with this. Given 1mg lorazepam IVP, with good effect. Dr. aware. CXR showing bitateral effusions (left effusion is new). Question of possible PE- but unable to anticoagulate- will draw ABG this am as well.\n\nNuero: Pt. alert and follows commands consistently. MAE, able to mouth words to make needs known. All side rails up for safety.\n\nCV: HR 105-120s, afib, no ectopy noted. HR increased to 130s periodically T/O the night. Received 5mg lopressor IVP x3, for a total of 15mg IVP given this shift in addition to 75mg PO. ? considering increasing PO dose of lopressor. BP 115-135s/85-85s. Diff. to palpate pedial pulse bilaterally.\n\nResp: Pt trached on vent settings AC 40% 450/14/5 PEEP. RR 18-26, with sats 95-99%. Sxned for sm. - mod. amounts of yellow thick secretions. Pt. able to oral sxn self. Mod. to Copious amounts of thick yellow secretions noted around tracheostomy. L/S coarse T/O, bilateral chest expansion noted. Noted missing mult. teeth while performing oral care.\n\nGI/GU: Abd soft, non-distended. Abd tender to palpation. PEG tube secure and patent. TF at goal rate of 65 ml/hr. TF residuals check q4h with 0.0mls returned. Pt. with FIB, draining golden loose stool. + BS in all 4 quadrants. Foley catheter is secure and patent, draining marginal amounts of clear amber urine. U/O 15-40 ml/hr. Did received 1L fluid bolus low U/O, with no effect. Last BUN/Cr 83/2.7 respectively.\n\nID: Remains on neutropenic precautions with WBC 2.5. Mult. antibiotics for coverage. Afebrile this shift.\n\nSkin: Mult. areas on buttox with breakdown noted. Red, open stage 2 ulcers, new duoderm was applied, D&I. Neck with mult. areas of abrasions and irritation radiation treatment. Performed \n"
},
{
"category": "Echo",
"chartdate": "2107-10-14 00:00:00.000",
"description": "Report",
"row_id": 83471,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Atrial fibrillation.\nWeight (lb): 128\nBP (mm Hg): 146/12\nHR (bpm): 103\nStatus: Inpatient\nDate/Time: at 15:37\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Severely depressed\nLVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV wall thickness. Dilated RV cavity. RV function\ndepressed.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Focal calcifications in ascending\naorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Calcified tips\nof papillary muscles. No MS. Moderate to severe (3+) MR. LV inflow\nuninterpretable due to tachycardia and/or fusion of spectral Doppler E and A\nwaves\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Moderate [2+] TR. Mild PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: 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. Overall left\nventricular systolic function is severely depressed (LVEF= 23-30 %). There is\nglobal hypokinesis with regional variation: the inferior free wall, posterior\nwall, and lateral wall are severely hypokinetic; the rest of the left\nventricle is at least mildly hypokinetic. There is no ventricular septal\ndefect. The right ventricular cavity is dilated. Right ventricular systolic\nfunction appears depressed. The ascending aorta is mildly dilated. The aortic\nvalve leaflets (3) are mildly thickened but aortic stenosis is not present.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is\nseen. There is mild pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nCompared with the findings of the prior study (images reviewed) of , the left ventricular ejection fraction is markedly reduced. The right\nventricle also is now hypocontractile. Mitral and tricuspid regurgitation are\nsignificantly increased.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2107-10-16 00:00:00.000",
"description": "Report",
"row_id": 227329,
"text": "Atrial fibrillation with rapid ventricular response. Intraventricular\nconduction defect. Diffuse ST-T wave changes may be related to the rate and\nrhythm but cannot rule out myocardial ischemia. Low QRS voltage in the limb\nleads. Compared to tracing of there is no significant diagnostic\nchange.\n\n"
},
{
"category": "ECG",
"chartdate": "2107-10-14 00:00:00.000",
"description": "Report",
"row_id": 227558,
"text": "Atrial fibrillation with a rapid ventricular response. Left ventricular\nhypertrophy. ST-T wave abnormalities which could be due to left ventricular\nhypertrophy. Compared to the previous tracing of rapid atrial\nfibrillation is new.\n\n"
},
{
"category": "ECG",
"chartdate": "2107-10-19 00:00:00.000",
"description": "Report",
"row_id": 227328,
"text": "Atrial fibrillation, mean ventricular rate 103. Compared to previous tracing\nof multiple abnormalities as previously noted persist without major\nchange.\n\n"
}
] |
382 | 165,617 | Cardiac catheterization on showed no MR, LVEF 68%, three vessel disease. On he underwent a CABG x 4, he was transferred to the SICU in critical but stable condition. She awoke neurologically intact and was extubated that same day. She had a brief episode of post op afib which converted with amiodarone. She was transferred to the floor on POD #1. She continued to do well postoperatively. She was seen in consultation by who changed her insulin regimen. She remained in the hospital for further blood sugar management. | There is a trivial/physiologic pericardial effusion.POST-BYPASS: Pt is in sinus rhythm and on an infusion of phenylephrine1. Focal calcifications in aortic root.Normal ascending aorta diameter. Simple atheroma in aortic arch. Focal calcifications in ascending aorta.Normal aortic arch diameter. Physiologic mitral regurgitation is seen (within normallimits).7. No MS. Physiologic MR (withinnormal limits).TRICUSPID VALVE: Physiologic TR.PULMONIC VALVE/PULMONARY ARTERY: Significant PR.PERICARDIUM: Trivial/physiologic pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. There are simple atheroma in the aortic arch. Normal descendingaorta diameter. These demonstrate that the previously noted right pleural effusion is at least partially free flowing. Normal regional LV systolic function.LV WALL MOTION: basal anterior - normal; mid anterior - normal; basalanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;mid inferoseptal - normal; basal inferior - normal; mid inferior - normal;basal inferolateral - normal; mid inferolateral - normal; basal anterolateral- normal; mid anterolateral - normal; anterior apex - normal; septal apex -normal; inferior apex - normal; lateral apex - normal; apex - normal;RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal aortic root diameter. The lungs are clear except for small left lower retrocardiac atelectasis. Minimal CT serosanguinous drainage. Biventricular systolic function is preserved2. There are simple atheroma inthe descending thoracic aorta.5. IMPRESSION: Stable post-surgery appearance of the chest. Aorta is intact post decannulation3. Regional left ventricular wall motion is normal.3. Cardiac silhouette remains at the upper limits of normal in size. Intra-op TEE for CABGHeight: (in) 62Weight (lb): 135BSA (m2): 1.62 m2Status: InpatientDate/Time: at 08:28Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. Simple atheroma in descending aorta.AORTIC VALVE: Normal aortic valve leaflets (3). IMPRESSION: Opacity projecting over the right lower lung zone, probably discoid atelectasis. The patient has been extubated, mediastinal and lateral chest tubes have been removed and an NG tube has been withdrawn. Cardiomediastinal contours are stable in the postoperative period. Assess pleural effusions. Tylenol and dilaudid with transient relief.Resp: Ls clear in upper lobes to dim at bases. Right ventricular chamber size and free wall motion are normal.4. Sternal dressing with small serosang drainage, occlusive. A left-to-right shunt across the interatrialseptum is seen at rest.2. The right internal jugular line tip is in the lower portion of SVC. The mitral valve leaflets arestructurally normal. There is blunting of both lateral CP angles, with bilateral effusions, small on the left, and moderate on the right. Sternal and mediastinal dressings CDI. The heart size and the mediastinal contours are normal. Nursing Progress NoteNeuro: Intact no defecits, hx of neuropathy.CVS: HR 90's sr, occasional self limited burst of afib to 120's stable pressure, . PA AND LATERAL CHEST: Comparison is made . pac's w few short bursts afib observed,much improved after elyte replacement.extubated to np's w/o incident,instructed in sternal splinting & is. No AR.MITRAL VALVE: Normal mitral valve leaflets. There are two left-sided chest tubes and one mediastinal drain inserted. FINDINGS: PA and lateral chest views were obtained with patient in upright position. Evaluate pleural effusion. On the frontal view only, there is parenchymal opacity overlying the right lower lung zone, probably due to atelectasis. Left ac iv dcd. Left-to-right shunt across the interatrial septum atrest.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%). TLC d/c. Minor areas of atelectasis are present in the lung bases adjacent to the effusions but otherwise clear lungs. Small bilateral pleural effusions are present, decreased on the right and minimally increased on the left since the recent chest radiograph. Left ace wrap intact. a line dc'd. Right effusion may be loculated. The patient appears to be in sinus rhythm. The left atrium is normal in size. The aortic valve leaflets (3) appear structurally normal with good leafletexcursion and no aortic regurgitation. Bilateral nipple shadows are noted. Aneurysmal interatrialseptum. The patient was under general anesthesia throughout theprocedure. Apatent foramen ovale is present. quiet but tolerating sips clears. PATIENT/TEST INFORMATION:Indication: Left ventricular function. See Conclusions for post-bypassdataConclusions:PRE-BYPASS:1. There is redemonstration of sternal wires and skin staples. A and V wires intact. Comparison is made with the next previous portable chest examination of . palp pedal pulses, skin warm dry pale and intact. TR appears slightly worse and is mild to moderate in severity4. transferred to chair with minimal assist of 2. The heart size is normal. Otherwise, the lungs are clear. CT to wall suction. 2 a and 2 v epicardial wires sense and pace appropriately, per prior shift. Prompt to CDB. Very anxious, calms when conversed with. Neo weaned to off, SBP remains > 100. IMPRESSION: Bilateral pleural effusions, decreased on the right but slightly increased on the left. Portable AP chest radiograph compared to the preoperative film from , . Overall, the volume of fluid is unchanged since study on . NSR with rare PAC's. Very drowsy with dilaudid and reglan. Sinus rhythmSeptal ST-T changes are nonspecificSince previous tracing of , no significant change Neo on then off again. There exist, however, bilateral plate atelectasis on the bases and the lateral pleural sinuses are blunted more marked than was detectable on the previous portable chest examination in supine position. Status post chest tube removal, evaluate for remaining pneumothorax. Sinus rhythmGeneralized low QRS voltagesNonspecific ST-T abnormalities in inferior leadsSince previous tracing of , inferior leads are more marked nausea, received reglan 10mg with relief. Nausea relieved with reglan 5 mg iv x 1. If this is of clinical concern, a right decubitus film could be obtained. Foley cath. The right effusion demonstrates different fluid levels on the frontal view, which could indicate loculation. Comparison is also made with the preoperative chest examination of demonstrating that neither pleural effusions nor the bilateral basal atelectases existed preoperatively. Significant pulmonic regurgitation is seen.8. ppi continues for hx hiatal hernia & gerd.husband in,questions answered. The interatrial septum is aneurysmal. CVP disconnected. Pt up in chair with minimal incisional pain. | 13 | [
{
"category": "Echo",
"chartdate": "2117-11-30 00:00:00.000",
"description": "Report",
"row_id": 74729,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Intra-op TEE for CABG\nHeight: (in) 62\nWeight (lb): 135\nBSA (m2): 1.62 m2\nStatus: Inpatient\nDate/Time: at 08:28\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. All four pulmonary veins identified and enter the\nleft atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Aneurysmal interatrial\nseptum. PFO is present. Left-to-right shunt across the interatrial septum at\nrest.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nNormal ascending aorta diameter. Focal calcifications in ascending aorta.\nNormal aortic arch diameter. Simple atheroma in aortic arch. Normal descending\naorta diameter. Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MS. Physiologic MR (within\nnormal limits).\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Significant PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient. See Conclusions for post-bypass\ndata\n\nConclusions:\nPRE-BYPASS:\n1. The left atrium is normal in size. The interatrial septum is aneurysmal. A\npatent foramen ovale is present. A left-to-right shunt across the interatrial\nseptum is seen at rest.\n2. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Regional left ventricular wall motion is normal.\n3. Right ventricular chamber size and free wall motion are normal.\n4. There are simple atheroma in the aortic arch. There are simple atheroma in\nthe descending thoracic aorta.\n5. The aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. 6. The mitral valve leaflets are\nstructurally normal. Physiologic mitral regurgitation is seen (within normal\nlimits).\n7. Significant pulmonic regurgitation is seen.\n8. There is a trivial/physiologic pericardial effusion.\n\nPOST-BYPASS: Pt is in sinus rhythm and on an infusion of phenylephrine\n1. Biventricular systolic function is preserved\n2. Aorta is intact post decannulation\n3. TR appears slightly worse and is mild to moderate in severity\n4. Other findings are unchanged\n\n\n"
},
{
"category": "ECG",
"chartdate": "2117-11-29 00:00:00.000",
"description": "Report",
"row_id": 167704,
"text": "Sinus rhythm\nSeptal ST-T changes are nonspecific\nSince previous tracing of , no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2117-11-30 00:00:00.000",
"description": "Report",
"row_id": 167705,
"text": "Sinus rhythm\nGeneralized low QRS voltages\nNonspecific ST-T abnormalities in inferior leads\nSince previous tracing of , inferior leads are more marked\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-12-01 00:00:00.000",
"description": "Report",
"row_id": 1265727,
"text": "Nursing Progress Note\nNeuro: Intact no defecits, hx of neuropathy.\n\nCVS: HR 90's sr, occasional self limited burst of afib to 120's stable pressure, . Neo weaned to off, SBP remains > 100. Rij multi lumen patent x 3 ports, CVP transduced . 2 a and 2 v epicardial wires sense and pace appropriately, per prior shift. A tested, V not tested due to HR. Sternal dressing with small serosang drainage, occlusive. Left ace wrap intact. palp pedal pulses, skin warm dry pale and intact. Chest tubes with scant serosang drainage.\n\nPain: C/o all over aches and pains, including ahoulders neck and back. Tylenol and dilaudid with transient relief.\n\nResp: Ls clear in upper lobes to dim at bases. Difficulty with cough and deep breathing r/t pain. IS to 500-750. Utilizing pillow. NC o2 at 4 l, mouthbreather but refuses mask or tent.\n\nGI: abd soft non tender, copious belching. Nausea relieved with reglan 5 mg iv x 1. Tolerating po meds and h20.\n\nGU: foley cath draining clear yellow urine > 30 cc hour.\n\nEndo: FS BS following insulin csru gtt scale, off at 0100 for bs 76.\n\nPlan: insulin change to sc and home nph when eating, pain control, pulmonary toileting, increase actiivty as tolerated. Transfer to 2 in am.\n\nSee carevue flowsheet and mars for further details and values.\n\n\n\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-12-01 00:00:00.000",
"description": "Report",
"row_id": 1265728,
"text": "Nursing Progress Note:\nAssumed care at 1100. Pt up in chair with minimal incisional pain. NSR with rare PAC's. BP 100/40's. TLC d/c. CT to wall suction. Minimal CT serosanguinous drainage. Started pt on nph. Gave 15u nph at noon. Foley cath. Good UO, Clear yellow, urine. Sternal and mediastinal dressings CDI. Pacer off. A and V wires intact. Will transfer to 2 at 1300.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-11-30 00:00:00.000",
"description": "Report",
"row_id": 1265725,
"text": "sbp dropping to 80's -90's esp. with movement,coughing with rising hct,low cvp & dark amber urine->add'l volume,increased neo & transient a pacing for bp support.occas. pac's w few short bursts afib observed,much improved after elyte replacement.extubated to np's w/o incident,instructed in sternal splinting & is. able to raise between 500 & 750 cc with coaxing.pain poorly controlled at first,lots morphine given with constant c/o back & shoulder pain when awake & stimulated but otherwise appeared overmedicated & would fall asleep instantly.not an nsaid candidate due to cri-baseline ~ 1.4-1.6. changed to dilaudid with improved relief & alertness. she states she has chronic back pain & usually treats with tylenol,position changes & aleve.tylenol resumed.glucoses in good control on protocol,see flow sheet. abd. quiet but tolerating sips clears. ppi continues for hx hiatal hernia & gerd.husband in,questions answered. encouraged to go home but plans to spend the night in the waiting room. icu visiting guidelines reviewed,will check in in a.m. to arrange visiting time with a.m. r.n.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-12-01 00:00:00.000",
"description": "Report",
"row_id": 1265726,
"text": "Nursing Progress Note\namiodarone bolus for more frequents burst of afib. Now 82 sr with very rare pac. Neo on then off again. a line dc'd. CVP disconnected. Left ac iv dcd. OOB to chair. nausea, received reglan 10mg with relief. Very drowsy with dilaudid and reglan. transferred to chair with minimal assist of 2. Very anxious, calms when conversed with. Prompt to CDB. Insulin gtt at 3, continue protocol.\n"
},
{
"category": "Radiology",
"chartdate": "2117-11-29 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 932737,
"text": " 5:33 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: ANGINA;CHEST PAIN\\CATH\n Admitting Diagnosis: ANGINA;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman with 3 v CAd, for Cabg.please do after 3 pm today\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, chf\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old woman with coronary artery disease, pre-operative for\n coronary artery bypass graft surgery.\n\n CHEST, PA AND LATERAL: There are no prior studies available for comparison.\n The heart size is normal. The mediastinal and hilar contours are\n unremarkable. There are no pleural effusions or pneumothorax. On the frontal\n view only, there is parenchymal opacity overlying the right lower lung zone,\n probably due to atelectasis. Otherwise, the lungs are clear. Bilateral\n nipple shadows are noted. The osseous structures are unremarkable.\n\n IMPRESSION: Opacity projecting over the right lower lung zone, probably\n discoid atelectasis.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-11-30 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 932844,
"text": " 11:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusion, pulmonary edema, pneumothorax, tamponade\n Admitting Diagnosis: ANGINA;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n pleural effusion, pulmonary edema, pneumothorax, tamponade\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup after CABG.\n\n Portable AP chest radiograph compared to the preoperative film from , . The ET tube tip is 4.6 cm above the carina. The right internal\n jugular line tip is in the lower portion of SVC. The NG tube tip is within\n the stomach. There are two left-sided chest tubes and one mediastinal drain\n inserted. The heart size and the mediastinal contours are normal. The lungs\n are clear except for small left lower retrocardiac atelectasis. There is no\n sizable pleural effusion. There is no pneumothorax.\n\n IMPRESSION: Stable post-surgery appearance of the chest.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-12-02 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 933199,
"text": " 2:26 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for pneumothorax s/p chest tube removal\n Admitting Diagnosis: ANGINA;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p cabgx4\n REASON FOR THIS EXAMINATION:\n evaluate for pneumothorax s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest PA and lateral.\n\n INDICATION: Status post quadruple bypass surgery. Status post chest tube\n removal, evaluate for remaining pneumothorax.\n\n FINDINGS: PA and lateral chest views were obtained with patient in upright\n position. Comparison is made with the next previous portable chest\n examination of . The patient has been extubated, mediastinal\n and lateral chest tubes have been removed and an NG tube has been withdrawn.\n There is no evidence of pneumothorax. There exist, however, bilateral plate\n atelectasis on the bases and the lateral pleural sinuses are blunted more\n marked than was detectable on the previous portable chest examination in\n supine position. Comparison is also made with the preoperative chest\n examination of demonstrating that neither pleural effusions\n nor the bilateral basal atelectases existed preoperatively. Consequently, it\n is suggested that the patient is followed up with further radiographs to\n document normalization of these changes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-12-04 00:00:00.000",
"description": "CHEST (LAT DECUB ONLY)",
"row_id": 933531,
"text": " 8:25 PM\n CHEST (LAT DECUB ONLY) Clip # \n Reason: evaluate ? loculated effusion noted on CXR please do t\n Admitting Diagnosis: ANGINA;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p CABG\n REASON FOR THIS EXAMINATION:\n evaluate ? loculated effusion noted on CXR please do this evening\n ______________________________________________________________________________\n FINAL REPORT\n CHEST LATERAL DECUB\n\n Two right lateral decubitus views are compared with the previous study done\n . These demonstrate that the previously noted right pleural effusion\n is at least partially free flowing.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-12-06 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 933692,
"text": " 10:54 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate effusion specifically right side\n Admitting Diagnosis: ANGINA;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p cabgx4\n\n REASON FOR THIS EXAMINATION:\n evaluate effusion specifically right side\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEWS CHEST X-RAY, \n\n COMPARISON: .\n\n INDICATION: Status post coronary bypass surgery. Evaluate pleural effusion.\n\n Small bilateral pleural effusions are present, decreased on the right and\n minimally increased on the left since the recent chest radiograph. Minor\n areas of atelectasis are present in the lung bases adjacent to the effusions\n but otherwise clear lungs. Cardiomediastinal contours are stable in the\n postoperative period.\n\n IMPRESSION: Bilateral pleural effusions, decreased on the right but slightly\n increased on the left.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2117-12-03 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 933390,
"text": " 7:02 PM\n CHEST (PA & LAT) Clip # \n Reason: evaluate plaeural effusions\n Admitting Diagnosis: ANGINA;CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old woman s/p cabgx4\n\n REASON FOR THIS EXAMINATION:\n evaluate plaeural effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Recent coronary artery bypass. Assess pleural effusions.\n\n PA AND LATERAL CHEST: Comparison is made . There is\n redemonstration of sternal wires and skin staples. Cardiac silhouette remains\n at the upper limits of normal in size. There is no evidence of worsening\n congestive heart failure. There is blunting of both lateral CP angles, with\n bilateral effusions, small on the left, and moderate on the right. The right\n effusion demonstrates different fluid levels on the frontal view, which could\n indicate loculation. Overall, the volume of fluid is unchanged since study on\n . There is no pneumothorax.\n\n IMPRESSION: No significant change in appearance. Right effusion may be\n loculated. If this is of clinical concern, a right decubitus film could be\n obtained.\n\n\n"
}
] |
5,866 | 122,438 | Patient underwent ex lap, LOA, ileostomy and MF takedown on without complications. She had post op hypotension and decreased urine output for which she was given fluid, her epidural was stopped and she was given a PCA, and she was given some pressors (Neo). HCT was stable. Central line was placed on POD1. She was tx from the PACU top the ICU for further observation. Neo was weaned down in ICU, she had fluid resuscitation, and her electorlytes were repleted as needed. She improved, passed flatus and she had her NGT removed and was tx to the floor on POD4. Her diet was advanced on the floor as tolerated - it she had to be slowed down because of nausea, her pain was well controlled, and she ambulated witht the help of PT and nursing staff. On POD7 foley was d/c'd. On POD8 she is in good condition for d/c to rehab. | PB's and sc heparin for DVT prophylaxis.Resp: LS clear, diminished at bases. Phos to be repleted.Endo: BS 87->89ID; afebrile; no abx coverageSkin: back/buttocks intact; abd incision with dsg intact; sm. Rule out pneumothorax. Dilaudid PCA 0.12mg Q6minutes with good effect.CV: HR 80-90's SR no ectopy noted. 10:05 PM ABDOMEN (SUPINE & ERECT) Clip # Reason: r/o ileus or obstruction. Noted waveform has positional respiratory variation.ENDOCRINE:Has not required coverage per sliding scale.FLUIDS:LR with KCl at 150mls/ hr. NGT to LCWS for scant bilious drainage. A left subclavian catheter terminates in the mid SVC. Rule out CHF. 4:29 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: still requires pressors. Some mild exp wheeze on exertion, resolved when settled. ?diuresis vs. fluid. Mildly tachypneic with anxiety, resps non labored after reassuance and talking down. NBP systolic 110-140's sytolic. These appearances are likely to represent post-operative ileus. To be reduced to 100mls/ hr.GI:Abd obese, bowel sounds present. REASON FOR THIS EXAMINATION: r/o ileus or obstruction. An NGT terminates in the stomach. to assess.CV: HR 70-80'sSR, BP 100-120's/40-50's. OOB as tolerated, PCA for pain ?resume pre op diuretics, cont to monitor and support, follow plan of care. There has been interval decrease in the width of the mediastinum. Benadryl given per order and pt's request. Re-orient prn. The heart size is at the upper limits of normal. 02 via prongs prn. Dr. in to assess pt. There has been interval improvement in the mediastinal contour. PCA off. No antibiotics.RENAL:Diuresed with HCTZ early in shift. Heart size top normal. LSC TLCL wnl. Pt attending to incentive spirometry with encouragement, and pulling 500mls.HEMODYNAMICALLY:SR no ectopy. (Discussed anxiety with pt's attending Dr , no further orders). c/o pain at 1 on scale 0-10, up to with activity. sersang. Primary dressing intact with no further drainage. Abd obease, incision dsg intact, protonix, ngt to LCWS with bilious drainage, npo.Skin/Mobility: Skin grossly intact. The lung volumes are again low. Cardiac silhouette is top normal size. The left subclavian central venous line tip is in the upper superior vena cava. SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: There are low lung volumes. A nasogastric tube tip is not visualized but descends below the diaphragm. Denies difficulty breathing when upright; anxious when HOB lowered for turning. NGT to suction with bilious output. Re-oriented. IMPRESSION: Interval improvement in the mediastinal contour likely related to clearing pulmonary edema. CXR attended. Will cont. IMPRESSION: AP chest compared to chest radiographs since , most recently : Lung volumes have been persistently low. BP stable 120-140 / 50-60s. Globally obese, some dependent edema also. IMPRESSION: AP chest compared to and , most recent prior chest radiographs: Lung volumes are appreciably lower on today's study, which may be due in part to subpulmonic pleural effusions and produces atelectasis at both lung bases. Little if any pleural effusion. Denies n/v. Followup examination at maximum inspiration is recommended for assessment. amt. At 1400 c/o SOB and wheezes treated with albuterol neb X1 with effect, chest x-ray done. Care attended. PCA dilaudid in use, pt using appropriately and it is providing good relief. Nasogastric tube passes to the distal stomach. Persistently low lung volumes. Nursing Progress Note.Please see CareVue for specifics.Pt condition stable overnight.NEURO:Pt sleeping well, wakes easily. 9:03 AM CHEST PORT. T-SICU NPN 1900-0700see carevue for specifics.ROS:Neuro: A+Ox3, MAE's,following commands consistently. Enc. The nasogastric tube tip is not visualized but is below the diaphragm. When asked if she remembered having surgery, pt stated "I don't want to remember". There is air distally within nondistended colon. NPO with frequent mouthcare attended by pt.ID:Afebrile. SINGLE PORTABLE AP CHEST RADIOGRAPH: Again seen is the left subclavian central venous catheter with its tip in the mid superior vena cava. There are low lung volumes with atelectatic opacities at the lung bases, more currently at the left base than was present in the prior chest x-ray 24 hours ago. Shortness of breath. IMPRESSION: Improvement in the widening of the mediastinum. pulmonary hygiene. Upper lungs clear. T/SICU RN Progress NoteNeuro: Alert and oriented X3, anxious at times with turning and moving, needs reassurance. CVP 8-12. Evaluate for obstruction. Sleeping well between interventions.RESP:Chest clear, cough minimally productive. please perform UPRIGHT END INSPIRATION CXR to eval lung volumes FINAL REPORT INDICATION: 64-year-old woman status post left subclavian line, hypotensive, follow up. LRw/20meq kcl @150cc/hr, p-boots, SQ heparin.Resp: Lungs clear on 3l n/c, IS encouraged cough/deep breathing. CVP 11-13 with 2 hours 18. Lines and tubes appropriately placed. Urine output remains >80 mls/hr.SKIN:Skin to back and heels intact, no breakdown. Equal hand grasps, pupils 3mm, equal and reactive, following commands. 10:00 AM CHEST PORT. IMPRESSION: Increasing opacity at the left base since . Approx. Pedal pulses palpable. 0530, pt removed BP cuff and o2sat probe, appeared confused; answering most questions "I don't know" or "I don't want to do this". FINDINGS: There are surgical clips along the left lateral abdomen and mid abdomen. Given 500ccLR bolus X1. No visitors overnight.PLAN:Consider active diuresis, recommencement of home meds.Out of bed to chair.Transfer to floor. Oriented. please perform UPRIGHT END INSPIRA Admitting Diagnosis: ILEOSTOMY CLOSE/SDA MEDICAL CONDITION: 64 year old woman s/p left subclavian central line placement for resucitation after elective ileostomy reversal REASON FOR THIS EXAMINATION: still requires pressors. | 9 | [
{
"category": "Nursing/other",
"chartdate": "2142-11-09 00:00:00.000",
"description": "Report",
"row_id": 1339052,
"text": "Nursing Progress Note.\nPlease see CareVue for specifics.\n\nPt condition stable overnight.\n\nNEURO:\nPt sleeping well, wakes easily. Oriented. Cooperative. Very anxious, escalates quickly, requiring reassurance, then apologising for snapping at staff. (Discussed anxiety with pt's attending Dr , no further orders). Initially denying she takes anxiolytic at home, then stated she takes benadryl for anxiety. Benadryl given per order and pt's request. She woke x1 occasion requesting more benadryl, for itch and to assist with sleep, but as it was too early for benadryl pt received phenergan with good effect. PCA dilaudid in use, pt using appropriately and it is providing good relief. Assisting staff with repositioning, but reluctant to turn on side despite education regarding importance of doing so. Sleeping well between interventions.\n\nRESP:\nChest clear, cough minimally productive. 02 via prongs prn. Some mild exp wheeze on exertion, resolved when settled. Mildly tachypneic with anxiety, resps non labored after reassuance and talking down. CXR attended. Pt attending to incentive spirometry with encouragement, and pulling 500mls.\n\nHEMODYNAMICALLY:\nSR no ectopy. BP stable 120-140 / 50-60s. Globally obese, some dependent edema also. CVP 11-13 with 2 hours 18. Noted waveform has positional respiratory variation.\n\nENDOCRINE:\nHas not required coverage per sliding scale.\n\nFLUIDS:\nLR with KCl at 150mls/ hr. To be reduced to 100mls/ hr.\n\nGI:\nAbd obese, bowel sounds present. NGT to suction with bilious output. Primary dressing intact with no further drainage. NPO with frequent mouthcare attended by pt.\n\nID:\nAfebrile. No antibiotics.\n\nRENAL:\nDiuresed with HCTZ early in shift. Urine output remains >80 mls/hr.\n\nSKIN:\nSkin to back and heels intact, no breakdown. Care attended. Pt rotated but initially declined to sleep on side despite education. Assisting staff to turn herself over.\n\nSOCIAL:\nDaughter called and spoke to pt. No visitors overnight.\n\nPLAN:\nConsider active diuresis, recommencement of home meds.\nOut of bed to chair.\nTransfer to floor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-11-08 00:00:00.000",
"description": "Report",
"row_id": 1339050,
"text": "T-SICU NPN 1900-0700\nsee carevue for specifics.\nROS:\nNeuro: A+Ox3, MAE's,following commands consistently. c/o pain at 1 on scale 0-10, up to with activity. Approx. 0530, pt removed BP cuff and o2sat probe, appeared confused; answering most questions \"I don't know\" or \"I don't want to do this\". Dr. in to assess pt. PCA off. Equal hand grasps, pupils 3mm, equal and reactive, following commands. Re-oriented. When asked if she remembered having surgery, pt stated \"I don't want to remember\". Will cont. to assess.\nCV: HR 70-80'sSR, BP 100-120's/40-50's. CVP 8-12. Skin warm, dry. Pedal pulses palpable. LSC TLCL wnl. PB's and sc heparin for DVT prophylaxis.\nResp: LS clear, diminished at bases. Denies difficulty breathing when upright; anxious when HOB lowered for turning. RR teens-20's, O2sats 96% on 3lnc.\nGI; abd obese, BS present, no stool/flatus. Denies n/v. NGT to LCWS for scant bilious drainage. Protonix for GI prophylaxis.\nGU: foley patent draining marginal amber urine 10-20cc/hr, 500cc LR bolus x2. Phos to be repleted.\nEndo: BS 87->89\nID; afebrile; no abx coverage\nSkin: back/buttocks intact; abd incision with dsg intact; sm. amt. sersang. drainage, outlined, no adavancement noted.\nPsych/social: pt called and spoke with her daughter via phone upon arrival to ICU; no further contact . pt, information may be shared with her daughter who is her contact person; NO INFORMATION is to be given to daughter per pt's request.\nA: s/p closure of ileostomy, LOA\nmarginal uo; increased confusion this am\nP: Monitor VS, I/O, labs, mental status. Re-orient prn. Enc. pulmonary hygiene. Await further orders from team. ?diuresis vs. fluid. Continue ongoing comfort/support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2142-11-08 00:00:00.000",
"description": "Report",
"row_id": 1339051,
"text": "T/SICU RN Progress Note\nNeuro: Alert and oriented X3, anxious at times with turning and moving, needs reassurance. Dilaudid PCA 0.12mg Q6minutes with good effect.\n\nCV: HR 80-90's SR no ectopy noted. NBP systolic 110-140's sytolic. CVP 4-8 throughout day. LRw/20meq kcl @150cc/hr, p-boots, SQ heparin.\n\nResp: Lungs clear on 3l n/c, IS encouraged cough/deep breathing. Strong congested cough. At 1400 c/o SOB and wheezes treated with albuterol neb X1 with effect, chest x-ray done. RR 12-20 with Sats 97-100%.\n\nGU/GI: Foley with marginal urine output 15-30cc/hr amber urine. Given 500ccLR bolus X1. Abd obease, incision dsg intact, protonix, ngt to LCWS with bilious drainage, npo.\n\nSkin/Mobility: Skin grossly intact. OOB to chair X3 hrs today, with min. assist tolerated well.\n\nSocial: Daughter in to visit, sister called on phone.\n\nPlan: Monitor fluid status, resp status, cont with aggressive pulmonary hygeine. OOB as tolerated, PCA for pain ?resume pre op diuretics, cont to monitor and support, follow plan of care.\n"
},
{
"category": "Radiology",
"chartdate": "2142-11-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 883258,
"text": " 5:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o failure\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p ileostomy reversal\n REASON FOR THIS EXAMINATION:\n r/o failure\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:54 A.M., \n\n HISTORY: Ileostomy reversal. Shortness of breath. Rule out CHF.\n\n IMPRESSION: AP chest compared to chest radiographs since , most\n recently :\n\n Lung volumes have been persistently low. Progressive opacification at the\n left lung base could be pneumonia but is more likely atelectasis, more severe\n than longstanding right lower lobe atelectasis or scarring. Upper lungs\n clear. Heart size top normal. Little if any pleural effusion. No\n pneumothorax. Nasogastric tube passes to the distal stomach.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-11-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 883212,
"text": " 3:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o failure\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p ileostomy reversal with new onset wheezing\n REASON FOR THIS EXAMINATION:\n r/o failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent abdominal surgery with wheezing.\n\n There are low lung volumes with atelectatic opacities at the lung bases, more\n currently at the left base than was present in the prior chest x-ray 24 hours\n ago. An NGT terminates in the stomach. A left subclavian catheter terminates\n in the mid SVC.\n\n IMPRESSION: Increasing opacity at the left base since .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-11-10 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 883433,
"text": " 10:05 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: r/o ileus or obstruction.\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p ileostomy closure, POD 5, now with nausea.\n REASON FOR THIS EXAMINATION:\n r/o ileus or obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMINAL X-RAY (SUPINE AND LEFT LATERAL DECUBITUS)\n\n CLINICAL DETAILS: Day 5 post-ileostomy closure. Evaluate for obstruction.\n\n FINDINGS: There are surgical clips along the left lateral abdomen and mid\n abdomen.\n\n There are a number of mildly dilated loops of small bowel noted in mid abdomen\n which measure up to 4 cm in diameter. No wall thickening. There is air\n distally within nondistended colon. These appearances are likely to represent\n post-operative ileus.\n\n No evidence of free intra-abdominal air on the lateral decubitus film.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-11-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 882997,
"text": " 9:03 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check line position and rule out pneumothorax\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p left subclavian central line placement\n REASON FOR THIS EXAMINATION:\n check line position and rule out pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:27 A.M. ON \n\n HISTORY: Left subclavian central venous line placement. Rule out\n pneumothorax.\n\n IMPRESSION: AP chest compared to and , most recent prior\n chest radiographs:\n\n Lung volumes are appreciably lower on today's study, which may be due in part\n to subpulmonic pleural effusions and produces atelectasis at both lung bases.\n It also may account for widening of the mediastinum though alternatively this\n may be due to vascular engorgement, adenopathy, or given the insertion of a\n left-sided central venous line whose tip projects over the SVC, mediastinal\n hematoma. Followup examination at maximum inspiration is recommended for\n assessment.\n\n Cardiac silhouette is top normal size. There is no pneumothorax.\n\n Dr. was paged to discuss these findings.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-11-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 883065,
"text": " 4:29 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: still requires pressors. please perform UPRIGHT END INSPIRA\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p left subclavian central line placement for resucitation\n after elective ileostomy reversal\n REASON FOR THIS EXAMINATION:\n still requires pressors. please perform UPRIGHT END INSPIRATION CXR to eval\n lung volumes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old woman status post left subclavian line, hypotensive,\n follow up.\n\n COMPARISON: Chest x-ray from 10:16 the same day.\n\n SINGLE PORTABLE AP CHEST RADIOGRAPH: Again seen is the left subclavian\n central venous catheter with its tip in the mid superior vena cava. A\n nasogastric tube tip is not visualized but descends below the diaphragm. There\n is no pneumothorax. The lung volumes are again low. There has been interval\n decrease in the width of the mediastinum. There is no evidence of congestive\n heart failure.\n\n IMPRESSION: Interval improvement in the mediastinal contour likely related\n to clearing pulmonary edema. Persistently low lung volumes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2142-11-07 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 883000,
"text": " 10:00 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: repeat CXR after left subclavian central line placement, poo\n Admitting Diagnosis: ILEOSTOMY CLOSE/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p left subclavian central line placement for resucitation\n after elective ileostomy reversal\n REASON FOR THIS EXAMINATION:\n repeat CXR after left subclavian central line placement, poor inspiratory\n effort and distortion of mediastinal anatomy on prior film\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old woman status post left subclavian line placement,\n mediastinal contour abnormality seen on prior chest x-ray.\n\n COMPARISON: Chest x-ray from at 9:27 a.m.\n\n SINGLE PORTABLE AP UPRIGHT CHEST RADIOGRAPH: There are low lung volumes.\n There has been interval improvement in the mediastinal contour. There is no\n pneumothorax. The left subclavian central venous line tip is in the upper\n superior vena cava. The nasogastric tube tip is not visualized but is below\n the diaphragm. The heart size is at the upper limits of normal.\n\n IMPRESSION: Improvement in the widening of the mediastinum. Lines and tubes\n appropriately placed. No pneumothorax.\n\n"
}
] |
6,081 | 179,050 | Admitted to hospital, on cardiac surgery service. Heart failure service consulted, recommended diuresis pre-operatively. He was subsequently started on a Lasix drip. Hepatology also consulted, recommending preoperative ultrasound and abdominal CT scan. The RUQ ultrasound showed normal portal venous flow and two small gallbladder polyps. The abdominal scan was essentially unremarkable - there was no focal liver lesions, with only a small amount of perihepatic ascites. He otherwise remained stable on medical therapy and was eventually cleared for surgery. On , Dr. performed four vessel coronary artery bypass grafting utilizing the left internal mammary artery to the diagonal branch of left anterior descending artery, saphenous vein graft to the distal left anterior descending artery, saphenous vein graft to the obtuse marginal branch of the circumflex, saphenous vein graft to the posterior descending coronary artery. Postoperative echo was notable for a LVEF of 20% with no mitral regurgitation or aortic insufficiency. After the operation, he was brought to the CSRU. Within 24 hours, chest tubes were removed and he was extubated. He was slow to wean from inotropic support and initially required AV pacing for junctional rhythm. Beta blockade was initially withheld. The EP service was consulted to evaluate for permanent pacemaker plus/minus AICD(given his severely depressed LV function). He concomitantly experienced aphonia. Bedside swallow examination showed bilateral vocal cord paralysis, diffuse pharyngeal weakness and silent aspiration. He was subsequently made NPO and started on tube feedings. Over several days, his native heart rate improved to the 80's. Epicardial wires were eventually removed without complication. He otherwise remained stable on medical therapy. It was decided that a pacemaker was not indicated at this time but the need for an AICD will need to be assessed three months postoperatively. On postoperative day five, he transferred to the Step Down Unit. He continued to require diuresis and remained stable from a cardiac and liver standpoint. Beta blockade was not resumed. Over several days, he made clinical improvements as he worked daily with physical therapy. At discharge, his oxygen saturations were 99% on room air. His aphonia gradually improved. Repeat bedside swallow examination showed no signs of aspiration with pureed diet. Aspiration was however noted with thin liquids. Videofluroscopic evaluation on confirmed aspiration but functional swallow was achieved with pureed/ground solids and honey thick liquids. Medications were subsequently crushed in puree and repeat videoswallow was recommended in one week to evaluate for diet advancement. By discharge, he was tolerating solids without difficulty. He was eventually cleared for discharge on postoperative day five. He will follow up in , RI on and again in two weeks. | Tolerated well.Endo: cont on reg ins gtt at 1unit/hr with FS q 2 hrs stable at 100-120.Skin; coccyx reddened, enc to lie on sides.Heme: recieved 1 u prbc today. PT S/P CABG X4-PT WITH LOW EF, CAME OFF PUMP WITH EPI. ASSESSMENT IS AS FOLLOWS:NEURO: REVERSALS GIVEN AND PROP WEANED, PT SLOW TO WAKE. PT INTERMITTENTLY DIAPHORETIC. NGT placed by fluro into jejunum succ right nare. Slept at intervals.CVS; Hemodynamically stable on IV Neo at 0.3mcg/kg/min, attempted wean to 0.2mcg/kg/min with MAP<60. ccu npn 7p-7aS:"I'm doing ok."O: Please see carevue for VS and objective dataCVS: Hemodynamically stable with HR 70-80's NSR, rare PVC noted. NO BS.GU: UOP INITIALLY GOOD NOW TAPERING OFF. scattered rhonchi, improved with TCDB and IS. CO INTIALLY LOW BUT RESPONDED TO IVF NOW CI>3. cont IS, enc cough and DB. Leg inc D&I, approximated. c/o incision discomfort and received percocett with good relief of pain.CV-VSS off pressors x 24hrs SBP 120-140's, HR 72-88 NSR with epicardial A rate decreased to 60. PT WITH RARE MULITFOCAL PVC DESPITE LYTES WNL. Mediast/sternal dressing intact, left leg ace wrap D/I.A: hemodynamically stable s/p cabg, tolerating A pacing with underlying conduction disturbance.P: Cont to monitor rhythm/ a pacing, hemodynamics, wean Neo as tolerated. Lungs clear with diminished bases, occ. PT WITH LG FLUID REQUIREMENT (LR 3.5L AND ALBUMIN X2 WITH LOW RT SIDE FILLING PRESSURES) INCREASE PRESSOR REQUIRMENT. CCU Progress Note:O- see flowsheet for all objective data.resp- In O2 4L via NC- lung sounds coarse & diminished @ the bases- cough weak but con't to expectorate tan colored mucous- resp status much better tonight- RR 22-24- SpO2 94-100%.cv- Tele: SR no ectopy- HR 70-74- no paced beats noted- R radial Aline with ABP 108-120/48-55- MAPs 67-73- sternal incision dry & intact- open to air- mediastinal dsg D&I- L leg incision line with steri strips intact & lower incision with bandaid dsg D&I- no c/o pain tonight- Hct yest 25.4- 1u PRBC's given.neuro- comfortable night- sleeping well- A&O X2- moving all extremities- cooperative- follows command.gi- abd soft (+) bowel sounds- FT removed after CXR read by HO- NPO- ? OOB to commode with assist of RN, MAE, transfers easily with minimal assist.A; Hemodynamically stable POD#5,P: Cont to monitor hemodynamics, rhythm, may remove epicardial wires in am. "O: Please see carevue for VS and objective data.Neuro: Pt. BP ranges 96-120/50-70 via non-invasive cuff.Resp; Sats 93-99% on 4L n/c. +BS no BM post op.Skin-intact, Sternal incision dressing off open to air, staples intact. SM STAINING ON STERNAL INCISION AND CT SITE.RESP: SLOW TO WEAN VENT. c/o incisional pain but refusing pain medication.CV-VSS gradual wean off Neo by 1430 with SBP 120-130. ARRVIED CSRU ON PROP/NEO/EPI. c/o minimal incisional discomfort, refusing pain medication.CV-VSS SBP 124-145 with HR 78-88 NSR. extubationextubated with rt per . cont plan per pt care rounds. EXTUBATE WHE APPROPRIATE. Right groin CDI, mediast/sternal dsgs spotted drainage, but intact. CCU Nursing Progress NoteS-"My throat still hurts"O-Neuro alert and oriented x2-3, quiet with minimal conversation. 2) Multiple lines and tubes removed; trace residual left apical pneumothorax. Bilateral loculated pleural effusions are noted. CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is a moderate loculated pleural effusion in the right hemithorax. Congestive failure and bilateral pleural effusions. There is flattening of the diaphragms, and retrosternal clear space opacity consistent with underlying chronic emphysematous changes. 2) Loculated small right pleural effusion, with small left pleural effusion. 2) Small residual right pleural effusion. There may be a previous inferiorwall myocardial infarction and possibly anteroseptal myocardial infarction.Diffuse ST-T wave abnormalities are noted. Lossof R waves suggests old anterior myocardial infarction. IMPRESSION: 1) Tiny left apical pneumothorax. Probable old inferior wall myocardial infarction. The aorta appears slightly tortuous. InferolateralST-T wave abnormalities suggestive of myocardial ischemia. There is blunting of the right costophrenic angle, consistent with pleural effusion. There is a tiny left apical pneumothorax remaining. IMPRESSION: 1) Slight worsening of pulmonary edema and bilateral pleural effusions. AP SUPINE CHEST: Compared to PA and lateral chest of . There is a compression deformity in the mid-thoracic spine. A small amount of perihepatic ascites is noted. IMPRESSION: Bilateral pleural effusions. There has been near resolution of the moderately sized right pleural effusion with just a small residual effusion remaining. Sternal wire sutures and mediastinal clips are noted. FINAL REPORT TYPE OF EXAMINATION: Chest AP portable single view. The Dobbhoff tube was not present on the previous preceding examination and now identified to terminate in the lower esophagus, but not reaching the stomach. Small amount of perihepatic ascites. IMPRESSION: Difficulty with oropharyngeal bolus handling, including residue in the valleculae and piriform sinuses. From a recent fluoroscopic examination, the patient is known to have incomplete closure of the vocal cords. There is associated partial compression atelectasis of the left lower lobe and the lingula.the right pleural effusion may be slightly larger at this time. CT OF THE PELVIS WITH IV CONTRAST: Distal ureters and bladder are within normal limits. Multiple left-sided chest tubes and mediastinal tube seen. The endotracheal tube, Swan-Ganz catheter, multiple chest tubes, and NG line have been removed. Assess effusions. Wedge compression deformity in the mid-thoracic spine. There is calcification of the aortic arch. IMPRESSION: 1) Multiple lines and tubes in satisfactory position; no pneumothorax. No definite new consolidation is visualized; however, there is some retrocardiac patchiness, which could be atelectasis or pneumonia. Compared to theprevious tracing of above noted abnormalities persist. 2) Slight interval increase in right-sided pleural effusion. Although he showed adequate elevation of the larynx and palate, there was a lack of epiglottic deflection, and mild to moderate residue in the valleculae, and to a lesser extent, the piriform sinuses. There is flattening of the diaphragms, and increased in the retrosternal clear space, consistent with underlying chronic emphysematous change. 2:42 PM LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # Reason: eval. | 30 | [
{
"category": "Nursing/other",
"chartdate": "2186-07-18 00:00:00.000",
"description": "Report",
"row_id": 1342103,
"text": "Nursing Note\nCVS: a paced at 88, a wires sense and capture, unable to test V wires, SBP to 70's when not paced. Underlying rythym was sinus to sinus brady with freq PVC'S. Pacing continued for better pressures and wean of vasoactive drugs. Currently off neo, remains on epi at 0.015. Map goal > 60. Received 1 unit PRBC's no S/S of reaction, crit was 25.9 cvp and filling pressures were dipping. (please see carevue flowsheet for specific details and values) Pulses by doppler, feet cooler than hands, + diabetic PVD.\n\nRESP: remains ett and vent due to rising Co2s with weaning, ?due to smoking hx. Plan to wean to at 430 am then extubate if continues alert and participatory in care. Lungs clear to diminished, sxn for copious thick yellow to bloody brown tinge secretions x 1. + strong cough. Chest tube to sxn, no leak, no crepitus.\n\nNEURO: arrouses to voice, focus, follows all commands. Attempting to mouth words over ett. bilateral soft wrist restraints for safety of lines tubes and drains.\n\nGI: continues without BS. OGT in place for meds, draining bright green bilious when not clamped for meds.\n\nGU: UOP adequate, conc amber urine clearing after blood and fluid. Foley patent.\n\nSkin: stage I breakdown of coccyx, red non-blanchable. Dressings CDI.\n\nEndo: insulin drip continues FS 63-109. requiring q 1 hour blood sugars and titration.\n\nIV's: right IJ thermo swan, DSG intact changed last eve. Right groin CDI, mediast/sternal dsgs spotted drainage, but intact. L leg ace wrap intact.\n\nSocial: lives in RI with wife who is staying in family room, she has no ride back to RI right now.\n\nPlan: wean and extubate, increase activity, pressure off coccyx, wean vasoactive drugs. Pain control, pulmo toilet after extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-18 00:00:00.000",
"description": "Report",
"row_id": 1342104,
"text": "extubation\nextubated with rt per . Face tent 50%, sats 96 rr 28. Able to speak in hoarse voice, deep breathing, coughing. cough pillow provided. Denies SOB or discomfort. Expectorated large amount of loose clear/yellow secretions post extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-18 00:00:00.000",
"description": "Report",
"row_id": 1342105,
"text": "CV: at 80 with no VEA noted, A wires sense and capture, unable to check either A or V wires as pt IMMEDIATELY drops SBP to 90's and HR to 40's; SBP 110's with MAP >60; Neo gtt cont at 0.5mcg/kg/min; CO >4.9 and CI >2, Swan pulled but cordis kept; Rfem A-line pulled but pt still has RRad A-line; pt currently receiving PCs for HCT 26.1\n\nResp: Cont to sat high 90's-100% on 5L NC since extubation at 0500; LS dim throughout\n\nNeuro: Pt oriented to person and place, unsure of year and month->reorients easily; MAE; PERLA;\n\nGI/GU: Abd soft but absent BS at this time, states feels hungry; adequate clear yellow HUO per foley catheter to gravity\n\nEndo: Pt has IDDM, cont on Ins gtt at 1unit/h with hourly BS running 80's-100's with rare 110's\n\nID: Afebrile, cont ABX\n\nSkin: Coccyx with Stage 1 pressure sore->red but unchanged\n\nPlan: EP for cardiac rhythm, wean neo as tolerated, increase activity as tolerated, transfer to CCU\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-18 00:00:00.000",
"description": "Report",
"row_id": 1342106,
"text": "Addendum: Swan to stay in until PC infused, will attempt additional PIV before transfer\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-20 00:00:00.000",
"description": "Report",
"row_id": 1342111,
"text": "CCU Progress Note:\n\nS- \" I can't cough!\"\n\nO- see flowsheet for all objective data.\n\nresp- Increased RR with congestion noted last evening-SpO2 dropped- encouraged to C&DB however said he couldn't cough- lasix & morphine given- Pt deep suctioned for large amt tan colored mucous- RT called- resp Rx given- IS done- O2 increased to 6L via NC- SpO2 now 95-97%- need much encouragement to C&DB- OOB in chair @ 4am- lung sounds coarse, diminished @ the bases with scattered rhonchi.\n\ncv- Tele: SR- A paced rhythm noted during the night- no ectopy- temp pacer attached to epicardial wires- rate @ 70 Ma 18- chest & L leg dsg D&I- R radial A line with ABP 113-144/51-64 off pressors- MAPs 69-87-\nHct 25.4- K 5- Mg 2.7\n\nneuro- A&O X2- moving all extremities- amb with 2 assist well- cooperative- follows command.\n\ngi- abd soft hypoactive bowel sounds- impaired gag ? if Pt can tolerate PO- no BM.\n\ngu- foley draining amber colored urine in small amts- lasix dose increased to 20mg IV TID- BUN 55 Crea 1.4\n\nA- S/P CABG post-op day 3- hemodynamically stable off pressors but con't to require pacer support.\n\nP- aggressive pulmonary toileting- C&DB with IS Q1 while awake- suction PRN- med for comfort- increase activity- ? swallow study- transfuse today-( Hct low & BUN/Crea climbing)- offer emotional support to Pt & family- keep them updated on plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-20 00:00:00.000",
"description": "Report",
"row_id": 1342112,
"text": "CCU Nursing Progress Note\nS-\"I can't speak any louder.\"\nO-Neuro alert and oriented x2-3, cooperative but quiet. Voice is still whisper soft, Speech and Swallow Consult revealed vocal cords not closing completely to protect airway with moderate aspiration via video procedure at bedside. c/o incision discomfort and received percocett with good relief of pain.\nCV-VSS off pressors x 24hrs SBP 120-140's, HR 72-88 NSR with epicardial A rate decreased to 60. No signs of bradycardia or junctional rhythm.\nResp-LS diminished at bases with occ coarse upper airway from secretions. COntinues to cough but voice is wet most of the time.\nO2 sats occ dropping to 88% on 4lNP but after IS/deep breathing exercises O2 sat increase back to 93-96% on 4lnp. IS q1-2hrs but only generating 200-250cc.\nID afebrile\nGU-foley draining 30-40cc/hr fair response to lasix 20mg IVB at 9am.\nGI-Pt had eaten breakfast oatmeal with nectar juice well with minimal coughing. After video study pt made NPO, MD placed feeding tube right nare without difficulty. Awaiting xray for placement confirment. Hypoactive BS no BM.\nSkin-coccyx less reddened, pt trying to change position himself. All surgical dressing intact with ace on left leg.\nActivity-physical therapy into see pt and walked pt in the hallway 100feet and tolerated very well. Sat in chair for 3 hours and did well. No c/o fatigue or SOB.\nSocial-wife with pt all day. Case manager to follow up on pt no insurance issue.\nA/P-s/p CABG post op day#3 with food/fluid aspiration from failure of vocal cord closure.\n*NPO\nFollow up with xray and start tube feeds.\nEncourage pt to get OOB, walk and do ADL's.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-20 00:00:00.000",
"description": "Report",
"row_id": 1342113,
"text": "NPN \nCV: HR 70-80 NSR, no paced rhythm. A and V epicardial wires still in place, Atrial rate set to 60. Atrial wire tested sensing and capturing appropriately. States incisional pain is less today, , tolerable, stating that he recieve pain pill earlier, did not want medication again yet. Later in eve, sat on side of bed, requested pain med, given 1mg IV Morphine with good effect.\n\nSkin: dressings to chest and leg removed. Chest inc approximated without drainage. left open to air. Old CT sites open, sm amt serosang drainage, covered with DSD. Leg inc D&I, approximated. Ace removed.\n\nResp: LS coarse, congested cough, encouraging pt to cough, deep breath and use IS. Pt using yankar. Sats have remained mid 90's on 4L NC. No episodes desaturation.\n\nGI: NPO, doboff tube not advancing, coiling in esophagus after 2 attempts, team will try again in AM. NPO as pt is high aspiration risk. No stool this eve.\n\nNeuro: A&Ox2, c/o being very fatigued this eve. Sat on side of bed for awhile, but sleeping most of time.\n\nID: afebrile.\n\nSkin: coccyx reddened, not open.\n\nA/P: 3 days post CABG, pt needs feeding tube, npo for swallowing difficulty, mod asp on swallow study. Cont monitor for dysrhythmia's, epicardial wires attached to pacer box. Cont pul toilet, enc increased activity. Support and inform pt/wife.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-21 00:00:00.000",
"description": "Report",
"row_id": 1342114,
"text": "CCU Progress Note:\n\nO- see flowsheet for all objective data.\n\nresp- In O2 4L via NC- lung sounds coarse & diminished @ the bases- cough weak but con't to expectorate tan colored mucous- resp status much better tonight- RR 22-24- SpO2 94-100%.\n\ncv- Tele: SR no ectopy- HR 70-74- no paced beats noted- R radial Aline with ABP 108-120/48-55- MAPs 67-73- sternal incision dry & intact- open to air- mediastinal dsg D&I- L leg incision line with steri strips intact & lower incision with bandaid dsg D&I- no c/o pain tonight- Hct yest 25.4- 1u PRBC's given.\n\nneuro- comfortable night- sleeping well- A&O X2- moving all extremities- cooperative- follows command.\n\ngi- abd soft (+) bowel sounds- FT removed after CXR read by HO- NPO- ? reinsert FT in IR today to assure proper placement- No BM this shift.\n\ngu- foley draining yellow colored urine qs- U/O >30cc/hr- (-) 100cc since 12am- (+) 4500cc LOS- BUN & Crea trending up- AM labs pending.\n\nA- S/P CABG day #4- improving resp status tonight- hemodynamically stable off pressors- failed swallow study- NPO ? reinsert FT today.\n\nP- monitor vs, lung sounds, I&O and labs- keep NPO until FT placed- con't aggressive pulmonary toileting- increase activity- offer emotional support to Pt & family- keep them updated on plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-17 00:00:00.000",
"description": "Report",
"row_id": 1342102,
"text": "PT S/P CABG X4-PT WITH LOW EF, CAME OFF PUMP WITH EPI. ARRVIED CSRU ON PROP/NEO/EPI. NO UNDERLYING RHYTHM INITIALLY IN OR, ARRIVED AV PACED--PT SB UNDERLYING WHEN ARRIVED. PT WITH LG FLUID REQUIREMENT (LR 3.5L AND ALBUMIN X2 WITH LOW RT SIDE FILLING PRESSURES) INCREASE PRESSOR REQUIRMENT. SLOW TO WAKE. ASSESSMENT IS AS FOLLOWS:\nNEURO: REVERSALS GIVEN AND PROP WEANED, PT SLOW TO WAKE. OPENS EYES AND FOLLOWS COMMANDS BUT FALLS ASLEEP EASILY. PERRLA. NO DEFICITIS NOTED\nCV: PT AT 88---UNDERLYING SB/JUNCTIONAL WITH PAC'S. PT WITH RARE MULITFOCAL PVC DESPITE LYTES WNL. PT WITH ST DEPRESSION ON MONITOR OUT OF OR, AWARE, NO TX ORDERED. BP LABILE, REQUIRING FLUID AND INCREASE PRESSOR REQUIRMENT. CURRENTLY NEO 1.1MCG/ EPI .02MCG. CVP 2-8 PAD 15-20. HCT 28. CO INTIALLY LOW BUT RESPONDED TO IVF NOW CI>3. CT OUPTUT MINIMAL. DOPPLERABLE PEDAL PULSES. PT INTERMITTENTLY DIAPHORETIC. LT FEM DSG SATURATED WITH SANG DRNG IN PM, CHANGED. SM STAINING ON STERNAL INCISION AND CT SITE.\nRESP: SLOW TO WEAN VENT. CHANGED TO CPAP AT 15 PS THIS PM WHEN ATTEMPT WEAN PCO2 IN 50'S, RESTED BACK ON PS 15. NOW ATTEMPTING SLOW WEAN. LUNGS CLEAR. SX FOR SCANT WHITE. OXYGENATION EXCELLENT ON FIO2 40%.\nGI: OGT TO LCWS-> BILIOUS DRNG. , PLACEMENT CONFIRMED BY AUSCULTATION. ABD SOFT. NO BS.\nGU: UOP INITIALLY GOOD NOW TAPERING OFF. TEAM AWARE. FOLEY PATENT.\nENDO: INITIALY BS 50'S, TX 1/4 AMP D50. INSULIN GTT STARTED THIS PM AND TITRATED UP PER PROTOCOL. SEE FLOWSHEET\nSOCIAL: PT WIFE PLEASANT, UPDATED ON CARE. WIFE STAYING IN HOSPITAL OVERNIGHT IN CC6 WAITING AREA\nSKIN: PT COCCYX WITH STAGE 1 PRESSURE AREA OUT OF OR, PINK AND UNBLANCHABLE. PT TURN SIDE TO SIDE. PT C/O PAIN IN AREA.\nPLAN: WEAN VENT. EXTUBATE WHE APPROPRIATE. CONT ASSESS HEMODYANMICS. WEAN PRESSORS AS TOL. CONT ASSESS UNDERLYING RHYTHM. CONT Q1HR BS WHILE ON GTT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-18 00:00:00.000",
"description": "Report",
"row_id": 1342107,
"text": "NPN \n61 yr old s/p 4 vessel transferred from CSRU earlier today.\n\nCV: HR 80 a-paced via epicardial wire. Atrial stimulation threshold 6, mA set at 10. Pacing consistantly, underlying rate ~50. BP 100-120/50, Neo decreased to .3mcg/kg/min. Dressing to chest and L leg ace bandage D&I.\n\nPain: incisional pain, level , give 2mg Morphine with good effect, gag still impaired, coughing with sips water, so unable to take po meds. Using cough pillow effectively.\n\nResp: cough productive of thick tan sputum. LS dim with scattered rhonchi. CT pulled earlier today.\n\nID: T 99 cont on, IV vanco for 4 doses.\n\nNeuro: alert, oriented, no voice, feeling weak. Did dangle for ~15min this eve. Tolerated well.\n\nEndo: cont on reg ins gtt at 1unit/hr with FS q 2 hrs stable at 100-120.\n\nSkin; coccyx reddened, enc to lie on sides.\n\nHeme: recieved 1 u prbc today. Order to check labs in AM.\n\nSoc; wife at bedside, has been staying in the hospital.\n\nA/P: s/p CABG, remains on low level of Neo, attempt to wean off, a-paced with intrinsic rate still low. need pacer/ICD, followed by EP. Cont to med for pain prn, increase act, OOB to chair tomorrow. cont IS, enc cough and DB. support pt/wife. cont plan per pt care rounds.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-19 00:00:00.000",
"description": "Report",
"row_id": 1342108,
"text": "ccu npn 11p-7a border\nS:\"I'm in Hospital, its .\"\n\nO: Please see carevue for VS and objective data.\n\nNeuro: Pt. A/A/Ox3, pleasant and cooperative, appreciative of care. MAE, PERLA. c/o incisional pain with turning, given 2mg IV Morphine x1 with good effect. Slept at intervals.\n\nCVS; Hemodynamically stable on IV Neo at 0.3mcg/kg/min, attempted wean to 0.2mcg/kg/min with MAP<60. MAP>60 on IV Neo at 0.3. BP ranges via right radial aline. HR 80's 100%, prolonged PR interval 0.28-.30. A/V epicardial wires intact with A wire settings stim. threshold 9, MA 18. /capturing appropriately. Increased and tested previous shift at 2200. MD aware. V wires remain off. No vea noted. Am Hct 27.0 s/p 2 units .\n\nResp; Sats 93-100% on 4L n/c. RR mid to high 20's. Lungs clear with diminished bases, occ. scattered rhonchi, improved with TCDB and IS. Pt. able to raise thick, yellow sputum with yankauer.\n\nGI:GU: Impaired gag, weak cough. No po's given this shift. Abdomen soft with hypoactive bowel sounds. Foley to drainage with clear, amber urine u/o 30-40cc/hour. Total I/O 600cc + at MN.\n\nEndo; Pt. on Regular Insulin drip 1.0-0.5 units/hour. blood sugars 108-89, drip off at 0300 with blood sugars 90's.\n\nID: Tmax 99.9, WBC 12.9, to receive last dose IV Vanco in am.\n\nSkin: Cocccyx remains red without breakdown, turned q2-3 hours, skin care provided. Encouraged Pt. to stay off back. Mediast/sternal dressing intact, left leg ace wrap D/I.\n\nA: hemodynamically stable s/p cabg, tolerating A pacing with underlying conduction disturbance.\n\nP: Cont to monitor rhythm/ a pacing, hemodynamics, wean Neo as tolerated. Pulm. toileting, IS, CPT, TCDB. Follow up with am labs with team. Monitor blood sugars, may switch to SS Regular Insulin. Assess gag, increase diet as tolerated. Activity progression with pain control. Comfort and emotional support to Pt. and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-19 00:00:00.000",
"description": "Report",
"row_id": 1342109,
"text": "CCU Nursing Progress Note\nS-\"My throat still hurts\"\nO-Neuro alert and oriented x2-3, quiet with minimal conversation. Voice is hoarse and c/o sore throat. c/o incisional pain but refusing pain medication.\nCV-VSS gradual wean off Neo by 1430 with SBP 120-130. HR 80 A pace 100%. Underlying rhythm is sinus brady with ventricular escape beats with pacer off, SBP drops 80-90. Atrial threshold 9 with output set at 18. EP following pt for pacer or ICD.\nResp-LS diminished bases, O2 4lnp with sats 94-96% RA sat 85%. Freq productive cough moderat amount thick tan sputum, using yankeur sx tip. CPT with fair effect because pt can cough secretions but not expectorate completely.\nID low grade temp received 4th dose vanco today.\nGU-foley draining 30-60cc/hr.\nGI-remains with weak/impaired gag. Unable to take clear liquids +asp/coughing, tolerates soft solid food without coughing. Appetite poor, no BM hypoactive BS x4.\nActivity-Dangle x2, physical therapy saw pt and walked pt to chair with minimal assist. Tolerated chair for 1 hour before getting fatigued.\nSocial-wife with pt all day.\nA/P-Succ CABG post op day #2, with persistant sinus brady/hypotension off pacer.\nContinue to monitor pacing threshold q shift.\nFollow VS off vasopressors.\nCheck gag before food/medications.\nmedicate for pain as needed.\nKeep pt and family aware of POC as discussed in multi disciplanary rounds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-19 00:00:00.000",
"description": "Report",
"row_id": 1342110,
"text": " npn\n1500-1900\n\n PA turned pmr down to 70, pt now in sr w/ rate mid 70's. Lasix ^ to 20 mg tid. BS ^ 176 at 1800, covered per riss. Taking soft solids well. Needs encouragement to CDB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-21 00:00:00.000",
"description": "Report",
"row_id": 1342115,
"text": "CCU Nursing Progress Note\nS-\"I feel alittle stronger today.\"\nO-Neuro alert and oriented x3, awake most of the day and more interactive. This morning voice was audible but hoarse for 2 words. By afternoon voice was whisper soft again. c/o minimal incisional discomfort, refusing pain medication.\nCV-VSS SBP 124-145 with HR 78-88 NSR. Epicardial a/v wires intact and attached to pacer. Atrial rate at 60 and ventricular pacer off, has not required pacer for 48hrs.\nResp-LS diminished bases, decreased coughing today while being NPO. Sputum is tan/thick, using yankeuer tip. Still requiring O2 3-4l NP with sat dropping to 78-80% on RA. No c/o SOB while walking in hallway.\nID afebrile\nGU-foley removed this morning but DTV 5-7pm.\nGI-Remains NPO d/t failed swallow study . NGT placed by fluro into jejunum succ right nare. Started ProBalance at 20cc/hr at 1730, with GOAL rate at 60cc/hr. +BS no BM post op.\nSkin-intact, Sternal incision dressing off open to air, staples intact. Left leg ace removed and d/c'd.\nActivity-OOB walking in hallway 3 times >yds today with 1 assist. Still using wheelchair to hold on to but endurance has improved.\nPhysical therapy working with pt this evening.\nSocial-wife with pt most of the day, staying with pt in the room.\nCase Manager following d/t no insurance.\nA/P-s/p CABG post op d#4 with failed swallow study now with feeding tube for nutrition.\nContinue to monitor rhythm for bradycardia and pacer use.\nEncourage independance with ADL's.\nCheck TF residuals q4hrs and increase rate 10cc for GOAL rate 60cc/hr by am.\nKeep pt/family aware of POC as discussed in multi disciplanary rounds.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2186-07-22 00:00:00.000",
"description": "Report",
"row_id": 1342116,
"text": "ccu npn 7p-7a\nS:\"I'm doing ok.\"\nO: Please see carevue for VS and objective data\nCVS: Hemodynamically stable with HR 70-80's NSR, rare PVC noted. Epicardial A/V wires intact, without requiring use. Atrial wire set at rate of 60, with MA 18. Ventricular wire remains off. BP ranges 96-120/50-70 via non-invasive cuff.\nResp; Sats 93-99% on 4L n/c. Lungs clear with diminished bases. Encouraged TCDB. RR 20's. Exporating small amounts of thick, tan sputum.\nGI:GU: Remains NPO after failed swallow studies. TF Probalance started at 20cc/hour, increased q 4hours by 10cc. No residuals with post pyloric tube intact via right nare. In good placement with auscultation. Abdomen soft with bowel sounds, up to commode multiple times for small amount of formed stool. Guaic neg. Voiding qs via urinal/commode, dark, yellow urine. Neg. 730cc at MN, TID IV Lasix dc'd this shift.\nEndo: glucose 141, SS Regular Insulin as ordered\nID: afebrile, see carevue for skin care assessment. Post op sites dry and intact without s/s infection.\nNeuro: Pt. A/A/0x3, pleasant and cooperative. Appreciative of care. Voice remains soft whisper. Wife went home tonight for first time. Called and spoke to RN and Pt. Pt. slept at intervals, given 1mg IV Morphine for sleep/comfort. OOB to commode with assist of RN, MAE, transfers easily with minimal assist.\nA; Hemodynamically stable POD#5,\nP: Cont to monitor hemodynamics, rhythm, may remove epicardial wires in am. Cont to monitor voice, gag. TF with goal rate of 60cc/hour. Assess I/O, U/O. Cont. pulmonary toileting. Activity progression. Comfort and emotional support to Pt. and family\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 870292,
"text": " 2:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p dobhoff placement. Please assess tip location. Include u\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG and ct removal\n\n REASON FOR THIS EXAMINATION:\n s/p dobhoff placement. Please assess tip location. Include upper abdomen.\n ______________________________________________________________________________\n FINAL REPORT\n\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Status post Dobbhoff line placement, status post bypass surgery .\n\n FINDINGS: AP single view of the chest performed on the patient in supine\n position has been directed on lower chest, upper abdominal area purpose to\n identify the recently placed Dobbhoff tube position. Its metallic distal end\n portion is noted to be located in the lower esophagus seen through the\n markedly enlarged heart shadow. Both diaphragms cannot be identified with\n certainty because of pleural densities, but it is most unlikely that the\n Dobbhoff has passed through the hiatal area and certainty is not in a position\n compatible with the fundus of the stomach. Comparison made with a next\n preceding portable chest examination obtained seven hours earlier the same\n date demonstrates grossly unchanged findings with massive bilateral pleural\n densities. The Dobbhoff tube was not present on the previous preceding\n examination and now identified to terminate in the lower esophagus, but not\n reaching the stomach.\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-24 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 870705,
"text": " 1:15 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: ASSESS SWALLOW\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man S/P CABG/FAILED SWALLOW\n REASON FOR THIS EXAMINATION:\n ASSESS SWALLOW\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 61-year-old man status post coronary artery bypass surgery with\n swallowing difficulty.\n\n TECHNIQUE: Videotaped oropharyngeal swallowing study under fluoroscopy.\n\n FINDINGS: The study was performed in conjunction with the speech pathologist.\n Several consistencies of barium were orally administered. With nectar, the\n patient exhibited swallowing delay and piecemeal bolus handling, as well as\n some spillover into the piriform sinuses. From a recent fluoroscopic\n examination, the patient is known to have incomplete closure of the vocal\n cords. Although he showed adequate elevation of the larynx and palate, there\n was a lack of epiglottic deflection, and mild to moderate residue in the\n valleculae, and to a lesser extent, the piriform sinuses.\n\n With nectar thickened liquids, both in the upright position and with chin\n tuck, the patient aspirated a small amount of barium and showed no spontaneous\n cough. A cued cough was fairly ineffective. With pureed consistency, he did\n not show aspiration, however.\n\n IMPRESSION: Difficulty with oropharyngeal bolus handling, including residue\n in the valleculae and piriform sinuses. With nectar thickened liquids,\n there was a tendency to aspiration, without adequate cough response.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-23 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 870627,
"text": " 4:16 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pna\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG and ct removal with prurulent sputum\n\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Chest tube removal and purulent sputum.\n\n COMPARISON: \n\n Comparison to the film obtained on at 8:10 is necessary since the film\n later that day was obscuring much of the chest.\n\n The right introducer sheath has been removed and there is no PTX. Extensive\n bilateral effusions are seen on the current study. The amount of pleural\n fluid appears to have decreased but may have distributed more dependently.\n Positioning may contribute to this apparent change. No definite new\n consolidation is visualized; however, there is some retrocardiac patchiness,\n which could be atelectasis or pneumonia.\n\n CABG changes are evident and a feeding tube extends below the imaged anatomy\n on the frontal view.\n\n IMPRESSION: Better aerated lung with less pleural fluid as described above.\n No new consolidations. Right introducer sheath removed and no PTX.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-21 00:00:00.000",
"description": "NASO-INTESTINAL TUBE PLACEMENT (W/FLUORO)",
"row_id": 870421,
"text": " 2:17 PM\n -INTESTINAL TUBE PLACEMENT (W/FLUORO) Clip # \n Reason: needs feeding tube, failed bedside attempts\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with aspiration\n REASON FOR THIS EXAMINATION:\n needs feeding tube, failed bedside attempts\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with aspiration. Detailed bedside attempts for\n nasogastric tube placement.\n\n TECHNIQUE/FINDINGS: A weighted - feeding tube was passed\n through the right naris into the esophagus, and into the stomach over a metal\n guidewire. Under fluoroscopic guidance, the tube was then advanced past the\n pylorus, into the duodenum, with the tip terminating at the ligament of\n Treitz. 20 cc of Conray was injected to confirm positioning.\n\n IMPRESSION: Successful placement of post pyloric feeding tube with tip at the\n ligament of Treitz.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-20 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 870315,
"text": " 6:14 PM\n PORTABLE ABDOMEN Clip # \n Reason: check feeding tube placement\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with\n REASON FOR THIS EXAMINATION:\n check feeding tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Feeding tube placement.\n\n COMPARISON: Portable chest of the same date at 14:50 hours.\n\n PORTABLE ABDOMEN: The feeding tube descends into the abdomen, loops\n superiorly into the mid esophagus and then back towards the gastroesophageal\n junction. The tip may reside below the gastroesophageal junction, but this is\n difficult to assess because the hemidiaphragms remain obscured by bilateral\n pleural effusions, left greater than right. The cardiac silhouette is also\n partially obscured. Failure is present. Sternal wire sutures and mediastinal\n clips are noted. Internal jugular line remains in similar position since the\n prior day.\n\n IMPRESSION:\n 1. Feeding tube looped in the stomach and esophagus, as above.\n 2. Congestive failure and bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-19 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 870088,
"text": " 6:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ptx/effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG and ct removal\n\n REASON FOR THIS EXAMINATION:\n assess ptx/effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old status post CABG , chest tube removal, re-evaluate\n for pneumothoraces or effusions.\n\n AP SEMI-UPRIGHT CHEST: Comparison to the film of the prior day. Right IJ\n catheter unchanged in position. A tiny left aypical pneumothorax is not\n identified on today's study. Persisting bilateral pleural effusions and\n cardiomegaly consistent with congestive heart failure.\n\n IMPRESSION:\n 1) Slight worsening of pulmonary edema and bilateral pleural effusions.\n 2) Tiny left aypical pneumothorax not identified on today's study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 869991,
"text": " 11:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG and ct removal\n\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG and chest tube removal.\n\n AP PORTABLE UPRIGHT CHEST: Compared to AP supine chest of the prior day. The\n endotracheal tube, Swan-Ganz catheter, multiple chest tubes, and NG line have\n been removed. The right IJ line remains in place. There is a tiny left\n apical pneumothorax remaining. There has been interval worsening of diffuse\n pulmonary edema with increased bilateral pleural effusions.\n\n IMPRESSION:\n\n 1) Interval development of pulmonary edema with worsening bilateral pleural\n effusions.\n\n 2) Multiple lines and tubes removed; trace residual left apical pneumothorax.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 870025,
"text": " 3:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG and ct removal\n\n REASON FOR THIS EXAMINATION:\n assess ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old status post CABG with CT removal, assess for\n pneumothorax.\n\n AP UPRIGHT CHEST: Comparison to film of 4 hours prior. Allowing for\n differences in technique, there is no significant change in the tiny left\n apical pneumothorax. There is slight interval increase in right-sided\n effusion. Persisting pulmonary edema. No other interval change.\n\n IMPRESSION:\n 1) Tiny left apical pneumothorax.\n 2) Slight interval increase in right-sided pleural effusion.\n 3) No other significant short interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-20 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 870230,
"text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess effusions\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG and ct removal\n\n REASON FOR THIS EXAMINATION:\n assess effusions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61-year-old status post CABG and chest tube removal. Assess\n effusions.\n\n Comparison is made to the prior examination of .\n\n The right IJ line remains in place, unchanged in position. Bilateral loculated\n pleural effusions are noted. The magnitude of the left pleural effusion has\n not changed. There is associated partial compression atelectasis of the left\n lower lobe and the lingula.the right pleural effusion may be slightly larger\n at this time. Associated compression partial atelectasis of the right lower\n lobe and the right middle lobe has worsened since the prior study.\n\n IMPRESSION: Bilateral pleural effusions. The large left pleural effusion has\n not changed since the prior study, but the right loculated pleural effusion\n may have slightly increased since the prior study. No evidence of\n pneumothoraces.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 869895,
"text": " 2:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pneumothorax, pleural effusion, pulmonary edema, tamponade\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man s/p CABG\n REASON FOR THIS EXAMINATION:\n Pneumothorax, pleural effusion, pulmonary edema, tamponade\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post CABG.\n\n AP SUPINE CHEST: Compared to PA and lateral chest of . Multiple\n devices overlying the patient obscure sensitivity of the study. Endotracheal\n tube tip 3 cm above the carina. Swan-Ganz catheter with its tip in the distal\n right main pulmonary artery. Multiple left-sided chest tubes and mediastinal\n tube seen. NG line with its tip in the body of the stomach. No pneumothorax\n is identified. There has been near resolution of the moderately sized right\n pleural effusion with just a small residual effusion remaining. The lungs are\n clear. There is no significant volume overload/CHF.\n\n IMPRESSION:\n 1) Multiple lines and tubes in satisfactory position; no pneumothorax.\n 2) Small residual right pleural effusion.\n 3) Cardiomegaly without evidence of significant volume overload/CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-16 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 869755,
"text": " 2:42 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: eval. arterial & venous flow of the liver of this preop for\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with HBV, cirrhosis, pre-op CABG\n REASON FOR THIS EXAMINATION:\n eval. arterial & venous flow of the liver of this preop for CABG liver\n cirrhotic.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with hepatitis B and cirrhosis. Preoperative for\n CABG.\n\n RIGHT UPPER QUADRANT ULTRASOUND: The liver is without focal lesions, and\n normal in echotexture and architecture. No intrahepatic biliary ductal\n dilatation is identified. There are a 6 mm polyp in the fundus and a 4 mm\n polyp in the most proximal portion of the gallbladder. No stones are seen.\n Portal venous flow is maintained in the appropriate direction, and no\n intraluminal thrombus is identified. Hepatic venous flow and hepatic arterial\n flow are within normal limits.\n\n IMPRESSION:\n 1) Normal portal venous flow.\n 2) Two small gallbladder polyps.\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-13 00:00:00.000",
"description": "CHEST (PRE-OP PA & LAT)",
"row_id": 869448,
"text": " 8:09 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: CORONARY ARTERY DISEASE\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with severe CAD, cirrhosis, CHF\n REASON FOR THIS EXAMINATION:\n eval pleural effusions/ eval for pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of coronary artery disease, cirrhosis, and CHF. Evaluate\n for pleural effusions or pneumonia. Preoperative evaluation.\n\n COMPARISON: None.\n\n PA AND LATERAL CHEST RADIOGRAPHS: There are increased interstitial markings,\n which may be chronic, though underlying CHF cannot be excluded. There is\n blunting of the right costophrenic angle, consistent with pleural effusion.\n There is cardiomegaly. The mediastinal contours are stable. There is\n calcification of the aortic arch. The aorta appears slightly tortuous. There\n is flattening of the diaphragms, and increased in the retrosternal clear\n space, consistent with underlying chronic emphysematous change. There is a\n compression deformity in the mid-thoracic spine.\n\n IMPRESSION:\n\n 1. There is flattening of the diaphragms, and retrosternal clear space\n opacity consistent with underlying chronic emphysematous changes.\n\n 2. While there are diffusely increased interstitium marking which may be\n chronic, though superimposed mild CHF cannot be excluded.\n\n 3. Cardiomegaly.\n\n 4. Wedge compression deformity in the mid-thoracic spine.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2186-07-16 00:00:00.000",
"description": "CT ABD W&W/O C",
"row_id": 869714,
"text": " 9:26 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: triple phase, arterial, venous, solideval. liver & vessels,\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CAD\n REASON FOR THIS EXAMINATION:\n triple phase, arterial, venous, solideval. liver & vessels, pre-op CABG\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with hepatitis, cirrhosis. Preoperative for\n CABG.\n\n TECHNIQUE: After administration of oral contrast, MDCT was used to obtain\n non-IV-contrast images through the liver. Contrast-enhanced images were\n obtained after 35 and 75 second delay. 3-minute delay images were also\n obtained through the abdomen and pelvis.\n\n CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is a moderate loculated\n pleural effusion in the right hemithorax. There is associated compressive\n atelectasis. There is also a small left pleural effusion. Cardiomegaly is\n present, but there is no pericardial effusion.\n\n Although somewhat nodular, the liver is without focal lesions. Portal venous\n flow is patent. The gallbladder is unremarkable. The spleen is borderline\n enlarged. The pancreas, adrenals, kidneys, stomach, and small bowel are\n unremarkable. A small amount of perihepatic ascites is noted. No significant\n lymphadenopathy is identified. There are aortic calcifications, but the aorta\n is not dilated.\n\n CT OF THE PELVIS WITH IV CONTRAST: Distal ureters and bladder are within\n normal limits. Bowel loops are grossly unremarkable. Vasculature is notable\n for extensive calcification. No lymphadenopathy is identified. There is no\n free fluid.\n\n Bone windows are notable for a hemangioma in the left posterior aspect of L3\n vertebral body.\n\n IMPRESSION:\n 1) No focal liver lesion. Small amount of perihepatic ascites.\n 2) Loculated small right pleural effusion, with small left pleural effusion.\n Associated compressive atelectasis.\n 3) Cardiomegaly.\n 4) Vascular calcifications.\n (Over)\n\n 9:26 AM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: triple phase, arterial, venous, solideval. liver & vessels,\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n"
},
{
"category": "ECG",
"chartdate": "2186-07-17 00:00:00.000",
"description": "Report",
"row_id": 211666,
"text": "Underlying rhythm is sinus rhythm. Occasional atrially paced rhythm. Probable\nleft atrial abnormality. Probable old inferior wall myocardial infarction. Loss\nof R waves suggests old anterior myocardial infarction. Inferolateral\nST-T wave abnormalities suggestive of myocardial ischemia. Compared to the\nprevious tracing of above noted abnormalities persist.\n\n"
},
{
"category": "ECG",
"chartdate": "2186-07-14 00:00:00.000",
"description": "Report",
"row_id": 211667,
"text": "Sinus rhythm, rate 62. Left axis deviation. There may be a previous inferior\nwall myocardial infarction and possibly anteroseptal myocardial infarction.\nDiffuse ST-T wave abnormalities are noted. No previous tracing available for\ncomparison.\n\n"
}
] |
27,668 | 169,809 | 44-year-old male patient with continued paroxysmal episodes of dyspnea associated with symptoms of laryngospasm admitted to the ICU after a witnessed 45 sec episode of resp distress. . #Respiratory distress: intermittent dyspnea over the past several weeks. Likely laryngospasm due to GERD-associated irritation or persistent sinus sx. Much less likely asthmatic sx as a rxn to allergens at home. Infections etiology also possible given sputum production, but pt has been on Levaquin recently, without effect, and hx is not c/w persistent infection to due episodic nature. Ground glass opacities on chest CT and pulmonary nodule RLL. Pt also has persistent allergic rhinitis. Psychogenic paradoxical vocal cord movement is also possible but less likely based on clinical presentation. Sputum gram stain negative, no antibiotics given. Treating GERD as below. Aggressive bronchodilators. Low dose anxiolytics, as anxiety during dyspneic episodes worsens dyspnea. Post nasal drip symptom relief with guaifenesin, cepacol. Needs repeat CT in 3 months to evaluate the pulm nodule. Speech evaluation recommended behavioral modifications to "break" attacks, which seem to be working well for patient. . #GERD. scope by ENT showed laryngeal changes associated with GERD. Normal esoph motility study , which is not uncommon with laryngeal-pharyngeal reflux. No aspiration. Currently on PPI and ranitidine qhs. Dietary modifications to reduce GERD symptoms. Outpatient GI f/u as already arranged. . #allergy sx. persistent sinusitis and reactive airway disease ? rxn to environmental allergens, ?rxns to mice and roaches at home? Sx of allergies--persistent PND and phlegm in throat that the patient cannot cough up. RAST neg and IgE levels wnl. Nasal inh steroids and anti-histamines. . #h/o +PPD 20 years ago; patient received BCG as child in Morrocco. Pt was sent for Quanti- Gold assay to determine whether he has latent TB or not--but has never followed up. has a h/o of "benign mediastinal tumor" removed and persistent lung nodules, in addition to ground glass opacities in RML and lingula. 3 induced sputums sent, although very low probability of active Tb. PPD positive this admission (22mm induration at 48 hrs); patient to see PCP who can discuss risks and benefits of treating positive PPD with isoniazid. . #FEN: regular diet . # PPX: SC heparin. PPI. . #code: FULL | Taking inhalers as ordered.CV: NSR no ectopy noted; BP stable; afebrile. constantly clearing throat.CV: HR 70s-80s NSR with no ectopy, NBP 100s-110s/60s-70s. 7a-3p Nursing Progress Note/review of systems:Neuro: Pt A/O x3; no c/o pain this shift. had enzymes drawn in ED, EKG without changes. All procedures/POC explained to pt prior to initiation with verbalization of understanding.Resp: Pt on RA, sats WNL; lungs clear with nonlabored respirations. Cardiac size is within normal limits. tolerating house diet well, one BM on shift.GU: UO adequate, pt. BP STABLE. NO C/O PAIN.RESP: PT ON ROOM AIR WITH O2 SAT'S IN THE HIGH 90'S. The trachea appears normal in caliber on both the PA and lateral films. WANTS TO BE SURE HE GOES HOME ON THEM.CV: PT IN NSR WITHOUT ECTOPY WITH RATES IN THE 60'S TO 70'S. LUNG SOUNDS CLEAR THROUGHOUT WITH NO C/O LARYNGEAL SPASPMS. Normal sinus rhythm. sbp 89-107/58-76resp: o2 sats 95-98 %.Lungs clear bilateral. On droplet precautions for +PPD/? Chest pain resoved without further episodes.Resp: RR teens, 02 sats high 90s on room air. He MAE, ambulates without difficulty, and c/o pain to his throat. Sinus rhythmSince previous tracing of the same date, no significant change VOIDING GOOD AMT'S OF CLEAR YELLOW URINE.SKIN: INTACT.ACCESS: ONE PIV. Pt instructed on diaphragmatic breathing and pursed lip W good effect increased aeration at bases. RN, pt. He has a hx of GERD for which he takes Prilosec and Ranitidine and is still completing a course of Levaquin for poss. Tracing within normal limits. Voiding in urinal.Skin: Intact.Plan: Pt d/c'd home at 1500-discharge instructions/medications/follow-up appts reviewed with pt prior to discharge; pt verbalized understanding. having h/o previous mantoux positive.Plan:call out to floor when bed available.resp management.emotional support to pt and family. Compared to the previous tracing of low precordialvoltage is present. PT OOB TO COMMODE. has one PIV which is WNL. Lungs are clear all lobes, no stridor noted. R hand PIV d/c'd-site WNL. He did not decrease his sat.Ativan 1 mg iv given to relax him and to aid in sleep.cv: hr 64-79 nsr no ectopy burst to 118 with laryngospasm episode. overnight, treat for anxiety addendum: pt reports benefits of humidified o2. voids.Skin: IntactSocial: No visits today but pt. PT TAKING INHALERS WITHOUT DIFFICULTY AND STATES THAT AFTER USING THEM IT'S THE BEST HE'S EVER FELT. IMPRESSION: Lung fields clear. Technically difficult studySinus rhythmNormal ECGSince previous tracing of the same date, no significant change NURSING PROGRESS NOTE:NEURO: PT ALERT AND ORIENTEDX 3, VERY PLEASANT AND COOPERATIVE. BS clear but shallow. laryngospasm. tolerating liquids.gu: voiding clear yellow urine.neuro: alert and oriented, cooperative. No edema, pulses present bilaterally.GI/GU: Abd soft/+BS; taking po diet, one episode of vomiting this afternoon upon coughing spell/getting up to ambulate. Sinus rhythm. his heart rate decreased to 80's as this Rn entered room.audible upper airway wheezing heard from doorway and ceased as this rn approached pt. In pt. The best exercises with the most noteable improvement were breathing exercises in conjunction with MDI's. Nsg.notes 0700-1900hrsplanned to discharge to home,but vomitted after , decided to call out to the floor when bed available.Neuro:alert and oriented well,pleasant ,calm.denies any pain.saying that having trouble breathing when sleeping on left side.went to outpatient clinic for speech and swallow evaluation.use ice chips or drink water when throat gets more irritated to avid more inflammation.Resp:O2 WEAN OFF TO RA,SATS > 95% LUNGS CLEAR.on respiratory treatments .no episode of laryngeal spasm todayCVS:HR 70-90/min,NSR,no ectopics noted.BP 100-120 SYS.GU/GI:on regular diet,said hungry too much,vomitted after ,but no nausea or vomitting after lunch.no BM tody.voids adequate urine output.IV access:PIV on Rt hand .patent.dressing intact.Integu:skin intact,afebrile,moves on bed self.PPD done on Rt forearm ,to be read on Social:visited by wife and family and updated with MD.calm and co operative.full code. Low precordial lead QRS voltage is non-specific and probably anormal variant. The patient is status post sternotomy. Pt. Pt. Pt. Pt. Pt. ABLE TO GET OOB TO USE COMMODE. He did have one very brief episode of ? No wheezes noted before or after treatment. he states his night was comfortable. PNA. No change from tracingof . feel much better. The right lower lobe nodule seen on the CT has not been demonstrated on the plain film. CHEST: Comparison is made with the prior chest x-ray of . had on episode up on arriving of chest"pressure" radiating to throat, EKG done, 1mg IV Morphine and .3mg SL Nitro given. No failure is seen. No episodes of laryngospasm since arriving here. anxious at times treated with ativan iv. he reported that he had fallen asleep and that it awakened him. He was scoped by ENT within last 10 days with normal results. Vital signs all WNL at this time. SEE FLOWSHEET FOR ALL DATA.GI: PT TOLERATED SOME DINNER WITH NO N/V. PT IS FULL CODE. NO CONTACT WITH RN OVERNIGHT. given 2mg IV Ativan for anxiety which made the pt. PPD planted on R forearm and one of 3 AFBs sent.GI: BSX4, pt. the episode ocurred ~2115, his heart rate was upo to 118 st for ~30 seconds. The lung fields are clear. MDI's given with spacer. TB. open face mask .35 % to provide humidity.gi: positive bowel sounds. 8:52 AM CHEST (PA & LAT) Clip # Reason: eval lung fields for interval change MEDICAL CONDITION: 44 yo M w/ repeat laryngospasms and cough REASON FOR THIS EXAMINATION: eval lung fields for interval change FINAL REPORT CLINICAL HISTORY: Recurrent laryngospasm and cough. | 13 | [
{
"category": "Radiology",
"chartdate": "2117-08-29 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 970643,
"text": " 8:52 AM\n CHEST (PA & LAT) Clip # \n Reason: eval lung fields for interval change\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 yo M w/ repeat laryngospasms and cough\n REASON FOR THIS EXAMINATION:\n eval lung fields for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Recurrent laryngospasm and cough.\n\n CHEST:\n\n Comparison is made with the prior chest x-ray of . The patient is\n status post sternotomy. Cardiac size is within normal limits. No failure is\n seen. The lung fields are clear. The costophrenic angles are sharp. The\n trachea appears normal in caliber on both the PA and lateral films. The right\n lower lobe nodule seen on the CT has not been demonstrated on the plain film.\n\n IMPRESSION: Lung fields clear.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-08-30 00:00:00.000",
"description": "Report",
"row_id": 1624315,
"text": "Nsg.notes 0700-1900hrs\n\nplanned to discharge to home,but vomitted after , decided to call out to the floor when bed available.\n\nNeuro:alert and oriented well,pleasant ,calm.denies any pain.saying that having trouble breathing when sleeping on left side.went to outpatient clinic for speech and swallow evaluation.use ice chips or drink water when throat gets more irritated to avid more inflammation.\n\nResp:O2 WEAN OFF TO RA,SATS > 95% LUNGS CLEAR.on respiratory treatments .no episode of laryngeal spasm today\n\nCVS:HR 70-90/min,NSR,no ectopics noted.BP 100-120 SYS.\n\nGU/GI:on regular diet,said hungry too much,vomitted after ,but no nausea or vomitting after lunch.no BM tody.voids adequate urine output.\n\nIV access:PIV on Rt hand .patent.dressing intact.\n\nIntegu:skin intact,afebrile,moves on bed self.PPD done on Rt forearm ,to be read on \n\nSocial:visited by wife and family and updated with MD.calm and co operative.full code. having h/o previous mantoux positive.\n\nPlan:call out to floor when bed available.resp management.emotional support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-08-31 00:00:00.000",
"description": "Report",
"row_id": 1624316,
"text": "NURSING PROGRESS NOTE:\nNEURO: PT ALERT AND ORIENTEDX 3, VERY PLEASANT AND COOPERATIVE. ABLE TO GET OOB TO USE COMMODE. NO C/O PAIN.\n\nRESP: PT ON ROOM AIR WITH O2 SAT'S IN THE HIGH 90'S. LUNG SOUNDS CLEAR THROUGHOUT WITH NO C/O LARYNGEAL SPASPMS. NO STRIDOR HEARD. PT TAKING INHALERS WITHOUT DIFFICULTY AND STATES THAT AFTER USING THEM IT'S THE BEST HE'S EVER FELT. WANTS TO BE SURE HE GOES HOME ON THEM.\n\nCV: PT IN NSR WITHOUT ECTOPY WITH RATES IN THE 60'S TO 70'S. BP STABLE. SEE FLOWSHEET FOR ALL DATA.\n\nGI: PT TOLERATED SOME DINNER WITH NO N/V. PT OOB TO COMMODE. VOIDING GOOD AMT'S OF CLEAR YELLOW URINE.\n\nSKIN: INTACT.\n\nACCESS: ONE PIV. WNL.\n\nID: PT HAD PPD PLANTED ON ARM AND IS TO BE READ .\n\nSOCIAL: PT SPEAKS WITH FAMILY ON CELL PHONE. NO CONTACT WITH RN OVERNIGHT. PT IS FULL CODE. PT IS A C/O AND WAITING FOR BED PLACEMENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-08-31 00:00:00.000",
"description": "Report",
"row_id": 1624317,
"text": "Respiratory therapy\nPt presents in high position on room air sats 96-97%. BS clear but shallow. Pt instructed on diaphragmatic breathing and pursed lip W good effect increased aeration at bases. MDI's given with spacer. No wheezes noted before or after treatment. The best exercises with the most noteable improvement were breathing exercises in conjunction with MDI's. Third AFB to be done later this AM. Plan: continue breathing exercises and follow-up with PFT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-08-31 00:00:00.000",
"description": "Report",
"row_id": 1624318,
"text": "7a-3p Nursing Progress Note/review of systems:\n\nNeuro: Pt A/O x3; no c/o pain this shift. All procedures/POC explained to pt prior to initiation with verbalization of understanding.\nResp: Pt on RA, sats WNL; lungs clear with nonlabored respirations. On droplet precautions for +PPD/? TB. Taking inhalers as ordered.\nCV: NSR no ectopy noted; BP stable; afebrile. No edema, pulses present bilaterally.\nGI/GU: Abd soft/+BS; taking po diet, one episode of vomiting this afternoon upon coughing spell/getting up to ambulate. Voiding in urinal.\nSkin: Intact.\nPlan: Pt d/c'd home at 1500-discharge instructions/medications/follow-up appts reviewed with pt prior to discharge; pt verbalized understanding. R hand PIV d/c'd-site WNL. Pt transported via wheelchair to main entrance with PCT; brother in law with pt.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-08-29 00:00:00.000",
"description": "Report",
"row_id": 1624311,
"text": "Nursing Progress Note: 1200-1900\n\nPt. is a 44 yo man who has had 6 visits to the ED in 12 days for c/o dyspnea at times associated with breathing and clearing his throat simultaneously thought to be laryngospasm. He states it often happens upon awakening and after eating. He has same complaint today but also states that he fainted upon standing up from a chair. He was scoped by ENT within last 10 days with normal results. He has a hx of GERD for which he takes Prilosec and Ranitidine and is still completing a course of Levaquin for poss. PNA. In pt. was given 2L fluids for dehydration (poor PO intake and 1 episode of vomiting in last few days). RN, pt. had episode of laryngospasm lasting 45 seconds with audible stridor after coughing. 02 sat monitor fell off during episode so unknown if sats dropped but per nurse pt was diaphoretic, pale, and felt very weak. Decison made to send to MICU for further observation.\n\nReview of systems:\n\nNeuro: Pt. is alert and oriented but upon arrival to MICU was holding his throat and stating he felt so weak that he thought he was to faint. Vital signs all WNL at this time. Pt. given 2mg IV Ativan for anxiety which made the pt. feel much better. He MAE, ambulates without difficulty, and c/o pain to his throat. Pt. constantly clearing throat.\n\nCV: HR 70s-80s NSR with no ectopy, NBP 100s-110s/60s-70s. Pt. has one PIV which is WNL. Pt. had on episode up on arriving of chest\"pressure\" radiating to throat, EKG done, 1mg IV Morphine and .3mg SL Nitro given. Pt. had enzymes drawn in ED, EKG without changes. Chest pain resoved without further episodes.\n\nResp: RR teens, 02 sats high 90s on room air. Lungs are clear all lobes, no stridor noted. No episodes of laryngospasm since arriving here. PPD planted on R forearm and one of 3 AFBs sent.\n\nGI: BSX4, pt. tolerating house diet well, one BM on shift.\n\nGU: UO adequate, pt. voids.\n\nSkin: Intact\n\nSocial: No visits today but pt. in phone contact with wife.\n\nPlan: Observe pt. overnight, treat for anxiety\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-08-29 00:00:00.000",
"description": "Report",
"row_id": 1624312,
"text": "Amitted today from ER on TB precaution first sample induced today and sent to lab.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-08-30 00:00:00.000",
"description": "Report",
"row_id": 1624313,
"text": "addendum: pt reports benefits of humidified o2. he states his night was comfortable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2117-08-30 00:00:00.000",
"description": "Report",
"row_id": 1624314,
"text": "pt slept well most of the night. He did have one very brief episode of ? laryngospasm. he reported that he had fallen asleep and that it awakened him. the episode ocurred ~2115, his heart rate was upo to 118 st for ~30 seconds. his heart rate decreased to 80's as this Rn entered room.audible upper airway wheezing heard from doorway and ceased as this rn approached pt. He did not decrease his sat.Ativan 1 mg iv given to relax him and to aid in sleep.\n\ncv: hr 64-79 nsr no ectopy burst to 118 with laryngospasm episode. sbp 89-107/58-76\n\nresp: o2 sats 95-98 %.Lungs clear bilateral. open face mask .35 % to provide humidity.\n\ngi: positive bowel sounds. tolerating liquids.\n\ngu: voiding clear yellow urine.\n\nneuro: alert and oriented, cooperative. anxious at times treated with ativan iv.\n"
},
{
"category": "ECG",
"chartdate": "2117-08-29 00:00:00.000",
"description": "Report",
"row_id": 119741,
"text": "Sinus rhythm\nSince previous tracing of the same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2117-08-29 00:00:00.000",
"description": "Report",
"row_id": 119742,
"text": "Technically difficult study\nSinus rhythm\nNormal ECG\nSince previous tracing of the same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2117-08-29 00:00:00.000",
"description": "Report",
"row_id": 119743,
"text": "Normal sinus rhythm. Tracing within normal limits. No change from tracing\nof .\n\n"
},
{
"category": "ECG",
"chartdate": "2117-08-25 00:00:00.000",
"description": "Report",
"row_id": 119744,
"text": "Sinus rhythm. Low precordial lead QRS voltage is non-specific and probably a\nnormal variant. Compared to the previous tracing of low precordial\nvoltage is present.\n\n"
}
] |
12,821 | 161,937 | The patient was treated for septic shock with 15 plus liters of fluid and broad spectrum antibiotics. All external lines and hardware with the exception of the VVI pacer were removed from the patient and the patient was started empirically on Vancomycin, Flagyl, Imipenem and Miconazole powder. She was kept well hydrated with fluids and pressor support as needed. Regarding her cardiac function the CK elevation was in the sating of a high cardiac output due to likely sepsis. Aspirin was continued and the patient was started on a heparin drip and enzymes were cycled. The electrocardiogram with the baseline left bundle branch block and now pacer placement made it difficult to say whether or not the patient was in acute coronary syndrome. The patient was not a good candidate for a cardiac catheterization in the context of sepsis. Echocardiogram revealed that the ejection fraction was 20% with a hypokinetic septum and moderate symmetrical hypertrophy and 3+ mitral regurgitation. The patient had a rhythm of chronic atrial fibrillation with a rate that varied between 60 and 100 beats per minute. Heparin drip was continued for anticoagulation and rate controlling medications were added onto the treatment regimen. Renal, the patient had acute renal failure on admission likely secondary to hypotension and decreased perfusion. The creatinine normalized down to a level of 0.6 on the day of discharge after aggressive hydration and treatment of the underlying causes of heart failure and sepsis. On the first day of admission the pressors that the patient was admitted to on were weaned off, but Dopamine was restarted at a renal dose to improve renal perfusion. The patient became tachycardic to the 130s and therefore the treatment regimen was switched to Levophed. The patient received intravenous fluid boluses for low urine output. Sputum cultures grew 1+ gram negative rods. The patient's ventilator was weaned down to 50% with a PEEP of 8. Tube feeds were started for nutrition and the patient's hematocrit dropped from 31 to 26. A TTE at this time revealed an EF of 20 to 30% with 3+ mitral regurgitation and apical akinesis. The following day diuresis with Lasix and Natrecor were pursued with a goal of removing 2 liters of fluid. Beta blocker was added on and increased with ace inhibitors to reduce SVR. Once the patient was extubated heart rate was aggressively controlled with beta blockers and Digoxin was added. This achieved rate control in the 60s to 80s, but atrial fibrillation persisted. After extubation the patient was cleared for eating by speech and swallow video evaluations and a diet was advanced to thick pureed foods. The patient was weaned off of diuretics as the congestive heart failure and cardiogenic shock resolved and all of her intravenous medications were changed to po. Zoloft was added back to her regimen of medications at this time to treat the depression that she had been managing chronically. Heparin was weaned off as Coumadin was started and the therapeutic INR of greater then 2 was achieved. On the day of discharge the patient's central line was discontinued. The patient was receiving nutrition through thick feedings and her atrial fibrillation, hypertension, hyperlipidemia were controlled on po medications. The patient was evaluated by physical therapy and it was recommended that the patient continue physical therapy, speech therapy and occupational therapy in a skilled nursing facility. The patient's care and needs in a skilled nursing facility were discussed with the family at length and Hungarian interpreters were obtained to clarify all the patient's outpatient needs. At the time of discharge the patient was discharged to an extended care facility. She was instructed to take all of her medications as described most importantly her Metoprolol 50 mg three times a day to control her heart rate and prevent flash pulmonary edema. She was instructed to see her primary care physician within one week and was told to see her heart failure cardiologist Dr. the attending who cared for her in the Critical Care Unit two weeks after discharge. She was instructed to follow a 2 gram sodium diet and to limit herself to 1.5 liters of fluid each day to manage her heart failure. She was also instructed to have daily blood pressure measurements to keep her systolic blood pressure below 140 mmHg and to weigh herself daily. If her weights increase by 2 pounds she was instructed to call her cardiologist or primary care physician to evaluate whether or not her diuresis needs required modification. The patient was discharged in stable condition to a skilled nursing facility. | Improved CHF with residual small pleural effusions and left basilar atelectasis. Aortic calcifications are once again noted. Aortic calcifications are once again noted. There is diffuse calcification of the aortic arch and descending aorta. Mild cardiomegaly and symmetric perihilar opacities as well as septal lines at the bases are present, slightly improved. A right sided subclavian central venous line terminates in the distal SVC. The right IJ catheter tip remains in the distal SVC. There is reduced laryngeal valve closure. FINDINGS: Endotracheal tube and single-chamber left-sided cardiac pacemaker are again seen. Small bilateral pleural effusions and adjacent atelectasis are unchanged. There are bilateral pleural effusions, R>L, with some fluid tracking into the minor fissure. There is calcification of the aorta. please assess position, effusion, edema. please assess position, effusion, edema. please assess position, effusion, edema. Patient is still in gross pulmonary edema with bilateral pleural effusions. A temporary pacing lead is also present, terminating in the region of the right ventricle. Mildtricuspid [1+] regurgitation is seen. BP TOL DIURESIS WELL. Moderate tosevere (3+) mitral regurgitation is seen. SECONDARY TO WHERE ABG DRAWN IN PATIENTS CHEYNES- CYCLE; PH ^ ? ON IV VANCO, FLAGGYL, & IMIPENUM.ENDO: BS 176->175. INC. STOOL X2 SM.->LG. Atrial fibrillation with a moderate ventricular response. Atrial fibrillation with a moderate ventricular response. There are layering bilateral pleural effusions with perihilar haziness. IMPRESSION: Aspiration with thin barium consistencies. LUNGS RHONCHOROUS IN AM ANTERIORLY BUT BY PM LUNGS MOSTLY CLEAR WITH SOME EXP WHEEZE POST. Right ventricularsystolic function appears depressed.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but notstenotic. please assess position, effusion, edema. ABG 7.44/36/109/25->7.44/36/78/25. SECOND C-DIFF CX SENT. PAD'S, CVP'S AND PCWP SLIGHTLY.RESP: TOL VENT WELL WITH ABG SLIGHTLY ALKALOTIC. Atrial fibrillation with ventricular response and occasional demand ventricularpacingLeft axis deviationPossible Inferior infarct, age indeterminateConsider old anteroseptal myocardial infarctionSince previous tracing, rate is slower Left ventricular function.Height: (in) 57Weight (lb): 139BSA (m2): 1.54 m2BP (mm Hg): 91/38HR (bpm): 78Status: InpatientDate/Time: at 14:46Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is mildly dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. hct 30.4 inr 3.8.coumadin on hold.resp- on 2l sats 94-98. l/s cxs/coarse 1/2 up l>r. Tmax 99.1 core temp.NEURO: lightly sedated on versed and fenanyl q1-2h. INC OF SM LIQ STOOL.GU:U/O BECOMING MORE CONCENTRATED.ENDO:BS ARE MORE STABLE AT THIS TIME.ID:TEMP UP, REPEAT BCSKIN: PT W/ AN EXCORIATED PERIRECTAL AREA. weaned off Levo. nsg referral done, f/u md d/c summary. PT NEG 600 FOR TODAY WITH VIGOROUS DIURESIS AFTER PO LASIX. RECHECK RISBI THIS AM. On Flagyl, Vanco, Imipenem. Abd soft with (+) BSs. CHECK K AND PTT AT . NO BM.ID:TEMP DOWN TO 99.4ENDO:BS W/IN PARAMETERS, NO COV.SKIN:REDDENED, EXCORIATED PERI AREA, APPEARS TO BE IMPROVINGSOC:SPOKE W/ DTR FOR UPDATE ON PHONEA/P:FAILURE TO WEAN, CONTINUE TO DIURESE, RSBI IN AM, ATTEMPT WEANING IN AM. HEPARIN @ 750u/hr.GI/GU: foley patent, good u/o - slightly cloudy. NAIL BEDS PINK, W/ BRISK CAP REFILL.CV:MHR DECREASED TO 80'S A-FIB, OCCASIONAL V-PACED BEATS AT REST.GI:TOL TF. Speech + Swall to re-eval. MAG REPLETED PO AND IV. ccu npnsee transfer note/referrals alsoo- afebrile. NGT in place per CXR. FEBRILE 102 rectal. CXR + EKG done. ALSO ON DIGOXIN. advance ETT per CXR. CCU NSG PROGRESS NOTE 7P-7A/ S/P PULM EDEMA; MRS- INTUBATEDO- SEE FLOWSHEET FOR OBJECTIVE DATA.CV- HR- 68-81 AFIB/ NO VEA. pm abg pnd. pm HCT 26.1 (am 31.4) ?dilutional? Started on Vanco, Imipenem, and Flagyl. admin abx when ordered. IVF boluses of NS started. Lactate 6.8 post NaHCO3 4.8. REMAINS ON CAPTOPRIL 75 TID AND LOPRESSOR 37.5 TID AS WELL AS DIGOXIN 0.125.CO/CI/SVR- 3.6/2.24/1444. CCU progress note 7a-7pEvents: weaned off Levo, fluid boluses of 2L. CXR DONE. epigastric pain gone after am. heparin/coumadin. PAN CXd. k- 4.0. hct 32.resp- as above, on bipap until 11am and back to 6l with sats 94-98, rr down and sob improved. +DIC. ivf d/c'd. Heparin d/c'd. Heparin d/c'd. CCU NSG PROGRESS NOTE 7P-7A/ RESP FX; MRS- INTUBATEDO- SEE FLOWSHEET FOR OBJECTIVE DATA PT OFF PRESSORS BUT WITH MARGINAL BP ONCE SEDATED/ BACK ON A/C MODE VENTILATION. OET pulled back at start of shift, with report of repeat CXR with OET in adequate position. CCU progress note 7a-7pNEURO: sedated on ATIVAN 1mg PO TID + VERSED 1mg/hr gtt. CCU progress note 7a-7pNEURO: lightly sedated on versed gtt @ 1mg/hr and ativan 1mg po TID. Plan to futher diurese this AM. pm ABG pnd. Am captopril dose held. 3+ generalize pitting edema. BS bilat E wheezes w/ rhonchi. pulm toliet. THEY HAVE ADDED NHP + SSI . purposful movements.ID: abx D/C'd. tolerating captopril 75mg tid. CO/CI ON CAPTOPRIL 6.25MG: 3.3/2.05 SVR 1479. IVF D/C'd. THEY HAVE BEEN UPDATE AND SUPPORT GIVENA: CRITICAL/ DIFFICULT WEAN D/T PULM EDEMA.P; CON'T TO DIURESE CHECK WITH HO. NSG NOTECV: REMAINS IN A-FIB. last CO 4.1 CI 2.55 SVR 1015 CVP 10->15. pm dose of lasix held per HO. Resp. Resp. 3+ pitting edema.GI/GU: foley patent. addendumpt. guiac neg. abg 7.47/41/69! ABG within normal limits. freq. +BS. Abd soft with (+) BSs. PT @ 2100 2 U REG/8 U NPH. D/C TO REHAB IN AM. Heparin continues at 800u/hr with AM PTT pending and Natrecor at 0.020mcg/kg/min.RESP: AC/400/10/.50/5 PEEP. 1+ gen edema.ID: afebrile. ABx coverage: Vanco, Flagyl, and Iminpenim. G(+).ID:Tm 100.2 and Tc 99.5. LAST ABG 7.47-74-37. RR 20-30's regular.HCT 31.9 , stable. Ativan dc'd. OGT to right nare changed to OGT oral. HR 70's afib with freq. TF off for extubation. nystatin applied. Increased again to 0.020mcgs/kg/min and awaiting results. ABX CONT. BS WNL. 2+ generalized edema.GI/GU/ENDO: foley patent. appearing comf. Resp. Resp. CPT done w/ turns.GI/GU: foley patent. PA pressures 35-42/17-20, cvp 12-13. HUOs 25-80cc/hr while on Natrecor gtt. LUNGS WITH EXP WHEEZE AND RHONCHI AT TIMES.ID: TMAX 100 CORE, WBC UNCHANGED. afebrile.CARDIAC: AFIB 60-80s. needs promting and enc. Heparin continues at 950u/hr with therepeautic PTTs. MAPs 60s to 70s.PAD 27-38, CVP 14-17, CO/CI/SVR high 3.0s/2.0s/1200-1500. +BS. +BS. Keep heparin gtt 700u/hr, ptt qd and as ordered (goal ptt 60-80). u/o ~30cc/hr. U/O ~30cc/hr. BP contin. on levoquin for UTI. CPT done with turns. Appears comfortable on versed 1mg/hr and ativan 1mg tid. Digoxin 0.25mg po qd.RESP: O2 2L n/c. SBP 100-1teens/60s. | 107 | [
{
"category": "Radiology",
"chartdate": "2152-09-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 797282,
"text": " 7:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate PA catheter placement; interval change in ch\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock and volume overload\n REASON FOR THIS EXAMINATION:\n please evaluate PA catheter placement; interval change in chf; ET placement\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: PA CATHETER PLACEMENT.\n\n CHEST, AP PORTABLE: Comparison is made to .\n\n There has been interval pull back of the right IJ PA catheter with the tip\n terminating in the main pulmonary artery. Again noted, is an NG tube, ET\n tube, and pacemaker, unchanged in position. There are bilateral pleural\n effusions and accounting for technical diffuerence there is no significant\n change, Also noted is mild pulmonary edema, unchanged from prior exam.\n\n IMPRESSION: The tip of the right IJ is in right main pulmonary artery in\n satisfactory position. Otherwise, no significant change from prior study.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 797368,
"text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Intubated with swan placed, please evaluate in comparison to\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock and volume overload\n\n REASON FOR THIS EXAMINATION:\n Intubated with swan placed, please evaluate in comparison to yesterday\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiac failure.\n\n PORTABLE CHEST: A supine view is compared to . The tip of the ETT is\n relatively low, approximately 1.5 cm above the carina. The nasogastric tube\n courses below the view of the image. The tip of the Swan- Ganz catheter is\n near the origin of the right upper lobe pulmonary artery, simialr to\n yesterday's film. A single electrode pacemaker is unchanged.\n\n The heart size is stable. Pulmonary edema has improved. There are small\n pleural effusions bilaterally. Atelectasis persists in the left lower lobe.\n\n IMPRESSION: 1. ETT tip relatively low, 1.5 cm above carina.\n\n 2. Improved CHF with residual small pleural effusions and left basilar\n atelectasis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 796772,
"text": " 7:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for ARDS - compare to prior films\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sepsis,on vent, hypotension,on IVF, pressors\n\n REASON FOR THIS EXAMINATION:\n eval for ARDS - compare to prior films\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79 y/o woman with sepsis on a vent. Hypertensive. ? ARDS.\n\n AP PORTABLE SUPINE CHEST AT 08:00:\n\n There is no change when compared to prior portable chest at 05:44 of the same\n date. Patient is still in gross pulmonary edema with bilateral pleural\n effusions. External support lines are unchanged.\n\n IMPRESSION: No change. Gross pulmonary edema with bilateral pleural\n effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-26 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 796768,
"text": " 5:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for PA catheter placement, ? new pulmonary p\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock on nesiritide with PA catheter;\n sudden increase in pulmonary artery pressure and peak inspiratory pressures,\n otherwise stable vital signs.\n\n REASON FOR THIS EXAMINATION:\n please evaluate for PA catheter placement, ? new pulmonary process.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79 y/o woman with cardiogenic shock. Sudden increase in pulmonary\n artery pressure and peak inspiratory pressure. Otherwise stable vital signs.\n Please evaluate.\n\n SUPINE PORTABLE CHEST AT 05:44:\n\n Since the prior study dated at 07:30, the right IJ central venous\n catheter has been replaced with a SG catheter, whose tip is in the right\n pulmonary artery. The patient is in gross pulmonary edema with bilateral\n effusions, right greater than left. The rest of the external support tubing\n is unchanged.\n\n IMPRESSION; New right IJ SG catheter with tip in right PA. No evidence of\n pneumothorax. Pulmonary edema with bilateral effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 797576,
"text": " 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p extubation for 24 hours, please comment on changes of CH\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker placement\n 3 weeks ago please and repositioning of ETT. please assess position,\n effusion, edema.\n REASON FOR THIS EXAMINATION:\n s/p extubation for 24 hours, please comment on changes of CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of cardiogenic shock and recent extubation.\n\n AP CHEST: In comparison to the prior study of , the NG and ET tubes\n have been removed. The right IJ line is in unchanged position in the distal\n SVC. There is no pneumothorax. Mild cardiomegaly and symmetric perihilar\n opacities as well as septal lines at the bases are present, slightly improved.\n Small bilateral pleural effusions and adjacent atelectasis are unchanged.\n There is diffuse calcification of the aortic arch and descending aorta.\n\n IMPRESSION: Mild left heart failure, slightly improving. Interval removal of\n ET and NG tubes.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-29 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 796998,
"text": " 8:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate for changes\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock on nesiritide with PA catheter\n otherwise stable vital signs.\n REASON FOR THIS EXAMINATION:\n Evaluate for changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Pulmonary artery catheter evaluation. Cardiogenic shock.\n\n PORTABLE AP CHEST: A Swan-Ganz catheter remains in place, terminating in the\n region of the interlobar right pulmonary artery. A temporary pacing lead is\n also present, terminating in the region of the right ventricle. Endotracheal\n tube and nasogastric tube are in satisfactory position. Cardiac and\n mediastinal contours are stable. There is vascular engorgement and perihilar\n haziness. A large right pleural effusion is noted as well as a moderate left\n pleural effusion.\n\n IMPRESSION:\n\n 1. Swan-Ganz catheter terminates in interlobar portion of right pulmonary\n artery.\n 2. Large right pleural effusion, and moderate left pleural effusion. Allowing\n for differences in patient positioning between the two studies, they are\n probably not significantly changed.\n 3. Stable CHF pattern.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 797492,
"text": " 8:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: REPOSITION ETT CHECKPOSITION\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker placement\n 3 weeks ago please and repositioning of ETT. please assess position,\n effusion, edema.\n REASON FOR THIS EXAMINATION:\n comparison\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ET tube position change.\n\n AP SEMI-UPRIGHT VIEW OF THE CHEST is compared to AP supine view dated .\n\n FINDINGS: The ET tube terminates 2 cm above the carina. The right IJ catheter\n tip remains in the distal SVC. A single pacemaker lead remains at the apex of\n the right ventricle. The NG tube position in the stomach is unchanged. LV\n enlargement and aortic calcifications are again noted. There has been slight\n worsening of the pulmonary edema. The bilateral pleural effusions are\n slightly increased. There is persistent left lower lobe atelectasis, as well\n as minor right lower lobe atelectasis. The visualized osseous structures are\n unchanged.\n\n IMPRESSION:\n\n 1. Satisfactory position of ET tube.\n 2. Slight worsening of CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 798051,
"text": " 10:33 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?infiltrate or evidence of aspiration\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker placement, recent\n extubation after prolonged ICU course. Now with possible aspiration.\n REASON FOR THIS EXAMINATION:\n ?infiltrate or evidence of aspiration\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Cardiogenic shock. Possible aspiration.\n\n COMPARISONS: -- 08:00\n\n FINDINGS: Compared to prior the pacemaker wire and right central venous line\n remain unchanged. There is less distention of the pulmonary vasculature and\n some clearing of air space disease with no evidence of new focal\n consolidations. Heart size is stable, bilateral effusions are stable and\n there is no pneumothorax.\n\n IMPRESSION: Persistent but improving CHF. No new consolidations.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 797728,
"text": " 4:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: newly placed NG tube, please evaluate whether it is in the s\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker\n placement 3 weeks ago please and repositioning of ETT. please assess\n position, effusion, edema.\n REASON FOR THIS EXAMINATION:\n newly placed NG tube, please evaluate whether it is in the stomach\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post NG tube placement.\n\n FINDINGS: AP supine view is compared to the AP supine view dated .\n The NG tube extends into the body of the stomach, but its tip is not well-\n visualized due to technique. The right IJ catheter and the single pacemaker\n lead remain in unchanged positions. There is persistent cardiomegaly, and the\n interstitial pulmonary edema appears slightly worse. The bilateral effusions\n are also slightly increased. The left lower lobe opacity is unchanged. Aortic\n calcifications are once again noted. The visualized osseous structures are\n unchanged.\n\n IMPRESSION:\n 1) NG tube in satisfactory position.\n 2) Mild worsening of congestive heart failure and bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 796833,
"text": " 7:39 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Line placement, eval of CHF\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock on nesiritide with PA catheter;\n sudden increase in pulmonary artery pressure and peak inspiratory pressures,\n otherwise stable vital signs.\n\n REASON FOR THIS EXAMINATION:\n Line placement, eval of CHF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 79 year old woman status post line placement.\n\n AP supine portable chest at 8:15 AM.\n\n Compared to prior study one day earlier, I see no new lines placed. The\n patient is still in gross pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-08 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 797926,
"text": " 2:18 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: please evaluate for swallowing ability\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with swallow evaluation neeeded\n REASON FOR THIS EXAMINATION:\n please evaluate for swallowing ability\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Please evaluate for swallowing ability.\n\n VIDEO OROPHARYNGEAL SWALLOW: Barium of various consistiencies was administered\n to the patient. Aspiration was noted with cup sips of nectar consistiency.\n Laryngeal penetration was seen with thin barium, though no aspiration was\n noted. There is reduced laryngeal valve closure. There is spillover of barium\n into the valleculae. No significant residue is present. Also noted is mild\n delay in initiating the swallow.\n\n IMPRESSION: Aspiration with large cup sips of nectar consistiency, as\n described above.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 796537,
"text": " 10:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for Pulmonary Edema\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sepsis, hypotension,on IVF and pressors\n\n REASON FOR THIS EXAMINATION:\n Assess for Pulmonary Edema\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Follow up CHF.\n\n CHEST, AP PORTABLE: Comparison is made to prior study from 5 hours earlier.\n\n There is interval withdrawal of right subclavian central line. Again noted is\n NG tube, ET tube and pacemaker, all of which remain in satisfactory position.\n The heart is stable in size. There is slight worsening of the prominent\n pulmonary vasculature consistent with bilateral pulmonary edema. There is a\n possible small bilateral pleural effusion.\n\n IMPRESSION: There is slight interval increase of pulmonary edema which could\n be attributed to worsening CHF or fluid overload.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 796574,
"text": " 8:47 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for Pulm edema and/or infiltrates\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sepsis, hypotension,on IVF and pressors\n\n REASON FOR THIS EXAMINATION:\n Eval for Pulm edema and/or infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79 y/o woman with sepsis, hypotension, on IV fluids and Pressors,\n evaluate for pulmonary edema/infiltrate.\n\n PORTABLE AP SUPINE VIEW OF THE CHEST: Comparison . An ETT is\n present in satisfactory position. A single lead pacemaker is unchanged. An NG\n tube is present with its tip in the region of the gastroesophageal junction\n and its side port in the distal esophagus. The heart size is upper limits of\n normal. There are bilateral pleural effusions. Patchy opacities bilaterally\n are slightly improved and consistent with improving failure.\n\n IMPRESSION: 1) NG tube with tip in the distal esophagus. Tube should be\n advanced. 2) Improving failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 797873,
"text": " 7:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tachypnea, tachycardia, recent extubation\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker\n placement, recent extubation after prolonged ICU course. please eval for pna,\n effusion, ptx.\n REASON FOR THIS EXAMINATION:\n tachypnea, tachycardia, recent extubation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress.\n\n FINDINGS: AP upright view is compared to the AP semi-upright view dated .\n The heart remains enlarged. There is bilateral perihilar air space\n consolidation consistent with pulmonary edema, which represents worsening of\n congestive heart failure since the prior study. There are persistent\n bilateral pleural effusions. There is fluid in the minor fissure. Aortic\n calcifications are once again noted. The visualized osseous structures are\n unchanged. The right IJ catheter and the right ventricular pace maker leads\n remain in unchanged positions.\n\n IMPRESSION: Interval worsening of congestive heart failure. Persistent\n bilateral pleural effusions.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 796520,
"text": " 4:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o Pneumothorax, edema, pneumonia\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sepsis\n REASON FOR THIS EXAMINATION:\n r/o Pneumothorax, edema, pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis.\n\n AP bedside chest film. Endotracheal tube is located just above the carina. An\n NG tube is seen with tip just beneath the GE junction. The proximal port is\n located within the esophagus. A right sided subclavian central venous line\n terminates in the distal SVC. There is a single lead cardiac pacer with tip\n in the expect location of the right ventricular apex. The heart size is\n normal. There are perihilar air space opacities but no effusions or septal\n lines. There is no pneumothorax.\n\n IMPRESSION: Malpositioned ETT and NGT. Central air space opacities suggest of\n fluid overload. The findings were relayed to the responsible medicine house\n officer via telephone on .\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 796639,
"text": " 5:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Placement of central line, pneumothorax? Please also check\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sepsis,on vent, hypotension,on IVF, pressors\n\n REASON FOR THIS EXAMINATION:\n Placement of central line, pneumothorax? Please also check NG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis, with central line and NG tube placement.\n\n Single portable AP view of the chest is compared with the prior study from ten\n hours ago.\n\n FINDINGS: Endotracheal tube and single-chamber left-sided cardiac pacemaker\n are again seen. NG tube has been advanced such that the tip now terminates\n within the abdomen with the sideport in the abdomen, as well. Right-sided IJ\n catheter has been placed, with the tip at the SVC/RA junction. There is no\n evidence of pneumothorax. There are bilateral pleural effusions, R>L, with\n some fluid tracking into the minor fissure. It is difficult to assess change\n in pleural effusion given differences in technique. Cardiac silhouette is\n grossly unchanged. There is retrocardiac collapse/consolidation. There is\n calcification of the aorta. Residual barium is present in the colon.\n\n IMPRESSION: Appropriate positioning of NG tube and right-sided IJ catheter;\n no pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 796674,
"text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?bilat infiltrates, ?ARDS vs PNA, CHF, line placements\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with sepsis,on vent, hypotension,on IVF, pressors\n\n REASON FOR THIS EXAMINATION:\n ?bilat infiltrates, ?ARDS vs PNA, CHF, line placements\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Sepsis.\n\n CHEST, AP PORTABLE: Comparison is made to . The lines and tubes remain\n unchanged in position. There is slight interval increase of bilateral pleural\n effusions. Again noted is left lower lobe collapse/consolidation not\n significantly changed from the prior exam. There are bilateral alveolar\n opacities noted consistent with extensive pulmonary edema/ARDS not\n significantly changed from the prior exam.\n\n IMPRESSION: There is slight increase of bilateral pleural effusions.\n Otherwise no significant change in the overall appearance of the extensive\n pulmonary edema/ARDS.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-25 00:00:00.000",
"description": "O CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.",
"row_id": 796707,
"text": " 12:27 PM\n CHEST FLUORO WITHOUT RADIOLOGIST IN O.R. Clip # \n Reason: SWANN LLINE PLACEMENT;TEMP WIIRE PLACE\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n A chest fluoro was performed without a radiologist present. 3 seconds of\n fluoro time was used. No films submitted.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-02 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 797395,
"text": " 2:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: central line position\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker placement 3\n weeks ago and volume overload s/p resiting central venous access. please\n assess position.\n REASON FOR THIS EXAMINATION:\n central line position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n PORTABLE CHEST: Comparison is made with earlier film from 7:30 am the same\n day. Endotracheal tube tip remains relatively low, approximatedly 1.7 cm\n above the carina. Of note, the nasogastric tube has moved more proximally,\n and has its endhole in the proximal stomach and sidehole in the distal\n esophagus. This can therefore be advanced approximately 7 cm for better\n placement.\n\n Swan-Ganz catheter has been removed and the right IJ central venous catheter\n now terminates in the region of the distal SVC. Midline structures are\n grossly unchanged. There is persistent CHF with a right pleural effusion and\n consolidation/atelectasis in the left retrocardiac area.\n\n IMPRESSION: 1) Endotracheal tube tip remains slightly low.\n 2) Sidehole of the NG tube is now in the distal esophagus.\n 3) Right IJ central venous catheter tip in SVC.\n\n Findings called to the floor.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-03 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 797433,
"text": " 8:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval progression of pulm edema, repositioning of ETT\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock, new pacemaker placement 3\n weeks ago please and repositioning of ETT. please assess position, effusion,\n edema.\n REASON FOR THIS EXAMINATION:\n eval progression of pulm edema, repositioning of ETT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ET tube and NG tube repositioning.\n\n PORTABLE CHEST: Comparison is made to film from one day earlier. The ET tube\n has been pulled back and is now in good position, with its tip 3 cm above the\n carina. The nasogastric tube has been advanced and is also in good position,\n with both end and sidehole in stomach. Cardiac and mediastinal contours are\n stable, and there is no change in the appearance of the lungs, with note again\n made of pulmonary edema, right effusion, and left retrocardiac density.\n\n IMPRESSION: 1. The ET tube and nasogastric tube are now in good position.\n 2. No change lungs.\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-09-11 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 798136,
"text": " 9:02 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: swallowing study\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with swallow evaluation neeeded before starting PO intake\n\n REASON FOR THIS EXAMINATION:\n swallowing study\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Evaluate swallow before starting p.o. intake.\n\n VIDEO OROPHARYNGEAK SWALLOW: Barium of varying consistencies was administered\n to the patient. There was delay in the initiation of the oral phase of\n swallowing. There is incomplete closure of the laryngeal valve. No residue\n was noted with any barium consistencies. There was aspiration with swallowing\n thin barium. Overall, there has been improvement from the study done several\n days earlier.\n\n IMPRESSION: Aspiration with thin barium consistencies.\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2152-08-28 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 796875,
"text": " 7:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for pulm vasc congestion vs infiltrate.\n Admitting Diagnosis: CHF,PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with cardiogenic shock on nesiritide with PA catheter;\n sudden increase in pulmonary artery pressure and peak inspiratory pressures,\n otherwise stable vital signs.\n REASON FOR THIS EXAMINATION:\n evaluate for pulm vasc congestion vs infiltrate.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 79 y/o woman with cardiogenic shock. Sudden increase in\n pulmonary pressure and peak inspiratory pressures.\n\n PORTABLE AP VIEW OF THE CHEST: Comparison . SG catheter is present\n with tip in a right interlobar artery. NG tube courses into the stomach, tip\n not visualized. The ET tube is approximately 2.4 cm from the carina (patient\n with neck in flexed position). There are layering bilateral pleural effusions\n with perihilar haziness.\n\n IMPRESSION: Bilateral layering pleural effusions and mild pulmonary edema. ET\n tube is likely in satisfactory position, given the flexed position of the\n neck.\n\n"
},
{
"category": "Echo",
"chartdate": "2152-08-24 00:00:00.000",
"description": "Report",
"row_id": 75890,
"text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation/flutter. Coronary artery disease. Left ventricular function.\nHeight: (in) 57\nWeight (lb): 139\nBSA (m2): 1.54 m2\nBP (mm Hg): 91/38\nHR (bpm): 78\nStatus: Inpatient\nDate/Time: at 14:46\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: Overall left ventricular systolic function is severely\ndepressed. There is no resting left ventricular outflow tract obstruction.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. Right ventricular\nsystolic function appears depressed.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. No 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. There is no significant mitral stenosis. Moderate to severe\n(3+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Mild\ntricuspid [1+] regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is no pericardial effusion. There is an anterior space\nwhich most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. The\nrhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is mildly dilated. Overall left ventricular systolic function\nis severely depressed (ejection fraction 20-30 percent) secondary to severe\nhypokinesis of the anterior septum and anterior free wall, with extensive\napical akinesis. Right ventricular chamber size is normal. Right ventricular\nsystolic function appears depressed. The aortic valve leaflets (3) are mildly\nthickened but not stenotic. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Moderate to\nsevere (3+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. There is moderate pulmonary artery systolic hypertension.\nThere is no pericardial effusion.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2152-08-25 00:00:00.000",
"description": "Report",
"row_id": 178685,
"text": "Atrial fibrillation\ndemand ventricular pacing\nMarked left axis deviation\nIntraventricular conduction defect\nInferior infarct - age undetermined\nAnteroseptal infarct - age undetermined\nLateral ST-T changes may be related to electronic pacemaker\nRepolarization changes may be partly due to rhythm\nLow QRS voltages in limb leads\nSince previous tracing of : no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2152-08-24 00:00:00.000",
"description": "Report",
"row_id": 178918,
"text": "Tracing taken with a magnet. Atrial fibrillation with a rapid ventricular\nresponse. Intermittent ventricular pacing. Compared to tracing #2 ventricularly\npaced rhythm is more frequent. The intrinsic ventricular response is faster.\nClinical correlation is suggested.\nTRACING #3\n\n"
},
{
"category": "ECG",
"chartdate": "2152-08-24 00:00:00.000",
"description": "Report",
"row_id": 178919,
"text": "Atrial fibrillation with a moderate ventricular response. There is intermittent\nventricularly paced rhythm. Compared to tracing #1 intermittent ventricular\npacing is new. Clinical correlation is suggested.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2152-08-23 00:00:00.000",
"description": "Report",
"row_id": 178920,
"text": "Atrial fibrillation with a moderate ventricular response. QRS duration is\nslightly greater than 0.12 - most likely left bundle-branch block. Cannot rule\nout old anteroseptal myocardial infarction. No previous tracing available for\ncomparison.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2152-09-04 00:00:00.000",
"description": "Report",
"row_id": 178680,
"text": "Atrial fibrillation with ventricular response and occasional demand ventricular\npacing\nLeft axis deviation\nPossible Inferior infarct, age indeterminate\nConsider old anteroseptal myocardial infarction\nSince previous tracing, rate is slower\n\n"
},
{
"category": "ECG",
"chartdate": "2152-08-28 00:00:00.000",
"description": "Report",
"row_id": 178681,
"text": "Atrial fibrillation with rapid ventricular response\nDemand ventricular pacing and ineffective stimuli\n*** complex QRS morphology - no further analysis ***\nPossible inferior myocardial infarct\nECG Taken with magnet\nSince previous tracing of : ventricular pacing is seen\n\n"
},
{
"category": "ECG",
"chartdate": "2152-08-28 00:00:00.000",
"description": "Report",
"row_id": 178682,
"text": "Atrial fibrillation with rapid ventricular response\nLeft axis deviation\nLeft bundle branch block\nPossible inferior infarct - age undetermined\nECG Taken without magnet\nSince previous tracing of : ventricular pacing not present\n\n"
},
{
"category": "ECG",
"chartdate": "2152-08-27 00:00:00.000",
"description": "Report",
"row_id": 178683,
"text": "Atrial fibrillation\nDemand ventricular pacing\nMarked left axis deviation\nConduction defect of LBBB type\nLow QRS voltages in limb leads\nSince last ECG, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2152-08-25 00:00:00.000",
"description": "Report",
"row_id": 178684,
"text": "Atrial fibrillation with rapid ventricular response\ndemand ventricular pacing\n*** complex QRS morphology - no further analysis ***\nECG Taken with magnet\nSince previous tracing of : no significant change\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-26 00:00:00.000",
"description": "Report",
"row_id": 1430772,
"text": "CCU NPN 0700-1900\nS/O:\n\nCV: NATRECOR UNCHANGED. PT LASIX 20 MG IV WITH VIGOROUS DIURESIS. C/O AND C/I ACTUALLY SLIGHTLY LOWER AFTER DIURESIS BECAUSE HCT INC TO 37. BP TOL DIURESIS WELL. PT CONT IN AF, RATE 70'S-130'S WITH OCC PVC'S. K 3.7, REC'D 40 KCL PO X1. HEP AT 7O0U/HR, PTT PND. PAD'S, CVP'S AND PCWP SLIGHTLY.\n\nRESP: TOL VENT WELL WITH ABG SLIGHTLY ALKALOTIC. FI02 INC TO 50% AND PEEP FROM 6 TO 5, ABG PND. SUCTIONED Q2-3H FOR THICK WHITE SPUTUM. LUNGS RHONCHOROUS IN AM ANTERIORLY BUT BY PM LUNGS MOSTLY CLEAR WITH SOME EXP WHEEZE POST. OVERBREATHING VENT 2-3 BREATHS.\n\nID: LOW GRADE CORE TEMP IN 99'S. ABX CONT. PACER SITE D/I WITH NO DRNG.\n\nGI: TF INC TO 45CC/HR, LOW RESIDUALS. PT INC SOFT STOOL FREQ IN SMALL AMOUNTS. SECOND C-DIFF CX SENT. POS BS.\n\nGU: URINE WITH SOME WHITE SEDIMENT. NEG 450CC FOR TODAY. WT DOWN.\n\nMS: OPENING EYES, NODDING YES AND NO TO QUESTIONS FROM FAMILY. REC'D FENT/VERSED Q2-3H BEFORE TURNING. PT C/O BACK PAIN AT ONE POINT, RELIEVED WITH FENT.\n\nSKIN: AREAS WITH YEAST IMPROVING, NO OTHER SKIN BREAKDOWN. PT PLACED ON FIRST STEP MATTRESS AND PNEUMOBOOTS APPLIED.\n\nENDO: BS 190 FOR HIGH, REC'ING SS REG INSULIN PRN.\n\nA/P: IMPROVING HEMODYNAMICS.FOLLOW K LATER TODAY. ? FURTHER DIURESIS TONIGHT. ? START ACE OR BETA BLOCKER TONIGHT. ASSESS TOL TO TF. PLACE RECTAL BAG IF SKIN STARTS TO BREAK DOWN WITH STOOL. ADJUST HEP ACCORDING TO PTT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-27 00:00:00.000",
"description": "Report",
"row_id": 1430773,
"text": "NEURO: SEDATED WITH FENTANYL & VERSED PRN. AROUSABLE TO VOICE STIMULA-\n TION. DOES NOT FOLLOW COMMANDS ? D/T LANGUAGE BARRIER. OPENS\n EYES SPONTANEOUSLY. APPEARS TO UNDERSTAND FAMILY MEMBERS THAT\n SPEAK WITH HER. MAE.\nRESP: ON VENT: .50X450 +AC 12 & 5 PEEP. BS CLEAR BUT DIMINISHED AT R.\n BASE. RR . O2 SAT 95-97%. SX FOR SM.-MOD. AMTS THICK\n WHITE-YELLOW SPUTUM. ABG 7.44/36/109/25->7.44/36/78/25. RISB\n 93.5.\nCARDIAC: HR 90-120 AF WITH RARE PVC. BP 101-131/46-66. PAD 28->23, CVP\n 15->12, W 24->21. HEPARIN GTT INFUSING AT 700U/HR. PTT 57.2.\n HEPARIN GTT INCREASED TO 800U/HR PER PROTOCOL. REPEAT PTT\n PENDING. CONT. ON NATRECOR GTT AT .02MCG/KG. MVO2 SAT 60->61.\n CO 3.7/2.3/1254. HCT 34.\nGI: ABD. SOFT. BS+. OGT IN PLACE FOR TF: FS PROMOTE WITH FIBER @ GOAL\n RATE 45CC/HR. RESIDUAL 140CC->TF OFF X 21/2HRS, THEN RESTARTED AT\n 45CC/HR. MINIMAL RESIDUALS. INC. STOOL X2 SM.->LG. AMT. BROWN\n LOOSE STOOL.\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. LASIX 20MG VP X1->\n DIURESED >2L. U/O PRESENTLY 30-80CC/HR.\nID: T(MAX)99.9(TD). CONT. ON IV VANCO, FLAGGYL, & IMIPENUM.\nENDO: BS 176->175. TREATED PER SLIDING SCALE.\nAM LABS PENDING.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-02 00:00:00.000",
"description": "Report",
"row_id": 1430801,
"text": "CCU NURSING NOTE 7A-7P\nS. REMAINS INTUBATED\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nID: TEMP 99.1 PO MAX WBC 9.1 OFF ANTIBX\n\nCV: HR 65-109 AFIB W/VENT PACED BEATS, LOPRESSOR 37.5 ; DIG .25\n BP 100-140'S/40-60 RECEIVING CAPTOPRIL 75 TID, PA LINE D/C'D LAST CO/CI/SVR = 3.8/2.36/1221; TLC PLACED IN RIJ (NEW SITE) CXR CONFIRMED PLACEMENT; LASIX 20 IV X1 W/~1500CC DIURESIS - 800 NEG TODAY LOS 7600+\n\nNEURO: PT VERY AFTER RECEIVING 6AM FENTANYL BOLUS - VERSED GTT D/C'D AT 0730, DID NOT RESTART - PT AWAKE ALT W/PERIODS SLEEP, CALM EXCEPT DURING PERIODS VIGOROUS STIMULATION IE SUX, APPEARS TO UNDERSTAND WHEN FAMILY SPEAKS IN HUNGARIAN\n\nRESP: SIMV + PS CHANGED ~ 1000 TO 15 PS/5 PEEP THEN LATER DECREASED TO 12 PS/5 PEEP - 1600 ABG 7.56/35/132/32/9 REPEAT 7.48/42/79/32/6\nSATS 94-100%, CONTINUES TO HAVE CHEYNES- RESPIRATIONS - LUNGS COARSE AT BASES TO CLEAR, SUX Q1-2 HR FOR THIN, WHITE SECRETIONS\n\nGI: PROMOTE W/FIBER @ 45CC/HR VIS NGT W/MINIMAL RESIDUALS, LARGE LOOSE GOLDEN STOOL X1\n\nENDOCRINE: FS @ 1200 FS 69 - REPEAT 1715 67 AFTR TUBE FEEDS OFF X 2-3 HRS FOR LINE PLACEMENT (RECEIVED 14U NPH USUAL DOSE IN AM)\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE\n\nSOCIAL: SON/DAUGHTER IN TO VISIT THIS EVENING, UPDATED REGARDING CARE\n\nA: VARYING ABG'S - ? SECONDARY TO WHERE ABG DRAWN IN PATIENTS CHEYNES- CYCLE; PH ^ ? SECONDARY CONTRACTION ALKALOSIS\nDIURESING WELL TO LASIX 20 IV\n\nP: MONITOR HR/RHYTHM, BP, CONT DIURESIS QD, PRN; MONITOR ABG'S AND SLOWLY WEAN PRESSURE SUPPORT AS TOLERATED, ? NEED FOR DIAMOX TO RX PH;\n FOLLOW FINGER STICKS, MONITOR PT'S LEVEL OF COMFORT OFF SEDATION; CONTINUE ATIVAN 1MG PO TID AND ADD SEDATION IF NEEDED FOR COMFORT; KEEP FAMILY UPDATED REGARDING PT'S CONDITION AND PLAN OF CARE, CONTINUE SUPPORTIVE CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-02 00:00:00.000",
"description": "Report",
"row_id": 1430802,
"text": "CCU NURSING ADDENDUM - 1830\nCXR NOTED ETT TO BE ~ 2 CM ABOVE CARINA - TUBED PULLED BACK AND RETAPED FROM 21 AT LIP LINE TO 20CM AT LIP LINE' REPEAT FINGER STICK AT 1815 = 78; WILL CONTINUE TO FOLLOW.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-02 00:00:00.000",
"description": "Report",
"row_id": 1430803,
"text": "CCU NURSING ADDENDUM 1900\nPRESSURE SUPPORT DECREASED TO 10; TV'S DECREASED TO 150-200, RR 38; HR UP TO 90-110 AFIB, BP 130'S, O2 SATS DECREASED TO 90; PT ALSO WITH INCREASED COUGHING, VERSED RESTARTED AT 1MG IV, RESP PAGED TO CHANGE PT BACK TO PS 12.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-04 00:00:00.000",
"description": "Report",
"row_id": 1430811,
"text": "CCU progress note 7a-7p\ncorrection!\n\nstated above pre intubation - meant to type pre extubation!!!\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-05 00:00:00.000",
"description": "Report",
"row_id": 1430812,
"text": "CCu Nursing Progress Note\nS:\nO: See for all objective data\nAfebrile\nHR 70's afib with no vea and occasional paced complex. Tolerated lopressor 50mg \nBP 130-150/50-60 Tolerated 75mg po captopril x2 with small drop in bp to 110// Heparin cont 750u/hr with PTT pnd.\nResp coarse bs which clear post cpt and coughing. Producing sputum, but pt swallows. Attempting to use sx catheter. O2 sat 97-100% on 2ln/l and 40%face tent\nu/o 40-60cc/hr is cloudy yellow\nGI - tolerated sips of water with po meds. No gag or difficulty. abd is soft with +bs and no stool this eve.\n4mm-4mm decub noted on coccyx, covered with tegaderm after being washed with soap and water\nTurned and positioned with compresion sleeves on\nA: tolerating po's/sips with meds\nP: Swallow study cx for ? asp difficulties. cont attempt at clear liqs, ?oob today, monitor sugars as pt is not getting tf's.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-10 00:00:00.000",
"description": "Report",
"row_id": 1430827,
"text": "CCU NPN 0700-1900\nS/O:\n\nCV: HR INC TO 90'S UNTIL 50 LOPRESSOR GIVEN AT 1100, HR THEN TO 70'S-80'S AF. BP STABLE. K WNL THIS AM, POOR RESPONSE TO LASIX 40 MG PO BUT PT STILL NEG FOR TODAY. MAG REPLETED PO AND IV. INR 5, WILL GIVE VITAMIN K SC X1.\n\nRESP: O2 WEANED DOWN TO 2LNP WITH SATS IN MID 90'S. LUNGS WITH CRACKLES 1/2 UP. NO SOB, RR COMFORTABLE.\n\nID: AFEB, WBC WNL\n\nGI: LIQUID STOOL THIS AM SO MOM HELD. PT WITH IMPROVED PO INTAKE OF PUREED FOOD. ABLE TO TOL PILLS WELL WHEN CRUSHED IN APPLESAUCE. 1/2 NS INC TO 75CC/HR TO PROVIDE ADEQUATE FLUID. PT STILL C/O OCC BELLY PAIN.\n\nGU: URINE WITH SEDIMENT AND SOME HEMATURIA. U/A, C/S SENT. NO C/O URGENCY\n\nMS: OOB ALL DAY, SPIRITS BETTER WITH FAMILY IN ROOM. PER FAMILY, MS IS CLOSE TO BASELINE WITH SOME INC IN DEPRESSION NOTED.\n\nA/P: QUIET DAY, PLAN IS TO REPEAT SWALLOW TEST TOMORROW AND ASSESS NUTRITION. CONT TO ENCOURAGE OOB AND INC ACTIVITY. ? REHAB EARLY IN WEEK.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-11 00:00:00.000",
"description": "Report",
"row_id": 1430828,
"text": "CCU NURSING PROGRESS NOTE\nS:PT ANSWERING IN ENGLISH VERY FEW WORDS\nO:PT AWAKE, ALERT FOLLOWED MOST COMMANDS. GRASPS EQUAL. PT DENIES PAIN. RESP:LUNGS W/ CRACKLES UP 1/2 BILAT AND UNCHANGED. O2 SATS REMAIN 96-97%. PT W/ PROD COUGH OF BLOOD TINGED SECRETIONS. SKIN WARM AND DRY. CV:MHR AFIB W/ OCCAS V-PACED BEATS. DP PULSES PALP. VS STABLE. +SYS MUR. GI:ABD SOFT DISTENDED ABLE TO TAKE MED CRUSHED IN CUSTARD. SM STOOL SMEARING. GU:AMBER COLOR URINE, SOME HEMATURIA,SEDIMENT,W/ FOUL ODOR,C+S PENDING.SKIN:PERI AREA AND GROIN SLOWLY IMPROVING W/ MACONAZOLE PWD.\nA/P:SWALLOW MON. PT AND OT FOR RECONDITIONING,MONITOR PT/INR\nPULM TOILETING AS NEEDED HAVE FAMILY TRANSLATE. PROVIDE INFORMATION AND ANSWER QUESTIONS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-11 00:00:00.000",
"description": "Report",
"row_id": 1430829,
"text": "ccu npn\nsee transfer note/referrals also\no- afebrile. started on bactrim for uti, then changed to levoquin and re'd 500mg po x1 today, then 250mg po x 4days.\ncv- hr 60-80s af, no vea. bp 120-140s/. k-3.6, re'd 40meq iv x1, to start po tomorrow. mg 1.9, re'd 2amps mgso4 iv x1. hct 30.4 inr 3.8.\ncoumadin on hold.\nresp- on 2l sats 94-98. l/s cxs/coarse 1/2 up l>r. no sob. on ivf 1/2ns at 75cc/hr d/t poor po in. u/o low in am 15-20cc/hr, then diuresed about 500cc over pm after po lasix.\ngi-for repeat swallowing study in early am, transient nausea but no vomiting after study. may have thickened liquids, pureed foods per s+s, asp. precautions. app. poor, needs assist with feeding. enc self feeding. refused most of dinner and refused some food brought in by fx, ?upset stomach. no bm.\nactivity- oob to chair after rested from swallowing study. transferred poorly, requiring max. assist from . oob for 4hrs.\nms- alert, dozed in naps after activity. oriented x1-2, difficult to understand, speech is hoarse and low, and language barrier. cooperative. non verbals appropriate.\nsocial- dtr/husband in , updated on pt status, s+s study and plan for d/c to rehab tomorrow.\nd/c- ?to rehab/ tomorrow, either or . nsg referral done, f/u md d/c summary.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-11 00:00:00.000",
"description": "Report",
"row_id": 1430830,
"text": "addendum\nsend clot in am for tlc d/c (risk bleeding). may require ffp prior to removal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-05 00:00:00.000",
"description": "Report",
"row_id": 1430813,
"text": "CCU progress note 7a-7p\nOOB to chair this afternoon. Speech and Swallow in to see pt earlier this morning, but didn't do well - ?language barrier - gave meds this afternoon w/ no coughing - using thickened liquids - tolerated well. no NGT inserted yet. Speech + Swall to re-eval. Aspiration precautions.\n\nNEURO: moves arms well. talking hungarian - nodding head to questions of 'okay' or 'water'.\n\nRESP: CPT given with turns. to ask family to instruct pt in hungarian to use incentive spirometry. O2 2L n/c w/ sats >97%. expectorating clear thin secretions. pt taught to use yankhaur suctioning.\n\nCARDIAC: AFIB w/ occ paced beats. Lopressor changed to Toprol XL. Tolerating captopril 75mg TID. MAPs >80-100s. ?anxiety factor? L radial aline patent. RIJ TLC patent. HEPARIN @ 750u/hr.\n\nGI/GU: foley patent, good u/o - slightly cloudy. no diuresis today. abd soft +BS no stool today +flatus. taking thickened water for meds without coughing this afternoon - asp prec.\n\nPLAN: pulm toliet. monitor VS. ?antianxiety meds if needed. family to visit this evening.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-03 00:00:00.000",
"description": "Report",
"row_id": 1430804,
"text": "CCU NURSING PROGRESS NOTE\nS:INTUBATED\nO:PT WITHDRAW, FLAT AFFECT, PT DOES NOT MAKE EYE CONTACT EVEN WHEN NAME CALLED. DISCUSSED PT SYMPTOMS WITH DAUGHTER PER TELEPHONE. DAUGHTER STATED SHE WAS TAKING PAXIL SINCE THE DEATH OF HER SON THREE YEARS AGO. THE ABOVE INFORMATION WAS REPORTED TO DR. . PT DOES NOT FOLLOW COMMANDS. SHE DOES MORE UPPER EXTREMITIES. WITHDRAWS LE TO NOXIOUS STIMULI. PT RESIST ORAL SUCTIONING WITH YANKAUER. STRONG COUGH AND GAG REFLEX. PT ALLOWED TO REST INBETWEEN CARE. REMAINS ON VERSED GTT AT 1MG/HR.\nRESP:VENT WAS ADJUSTED PSV UP TO 15. PT WITH IRREGULAR RESP PATTERN. PAUSES TRIGGERED APNEA ALARM, RT AWARE. NOW PSV BACK DOWN TO 12 WITH TV 330-420, RR 11-26. SATS MAINTAINED 94-97%. LUNGS WITH COARSE BS IN UPPER LUNGFIELDS. BASES DIMINISHED. SKIN PINK, WARM, AND DRY. NAIL BEDS PINK, W/ BRISK CAP REFILL.\nCV:MHR DECREASED TO 80'S A-FIB, OCCASIONAL V-PACED BEATS AT REST.\nGI:TOL TF. INC OF SM LIQ STOOL.\nGU:U/O BECOMING MORE CONCENTRATED.\nENDO:BS ARE MORE STABLE AT THIS TIME.\nID:TEMP UP, REPEAT BC\nSKIN: PT W/ AN EXCORIATED PERIRECTAL AREA. REDDENED PERIRECTAL AREA\nMICONAZOLE APPLIED.\nFAMILY:DAUGHTER UPDATED ON PT STATUS.\nA/P REPEAT BC SENT, TYLENOL GIVEN. CONTINUE TO MONITOR TEMP,CBC, CXR IN AM. RECHECK RISBI THIS AM. ATTEMP WEANING IN AM. SEE FLOW SHEET FOR ADDITIONAL INFORMATION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-03 00:00:00.000",
"description": "Report",
"row_id": 1430805,
"text": "Respiratory Care:\n\nPatient remains intubated on Psv. Vent settings Psv 12, Cpap 5, Fio2 40%. RR increasing to low to mid 30's. Psv increased to 15 with good results. RR decreasing to 12-mid teens. Psv later weaned to 12. Spont vols 340-400's. Abg reveal metabolic alkalosis. Sx'd for sm amounts of thick white sputum. RSBI 194. RSBI improved from yesterday. No further changes made. Increased fluid. Slow wean. Continue with Psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-03 00:00:00.000",
"description": "Report",
"row_id": 1430806,
"text": "CCU NURSES NOTE\nO:ABG W/ DECREASED PAO2 TO 67 WHILE PT SLEEPING. PT SUCTIONED AND STIMULATED O2 SAT IMPROVED AND PAO2 UP TO 90. U/O ALSO DECREASED WHILE SBP LESS THAN 110. SEE FLOWSHEET FOR MORE INFORMATION. LASIX ORDERED. PERI RECTAL AREA, GROIN,AND LABIA REDDENED AND EXCORIATED, MICONAOLE POWDER APPLIED TO AFFECTED AREA. M-POWDER APPLIED TO REDDENED PEELING SKIN UNDER BOTH AXILLA-REPORTED TO MD.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-03 00:00:00.000",
"description": "Report",
"row_id": 1430807,
"text": "CCU NURSING 7A-7P\nS. REMAINS INTUBATED\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nNEURO: PT AWAKE ALTERNATING W/PERIODS OF SLEEP, EYES OPENING SPONTANEOUSLY, MOVING UPPER EXTREMITIES PURPOSEFULLY, NODDED HEAD X 1\nTO RN - DIFFICULT TO ASSESS STATUS SECONDARY TO HUNGARIAN SPEAKING BUT APPEARS WITHDRAWN; REMAINS ON VERSED 1MG/HR, ATIVAN 1MG PO TID\n\nID: TEMP MAX 100.8 R - TYLENOL 650 X1, WBC STABLE AT ~9.5, ? VAGINAL YEAST W/SEVERE REDDNESS OF LABIA, GROIN AREA, WHITISH DISCHARGE NOTED, DOSE DIFLUCAN GIVEN\n\nCV: HR 60'S TO 90'S W/BURSTS TO 120 AFIB, NO VEA, LOPRESSOR INCREASED TO 50MG , BP 109-170/40-60'S, CAPTOPRIL 75MG TID - TOLERATED WELL\nLASIX 20MG IV THIS AM W/ONLY 400CC U/O, REMAINED 200CC+ FOR DAY - 1700 RECEIVED LASIX 40MG IV W/EXCELLENT RESPONSE THUS FAR ~ 700CC IN FIRST HOUR; HEPARIN CONTINUES @ 700U/HR W/PTT 76; 4.0 - RECEIVED 40 PO\n\nRESP: VENTED ON PS 12/5 PEEP 40%, ABG @ 1600 AFTER 1 DOSE DIAMOX - 7.49/40/99/31/6 - 1730 PS DOWN TO 10 W/INITIAL TV'S 200-350CC, RR 20-30, RESP PATTERN MORE REGULAR TODAY W/ LESS PERIODS OF CHEYNES-/APNEA NOTED, DAUGHTER STATES SHE IS \"ALMOST POSITIVE SHE HAS SLEEP APNEA AT HOME. SHE SNORES LOUDLY THEN STOPS ALTOGETHER THEN STARTS UP AGAIN\"; LUNGS REMAIN COARSE W/THIN WHITE SECRETIONS FROM ETT\n\nGI: PROMOTE W/FIBER AT 45CC/HR - MINIMAL RESIDUALS GUIAC NEGATIVE, LT BROWN SOFT STOOL X2 - GUIAC NEGATIVE, ABDOMEN SOFT, OBESE, NON-TENDER\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE - UA/C+S SENT\n\nENDOCRINE: FS 120-140, RECEIVED 14 NPH IN AM, NO SS NEEDED\n\nSOCIAL: DAUGHTER , HUSBAND IN TO VISIT, UPDATED REGARDING PT'S CONDITION, PROGRESS MADE\n\nA: HR HIGHER THAN PAST COUPLE DAYS - ? SECONDARY TO LOW GRADE FEVER - NOT COMPLETELY BETA-BLOCKED DESPITE INCREASE IN LOPRESSOR\nRESPONDING VERY WELL TO 40MG IV LASIX, RESP LESS IRREGULAR - ? SEC TO IMPROVED HEART FAILURE\nTOLERATING 10 PS SO FAR - ABG PND\n\nP: FOLLOW RESP RATE/RHYTHM, VITAL SIGNS, ASSESS RESPONSE TO LASIX, REPELTE LYTES AS NEEDED, FOLLOW TEMPS/WBC, TYLENOL, PRN, ASSESS YEAST INFECTION, CONT MICONAZOLE POWDER, CONTINUE TO WEAN VENT AS TOLERATED, CONT DIAMOX AS ORDERED, MONITOR ABG'S, TIDAL VOLUMES; CONTINUE TO KEEP FAMILY INFORMED OF PLAN OF CARE, CONTINUE SUPPORTIVE CARE FOR PATIENT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-04 00:00:00.000",
"description": "Report",
"row_id": 1430808,
"text": "CCU NURSING PROGRESS NOTE\nS:VENTED\nO:PT WITH EYES OPEN BUT HAD NO EYE CONTACT WHEN HER NAME IS CALLED. MAE, DOES NOT FOLLOW COMMANDS, LANGUAGE BARRIER. CALM ON VERSED GTT, HAS NOT REQUIRED ANY ADDITIONAL SEDATION.\nRESP:RR UP, TV 200S, PSV INCREASED BACK TO 12 WITH IMPROVEMENT IN RR AND TV. O2 SATS REMAINED >95%. LUNGS W/ COARSE BS AND CRACKLES AT RIGHT BASE. PT SUCTIONED FOR THIN WHITE SECRETIONS. LARGE AMTS OF ORAL SECRETIONS. PT RESISTS MOUTH CARE.\nCV:MHR AFIB W/ OCCASS V-PACED BEATS. DP PALP, SEE FLOW SHEET FOR VS\nGI:TOL TF, MIN RESID, +BS. NO BM.\nID:TEMP DOWN TO 99.4\nENDO:BS W/IN PARAMETERS, NO COV.\nSKIN:REDDENED, EXCORIATED PERI AREA, APPEARS TO BE IMPROVING\nSOC:SPOKE W/ DTR FOR UPDATE ON PHONE\nA/P:FAILURE TO WEAN, CONTINUE TO DIURESE, RSBI IN AM, ATTEMPT WEANING IN AM. EVAL FOR TRACH, OOB TO CHAIR. BC PENDING.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-25 00:00:00.000",
"description": "Report",
"row_id": 1430765,
"text": "CCU Nursing Progress Note 1900-0700:\nS-Intubated and sedated\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VS\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\n\nO-MS:Arousing to stimuli and voice. Pt appearing more agitated than previous pulling at restraints and found pulling att ETT suction catheter. Recieving Versed and Fentanyl (1mg and 50mcgs times three doses with good effect), resuming 0.5mg and 25mcg dose thereafter Q1-2hr.\nCV:HR 70s to 100s. Afib with intrisic beats and occasional pauses. Periods where pacer not sensing. Attempting to document on EKG, unsuccesful. Dopa shut off for increasing run of RAF/VT. Levo restarted at previous dose and titrated to MAP > 60. CVP transduced and noted to 15-16 overnight. Left groin TLC removed. Site ecchymotic with no hematoma palpated. Pulses palpable distal. K 3.3 this AM with repletion begun.\nRESP: LS course throughout. Vent: AC/450/12/.50/8 PEEP. SpO2 trending down to high 80s. PO2 down to 60s on gas. Inreased Fio2 to 50%. Later found pt to do same thing, noted to have cuff leak. Issues resolving once leak fixed. Suctioning for thick tan secretion in small to moderate amounts. AM RSBI 88.\nGU/GI: HUO trending down post Dopa wean. Given two 500cc fluid boluses with some improvement. At MN 9L(+) and 10L for LOS. Abd soft with (+) BSs. Passing flatus. Passing small amount of brown liqiud stool. G(+). TF advanced to GR at 5AM this morning and thus far tolerating well.\nENDO: FS at MS 149, requiring no coverage and AM FS 190 and treated with sliding scale.\nHCT: Repeat HCT down to 25. Ordered to transfuse 2UPRBCs. 1st unit in and awaiting 2nd unit from BB.\nID: Tm 99.1 Tc 98.1. Continues triple Abx. Cultures still pending. WBC noted to be trending up to 17 from 13 this AM.\nA/P:\nContinue to monitor.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-25 00:00:00.000",
"description": "Report",
"row_id": 1430766,
"text": "RESP CARE\nPT remained intubated and ventilated overnight. Required an inc in fio2 to 50% for a sat of 88. Suctioned for thick tan sput. RSBI done this am=88. Will follow as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-25 00:00:00.000",
"description": "Report",
"row_id": 1430767,
"text": "Respiratory Care\nPt remains ventilated with small changes made as a result of ABG resluts. Breath sounds dimished throughout. Sx for small amts of light tan secreations. RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-25 00:00:00.000",
"description": "Report",
"row_id": 1430768,
"text": "CCU progress note 7a-7p\nID: initial Cx's show gram neg rods in sputum + yeast in urine. Cdiff cx pnd (need 2 more cultures). BCs pnd. On Flagyl, Vanco, Imipenem. Tmax 99.1 core temp.\n\nNEURO: lightly sedated on versed and fenanyl q1-2h. nods head when awake. husband visiting this evening.\n\nRESP: LS coarse. sx tan to whitish thin secretions. Sats 94-97%. ABG: 77/32/7.45/20/-4 Vented: AC 450x12 50% peep 6. overbreathing vent when awake.\n\nCARDIAC: AFIB 70s-140s (short bursts of RVR w/ lightening of sedation) MAPs 60-70s. weaned off Levo. PA line placed over wire in RIJ. L radial aline patent. goal wedge in the teens.\nPA 57/35 PCWP 31 CVP 21 CO 3.3 CI 2.05 SVR 1455\nHEPARIN started @ 950u/hr - ptt due 2400hrs.\nNATRECOR started @ 0.01mcg/k/min w/ bolus.\n\nGI/GU: foley decreased output - BUN 25 CR 0.9. given 1 fluid bolus 500cc prior to PA line insertion - post insertion noting elvated wedge/cvp - started on natrecor for low bp + high wedge/cvp/pa. stooled in small amts - golden loose stool. NGT - TF promote w/ fibre GR 45cc/hr.\n\nPLAN: cont' natrecor , check PTT @ mn. keep pt sedated for comfort. collect stool for CDIFF.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-09 00:00:00.000",
"description": "Report",
"row_id": 1430825,
"text": "CCU NPN 0700-1900\nS/O:\n\nCV: VSS, CONT IN AF. HEP D/C'ED THIS AM AFTER INR HIGH BUT THEN RESTARTED WHEN INR TO 4.9 AT 600U/HR. PTT DUE AT . CAPTOPRIL CHANGED TO ZESTRIL 40 MG QD AND LASIX STANDING DOSE OF 40 MG STARTED TODAY. REC'D 20 MEQ KCL IV BECAUSE PT GAGGED AT ONE POINT WHEN TAKING PILLS MIXED IN CUSTARD, TOL PILLS LATER IN THE DAY. PT NEG 600 FOR TODAY WITH VIGOROUS DIURESIS AFTER PO LASIX. EDEMA IMPROVED, ONLY + IN EXTREMETIES.\n\nRESP: WEANED TO 2LNP WITH SATS IN MID 90'S. LUNGS WITH CRACKLES 1/3 UP BILAT, IMPROVED AFTER DIURESIS. NO SOB. OCC PROD COUGH.\n\nID: AFEB, WBC WNL.\n\nGI: SS INSULIN COVERAGE D/C'ED. PT EATING PUREED FOOD ALTHOUGH SHE DOES NOT LIKE THE TASTE. NO BM, POS BS. 1/2 NS STARTED AT 50CC/HR AS PT UNABLE TO SAFELY DRINK LIQUIDS ACCORDING TO LAST SWALLOW STUDY. PLAN IS TO RECHECK SWALLOW STUDY ON MONDAY. NO EVIDENCE OF ASPIRATION DURING MEALS, PT ABLE TO TAKE PILLS WHEN CRUSHED AND MIXED WITH APPLESAUCE.\n\nGU: FOLEY DRAINING CLEAR URINE.\n\nMS: PT ASKING APPROPRIATE QUESTIONS, ABLE TO CONVERSE IN BROKEN ENGLISH. COOPERATIVE ALTHOUGH DID NOT WANT TO GET OOB IN AFTERNOON AND TRIED TO GET BACK IN BED HERSELF AT ONE POINT. PT APPEARS DEPRESSED, C/O BEING \"SO TIRED\" TODAY. ABLE TO TRANSFER TO CHAIR WITH 2 ASSIST AND TAKE FEW STEPS TO PIVOT.FAMILY IN TO VISIT THIS EVENING.\n\nA/P: TOL PUREED FOOD. STABLE ON CURRENT MEDS FOR TODAY. CHECK K AND PTT AT . CONT TO ENCOURAGE REHAB AND INC ACTIVITY. SAFETY PRECAUTIONS AS PT DOES NOT FULLY UNDERSTAND ALL EXPLANATIONS. CONT TO PT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-10 00:00:00.000",
"description": "Report",
"row_id": 1430826,
"text": "CCU NURSING PROGRESS NOTE\nS \"HURTS\"\nO:PT COUGHING AND GAGGING AFTER RECIEVING LOPRESSOR XL W/ APPLESAUCE. PT VOMITED SM AMT OF UNDIGESTED GASTRIC CONTENT. SATS DROPPED TO 91% ON 2L. O2 INCREASED TO 4L. SATS UP TO 94% PT'S FACE ALSO TACHYPNEIC AND DYSPNEIC. LUNGS W/ DEPENDANT CRACKLES ON RIGHT 2/3 UP. SITTING UP PT WITH BIB CRACKLES >ON RIGHT. DR. AND DR. IN TO PT. CXR DONE. PT GIVEN LASIX W/ GOOD DIURESIS. RESP STATUS IMPROVED BUT PT HAVE ASPIRATED. PT WAS NOT ABLE SWALLOW LOPRESSOR. MD AWARE. PT REMAINED NPO AND LOW DOSE MAINT. FLUID WICH ARE TO CONTINUE AS PER DR. .\nGI:PT RUBBING LOWER ABD, WHEN ASKED, PT REPEATED HURTS. ABD SOFT AND DISTENDED. +BS, PLACED ON BED PAN BUT W/O BM. LATER PT WAS INC OF A SM FORM BM. MD NOTIFIED OF PT .\nGU:URINE DRK, + HEMATUREA,+SEDIMENT.\nNEURO:PT ALERT EYES ONPEN BUT SPEAKING MOSTLY HUNGARIAN. PT ABLE TO FOLLOW MOST SIMPLE COMANDS GIVENT WITH GESTURES\nID: THE PT AFEBRILE\nSKIN: PERI-AREA REMAINS REDDED SITE CLEANSED. MACONAZOLE APPLI\nA/P CONTINUE TO MONITOR FOR ASPIRATION PERCAUTIONS. SWOLLOW TO BE REPEATED, MONDAYTO CONTINUE. CONTINURE TO MONITOR HEMODYNAMIC STATUS. OOB TO CHAIR TODAY . PT /OT\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-23 00:00:00.000",
"description": "Report",
"row_id": 1430760,
"text": "CCU admit note 1600hrs\nSEE FHP for admit note.\n\nArrived on floor via med flight from . On LEVO titrated up for sBP 80. Aline inserted. CXR + EKG done. PAN CXd. IVF boluses of NS started. FEBRILE 102 rectal. labs drawn.\n\n\nID: TEMP 102 rectal. BC x 3 sets sent - Fungal Cx sent. Nystatin ordered and applied under both breasts, both axilla and to excoriated reddened groins! New Foley cath inserted, scant urine - send u/a + c+s when enough urine accumulated in catheter. To have femoral line inserted tonite - Cx tip when d/c'd. Noted purulent drainage from TLC site. L s/c pacer site dsg was soaked w/ serous/yellowish drainage - dsg removed and site cleansed w/ betadine. site puffy. abx to be ordered. WBC 35.9 (WBC 12 )\n\nNEURO: was paralyzed + sedated for transfer to - woke ~6pm given versed and fentanyl for sedation w/ good effect IVPush. bilat wrist restraints.\n\nCARDIAC: AFIB 70-130s. SBP 80-100s. L radial ALine inserted. to have R s/c line d/c'd tonite and new fem line inserted. LEVO titrated for maps 70s.\n\nRESP: Vented - sx mod amt tan thick bld tinged secretions. 100%. sats 100%. pm abg pnd. LS coarse. CXR showed pneumonia not chf.\n\nGI/GU: new foley inserted - please collect Cx/u/a. abd soft +BS. cleaned up mod amt yellow stool on arrival to CCU. NPO. NGT intact.\n\n\nPLAN: to be collected :urine cx, R s/c TLC tip for cx. admin abx when ordered. con't levo gtt. adjust vent settings per abg results. advance ETT per CXR.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-24 00:00:00.000",
"description": "Report",
"row_id": 1430761,
"text": "CCU Nursing Progress Note 1900-0700:\nS-Intubated and sedated\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN HEMODYNAMICS\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\n\nO-MS:Arousing to voice, when calling pt's name. Looking around and later closing eyes. Pt \"slavic\" speaking only. Making purposeful movement when hands untied, ie reaching for ETT. Sedated with IVP Versed and Fentanyl, 1mg of Versed and 50mcgs of Fentanyl IVP Q1-2hrs.\nMAEs on bed.\nCV:HR 70s to 100s. AFIB with occasional PVCs. Periods where pacer not sensing. Cards aware. K 5.3 and recently down to 5.1. BPs 70s to 180s. IVF boluses continued, given as much as 3Ls of NS overnight, Levo as high at .4mcgs/kg/min. Pt precipitously dropping BPs once boluses finished infusing. Levo currently at .150mcg/kg/min. Dopa later added for \"renal perfusion,\" with increasing runs. AED placed and continued to monitor. TLL catheter inserted per left femoral sight with difficulty. Site slightly eccyhmotic with no hematoma palpated. Pulses palpable distal. BLEs cool to touch, and slighly mottled.\nRESP: LSs course with some exp wheeze and crackle at bases. ABGs later with metabolic acidosis and later pt hypoxic. Intially increasing rate with no effect. NaHCO3 given with improvement. PEEP and FIO2 increased with effect. Current vent settings: AC/450/16/.60/10 PEEP. Suctioned for thick tan secretion in small amounts. CXR with some worsening failure vs ARDS, (+) b/l infiltrates.\nGU/GI: Intially anuric. Post IVFs and higher BPs, HUOs 80-160cc/hr. Since MN 4.7L(+) and for LOS 5.3Ls(+). Creat slightly down to 1.4(1.5) last night, AM pending. Lactate 6.8 post NaHCO3 4.8. AM pending. Abd soft, non-tender with hypoactive sound. NGT in place per CXR. Aspirating for clear aspirate and heme(+). Nutrition c/s'd for AM, for possible start of TFs today. Tiny smear of stool on pad but not enough to guiac or cx.\nID: Tm 99.0 rectal Tc 98.9 orally. Started on Vanco, Imipenem, and Flagyl. Urine cx and catheter tip cx sent prior. Sputum with prelims of GNR but 25+ PMNs. Blood, urine, and tip pending.\nHEME: HCT on repeat, 32 down from 37. Continue to monitor. DIC work-up (+) in addition to AST and LD elevation. Question hypoperfusion and continue to monitor.\nSOC:Family staying for most of night, two supportive daughters. , youngest daughter is ICU RN at Medical Center in NH. is HCP. is eldest daughter and staying overnight. In all three children. is primary contact. In addition husband in and visiting, slavic speaking only as well, very distraut over wife illness and weeping at bedside. Updated by RN and MDs. Very supportive and kind family.\nA/P: 80 yo female who present to with septic shock with possible sources of sputum, PPM, blood, or urine.\nPlan for possible swan\nAnticipate starting of TFs\nWean pressors as tolerated\nUnlikely to go to cath lab but anticipate\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-24 00:00:00.000",
"description": "Report",
"row_id": 1430762,
"text": "Respiratory Care:\nPt. with marginal oxygenation, requiring increased peep and FIO2>>no RSBI done. ABG's currently showing adequate oxygeantion and a partially compensate metabolic acidosis, with a HCO3 given>>overcompensating for the acidosis, causing a slight alkalosis. ? travel to CT for look at her belly, postponed for now, due to lactate level decreased. OET pulled back at start of shift, with report of repeat CXR with OET in adequate position. Will follow.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-24 00:00:00.000",
"description": "Report",
"row_id": 1430763,
"text": "RESPIRATORY CARE\nPT REMAINS VENTILATED WITH CORRESPONDING VENT CHANGES TO ABG RESULTS. BREATH SOUNDS DIMINISHED THROUGHOUT. RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-24 00:00:00.000",
"description": "Report",
"row_id": 1430764,
"text": "CCU progress note 7a-7p\nEvents: weaned off Levo, fluid boluses of 2L. Heparin d/c'd. renal dose dopa this afternoon for maps 55 + decreased u/o. New TLC placed in RIJ and L fem TLC to be d/c'd.\n\nNEURO: lightly sedated on boluses of fentanyl and versed. pt opens eyes to stimuli, nodding head appropriately to family - nodded head to \"okay?\". speaks hungarian only - daughters translate if necessary. moves arms when suctioned - soft wrist restraints.\n\nID: Tmax 101 early this morning - tylenol given @ 7am. Temp ranging from 99.6 to 98 this evening. Increased doses of IMIPENUM, FLAGYL + VANCO. Cultures still pnd. WBC 13.5 this afternoon (am 19.6). Culture tip of femoral TLC. nystatin to groins, under breasts and axilla - angry red candidal infection (groins excoriated purple/red).\n\nRESP: LS coarse, sx'd thin tan secretions. multiple vent changes today - current settings: AC 450x12 peep 8 40% ABG: 7.43/36/80/25/0 sats 94-97%. CXR showing improved failure. sputum Cx: gram neg rods.\n\nCARDIAC: AFIB 60s-130s - freq pauses causing paced beats from VVI pacer rate set at 60. short spurts of rapid ventricular response to 100-130s then back to 60-80s. MAPS 50-70s. Dopa initally turned off at 8am. Weaned off LEVO by 1430hrs - total of 2L NS boluses today - on NS @ 100cc/hr. renal dose Dopa restarted @ 3mcg/k/min for low u/o and low maps ~55. Heparin d/c'd. +DIC. INR this afternoon 1.7 (am 2.2). lactic acid 1.9 this afternoon. K + Mg repleated this evening. pm HCT 26.1 (am 31.4) ?dilutional? HO aware. L fem TLC intact, but site comprimised by candidal infection of groins. New site obtained RIJ this evening - CXR pnd.\n\nGI/GU: foley patent, decreased u/o - given fluid boluses earlier now on renal dose dopa. BUN 25 CR 1.1 (am 1.3) abd soft +BS. small amt golden loose stool +flatus. very small trace OB in stool - pt's bottom excoriated + has some hemhrroids bleeding. NGT to be advanced and checked in next CXR this evening post TLC insertion. TF started this afternoon - promote w/ fibre @ 15cc/hr GR 45cc/hr.\n\nENDO: FS QID, started on SSRI.\n\n\nPLAN: titrate pressors to off as tolerated. monitor u/o. con't IVF. con't TF. monitor residuals. FS QID. remove femoral TLC and send tip for culture. save 1 port on TLC for possible TPN. obtain stool cultures if pt stools.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-08 00:00:00.000",
"description": "Report",
"row_id": 1430821,
"text": "CCU NPN 1900-0700\nO: afeb. HR 70-80's afib with V paced beats. BP stable 120-130's/50's. tolerating 75 captopril in eve. u/o 50-100cc/hr. (-) 1L for and (+) 2L LOS.\n\nLS diminished bases. 2lNC sats 97%. RR 20-30\ntaking meds well with pudding or jello either crushed or whole. appears to be swallowing well with no signs of coughing, difficulty.\n\npt. appearing anxious in eve, moving all around bed, moving legs up in air and wanting to get OOB. given .25 po ativan with very good effect. pt. slept well and is alert this morning, responding to simple commands. unable to determine orientation d/t language barrier.\n\nno stool.\n\nheparin 750u/hr. IVF at 75cc/hr while pt. not taking enough po's.\n\nA: stable night.\nP: contin. with PT/OT> rehab screening. needs additional swallow study with flouro/video ? today.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-08 00:00:00.000",
"description": "Report",
"row_id": 1430822,
"text": "ccu npn\no- afebrile po.\ncv- hr climbing 7:30am and re'd ativan .25mg po for anxiety. however, hr cont to rise to 150-160, bp up to 160/ and became acutely sob/diaphoretic, c/o epigastric pain. re'd total lasix 40mg, lopressor 15mg, iv ntg on to 4.3mic/kg/min and 2mg mso4. ivf d/c'd. 02 increased to 6l n/c plus 100%neb with sats up, but still with high rr and labored breathing. on bipap. hr grad down to 80-100s and bp grad. down. unable to obtain ekg d/t very diaphoretic. cxr done showed increased chf, etc. re'd additional lopressor 5mg iv and then usual po dose. hr high 50s-70s af with occ pacing. bp down to 85-90s and iv ntg grad. weaned off. bp up to 100-120s this pm. cont. on heparin, increased to 800units/hr for ptt 60.4, inr 1.5. check pt/ptt in am. k- 4.0. hct 32.\nresp- as above, on bipap until 11am and back to 6l with sats 94-98, rr down and sob improved. diuresed about 500cc, goal is i+o even today. is neg about 100cc currently. l/s dim, clear upper, cxs on left lower, right lower coarse.\ngi- on thickened liquids/pureed food and tol well. taking meds with thickened water or applesauce (whole), no coughing. down for swallowing study this pm and verbal result per s+s, ?slight aspiration. vomited lge white at end of study while upright. recommended meds with pureed food only. no liquids. reassess monday.\nabd soft with b. sounds. epigastric pain gone after am. no bm.\nms- speaking hungarian, does interact appropriaely nonverbally. ?confused. cooperative.\nskin- intact, nystatin powder to groins, axilla which are pink. repos side to side with skin care q2-3hrs as tolerated. on back, uppright with sob. has 1st step mattress, pneumoboots.\nsocial- fx called, no visitors yet today. dtr updated on am event and pt status.\na- pul edema in am\np- cont. to monitor for high hr, sob. increase lopressor dose this eve. cont. heparin/coumadin. check k if diuresed again this eve. goal i+o even. hold meals and give pureed food with meds only until further notice. ?ngt. ?repeat swallowing study monday. asp. precautions.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-01 00:00:00.000",
"description": "Report",
"row_id": 1430794,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ S/P PULM EDEMA; MR\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA.\n\nCV- HR- 68-81 AFIB/ NO VEA. K- 3.8- 40 KCL.\nBP- 108/43-125/53. REMAINS ON CAPTOPRIL 75 TID AND LOPRESSOR 37.5 TID AS WELL AS DIGOXIN 0.125.\nCO/CI/SVR- 3.6/2.24/1444. HEPARIN AT 800U- AM LYTES/CBC/COAG PENDING.\n\n PT REMAINS 50% PS- 15; TV- 420-450 WITH RESP RATE- MID 20'S. PH 7.55- 7.48. OFF LASIX CURRENTLY.\nPO2- 77-88. SX Q 3 HOUR FOR WHITISH THIN SPUTUM.\nCOARSE BREATH SOUNDS BILATERAL.\nPAD- 22-24, CVP- , PCW- 22.\n\nID- AFEBRILE.\n\nGI- TUBE FEEDS 45CC/HOUR- STOOL SOFT FORMED G (-).\n(+) BOWEL SOUNDS. SS/NPH INSULIN COVERAGE\n\nGU- GOOD UO- 40-60CC/HOUR. HELD PM LASIX D/T ALKALOSIS.\nI/O (-) 1 LITER .\n\nMS- VERSED GTT 1 MG.\nSOME BOLUSES WITH AGITATION.\nFAMILY IN TO VISIT.\nDAUGHTER X 2 CALLED, SPOKE AT LENGTH ABOUT PLAN OF CARE\nCURRENT PROGRESS.\n\n\nA/ PT WITH LONG HOSPITAL COURSE WITH MR/LOW EF/PULM EDEMA- CURRENTLY WITH GOOD DIURESIS C/B PERSISTENT ALKALOSIS.\n\nCONTINUE PULM TOILET/WATCH I/O AND PA # AS WELL AS HEMODYNAMICS/CO.\nMAX RPP/CV MEDS.\n?DIAMOX IF PERSISTS WITH ALKALOSIS.\nSEDATION/COMFORT WHILE INVASIVE LINED AND ETT.\nKEEP FAMILY AND PT AWARE OF PLAN OF CARE.\nCONTINUE TO WATCH FOR TEMP/FEVER OFF ANTIBX X 3.\nCULTURE AS NEEDED.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-01 00:00:00.000",
"description": "Report",
"row_id": 1430795,
"text": "Respiratory Care:\n\nPatient remains intubated on Psv. Current settings Psv 15, Cpap 5, Fio2 50%. Spont vols 400's with RR mid teens. Sx'd for moderate amounts of thick white sputum. Bs clear bilaterally. RSBI results 200. PaO2 improving. No further changes made. Continue with Psv as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-01 00:00:00.000",
"description": "Report",
"row_id": 1430796,
"text": "CCU NURSING NOTE 7A-3P\nS. INTUBATED\n\nO. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA\n\nID: TMAX 99.7 CORE, NO ANTIBX, UA/C+S SENT, WBC 11 FROM 9\n\nCV: HR 60-80'S AFIB, DIG GIVEN, LOPRESSOR REMAINS AT 37.5MG\nBP 117-141/50-60'S, CAPTOPRIL AT 75MG TID, PAP'S 36-43/17-22, CVP 10-13, LASIX 20MG IV AT 1030 W/ > 1 LITER DIURESIS, SATS 98/66 W/CO/CI AT 1200 - 4.4/2.73 SVR 1036; HEPARIN DECREASED TO 700U/HR FOR PTT 96\n\nRESP: REMAINS INTUBATED AT 50% 15 PS/5 PEEP - SATS 98-10%, TV 350-550 W/CHEYNES- PATTERN AND FREQUENT PERIODS OF APNEA, LUNGS REMAIN COARSE THROUGHOUT, SUX FOR SM THIN WHITISH SPUTUM Q 2-3HR; LAST ABG 7.45/47/110/34/7\n\nMENTAL STATUS: EASILY ARROUSABLE TO VOICE, DIFFICULT TO ASSESS ORIENTATION SECONDARY TO INTUBATED AND LANGUAGE BARRIER, SLEEPING ON/OFF THROUGHOUT DAY ON VERSED 1MG IV GTT, ATIVAN PO TID CONTINUES FOR PERIODS OF ANXIETY\n\nGI: TOLERATING PROMOTE W/FIBER AT GOAL 45CC/HR, MINIMAL RESIDUALS, ABDOMEN SOFT, DISTENDED, MOD GOLDEN SOFT STOOL X1- LG AMT.\n\nGU: FOLEY DRAINING CLEAR YELLOW URINE W/SEDIMENT NOTED - UA/C+S SENT.600 CC NEGATIVE THUS FAR TODAY\n\nSOCIAL: FAMILY CALLED X2 - WILL BE IN LATER TODAY\n\nSKIN: INTACT EXCEPT FOR RED RASH BILAT AXILLA/UNDER BREASTS/GROIN AREA - CLEANSED THIS AM W/SOAP/H20, MICONAZOLE POWDER APPLIED\n\nA: IMPROVED CARDIAC OUTPUT/INDEX, ABG BETTER W/ONLY MARGINAL ALKALOSIS, TOLERATING CAPTOPRIL/LOPRESSOR W/GOOD BP AND SLOWER HR\nCHEYNES- BREATHING CONTINUES\n\nP: MONITOR HEMODYNAMICS, INCREASE CAPTOPRIL/LOPRESSOR PER TEAM AS TOLERATED; CONTINUE GENTLE DIURESIS AS TOLERATED, DECREASE PRESSURE SUPPORT TO 12 PER TEAM - FOLLOW ABG'S/I+, RECHECK PTT AT 1630,\nEMOTIONAL SUPPORT FOR PT/FAMILY, CONTINUE SUPPORTIVE CARE.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-08 00:00:00.000",
"description": "Report",
"row_id": 1430823,
"text": "77 years old female admitted with S.O.B. Patient has PMHX:CAD,multiple cva's,carotid stenosis,anxiety,depressionand insomnia. Went in acute resp distress this am associated with desaturation. Patient placed on non-invasive ventilation for a while now on 5 liter N/C. vent still in room on stand-by.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-09 00:00:00.000",
"description": "Report",
"row_id": 1430824,
"text": "NSG NOTE\n\nCV: REMAINS IN A-FIB WITH HR 64-74. CON'T ON METROPOLOL XL 100MG/25MG @HS. ALSO ON DIGOXIN. SBP 118-140/38-69 CON'T ON HEPARIN @ 800U/HR AND GETTING COUMADIN 5MG QD.\n\nRESP; O2 SATS ACCEPTABLE 97-99%. HAS RALES 1/2 UP BILAT,BUT APPEARS COMFORTABLE AND RR-20'S. M.D. INTO ASSESS BS IN LIGHT OF RECENT EPISODES OF CHF. NO FURTHER ORDERS GIVEN FOR LASIX.\n\nGI: TOL CUSTARD AND THICK FOODS WITH MEDS ONLY. REMAINS NPO FOR REPEAT SWALLOW STUDY ON MONDAY. ABD SOFT. +BS NONTENDER ABD. NO STOOL THIS SHIFT. M.D. ATTEMPTED NGT PLACMENT,UNSUCCESSFUL.\n\nGU: U/O DOWN TO 10CC-26CC/HR M.D. NOTIFIED. I/O NEG BY 160CC. M.D. WANTS I/O EVEN.\n\nSKIN: PACER SITE UNCHG. BUTTOCKS SL REDDENED BUT INTACT.\n\nNEURO: WILL SMILE ON OCCASSION. FOLLOWS COMMANDS DESPITE LANGUAGE BARRIER. MAE. RESPONDING WELL TOWARDS FAMILY AND INTERACTING WITH THEM.\n\nID: TEMP MAX 96.9\n\nLABS: BS 129 NO SSI REQUIERED.\n\nSOCIAL: FAMILY IN ON EVES.\n\nA: STABLE/DISCHG PLANS IN PROGRESS\n\nP; REPEAT SWALLOW STUDY MONDAY\n ASPIRATION PRECAUTIONS\n PREPARING FOR D/C TO REHAB ONCE SWALLW ISSUES RESOLVED\n\nA: STABLE\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-30 00:00:00.000",
"description": "Report",
"row_id": 1430788,
"text": "CCU progress note 7a-7p\naddendum:\n\nLasix given at 530pm w/ 400cc out in 30min. To be given evening dose of captopril. Cardiac Calcs pending.\n\nBlood Cultures to be drawn later tonite per HO - watching for temp spike - last temp 100.2.\n\nFamily in to visit @ 6pm.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-29 00:00:00.000",
"description": "Report",
"row_id": 1430783,
"text": "CCU progress note 7a-7p\nNEURO: started on versed gtt for anxiety/sedation - still remains lightly sedated on 2mg/hr - nodding head to questions posed by family - Hungarian speaking only. opens eyes spontaneously, moves arms and legs. to start ativan TID po.\n\nID: tmax 99.5 core. remains on flagyl, vanco, imipenem.\n\nCARDIAC: AFIB 80-140s - VVI pacer set 60 - SBP 120s. PA line RIJ patent. PA 43/26 CVP 16 CO 3.6 CI 2.24 SVR 1222. L radial aline patent. Heparin @ 800u/hr. Natrecor increased to 0.025mcg/k/min. Captopril 37.5mg TID tolerating well ?increase next dose to 50mg. Lopressor 37.5mg tolerating well.\n\nRESP: AC 400x10/50%/5peep - PS wean this evening - alkalotic 7.55ph RR stoking 28-33 to apneic periods <15sec. sats >95%. Sx frothy white this morning, to thick white this afternoon. Diuresed x 2 today. LS coarse, occ exp wheezes. MDI per RT.\n\nGI/GU: foley patent. lasix started 20mg IV BID. good diuresis. goal -1L/24hrs. abd soft +BS. + flatus. stooling small amts loose/soft golden stool. guiac neg. TF goal via OGT - promote w/ fibre @ 45cc/hr. FS QID w/ RISS.\n\nPLAN: cont' to try to adequately relieve pt's anxiety w/ anxiolytics, increase next dose captopril. monitor u/o for goal -1L for today. con't vent wean as tolerated. Cardiac calcs q4h.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-29 00:00:00.000",
"description": "Report",
"row_id": 1430784,
"text": "addendum\nchanged back to AC - poor cardiac calcs at 6pm. given additional dose of captopril 25mg po at 7pm. Recheck calcs at 8pm.\nAtivan 1mg po given at 6pm - versed gtt off at 7pm until pt is more anxious (maps 58-60).\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-30 00:00:00.000",
"description": "Report",
"row_id": 1430785,
"text": "Respiratory Care\nVent settings unchanged this shift. Attempted RSBI @ 4:30am, no effective spontaneous respiratory efforts noted over 60 second period. Suction several times for small amounts of pale white secreations. RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-30 00:00:00.000",
"description": "Report",
"row_id": 1430786,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ RESP FX; MR\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n PT OFF PRESSORS BUT WITH MARGINAL BP ONCE SEDATED/ BACK ON A/C MODE VENTILATION. INITIALLY- BP- 130-170/ WITH AGITATION AND SEDATED WITH VERSED 2 MG BOLUSES- RESTARTED GTT 2MG-1.5 MG. BP THROUGHOUT SHIFT RANGED FROM 88/47-114/60 WITH MAPS 55-62. HR 100-110'S AFIB WITH BURSTS UP TO 130'S WITH AGITATION AS WELL. HEPARIN GTT FOR AFIB REMAINS AT 800U/HOUR. CO/CI/SVR THIS SHIFT- 2.9-3/1.8-1.86/1000. NO SIGNIFICANT CHANGES WITH LOWER MAPS ON SEDATION.\nRECEIVED INCREASE CAPTOPRIL DOSE ONCE BP>90/ AND REMAINS ON LOPRESSOR 25 . NO OTHER CHANGE TO MED REGIMEN THIS SHIFT BESIDES INCREASE IN CAPTOPRIL.\n\n PT BACK ON A/C- 50/600/10 - BREATHING OVER VENT RATE- 16-20- SUCTIONED FOR THICK WHITISH SPUTUM Q 2-3 HOURS. COARSE SOUNDS BILATERALLY- PAD- 22-28, CVP 14-17, PCW- 22. GIVEN LASIX LATE AFTERNOON- NO MORE THIS SHIFT= STOPPED NATRECOR D/T MARGINAL BP AT 12 AM. HOLDING FURTHER PUSH FOR DIURETICS D/T RESP ALK AND LOW NORMAL CI WITH DIURESIS 7/29 PER TEAM PLAN.\n\nID- CORE TEMP MAX- 100 REMAINS ON TRIPLE ANTIBX. NO TEMP /FEVER SPIKE THIS SHIFT.\n\nGI- TUBE FEEDS- 45/HOUR PROMOTE WITH FIBER.\n(+) BOWEL SOUNDS. NO STOOL THIS SHIFT.\nSS REG INSULIN- HOLDING D/T BLOOD SUGAR < 160.\n\nGU- FAIR UO WITH MAPS 55-62= MAINTAINING UO 20-50/HOUR VIA FOLEY CATH.\nNO DIURESIS THIS SHIFT- SEE ABOVE.\n\nMS- HUGE AMOUNTS AGITATION/ BRONCHOSPASTIC, COUGHING AND TONGUING ETT WITH ANY SLIGHT STIMULATION; TACHYPNIC, HTN, TACHYCARDIA WITH AGITATION NECESSITATING SEDATION. GIVEN VERSED 2 MG BOLUSES AND RESUMED GTT AT 2 MG, NOW 1.5 MG WITH SLIGHT IMPROVEMENT IN BP/MAP.\nDAUGHTER CALLED 11P TO CHECK ON PROGRESS.\n\n\nA/ PT WITH LONG HOSPITALIZATION /RESP FX REMAINS WITH DIFFICULT TO CONTROL RATE/PRESSURE/PRODUCT- LABILE HEMODYNAMICS/\n\n-CONTINUE TO ATTEMPT TO DECREASE AFTERLOAD WHILE MAINTAINING MAP>60 WITH CURRENT MED REGIMEN.\n-CONSIDER RESTARTING PRESSORS IF UO DROPS OR CREAT THIS AM RISES.\n-CONTINUE TO DISCUSS ? AGGRESSIVE DIURESIS/NOT FOR ELEVATED FILLING PRESSURES/CHF/FX TO WEAN. APPROACH FAMILY WITH CONCEPT OF TRACH IF CONTINUES TO NOT SIGNIFICANTLY IMPROVE FROM RESP STATUS.\n-SEDATION AND COMFORT TO INSURE PT COMFORT/SAFETY AND VENTILATION,\n-ATTEMPT TO WEAN TO MINIMAL AMOUNT NEEDED AS WILL DIRECTLY HELP IMPROVED MAP/BP.\n- KEEP PT AND FAMILY AWARE OF PLAN OF CARE\n-RATE CONTROL WITH LOPRESSOR, AS BP ALLOWS.\n- NUTRITION/BOWEL MEDS/SKIN CARE/ SS REG INSULIN PER PROTOCOL\n- KEEP HEPARIN AT THERAPEUTIC DOSE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-30 00:00:00.000",
"description": "Report",
"row_id": 1430787,
"text": "CCU progress note 7a-7p\nNEURO: lightly sedated on versed gtt @ 1mg/hr and ativan 1mg po TID. opens eyes, nods head. hungarian speaking only. family communicates with pt. purposful movements.\n\nID: abx D/C'd. Tmax 99.6. con't to monitor for spike in temp. surveylance blood cultures need to be obtained.\n\nRESP: LS coarse. frothy secretions this morning pre lasix 20mg ivp - then had clear thick secretions during the day. this afternoon ~4pm having white frothy secretions again. pm dose of lasix held per HO. AC most of day, switched to PS 15/5 50% @ 4pm. pm ABG pnd. sats >97%. RR 11-38 - stoking.\n\nCARDIAC: AFIB 90-140s during the day - digoxin load started and now rate AFIB 60-80s this evening. 2nd + 3rd doses of dig IV to be given this evening/nite. PA line RIJ patent. PADs 26-30 CVP 16 PA sats ~ 60% last CO 3.8 CI 2.36 SVR 1200. L radial aline patent. 3+ generalize pitting edema. Remains on Heparin @ 800u/hr. Natrecor remains off. Am captopril dose held. Lopressor 37.5mg . new PIV placed in R hand.\n\nGI/GU: foley patent. fair urine output. lasix 20mg ivp given this morning, pm dose held per HO this evening. u/o >30cc/hr. abd soft, +BS. +BS. +flatus. guiac neg. stooling mod amts loose golden stool.\nENDO: FS QID w/ SSRI and standing dose NPH am/pm.\nNUTRITION: TF promote w/ fibre @ 45cc/hr. minimal residuals. OGT patent.\n\nPLAN: con't to monitor Cardiac Calcs, VS, UO-- complete DIG load. monitor resp status on PS. keep pt comfortable. keep family informed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-30 00:00:00.000",
"description": "Report",
"row_id": 1430789,
"text": "Resp. Care Note:\nPt remains intubated and ventilated. Bs coarse throughout. Sx for moderate amounts of white to clear frothy secretions. Pt placed on PSV, tolerating well. ABG within normal limits. Pt has cheynes breathing pattern, Dr . CXR from yesterday showed bilat pleural effusions R>L. Continue on PSV as tolerated, monitor resp. status and vitals.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-31 00:00:00.000",
"description": "Report",
"row_id": 1430790,
"text": "RESP CARE NOTE\nPT REMAINS INTUBATED, VENTILATION SUPPORTED VIA PB7200 VENT IN CPAP/PS MODE. CHEYNNE- BREATHING PATTERN NOTED W/ SEC APNEIC PERIODS, VT 350-400CC. BS OCCAS SL COARSE, SXN FOR SM-MOD AMTS WHITE FROTHY SEC. AM ABG REFLECTS UNCOMPENSATED METABOLIC ALKALOSIS W/NORMOXIA. RSBI THIS AM 125. SBT NOT INDICATED. PLAN TO CONTINUE CURRENT SUPPORT, WEAN PER TEAM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-31 00:00:00.000",
"description": "Report",
"row_id": 1430791,
"text": "CCU NSG PROGRESS NOTE 7P-7A/ RESP FX; MR\n\nS- INTUBATED\n\nO- SEE FLOWSHEET FOR OBJECTIVE DATA\n\n\n PT REMAINS WITH STABLE HEMODYNAMICS AND BETTER RATE/PRESSURE PRODUCT AS WELL AS CO/CI/SVR ON DIGOXIN/CAPTOPRIL/LOPRESSOR. HR- 60'S AFIB . BP= 130/50- 100/50. RECEIVED LAST OF DIG LOAD AND TO START PO DOSE. REMAINS ON CAPTOPRIL 50, LOPRESSOR 37.5- SEE FLOW FOR CO/CI/SVR VALUES ON CURRENT MED REGIMEN.\nRECEIVED MG 2 AMPS FOR MG- 1.8.\nAM LAB PENDING.\n\n PT DOING WELL ON PRESSURE SUPPORT 15CM/50%. TIDAL VOLUMES 375-450CC WITH RESP RATE LOW TO MID 20'S CHEYNNE STOKE PATTERN\nREMAINS WITH COARSE BREATH SOUNDS, DIM AT BASE WITH SUCTIONING Q 1-3 HOURS THICK WHITISH SPUTUM- LESS THICK THIS AM. MUCH ORAL SECRETIONS.\nROTATED TUBE AND RETAPED.\nPA- 40/22-50/26. CVP- 14-16. PCW- 22.\nNO SIGNIFICANT INCREASE OR DECREASE THIS SHIFT.\n\nID- AFEBRILE- REMAINS OFF ANTIBX THIS SHIFT.\nNO TEMP SPIKE, NO CULTURES OBTAINED.\nWC- 12\n\nGI- TUBE FEEDS 45/HOUR, MINIMAL RESID- SMALL AMOUNTS LIX STOOL- BROWN, G (-).\n\nGU- FAIR TO GOOD UO- DROPPING OFF LATE EVE- REPEAT 20 LASIX WITH GOOD UO- 800CC DIURESIS.\nWITH D/C 1000CC ANTIBX- ABLE TO MAKE I/O (-) FOR 1ST TIME- CURRENTLY (-) 500CC.\nTO REASSESS ? MORE DIURESIS THIS AM.\nDUE FOR DOSE THIS AM\n\n PT AWAKE, FAMILY ALL PRESENT- SPOKE AT LENGTH TO DAUGHTER RE: PLAN OF CARE/NEED FOR DIURESIS PRE-WEANING- LENGTH OF TIME TO TAKE PLACE OVER SEVERAL DAYS, GRADUAL DIURESIS, AND WEAN, ETC.\nAPPEARS TO UNDERSTAND AND TO RELAY PLAN TO NURSE-DAUGHTER .\nCALLED X 1 OVERNITE.\n\nA/ PT WITH EXTENSIVE HOSPITAL COURSE CURRENTLY TOLERATING GRADUAL DIURESIS/PRESSURE SUPPORT WEAN.\nREMAINS IN NEED OF GOOD RPP CONTROL AND VENT SUPPORT AS WELL AS SEDATION FOR VENTILATION.\n\nCONTINUE CV MEDS FOR GOOD DIASTOLIC FILL/RPP.\nCHECK AM LABS- REPLETE AS NEEDED.\nCONTINUE GRADUAL YET AGGRESSIVE AND CONSISTENT DIURESIS -\nPULM TOILET/SEDATION WHILE INTUBATED\nNUTRITION/BS COVERAGE.\nKEEP FAMILY AWARE OF PLAN OF CARE AS WELL AS PT.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-31 00:00:00.000",
"description": "Report",
"row_id": 1430792,
"text": "CCU progress note 7a-7p\nNEURO: sedated on ATIVAN 1mg PO TID + VERSED 1mg/hr gtt. opens eyes spontaneously, doesn't nod head to questions today. family called on phone, husband visiting this evening.\n\nID: Tmax 100 core temp. Surveylance BC x 2 sent. off all ABX. WBC 9\n\nRESP: LS coarse. large amts clear to white sputum. remains on PS - attempted to go to PS 10/5 but PO2 down to 69 w/ decreased TVs sats 89% - increased PS to w/ good TV 300-350s sats 97%. abg 7.48/37/88. This evening pt more tachynpnic w/ TV 250-300 RR 37-44 sats 94%, lg amts clear secretions. abg 7.47/41/69! Increased PS to 15/5. RR decreased to 20-30s - TV increased to >350s. sats ^97%.\n\nCARDIAC: AFIB 60-70s occ paced beats. PAD 21 in am ->25 this evening. last CO 4.1 CI 2.55 SVR 1015 CVP 10->15. HEPARIN @ 800u/hr. Digoxin 0.125mg qd, lopressor 37.5mg + captopril increased to 75mg TID - tolerating well. Aline intact. 3+ pitting edema.\n\nGI/GU: foley patent. diuresed x 1 today Lasix 20mg. abd soft +BS. + flatus. no stool today. TF Promote w/ fibre @ 45cc/hr via OGT. nutrition on consult.\n\n\nPLAN: con't to monitor resp- adjust PS as necessary per ABGs. con't digoxin for rate control. tolerating increased dose of captopril. con't to monitor Cardiac Calcs q4h. keep pt comfortable. keep family notified of pt condition.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-31 00:00:00.000",
"description": "Report",
"row_id": 1430793,
"text": "Resp. Care Note:\nPt remains intubated and ventilated. Bs coarse throughout. Sx for large amounts of thick clear to white secretions. Attempted to wean PSV throughout day, pt tolerated for short time. Returned to PSV 15/5. Pt continues to have - breathing pattern. Continue to wean as tolerated. See carevue for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-29 00:00:00.000",
"description": "Report",
"row_id": 1430780,
"text": "CCU Nursing Progress Note 1900-0700:\nS-Intubated and sedated\n\nSEE CAREVUE FOR OBJECTIVE DATA AND TRENDS IN VS\nSEE ICU UPDATE FOR OVERNIGHT EVENTS\n\nO-MS:Alert and opening eyes to name. Slavic speaking only. Family at bedside and emotionally supporting and interacting with pt during evening. Appearing comfortable on Versed and Fentanyl push boluses.\nMAEs on bed and making purposeful movements.\nCV: HR 70s to 110s. Afib with rare PVCs. K rechecked and 4.1 on eves. Continues to tolerate Lopressor dose, could withstand increases. ABPs 70s to 120s. VSs hypodynamic with sedation on board and hyperdynamic with suctioning or nursing intervention. PAD 21-27, PCWP 24-27, occasionally unable to wedge swan, CIs > 2.0. Captopril increased in attempt to increased COs. increased and CO/CIs improving slightly. Team wanting to increase but BPs currently unable to withstand. Heparin continues at 800u/hr with AM PTT pending and Natrecor at 0.020mcg/kg/min.\nRESP: AC/400/10/.50/5 PEEP. LS course, occasionally clear in upper fields post suctioning. Suctioning for white thick secretions in small to moderate amounts. Extremely strong gag with suctioning. Tachypenic post with RR mid to high 20s but settling out thereafter.\nGU/GI: Foley draining golden colored urine. HUO 30-70cc/hr. No further diuresis given overnight. At MN (-) 870cc and (+) 9L for LOS. Plan to futher diurese this AM. Abd soft with (+) BSs. Passing golden-brown stool. Loose in appearance. G(-). TF continue at GR, 45cc/hr.\nID: Low grade temps. Continue on ABx.\nENDO: FS at HS 133 and given standing NPH dose. AM FS pending.\nSOC: Family updated by RN and visiting on evenings. Later going home and later updated by RN over phone.\nA/P: CHF and PNA c/b septic and cardiogenic shock\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-29 00:00:00.000",
"description": "Report",
"row_id": 1430781,
"text": "Respiratory Care\nPt remains ventilated with no changes noted. RSBI checked, 125 with irregular spontaneous respiratory pattern. RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-29 00:00:00.000",
"description": "Report",
"row_id": 1430782,
"text": "Resp Care: Pt remains intubated via #7.5 ETT secured 21cm at lip. BS bilat E wheezes w/ rhonchi. Sx'd for mod amt white thick sputum. Pip/Plat 24/21. No vent changes made this shift. Please see carevue for further vent inqueries.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-07 00:00:00.000",
"description": "Report",
"row_id": 1430817,
"text": "CCU NPN 1900-0700\nO: afeb. HR 70-80's afib. no vEA. occas. Vpaced beats. BP 135-160/40-60. u/o 50cc/hr. IVF D/C'd. (+) 3.3L LOS.\n\nheparin 750u/hr.\n\nTF increased to 20cc/hr. hands restrained. however pt. self d/c'd NGT ~ 0330. not replaced per HO. pt. able to take meds crushed.\n\npt. awake and alert. appearing to doze occas.\ndaughter called during night and stated that pt. was intermittantly confused yesterday req. freq. orientation. unable to determine d/t language barrier but pt. appears to understand simple commands in english.\n\nLS course upper, diminished lower. sats 96-99% on 2-4L NC. RR 20-30. CPT x2. stimulates strong cough, non productive.\n\nmoving all extrem. full lift back to bed in eve.\nTLC Right IJ. foley.\nno stool.\n\nA: pt. pulling out NGT despite hands restrained\nP: swallow study planned for today. OOB. contin. CPT q4-6hours. crush meds.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-07 00:00:00.000",
"description": "Report",
"row_id": 1430818,
"text": "addendum\npt. becoming more anxious, restless ~ 0600, reaching for siderails and motioning to get out of bed. speaking in hungarian. HR up to 90's - 110 AF. BP stable. HO aware. given .5mg po ativan and lopressor XL early crushed. sats 95-96% on 4lnc.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-07 00:00:00.000",
"description": "Report",
"row_id": 1430819,
"text": "CCU progress note 7a-7p\nNEURO: sedated this morning from 0.5mg ativan - no further episodes of agitation. MAE. PT/OT on consult. oob to chair - used walker w/ assist of 2 - gen weakness, but did take a few steps. used interpreter for PT excercises and for speech + swallow eval this afternoon. Hungarian speaking - does understand and speak broken english.\n\nID: afebrile. no abx\n\nRESP: LS coarse, occ congested nonproductive cough. O2 2L w/ sats 93-96%. sl SOB on exertion. CPT w/ turns.\n\nCARDIAC: AFIB 120s this morning - now PACED/AFIB 60s-80s. SBP 120s. tolerating captopril 75mg tid. RIJ TLC patent. unable to obtain peripheral access today. HO aware. no aline. veinodynes on.\n\nGI/GU: foley patent, sl mucous noted in urine. good u/o. IVF .45NS 100cc/hr while not taking po well. speech and swallow wants video swallow study tomorrow - but pt may take pureed soft diet as tolerated, aspiration precautions. dentures too loose to wear ?denture paste? no BM today. +BS.\n\nSKIN: groins slightly reddened, nystatin pwd to groins and under breasts and axilla. no further breakdown on buttocks. barrier cream. on 1st step air mattress. OOB to chair.\n\nPLAN: monitor VS -HR/BP. monitor u/o. pulm toliet. emotional support. video swallowing study in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-07 00:00:00.000",
"description": "Report",
"row_id": 1430820,
"text": "addendum:\n\nLasix 20mg IVP given this evening. monitor u/o.\nstarted on coumadin this evening also.\nOnly took a few mouthfuls of pudding this evening - then stated \"enough\".\nHusband and grandson visiting.\nAssisted back to bed by OT w/ walker with assist of 2. Did not weight bear well this time or pivot well.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-28 00:00:00.000",
"description": "Report",
"row_id": 1430776,
"text": "NSG NOTE\n\nCV: REMAINS IN A-FIB. BETTER RATE CONTROL WITH LOPRESSOR INCREASE TO 25MG . CON'T TO HAVE OCCASSIONAL PVC'S K+ RELATED ,RESOLVING WITH REPLACEMENT KCL. CON'T ON NATRECOR 0.02MCG/KG AND HEPARIN 800U/HR. MAP'S REMAIN > 60. HR 80-102. BECOMES MORE TACHY WITH WAKEFUL PERIODS. CO/CI ON CAPTOPRIL 6.25MG: 3.3/2.05 SVR 1479. THIS AM RECEIVED CAPTOPRIL 12.5MG HEMODYNAMICS CO/CI 3.6/2.24 SVR 1244. NO SIGN CHG IN BP. PT WOULD BENEFIT FROM INCREASE IN LOPRESSOR DOSE AS WELL. PAD 24-29,CVP 16-14,WEDGE 26-23.\n\nGU: RECEIVED LASIX 20MG @ AND AGAIN @ 0330. AGGRESSIVE DIURESIS NOTED. @ MN PT WAS NEG BY 1200CC,HOWEVER OVERALL LOS CON'T TO BE POSITIVE.\n\nRESP: INITIALLY ON CPAP+PS 16 PEEP5. MORE ALKALOTIC ON PS. PT RESTING ON AC OVERNOC. CURRENT SETTINGS AC 50%,VT 400,R-10,PEEP 5. AM ABG'S 7.46,40,81,4,29,97%. PLEASE SEE FLOW SHEET FOR ABG'S AND VENT CHG. SUCTIONED FOR THICK WHITE SECRETIONS. BS CL BILAT RHONCHI AT BASES.\n\nGI: CON'T ON TF @ GOAL RATE OF 45CC VIA OG TUBE. RESIDUALS <10CC. HAD 1 STOOL SOFT/LOOSE GOLDEN WHICH WAS HEME NEG. ON PEPCID 20MG QD. ABD IS SOFT NON TENDER.\n\nSKIN: PACER SITE SS C&D. CON'T TO HAVE YEAST RASH TO GROIN AREAS AND BREAST HOLDS. MYCOSTATIN AS ORDERED APPLIED.\n\nID: LOW GRADE TEMPS NOTED 99.7 WBC DOWN THIS AM TO 14.7 CON'T ON VANCOMYACIN,FLAGYL AND IMINPENIUM. PT HAS IN SPUTUM, + URINE CULTURE/YEAST AND STAPH FROM OLD CVL SITE. PT IS ON DAY 4 OF 7 DAY COURSE.\n\nNEURO: ALERT AT TIMES AND WILL OPEN EYES TO VOICE. RESPONDS BY NODDING AND HAS PURPOSFUL MOVEMENTS. SHE IS STILL NOT FOLLOWING COMMANDS. SHE WILL REACH FOR TUBES AND LINES AND AT TIMES ATTEMPTS TO PULL AT THEM. FENTAYL AND VERSED HAVE BEEN GIVEN WITH ADEQAUTE RESULT.\n\nLABS: CON'T TO HAVE HIGH BS 170-190. SPOKE WITH TEAM LAST EVE. THEY HAVE ADDED NHP + SSI . OVERNOV BS 182,167. PT @ 2100 2 U REG/8 U NPH.\n K+ 3.9 LAST EVE RECEIVED 20 MEQ KCL.\n\nSOCIAL: HUSBAND AND DAUGHTERS IN ON EVES. THEY HAVE BEEN UPDATE AND SUPPORT GIVEN\n\nA: CRITICAL/ DIFFICULT WEAN D/T PULM EDEMA.\n\nP; CON'T TO DIURESE\n CHECK WITH HO. INCREASE LOPRESSOR\n NEEDS ID APPROVAL FOR VANCO(TEAM IS AWARE)\n FAMILY SUPPORT\n PER NSG JUDGEMENT.\n CPAP+PS TRIALS TO CONTINUE TODAY\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-28 00:00:00.000",
"description": "Report",
"row_id": 1430777,
"text": "pt.changed from psv to ac for the noc to rest. changes made in vt-decreased to 400, bs with rhonchi, sx for white secretions, will probably switch to cpap, failed wean trial this a.m., became agitated, rsbi 225, pt.reamins alkalotic, with metabolic issues.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-28 00:00:00.000",
"description": "Report",
"row_id": 1430778,
"text": "Resp Care:Received pt on a/c 400,10,.50,peep5.Attempted cpap/psv wean of 16/5 and .50 with pt lasting approx 1 and 1/2 hours. Pt was having frequent periods of apnea so pt was changed back to a/c. Later in the shift pt appeared more alert so cpap/psv wean was attempted again however pt only lasted about 1 hour. At that time pt had an increase in hr 160bpm so pt was returned to a/c. Plan rest pt overnight and attempted wean in am.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-28 00:00:00.000",
"description": "Report",
"row_id": 1430779,
"text": "NPN 0700-1900;\n\nNEURO; HUNGARIAN SPEAKING LADY INTUBATED AND VENTILATED. SEDATED WITH MIDAZOLAM AND FENTANYL.OPENS EYES SPONTANEOUSLY.MAE SPONTANEOUSLY. FOLLOWS SIMPLE COMMANDS. STUCK TONGUE OUT FOR DAUGHTER.MOVEMENTS ARE VERY PURPOSEFUL WILL ATTEMPT TO PULL OUT TUBES WHEN WRIST RESTRAINTS ARE RELEASED. BECOMES ANXIOUS AT TIMES ESPECIALLY WITH ETT SUCTIONING.\n\nRESP; REMAINED ON AC 50% 400 X10 FOR MOST OF DAY., TOLERATED CPAP WITH 16 PS FOR 2 PERIODS OF 1.30 HOURS PLACED BACK ON VENT FIRST TIME FOR PERIODS OF APNEA AND THE SECOND TIME FOR HR TO 160, AFTER SUCTIONING.LUNG SOUNDS COARSE. SUCTIONED Q1-2 HRS FOR THICK WHITE SECRETIONS,SATS 94-96%.\n\nCVS. TMAX 37.6 CORE, BP 105-134/57. AFIB 94-121 WITH A BURST TI 150-160 TREATED WITHN BOLUS DOSE OF LOPRESSOR 2.5MGDS I,V, WITH GOOD EFFECT.CI DROPPED TO 1.9 WITH THIS EPISODE REPEAT PENDING.PLEASE SEE FLOW SHEETS FOR DETAILS.\n\nGU; GOOD RESPONSE TO LASIX 20 MGS I.V.K 3.5 NEED TO REPLETE.\n\nGI; TOLERATING T/F FS PROMOTE WITH FIBRE AT 45 MLS WITH MIN RESIDUAL. HAD SEVERAL EPISODES OF LARGE AMOUNTS OF THICK SEMI FORMED STOOL RECTAL BAG APPLIED BUT NO FURTHER EPISODES SO FAR.FELT THAT THIS CONTRIBUTED TO EXHAUSTION THIS AM. RECEIVING NPH INSULIN BS 174-134.\n\nID ;CONTINUES ON TRIPLE ANTIBIOTICS.AWAITING RANDOM.LEVEL RESULT.\n\nHEME STABLE HCT 35%\n\nSKIN CONTINUES TO HAVE YEAST IN GROIN. BUT UNDER ARMS AND BREAST SEEMS TO HAVE IMPROVED.\n\nFAMILY INTO VISIT AND UPDATED WITH PT,S CURRENT CONDITION.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-12 00:00:00.000",
"description": "Report",
"row_id": 1430833,
"text": "CCU NPN 1900-2300\nS/O:\n\nF/E: 20 MG LASIX GIVEN IV X1 WITH 600 CC U/O. LUNGS CONT WITH CRACKLES AT BASES. SATS IN HIGH 90'S ON 2LNP.\n\nGI: INC LARGE AMOUNTS OF STOOL X3, FAILED MUSHROOM CATHETER. FECAL INC BAG ON AND HOLDING. STOOL OB NEG, WITH SOME FORMED STOOL.\n\nA/P: HOLD ALL LAXATIVES, CHECK K WITH AM LABS. D/C TO REHAB IN AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-13 00:00:00.000",
"description": "Report",
"row_id": 1430834,
"text": "CCU progress note 11p-7a\nUneventful nite. slept in naps. VSS. sats 94-97% on 2L n/c. Took hs po med crushed in pudding. aspiration precautions.\n\nNEURO: MAE, gen weakness. speaks/understands small amt broken english - hungarian speaking. Ox2 per family. slight confusion at times. obeys simple commands.\n\nID: on levo for UTI. nystatin to reddened groins. afebrile.\n\nCARDIAC: AFIB 60-80s. Lopressor increased to 75mg TID - tolerating well. Increased dose of Lisinopril to 60mg po qd. coumadin remains on hold d/t still elevated INR. am labs pnd. RIJ TLC patent - pt difficult access (remove line access prior to discarge to rehab facility).\n\nRESP: LS clear, dim/coarse to bases. strong congested occasionally productive cough. O2 2L n/c w/ sats 94-97%. pt took off n/c and on room air w/ sats 88-92% w/ SOB noted. RR 18-32 overnite.\n\nGI/GU/ENDO: FS QID - no sliding scale ordered at present - NPH on hold until pt tolerating diet. ASPIRATION PRECAUTIONS. sit pt bold upright for meals/meds - crush meds in puddings/pureed foods - diet of pureed and nectar thick liquids. Abd soft, distended. +BS. +flatus. stooling overnite large amts of yellow liquid stool. slowing down this morning - failed attempts on rectal tube and fecal incont bags. Foley patent. U/O ~30cc/hr. some sediment/mucous noted in urine. on daily lasix 80mg QD w/ daily KCL supplement.\n\nPT/OT: pt gets OOB to chair - pivots w/ assist of 2 and walker. on air bed. pneumoboots.\n\n\nPLAN: transfer to rehab facility today if INR WNL. monitor VS. keep pt comfortable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-01 00:00:00.000",
"description": "Report",
"row_id": 1430797,
"text": "Resp. Care Note\nPt remains intubated and vented on settings as per Resp. flowsheet. PSV level decreased this shift from 15-12-10. Good ABG's on PSV 12, ABG pending on PSV 10. Improved oxygenation. Cont present support, wean vent as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-01 00:00:00.000",
"description": "Report",
"row_id": 1430798,
"text": "D: Please see data, MD notes/orders. Neuro: Pt opens eyes to family, MAE, PERRL. Appears comfortable on versed 1mg/hr and ativan 1mg tid. CV: Afib on monitor, HR 70-90. SBP 100-1teens/60s. PA pressures 35-42/17-20, cvp 12-13. CO/CI 3.7/2.3 with team aware of values.Heparin gtt currently at 700u/hr in theraputic range with last ptt 75. Pulm: Vent changes/settings per care view. Lung sounds coarse, clearing after suction of thin white secretions. Respitory effort unlabored, 02 sat 98%. Latest Abgs per care view.PH 7.5 felt to be due to volume contraction from diuresis after lasix 20mg IVP x 2 today. Pt currently with neg fluid balance 600cc+. GI: Abd soft, bs+, incontinent of med soft brown stool. TF at goal rate, residuals minimal. Skin: surfaces intact, perianal area excoriated. Peripheral pulses palpable. soc: Husband and daughter in this evening. Pts daughter with many questions, Husband speaks minimal english.\n\nP: Titrate versed gtt prn pt comfort. Keep heparin gtt 700u/hr, ptt qd and as ordered (goal ptt 60-80). No further vent changes tonight, prn abg's, notify team of any decline in respitory status. Monitor hourly uo with goal neg fluid bal 1L/24hr per team. Provide meticulous skin care, frequent postion changes, barrier cream/nystatin powder prn. Keep family updated on pt condition and plan of care.\n\nR: As above, Family updated and agreeable to plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-02 00:00:00.000",
"description": "Report",
"row_id": 1430799,
"text": "NPN\nCCU\n11 PM - 7 AM\nINTUBATED AND SEDATED\nS/O PLS SEE FLOWSHEET FOR ALL OBJ/NUMERICAL DATA ..\nCV HR 60'S PACED RHYTHM...SBP 120-150'S/40-60'S...TOLERATING TITRATION OF LOP/CAPTOPRIL ...PAD 18-22..CVP 8-10...\nRESP ON 40%..SIMV AND PS ..RATE OF 12 ..INSP TIDAL VOLUMES 250-320...5 PEEP....LUNGS DIMINISHED AT THE BASES ..SUCTIONED FOR SMALL AMOUNTS OF WHITE SXNS ..\nGI ON PROMOTE AT 45 CC/HR VIA OGT..SMALL SOFT STOOL ..OB NEG..MINIMAL RESIDUALS ..\nGU 1500 CC NEG AT MN....\nCOMFORT ..CONTINUES ON VERSED GTT AT 1 MG/HR WITH - 2 MG IVP BOLUS WITH SUCTIONING/BATHING ..TOLERATED WELL...\nTURNED Q3...\nA HEMODYN STABLE\nP FOLLOW HEMODYNAMIC #'S....LABS ..PULM TOILET\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-02 00:00:00.000",
"description": "Report",
"row_id": 1430800,
"text": "Resp. Care Note\nPt remains intubated and vented on settings as per Resp. flowsheet. Pt on SIMV in AM after fentanyl given due to low RR and minute vol. Pt changed back over to CPAP/PSV when more awake. Cont to show alkalosis on ABG's. Plan to cont PSV and wean slowly as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-06 00:00:00.000",
"description": "Report",
"row_id": 1430814,
"text": "CCU NPN 1900-0700\nO: afeb. HR 70's afib with freq. paced beats.\nBP 117-140's/60's. increasing to 160-170's/70's during evening. given captopril 75mg at 2200 crushed with custard. BP contin. to remain high. pt. awake, eyes open, responding to name and simple commands. understands english. ordered for ativan po q8hr for potential benzo . given 1mg at 2300 with good results. pt. falling asleep and BP coming down to goal 120-130's/60. pt. waking again ~ 0500 and BP trending up again to 160/70. HR 70's. pt. appearing comf. with no overt anxiety. due for captopril at 0600.\n\nu/o 40-75cc/hr. (-) 1L for and (+) 3L LOS.\n\ntaking meds crushed with custard. holds in mouth but able to move tongue and swallow with encouragment.\n\nLS course upper airways, somewhat cleared with weak cough. CPT x2. sats 97-98% on 2lnc. trending down in AM to 94%, given CPT and increased to 4lnc-> sats 98% at 0500. RR 20-30's regular.\n\nHCT 31.9 , stable. WBC 8.4.\n\nneuro: as above, pt. awake, moderately alert. responding to name and to simple commands in english. needs promting and enc. to respond to questions. daughter states that pt. understands more english than thought.\n\nheparin 750u/hr via right IJ TLC.\n\nA: stable night , taking po meds. BP stable.\n ativan RTC for possible benzo .\nP: OOB again today. contin. to thicken foods/liquids. crush meds as needed. CPT, wean FIO2. contin. to monitor neuro status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-06 00:00:00.000",
"description": "Report",
"row_id": 1430815,
"text": "7a-3p\ncv: hr a-fib with occasional paced bts(66-80), no ectopy, sbp stable(122-162), continues on po digoxin, captopril & lopressor XL\n\nresp: on 4 l np this am, bs+ all lobes & clear, abg sent with good result & o2 decreased to 2 l np, sats 97-99, rr 20-24, coughing productively @ times-sm amts tan sputum\n\ngi: continues on aspiration precautions, thicken liquids/soft solids tol fair, poor po intake, to have feeding tube placed this afternoon, no stool\n\ngu: foley patent, clear yellow urine, uo 30-50 cc/hr\n\nneuro: awake, follows commands, moving all extremities\n\nother: iv fluids started x 1 liter(1/2 ns @ 100cc/hr), L rad a-line dc'd, heparin gtt continues @ 750u/hr, oob to chair with PT @ 1200-tol fair, pt very weak with poor wt. bearing, family called & updated on pt's condition\n\nplan: continue to monitor in icu, start tube feed as ordered once FT placed, ? tx to floor tomorrow\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-06 00:00:00.000",
"description": "Report",
"row_id": 1430816,
"text": "CCU NPN \nGI: NGT placed, placement confirmed by x-ray, started FS Promote with fiber at 10cc/hr at 1800, advance q 4hrs by 10cc to goal 45cc/hr. No residual at onset. NPO until swallow study.\n\nNeuro: alert, confused to time/day per family. Encouraged family to reoriented freq. Pt OOB in chair, has not wanted to return to bed yet. Would lift back, did not bear wt well getting up. Ativan dc'd. Watch for ^HR/BP/agitation, if occurs will need to get order for ativan from team.\n\nA/P: stable, cont to follow resp status, pul toilet, await swallow study, advance TF's as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-27 00:00:00.000",
"description": "Report",
"row_id": 1430774,
"text": "pt.remains on ac ventilation, sx for thick light yellow secretions, rsbi=93.5, no weans scheduled, to unstable at present time, normal abg.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-27 00:00:00.000",
"description": "Report",
"row_id": 1430775,
"text": "CCU NPN 0700-1900\nS/O:\n\nCV: CAPTOPRIL STARTED AT 1100, C/O DOWN SLIGHTLY X2 AFTER DOSE, AND C/I INC TO 1900. LOPRESSOR INC TO 25 MG TID AND PLAN TO INC TO 50 TOMORROW. HEP AND NATRACOR UNCHANGED. CVP TO 14 AFTER LASIX 20 MG X1 IN AM, UP AGAIN IN AFTERNOON. K 3.9 SO 40 KCL GIVEN X1, MAG 3GM GIVEN X1 FOR MAG 1.6. CONT IN AF WITH RATES TO 80'S-100'S. GOOD DIURESIS AGAIN TO LASIX, NEG ABOUT 500CC FOR NOW. PERIPHERAL EDEMA IMPROVED. PT NEEDS ANOTHER LASIX DOSE TONIGHT.\n\nRESP: ABG ACIDOTIC IN AM AND ALKALOTIC IN PM. VENT WEANED TO 16 PS AND 5 PEEP WITH TV IN LOW 300'S AND RR 12-30, CHEYNES RESP AT TIMES. LAST ABG 7.47-74-37. SUCTIONED Q4-5H FOR THICK WHITE SPUTUM. NO EVIDENCE OF CUFF LEAK. LUNGS WITH EXP WHEEZE AND RHONCHI AT TIMES.\n\nID: TMAX 100 CORE, WBC UNCHANGED. ABX CONT. ALL DRSG AND OF INFECTION.\n\nGI: TOL 45CC/HR OF TF WITH HIGH RESIDUAL AT TIMES BUT NO NEED TO TURN OFF TF. INC SOFT STOOL, TRACE POS. POS BS.\n\nGU: URINE CLEAR.\n\nMS: REC'D LESS FENT/VERSED TODAY, SEEMS TO BE MORE COMFORTABLE ON PS VENT. SITTING UP IN BED AND TURNED FREQ. BOTH DAUGHTERS AND HUSBAND IN TO VISIT.\n\nFAMILY: DAUGHTER WILL RETURN HOME TO WORK TOMORROW, SHE HAS 3 KIDS N VT. STATES FATHER IS CONFUSED AND VERY UPSET ABOUT WIFE.\n\nSKIN: FUNGAL SKIN INFECTION CONT TO IMPROVE, NO OTHER SKIN BREAKDOWN. PNEUMO BOOTS CONT.\n\nA/P: C/O SLIGHTLY AND SVR UP WITH NEW CAPTOPRIL AND INC LOPRESSOR. PT NEEDS MORE LASIX TONIGHT. CONT TO FOLLOW NUMBERS AND ABG. ? REST ON A/C TONIGHT. CONT TO SUPPORT FAMILY.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-26 00:00:00.000",
"description": "Report",
"row_id": 1430769,
"text": "CCU Nursing Progress Note 1900-0700: CV shock\nS-Sedated and intubated\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VS\nSEE ICU UPDATE REPORT FOR OVERNIGHT EVENTS\n\nO-MS:Sedated and intubated overnight on Fent and Versed IVP, requiring Q1-2hrs. Usually requiring 0.5mg of Versed and 25mcgs of Fentanyl. Remaining fairly comfortable with above doses, opening eyes to verbal to name, pt slavic speaking only. Family usually able to engage with pt and pt nodding appropriately. Seeming more \"out of it\" according to family.\nCV: HR 70s to 100s. Afib with occasional PVCs and occasional paced beat. K and Mg in WNLs on eves. SBPs 90s to 110s. MAPs 60s to 70s.\nPAD 27-38, CVP 14-17, CO/CI/SVR high 3.0s/2.0s/1200-1500. Natrecor titrated up to 0.015mcg/kg/min with fair results. PADs down from 38 to 28-30. Increased again to 0.020mcgs/kg/min and awaiting results. Heparin continues at 950u/hr with therepeautic PTTs. Skin warm and dry to touch with palpable pulses distal.\nRESP: LS course, more so on exhalation. VENT: AC/450/12/.50/6 PEEP. Suctioned for thick white secretions in small to moderate amounts. RBSI performed this AM with score of 80, in addition to RR into the 30s and filling pressure elevated as well.\nGU/GI: Foley draining minimal amounts of golden yellow urine. HUOs 25-80cc/hr while on Natrecor gtt. At MN 4L(+) and for LOS 13L(+). BUN/Creat in WNLs AM. Anticipate possible increase this AM.\nAbd soft with (+) BSs. Passing flatus. OGT to right nare changed to OGT oral. Prior to TF at GR of 45cc/hr(Promote w/ fiber). Please confirm placement with CXR prior to use. Passing golden to brown colored loose stools in small to moderate amounts. G(+).\nID:Tm 100.2 and Tc 99.5. Most recent cultures, urine (+) for > 100,000 org, CVL tip cx with staph, sputum with GNR, and blood and stool still pending. ABx coverage: Vanco, Flagyl, and Iminpenim. Yeast not covered as yet, team to discuss on rounds.\nA/P: CV shock c/b by septic shock\nContinue to monitor\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-26 00:00:00.000",
"description": "Report",
"row_id": 1430770,
"text": "pt.maintained on ac ventilation, unstable cardiac wise, septic, bs with coarse rhonchi bilat, some rales, normal abg, rsbi-80.6, no weans are planned, sx for thin watery clear to white secretions,\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-08-26 00:00:00.000",
"description": "Report",
"row_id": 1430771,
"text": "Respiratory Care\nPt remains ventilated with no change in settings. Breath sounds equal/few scattered expiratory wheezes. Sx for small amount of light tan secreations. RRT\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-12 00:00:00.000",
"description": "Report",
"row_id": 1430831,
"text": "CCU progress note 7p-7a\nUneventful pm. Family visited late evening. Pt stated to husband \"I feel like I can't swallow\" HO notified. Pt did take crushed medication at midnite in apple sauce - seemed to tolerate well. remains on aspiration precautions and on thickened liquids + pureed foods. transfer to Rehab facility. See Transfer note if transferred to floor.\n\nNEURO: A+Ox3 per family. hungarian speaking - speaks broken english. MAE. gen weakness. 1+ gen edema.\n\nID: afebrile. on levoquin for UTI. no other abx.\n\nCARDIAC: AFIB 70-80s 0cc paced beats. SBP 130-160s. on Lopressor 50mg TID. Daily Lasix 40mg po. Lisinopril 40mg po qd. Digoxin 0.25mg po qd.\n\nRESP: O2 2L n/c. sats 94-97%. sl SOB on exertion. LS clear, coarse/dim bases. weak congested cough. CPT done w/ turns.\n\nGI/GU: foley patent. u/o ~30cc/hr. on daily diuresis w/ daily po KCL. abd soft, distended. +BS. no stool. takes pills crushed in pureed food w/ thickened liquids per swallowing study. ASPIRATION PRECAUTIONS. pt stating she feels like she can't swallow. HO aware.\n\nSKIN: perineum healed well. nystatin applied. on air mattress. turned + repo'd.\n\n\nPLAN: keep pt comfortable. continue pulmonary toliet. con't cardiac meds. aspiration precautions. ?transfer to rehab facility or to floor today?\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-12 00:00:00.000",
"description": "Report",
"row_id": 1430832,
"text": "CCU Nursing Progress Note\nS: That's enough\nO: Pt voicing \"enough\", after few teaspoons of soft solids, yogurt, pudding. Taking very little in po. Pt will assist with encouragement, but minimal po intake today. Able to tolerated smaller pills later in day, otherwise pills were crushed and mixed with nectar consistency water.\n\n 8am meds given crushed in applesauce, then pt vomited. Bp up to 160/ with HR up 140. RR 40 with sat down to 85%. Increased o2 to 100%cool neb with subsequent sat up to 100%. Lopressor 5mg IVP with BP to 130/ and HR to 70-80. Lasix 20IVP with u/o @400cc within 1hr.\n\nAfebrile- cont on Levofloxacin\nHR 80's afib with rare paced. Lopressor increased to 75mg po tid\nBP 130-160/ Increased dose of Lisinopril to 60mg po qd starting , but extra 20mg given at 1800.\nResp - as above, cont with bibase rales despite diuresis and productive cough. Able to wean O2 down to 2ln/p.\nGI - as above for po intake. Passed small amt ob-, soft formed stool\nActivity - OOB to chair with 2 assist. OT to see pt\n\nA: Event of Inc HR and BP responding well to Lopressor IV and Lasix\n\nP: Cont aspiration precautions and encourage po intake\nMonitor need for diuresis this evening. Monitor HR and BP on increased dose of meds. OOB this eve. ? tx to NE \n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-04 00:00:00.000",
"description": "Report",
"row_id": 1430810,
"text": "CCU progress note 7a-7p\nEVENTS: EXTUBATED @ 10am - tolerating well!\n\nNEURO: no sedation - versed gtt off since 6am. no ativan given today. mae - very weak. moves feet, moves arms across bed and up to face. nodding head to questions of 'okay?' , mouthing words to family when they visited this afternoon.\n\nID: afebrile. Tmax 98.9po. no abx.\n\nRESP: Extubated at 10am. LS coarse. coughing up some clear thick secretions. O2 3L n/c. cool neb face tent @ 50% for moisture. CPT done with turns. post extubation abg: 7.41/41/114 sats >96%.\n\nCARDIAC: AFIB 70-100s occ paced beats. Lopressor 50mg dose given early pre intubation. Captopril 75mg dose held this afternoon due to NPO status - HO aware - ?may need NGT inserted for meds tonite. Good SBP >130s. L radial aline patent. RIJ TLC patent. HEPARIN gtt increased to 750u/hr per HO tonite. 2+ generalized edema.\n\nGI/GU/ENDO: foley patent. given lasix 20mg IVP x 1 pre intubation w/ good results. abd soft +BS. stooling golden soft stool mod amts q2-3 hrs. TF off for extubation. to attempt sips this evening for meds - otherwise NGT will have to be inserted for meds/feeding. aspiration precautions. BS WNL. no RISS given. on standing dose NPH insulin .\n\nCODE STATUS: FULL CODE. (daughter) {a CCU nurse} is HCP (proxy).\nFAMILY: husband and other daughter () in to visit this afternoon.\n\n\nPLAN: check PM lab results (K,Mg). keep pt comfortable. pulmonary toliet. ?NGT insertion for meds tonite if pt unable to take pills orally due to aspiration concerns. monitor VS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2152-09-04 00:00:00.000",
"description": "Report",
"row_id": 1430809,
"text": "Respiratory Care:\n\nPatient remains intubated on Psv. Psv increased back to 12cm to rest at noc. RR increasing to 30's. Improved on Psv 12. Current settings Psv 12, Cpap 5, Fio2 40%. RR 13-25 with spont vols 400's. O2 sats 97-100%. Bs clear bilaterally. RSBI 185. RSBI improving over the last 2 days. Still with increased fluid. Plan: Continue with slow Psv wean increasing Psv at noc as needed.\n"
}
] |
11,784 | 136,351 | On arrival to pt. was evaluated by the emergency department and trauma surgery staff. Pt was imaged and found to have a small splenic laceration and a large perinephric hematoma. Pt was admitted to the trauma SICU for monitoring of vital signs and serial hematocrits. During stay in TSICU, hematocrits dropped to mid 20's, but then stabilized. Pt. was transferred to the floor on bedrest and observed for a number of days. Pt was ready for d/c when had one episode while climbing stairs with PT of transient hypotension, lightheadedness and oxygen desaturation & quickly recovered with addition of 2L o2. Pt. was cleared by PT to return home. Pt was kept for one more night in hospital for observation and was stable. Morning of d/c crit was low but still in stable range, and pt. was offered a blood transfusion for his anemia. Pt refused transfusion and decided that he would return home without it being done. Pt made aware that if there are any concerns or problems including any signs/symptoms of increasing anemia or bleeding, he is to go to the emergency room & to call for the trauma team to adress his concerns. Pt. d/c'd home with PCP follow up within 2 weeks and trauma follow up within 4 weeks. | Lungs clear with diminished bases L>R.CV- NSR, normotensive. Denies N/V Abd slightly distended. The heart and mediastinum are within normal limits. (Over) 2:54 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: eval splenic lac, perinephric hematoma Admitting Diagnosis: SPLENIC LACERATION Contrast: OPTIRAY Amt: 150 FINAL REPORT (Cont) Small amount of fluid is identified within the right inguinal ring. In addition, there is a focal cleft within the posterolateral splenic body, which could represent a tiny laceration, however, could represent normal anatomic cleft. Widened mediastinum on flat AP portable CXR. Mild pain to LLQ.GU: Adequate u/o via foley. Nursing Note:REVIEW OF SYSTEMS:CV: Hemodynamic status stable, hr=59-69, sinus bradycardia to nsr, bp=112/53-122/54, ext. There is a trace perihepatic fluid. There are bilateral calcified pleural plaques, compatible with prior asbestos exposure. Small left-sided pleural effusion, and atelectasis within the left lung base. IMPRESSION: Small left pleural effusion and atelectasis in the left lung base. +Bowel sounds. little sore on L side with activity.GI/GU- Abd soft, +BS. widened mediastinum.GI: Abd. There is small left pleural effusion associated with atelectasis in the left lung base. done, reported as unchanged.RESP: Maintained on RA, sat=96=98%, resp. A soft tissue density in the upper Mediastinum. Pt has h/o HTN and takes atenolol QD. Possible tiny splenic laceration, without evidence of active extravasation. Foley patent with adeq UO. Calcified gallstones are identified. The right kidney is grossly normal. Trans to , admit to TSICU for serial hct's.NEURO: Pt is A+Ox3. Lytes WNL.ID: Afebrile.ENDO: Serum gluc WNL.SKIN: Abrasion to left elbow covered with steristrips. There is a large left-sided perinephric hematoma, which measures 10.2 x 6.3 x 8.9 cm. Sinus rhythm. There is minimal amount of low density fluid surrounding the posterolateral aspect of the spleen. The prevertebral soft tissue is unremarkable. The left kidney opacifies well with contrast. There is anterior displacement of the left kidney, however, no active extravasation is identified. If pt hct remain stable, should transfer to floor. There is a small amount of fluid tracking along the left pericolic gutter. Admitted to TSICU for serial hcts and close hemodynamic monitoring. +LOC, and pt hit his head. LS CTA bilat.CV: HR 50s-60s SB/SR no ectopy noted. IVF at 100cc cont. rate=14=17, diminished BS RLL. COMMENTS: PA and lateral radiographs of the chest are reviewed. There is question of pleural plaques in the lateral portion of the right lung as well as right hemidiaphragm. PA and lateral chest radiograph is recommended for further evaluation. Repeat CXR for ? CERVICAL SPINE, MULTIPLE VIEWS: The vertebral body heights are preserved. There is a Foley catheter within a decompressed urinary bladder. Vertebral body height is preserved throughout. The renal vein is patent, and the collecting system is intact. warm, + dp bil. CHEST AP: There is widening of the mediastinum. The pulmonary vasculature is normal. The pancreas and adrenal glands are normal. He sustained a left elbow abrasion. VS/labs stable at this time.PLAN: Cont to monitor vs, serial hcts, monitor abd and report increases in pain, f/u with team re: ?trans to floor if hct's stable today. The surrounding soft tissue and osseous structures are unremarkable. BG <100. Afebrile. IMPRESSION: 1. No free intraperitoneal gas. NPN 1900-0700 Pt intact.Resp- On RA, adeq sats >96% when awake, drifts to 93% when sound asleep. Pt c/o headache and recievd tylenol, otherwise no pain at rest. There is some disc space narrowing at the C5-C6 level with anterior and posterior osteophytosis, consistent with degenerative changes. Gallstones. 650mg tylenol PO x 1 for headache with effect. Evaluation of osseous structures reveals degenerative change amongst both hip joints, right side greater than left. Contrast is visualized in the urinary bladder from a previous examination. The lungs are clear otherwise. BP currently 120s/50s.HEME: Hct in 30s. Back/buttocks grossly intact.SOCIAL: Wife and son at bedside and supportive.ASMT: Pt s/p fall, left perinephric hematoma, splenic lac. At OSH pt had GCS 16, he was dx'd with a splenic lac and left perinephric hematoma. 9:58 PM TRAUMA #2 (AP CXR & PELVIS PORT) Clip # Reason: TRAUMA FINAL REPORT INDICATION: Trauma. Probable asbestos related pleural disease. States mild discomfort to left flank which is tolerable. distended, soft, hypoactive BS, denies nausea, notes left flank tenderness to touch and with re-positioning.GU: Foley to gravity, u/o=60-100cc/hrSKIN: Steri-strips to left elbow, full ROM, mild edemaMENTATION: Alert and oriented x3, follows commands, sleeping in napsENDO: No insulin requirementID: AfebrileSOCIAL: Wife and children in to visit, members updated by Dr. PLAN: Continue to follow serial hct, plan for transfer in am if hct/hemodynamic status stable. The patient is status post prostatectomy and nodal dissection, with numerous clips within the pelvis. No active extravasation identified. No BM. 2:54 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # CT 150CC NONIONIC CONTRAST Reason: eval splenic lac, perinephric hematoma Admitting Diagnosis: SPLENIC LACERATION Contrast: OPTIRAY Amt: 150 MEDICAL CONDITION: 74 year old man s/p fall REASON FOR THIS EXAMINATION: eval splenic lac, perinephric hematoma No contraindications for IV contrast FINAL REPORT CT OF THE ABDOMEN AND PELVIS WITH THE ADMINISTRATION OF INTRAVENOUS CONTRAST INDICATION: 74-year-old male status post fall with splenic laceration and perinephric hematoma. | 8 | [
{
"category": "Radiology",
"chartdate": "2140-10-28 00:00:00.000",
"description": "TRAUMA #2 (AP CXR & PELVIS PORT)",
"row_id": 884144,
"text": " 9:58 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: Trauma.\n\n CHEST AP: There is widening of the mediastinum. Although this could be\n projectional, a mediastinal injury cannot be excluded. The lungs are clear.\n There are no pleural effusions. The pulmonary vasculature is normal. The\n surrounding soft tissue and osseous structures are unremarkable.\n\n PELVIS AP: There are no fractures, dislocations or focal bony lesions.\n Contrast is visualized in the urinary bladder from a previous examination.\n Multiple surgical clips are present in the pelvis.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-10-28 00:00:00.000",
"description": "C-SPINE, TRAUMA",
"row_id": 884145,
"text": " 10:30 PM\n C-SPINE, TRAUMA Clip # \n Reason: fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man status post fall.\n\n CERVICAL SPINE, MULTIPLE VIEWS: The vertebral body heights are preserved.\n There is some disc space narrowing at the C5-C6 level with anterior and\n posterior osteophytosis, consistent with degenerative changes. There are no\n fractures or dislocations visualized. The prevertebral soft tissue is\n unremarkable. A soft tissue density in the upper Mediastinum. PA and lateral\n chest radiograph is recommended for further evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-10-29 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 884219,
"text": " 2:54 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval splenic lac, perinephric hematoma\n Admitting Diagnosis: SPLENIC LACERATION\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p fall\n REASON FOR THIS EXAMINATION:\n eval splenic lac, perinephric hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE ABDOMEN AND PELVIS WITH THE ADMINISTRATION OF INTRAVENOUS CONTRAST\n\n INDICATION: 74-year-old male status post fall with splenic laceration and\n perinephric hematoma.\n\n TECHNIQUE: Contiguous 5 mm axial images were obtained from the lung bases to\n the pubic symphysis with the administration of intravenous contrast. Images\n were reformatted in the sagittal and coronal planes.\n\n FINDINGS: No prior examination for comparison. There are bilateral\n calcified pleural plaques, compatible with prior asbestos exposure. Small\n left-sided pleural effusion, and atelectasis within the left lung base. No\n consolidation or pulmonary mass in the visualized lung fields.\n\n Evaluation of the liver demonstrates numerous hypodense lesions, the largest\n measuring 1.5 cm within the liver dome, with central density measurements of-5\n Hounsfield units. Findings most compatible with simple cysts, however, some\n of the smaller lesions are too small to characterize. There is no\n intrahepatic biliary ductal dilatation. There is a trace perihepatic fluid.\n Calcified gallstones are identified.\n\n There is minimal amount of low density fluid surrounding the posterolateral\n aspect of the spleen. In addition, there is a focal cleft within the\n posterolateral splenic body, which could represent a tiny laceration, however,\n could represent normal anatomic cleft. No active extravasation is seen.\n\n There is a large left-sided perinephric hematoma, which measures 10.2 x 6.3 x\n 8.9 cm. There is anterior displacement of the left kidney, however, no active\n extravasation is identified. The left kidney opacifies well with contrast.\n The renal vein is patent, and the collecting system is intact. The right\n kidney is grossly normal. The pancreas and adrenal glands are normal.\n\n There are no dilated loops of large or small bowel. No free intraperitoneal\n gas. There is a small amount of fluid tracking along the left pericolic\n gutter.\n\n The patient is status post prostatectomy and nodal dissection, with numerous\n clips within the pelvis. There is a Foley catheter within a decompressed\n urinary bladder.\n (Over)\n\n 2:54 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: eval splenic lac, perinephric hematoma\n Admitting Diagnosis: SPLENIC LACERATION\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n Small amount of fluid is identified within the right inguinal ring.\n\n Evaluation of osseous structures reveals degenerative change amongst both hip\n joints, right side greater than left. There is also degenerative change and\n osteophyte formation within the thoracic and upper lumbar spine. No displaced\n rib fractures are identified. Vertebral body height is preserved throughout.\n\n IMPRESSION:\n 1. Large left perinephric hematoma with associated mass effect on the left\n kidney. No active extravasation identified.\n\n 2. Possible tiny splenic laceration, without evidence of active\n extravasation.\n\n 3. Gallstones.\n\n\n\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-10-28 00:00:00.000",
"description": "Report",
"row_id": 213036,
"text": "Sinus rhythm. No previous tracing available for comparison.\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-10-29 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 884187,
"text": " 9:44 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate mediastinum with PA/lat CXR\n Admitting Diagnosis: SPLENIC LACERATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with L perinehpric hematoma & splenic lac s/p fall. Widened\n mediastinum on flat AP portable CXR.\n REASON FOR THIS EXAMINATION:\n evaluate mediastinum with PA/lat CXR\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS.\n\n INDICATION: 74-year-old man with left perinephric hematoma.\n\n COMMENTS: PA and lateral radiographs of the chest are reviewed. No previous\n study is available for comparison.\n\n There is small left pleural effusion associated with atelectasis in the left\n lung base. The lungs are clear otherwise. The heart and mediastinum are\n within normal limits.\n\n There is question of pleural plaques in the lateral portion of the right lung\n as well as right hemidiaphragm.\n\n IMPRESSION: Small left pleural effusion and atelectasis in the left lung\n base. Probable asbestos related pleural disease.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-10-29 00:00:00.000",
"description": "Report",
"row_id": 1416273,
"text": "TSICU ADMIT NOTE\nPt is 74 yo male who works in a warehouse. At approx 1230 on he fell from a standing position onto left side with left arm pinned under torso. No LOC. He sustained a left elbow abrasion. Pt cont to work through the day and proceeded home. At approx 1600, pt was talking to wife and turned pale, fainted and fell from standing position. +LOC, and pt hit his head. Wife helped pt off of the floor and later took pt to the ER. (Pt decided to shower before going to ER so was admitted some time after 1700). At OSH pt had GCS 16, he was dx'd with a splenic lac and left perinephric hematoma. Trans to , admit to TSICU for serial hct's.\n\nNEURO: Pt is A+Ox3. MAE, follows commands. States mild discomfort to left flank which is tolerable. 650mg tylenol PO x 1 for headache with effect. C-spine cleared at 0400.\n\nRESP: Sats 95% on RA. LS CTA bilat.\n\nCV: HR 50s-60s SB/SR no ectopy noted. Pt has h/o HTN and takes atenolol QD. BP currently 120s/50s.\n\nHEME: Hct in 30s. Serial hcts ordered q4.\n\nGI: NPO. Denies N/V Abd slightly distended. +Bowel sounds. Mild pain to LLQ.\n\nGU: Adequate u/o via foley. Lytes WNL.\n\nID: Afebrile.\n\nENDO: Serum gluc WNL.\n\nSKIN: Abrasion to left elbow covered with steristrips. Back/buttocks grossly intact.\n\nSOCIAL: Wife and son at bedside and supportive.\n\nASMT: Pt s/p fall, left perinephric hematoma, splenic lac. Admitted to TSICU for serial hcts and close hemodynamic monitoring. VS/labs stable at this time.\n\nPLAN: Cont to monitor vs, serial hcts, monitor abd and report increases in pain, f/u with team re: ?trans to floor if hct's stable today.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-10-29 00:00:00.000",
"description": "Report",
"row_id": 1416274,
"text": "Nursing Note:\nREVIEW OF SYSTEMS:\n\nCV: Hemodynamic status stable, hr=59-69, sinus bradycardia to nsr, bp=112/53-122/54, ext. warm, + dp bil. Serial hct, hct=25.3, cat scan abd. done, reported as unchanged.\n\nRESP: Maintained on RA, sat=96=98%, resp. rate=14=17, diminished BS RLL. Repeat CXR for ? widened mediastinum.\n\nGI: Abd. distended, soft, hypoactive BS, denies nausea, notes left flank tenderness to touch and with re-positioning.\n\nGU: Foley to gravity, u/o=60-100cc/hr\n\nSKIN: Steri-strips to left elbow, full ROM, mild edema\n\nMENTATION: Alert and oriented x3, follows commands, sleeping in naps\n\nENDO: No insulin requirement\n\nID: Afebrile\n\nSOCIAL: Wife and children in to visit, members updated by Dr. \n\nPLAN: Continue to follow serial hct, plan for transfer in am if hct/hemodynamic status stable.\n"
},
{
"category": "Nursing/other",
"chartdate": "2140-10-30 00:00:00.000",
"description": "Report",
"row_id": 1416275,
"text": "NPN 1900-0700\n Pt intact.\n\nResp- On RA, adeq sats >96% when awake, drifts to 93% when sound asleep. Lungs clear with diminished bases L>R.\n\nCV- NSR, normotensive. Afebrile. Serial HCTs stable, 6am pending. BG <100. IVF at 100cc cont. Pt c/o headache and recievd tylenol, otherwise no pain at rest. little sore on L side with activity.\n\nGI/GU- Abd soft, +BS. No BM. Foley patent with adeq UO.\n\n If pt hct remain stable, should transfer to floor.\n"
}
] |
14,060 | 171,645 | The patient was admitted to the East surgical service from the emergencydepartment. An NG tube was placed, started on IVF, kept NPO and IV pain medicine given as needed. | There is a small amount of mesenteric free air (2:48) anteriorly adjacent to an open anterior abdominal wall defect with overlying packing material. Moderate PA systolichypertension.PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.PERICARDIUM: Small pericardial effusion. Mildly dilated rightventricle with preserved systolic function. TECHNIQUE: MDCT acquired images were obtained through the chest, abdomen and pelvis after the uneventful administration of 130 cc IV Optiray contrast. Small amount of free fluid in the midline which cannot be further characterized with ultrasound. Pulmonary embolus.Height: (in) 68Weight (lb): 204BSA (m2): 2.06 m2BP (mm Hg): 83/58HR (bpm): 126Status: InpatientDate/Time: at 15:28Test: Portable TTE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:This study was compared to the prior study of .LEFT ATRIUM: Normal LA size.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/globalsystolic function (LVEF >55%).RIGHT VENTRICLE: Mildly dilated RV cavity. Right IJ catheter terminates in the superior vena cava in appropriate position. A new small left pleural effusion is noted on today's examination. IMPRESSION: Appearances consistent with small-bowel obstruction either recent or incomplete. FINDINGS: Patient is status thoracic fixation. Persistent right hilar and infrahilar well-defined opacity likely atelectasis versus aspiration. BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and Doppler son of the right and left common femoral, superficial femoral, deep femoral, and popliteal veins were obtained demonstrating appropriate flow, compressibility, augmentation, and waveforms. FINDINGS: Again identified are the diffuse multifocal alveolar opacities that have remained stable in the right lung while they have started to decrease in the left lung. There is atelectasis versus consolidation at the left lung base with a small left pleural effusion. Again noted is patchy opacification of the right lung and left lung with small left pleural effusion and atelectasis at the left lung base. As outpatient he is on Atenolol, Aldactone, Norvasc. As outpatient he is on Atenolol, Aldactone, Norvasc. As outpatient he is on Atenolol, Aldactone, Norvasc. Now oliguric, hypotensive, requiring max vent support. Received prn dose of zofran. Received prn dose of zofran. Received prn dose of zofran. pt was febrile to 101.6, tachycardic to and tachypneac. pt was febrile to 101.6, tachycardic to and tachypneac. pt was febrile to 101.6, tachycardic to and tachypneac. pt was febrile to 101.6, tachycardic to and tachypneac. 7.39/34/65 on NRB, lactate 3.0. Resp distress with tachypnea, 7.39/35/81 on NRB. #FEN - Hypokalemia: Arrived to with K replacement hanging. #FEN - Hypokalemia: Arrived to with K replacement hanging. #FEN - Hypokalemia: Arrived to with K replacement hanging. Now oliguric, hypotensive, requiring max vent support. Now oliguric, hypotensive, requiring max vent support. 7.39/34/65 on NRB, lactate 3.0. 7.39/34/65 on NRB, lactate 3.0. Resp distress with tachypnea, 7.39/35/81 on NRB. Resp distress with tachypnea, 7.39/35/81 on NRB. Lactate 3.0 Upon arrival here pt. # Abdominal source sepsis. C/o pain despite dilaudid PCA. # Prophylaxis: Pneumoboots, PPI. BS clear apeces, descending to bases audible crackles to diminished. # Hypertension. - Back to OR for re-exploration and abdominal decompression. Lung exam with dffuse crackles. Lung exam with dffuse crackles. Response: Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L. Response: Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L. Response: Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L. LGE AMT HUO/ADEQUATE DIURESIS LASIX DRIP. CONT ++GEN/SCROTAL EDEMA, PALP PP. A-LINE DAMPENED AT TIMES R/T LOCATION/PT . ABD DSD C/D/I, LLQ POUCH/DRAIN W/SM AMT SEROUS DRNG. PEEP and PSV weaned. RESP SUPPORT, WEAN AS TOL. +generalized edema. GEN EDEMA. LYTES REPLETED PRN. CONT TF VIA NGT, MIN RESIDUALS. K+ 3.1 repleted with 60meq IV. Abg shows compensated metabolic alkolosis. WEAN VENT AS TOL. SUCTIONED FOR MOD-LGE AMTS THICK, TAN SECRETIONS, CPT DONE AS TOL. K/CALCIUM REPLETED AS NEEDED DIURESIS. Midline abd incision with some purlulent drainage noted, primary team aware. ABD INC W/COPIOUS AMTS SEROUS DRNG, STAPLES REMOVED THIS AM BY DR. . CONT LASIX DRIP FOR DIURESIS/NEG FLUID BAL GOALS. Generalized edema. BS essentially clear w diminished bases. SICU NN: SEE CAREVUE FOR SPECIFICS. on AC as noted in Carevue. Albuterol given at appropriate times. Continue to replace cc:cc of OG output. PROTONIX CHANGED TO FAMOTADINE.GU--LASIX ONCE, CURRENTLY ON LASIX GTT WITH GOAL 1-1.5 LITERS NEGATAIVE.CV--STABLE OFF PRESSORS. Prn Nebs are ordered yet not indicated at this time; bs = cta with good aeration. Palpable peripheral pulses.RESP-Pt remains intubated, ventilated on settings: AC mode-45%fio2,450 X 26, 16 PEEP. EKG/CKW/TROPONIN DONE AFTER? AFEBRILE.ENDO--BLOOD SUGARS CONTROLLED WITH SLIDING SCALE.PLAN: CONTINUE WITH SLOW WEAN ON FENT/ATIVAN (APPROX. TOLERATING CPAP + PRESSURE SUPPORT . Pt continues to have generalized edema present. focus update noteD: ARDS resolved with active vent wean, diuresis with lasix gtt goal 1-2 liters negative-, pt length of stay is 16L positive, hemodynamically stable off pressors and moniotoring device discontinued.T max 98 50s- 70 NSR, no ectopy, sbp 106-120 /50-60, with aggitation repositioning and suctioning pt hypertensive SBP 160-170. ativan gtt discontinued pt may have PRN ativan for aggitation. Respiratory carePt remains intubated recieved on a/c weaned to cpap/psv. Line placement trial.Palpable pulses,Plasma lyte at 150ml/hr, cvp 14-21cm,afebrile.HCT 30's and wbc 23, plt 44, primary team aware.K and calcium replaced.Resp: Remains on vent, vent changes with ABG's, pls see resp notes and flow sheet for changes. CXR done, results pending.GI-OG with no output, now pt with increased output via ileostomy. Nsg.progress notes:See flow sheet for specific:Neuro: Pt is alert and oriented x , confused inbetween,but easily reoriented back, c/o pain, dilaudid prn with good effcet, ativan 1mg as pt c/o insomnia with fair effect, pleasant and co op with care.CV: NSR, HR in 60's, SBP 140-170, on po lopressor,ivf kvo only, afebrile, ++PP, + edema scrotum & penis, still on aldactone.CVP 2-4cm.denies Cp or discomfort.Resp: Remains on RA, ls clear, ++cough, pt is able to suction it from mouth, using IS appropriately, encouraged deep breath and cough.O2 sat 96-99%.GI: Abd softly distneded, Hypoactive BS, Tf at goal. | 123 | [
{
"category": "Radiology",
"chartdate": "2178-06-16 00:00:00.000",
"description": "CT ABDOMEN W/CONTRAST",
"row_id": 1020280,
"text": " 1:15 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: evaluate for fever source including fluid collection\n Admitting Diagnosis: OBSTRUCTION\n Field of view: 44\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man w/ respiratory failure s/p aspiration and s/p parastomal hernia\n repair. PO and IV contrast\n REASON FOR THIS EXAMINATION:\n evaluate for fever source including fluid collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56 year old man with repiratory failure and history of aspiration\n post parastomal hernia repair.\n\n COMPARISON: Multiple prior chest radiographs and CT abdomen/pelvis performed\n .\n\n TECHNIQUE: MDCT acquired images were obtained through the chest, abdomen and\n pelvis after the uneventful administration of 130 cc IV Optiray contrast. Oral\n contrast was also administered. Multiplanar reformats were reviewed.\n\n CT CHEST: The lungs demonstrate diffuse bilateral tree-in- opacities\n involving the right middle lobe and both lower lobes. There is dense\n consolidation in the lower lobe with left lower lobe cavitating lesion\n measuring approximately 6.3 x 5.5 cm. There may be a low density fluid\n component which may be pleural.\n\n CT ABDOMEN: The liver, spleen, adrenals, pancreas and kidneys are grossly\n unremarkable. There is a small amount of mesenteric free air (2:48)\n anteriorly adjacent to an open anterior abdominal wall defect with overlying\n packing material. The bowel id exposed to air, and the intraperitoneal air\n is likley related to the abdominal wall defect - rather than an\n intraabdominal process. (This was discussed with the ICU resident)..\n\n CT PELVIS: The rectum, sigmoid, Foley and bladder are unremarkable. There is\n no pelvic free fluid or free air.\n\n Bone windows demonstrate no suspicious lytic or blastic lesions with marked\n degenerative . A right iliac bone harvesting site is again noted.\n\n Spinal fusion hardware in the thoracic spine is unchanged. An endotracheal\n tube terminates in the mid trachea. A nasogastric tube terminates in the mid\n stomach. A left internal jugular catheter terminates at the superior\n cavoatrial junction.\n\n IMPRESSION:\n 1. Extensive bilateral bronchopneumonia with left lower lobe cavitating\n lesion which could represent necrotizing pneumonia (possibly aspergillosis).\n\n (Over)\n\n 1:15 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: evaluate for fever source including fluid collection\n Admitting Diagnosis: OBSTRUCTION\n Field of view: 44\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Small amount free air in adjacent to the anterior bowel loops is likley\n relsated to open peritoneum.\n\n Findings were discussed with Dr. at 4 PM on and the SICU\n resident at 5:15 PM, who confirmed that the peritoneum was open.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-10 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1019308,
"text": " 2:49 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval OGT placement prior to starting tube feeds\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man s/p parastomal hernia repair and ex lap\n REASON FOR THIS EXAMINATION:\n eval OGT placement prior to starting tube feeds\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man status post hernia repair. Here to evaluate for\n OGT placement prior to initiating tube feeds.\n\n COMPARISON: Abdominal radiograph from .\n\n FINDINGS: Portable supine image is provided showing a paucity of bowel gas\n with no tube detected within the abdomen. Note is made of thoracic spine\n hardware and clips to the right of the midline, and a stent overlying the\n lower thoracic vertebra.\n\n IMPRESSION: Paucity of bowel gas with no tube detected within the abdomen.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-25 00:00:00.000",
"description": "O CHEST (SINGLE VIEW) IN O.R.",
"row_id": 1021853,
"text": " 8:47 PM\n CHEST (SINGLE VIEW) IN O.R.; CHEST FLUORO WITHOUT RADIOLOGIST IN O.R.Clip # \n Reason: IVC FILTER PLACEMENT\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n AP SPOT FILM, P.M., \n\n A single frontal fluoroscopic spot film centered on the upper abdomen in the\n midline shows inferior vena caval umbrella filters and the lower end of spinal\n stabilization hardware, is submitted for documentation of a procedure\n performed under fluoroscopic guidance without a radiologist in attendance.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019743,
"text": " 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: Question pneumonia, ARDS.\n\n COMPARISON STUDY: .\n\n Patient is status post posterior fixation of the thoracic spine.\n\n There is an increased patchy density in the right mid to lower lung zone which\n could represent pneumonia. There is also increased opacification of the mid\n and left lower lung zones which could also represent pneumonia, or aspiration.\n There is a small left lower lobe effusion.\n\n Right IJ catheter terminates in the cavoatrial junction. ET tube terminates\n at the thoracic junction. Nasogastric tube courses towards the stomach but\n the tip is not seen.\n\n IMPRESSION:\n 1. Increased density of right mid to lower lung zone opacity, concerning for\n pneumonia.\n 2. Increased density of left lung opacities also concerning for pneumonia.\n Small left pleural effusion.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-23 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1021504,
"text": ", A. 12R 6:10 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: R/O LOWER EXTREMITY DVT/PT HAS PULMONARY EMBOLI ? SOURCE\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with PE's\n REASON FOR THIS EXAMINATION:\n r/o lower extremity dvt\n ______________________________________________________________________________\n PFI REPORT\n No evidence of lower extremity DVT.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-11 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019574,
"text": " 10:10 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NGT placement\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ARDS, for NG placement.\n\n FINDINGS: In comparison with the study of , the nasogastric tube extends\n to the distal stomach. Patchy areas of increased opacification are seen at\n both bases. Although these could represent atelectasis, the possibility of\n superimposed pneumonia can certainly not be excluded. Probable small\n bilateral pleural effusions.\n\n The metallic devices and monitoring leads remain in place.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-05-27 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1017145,
"text": " 5:38 PM\n CHEST (PA & LAT) Clip # \n Reason: ? pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with n/v\n REASON FOR THIS EXAMINATION:\n ? pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with nausea and vomiting, evaluate for pneumonia.\n\n COMPARISON: .\n\n PA AND LATERAL VIEWS, CHEST: Limited radiograph due to underpenetration and\n soft tissue scatter. The lung volumes are low. Otherwise, the lungs are\n clear without focal consolidations. There is no pleural effusion or\n pneumothorax. The heart size is normal. Pulmonary vasculature is\n unremarkable without evidence of pulmonary edema. Posterior thoracic fusion\n hardware is noted.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-06 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018683,
"text": " 9:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with sepsis, ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Sepsis and ARDS.\n\n Indwelling devices are unchanged in position. Widespread heterogeneous\n alveolar opacities demonstrate mixed changes, with improvement in left upper\n lobe, worsening in left lower lobe, and overall slight progression within the\n right lung. Small left pleural effusion is unchanged.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-05 00:00:00.000",
"description": "P BILAT LOWER EXT VEINS PORT",
"row_id": 1018543,
"text": " 3:13 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: Please eval for DVT\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ? PE\n REASON FOR THIS EXAMINATION:\n Please eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY ULTRASOUND WITH DOPPLER STUDIES.\n\n HISTORY: Shortness of breath. Question pulmonary embolism. Also evaluate\n for DVT.\n\n FINDINGS: No prior scans available for comparison.\n\n The common femoral, superficial femoral and the popliteal veins show normal\n appearance, compressibility and Doppler flow bilaterally.\n\n CONCLUSION: No ultrasound evidence of DVT in either lower leg.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018222,
"text": " 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, pulm edema\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with UC s/p colectomy now presents with SBO s/p LOA, parastomal\n hernia repair.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, pulm edema\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 9:21 AM\n Increase in right-sided opacity.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n As compared to the previous radiograph from , there is unchanged\n visualization of thoracic fusion hardware. The lung volumes are slightly\n lower than on the previous examination, the cardiac silhouette is slightly\n larger. Probably due to positioning effect, the transparency of the right\n hemithorax has decreased, however, some small amount of right-sided pleural\n effusion cannot be excluded. There are no signs suggestive of overhydration.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-04 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018223,
"text": ", M. MED 6:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, pulm edema\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with UC s/p colectomy now presents with SBO s/p LOA, parastomal\n hernia repair.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, pulm edema\n ______________________________________________________________________________\n PFI REPORT\n Increase in right-sided opacity.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-07 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018717,
"text": " 4:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with sepsis, ards\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Sepsis and ARDS.\n\n New 6 mm diameter radiopaque density is identified to the left of the trachea,\n and appears separate from the expected esophageal lumen based upon the\n rightward location of nasogastric tube at this level. This structure could\n potentially be external to the patient, but repeat radiograph following\n removal of external structures may be helpful to exclude a foreign body. With\n the exception of this finding, the remainder of the examination is unchanged.\n\n\n"
},
{
"category": "Echo",
"chartdate": "2178-06-05 00:00:00.000",
"description": "Report",
"row_id": 79059,
"text": "PATIENT/TEST INFORMATION:\nIndication: ? Pulmonary embolus.\nHeight: (in) 68\nWeight (lb): 204\nBSA (m2): 2.06 m2\nBP (mm Hg): 83/58\nHR (bpm): 126\nStatus: Inpatient\nDate/Time: at 15:28\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 size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%).\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: ?# aortic valve leaflets. No AR.\n\nMITRAL VALVE: Trivial MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Moderate PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: Small pericardial effusion. No echocardiographic signs of\ntamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\nEchocardiographic results were reviewed by telephone with the MD caring for\nthe patient.\n\nConclusions:\nViews were limited. The left atrium is normal in size. Left ventricular wall\nthickness, cavity size and regional/global systolic function are normal (LVEF\n>55%) The right ventricular cavity is mildly dilated with normal free wall\ncontractility. The number of aortic valve leaflets cannot be determined. No\naortic regurgitation is seen. Trivial mitral regurgitation is seen. There is\nmoderate pulmonary artery systolic hypertension. There is a small pericardial\neffusion. There are no echocardiographic signs of tamponade. Dr. was\nnotified by telephone on at 3:50 pm\n\nCompared with the prior study (images reviewed) of ,pulmonary\npressures are higher, right ventricle appears bigger.\n\nIMPRESSION: Preserved left ventricular systolic function. Mildly dilated right\nventricle with preserved systolic function. Moderate pulmonary hypertension.\nNo obvious valvular abnormalities but views were limited.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-05-27 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1017146,
"text": " 5:39 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ? SBO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with n/v\n REASON FOR THIS EXAMINATION:\n ? SBO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with nausea and vomiting. Rule out small bowel\n obstruction.\n\n COMPARISON: .\n\n ABDOMEN, SUPINE AND ERECT VIEWS: Mildly distended small bowel loops measuring\n up to 4.3 cm are noted. The bowel gas pattern is otherwise nonspecific. There\n are also scattered air-fluid levels predominantly noted in the right upper\n quadrant. There is no evidence of pneumoperitoneum. Lower thoracic fusion\n hardware is in unchanged location.\n\n IMPRESSION: Mildly distended small bowel loops and scattered air-fluid\n levels, may indicate partial obstruction. CT may be obtained for further\n evaluation.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-01 00:00:00.000",
"description": "SMALL BOWEL ONLY (BARIUM)",
"row_id": 1017809,
"text": " 1:02 PM\n SMALL BOWEL ONLY (BARIUM) Clip # \n Reason: Rule out obstruction, massess, fistulae, abscess\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56M w/ colitis s/p lap total abd colectomy, end ileostomy presented\n with abd pain, no output, bilious emesis on , n/w excessive ostomy output\n with intermittent s/s of PSBO.\n REASON FOR THIS EXAMINATION:\n Rule out obstruction, massess, fistulae, abscess\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old male with colitis, status post total abdominal\n colectomy and end ileostomy from . Here with abdominal pain.\n\n COMPARISON: CT of the abdomen and pelvis from , MR\n enterography from .\n\n FINDINGS: Thin barium was orally ingested for this small bowel follow-through\n study. Overhead radiographs and fluoroscopic images show filling of the bowel\n loops after about approximately three hours. There is likely fluid in the\n bowel loops as the contrast appears markedly diluted. The small bowel is\n dilated in some regions measuring up to 5.7 cm. There is no transition point\n identified, no obvious fistula formation with no apparent leak or area of\n stricture as barium visibly made it to the patient's ostomy bag.\n\n IMPRESSION: Ingested oral contrast found in the ostomy bag after slight\n motility delay with dilated small bowel loops with no obvious fistula\n formation or obstruction.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-05-27 00:00:00.000",
"description": "T-SPINE",
"row_id": 1017107,
"text": " 1:44 PM\n T-SPINE Clip # \n Reason: S/p Thoracie Fusion, T6-T12 Assess fpr healing\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Ostomyelitis, Kyphosis\n REASON FOR THIS EXAMINATION:\n S/p Thoracie Fusion, T6-T12 Assess fpr healing\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Thoracic fusion, to assess for healing.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Again the patient is status post placement of cage prosthesis across\n the wedged T10 vertebral body with lateral fusion from T9-T11. Anterior\n interbody fusion device is seen at T11-12, unchanged in position. Posterior\n fusion hardware extends from T6-7 through T12 level, with paired pedicle\n screws at T11 and T12. No evidence of hardware-related complication.\n\n IMPRESSION: Little change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-08 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1018928,
"text": " 12:48 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: assess obstruction vs. infection\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS, now with rising wbc, elevated tbili\n REASON FOR THIS EXAMINATION:\n assess obstruction vs. infection\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JBK MON 8:37 PM\n No biliary dilatation and no findings to suggest infection.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with rising white blood count and elevated T-\n bili.\n\n COMPARISON: Abdomen CT, .\n\n FINDINGS: The liver shows no focal or textural abnormality. There is no\n biliary dilatation and the common duct measures 0.3 cm. The portal vein is\n patent with hepatopetal flow. The gallbladder is normal without evidence of\n stones, and there are no signs of cholecystitis. A small right pleural\n effusion is seen. A small amount of free fluid is identified adjacent to the\n midline surgical incision. The spleen is somewhat enlarged measuring 13.7 cm.\n\n IMPRESSION:\n 1. No gallstones, no signs of cholecystitis, and no biliary dilatation.\n 2. Small amount of free fluid in the midline which cannot be further\n characterized with ultrasound. If concern for infection persists, an\n abdominal CT is recommended.\n 3. Small right pleural effusion.\n 4. Splenomegaly.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-08 00:00:00.000",
"description": "P LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT",
"row_id": 1018929,
"text": ", J. SICU-B 12:48 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Clip # \n Reason: assess obstruction vs. infection\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS, now with rising wbc, elevated tbili\n REASON FOR THIS EXAMINATION:\n assess obstruction vs. infection\n ______________________________________________________________________________\n PFI REPORT\n No biliary dilatation and no findings to suggest infection.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-05 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1018449,
"text": " 9:40 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess for infiltrate and new line position\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with resp failure\n REASON FOR THIS EXAMINATION:\n please assess for infiltrate and new line position\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable for line placement on .\n\n COMPARISON: at 03:31.\n\n HISTORY: 50-year-old man with respiratory failure, evaluate for infiltrate\n and new line position.\n\n FINDINGS:\n\n Over a period of only 6 hours, there is diffuse airspace disease occupying\n almost all of the left lung and a major portion of the right lung. The\n infiltrate and/or atelectasis seen in the right hilar area has also worsened.\n A new small left pleural effusion is noted on today's examination. There is\n no right pleural effusion. The heart size is normal. Multiple fixation\n vertebral body plates and screws in intervertebral body are again noted\n unchanged. A new endotracheal tube has been placed with tip approximately 4.5\n cm from the carina. A right internal jugular line has also been introduced\n recently with a tip in the upper one-third of the SVC.\n\n IMPRESSION:\n 1. New diffuse airspace disease in both lungs, left more than right. This\n can represent a non-cardiogenic pulmonary edema, ARDS, diffuse alveolar\n damage, or even alveolar hemorrhage.\n 2. Newly placed endotracheal tube, right internal jugular line, and feeding\n tube, all in satisfactory location.\n 3. New small left pleural effusion.\n\n\n Case discusses with Dr \n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019057,
"text": ", J. SICU-B 4:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Patient with ARDS, evaluate for change.\n\n Stable diffuse air space disease in the right lung while the air space disease\n in the left lung has slightly started to decrease.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-10 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019206,
"text": " 5:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: ARDS, to evaluate for change.\n\n FINDINGS: In comparison with the study of , there is progression of the\n multifocal alveolar opacifications, especially involving the right mid and\n lower lung zones. Some prominence of interstitial markings suggests\n superimposed elevated pulmonary venous pressure. Probable bilateral pleural\n effusions. The monitoring devices remain in place.\n\n IMPRESSION: Worsening appearance primarily involving the right mid and lower\n lung zones.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1020049,
"text": " 11:08 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: congfirm NGT placement\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ards\n REASON FOR THIS EXAMINATION:\n congfirm NGT placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB MON 11:58 AM\n Nasogastric tube terminates in the stomach.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Nasogastric tube placement.\n\n Nasogastric tube terminates in the stomach. Approximately 8 mm diameter\n radiodense foreign body is demonstrated in the left upper quadrant of the\n abdomen. It is not seen on older radiographs but is identifiable since more\n recent studies dating to . This could potentially be an\n aspirated piece of dental hardware if the patient had a traumatic intubation\n during the hospital course. Appearance of the lungs and pleura are unchanged\n since the recent radiograph of approximately two hours earlier.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1020050,
"text": ", A. SICU-B 11:08 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: congfirm NGT placement\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ards\n REASON FOR THIS EXAMINATION:\n congfirm NGT placement\n ______________________________________________________________________________\n PFI REPORT\n Nasogastric tube terminates in the stomach.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-08 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018811,
"text": " 4:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change, worsening hypoxia\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with sepsis, ards\n REASON FOR THIS EXAMINATION:\n eval for interval change, worsening hypoxia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis and ARDS.\n\n COMPARISON: , and .\n\n SEMI UPRIGHT CHEST RADIOGRAPH: A nasogastric tube, endotracheal tube,\n and right- sided internal jugular central venous line are appropriately\n positioned. The cardiomediastinal silhouette is unchanged. Again identified\n are diffuse multifocal alveolar opacities. There has been a mixed response\n with increased aeration in the left upper lung zone and increased opacity\n within the right lower lung zones. There is evidence of prior thoracic\n vertebral body fusion.\n\n IMPRESSION: Mixed response of multifocal alveolar opacities improved in the\n left upper lung zone and worsened within the right lower lung zone.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019860,
"text": " 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 05:32.\n\n COMPARISON STUDY: .\n\n CLINICAL INFORMATION: ARDS.\n\n FINDINGS:\n\n Patient is status thoracic fixation. There is essentially no change in the\n appearance of the chest since the prior study with the exception of removal of\n a right IJ catheter. The patient is intubated, and the ET tube terminates\n somewhat high just above the thoracic inlet. Nasogastric tube courses towards\n the stomach but the tip is not seen. Left subclavian catheter terminates at\n the superior vena cava.\n\n There is patchy opacification of the right lung base, unchanged, consistent\n with pneumonia. There is atelectasis versus consolidation at the left lung\n base with a small left pleural effusion. There is mild cardiomegaly and\n probable superimposed mild congestive failure.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018408,
"text": " 3:15 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Please evaluate for infiltrate or volume overload. Recent CX\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with recent abdominal surgery transferred to the ICU with\n tachypnea and hypoxia.\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrate or volume overload. Recent CXR with very poor\n inspiratory effort limits interpretation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Recent abdominal surgery with hypoxia.\n\n FINDINGS: In comparison with earlier study of this date, the patient has\n taken a slightly better inspiration. Extensive opacification persists in the\n right mid and lower lung zones medially. This is consistent with atelectasis\n or possible supervening pneumonia. There may also be some increased\n opacification in the retrocardiac region that would be better evaluated by\n lateral view if this were clinically possible.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-09 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1019056,
"text": " 4:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MEz TUE 12:42 PM\n PFI: Patient with ARDS, evaluate for change.\n\n Stable diffuse air space disease in the right lung while the air space disease\n in the left lung has slightly started to decrease.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 56-year-old man with ARDS, evaluate for interval change.\n\n FINDINGS: Again identified are the diffuse multifocal alveolar opacities that\n have remained stable in the right lung while they have started to decrease in\n the left lung. The cardiomediastinal silhouette is stable. The nasogastric\n tube, endotracheal tube, and right-sided internal jugular central venous line\n are appropriately positioned. There is no pleural effusion. The patient is\n status post thoracic vertebral body fusion.\n\n IMPRESSION: Stable mixed response of multifocal alveolar opacities,pneumonia\n in the right lung and edema in the left lung.\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-13 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 1019766,
"text": " 8:05 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: assess position of new left subclavian line\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDs, new left subclavian line placement\n REASON FOR THIS EXAMINATION:\n assess position of new left subclavian line\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 08:23\n\n COMPARISON STUDY: at 04:29\n\n CLINICAL INFORMATION: ARDS, new subclavian line placement.\n\n FINDINGS:\n\n Patient is status post fusion of the thoracic spine. Right IJ catheter\n terminates in the superior vena cava in appropriate position. Nasogastric\n tube terminates in the stomach. Again noted is patchy opacification of the\n right lung and left lung with small left pleural effusion and atelectasis at\n the left lung base. There is no appreciable change since the prior study.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-22 00:00:00.000",
"description": "CT CHEST W/CONTRAST",
"row_id": 1021285,
"text": " 6:39 PM\n CT CHEST W/CONTRAST Clip # \n Reason: please assess for interval change in abscess.\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with known lung abscess\n REASON FOR THIS EXAMINATION:\n please assess for interval change in abscess.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: RSRc MON 10:57 PM\n Unchanged B lower lobe consolidations, L > R; left demonstrates low density\n component. Precarinal lymph node enlargement. -\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 56-year-old man with known lung abscess. Assess for interval\n change.\n\n COMPARISON: .\n\n TECHNIQUE: MDCT axial images through the chest were obtained following the\n administration of intravenous contrast and displayed at 5- and 1.25-mm\n collimation. A series of sagittal and coronal images were reformatted for\n review.\n\n CT CHEST WITH IV CONTRAST: The lung abscess in the left lower lobe measures\n 62 x 42 mm (previously 63 x 55 mm). The amount of fluid within the collection\n has mildly decreased and has been replaced by air/gas. The abscess\n demonstrates connection with the subsegmental left lower lobe bronchi and\n likely has two loculated components medially. The remaining diffuse\n parenchymal abnormalities continue improve. Dense consolidation within the\n right lower lobe has decreased with some residual consolidation demonstrating\n central lucency without frank cavitation. Parenchymal consolidation within the\n right upper lobe as well as diffuse centrilobular nodules and tree-in-\n opacities have also mildly decreased.\n\n Filling defects in the right and left lower lobe segmental and subsegmental\n pulmonary arteries are consistent with acute pulmonary emboli. There are no\n enlarged central lymph nodes. The airways are patent to the subsegmental\n level bilaterally. There are calcifications of the coronary arteries.\n\n While not tailored to infradiaphragmatic evaluation, the patient is status\n post parastomal hernia repair and an open anterior abdominal wall defect with\n overlying packing material again identified.\n\n Patient has undergone prior T6 through T12 fusion as well as prior left\n thoracotomy.\n\n IMPRESSION:\n\n 1. Bilateral lower lobe segmental and subsegmental pulmonary emboli.\n\n (Over)\n\n 6:39 PM\n CT CHEST W/CONTRAST Clip # \n Reason: please assess for interval change in abscess.\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Minimal interval decrease in the size of the left lower lobe lung abscess.\n\n 3. Mild improvement in right upper and lower lobe consolidations, as well as\n diffuse tree-in- opacities.\n\n The above findings were discussed with Dr. on .\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-05-31 00:00:00.000",
"description": "ABDOMEN (SUPINE & ERECT)",
"row_id": 1017658,
"text": " 10:05 AM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: ?obstruction\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with abd pain, distention\n REASON FOR THIS EXAMINATION:\n ?obstruction\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Abdominal pain and distention, evaluate for obstruction.\n\n Spinal hardware is again seen.\n\n Distended loops of small bowel are present with multiple air-fluid levels on\n the upright film indicating likely small-bowel obstruction. Some air is seen\n within non dilated loops which indicates either the obstruction is recent or\n is incomplete.\n\n IMPRESSION: Appearances consistent with small-bowel obstruction either recent\n or incomplete. Dr. informed.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-05 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1018402,
"text": " 12:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess for effusion\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man POD 1 s/p parastomal hernia repair now in respiratory distress,\n crackles on physical exam\n REASON FOR THIS EXAMINATION:\n please assess for effusion\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest portable AP on .\n\n COMPARISON: .\n\n HISTORY: 56-year-old man with POD status post stomal hernia repair, no\n respiratory distress. Crackles on physical examination.\n\n FINDINGS: A persistent perihilar opacity with well-defined margin inferiorly\n is stable on today's examination. The left lung is clear. There is no\n evidence of pleural effusion at the bases. The heart size is normal.\n\n IMPRESSION:\n 1. Persistent right hilar and infrahilar well-defined opacity likely\n atelectasis versus aspiration. Pneumonia in the proper clinical setting\n cannot be completely excluded.\n 2. No pleural effusion is seen.\n\n The case was discussed with Dr. .\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1020016,
"text": " 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PMB MON 10:49 AM\n Coiling of nasogastric tube in cervical region. Slight improved aeration at\n the lung bases.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, .\n \t\n COMPARISON: .\n\n INDICATION: ARDS.\n\n Lines and tubes remain in standard position except for a nasogastric tube.\n Although the tip terminates in the stomach, there is apparent coiling of the\n tube in the cervical region, as communicated by phone to Dr. . The exam is\n mostly without change since the recent study, except for slight improved\n aeration at the lung bases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1020017,
"text": ", A. SICU-B 9:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess interval change\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with ARDS\n REASON FOR THIS EXAMINATION:\n assess interval change\n ______________________________________________________________________________\n PFI REPORT\n Coiling of nasogastric tube in cervical region. Slight improved aeration at\n the lung bases.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2178-06-23 00:00:00.000",
"description": "BILAT LOWER EXT VEINS",
"row_id": 1021503,
"text": " 6:10 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: R/O LOWER EXTREMITY DVT/PT HAS PULMONARY EMBOLI ? SOURCE\n Admitting Diagnosis: OBSTRUCTION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with PE's\n REASON FOR THIS EXAMINATION:\n r/o lower extremity dvt\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe TUE 7:57 PM\n No evidence of lower extremity DVT.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 56-year-old man with newly diagnosed bilateral pulmonary emboli.\n Evaluate for DVT.\n\n Comparison is made to ultrasound.\n\n BILATERAL LOWER EXTREMITY ULTRASOUND:\n\n Grayscale and Doppler son of the right and left common femoral,\n superficial femoral, deep femoral, and popliteal veins were obtained\n demonstrating appropriate flow, compressibility, augmentation, and waveforms.\n Appropriate compression was noted within the tibial veins bilaterally.\n Appropriate color flow was noted within the peroneal veins bilaterally.\n\n IMPRESSION:\n\n No evidence of bilateral lower extremity DVT.\n\n"
},
{
"category": "ECG",
"chartdate": "2178-06-17 00:00:00.000",
"description": "Report",
"row_id": 192611,
"text": "Sinus rhythm. T wave inversion in leads V1-V2 with ST segment depression\nin these leads. Biphasic T waves in lead V3. These findings are new as\ncompared with tracing . The rate has slowed. The ST-T wave changes\nraise the question of anterior ischemia. Followup and clinical correlation are\nsuggested.\n\n"
},
{
"category": "ECG",
"chartdate": "2178-06-05 00:00:00.000",
"description": "Report",
"row_id": 192612,
"text": "Sinus tachycardia. The P-R interval is short without evidence of\npre-excitation. Non-specific ST-T wave changes. Compared to the previous\ntracing there is no significant change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2178-06-05 00:00:00.000",
"description": "Report",
"row_id": 192613,
"text": "Sinus tachycardia. The P-R interval is 110 milliseconds which is short but\nwithout evidence of pre-excitation. Non-specific ST-T wave changes. Compared\nto the previous tracing the rate is faster and the P-R interval is shorter.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2178-06-03 00:00:00.000",
"description": "Report",
"row_id": 192614,
"text": "Sinus bradycardia\nModest nonspecific precordial/anterior T wave changes\nSince previous tracing of , sinus bradycardia and modest T wave changes\nnow present\n\n"
},
{
"category": "ECG",
"chartdate": "2178-06-02 00:00:00.000",
"description": "Report",
"row_id": 192615,
"text": "Sinus rhythm\nBorderline prolonged/upper limits of normal Q-Tc interval - is nonspecific -\nwithin normal limits\nBaseline artifact in lead V4 -V6 makes assessment difficult\nClinical correlation is suggested\nSince previous tracing of , sinus bradycardia absent\n\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328765,
"text": "56yo man with PMH of ulcerative colitis s/p total colectomy w/\n illeostomy in . Admitted to on w/ abd pain and\n increased ostomy output. Pain remained persistant during admission and\n pt underwent exploratory laprascopy w/ hernia repair and lysis of\n adhesions on . pt was febrile to 101.6, tachycardic to\n and tachypneac. Pt received total of 5 liters IVF in OR/PACU.\n Pt was transferred to M/SICU for further mgt of tachycardia/tachypnea.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n HR 110-125 ST, no ectopy.\n SBP 95-110\n UO 15-30cc/hr, dark amber. Cr 1.2 in PACU.\n JP drain and ostomy w/ minimal output.\n Pt states he has\ndry mouth and is thirsty\n, NPO at present.\n Action:\n Received 2 L IVF bolus overnight.\n Receiving D5NS 150cc/hr.\n Received 650mg Tylenol overnight.-\n Response:\n Minimal increase in urine output following IVF bolus.\n HR remains 115-125 ST.\n 6.5 L positive LOS at present.\n House staff and surgery aware.\n Plan:\n Cont to monitor vitals, intake/output, labs.\n Cont IV fluid replacement as ordered.\n ? advance PO intake today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain in abdominal incision and foley cath on dilaudid PCA.\n c/o nausea, no vomiting.\n Action:\n PCA dose increased overnight.\n Lidocaine urojet applied to foley cath.\n Received prn dose of zofran.\n Response:\n Pain improved to following increase in PCA and urojet.\n Nausea improved w/ zofran.\n Plan:\n Cont to monitor pain level, effectiveness of PCA.\n Cont to encourage deep breathing/IS as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328838,
"text": "Mr. is a 56 year old male with history of ulcerative colitis (pt\n of Dr. failed medical management, s/p colectomy with ileostomy\n and preservation of rectum 12/. Post operative course was\n complicated by ileus. He had been doing well post operatively until\n when he presented to the ED with abdominal pain at the site of the\n stoma and increased ostomy output. He was admitted to the surgical\n service and treated conservatively with IVF, NG tube, and NPO. Serial\n abdominal films showed air fluid levels in the small bowel. Small\n bowel follow through showed no fistula formation or obstructive point\n but patient continued to have episodic cramping pain. Due to\n persistent pain, the patient was consented and taken to the OR for\n exploratory laparoscopy. He was found to have parastomal hernia and\n adhesive disease, hernia repair and lysis of adhesions was performed.\n He was transferred from the PACU here to ICU for monitoring due to\n tachypnea, tachycardia. He was transferred to 12R as he was\n stable.\n .\n Early this am pt. became tachypneic, tachycardic up to 140\ns and\n oliguric. Placed on 100% NRB with good effect. CXR wnl, EKG wnl,\n Crackles bilat. Given 80mg of lasix and transferred here to ICU for\n further management.\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328759,
"text": "56yo man with PMH of ulcerative colitis s/p total colectomy w/\n illeostomy in . Admitted to on w/ abd pain and\n increased ostomy output. Pain remained persistant during admission and\n pt underwent exploratory laprascopy w/ hernia repair and lysis of\n adhesions on . pt was febrile to 101.6, tachycardic to\n and tachypneac. Pt received total of 5 liters IVF in OR/PACU.\n Pt was transferred to M/SICU for further mgt of tachycardia/tachypnea.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n HR 110-125 ST, no ectopy.\n SBP 95-110\n UO 15-30cc/hr, dark amber. Cr 1.2 in PACU.\n JP drain and ostomy w/ minimal output.\n Pt states he has\ndry mouth and is thirsty\n, NPO at present.\n Action:\n Received 1.5 L IVF bolus overnight.\n Receiving D5NS 150cc/hr.\n Received 650mg Tylenol overnight.-\n Response:\n Minimal increase in urine output following IVF bolus.\n HR remains 115-125 ST.\n 6.5 L positive LOS at present.\n House staff and surgery aware.\n Plan:\n Cont to monitor vitals, intake/output, labs.\n Cont IV fluid replacement as ordered.\n ? advance PO intake today.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain in abdominal incision and foley cath on dilaudid PCA.\n c/o nausea, no vomiting.\n Action:\n PCA dose increased overnight.\n Lidocaine urojet applied to foley cath.\n Received prn dose of zofran.\n Response:\n Pain improved to following increase in PCA and urojet.\n Nausea improved w/ zofran.\n Plan:\n Cont to monitor pain level, effectiveness of PCA.\n Cont to encourage deep breathing/IS as tolerated.\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328757,
"text": "56yo man with PMH of ulcerative colitis s/p total colectomy w/\n illeostomy in . Admitted to on w/ abd pain and\n increased ostomy output. Pain remained persistant during admission and\n pt underwent exploratory laprascopy w/ hernia repair and lysis of\n adhesions on . pt was febrile to 101.6, tachycardic to\n and tachypneac. Pt received total of 5 liters IVF in OR/PACU.\n Pt was transferred to M/SICU for further mgt.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n HR 110-125 ST, no ectopy.\n SBP 95-110\n UO 15-30cc/hr, dark amber. Cr 1.2 in PACU.\n JP drain and ostomy w/ minimal output.\n Pt states he has\ndry mouth and is thirsty\n Action:\n Received 1.5 L IVF bolus overnight.\n Receiving D5NS 150cc/hr.\n Response:\n Minimal increase in urine output following IVF bolus.\n HR remains 115-125 ST.\n House staff and surgery aware.\n Plan:\n Cont to monitor vitals, intake/output, labs.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt c/o pain in abdominal incision and foley cath on dilaudid PCA.\n c/o nausea, no vomiting.\n Action:\n PCA dose increased overnight.\n Lidocaine urojet applied to foley cath.\n Received prn dose of zofran.\n Response:\n Pain improved to following increase in PCA and urojet.\n Nausea improved w/ zofran.\n Plan:\n Cont to monitor pain level, effectiveness of PCA.\n Cont to encourage deep breathing/IS as tolerated.\n"
},
{
"category": "Physician ",
"chartdate": "2178-06-04 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 328752,
"text": "Chief Complaint: Xfer from surgery for tachypnea, tachycardia\n HPI:\n Mr. is a 56 year old male with history of ulcerative colitis (pt\n of Dr. failed medical management, s/p colectomy with ileostomy\n and preservation of rectum 12/. Post operative course was\n complicated by ileus. He had been doing well post operatively until\n when he presented to the ED with abdominal pain at the site of the\n stoma and increased ostomy output. He was admitted to the surgical\n service and treated conservatively with IVF, NG tube, and NPO. Serial\n abdominal films showed air fluid levels in the small bowel. Small\n bowel follow through showed no fistula formation or obstructive point\n but patient continued to have episodic cramping pain. Due to\n persistent pain, the patient was consented and taken to the OR today\n for exploratory laparoscopy. He was found to have parastomal hernia\n and adhesive disease, hernia repair and lysis of adhesions was\n performed. Estimated blood loss was minimal. He was given 2700 IVF\n however had 55cc urine output. He is being transferred from the PACU\n for monitoring due to tachypnea, tachycardia.\n .\n On arrival to the the patient is somnolent but arousable. He has\n dilaudid PCA within reach. He denies pain at rest but has pain\n with any movement. He denies fevers, chills, shortness of breath,\n nausea, chest pain or palpitations. He states that he is thirsty.\n Patient admitted from: OR / PACU\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 Celexa 10mg daily\n Aciphex 20mg daily\n Atenolol 25mg daily\n Aldactone 25mg daily\n Norvasc 2.5mg daily\n Past medical history:\n Family history:\n Social History:\n (taken from surgical admission note)\n Hypertension\n Depression\n Ulcerative colitis as above, history of chronic steroid use\n GERD\n MSSA bacteremia\n T10 diskitis\n Multiple spine surgeries: Fusion T6-T12\n Multiple thoracic laminetomies\n Partial vertebrectomy of T10-T11\n Hyperlipidemia\n History of PE\n C diff\n Hemochromatosis\n s/p arthroscopic knee surgery\n Non-contributory\n Occupation: Does not work\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Married with two children\n Review of systems:\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: Foley\n Psychiatric / Sleep: No(t) Agitated\n Pain: No pain / appears comfortable\n Pain location: Pain with movement\n Flowsheet Data as of 12:33 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: 38\nC (100.4\n HR: 125 (125 - 125) bpm\n BP: 102/66(74) {96/66(74) - 102/66(74)} mmHg\n RR: 34 (29 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n 6,218 mL\n 4 mL\n PO:\n TF:\n IVF:\n 6,218 mL\n 4 mL\n Blood products:\n Total out:\n 875 mL\n 32 mL\n Urine:\n 120 mL\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,343 mL\n -29 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, very dry mm, JVP flat\n Cardiovascular: (S1: Normal, Absent), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Tender: to palpation diffusely,\n Obese, Soft, ND, tender to palpation diffusely across abdomen,\n ileostomy intact with no drainage, hypoactive BS. JP drain in place\n with minimal output. Dressing c/d/i.\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 226\n 125\n 1.2\n 24\n 22\n 102\n 3.1\n 137\n 39.1\n 6.4\n [image002.jpg]\n Other labs: PT / PTT / INR:14/23/1.2, Ca++:9.0, Mg++:2.4, PO4:3.1\n Imaging: SB follow through: FINDINGS: Thin barium was orally\n ingested for this small bowel follow-through\n study. Overhead radiographs and fluoroscopic images show filling of the\n bowel loops after about approximately three hours. There is likely\n fluid in the\n bowel loops as the contrast appears markedly diluted. The small bowel\n is\n dilated in some regions measuring up to 5.7 cm. There is no transition\n point\n identified, no obvious fistula formation with no apparent leak or area\n of\n stricture as barium visibly made it to the patient's ostomy bag.\n IMPRESSION: Ingested oral contrast found in the ostomy bag after slight\n motility delay with dilated small bowel loops with no obvious fistula\n formation or obstruction.\n KUB: Distended loops of small bowel are present with multiple\n air-fluid levels on the upright film indicating likely small-bowel\n obstruction. Some air is seen within non dilated loops which indicates\n either the obstruction is recent or is incomplete.\n IMPRESSION: Appearances consistent with small-bowel obstruction either\n recent or incomplete. Dr. informed.\n Microbiology: Urine culture: Negative\n Assessment and Plan\n Mr. is a 56 year old male with history of UC s/p colectomy and\n ileostomy () who presented on with SBO and parastomal\n hernia now s/p LOA and parastomal hernia repair transferred to for\n tachypnea.\n .\n # Tachypnea: Upon arrival to patient RR 29-30. He is somnolent\n but arousable with shallow breaths, likely has atelectasis.\n - Continue supplemental O2.\n - Would like to try incentive spirometry however patient limited due to\n pain.\n - Treat pain with dilaudid PCA\n - Consider CXR in the AM\n .\n # Tachycardia: Likely multifactorial due to pain, fever, dehydration as\n well as withdrawal from daily atenolol. Patient stated that he is\n thirsty and has very dry MM. Had poor UOP during case which picked up\n after 3L IVF.\n - Continue with IVF to catch up and then continue with maintenance\n fluids. Normal EF on echocardiogram in 04/.\n - Tylenol for fever\n - Dilaudid PCA to treat pain\n - Continue with IV metoprolol per surgery\n .\n # s/p laparoscopy, parastomal hernia repair: POD1. Site appears clean,\n dry, intact. Tender at surgical site. JP drain in place.\n - NPO, IVF bolus plus maintenance. Has low grade fever post op.\n - Continue PCA\n - No antibiotics per surgery\n - Anticoagulation with heparin subq\n - Surgery recs in the AM.\n - Monitor JP drain output.\n - Continue PPI, ondansetron\n - Will continue to monitor fever curve. be related to\n atelectasis. Will hold on abx for now per surgical team.\n .\n # Acute renal failure: Presented with acute renal failure which was\n attributed to ileostomy losses, now resolved with fluids. Urine lytes\n on appear prerenal.\n - Continue to monitor and give IVF as above. Follow urine output\n overnight.\n .\n # Hypertension: Not active issue.\n - Plan to start PO meds once patient's diet is advanced. As outpatient\n he is on Atenolol, Aldactone, Norvasc.\n .\n # Depression:\n - Continue celexa once able to tolerate PO\n .\n #FEN\n - Hypokalemia: Arrived to with K replacement hanging. Will\n recheck in the AM and replete lytes PRN\n .\n #ACCESS: PIV\n .\n #PPx\n - Heparin sub-q for DVT prophylaxis\n - replete lytes PRN\n - PPI IV convert to PO once able.\n - bowel meds\n .\n #CODE: FULL\n .\n #COMMUNICATION: patient, medical records\n .\n #DISPO: ICU, likely call out to the floor in the AM.\n ICU Care\n Nutrition:\n Comments: NPO as diet overnight\n Glycemic Control:\n Lines:\n 22 Gauge - 11:00 PM\n Prophylaxis:\n DVT: Boots, 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": "2178-06-04 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 328755,
"text": "Chief Complaint: Xfer from surgery for tachypnea, tachycardia\n HPI:\n Mr. is a 56 year old male with history of ulcerative colitis (pt\n of Dr. failed medical management, s/p colectomy with ileostomy\n and preservation of rectum 12/. Post operative course was\n complicated by ileus. He had been doing well post operatively until\n when he presented to the ED with abdominal pain at the site of the\n stoma and increased ostomy output. He was admitted to the surgical\n service and treated conservatively with IVF, NG tube, and NPO. Serial\n abdominal films showed air fluid levels in the small bowel. Small\n bowel follow through showed no fistula formation or obstructive point\n but patient continued to have episodic cramping pain. Due to\n persistent pain, the patient was consented and taken to the OR today\n for exploratory laparoscopy. He was found to have parastomal hernia\n and adhesive disease, hernia repair and lysis of adhesions was\n performed. Estimated blood loss was minimal. He was given 2700 IVF\n however had 55cc urine output. He is being transferred from the PACU\n for monitoring due to tachypnea, tachycardia.\n .\n On arrival to the the patient is somnolent but arousable. He has\n dilaudid PCA within reach. He denies pain at rest but has pain\n with any movement. He denies fevers, chills, shortness of breath,\n nausea, chest pain or palpitations. He states that he is thirsty.\n Patient admitted from: OR / PACU\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 Celexa 10mg daily\n Aciphex 20mg daily\n Atenolol 25mg daily\n Aldactone 25mg daily\n Norvasc 2.5mg daily\n Past medical history:\n Family history:\n Social History:\n (taken from surgical admission note)\n Hypertension\n Depression\n Ulcerative colitis as above, history of chronic steroid use\n GERD\n MSSA bacteremia\n T10 diskitis\n Multiple spine surgeries: Fusion T6-T12\n Multiple thoracic laminetomies\n Partial vertebrectomy of T10-T11\n Hyperlipidemia\n History of PE\n C diff\n Hemochromatosis\n s/p arthroscopic knee surgery\n Non-contributory\n Occupation: Does not work\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Married with two children\n Review of systems:\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: Foley\n Psychiatric / Sleep: No(t) Agitated\n Pain: No pain / appears comfortable\n Pain location: Pain with movement\n Flowsheet Data as of 12:33 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: 38\nC (100.4\n HR: 125 (125 - 125) bpm\n BP: 102/66(74) {96/66(74) - 102/66(74)} mmHg\n RR: 34 (29 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n 6,218 mL\n 4 mL\n PO:\n TF:\n IVF:\n 6,218 mL\n 4 mL\n Blood products:\n Total out:\n 875 mL\n 32 mL\n Urine:\n 120 mL\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,343 mL\n -29 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, very dry mm, JVP flat\n Cardiovascular: (S1: Normal, Absent), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Tender: to palpation diffusely,\n Obese, Soft, ND, tender to palpation diffusely across abdomen,\n ileostomy intact with no drainage, hypoactive BS. JP drain in place\n with minimal output. Dressing c/d/i.\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 226\n 125\n 1.2\n 24\n 22\n 102\n 3.1\n 137\n 39.1\n 6.4\n [image002.jpg]\n Other labs: PT / PTT / INR:14/23/1.2, Ca++:9.0, Mg++:2.4, PO4:3.1\n Imaging: SB follow through: FINDINGS: Thin barium was orally\n ingested for this small bowel follow-through\n study. Overhead radiographs and fluoroscopic images show filling of the\n bowel loops after about approximately three hours. There is likely\n fluid in the\n bowel loops as the contrast appears markedly diluted. The small bowel\n is\n dilated in some regions measuring up to 5.7 cm. There is no transition\n point\n identified, no obvious fistula formation with no apparent leak or area\n of\n stricture as barium visibly made it to the patient's ostomy bag.\n IMPRESSION: Ingested oral contrast found in the ostomy bag after slight\n motility delay with dilated small bowel loops with no obvious fistula\n formation or obstruction.\n KUB: Distended loops of small bowel are present with multiple\n air-fluid levels on the upright film indicating likely small-bowel\n obstruction. Some air is seen within non dilated loops which indicates\n either the obstruction is recent or is incomplete.\n IMPRESSION: Appearances consistent with small-bowel obstruction either\n recent or incomplete. Dr. informed.\n Microbiology: Urine culture: Negative\n Assessment and Plan\n Mr. is a 56 year old male with history of UC s/p colectomy and\n ileostomy () who presented on with SBO and parastomal\n hernia now s/p LOA and parastomal hernia repair transferred to for\n tachypnea.\n .\n # Tachycardia: Likely multifactorial due to pain, fever, dehydration as\n well as withdrawal from daily atenolol. Patient stated that he is\n thirsty and has very dry MM. Had poor UOP during case which picked up\n slightly after 3L IVF.\n - Continue with maintenance IVF per surgery. They would like no\n additional fluids\n only maintenance. Concern because patient got so\n much fluid in OR as well as in PACU.\n - Tylenol for fever\n - Dilaudid PCA to treat pain\n - Continue with IV metoprolol per surgery\n - Monitor on telemetry. Per surgery ok for HR 110-120s.\n .\n # Tachypnea: Upon arrival to patient RR 29-30. He is somnolent\n but arousable with shallow breathing. No evidence of respiratory\n distress.\n - Continue supplemental O2.\n - Would like to try incentive spirometry however patient limited due to\n pain.\n - Treat pain with dilaudid PCA\n - Consider CXR in the AM as patient has received multiple liters of IVF\n over the day.\n .\n # s/p laparoscopy, parastomal hernia repair: POD1. Site appears clean,\n dry, intact. Tender at surgical site. JP drain in place.\n - NPO, IVF maintenance only as above. Has low grade fever post op.\n - Continue PCA\n - No antibiotics per surgery\n - Anticoagulation with heparin subq\n - Surgery recs in the AM.\n - Monitor JP drain output, ostomy output. Match output from ostomy 1cc\n to 1cc with NS.\n - Continue PPI, ondansetron\n - Will continue to monitor fever curve, WBC count. be related to\n atelectasis. Will hold on abx for now per surgical team.\n .\n # Acute renal failure: Presented with acute renal failure which was\n attributed to ileostomy losses, now resolved with fluids. Urine lytes\n on appear prerenal.\n - Continue to monitor and give IVF as above. Follow urine output\n overnight.\n .\n # Hypertension: Not active issue.\n - Plan to start PO meds once patient's diet is advanced. As outpatient\n he is on Atenolol, Aldactone, Norvasc.\n .\n # Depression:\n - Continue celexa once able to tolerate PO\n .\n #FEN\n - Hypokalemia: Arrived to with K replacement hanging. Will\n recheck in the AM and replete lytes PRN\n .\n #ACCESS: PIV\n .\n #PPx\n - Heparin sub-q for DVT prophylaxis\n - replete lytes PRN\n - PPI IV convert to PO once able.\n - bowel meds\n .\n #CODE: FULL\n .\n #COMMUNICATION: patient, medical records\n .\n #DISPO: ICU, likely call out to the floor in the AM.\n ICU Care\n Nutrition:\n Comments: NPO as diet overnight\n Glycemic Control:\n Lines:\n 22 Gauge - 11:00 PM\n Prophylaxis:\n DVT: Boots, 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": "Nursing",
"chartdate": "2178-06-04 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328756,
"text": "56yo man with PMH of ulcerative colitis s/p total colectomy w/\n illeostomy in . Admitted to on w/ abd pain and\n increased ostomy output. Pain remained persistant during admission and\n pt underwent exploratory laprascopy w/ hernia repair and lysis of\n adhesions on . pt was febrile to 101.6, tachycardic to\n and tachypneac. Pt received total of 5 liters IVF in OR/PACU.\n Pt was transferred to M/SICU for further mgt.\n"
},
{
"category": "Physician ",
"chartdate": "2178-06-04 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 328813,
"text": "Chief Complaint: Xfer from surgery for tachypnea, tachycardia\n HPI:\n Mr. is a 56 year old male with history of ulcerative colitis (pt\n of Dr. failed medical management, s/p colectomy with ileostomy\n and preservation of rectum 12/. Post operative course was\n complicated by ileus. He had been doing well post operatively until\n when he presented to the ED with abdominal pain at the site of the\n stoma and increased ostomy output. He was admitted to the surgical\n service and treated conservatively with IVF, NG tube, and NPO. Serial\n abdominal films showed air fluid levels in the small bowel. Small\n bowel follow through showed no fistula formation or obstructive point\n but patient continued to have episodic cramping pain. Due to\n persistent pain, the patient was consented and taken to the OR today\n for exploratory laparoscopy. He was found to have parastomal hernia\n and adhesive disease, hernia repair and lysis of adhesions was\n performed. Estimated blood loss was minimal. He was given 2700 IVF\n however had 55cc urine output. He is being transferred from the PACU\n for monitoring due to tachypnea, tachycardia.\n .\n On arrival to the the patient is somnolent but arousable. He has\n dilaudid PCA within reach. He denies pain at rest but has pain\n with any movement. He denies fevers, chills, shortness of breath,\n nausea, chest pain or palpitations. He states that he is thirsty.\n Patient admitted from: OR / PACU\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 Celexa 10mg daily\n Aciphex 20mg daily\n Atenolol 25mg daily\n Aldactone 25mg daily\n Norvasc 2.5mg daily\n Past medical history:\n Family history:\n Social History:\n (taken from surgical admission note)\n Hypertension\n Depression\n Ulcerative colitis as above, history of chronic steroid use\n GERD\n MSSA bacteremia\n T10 diskitis\n Multiple spine surgeries: Fusion T6-T12\n Multiple thoracic laminetomies\n Partial vertebrectomy of T10-T11\n Hyperlipidemia\n History of PE\n C diff\n Hemochromatosis\n s/p arthroscopic knee surgery\n Non-contributory\n Occupation: Does not work\n Drugs: None\n Tobacco: None\n Alcohol: None\n Other: Married with two children\n Review of systems:\n Cardiovascular: No(t) Chest pain, No(t) Palpitations\n Respiratory: No(t) Dyspnea, No(t) Wheeze\n Gastrointestinal: Abdominal pain, No(t) Nausea, No(t) Emesis\n Genitourinary: Foley\n Psychiatric / Sleep: No(t) Agitated\n Pain: No pain / appears comfortable\n Pain location: Pain with movement\n Flowsheet Data as of 12:33 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: 38\nC (100.4\n HR: 125 (125 - 125) bpm\n BP: 102/66(74) {96/66(74) - 102/66(74)} mmHg\n RR: 34 (29 - 34) insp/min\n SpO2: 95%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n 6,218 mL\n 4 mL\n PO:\n TF:\n IVF:\n 6,218 mL\n 4 mL\n Blood products:\n Total out:\n 875 mL\n 32 mL\n Urine:\n 120 mL\n 32 mL\n NG:\n Stool:\n Drains:\n Balance:\n 5,343 mL\n -29 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic, very dry mm, JVP flat\n Cardiovascular: (S1: Normal, Absent), tachycardic\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, No(t) Non-tender, Tender: to palpation diffusely,\n Obese, Soft, ND, tender to palpation diffusely across abdomen,\n ileostomy intact with no drainage, hypoactive BS. JP drain in place\n with minimal output. Dressing c/d/i.\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm\n Neurologic: Follows simple commands, Responds to: Verbal stimuli,\n Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 226\n 125\n 1.2\n 24\n 22\n 102\n 3.1\n 137\n 39.1\n 6.4\n [image002.jpg]\n Other labs: PT / PTT / INR:14/23/1.2, Ca++:9.0, Mg++:2.4, PO4:3.1\n Imaging: SB follow through: FINDINGS: Thin barium was orally\n ingested for this small bowel follow-through\n study. Overhead radiographs and fluoroscopic images show filling of the\n bowel loops after about approximately three hours. There is likely\n fluid in the\n bowel loops as the contrast appears markedly diluted. The small bowel\n is\n dilated in some regions measuring up to 5.7 cm. There is no transition\n point\n identified, no obvious fistula formation with no apparent leak or area\n of\n stricture as barium visibly made it to the patient's ostomy bag.\n IMPRESSION: Ingested oral contrast found in the ostomy bag after slight\n motility delay with dilated small bowel loops with no obvious fistula\n formation or obstruction.\n KUB: Distended loops of small bowel are present with multiple\n air-fluid levels on the upright film indicating likely small-bowel\n obstruction. Some air is seen within non dilated loops which indicates\n either the obstruction is recent or is incomplete.\n IMPRESSION: Appearances consistent with small-bowel obstruction either\n recent or incomplete. Dr. informed.\n Microbiology: Urine culture: Negative\n Assessment and Plan\n Mr. is a 56 year old male with history of UC s/p colectomy and\n ileostomy () who presented on with SBO and parastomal\n hernia now s/p LOA and parastomal hernia repair transferred to for\n tachypnea.\n .\n # Tachycardia: Likely multifactorial due to pain, fever, dehydration as\n well as withdrawal from daily atenolol. Patient stated that he is\n thirsty and has very dry MM. Had poor UOP during case which picked up\n slightly after 3L IVF.\n - Continue with maintenance IVF per surgery. They would like no\n additional fluids\n only maintenance. Concern because patient got so\n much fluid in OR as well as in PACU.\n - Tylenol for fever\n - Dilaudid PCA to treat pain\n - Continue with IV metoprolol per surgery\n - Monitor on telemetry. Per surgery ok for HR 110-120s.\n .\n # Tachypnea: Upon arrival to patient RR 29-30. He is somnolent\n but arousable with shallow breathing. No evidence of respiratory\n distress.\n - Continue supplemental O2.\n - Would like to try incentive spirometry however patient limited due to\n pain.\n - Treat pain with dilaudid PCA\n - Consider CXR in the AM as patient has received multiple liters of IVF\n over the day.\n .\n # s/p laparoscopy, parastomal hernia repair: POD1. Site appears clean,\n dry, intact. Tender at surgical site. JP drain in place.\n - NPO, IVF maintenance only as above. Has low grade fever post op.\n - Continue PCA\n - No antibiotics per surgery\n - Anticoagulation with heparin subq\n - Surgery recs in the AM.\n - Monitor JP drain output, ostomy output. Match output from ostomy 1cc\n to 1cc with NS.\n - Continue PPI, ondansetron\n - Will continue to monitor fever curve, WBC count. be related to\n atelectasis. Will hold on abx for now per surgical team.\n .\n # Acute renal failure: Presented with acute renal failure which was\n attributed to ileostomy losses, now resolved with fluids. Urine lytes\n on appear prerenal.\n - Continue to monitor and give IVF as above. Follow urine output\n overnight.\n .\n # Hypertension: Not active issue.\n - Plan to start PO meds once patient's diet is advanced. As outpatient\n he is on Atenolol, Aldactone, Norvasc.\n .\n # Depression:\n - Continue celexa once able to tolerate PO\n .\n #FEN\n - Hypokalemia: Arrived to with K replacement hanging. Will\n recheck in the AM and replete lytes PRN\n .\n #ACCESS: PIV\n .\n #PPx\n - Heparin sub-q for DVT prophylaxis\n - replete lytes PRN\n - PPI IV convert to PO once able.\n - bowel meds\n .\n #CODE: FULL\n .\n #COMMUNICATION: patient, medical records\n .\n #DISPO: ICU, likely call out to the floor in the AM.\n ICU Care\n Nutrition:\n Comments: NPO as diet overnight\n Glycemic Control:\n Lines:\n 22 Gauge - 11:00 PM\n Prophylaxis:\n DVT: Boots, 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 ------ 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.\n Very well appearing on my exam this morning. Sleepy but easily\n arousable. Comfortable on pain regimen. Lungs CTA. No further need for\n ICU level care.\n ------ Protected Section Addendum Entered By: , MD\n on: 17:10 ------\n"
},
{
"category": "Respiratory ",
"chartdate": "2178-06-05 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 328903,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: OR\n Reason:\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: 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: Nasal flaring, Accessory muscle\n use, Tachypneic (RR> 35 b/min), Gasping efforts, Intercostal\n retractions, Active exhalations\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\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 Recruitment Maneuvers Done\n CPAP pressure used: 35 cm H2O\n Duration: 30 sec\n Times per shift: 2\n Comments: poorly tolerated decreased bp.\n Multiple vent changes through out shift , please see metavision.\n"
},
{
"category": "General",
"chartdate": "2178-06-05 00:00:00.000",
"description": "ICU Event Note",
"row_id": 328905,
"text": "Clinician: Attending\n Spoke with Dr who requests that all management issues for Mr\n are handled only by the surgical service. MICU residents will be\n available for emergency backup, but will not be called for management\n issues and pt will not be rounded on by MICU team or seen by MICU\n attending. Pt will transfer to SICU as soon as it is safe for .\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328906,
"text": "56yo male POD #2 for exploratory lap w/ hernia repair, back to OR for\n ?acute abdomen, bladder pressure of 40. No apparent intra peritoneal\n process , tube placed, had edematous bowel and 3L fluid in\n abdomen removed. ? aspiration -> bronched -> no significant\n secretions, BAL sent. Abdomen decompressed, bladder pressures 23-25.\n Acidosis, Metabolic\n Assessment:\n Pt returned from OR at ~ 0900, intubated with poor ABG\ns despite fiO2\n of 100%. Lactate 4.2\n Action:\n Multiple changes made to vent throughout the day with plan to follow\n ARDS protocol. Presently is on AC 550X32X100%X15 with ABG\n 7.30/45/71/-3. Given bicarb gtt 150meq/1000 D5W at 150/hr and total of\n 5L LR.\n Response:\n ABG\ns as above.\n Plan:\n Monitor ABG\ns frequently and adjust vent accordingly following ARDS\n guidelines.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Persistent hypoxemia and hypercapnia despite high fiO2 and peeps. CXR\n -> bilat patchy infiltrates esp L upper lobe; TTE showed pulm embolism\n unlikely but has some pulmonary hypertension, LENI\ns also negative.\n Lung sounds are clear throughout, diminished LLL. No secretions noted.\n Action:\n Vent settings adjusted as above with satisfactory ABG\ns, given total of\n 5L of IVF today for hypotension and low urine output. Triadyne bed\n ordered for proning but so far not needed. Sedation changed from\n propofol to fent/versed 50/2 but resp pattern is shallow, labored and\n disynchronous so fent increased to 75mcg.\n Response:\n Resp status unstable.\n Plan:\n Prone pt if does not improve, titrate sedation to keep respirations\n unlabored without dropping BP,\n Sepsis without organ dysfunction\n Assessment:\n No infectious source identified so far. Tmax 99.7, lactate 4.2\n Action:\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\n flagyl/levo/vanc.\n Response:\n Pending.\n Plan:\n Monitor temp, wbc\ns, lactate. Follow cultures, continue abx until\n sensitivities available.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP\ns 70\ns-130/ 50-70\ns, HR 118-128 ST no ectopy, CVP 10-16\n Action:\n Phenylephrine gtt titrated throughout the day, was maxed for a short\n time but presently is at .9mcg/kg/min. Received total 5L LR, 25gm\n albumin, 1L D5W w/ 150meq bicarb.\n Response:\n Presently ABP\ns are 100\ns/ 60\ns, fluid status is +4L, urine output is\n 40-200cc/hr.\n Plan:\n Titrate neo to map >60, wean if possible, monitor fluid status, give 1L\n LR boluses for low urine output and hypotension.\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328907,
"text": "56yo male POD #2 for exploratory lap w/ hernia repair, back to OR for\n ?acute abdomen, bladder pressure of 40. No apparent intra peritoneal\n process , tube placed, had edematous bowel and 3L fluid in\n abdomen removed. ? aspiration -> bronched -> no significant\n secretions, BAL sent. Abdomen decompressed, bladder pressures 23-25.\n Acidosis, Metabolic\n Assessment:\n Pt returned from OR at ~ 0900, intubated with poor ABG\ns despite fiO2\n of 100%. Lactate 4.2\n Action:\n Multiple changes made to vent throughout the day with plan to follow\n ARDS protocol. Presently is on AC 550X32X100%X15 with ABG\n 7.30/45/71/-3. Given bicarb gtt 150meq/1000 D5W at 150/hr and total of\n 5L LR.\n Response:\n ABG\ns as above.\n Plan:\n Monitor ABG\ns frequently and adjust vent accordingly following ARDS\n guidelines.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Persistent hypoxemia and hypercapnia despite high fiO2 and peeps. CXR\n -> bilat patchy infiltrates esp L upper lobe; TTE showed pulm embolism\n unlikely but has some pulmonary hypertension, LENI\ns also negative.\n Lung sounds are clear throughout, diminished LLL. No secretions noted.\n Action:\n Vent settings adjusted as above with satisfactory ABG\ns, given total of\n 5L of IVF today for hypotension and low urine output. Triadyne bed\n ordered for proning but so far not needed. Sedation changed from\n propofol to fent/versed 50/2 but resp pattern is shallow, labored and\n disynchronous so fent increased to 75mcg.\n Response:\n Resp status unstable.\n Plan:\n Prone pt if does not improve, titrate sedation to keep respirations\n unlabored without dropping BP,\n Sepsis without organ dysfunction\n Assessment:\n No infectious source identified so far. Tmax 99.7, lactate 4.2\n Action:\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\n flagyl/levo/vanc.\n Response:\n Pending.\n Plan:\n Monitor temp, wbc\ns, lactate. Follow cultures, continue abx until\n sensitivities available.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP\ns 70\ns-130/ 50-70\ns, HR 118-128 ST no ectopy, CVP 10-16\n Action:\n Phenylephrine gtt titrated throughout the day, was maxed for a short\n time but presently is at .9mcg/kg/min. Received total 5L LR, 25gm\n albumin, 1L D5W w/ 150meq bicarb.\n Response:\n Presently ABP\ns are 100\ns/ 60\ns, fluid status is +4L, urine output is\n 40-200cc/hr.\n Plan:\n Titrate neo to map >60, wean if possible, monitor fluid status, give 1L\n LR boluses for low urine output and hypotension.\n"
},
{
"category": "Physician ",
"chartdate": "2178-06-05 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 328885,
"text": "Clinician: Attending\n 56 yo man with colitis, presumed UC, colectomy , adm with\n high ostomy output and abd pain. Ostomy output attributed to bowel wall\n edema and poor absorption. In MICU with transient tachypnea and\n tachycardia but not hypoxemia following hernia repair and ex-lap. Was\n persistantly tachycardic, likely dehydrated. Tachypnea resolved\n overnight, transferred back to surgical floor yesterday morning. Total\n 6L net + over 24 h, with decreasing urine output finally to < 10cc/h.\n WBC rose 6--> 26--> 38K with 20% bandemia. Resp distress with\n tachypnea, 7.39/35/81 on NRB. Tranferred to MICU. Initial mental status\n normal, becamse confused within hours. Increasing oxygen requirement.\n 7.39/34/65 on NRB, lactate 3.0. Lung exam with dffuse crackles.\n Oliguric with no response to lasix. Concern for abd distension, bladder\n pressure was 40 mm Hg. Initial CXR showed low lung volumes but no sig\n parenchymal process, right mid lung zone atelectasis. Went to OR got\n right IJ, art line, found to have edematous bowel, stomach had 3L\n fluid. Bowel decompressed. Bronch with no sig secretions, BAL done.\n Since surgery hypoxia progressed. Severe metabolic acidosis. CXR with\n bilateral patchy infiltrates esp left upper lung field. Sedated on\n propofol. Hypotensive with 87/64, MAP 71. SpO2 88% on FiO2 1.0, PEEP 15\n TV 450 RR 35 PIP 35 Plateau 26 Compliance 45. Abdomen distension much\n improved.\n 7.13/63/70 on rate 26.\n HCo3 22, gap 15. BUN/Cr 39/2.5 (inc from 1.4 yest). WBC 25K. Hct 42%.\n LFTs wnl. INR 1.6. Lactate rose to 4.5.\n Severely critically ill with ARDS, septic shock, unclear if he had\n aspiration event or secondary to sepsis, abd surgery. Now oliguric,\n hypotensive, requiring max vent support. Bladder pressure decreased\n from 40 to 25 after decompression. Broad abx, no cx data yet.\n flagyl/levo/vanc to cover bowel and lung sources. ARDSnet but pushing\n PEEP for continued hypoxia. Permissive hypercapnia, and RR raised for\n acidemia, but will give bicarb if repeat ABG shows no correction of pH.\n Trying right side down to try to improve V/Q mismatch. Will likely\n switch to PCV to improve oxygenation if ineffective.\n Patient is critically ill.\n ------ Protected Section ------\n Spoke with Dr , who told me there is no contraindication\n to proning, if that becomes necessary.\n Bicarb infusion.\n Phenylephrine now at 2.5mcg/kg/min.\n Placing esophageal balloon, as abd pressure suggested he will need much\n higher PEEP.\n Time spent 80 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:29 ------\n Remains critically ill with ARDS, septic shock. pH improved now at 7.30\n on PRVC vent, PEEP 15, Vt at 4.5cc/kg. Received 5L crystalloid, with\n good urine output and CVP 15 (though high PEEP). Remains on\n phenylephrine, but down to 0.9. Highly doubt PE given that we have a\n good reason for hypoxic resp failure given cxr and ARDS physiology, I\n suspect aspiration event. I feel risk of empiric heparin outweighs\n theoretical benefit, despite h/o PE 1 year ago. Repeat coags pending.\n Echo result pending but on my review RV appeared to contract well and\n have reasonably normal chamber size.\n Time: additional 60 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 16:30 ------\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 328782,
"text": "Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Hernia, other\n Assessment:\n Action:\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328898,
"text": "56yo male POD #2 for exploratory lap w/ hernia repair, back to OR for\n ?acute abdomen, bladder pressure of 40. No intra peritoneal process ,\n tube placed, had edematous bowel and 3L fluid in abdomen. ?\n aspiration -> bronched -> no significant secretions, BAL sent. Abdomen\n decompressed, bladder pressures 23-25.\n Acidosis, Metabolic\n Assessment:\n Pt returned from OR at ~ 0900, intubated with poor ABG\ns despite fiO2\n of 100%. Lactate 4.2\n Action:\n Multiple changes made to vent throughout the day with plan to follow\n ARDS protocol. Presently is on AC 550X32X100%X15 with ABG\n 7.30/45/71/-3. Given bicarb gtt 150meq/1000 D5W at 150/hr and total of\n 5L LR.\n Response:\n ABG\ns as above.\n Plan:\n Monitor ABG\ns frequently and adjust vent accordingly following ARDS\n guidelines.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Persistent hypoxemia and hypercapnia despite high fiO2 and peeps. CXR\n -> bilat patchy infiltrates esp L upper lobe; TTE showed pulm embolism\n unlikely but has some pulmonary hypertension, LENI\ns also negative.\n Lung sounds are clear throughout, diminished LLL. No secretions noted.\n Action:\n Vent settings adjusted as above with satisfactory ABG\ns, given total of\n 5L of IVF today for hypotension and low urine output. Triadyne bed\n ordered for proning but so far not needed. Sedation changed from\n propofol to fent/versed 50/2 but resp pattern is shallow, labored and\n disynchronous so fent increased to 75mcg.\n Response:\n Resp status unstable.\n Plan:\n Prone pt if does not improve, titrate sedation to keep respirations\n unlabored without dropping BP,\n Sepsis without organ dysfunction\n Assessment:\n No infectious source identified so far. Tmax 99.7, lactate 4.2\n Action:\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\n flagyl/levo/vanc.\n Response:\n Pending.\n Plan:\n Monitor temp, wbc\ns, lactate. Follow cultures, continue abx until\n sensitivities available.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP\ns 70\ns-130/ 50-70\ns, HR 118-128 ST no ectopy, CVP 10-16\n Action:\n Phenylephrine gtt titrated throughout the day, was maxed for a short\n time but presently is at .9mcg/kg/min. Received total 5L LR, 25gm\n albumin, 1L D5W w/ 150meq bicarb.\n Response:\n Presently ABP\ns are 100\ns/ 60\ns, fluid status is +4L, urine output is\n 40-200cc/hr.\n Plan:\n Titrate neo to map >60, wean if possible, monitor fluid status, give 1L\n LR boluses for low urine output and hypotension.\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-04 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 328784,
"text": "Mr. is a 56 year old male with history of ulcerative colitis (pt\n of Dr. failed medical management, s/p colectomy with ileostomy\n and preservation of rectum 12/. Post operative course was\n complicated by ileus. He had been doing well post operatively until\n when he presented to the ED with abdominal pain at the site of the\n stoma and increased ostomy output. He was admitted to the surgical\n service and treated conservatively with IVF, NG tube, and NPO. Serial\n abdominal films showed air fluid levels in the small bowel. Small\n bowel follow through showed no fistula formation or obstructive point\n but patient continued to have episodic cramping pain. Due to\n persistent pain, the patient was consented and taken to the OR today\n for exploratory laparoscopy. He was found to have parastomal hernia\n and adhesive disease, hernia repair and lysis of adhesions was\n performed. Estimated blood loss was minimal. He was given 2700 IVF\n however had 55cc urine output. He is being transferred from the PACU\n for monitoring due to tachypnea, tachycardia.\n .\n On arrival to the the patient is somnolent but arousable. He has\n dilaudid PCA within reach. PCA dose increased overnight. He reports\n pain at 3/10, reports that it is now much better controlled. Pain with\n any movement. He denies fevers, chills, shortness of breath, nausea,\n chest pain or palpitations. He states that he is thirsty.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n Pt received 3 fluid boluses overnight for total of 2 L, was started\n on maintenance fluid at 150cc/hr, HR: 102-125, trending down,\n BP:94-109/65-87, trending up, u/o~20-30 cc/hr, cr this am 1.4\n Action:\n No further fluid boluses given this shift per surgery, pt reporting\n that he is thirsty, following hemodynamics, pt receiving metoprolol as\n ordered\n Response:\n Ongoing\n Plan:\n Encourage Po intact when ordered, pt currently NPO, continue maintance\n fluids, montitor I/O, ? recs, continue cardiac meds per wants\n pt beta blocked on atenolol at home\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt on dilaudid PCA as noted above, 0.37 mg increased overnight with\n good effect, 6min lock out, no basal rate, 1 hour max 3.7mg, pt\n reporting pain at 3/10 at rest, increased pain with activity, pt\n describes pain as sharp and radiating, sleeping at times arouses with\n pain but controlled with PCA dosing\n Action:\n Encouraging pt to use PCA, PCA teaching, continuing to provide current\n dosing as ordered\n Response:\n Pt with good pain control, pain reported at 3/10 while at rest\n Plan:\n Transition to po pain meds as tolerated when pt started on Pos,\n continue PCA for now, continue to monitor pain control\n Hernia, other\n Assessment:\n Pt with hernia repair , by this am to view incision, two mid\n line incisions noted, dressing dry and intact, serous drainage\n noted on upper dsg, JP drain on lower, draining serous fluid, iliostomy\n with minimal out put draining serous fluid as well, bowel sounds\n present\n Action:\n Monitoring\n Response:\n Ongoing\n Plan:\n Continue to monitor abd for increased tenderness, redness and pain,\n monitor JP drainage for change in color or odor, f/ recs for dsg\n changes\n Demographics\n Attending MD:\n \n Admit diagnosis:\n OBSTRUCTION\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 95.3 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: ulcerative colitis s/p total colectomy in .\n Depression, GERD.Thoracic back pain. multiple spinal surgeries,\n arthroscopic knee surgery.\n Surgery / Procedure and date: Exploratory Lap w/ Hernia Repair \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:87\n Temperature:\n 97.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 108 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 97% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 2,607 mL\n 24h total out:\n 219 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 04:05 AM\n Potassium:\n 4.1 mEq/L\n 04:05 AM\n Chloride:\n 109 mEq/L\n 04:05 AM\n CO2:\n 19 mEq/L\n 04:05 AM\n BUN:\n 24 mg/dL\n 04:05 AM\n Creatinine:\n 1.4 mg/dL\n 04:05 AM\n Glucose:\n 144 mg/dL\n 04:05 AM\n Hematocrit:\n 35.7 %\n 04:05 AM\n Additional pertinent labs:\n BUN 24 CR 1.4\n Lines / Tubes / Drains:\n JP drain, 2 PIV\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/\n Transferred to: 12R\n Date & time of Transfer: 1100\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-05 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328843,
"text": "Mr. is a 56 year old male with history of ulcerative colitis (pt\n of Dr. failed medical management, s/p colectomy with ileostomy\n and preservation of rectum 12/. Post operative course was\n complicated by ileus. He had been doing well post operatively until\n when he presented to the ED with abdominal pain at the site of the\n stoma and increased ostomy output. He was admitted to the surgical\n service and treated conservatively with IVF, NG tube, and NPO. Serial\n abdominal films showed air fluid levels in the small bowel. Small\n bowel follow through showed no fistula formation or obstructive point\n but patient continued to have episodic cramping pain. Due to\n persistent pain, the patient was consented and taken to the OR for\n exploratory laparoscopy. He was found to have parastomal hernia and\n adhesive disease, hernia repair and lysis of adhesions was performed.\n He was transferred from the PACU here to ICU for monitoring due to\n tachypnea, tachycardia. He was transferred to 12R as he was\n stable.\n .\n Early this am pt. became tachypneic, tachycardic up to 140\ns and\n oliguric. Placed on 100% NRB with good effect. CXR wnl, EKG wnl,\n Crackles bilat. Given 80mg of lasix and transferred here to ICU for\n further management. Labs drawn on floor. White count rising. Lactate\n 3.0\n Upon arrival here pt. found to have HR up to 150\ns. BP WNL. Tachypneic\n and very confused. Notably cold/clammy. Unable to draw labs. Abdomen\n Firm. Bowel sounds absent. C/o pain despite dilaudid PCA. Bladder\n pressure checked and was 40. Surgeon called immediately. Pt. refusing\n central line and a line. Plan is to go to OR. ? Compartment syndrome\n vs. intra-abdominal process.\n"
},
{
"category": "Physician ",
"chartdate": "2178-06-05 00:00:00.000",
"description": "Physician Resident Admission Note",
"row_id": 328844,
"text": "Chief Complaint: Transfer from surgery for tachypnea, shortness of\n breath.\n HPI:\n 56 yo M with a history of UC s/p colectomy with ileostomy in \n admitted on with abdominal pain and increased ostomy output\n now POD #2 from ex lap with parastomal hernia repair and lysis of\n adhesions who represents to the ICU with acute onset tachypnea and\n shortness of breath and oliguric renal failure.\n .\n The patient was originally admitted on . He had been doing well\n since his surgery in until he developed abdominal pain at the\n site of the stoma and increased ostomy output. He was admitted to the\n surgical service and treated conservatively with IVF, NG tube, and\n NPO. Serial abdominal films showed air fluid levels in the small\n bowel. Small bowel follow through showed no fistula formation or\n obstructive point but patient continued to have episodic cramping\n pain. Due to persistent pain, the patient was consented and taken to\n the OR on for exploratory laparoscopy. He was found to have\n parastomal hernia and adhesive disease, hernia repair and lysis of\n adhesions was performed. The patient was in the ICU overnight the\n evening after surgery for tachypnea, tachycardia and relative hypoxia.\n At that time he was felt likely to be hypovolemic possibly with a\n component of beta-blocker withdrawal. With minimal intervention\n overnight, the patient's symptoms improved and he was called back out\n to the surgical floor.\n .\n Since that time, the patient has received an estimated 6L of fluid\n rescucitation per the report of the surgery team and recent \n records. He had poor urine output of approximately 500cc. He had rising\n WBC, Hct and platelets.\n .\n The surgical resident was called to evaluate the patient where he was\n found to be tachycardic, tachypneic and hypoxic requiring a\n non-rebreather. He was noted to be oliguric with declining urine output\n to approximately 10cc/hr. ABG at that time revealed 7.39/35/81 on a\n NRB. He was transferred to the ICU where repeat ABG revealed 7.39/34/65\n on a NRB with lactate 3.0. He received 50mg IV lasix on the floor and\n an additional 80mg IV lasix in the ICU without significant urine\n output.\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 Furosemide (Lasix) - 02:15 AM\n Other medications:\n Meds on admission:\n Celexa 10mg daily\n Aciphex 20mg daily\n Atenolol 25mg daily\n Aldactone 25mg daily\n Norvasc 2.5mg daily\n .\n Meds on transfer:\n Hyoscyamine 0.125 mg SL QID\n Ipratropium Bromide Neb 1 NEB IH Q6H\n Acetaminophen 325-650 mg PO Q6H:PRN\n Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN\n Metoprolol Tartrate 5 mg IV Q6H\n DiphenhydrAMINE 25 mg PO HS:PRN\n Ondansetron 4 mg IV Q8H:PRN\n Pantoprazole 40 mg IV Q24H\n HYDROmorphone (Dilaudid) 0.37 mg IVPCA\n Heparin 5000 UNIT SC TID\n Past medical history:\n Family history:\n Social History:\n Hypertension\n Depression\n Ulcerative colitis as above, history of chronic steroid use\n GERD\n MSSA bacteremia\n T10 diskitis\n Multiple spine surgeries: Fusion T6-T12\n Multiple thoracic laminetomies\n Partial vertebrectomy of T10-T11\n Hyperlipidemia\n History of PE\n C diff\n Hemochromatosis\n s/p arthroscopic knee surgery\n See recent admit note\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: See recent admit note\n Review of systems: Notes abdominal pain and shortness of breath,\n otherwise negative in detail.\n Flowsheet Data as of 04:54 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: 35.7\nC (96.3\n HR: 143 (102 - 147) bpm\n BP: 125/108(112) {100/68(75) - 133/108(112)} mmHg\n RR: 28 (20 - 35) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Bladder pressure: 40 (40 - 40) mmHg\n Total In:\n 2,853 mL\n 23 mL\n PO:\n TF:\n IVF:\n 2,853 mL\n 23 mL\n Blood products:\n Total out:\n 249 mL\n 337 mL\n Urine:\n 229 mL\n 67 mL\n NG:\n Stool:\n Drains:\n 20 mL\n 70 mL\n Balance:\n 2,604 mL\n -314 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n Physical Examination\n Gen: Somewhat uncomfortable gentleman with NRB on. Intermittent\n complaints of abdominal pain.\n HEENT: JVP difficult to assess.\n CV: RRR. Normal S1 and S2. No M/R/G.\n Pulm: Diffuse crackles R>L.\n Abd: Mildly distended. Hypoactive bowel sounds. Diffuse tenderness.\n Ext: No edema.\n Bladder pressure: 40\n Labs / Radiology\n 245 K/uL\n 11.4 g/dL\n 144 mg/dL\n 1.4 mg/dL\n 24 mg/dL\n 19 mEq/L\n 109 mEq/L\n 4.1 mEq/L\n 140 mEq/L\n 35.7 %\n 26.9 K/uL\n [image002.jpg]\n \n 2:33 A6/19/ 04:05 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 26.9\n Hct\n 35.7\n Plt\n 245\n Cr\n 1.4\n Glucose\n 144\n Other labs: Lactic Acid:3.0, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Fluid analysis / Other labs: ABG: 7.39/35/81 -> 7.39/34/65\n Imaging: CXR (): As compared to the previous radiograph from\n , there is unchanged visualization of thoracic fusion\n hardware. The lung volumes are slightly lower than on the previous\n examination, the cardiac silhouette is slightly larger. Probably due to\n positioning effect, the transparency of the right hemithorax has\n decreased, however, some small amount of right-sided pleural effusion\n cannot be excluded. There are no signs suggestive of overhydration.\n .\n CXR (): Small lung volumes. No infiltrates. No obvious signs of\n volume overload.\n Microbiology: Urine culture (): <10,000 organisms/ml\n ECG: Sinus tachycardia at 147. Normal axis and intervals. Downgoing t's\n in V1 as seen previously. Morphologic change across the precordium with\n very poor R wave progression and predominantly negative QRS complex in\n V2-4 more pronounced than prior and near isoelectric V5-6 new from\n prior. No signs of right heart strain.\n Assessment and Plan\n A/P: 56 yo M with a history of UC s/p colectomy with ileostomy in\n admitted on with abdominal pain and increased ostomy\n output now POD #2 from ex lap with parastomal hernia repair and lysis\n of adhesions who represents to the ICU with sepsis physiology, acute\n onset tachypnea and shortness of breath and oliguric renal failure\n concerning for abdominal compartment syndrome.\n .\n # Abdominal source sepsis. Tachycardia, tachypnea, leukocytosis and\n lacate elevation suggestive of sepsis physiology. Likely source is\n recent abdominal surgery with enterotomy.\n - Broad spectrum antibiotics with vanc, levo, flagyl.\n - Blood and urine cultures.\n - Back to OR per surgery.\n .\n # Tachypnea, shortness of breath. Most likely secondary to pulmonary\n edema due to 3rd spacing of fluid in the lungs with diffuse crackles on\n exam and large A-a gradient. This is likely in part due to sepsis\n physiology (leukocytosis and lactate elevation) with capillary leak\n Cannot exclude PE though less likely given exam and clinical\n appearance. Flash edema from hypertension or MI cannot be excluded\n though also less likely. Hypoventilation due to pain and abdominal\n compartment syndrome with elevated bladder pressure is possible though\n this does not explain the large A-a gradient well. These seems unlikely\n to represent a pulmonary source of infection.\n - Continue oxygen supplementation support. Positive pressure and\n mechanical ventilation as necessary for respiratory decline.\n - Difficult volume status, intravascularly deplete, 3rd space volume\n overloaded in lungs and abdomen. Unresponsive to lasix likely secondary\n to abdominal compartment syndrome. Maintain I/O status even as\n possible.\n - Requires decompression of likely abdominal compartment syndrome to\n allow for improved perfusion of kidneys and diuresis.\n - Rule out MI.\n - Likely TTE post-operatively.\n .\n # Tachycardia. Likely sepsis physiology. Cannot exclude a component of\n pain or secondary to respiratory distress.\n - Broad spectrum antibiotics.\n - Maintain I/O even as possible.\n .\n # Oliguric renal failure. Likely secondary to abdominal compartment\n syndrome. Bladder pressure 40.\n - To OR for decompression of abdominal compartment syndrome.\n .\n # UC s/p ostomy with recent abdominal surgery for paraostomy hernia\n repair and lysis of adhesions. Complications as above of likely\n abdominal source sepsis +/- abdominal compartment syndrome.\n - Back to OR for re-exploration and abdominal decompression.\n .\n # Hypertension. Hold beta-blocker in the setting of likely hypotension.\n .\n # FEN: NPO.\n .\n # Access: Peripheral IV. Refusing central line.\n .\n # Prophylaxis: Pneumoboots, PPI.\n .\n # Code: Full\n .\n # Dispo: ICU.\n .\n ICU Care\n Nutrition:\n 22 Gauge - 02:20 AM\n Prophylaxis:\n DVT: Boots\n Code status: Full code\n"
},
{
"category": "Physician ",
"chartdate": "2178-06-05 00:00:00.000",
"description": "Physician Attending Admission Note",
"row_id": 328839,
"text": "Chief Complaint: Increasing dyspnea, s/p abdom surgery today with\n lysis of adhesions and one incidence of inadvertent enterotomy. Since\n surgery, increasing WBC, abdominal distention, worsening hypoxemia with\n rising lactate.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n As Above\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 Furosemide (Lasix) - 02:15 AM\n Other medications:\n Metoprolol, Albuterol Nebs, Ipratropium, Dilaudid PCA\n Past medical history:\n Family history:\n Social History:\n Ulcerative Colitis\n PE\n C Difficile\n Non contrib\n Occupation: Disability\n Drugs: None\n Tobacco: Quit \n Alcohol: None\n Other:\n Review of systems:\n Constitutional: Fatigue\n Cardiovascular: Tachycardia\n Nutritional Support: NPO\n Respiratory: Tachypnea\n Gastrointestinal: Diarrhea, Watery output from enterostomy\n Genitourinary: Foley\n Flowsheet Data as of 04:20 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.5\n Tcurrent: 35.7\nC (96.3\n HR: 143 (102 - 147) bpm\n BP: 125/108(112) {100/68(75) - 133/108(112)} mmHg\n RR: 28 (20 - 35) insp/min\n SpO2: 100%\n Heart rhythm: ST (Sinus Tachycardia)\n Height: 68 Inch\n Total In:\n 2,853 mL\n 16 mL\n PO:\n TF:\n IVF:\n 2,853 mL\n 16 mL\n Blood products:\n Total out:\n 249 mL\n 337 mL\n Urine:\n 229 mL\n 67 mL\n NG:\n Stool:\n Drains:\n 20 mL\n 70 mL\n Balance:\n 2,604 mL\n -321 mL\n Respiratory\n O2 Delivery Device: Non-rebreather\n SpO2: 100%\n ABG: 7.39/34/65\n Physical Examination\n General Appearance: 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: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: No(t)\n Resonant : ), (Breath Sounds: Crackles : )\n Abdominal: Distended, Tender: Rebound present\n Extremities: Right: 1+, Left: 1+\n Musculoskeletal: 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 245 K/uL\n 35.7 %\n 11.4 g/dL\n 144 mg/dL\n 1.4 mg/dL\n 24 mg/dL\n 19 mEq/L\n 109 mEq/L\n 4.1 mEq/L\n 140 mEq/L\n 26.9 K/uL\n [image002.jpg]\n 04:05 AM\n WBC\n 26.9\n Hct\n 35.7\n Plt\n 245\n Cr\n 1.4\n Glucose\n 144\n Other labs: Lactic Acid:3.0, Ca++:7.9 mg/dL, Mg++:1.6 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan\n Acute Abdomen with Compartment Syndrome - Bladder Pressure 40\n Needs re-explore for possible enterostomy leak, ? abdominal sepsis\n Doubt PE - hold heparin\n Will cover with broad spectrum antibiotics\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines / Intubation:\n 22 Gauge - 02:20 AM\n Comments:\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: 75 minutes\n Patient is critically ill\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328916,
"text": "56yo male POD #2 for exploratory lap w/ hernia repair, back to OR\n yesterday for ?acute abdomen, bladder pressure of 40. No apparent\n intra peritoneal process , tube placed, had edematous bowel and\n 3L fluid in abdomen removed. ? aspiration, apparently vomited during\n procedure -> bronched in MICU -> no significant secretions, BAL sent.\n Abdomen decompressed, bladder pressures 23-25.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n CXR -> bilat patchy infiltrates, opacities esp. in left lobe; Echo\n done, showed PE unlikely. Lung sounds are slightly coarse upper with\n significantly diminished lower lobes. ABG at 1900 7.33/46/93/25 on\n 100%FiO2/15 PEEP. Fent at 75mcg/hr/Versed at 2 mg/hr.\n Action:\n Surgery in to see patient overnight, dropped Fi02 to 60%, PEEP 13.\n Corresponding ABG 7.38/45/65/28. Surgery fine with PaO2 > 60 on 60%.\n Response:\n Pt. overbreathing vent by 2-5 bpm, appearing uncomfortable and awake.\n Increased Fent to 100mcg/hr and Versed to 3mg/hr with improvement in RR\n and comfort. BP remained stable after increase in sedation.\n Plan:\n Prone pt if does not improve, titrate sedation to keep respirations\n unlabored without dropping BP,\n Sepsis without organ dysfunction\n Assessment:\n No infectious source identified so far. Tmax 100.7, lactate 4.3, skin\n much more warm to touch.\n Action:\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\n flagyl/levo/vanc.\n Response:\n Pending.\n Plan:\n Monitor temp, wbc\ns, lactate. Follow cultures, continue abx until\n sensitivities available.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP\ns 70\ns-110/ 50-70\ns, HR 118-128 ST no ectopy, CVP 10-16. Neo turned\n off at . Yesterday received total 5L LR, 25gm albumin, 1L D5W w/\n 150meq bicarb. UO 70-300cc/hr.\n Action:\n Overnight, surgery ordered 2 L LR, 5% Albumin. SBP remained stable in\n high 90\ns-low 100\ns. At 0300 was slightly tachy into 130\ns, SBP\n dropping into 80\ns, T 100.7, UO around 70cc/hr. Bolused another liter\n of LR.\n Response:\n Plan:\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328922,
"text": "56yo male POD #2 for exploratory lap w/ hernia repair, back to OR\n yesterday for ?acute abdomen, bladder pressure of 40. No apparent\n intra peritoneal process , tube placed, had edematous bowel and\n 3L fluid in abdomen removed. ? aspiration, apparently vomited during\n procedure -> bronched in MICU -> no significant secretions, BAL sent.\n Abdomen decompressed, bladder pressures 23-25.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n CXR -> bilat patchy infiltrates, opacities esp. in left lobe; Echo\n done, showed PE unlikely. Lung sounds are slightly coarse upper with\n significantly diminished lower lobes. ABG at 1900 7.33/46/93/25 on\n 100%FiO2/15 PEEP. Fent at 75mcg/hr/Versed at 2 mg/hr.\n Action:\n Surgery in to see patient overnight, dropped Fi02 to 60%. Corresponding\n ABG 7.38/45/65/28.\n Response:\n Pt. overbreathing vent by 2-5 bpm, appearing uncomfortable and awake.\n Increased Fent to 100mcg/hr and Versed to 3mg/hr with improvement in RR\n and comfort. BP remained stable after increase in sedation. PEEP to 13.\n ABG at 0430 7.46/41/97/30. PEEP decreased to 10. ABG:\n Plan:\n Prone pt if does not improve, titrate sedation to keep respirations\n unlabored without dropping BP,\n Sepsis without organ dysfunction\n Assessment:\n No infectious source identified so far. Tmax 100.8, lactate 3.1, skin\n much more warm to touch.\n Action:\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\n flagyl/levo/vanc.\n Response:\n Pending.\n Plan:\n Monitor temp, wbc\ns, lactate. Follow cultures, continue abx until\n sensitivities available.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP\ns 70\ns-110/ 50-70\ns, HR 118-128 ST no ectopy, CVP 8-12. Neo turned\n off at . Yesterday received total 5L LR, 25gm albumin, 1L D5W w/\n 150meq bicarb. UO 70-300cc/hr.\n Action:\n Overnight, surgery ordered 2 L LR, 5% Albumin. SBP remained stable in\n high 90\ns-low 100\ns. At 0300 was slightly tachy into 130\ns, SBP\n dropping into 80\ns, T 100.7, UO around 70cc/hr. Bolused another liter\n of LR. Pt. put out 500cc via oral gastric tube over 8 hrs. Cannister\n changed and immediately put out another 450cc of bilious fluid.\n Response:\n ABPs 90-110/55-70. MAP >60. UO >50cc/hr.\n Plan:\n Continue boluses for hypotension and decreased urine output.\n Dr. has expressed she would like patient to go west if stable\n enough for transport today.\n"
},
{
"category": "Respiratory ",
"chartdate": "2178-06-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 328923,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\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: 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: Clear / 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: Gasping efforts, High flow\n 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 Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\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: Pt remains on vent. Weaning as tolerated per team. Abgs\n improving. Plan to transfer to . Will continue to monitor.\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328976,
"text": "56 yo M with history of UC s/p colectomy with ileostomy in \n admitted on with abdominal pain and increased ostomy output now\n POD #3 from ex lap with parastomal hernia repair and lysis of\n adhesions. Transferred to ICU from floor 2 days post op with acute\n onset tachypnea, SOB, and oliguric renal failure. In ICU he was on\n 100% NRB with good sats, CXR wnl, EKG wnl, crackles bilateral lung\n bases -> given lasix, labs showed rising wbc\ns and lactate. Also found\n to have bladder pressure of 40 so taken back to OR for ? abdominal\n compartment syndrome. No apparent intra-peritoneal process, tube\n placed, had edematous bowel and 3L fluid in abdomen removed. Had\n vomiting with ?aspiration during induction -> bronched, no significant\n secretions, BAL sent. To ICU intubated with O2 sats in high 80\ns, low\n 90\ns despite 100% fiO2. On phenylephrine at .9mcg for hypotension.\n Throughout the next 24hrs pt was given a total of 9-10L of LR for low\n urine output, hypotension, and tachycardia. Vent settings were adjusted\n per ARDS protocol and antibiotics levo/flagyl/vanc started. Also had\n echo to r/o PE since too unstable for CT and LENI\ns done. Both were\n negative.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vented on PRVC mode with settings 450X32X60%X10 and ABG\ns early this am\n 7.47/37/109/3/28. Lung sounds are clear, diminished in bases. Suctioned\n for small amts thick tan secretions or no secretions at all.\n Action:\n Sedated on fentanyl/versed 75/2 but requiring boluses of 25-30mcg for\n RR in the 40\ns and agitation. No vent changes made today.\n Response:\n Respiratory status stable.\n Plan:\n Transfer to SICU. Wean vent as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n Tmax 101.2, last BC done on is pending. Also pending are urine,\n BAL, and abdominal fluid cultures. Abdomen is softly distended, bowel\n sounds are absent although there is some greenish liquid output in\n ileostomy and j-tube drain. OGT to low suction drained ~700cc\n bilious liquid. Abdominal dressings are D&I, small amt of old SS drnge\n on L quad dressing. Hemodynamic status is much improved, no IVF\n boluses or pressors required.\n Action:\n Antibiotics changed from levo/flagyl/vanc to zosyn/vanc. Vanc trough\n this am 6.3\n Response:\n Sepsis improving.\n Plan:\n Follow fever curve, wbc\ns, cultures, sensitivities, continue abx.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP 95-131/52-71; HR 115-123, ST no ectopy, CVP 10-12. Urine output\n 50-120cc/hr\n Action:\n 1unit PRBC\ns given for volume. Crit this am 27.7; receiving maintenance\n IVF LR at 125/hr, no fluid boluses or pressors required.\n Response:\n Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L.\n Plan:\n Continue to monitor ABP, CVP, UO, HR.\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-06 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 328977,
"text": "56 yo M with history of UC s/p colectomy with ileostomy in \n admitted on with abdominal pain and increased ostomy output now\n POD #3 from ex lap with parastomal hernia repair and lysis of\n adhesions. Transferred to ICU from floor 2 days post op with acute\n onset tachypnea, SOB, and oliguric renal failure. In ICU he was on\n 100% NRB with good sats, CXR wnl, EKG wnl, crackles bilateral lung\n bases -> given lasix, labs showed rising wbc\ns and lactate. Also found\n to have bladder pressure of 40 so taken back to OR for ? abdominal\n compartment syndrome. No apparent intra-peritoneal process, tube\n placed, had edematous bowel and 3L fluid in abdomen removed. Had\n vomiting with ?aspiration during induction -> bronched, no significant\n secretions, BAL sent. To ICU intubated with O2 sats in high 80\ns, low\n 90\ns despite 100% fiO2. On phenylephrine at .9mcg for hypotension.\n Throughout the next 24hrs pt was given a total of 9-10L of LR for low\n urine output, hypotension, and tachycardia. Vent settings were adjusted\n per ARDS protocol and antibiotics levo/flagyl/vanc started. Also had\n echo to r/o PE since too unstable for CT and LENI\ns done. Both were\n negative.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vented on PRVC mode with settings 450X32X60%X10 and ABG\ns early this am\n 7.47/37/109/3/28. Lung sounds are clear, diminished in bases. Suctioned\n for small amts thick tan secretions or no secretions at all.\n Action:\n Sedated on fentanyl/versed 75/2 but requiring boluses of 25-30mcg for\n RR in the 40\ns and agitation. No vent changes made today.\n Response:\n Respiratory status stable.\n Plan:\n Transfer to SICU. Wean vent as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n Tmax 101.2, last BC done on is pending. Also pending are urine,\n BAL, and abdominal fluid cultures. Abdomen is softly distended, bowel\n sounds are absent although there is some greenish liquid output in\n ileostomy and j-tube drain. OGT to low suction drained ~700cc\n bilious liquid. Abdominal dressings are D&I, small amt of old SS drnge\n on L quad dressing. Hemodynamic status is much improved, no IVF\n boluses or pressors required.\n Action:\n Antibiotics changed from levo/flagyl/vanc to zosyn/vanc. Vanc trough\n this am 6.3\n Response:\n Sepsis improving.\n Plan:\n Follow fever curve, wbc\ns, cultures, sensitivities, continue abx.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP 95-131/52-71; HR 115-123, ST no ectopy, CVP 10-12. Urine output\n 50-120cc/hr\n Action:\n 1unit PRBC\ns given for volume. Crit this am 27.7; receiving maintenance\n IVF LR at 125/hr, no fluid boluses or pressors required.\n Response:\n Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L.\n Plan:\n Continue to monitor ABP, CVP, UO, HR.\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328978,
"text": "56 yo M with history of UC s/p colectomy with ileostomy in \n admitted on with abdominal pain and increased ostomy output now\n POD #3 from ex lap with parastomal hernia repair and lysis of\n adhesions. Transferred to ICU from floor 2 days post op with acute\n onset tachypnea, SOB, and oliguric renal failure. In ICU he was on\n 100% NRB with good sats, CXR wnl, EKG wnl, crackles bilateral lung\n bases -> given lasix, labs showed rising wbc\ns and lactate. Also found\n to have bladder pressure of 40 so taken back to OR for ? abdominal\n compartment syndrome. No apparent intra-peritoneal process, tube\n placed, had edematous bowel and 3L fluid in abdomen removed. Had\n vomiting with ?aspiration during induction -> bronched, no significant\n secretions, BAL sent. To ICU intubated with O2 sats in high 80\ns, low\n 90\ns despite 100% fiO2. On phenylephrine at .9mcg for hypotension.\n Throughout the next 24hrs pt was given a total of 9-10L of LR for low\n urine output, hypotension, and tachycardia. Vent settings were adjusted\n per ARDS protocol and antibiotics levo/flagyl/vanc started. Also had\n echo to r/o PE since too unstable for CT and LENI\ns done. Both were\n negative.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vented on PRVC mode with settings 450X32X60%X10 and ABG\ns early this am\n 7.47/37/109/3/28. Lung sounds are clear, diminished in bases. Suctioned\n for small amts thick tan secretions or no secretions at all.\n Action:\n Sedated on fentanyl/versed 75/2 but requiring boluses of 25-30mcg for\n RR in the 40\ns and agitation. No vent changes made today.\n Response:\n Respiratory status stable.\n Plan:\n Transfer to SICU. Wean vent as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n Tmax 101.2, last BC done on is pending. Also pending are urine,\n BAL, and abdominal fluid cultures. Abdomen is softly distended, bowel\n sounds are absent although there is some greenish liquid output in\n ileostomy and j-tube drain. OGT to low suction drained ~700cc\n bilious liquid. Abdominal dressings are D&I, small amt of old SS drnge\n on L quad dressing. Hemodynamic status is much improved, no IVF\n boluses or pressors required.\n Action:\n Antibiotics changed from levo/flagyl/vanc to zosyn/vanc. Vanc trough\n this am 6.3\n Response:\n Sepsis improving.\n Plan:\n Follow fever curve, wbc\ns, cultures, sensitivities, continue abx.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP 95-131/52-71; HR 115-123, ST no ectopy, CVP 10-12. Urine output\n 50-120cc/hr\n Action:\n 1unit PRBC\ns given for volume. Crit this am 27.7; receiving maintenance\n IVF LR at 125/hr, no fluid boluses or pressors required.\n Response:\n Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L.\n Plan:\n Continue to monitor ABP, CVP, UO, HR.\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-06 00:00:00.000",
"description": "Nursing Transfer Note",
"row_id": 328979,
"text": "56 yo M with history of UC s/p colectomy with ileostomy in \n admitted on with abdominal pain and increased ostomy output now\n POD #3 from ex lap with parastomal hernia repair and lysis of\n adhesions. Transferred to ICU from floor 2 days post op with acute\n onset tachypnea, SOB, and oliguric renal failure. In ICU he was on\n 100% NRB with good sats, CXR wnl, EKG wnl, crackles bilateral lung\n bases -> given lasix, labs showed rising wbc\ns and lactate. Also found\n to have bladder pressure of 40 so taken back to OR for ? abdominal\n compartment syndrome. No apparent intra-peritoneal process, tube\n placed, had edematous bowel and 3L fluid in abdomen removed. Had\n vomiting with ?aspiration during induction -> bronched, no significant\n secretions, BAL sent. To ICU intubated with O2 sats in high 80\ns, low\n 90\ns despite 100% fiO2. On phenylephrine at .9mcg for hypotension.\n Throughout the next 24hrs pt was given a total of 9-10L of LR for low\n urine output, hypotension, and tachycardia. Vent settings were adjusted\n per ARDS protocol and antibiotics levo/flagyl/vanc started. Also had\n echo to r/o PE since too unstable for CT and LENI\ns done. Both were\n negative.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Vented on PRVC mode with settings 450X32X60%X10 and ABG\ns early this am\n 7.47/37/109/3/28. Lung sounds are clear, diminished in bases. Suctioned\n for small amts thick tan secretions or no secretions at all.\n Action:\n Sedated on fentanyl/versed 75/2 but requiring boluses of 25-30mcg for\n RR in the 40\ns and agitation. No vent changes made today.\n Response:\n Respiratory status stable.\n Plan:\n Transfer to SICU. Wean vent as tolerated.\n Sepsis without organ dysfunction\n Assessment:\n Tmax 101.2, last BC done on is pending. Also pending are urine,\n BAL, and abdominal fluid cultures. Abdomen is softly distended, bowel\n sounds are absent although there is some greenish liquid output in\n ileostomy and j-tube drain. OGT to low suction drained ~700cc\n bilious liquid. Abdominal dressings are D&I, small amt of old SS drnge\n on L quad dressing. Hemodynamic status is much improved, no IVF\n boluses or pressors required.\n Action:\n Antibiotics changed from levo/flagyl/vanc to zosyn/vanc. Vanc trough\n this am 6.3\n Response:\n Sepsis improving.\n Plan:\n Follow fever curve, wbc\ns, cultures, sensitivities, continue abx.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP 95-131/52-71; HR 115-123, ST no ectopy, CVP 10-12. Urine output\n 50-120cc/hr\n Action:\n 1unit PRBC\ns given for volume. Crit this am 27.7; receiving maintenance\n IVF LR at 125/hr, no fluid boluses or pressors required.\n Response:\n Post transfusion crit 29.2; interval fluid balance is +144, LOS +16L.\n Plan:\n Continue to monitor ABP, CVP, UO, HR.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n OBSTRUCTION\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 95.3 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH: Hypertension\n Additional history: ulcerative colitis s/p total colectomy in .\n Depression, GERD.Thoracic back pain. multiple spinal surgeries,\n arthroscopic knee surgery.\n Surgery / Procedure and date: Exploratory Lap w/ Hernia Repair \n Latest Vital Signs and I/O\n Non-invasive BP:\n S:103\n D:60\n Temperature:\n 100.4\n Arterial BP:\n S:95\n D:59\n Respiratory rate:\n 36 insp/min\n Heart Rate:\n 121 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Non-rebreather\n O2 saturation:\n 98% %\n O2 flow:\n 6 L/min\n FiO2 set:\n 60% %\n 24h total in:\n 6,578 mL\n 24h total out:\n 3,740 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:05 PM\n Potassium:\n 3.4 mEq/L\n 02:05 PM\n Chloride:\n 102 mEq/L\n 02:05 PM\n CO2:\n 27 mEq/L\n 02:05 PM\n BUN:\n 31 mg/dL\n 02:05 PM\n Creatinine:\n 1.7 mg/dL\n 02:05 PM\n Glucose:\n 98 mg/dL\n 02:05 PM\n Hematocrit:\n 29.2 %\n 02:05 PM\n Finger Stick Glucose:\n 114\n 10:18 PM\n Valuables / Signature\n Patient valuables: with pt.\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: none\n Jewelry:\n Transferred from: \n Transferred to: SICU B\n Date & time of Transfer: 1800\n"
},
{
"category": "Respiratory ",
"chartdate": "2178-06-06 00:00:00.000",
"description": "Respiratory Care Shift Note",
"row_id": 328983,
"text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\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: 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: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions,\n Accessory muscle use, Prolonged exhalation, Tachypneic (RR> 35 b/min),\n Gasping efforts, Intercostal retractions, Active exhalations, High flow\n 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, Abnormal trigger\n efforts (efforts during inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts, Possible air\n trapping, Erratic exhaled Tidal Volumes, Frequent alarms (High rate)\n Comments:\n Plan\n Next 24-48 hours: Utilize ARDSnet protocol\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 Pt to transfer to .\n"
},
{
"category": "Nursing",
"chartdate": "2178-06-06 00:00:00.000",
"description": "Nursing Progress Note",
"row_id": 328931,
"text": "56yo male POD #2 for exploratory lap w/ hernia repair, back to OR\n yesterday for ?acute abdomen, bladder pressure of 40. No apparent\n intra peritoneal process , tube placed, had edematous bowel and\n 3L fluid in abdomen removed. ? aspiration, apparently vomited during\n procedure -> bronched in MICU -> no significant secretions, BAL sent.\n Abdomen decompressed, bladder pressures 23-25.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n CXR -> bilat patchy infiltrates, opacities esp. in left lobe; Echo\n done, showed PE unlikely. Lung sounds are slightly coarse upper with\n significantly diminished lower lobes. ABG at 1900 7.33/46/93/25 on\n 100%FiO2/15 PEEP. Fent at 75mcg/hr/Versed at 2 mg/hr.\n Action:\n Surgery in to see patient overnight, dropped Fi02 to 60%. Corresponding\n ABG 7.38/45/65/28.\n Response:\n Pt. overbreathing vent by 2-5 bpm, appearing uncomfortable and awake.\n Increased Fent to 100mcg/hr and Versed to 3mg/hr with improvement in RR\n and comfort. BP remained stable after increase in sedation. PEEP to 13.\n ABG at 0430 7.46/41/97/30. PEEP decreased to 10. ABG: 7.47/37/109/28\n Plan:\n Prone pt if does not improve, titrate sedation to keep respirations\n unlabored without dropping BP,\n Sepsis without organ dysfunction\n Assessment:\n No infectious source identified so far. Tmax 100.8, lactate 3.1, skin\n much more warm to touch.\n Action:\n Blood cultures sent, BAL and abdominal fluid cultures sent. Pt is on\n flagyl/levo/vanc.\n Response:\n Pending.\n Plan:\n Monitor temp, wbc\ns, lactate. Follow cultures, continue abx until\n sensitivities available.\n Hypovolemia (Volume Depletion - without shock)\n Assessment:\n ABP\ns 70\ns-110/ 50-70\ns, HR 118-128 ST no ectopy, CVP 8-12. Neo turned\n off at . Yesterday received total 5L LR, 25gm albumin, 1L D5W w/\n 150meq bicarb. UO 70-300cc/hr.\n Action:\n Overnight, surgery ordered 2 L LR, 5% Albumin. SBP remained stable in\n high 90\ns-low 100\ns. At 0300 was slightly tachy into 130\ns, SBP\n dropping into 80\ns, T 100.7, UO around 70cc/hr. Bolused another liter\n of LR. Pt. put out 500cc via oral gastric tube over 8 hrs. Cannister\n changed and immediately put out another 450cc of bilious fluid. Pt.\n remained hypotensive with SBP in 80\ns, MAPs 50-55. Bolused 1L LR x2, 5%\n Albumin hung to gravity.\n Response:\n ABP remains 80\ns-90\ns with MAPs around 55.\n Plan:\n Continue boluses for hypotension and decreased urine output. Albumin\n for intravascular volume, consider PRBC.\n Dr. has expressed she would like patient to go west if stable\n enough for transport today.\n"
},
{
"category": "Nutrition",
"chartdate": "2178-06-05 00:00:00.000",
"description": "Clinical Nutrition Note",
"row_id": 328861,
"text": "Subjective\n Nausea, has been thirsty\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 95.3 kg\n 31.9\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 70 kg\n 136%\n 76\n Diagnosis: Obstruction\n PMH : UC s/p colectomy/ileostomy (), hypertension, depression,\n GERD, hyperlipidemia, PE, c.diff\n Food allergies and intolerances: None needed\n Pertinent medications: flagyl, pantoprazole\n Labs:\n Value\n Date\n Glucose\n 146 mg/dL\n 08:01 AM\n BUN\n 24 mg/dL\n 04:05 AM\n Creatinine\n 1.4 mg/dL\n 04:05 AM\n Sodium\n 140 mEq/L\n 08:01 AM\n Potassium\n 3.4 mEq/L\n 08:01 AM\n Chloride\n 104 mEq/L\n 08:01 AM\n TCO2\n 19 mEq/L\n 04:05 AM\n Albumin\n 3.4 g/dL\n 06:45 PM\n Calcium non-ionized\n 7.9 mg/dL\n 04:05 AM\n Phosphorus\n 2.9 mg/dL\n 04:05 AM\n Ionized Calcium\n 1.11 mmol/L\n 08:01 AM\n Magnesium\n 1.6 mg/dL\n 04:05 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen firm/distended with absent BS, ostomy - 200ml, JP - 100ml\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: 1900-2300 (BEE x or / 25-30 cal/kg)\n Protein: 90-110 (1.2-1.5 g/kg)\n Fluid: per team\n Specifics:\n 56 year old male with history of UC s/p colectomy, ileostomy with\n preservation of rectum in doing well post-op until presenting\n with abdominal pain, increased ostomy output now s/p ex-lap, hernia\n repair on transferred to ICU with tachycardia, tachypnea, sepsis\n with concern for acute abdomen. Noted per chart, patient refused\n central line. If unable to advance diet and patient continues to refuse\n central line, could use PPN temporarily (goal if TF<400 is 2L standard\n PPN with 250ml lipids to provide 1140kcal and 70g protein. PPN not able\n to meet patient\ns needs. If Patient agrees to central line, can do TPN\n with goal of 1.9L (320gdex/100gAA/40g lipids) to provide 1888kcal and\n 100g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Continue parenteral nutiriton if continues to be unable to\n take PO intake.\n 2. Monitor/replete lytes\n 3. Check TG if PPN or TPN to start\n 09:46\n"
},
{
"category": "Physician ",
"chartdate": "2178-06-05 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 328862,
"text": "Clinician: Attending\n 56 yo man with colitis, presumed UC, colectomy , adm with\n high ostomy output and abd pain. Ostomy output attributed to bowel wall\n edema and poor absorption. In MICU with transient tachypnea and\n tachycardia but not hypoxemia following hernia repair and ex-lap. Was\n persistantly tachycardic, likely dehydrated. Tachypnea resolved\n overnight, transferred back to surgical floor yesterday morning. Total\n 6L net + over 24 h, with decreasing urine output finally to < 10cc/h.\n WBC rose 6--> 26--> 38K with 20% bandemia. Resp distress with\n tachypnea, 7.39/35/81 on NRB. Tranferred to MICU. Initial mental status\n normal, becamse confused within hours. Increasing oxygen requirement.\n 7.39/34/65 on NRB, lactate 3.0. Lung exam with dffuse crackles.\n Oliguric with no response to lasix. Concern for abd distension, bladder\n pressure was 40 mm Hg. Initial CXR showed low lung volumes but no sig\n parenchymal process, right mid lung zone atelectasis. Went to OR got\n right IJ, art line, found to have edematous bowel, stomach had 3L\n fluid. Bowel decompressed. Bronch with no sig secretions, BAL done.\n Since surgery hypoxia progressed. Severe metabolic acidosis. CXR with\n bilateral patchy infiltrates esp left upper lung field. Sedated on\n propofol. Hypotensive with 87/64, MAP 71. SpO2 88% on FiO2 1.0, PEEP 15\n TV 450 RR 35 PIP 35 Plateau 26 Compliance 45. Abdomen distension much\n improved.\n 7.13/63/70 on rate 26.\n HCo3 22, gap 15. BUN/Cr 39/2.5 (inc from 1.4 yest). WBC 25K. Hct 42%.\n LFTs wnl. INR 1.6. Lactate rose to 4.5.\n Severely critically ill with ARDS, septic shock, unclear if he had\n aspiration event or secondary to sepsis, abd surgery. Now oliguric,\n hypotensive, requiring max vent support. Bladder pressure decreased\n from 40 to 25 after decompression. Broad abx, no cx data yet.\n flagyl/levo/vanc to cover bowel and lung sources. ARDSnet but pushing\n PEEP for continued hypoxia. Permissive hypercapnia, and RR raised for\n acidemia, but will give bicarb if repeat ABG shows no correction of pH.\n Trying right side down to try to improve V/Q mismatch. Will likely\n switch to PCV to improve oxygenation if ineffective.\n Patient is critically ill.\n"
},
{
"category": "Physician ",
"chartdate": "2178-06-05 00:00:00.000",
"description": "ICU Attending Note",
"row_id": 328869,
"text": "Clinician: Attending\n 56 yo man with colitis, presumed UC, colectomy , adm with\n high ostomy output and abd pain. Ostomy output attributed to bowel wall\n edema and poor absorption. In MICU with transient tachypnea and\n tachycardia but not hypoxemia following hernia repair and ex-lap. Was\n persistantly tachycardic, likely dehydrated. Tachypnea resolved\n overnight, transferred back to surgical floor yesterday morning. Total\n 6L net + over 24 h, with decreasing urine output finally to < 10cc/h.\n WBC rose 6--> 26--> 38K with 20% bandemia. Resp distress with\n tachypnea, 7.39/35/81 on NRB. Tranferred to MICU. Initial mental status\n normal, becamse confused within hours. Increasing oxygen requirement.\n 7.39/34/65 on NRB, lactate 3.0. Lung exam with dffuse crackles.\n Oliguric with no response to lasix. Concern for abd distension, bladder\n pressure was 40 mm Hg. Initial CXR showed low lung volumes but no sig\n parenchymal process, right mid lung zone atelectasis. Went to OR got\n right IJ, art line, found to have edematous bowel, stomach had 3L\n fluid. Bowel decompressed. Bronch with no sig secretions, BAL done.\n Since surgery hypoxia progressed. Severe metabolic acidosis. CXR with\n bilateral patchy infiltrates esp left upper lung field. Sedated on\n propofol. Hypotensive with 87/64, MAP 71. SpO2 88% on FiO2 1.0, PEEP 15\n TV 450 RR 35 PIP 35 Plateau 26 Compliance 45. Abdomen distension much\n improved.\n 7.13/63/70 on rate 26.\n HCo3 22, gap 15. BUN/Cr 39/2.5 (inc from 1.4 yest). WBC 25K. Hct 42%.\n LFTs wnl. INR 1.6. Lactate rose to 4.5.\n Severely critically ill with ARDS, septic shock, unclear if he had\n aspiration event or secondary to sepsis, abd surgery. Now oliguric,\n hypotensive, requiring max vent support. Bladder pressure decreased\n from 40 to 25 after decompression. Broad abx, no cx data yet.\n flagyl/levo/vanc to cover bowel and lung sources. ARDSnet but pushing\n PEEP for continued hypoxia. Permissive hypercapnia, and RR raised for\n acidemia, but will give bicarb if repeat ABG shows no correction of pH.\n Trying right side down to try to improve V/Q mismatch. Will likely\n switch to PCV to improve oxygenation if ineffective.\n Patient is critically ill.\n ------ Protected Section ------\n Spoke with Dr , who told me there is no contraindication\n to proning, if that becomes necessary.\n Bicarb infusion.\n Phenylephrine now at 2.5mcg/kg/min.\n Placing esophageal balloon, as abd pressure suggested he will need much\n higher PEEP.\n Time spent 80 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 11:29 ------\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-14 00:00:00.000",
"description": "Report",
"row_id": 1445651,
"text": "Respiratory Therapy\nPt remains orally intubated on PSV, appears comfortable. Vt 400-600. BS clear apeces, descending to bases audible crackles to diminished. Sx for moderate amounts thick tenacious dark tan secretions. ABG this AM: 7.42/49/130/33. RSBI held due to Peep requirement.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-14 00:00:00.000",
"description": "Report",
"row_id": 1445652,
"text": "SICU NN: SEE CAREVUE FOR SPECIFICS. PATIENT SEDATED ON FENTANYL DRIP AND PRN ATIVAN. ET TO VENT, NO CHANGES OVERNIGHT. RSR. BP WNL. AFEBRILE. ANASARCA. TUBE FEEDS AT GOAL VIA NGT. ILEOSTOMY, RED STOMA, PUTTING OUT LIQUID BROWN STOOL AND FLATUS. ABDOMINAL INCISION WITH STAPLES AND PARTIALLY OPENED AND PACKED, DRAINING MODERATE TO LARGE AMTS OF SEROSANG. FOLEY, LASIX DRIP, TITRATING FOR GOAL 3L NEG. SACCRUM INTACT. LEFT SC CVL. LEFT AXILLARY ALINE. NO PHONE CALLS NO VISITORS. REPLETING LYTES PRN. PLAN: CONTINUE DIURESIS, DIAMOX AS ORDERED, VENT WEAN AS TOL, MONITOR HEMODYNAMICS, PULM TOLIET, SEDATION/PAIN CONTROL, ANTIBIOTICS AS ORDERED, BLOOD GLUCOSE CONTROL, EMOTIONAL SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-14 00:00:00.000",
"description": "Report",
"row_id": 1445653,
"text": "BS coarse crackles; no change with MDI's. Suctioned for moderate amount thick tan secretions, less than yesterday. CXR ? slight improvement. Diuresis with Diamox proceeds but still 7 liters positive. Will not wean vent until fluid balance improved more.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-14 00:00:00.000",
"description": "Report",
"row_id": 1445654,
"text": "focus update note\nT-98.6, 60-80s NSR, no ectopy, sbp 100-150/60-80\n\nlasix gtt at 2-4 mg /hr goal diuresis 3 liters negative by 12 midnight, pt given 2 doses of diamox and ordered for one more dose tonight. potassium level 3 despite 80 meq kcl given po x 2 and 100 meq kcl given 1v, icu resident aware.\n\nresp: no vent changes today as pt is still 6.5 liters positive for his length of stay and will not bee extubated in the next 24 hours, abgs improved 7.44/40/172/28/3/98, lung sounds clear to coarse, pt suctioned for moderate amount brown thick secretions from ETT, pt continues on zosyn and cipro.\n\ngu/gi: tube feeding at goal, bowel sounds positive, 350 cc brown liquid stool from ileostomy- pink stoma, clear light yellow urine from foley cath.\n\nabd: vac dressing to be placed over open abd incision on Tuesday, copious amounts of serous fluid from abd wound,surgical team assessed abd wound this am and packing was changed by team at 0830, pink wound base, pt nodding head yes to pain intermittently throughout day, fentanyl gtt provides good reilf of pain as well as repositioning.\n\nskin: generalized edema, left groin drainage from old puncture site has resolved, waffle boots on\n\nneuro: ativan discontinued today, pt not aggitated today, pt easily redirected when talked to, following commands consistently, mae+, nodding head inconsistently to questions, pupils perla- 3mm brisk reaction, opens eyes to voice or spontaneously, spontaneous movement purposful\n\nsocial: wife into visit with 2 other family members, wife updated at pt bedside by nursing, pt likes to watch golf/cooking channel on TV.\n\nplan: continue with aggressive diuresis and repleation of electrolytes, consider extubation when pt fluid body status at admission weight, monitor resp status, continue with antibiotic therapy, vac dressing planned for tuesday to open abd wound, limit sedation, provide supportive care to pt and family\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-15 00:00:00.000",
"description": "Report",
"row_id": 1445655,
"text": "SICU NN: SEE CAREVUE FOR SPECIFICS. PATIENT SEDATED ON FENTANYL DRIP. INCONSISTENTLY FOLLOWING COMMANDS. MOVING ALL EXTREMITIES SPONTANEOUSLY. PERRL. ET TO VENT, NO CHANGES OVERNIGHT. FREQUENT SUCTIONING REQUIRED FOR THICK BROWN SECRETIONS, PLUGGY AT TIMES. RSR. BP WNL. AFEBRILE. CVL AND ALINE INTACT. PALP PEDALS. GEN EDEMA. TUBE FEEDS AT GOAL. ILEOSTOMY WITH LOOSE BROWN STOOL AND FLATUS. STOMA PINK AND MOIST. APPLIANCE INTACT. MIDLINE ABD INCISION WITH STAPLES AND TWO LARGE OPEN AREAS. PACKING IN PLACE, DRESSING REINFORCED. HEAVY TO COPIOUS SEROUS/SEROSANG DRAINAGE, FOUL SMELLING AT TIMES, TEAM AWARE. FOLEY, LASIX DRIP GOAL 3 LITERS NEGATIVE. SACCRUM INTACT. FENTANYL DRIP FOR PAIN. LYTES REPLETED PRN. NPH AND SSI FOR GLUCOSE CONTROL. FAMILY VISITED LAST PM. PLAN: AGGRESSIVE DIURESIS, VAC ABD WOUND TUES, OSTOMY CARE, SKIN CARE, PAIN CONTROL, VENT WEAN AS TOL, PULM TOLIET, FOLLOW CULTURES, ANTIBIOTICS AS ORDERED, EMOTIONAL SUPPORT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-15 00:00:00.000",
"description": "Report",
"row_id": 1445656,
"text": "Respiratory Therapy\nPt remains orally intubated on PSV. No changes overnight. BS essentially clear w diminished bases. Sx for moderate amounts thick dark tan secretions SPC. RSBI 31 This AM . Plan continue ventilatory support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-15 00:00:00.000",
"description": "Report",
"row_id": 1445657,
"text": "nursing progress note\nSee carevue for specifics.\nT-max 101.5 md aware. Pan cx sent. Tylenol elixer given. Abd incision open, packed with dsd. Changed frequently due to large amt of serosang foul smelling secretion. SICU team aware of odor. No order to culture wound at this time. Remains lightly sedated on 200mcg's of fent. Inconsistantly follows commands. Clonidine 0.2mg po given for aggitation with no real changes observed in behavior. LS clear with dim bases. Suctioned for moderate amt of thick brown/secretions.Small Vent changes made per ABG's, see resp note for specifics.\nHr NSR no ectopy noted.\nLasix Gtt @ 2mg/hr diuresing ~200ml/hr. Goal is to pull off 2L qday. Currently -2500 since MN. Md aware. K+ 3.1 repleted with 60meq IV. In addition to 80meq Q6hr po dose.\nCxr this am showed ngt coiled in the cervical area. Pulled back ~2cm per SICU team. Repeat cxr shows ngt in good position, viewed by , MD. @ goal of 65ml/hr, residuals 0-10ml's.\nPOC\nkeep lightly sedated for possible extubation in am.\nmonitor temp\ncontinue to monitor electrolytes, replete as needed.\nchange dsg's TID and prn packing with dsd.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-15 00:00:00.000",
"description": "Report",
"row_id": 1445658,
"text": "BS CTAB; no change with MDI's. Suctioned for moderate amount thick tan secretions. Tmax 101.5. PEEP and PSV weaned. Could extubate put team wants to draw of L of fluid today and extubate in AM.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-16 00:00:00.000",
"description": "Report",
"row_id": 1445659,
"text": "Respiratory Care\nPt remains on ventilator, with pressure support settings being adequate for pt's spontanous respiratory drive. Pt was suctioned by both RT and RN for copious amounts of brown/yellow/thick sputum. Pt becomes agitated after suctioning procedures. Albuterol given at appropriate times. Pt performed strong RSBI, and responds to questions. Pt to be considered for extubation by MD team, continuing current support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-13 00:00:00.000",
"description": "Report",
"row_id": 1445646,
"text": "Respiratory Therapy\nPt remains orally intubated on PSV. BS clear bilaterally Sx moderate amounts thick dark tan secretions. MDI's as ordered. ABG on .4, 7.44/50/102/35 no RSBI due to peep requirement. CXR done awaiting official read. Plan: wean as tol\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-13 00:00:00.000",
"description": "Report",
"row_id": 1445647,
"text": "Condition update\nSee careview for details:\n\nRemains sedated on fentanyl gtt and prn ativan for sedation with good effect. Appears comfortable when sedated. Afebrile. WBC 16.7 this am (up from 13). Dr (sicu) aware. SR HR 60-70 no ectopy. BP stable, becomes hypertensive with aggitation but returns to baseline when sedated. Generalized edema. Lungs coarse but clears with suction. Diminished at bases. Suction for large amt thick tan secreations with some plugs, Dr aware. Remains on CPAP, fio2 weaned to 40% and PEEP down to 5 from 8 briefly, although cont to have adequate oxygenation increased d/t worsening chest xray. Remains on 10 pressure support. Abg shows compensated metabolic alkolosis. Abd soft, ostomy putting out stool, tolerating tube feeds. RISS, requiring mod amt coverage. Midline abd incision with some purlulent drainage noted, primary team aware. Cont on lasix gtt for goal 2-3 liters negative, 2.9 neg at midnight. Plan to cont to diureses, ?start diamox for increasing metabolic alkososis, start long acting insulin, wean vent as tolerated, maitain comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-13 00:00:00.000",
"description": "Report",
"row_id": 1445648,
"text": "NURSING NOTE\nAddendum: Son in to visit this evening\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-13 00:00:00.000",
"description": "Report",
"row_id": 1445649,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n PT REMAINS LIGHTLY SEDATED ON FENTANYL FOR COMFORT, EASILY . ATIVAN FOR INTERMITTENT AGITATION/RESTLESSNESS W/EFFECT. INCONSISTENTLY FOLLOWS COMMANDS, MAES, NOT TRACKING. AFEBRILE, HR 70S-90S, NSR, SBP 100S-150S, UP TO 180S W/AGITATION. A-LINE DAMPENED AT TIMES R/T LOCATION/PT . CVL RE-SITED, OLD CVL TIP SENT FOR CX. CVP 6-9, CONT ++GEN/SCROTAL EDEMA, PALP PP. LASIX DRIP CONT FOR AGGRESSIVE DIURESIS AS BP TOL PER DR.. GOAL FLUID BAL 2-3L NEG, REMAINS >10L UP FOR LOS. K/CALCIUM REPLETED AS NEEDED DIURESIS. NO VENT CHANGES MADE, MINI BAL SENT. LUNGS COARSE, VERY DIMINISHED AT BASES. SUCTIONED FOR MOD-LGE AMTS THICK, TAN SECRETIONS, CPT DONE AS TOL. ABD INC W/COPIOUS AMTS SEROUS DRNG, STAPLES REMOVED THIS AM BY DR. . WND PACKED W/DRY DSGS, CONT DRAINING COPIOUS SEROUS FLUID, DR. AWARE. CONT TF VIA NGT, MIN RESIDUALS. NPH ADDED TO INSULIN REGIMEN. NO FAMILY CONTACT.\n\n PLAN: CONT AGGRESSIVE DIURESIS AS HEMODYNAMICS ALLOW. FENTANYL DRIP FOR COMFORT, ATIVAN FOR INT AGITATION. WEAN VENT AS TOL. MONITOR FOR ALKALOSIS DIURESIS, LYTE REPLETION AS NEEDED. WND/SKIN CARE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-13 00:00:00.000",
"description": "Report",
"row_id": 1445650,
"text": "BS coarse crackles, occasional rhonchi; no change with MDI's. Suctioned for large amount thick, tan-yellow secretions with plugs. Mini-BAL sent. Metabolic alkalosis persists; ? 0800 ABG. PEEP still at 8cm due to possibility of increased atelectasis though CXR more consistent with increased bilateral LL densities. Plan is to continue with aggressive diuresis.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-12 00:00:00.000",
"description": "Report",
"row_id": 1445641,
"text": "Condition update\nSee careview for objective data/trends:\n\nEpisodes tachypnia and tachycardia with stimulation this evening, prn ativan increased and given with good effect. Fentanyl gtt continues for sedation, decreased this am as pt appears comfortable. More alert this am, opening eyes spontanously and moving all ext spontanously. Not following any commands. Afebrile. SB-SR HR 50-80's no ectopy. BP stable 110-140's when well sedated. +generalized edema. CVP 9-12. Lungs coarse throughout, diminished at bases. CPAP +PS, pt very tachypnic this evening, Dr aware and increased support from 8 peep 10 ps to 10 peep and 12 ps. Peep decreased back to 8 this morning. Abd softly distended, no bowel sounds noted, Dr aware. Tubefeeds at goal and residuals 10-50cc. Ileostomy with sm amt stool ouptut. Stoma pink. 1.7L neg at MN. BUN/Creat remain slightly elevated but stable. Requiring frequent potassium repleation. Attempted to repleate with po slidding scale but unable to maintain adequate k levels. Plan to cont to monitor neuro status, wean sedation as tolerated monitor hemodyanmics, maintain comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-12 00:00:00.000",
"description": "Report",
"row_id": 1445642,
"text": "Respiratory Care:\n\nPt remain orally intubated on spontaneous ventilation. Yesterday eve we increased PEEP & IPS for increased WOB & tachypnea, we increased sedation also. We attempting to wean it again this morning. RSBI done ~138. Bs are dim & coarse bil. W are sxtn for small amt of thick brownish secretions from ETT. Plan: wean as tol & monitor VS. See Careview for more details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-12 00:00:00.000",
"description": "Report",
"row_id": 1445643,
"text": "NURSING NOTE\nAddendum: Pt w/copious amts serous drng originating from ABD dsg this eve. ABD inc w/staples DSD changed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-12 00:00:00.000",
"description": "Report",
"row_id": 1445644,
"text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\n PT EASILY ON FENTANYL FOR LIGHT SEDATION. INCONSISTENTLY FOLLOWS COMMANDS, MAES. HR 60S-70S, NSR, NO ECTOPY. SBP 110S-130S, UP TO 170'S W/STIMULATION OR AGITATION. CVP 6-11, LASIX DRIP UP TO 5MG/HR FOR GOAL NEG FLUID BAL 2-2.5L, CURRENTLY ~1.5L NEG. CONT ++GEN/SCROTAL EDEMA, PALP PP. PO/IV K REPLETED FOR PERSISTENT HYPOKALEMIA DOWN TO 3, CA REPLETED. CONT ON PSV-50%/8/PS DOWN TO 10, RR 17-20S, BECOMES TACHYPNEIC TO 30S W/STIM. LUNGS COARSE, DIMINISHED AT BASES, SUCTIONED FOR SM-MOD AMTS THICK, TAN SECRETIONS. ABD SOFT, +BS ILEOSTOMY PATENT W/MOD AMT LOOSE, BROWN STOOL-APPLIANCE CHANGED BY OSTOMY RN. LGE AMT HUO/ADEQUATE DIURESIS LASIX DRIP. ABD DSD C/D/I, LLQ POUCH/DRAIN W/SM AMT SEROUS DRNG. SON IN TO VISIT BRIEFLY, NO OTHER FMAILY CONTACT.\n\n PLAN: CONT HEMODYNAMIC MONITORING, FENTANYL DRIP FOR COMFORT. CONT LASIX DRIP FOR DIURESIS/NEG FLUID BAL GOALS. RESP SUPPORT, WEAN AS TOL. REPLETE LYTES FREQUENTLY.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-12 00:00:00.000",
"description": "Report",
"row_id": 1445645,
"text": "Respiratory\nPt. weaned from 12 to 10 of PS as noted in Carevue. Pt. on AC as noted in Carevue. Diminished breath sounds bilaterally in the bases more pronounced on RLL. After MDI's and Sx'ing, greater aeration was heard throughout but still decreased in bases. Pt. producing moderate amount of thick brown blood tinged secretions. Plan: wean vent. settings slowly as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-07 00:00:00.000",
"description": "Report",
"row_id": 1445622,
"text": "Nursing Note\nPt transferred from () at 1800 to SICU for monitoring and management. Pt s/p exploratory lap with parastomal hernia repair and LOA on . Pt had post-op complications of severe tachypnea/tachycardia, fevers with elevating WBC, oliguria and bladder pressure of 40 and subsequently had to return to the OR . Pt had 3 liters fluid removed from abdomen and had tube placed in abdomen and pt transferred to SICU.\nUpon arrival to SICU, pt sedated as he had required versed/fentanyl boluses during tranfer from east to west campuses. Pt's Fentanyl drips and versed drips on hold initially as pt sedated and SBP low. Pt intubated and ventilated on CMV settings-Multiple setting changed overnoc (see carevue) Having difficult time ventilating patient. Pt RR ranging from 30-40s and ABGs showing a respiratory alkalosis. Pox maintaining at 96-100%, LS diminished and pt being suctioned for moderate amounts of thick, tanish/ colored sputum. Pt abdomen is large, soft. Absent BS. Dressing and tube intact to abdomnen, ostomy also present with pink, moist stoma. Pt putting out large amounts of bilious fliud via OG tube and now being replaced cc:cc of NS.\nPt's HR 100-120s, BP elevates to 180s when turning/repositioning/suctioning and gets very restless requiring increasing amounts of sedation however pt's BP drops after pt settles down and sedation is subsequently put on hold. Pt BP dropping into 70s and requiring multiple fluid boluses to maintain BP. Pt also given one unit PRBC . Follow Q 6 hour HCTS\nPt has been febrile with Tmax 101.9. Dr. aware. Pt pan cultured prior to transfer from , results pending.\nPLAN-sedate patient in ordert o ventilate andf manage BP. Administer fluids/colloids as needed. Continue to replace cc:cc of OG output. Follow ABGs.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-07 00:00:00.000",
"description": "Report",
"row_id": 1445623,
"text": "RESP CARE NOTE\n56 YO S/P COLOSTOMY CONTINUES ON A/C 32/450/50%/+10. LAS TABG 7.56/29/108/5/98. PT CONTINUES IN ARDS. DIFFICULTY CORRECTING RESPIRATORY ALKALOSIS SINCE PT IS OVERBREATHING VENT. DIFFICULTY MAINTAINING BP WAS LIMITING SEDATION. SX VERY THICK BROWN\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-07 00:00:00.000",
"description": "Report",
"row_id": 1445624,
"text": "RESPIRATORY CARE: PT REMAINS INTUBATED W/ A 7.5 ORAL ETT IN PLACE AND CHANGED TO PS 22/8 .50 AS PER CV DUE TO PERSISTENT AGGITATION AND VENTILATOR DYSYNCHRONY. ABG C/W A COMBINED METABOLIC AND RESPIRATORY ALKALOSIS AND MARGINAL OXYGENATION. WILL TOLERATE PO2 55 OR GREATER PER DR AT LEAST FOR TODAY. WILL INCREASE TO .60 IF NECESSARY. SEDATION REGIMEN ADJUSTED BY SICU TEAM. SX FOR TAN SPUTUM. WILL C/W PS 22 AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-18 00:00:00.000",
"description": "Report",
"row_id": 1445667,
"text": "NURSING NOTE\nASSESSMENT:\n PATIENT ABLE TO OBEY COMMANDS & MOVE ALL EXTREMITIES. COMMUNICATING BY MOUTHING WORDS AND NODDING. PATIENT OCCASIONALLY GETTING ANXIOUS & STATING HE WANTS ET TUBE OUT, GIVEN ATIVAN AS NEEDED WITH GOOD EFFECT. FENTANYL GTT CONTINUES WITH ADEQUATE PAIN CONTROL.\n AFEBRILE. HEART RATE RANGING 60-70'S NORMAL SINUS. BRADYCARDIC AFTER LOPRESSOR WITH HR 40'S-50'S. SBP REMAINS 110-160'S. PATIENT MAKING ADEQUATE HOURLY URINE, WEIGHT CONTINUES TO DECREASE.\n TOLERATING CPAP + PRESSURE SUPPORT . LUNG SOUNDS OCCASIONALLY COARSE AND SUCTIONED FREQUENTLY FOR THICK RUST/BROWN SECRETIONS. PATIENT HAS STRONG COUGH & ABLE TO RAISE SECRETIONS IN ET TUBE.\n ABDOMEN SOFT, NONDISTENDED. ABDOMINAL WOUND VAC INTACT, DRAINING MODERATE AMOUNTS SEROSANG DRAINAGE. STOPPED @ 12AM AND IV FLUIDS STARTED. ILEOSTOMY CONTINUES TO PUT OUT LOOSE BROWN STOOL. 10 UNITS NPH GIVEN LAST NIGHT (1/2 DOSE) PER DR. DUE TO NPO STATUS.\nPLAN:\n IR TODAY FOR ? DRAINAGE FLUID COLLECTION. ? EXTUBATE AFTER IR. CONTINUE TO PROVIDE SUPPORT. ? PHYSICAL THERAPY CONSULT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-18 00:00:00.000",
"description": "Report",
"row_id": 1445668,
"text": "Resp Care\nPt maintained intubated and on mech ventilation PCV. tol well AM RSBI 28. Bilat breath sounds course rhonchi with some inspiratory wheezes, suctioned for moderate to large thick tan secretions. plan to further wean and possible extubation. no vent settings changed during the shift see flowsheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-18 00:00:00.000",
"description": "Report",
"row_id": 1445669,
"text": "focus update note\nafebrile, 40-80 heart rate no ectopy, sbp 120-170/50-60.\n\nresp: electively extubated, pt now on 2 liters o2 via nasal cannula, o2 sat 100%, lung sounds clear, pt coughing and raising secretions, LLL abcess to be treated conservatively with current regime of antibiotics verses ct guided drainage per pulmonology and infectious disease.\n\nneuro: pt confused, alert x , follows commands consistently, opens eyes spontaneously, mae+, no ativan given today.\n\npain: fentanyl gtt discontinued, new pt order for PRN diludid, pt has had no complaints of abdominal pain.\n\nskin: ostomy appliance changed today, stoma red, brown liquid stool large amount, + bowel sounds no breakdown on back, vac dressing to open abd wound. per icu team black foam covers white foam.\n\nmobility: pt worked with PT/OT today OOB to chair\n\nsocial : wife called and sons called, nurse updated wife regarding pt upodate over the telephone\n\ngu/gi: foley catheter draining > 50 cc urine q 1 hr, pt continues on aldactone po, fluid volume status now negative for length of stay, tube feedings restarted at goal rate, no residual. NPH held this am as pt was NPO icu team aware\n\nplan: continue to monitor resp status, fluid volume status, consider hydrocort taper, consider discontinuing aldactone, encourage coughing and deep breathing and incentive spirometry, ? speech and swallow consult tomorrow\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-18 00:00:00.000",
"description": "Report",
"row_id": 1445670,
"text": "Resp Care:\n\nPt extubated this a.m. & placed on cool mist at 40% FiO2. Tol prcedure well & able to give strong cough & vocalize well. FiO2 titrated to n/c. Prn Nebs are ordered yet not indicated at this time; bs = cta with good aeration. Plan to continue to monitor patient & encourage DB & C.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-06 00:00:00.000",
"description": "Report",
"row_id": 1445621,
"text": "RESPIRATORY CARE: PT TRANSFERRED FROM 4 TO SICU B AT 1830 TODAY. PT W/ A 7.5 ORAL ETT AT 21 LIP AND ON THE AC MODE AS\nPER CV. WILL ADJUST SETTINGS AS PER ABG'S POST TRANSFER.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-11 00:00:00.000",
"description": "Report",
"row_id": 1445637,
"text": "7pm-7am Nursing Note\nSee CareVue for objective data and trends:\nNEURO-Pt sedated on fentanyl/ativan drips. Pt with facial grimacing during turing/painful stimuli. Withdraws upper extremities to nail bed pressure. Facial grimace with BLE nailbed pressure and some minimal spontaneous movement noted to feet. Pupils at 2mm and reactive to light.\nCV-ABP ranging 100s-120s/60s-70s. CVP 10-14,C.O ranging . SVV although pt remains on lasix drip to goal of liters negative per day. Pt continues to have generalized edema present. Palpable peripheral pulses.\nRESP-Pt remains intubated, ventilated on settings: AC mode-45%fio2,450 X 26, 16 PEEP. LS clear, occasionally coarse prior to suctioning, diminished in bilateral lower bases with right worse than left. Suctioning pt for thick, blood tinged sputum.\nGI-Pt continues TF via OG. No residuals. Abdomen is large, soft with hypoiactive bowel sounds. Minimal output via ostomy-started on reglan Q 6 hours. Surgical insicion with staples, dressing changed X 1.\nGU-pt on lasix drip, urine clear yellow.\nID-Pt afebrile. WBC trending down. Continue Zosyn.\nPLAN-wean vent slowly, pulmonary toilet. Follow abdominal exams, labs. Continue IV antibiotics.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-11 00:00:00.000",
"description": "Report",
"row_id": 1445638,
"text": "RESP CARE: Pt remains orally intubated/on vent on settings per carevue. Off paralytic.No changes in settings overnoc. Overbreathing vent 1-2bpm. Esophageal balloon remains in place. ABGs acceptable. Lungs dim bibasilar R>L,rhonchi. Sxd thick bld tinged yellow sputum. Difficulty passing sx catheter at times, pt biting ETT. No RSBI due to PEEP level.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-11 00:00:00.000",
"description": "Report",
"row_id": 1445639,
"text": "focus update note\nD: ARDS resolved with active vent wean, diuresis with lasix gtt goal 1-2 liters negative-, pt length of stay is 16L positive, hemodynamically stable off pressors and moniotoring device discontinued.\n\nT max 98 50s- 70 NSR, no ectopy, sbp 106-120 /50-60, with aggitation repositioning and suctioning pt hypertensive SBP 160-170. ativan gtt discontinued pt may have PRN ativan for aggitation. fentanyl gtt continues at 150 mcq/hr\n\nresp: vent wean to cpap with pressure support peep 8 pressure support at 10 40% fio2- RR 20s, Vt 500, lung sounds clear to coarse with diminished bases.\n\nneuro: pt opening eyes spontaneously at times, mae+, intermittently following commands, will grasp with hands to command. pupils 2mm with brisk reaction\n\ngu/gi: nutrition consult- probalance with goal rate 65cchr, low residuals 10-20cc q 4 hours, no bowel sounds heard icu team aware, small amount brown liuid from ileostomy, midline incision well approximated and scant serous drainage. lasix gtt at 8 mg hr to max 10 mg hr- to achieve goal 2 liters negative by 12 nidnight.\n\nskin: ETT not rotated mouth sore in right corner, skin on back intact- pt transferred back to atmos icu bed, pt continues to have generalized edema.\n\nplan; continue with aggressive diuresis with lasix gtt, continue with vent wean as tolerated by pt, monitor residuals with tube feedings, provide supportoive care to pt and family\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-11 00:00:00.000",
"description": "Report",
"row_id": 1445640,
"text": "Respiratory care\nPt remains intubated recieved on a/c weaned to cpap/psv. recieved on peep of 16 wened to 8cm , abg on psv of 12cm 746/39/98/29/3 weaned to 10cm. Fio2 weaned to 40%. Plan to continue to wean support as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-17 00:00:00.000",
"description": "Report",
"row_id": 1445663,
"text": "NPN (NOC):\n\nRESP: PT REMAINS INTUBATED. CURRENT VENT SETTINGS: PS 8 X 5 PEEP X40%. RR TEENS TO 20'S, VT'S 700'S, LATEST ABG: 163/35/7.40/23. BS'S FAIRLY CLEAR. SX'D X 2 FOR MOD AMTS OF THICK BROWN SECRETIONS. RSBI = 40.\n\nNEURO: PT HAD BECOME INCREASINGLY MORE RESTLESS, TACHYPNEIC AND HYPERTENSIVE ON FENTYNL 200 MCG'S. ATIVAN 1 MG IV GIVEN AT MN AND PT IMMEDIATELY FELL ASLEEP AND BP AND RR CAME DOWN. IS BECOMING MORE AWAKE AND INTERMITTANTLY RESTLESS NOW (6 AM ). ? EXTUBATE TODAY.\n\nGI: TOL TF WELL. OSTOMY WAS PUTTING OUT ALOT OF WATERY STOOL BUT HAS SLOWED DOWN CONSIDERABLE SINCE MN. ABD REMAINS OPEN. DSG CHANGED AT 4AM. SURGICAL TEAM IS CONSIDERING A VAC DSG TODAY.\n\nF/E: I&O - 6 LITERS AT MN AND WT IS DOWN 8 KG'S. HIS UO HAS ALSO SLOWED CONSIDERABLY SINCE MN. 100 MEQ'S OF KCL AND 2 AMPS CALCIUM GIVEN OVERNOC. NA IS NORMALIZING ON D5W DRIP. FSBS' CONTROLLED W/ SSI.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-17 00:00:00.000",
"description": "Report",
"row_id": 1445664,
"text": "Resp Care\npt maintained on mech vetilation PSV, tol well AM RSBI 40.6. Bilat breath sounds course rhonchi, suctioned moderate thick yellow. no vent settings changed seeflow sheet.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-17 00:00:00.000",
"description": "Report",
"row_id": 1445665,
"text": "Resp Care:\n\nPt remains intubated & ventilated. PSV decreased this a.m. to with good results; pt remains on 40% FiO2. Suctioned for mod amts of rust colored secs throughout shift; with BS = crse t/o. MDI's given as ordered. Plan to continue ventilating pt through noc with IR procedure planned for tomorrow. Please see flowsheet for details.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-17 00:00:00.000",
"description": "Report",
"row_id": 1445666,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\nNEURO--VERY AWAKE , ALERT AND COOPERATIVE. FENT @200 MCG. ATIVAN ORDERED FOR PRN DUE TO ONE MORE DAY OF INTUBATION.\nRESP--WEANED TO CPAP 5/5. READY TO EXTUBATE TODAY, DECISION MADE NOT TO AS PATIENT WILL TO TO IR TOMORROW FOR FLURO GUIDED DRAINAGE OF LUNG MASS/ABCESS. SUCTIONED FOR MOD-LARGE AMOUNTS OF THICK RUST SPUTUM.\nGU--ADEQUATE URINE, MUCH LESS THAN YESTERDAY.\nGI--THICK LOOSE BROWN STOOL FROM ILEOSTOMY. ABD. WOUND VAC'ED BY PRIMARY TEAM W/ WHITE THEN BLACK SPONGE W/GOOD SUCTION. BELLY SOFT.\nENDO-- NPH AND SLIDING SCALE CONTROLLING BLOOD SUGARS.\nID--AFBERILE TODAY. FLAGYL ADDED TO ZOSYN AND CIPRO. WBC DOWN.\nCV--STABLE. EKG/CKW/TROPONIN DONE AFTER? 5BEAT VTACH/ARTIFACT. (MOST LIKELY ARTIFACT). DENYS AND CPAIN, NO FURTHER EPISODES, LOTS OF ARTIFACT WHEN PATIENT MOVING.\nSOCIAL--WIFE/SON . UPDATE GIVEN.\nPLAN: NPH THIS PM, NPO AFTER MIDNIGHT FOR PROCEDURE\n PRN ATIVAN @ HS.\n CPT /PULMONARY TOILET FOR THICK SECRETIONS.\n TEAM AWARE OF ABOVE. CALL HO WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-10 00:00:00.000",
"description": "Report",
"row_id": 1445633,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: PT is still on fentanyl, ativan and cisatracurium gtt,with Lt ulnar TOF monitor with twitches, nimbex ^ 0.08mg as pt overbreahing vent.other than that fully relaxed and sedated.\n\nCV: NST- SB, HR 56-60/min, no ectopy noted, SBP 110-120, levo off sine yesterday.Afebrile, + PP, ++generalized edema.IVF KVO only, Plt still low 56 today with am lab, WBC trending down and 16.5 this am, hct:27.8.cont with PCCO monitoring.\n\nResp; Remains on vent FIo2 down to 45% , Good ABG's.LS coarse and dinished at bases, O 2sat 96-100%, Minimal secretion only.\n\nGI: Abd distended, very hypoactive BS, ileostomy with minimal greenish out put more thick today. tube kept clamped per primary team since day time.OGT to LCWS with bilious out put.\n\nGU: Foley cath patent with amber clear urine adq amt.\n\nEndo; Bld sug q6h, on ssri, treated per SS.\n\nID: Afebrile,cont with anbx.\n\nAct: Pt is on kinair bed, turned q2h, stable during turning and positioning.\n\nSocial: Visited by wife and her sister during early shift, updated with POC.\n\nPlan: Cont monitoring,cont pulm toilet, frequent positioning, skin care,pain mngt, ? DC paraletic today, ? start nutrition OGT or TPN.support to pt and family.abg's.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-10 00:00:00.000",
"description": "Report",
"row_id": 1445634,
"text": "RESP CARE: Pt remaisn orally intubated with 7.5ETT/21 lip. On AC 450/26/.45/18 PEEP. 02 Sat dropped to 89% at start of shift following turn to R. FI02 increased to .50 at that time. No drops in sats overnight/ABGs WNL. Esophageal balloon remains in place. No measurements overnight.Lungs coarse rhonchi bilat. Sxd thick bld tinged tan sputum. No RSBI due to pEEP level. Continue to wean FI02/vent as tol\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-10 00:00:00.000",
"description": "Report",
"row_id": 1445635,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\nNEURO--PARALYTIC OFF THIS AM. RESPONDING TO PAIN WITH SOME SPONTANEOUS MOVEMENT OF LOWER ARMS. WINCES TO STERNAL RUB. TOLERATING VENTILATOR WELL AT THIS POINT ON FENT/ATIVAN. SLOWLY WEANING THESE DOWN AS WELL.\nPUPILS 2=REACTIVE.\n\nRESP--PEEP TO 16, TOLERATED WELL. ONE PERIOD OF DESATURATION DUE TO LARGE AMOUNT OF THICK, RUSTY SECRETIONS. SUCTIONED AND LARVAGED FOR LARGE AMOUNT WITH IMPROVING SATS AND IMPRVOING GASES. LUNGS CLEAR AND DIMINISHED.\n\nGI---BELLY DISTENDED, SOFT., NICE PINK STOMA, MINIMAL STOOL. REPLETE W/FIBER STARTED AT 10CC HR AFTER PLACEMENT OF NGT CONFIRMED BY CXRAY. PROTONIX CHANGED TO FAMOTADINE.\n\nGU--LASIX ONCE, CURRENTLY ON LASIX GTT WITH GOAL 1-1.5 LITERS NEGATAIVE.\n\nCV--STABLE OFF PRESSORS. CARDIAC NUMBERS PER FLOW SHEET. AFEBRILE.\n\nENDO--BLOOD SUGARS CONTROLLED WITH SLIDING SCALE.\n\nPLAN: CONTINUE WITH SLOW WEAN ON FENT/ATIVAN (APPROX. 20% Q 12 HRS)\nCONTINUE PEEP WEAN AS DIRECTED BY HO AND GASES.\nCONTINUE DIURESIS AS LONG AS TOLERATES, WILL CHECK LATATE AND BLOOD PRESSURE PARAMETERS.\nREPLACE LYTES AS NEEDED.\nCALL HO WITH ANY CHANGES.\nVANCO DOSED ACCORDING TO LEVEL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-10 00:00:00.000",
"description": "Report",
"row_id": 1445636,
"text": "Respiratory care\nPt remains on a/c vent with peep decreased to 16cm, ttp -5.5. Abgs wnl on 40%. Plan to wean paralytic and continue to wean support as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-16 00:00:00.000",
"description": "Report",
"row_id": 1445660,
"text": "pt febrile 102-101 wbc^up 14k. tylenol 650mg x2 given\nhtn sb/p 180-160 most of night agitation. lopressor 25mg via ngt\nw/ min effect.\nrr-35 w/ stimulation(turning/bathing/suctioning) but settles down w/ rr24-28. suction frequently q2hrs for mod amt thick brown sputum.\no2sats 99-97% on cpap 5/8ips/40%.\npt slightly sedated on fentanyl 200mcg/hr. pt nodding to ?'s. restless\n@ times. mae in bed.\nlasix gtt was stopped last evening @ 1800 pt autodiuresising large amt of urine 500-230cc/hr. wt down 5kgs from previous day. k+ low repleted\nw/ 80meq down ngt and 40meq iv.\nabd. soft-ileostomy stoma pink-large amt watery brown stool and air.\nabd. dsg changed x1 for mod. serous drge\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-16 00:00:00.000",
"description": "Report",
"row_id": 1445661,
"text": "Resp Care\nPt remains intaubted on PSV 8/5 with vts 500-600 rr 20-30. BLBS course and diminished suctioned for very thick tan/brown secretions, mdis given. PLan to continue on current settings overnight as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-08 00:00:00.000",
"description": "Report",
"row_id": 1445627,
"text": "resp care\npt continues on psv. more frank blood sx from ett. o2 slowwean presently 70%. plan to bronch today\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-08 00:00:00.000",
"description": "Report",
"row_id": 1445628,
"text": "resp care - Pt remains intubated, paralyzed and on full vent support. A copious amount of bloody secretions were suctioned when pt was turned early in shift. Pt was additionally suctioned for blood-tinged secretions during bronch. Sample was sent to lab. PEEP was raised, balloon measurement indicating that transpulmonary pressure was +1. Plan is to wean as tolerated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-08 00:00:00.000",
"description": "Report",
"row_id": 1445629,
"text": "SICU Nursing Note: See flowsheet for details\nEvents: Patient bronched - went into SVT 190s-200s, converted while 150 mg bolus of amiodarone infusing; PCCO monitor applied to watch C.O./CI; septic looking picture with increasingly worse CXR/ARDS picture; multiple vent setting changes, paralyzed with nimbex.\n\nRespiratory: Increased sedation levels this morning, changing over to ativan gtt from versed and increasing fentanyl gtt then pt placed on controlled settings. Currently able to wean Fi02 to 60 and slightly decreased PEEP. Pt bronched for thick bloody secretions - LS coarse but slightly less diminished in bases than this morning. Turning patient on his sides, keeping him off back to maximize use of lung space.\n\nHemodynamics: Remains on low dose levo; T max 102.1, currently afebrile; SR/ST 80s-120s. After bronch, patient went into an SVT 190s-200s - converted back to sinus tach in 100s-110s during 150 mg amiodarone bolus. PCCO monitor applied, Aline placed on L axilla for use of PCCO. Pt's C.O./C.I. showing low normal numbers, decreased SVR. 2 500 cc boluses of LR administered; currently remains on plasmalyte at 150/hour. CVP 16-24; generalized anasarca; peripheral pulses easily palpable. Ca repleted multiple times. Hydrocort. started because patient didn't respond normally to stem test administered this morning.\n\nNeuro: PERRL; sedated on fentanyl/ativan gtts and paralyzed with nimbex; TOF applied to L ulnar, currently getting thumb twitches. Earlier pre-paralytic, pt. withdrawing to pain in all 4 extremities and spontaneously moving limbs to stimulation but not following commands, grimacing to pain.\n\nGI: Remains NPO; no output via OGT which is on CLWS; ostomy put out guiac - liquid green stool, mainly water; tube in place putting out same liquid green substance as his ostomy; abd soft distended with very hypo bowel sounds. Glucose WNL, no insulin required this shift.\n\nSkin: Intact, very edematous, generalized edema; buttocks slightly red but intact; barrier creme applied to scrotum.\n\nFamily: Son into visit, spoke to ; wife phoned. Family needs support as they continue to understand patient's condition and relative gravity.\n\nPLAN: Keep low dose levo for squeeze (per ); ARDS protocol; monitor culture results/cont ABX; monitor PCCO, bolus fluid as needed; monitor train of fours while paralyzed; pain and sedation management for comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-16 00:00:00.000",
"description": "Report",
"row_id": 1445662,
"text": "FOCUS: CONDITION UPDATE\nD: SEE CAREVUE FOR SPECIFIC VITAL SIGNS/LABS/ASSESSMENTS\nNEURO--SEDATED ON FENTANYL 175 MCG. ALERT TO NAME AND WILL FOLLOW COMMANDS. PURPOSEFUL MOVEMENT OF UPPER EXTREMITIES, MOVES ALL EXTREMITIES. SLOWLY WEANING FENTANYL.ATIVAN DC/D YESTERDAY, DID WELL OFF IT TODAY.\nRESP--NO VENT CHANGES TODAY, TOLERATING CPAP WELL. CAN DECREASE PRESSURE SUPPORT TO 5 TOMORROW. LUNGS CLEAR TO COARSE DEPENDING UPON WHEN SUCTIONED LAST. SUCTIONED FOR THICK BROWN SPTUTUM.\nGI--NOT TOLERATING TUBE FEEDS WELL AS HAS A LARGE IEOSTOMY OUTPUT, AND DOES NOT ABSORB ANY PO K. BELLY SOFT, INCISION ESSENTIALLY OPENED EXCEPT FOR A FEW STAPLES AROUND BELLY BUTTON. SMALL BOWEL VISIBLE IN LOWER ASPECT OF WOUND. CHANGED MULTIPLE TIMES TODAY WITH DSD KERLIX. MOD AMOUNT OF SEROUS DRAINAGE. WOUND LOOKS PINK IN LOWERS ASPECT, LESS PINK IN UPPER ASPECT. CT OF CHEST/ABD W/CONTRAST DONE--?RESULTS.\nGU--AUTO DIURESING LARGE AMOUNTS OF URINE. CONTINUOUS K REPLACEMENT. D5W@80 STARTED FOR FLUID BALANCE MANAGEMENT. WEIGHT CONTINUES TO GO DOWN.\nID--LESS FEBRILE TODAY. CHANGED TO MOTRIN FROM TYLENOL FOR FEVER MANAGEMENT. STOOL SENT FOR CDIF. OTHER ANTIBIOTICS UNCHANGED.\nCV--STABLE. LOPRESSOR INCREASED WITH BETTER BLOOD PRESSURE CONTROL\nPLAN: CONTINUE TO MONITOR WOUND, CHANGE PRN\n FREQUENT LYTE CHECKS, NEEDS K QUITE FREQUENTLY\n SUCTION WHEN NEEDED, ?DECREASE PRESSURE SUPPORT IN AM\n NUTRITION CONSULT FOR IMPORVED ABSORPTION OF FEEDS.\nFAMILY IN, UPDATE GIVEN. APPROPRIATELY SUPPORTIVE. ALL TEAMS AWARE OF ABOVE. WILL CALL HO WITH ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-07 00:00:00.000",
"description": "Report",
"row_id": 1445625,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Pt is on fentanyl and versed gtt, opens eyes to call, not following any commands, agitated when low sedation,so prn dilaudid for pain started with good effect, PERL.moving all extrimities to pain and spontaneously.\n\nCV: ST-NSR, HR 106-83, no ectopy noted, SBP was in 80's early shift, fluid bolus x2 with immediate effect and drops down once fluid is off, Neo started at 2mcg/kg/min and tapered to 0.5mcg now, 25% alb 50ml & 2 units PRBC given. ++PP, ++edema.IVF LR at 200ml/hr, lytes replaced per sliding scale.\n\nResp: Remains on vent, pls see flow sheet and resp notes for changes, LS coarse - clear and diminished at bases, sxn thick bld tinged secretion, ABG's still reps alkalosis, O2 sat 90-94% can tolerate sats 90-92 today per Dr..\n\nGI: Abd softly distended, hypoactive BS, No BM. OGT with bilious drain replaicng cc:cc with NS. tube with clear drain, and ileostomy with light greenish thin out put.abd . staples intact and dry, DSD removed by primary team today.\n\nGU: Foley cath patent with yellow clear urine adq amt.\n\nEndo: Bld sug q6h, WNL.\n\nAct: Turned from side to side,skin intact.\n\nSocial: Visited by wife , updated by Dr. and RN.\n\nID: T max 102.3, pan cx, on anbx.\n\nPlan: Cont monitoring, pulm hygiene, abg's,pain mngt, wean Neo as tolerates.support to pt and family, check lytes and replace per sliding scale. change position q2h and skin care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-09 00:00:00.000",
"description": "Report",
"row_id": 1445630,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Patient is on fentanyl, ativan and cisatracurium gtt, lt ulnar TOF monitor with twitches, Pupils 1-2mm sluggishly reactive.cont same amt of cisatracurium per Dr..\n\nCV: NSR, HR in 70's,no ectopy noted, SBP 100-110 w/ map of 80-90 levophed wean down to 0.03 per Dr..PCCO monitor with better numbers now, calibrated q8h, CO 5-6.7L,++ generalized edema, weeping from rt. groin ? Line placement trial.Palpable pulses,Plasma lyte at 150ml/hr, cvp 14-21cm,afebrile.HCT 30's and wbc 23, plt 44, primary team aware.K and calcium replaced.\n\nResp: Remains on vent, vent changes with ABG's, pls see resp notes and flow sheet for changes. Ls coarse - clear and diminished at bases, O2 sat 94 -97%, sxn bld tinged secretions.ABG acceptable.\n\nGI: Abd distended, very hypoactive BS, NO BM today, OGT w/very minimal drain , primary team informed, ileostomy with small amt greenish liq drain, tube with minimal out put also, all drains greenish.abd post op wound +oozing, dressing changed.\n\nGU: Foley cath patent with amber clear urine adq amt.\n\nEndo: Bld sug q6h, on SSRI.\n\nID: Afebrile, on anbx, ciprofloxacin started last night.\n\nAct: Turned q2h, skin intact.\n\nSocial; Visted by pt's wife early shift, updated by RN and SICU MD.\n\nPlan: Cont monitoring, pulm hygiene, regular positioning,skin care cont tof monitoring, wean off levophed as tolerates, support to pt and family.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-09 00:00:00.000",
"description": "Report",
"row_id": 1445631,
"text": "Resp Care\nPt remains on vent. Sucitoned for mod amt of thick blood-tinged secreitons. Weaning based on abgs, Improving. Mdis given as ordered. Will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-09 00:00:00.000",
"description": "Report",
"row_id": 1445632,
"text": "SICU Nursing Note: See flowsheet for details\nResp: Continues on CMV; no sputum via ETT; LS coarse/rhonchorous; de-recruited after a re-position with desats to 86% - ambu bagged and placed on 100-% Fi02 then PEEP increased to 18 after esoph. balloon revealed a PEEP of 14 too low at this time. After moving into Kinair bed, placed patient in modified swimmer's position and he didn't tolerate it despite re-recruitment, sats remained at 87-88% so he was placed on his side instead.\n\nHemodynamics: Afebrile; sinus brady/normal sinus in 50s-70s with no ectopy noted; SBP 80s-120s with MAPs above 65. Low dose levo off since mid-afternoon after patient was hypertensive in 140s and heart rate dipped to 49-50, currently remains off but should be titrated back on if MAP <65. Still w/ generalized 3+ edema; UO 30-60 an hour via foley. Lytes repleted PRN; showing low normal CO, SVV within normal limits, water volume in lungs slightly less than yesterday but still higher than PICCOs normal range; CVP 14-20. PLT increased to 59 from 44, no s/s bleeding/hematoma noted.\n\nGI: Remains NPO; off nutrition for 10 days; insulin per sliding scale, scale tightened for better controls; abd soft distended with hypo BS; ostomy put out scant amounts of slightly formed green stool. tube capped per Dr. - before being capped, no output from it\n\nNeuro: Paralyzed; PERRL; train of fours eliciting 2,3, or 4 twitches; titrating nimbex today based on patient at one point moving mouth and bucking vent slightly; able to titrate back down.\n\nSkin: Intact; scrotum still extremely edematous but intact; turn and reposition frequently.\n\nSocial: Son into visit and called on behalf of patient's wife.\n\nPLAN: Titrate MAP >65; plan to stop paralysis tomorrow; continue sedation; No PEEP decreases without knowledge and assent; if tighter insulin scale fails to control glucose, should start insulin gtt; encourage teams to make nutrition plan for patient either enteral or TPN; continue to titrate sedation to ensure patient's comfort; continue SICU plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-08 00:00:00.000",
"description": "Report",
"row_id": 1445626,
"text": "7pm-7am Nursing Note\nSee CareVue for objective data and trends:\nNEURO-Pt sedated on versed and fentanyl drips, also receiving intermittent dosing of IV dilaudid for further pain management. Pt will grimace face but not open eyes. Pt's pupils at 2mm bilaterally and reactive to light. Pt withdraws extremities to nail bed pressure.\nCV-Pt HR 90s-110s, SR. SBP maintaining 90s-100. Continue phenylephrine drip to maintain MAP >60. Pt with generalized edema present.\nRESP-LS clear to coarse and very diminished at bases. Pt's sputum now more bloody and remains thick. Dr. aware. Pt continues to be ventilated and initially on CPAP settings, ABG improved however pt requiring 100% fio2 and has been unable to wean fio2 down as pt's sats decrease into the high 80s. Pt changed over to AC mode at 0500 - will monitor ABG but repiratory rate elevated into 40s. CXR done, results pending.\nGI-OG with no output, now pt with increased output via ileostomy. Abdomen is softly distended with faint, hpoactive bowel sounds present. Midline surgical incision with staples and small amounts of serosanquinous drainaige-DSD applied. drain remains intact with minimal output.\nGU-foley intact and putting out adequate amounts of urine.\nLABS-Pt's platelets continue to drop, INR elevated. HIT panel pending. WBC elevated as well- Tmax 102.1, SICU team aware, Pan cultured yesterday. Continues Vancomycin and zosyn.\nPLAN-Monitor respiratory status, pulmonary toilet. ?bronchoscopy today secondary to thick, bloody secretions. Follow temps, continue antibiotics. Follow GI status/exams. Monitor labs.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-19 00:00:00.000",
"description": "Report",
"row_id": 1445671,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Pt is alert and oriented x , confused inbetween,but easily reoriented back, c/o pain, dilaudid prn with good effcet, ativan 1mg as pt c/o insomnia with fair effect, pleasant and co op with care.\n\nCV: NSR, HR in 60's, SBP 140-170, on po lopressor,ivf kvo only, afebrile, ++PP, + edema scrotum & penis, still on aldactone.CVP 2-4cm.denies Cp or discomfort.\n\nResp: Remains on RA, ls clear, ++cough, pt is able to suction it from mouth, using IS appropriately, encouraged deep breath and cough.O2 sat 96-99%.\n\nGI: Abd softly distneded, Hypoactive BS, Tf at goal. tolerated well, ileostomy with brown loose stool, banana flakes TID. tube clamped.\n\nGU: Foley cath patent with yellow clear urine adq amt.\n\nEndo; Bld sug q6h, on SSRI and NPH .\n\nID: Afebrile, on anbx.\n\nSocial: Visited by wife early shift, aware of \n\nAct: turned in bed, skin intact.\n\nPlan: Cont monitoring, pulm hygiene, encourage deep breath cough & IS, ? ^ lopressor for SBP 170's, taper hydrocortisone, ambulate as tolerates , support to pt and family.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-19 00:00:00.000",
"description": "Report",
"row_id": 1445672,
"text": "SICU Nursing Note: See flowsheet for details\nPt remains on RA, coughing scant secretions, using IS, pivoted with 2 assist to chair, needed heavy 3-assist to return to chair however; motivated to get physical therapy for his sons' weddings upcoming. Added norvasc to his BP regime for better BP control; taking clear liquids without problem, appetite fair. VAC dressing to abd incision changed by surgery, ileostomy appliances changed at same time. Remains slightly confused by pleasant, oriented, cooperative with care. Wife phoned today for update.\n\nPLAN: VAC and ileo appliances due to be changed on Sunday (VAC changed by east surgery team only); advance diet as tol; PT/OT; pain management; continue to encourage IS, cough/deep breathe, continue ICU plan of care.\n"
},
{
"category": "Nursing/other",
"chartdate": "2178-06-20 00:00:00.000",
"description": "Report",
"row_id": 1445673,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro:Alert and orinented x3, MAE, c/o abd pain dilaudid x1 and ativan 1mg per pt's request and slightly confused towards late night,\" No body told me it is time to go for the wedding\"reoriented back,appropriate with answers,aware of palce, time and self.trying to get OOB at times, bed alarm on.\n\nCV: HR 60-70, no ectopy noted, SBP 140-170, ++PP,less edema good diuresis with aldectone, K and calcium replaced.\n\nResp : On RA O 2sat 99-100%, LS clear, good cough w/ minimal secretion,Deep breath and cough and IS encouraged.\n\nGI: Abd soft,Hypoactive BS, Ileostomy w/ more thick stool with gas. can't drain to the bag, banana flakes held last night, vac dressing intact with SS drain.TF at goal, tolerated clears too.\n\nGU: Foley cath patent with yellow clear uirne adq amt.\n\nEndo; bld sug q6h, on SSRI & NPH.\n\nAct: Turned in bed, skin intact.\n\nSocial; Called by pt's son last night, updated with him.\n\nPlan: Cont monitoring, pulm hygiene, ambulate, ? Advance diet, change pain meds to po., support to pt nad family.\n"
}
] |
4,113 | 146,014 | The patient was admitted under the Pulmonary Service, at which time she was followed by Pulmonary and Renal Departments, at which time Cardiology also saw the patient. The patient eventually underwent coronary artery bypass grafting on . The patient underwent coronary artery bypass grafting times four using the left internal mammary artery. On postoperative day zero, after surgery, Renal came by to see the patient. Intraoperatively, the patient had atrial fibrillation for which she was cardioverted and placed on amiodarone. Renal decided to schedule dialysis for the following day without heparin. On postoperative day one, status post coronary artery bypass graft times four, over the last 24 hours the patient was transfused 1 unit of packed red blood cells for a hematocrit of 26. The patient with a low-grade temperature of 100, in sinus rhythm at 85, blood pressure stable at 107/50, central venous pressure of 8, cardiac index of 3.27, with an systemic vascular resistance of 800. Potassium of 3.6, BUN of 23, creatinine of 3.5, with a blood glucose of 155. Ionized calcium of 1.1, magnesium of 2, hematocrit of 30. On physical examination, the patient was awake, following commands. Heart had a regular rate and rhythm. Lungs were clear to auscultation bilaterally. Sternum was dry and stable. Abdomen was benign. Extremities were warm with right ankle with increased color. The patient was on Esmolol, and amiodarone, as well as vancomycin, carafate, and a sliding-scale of insulin. The plan was to change her pain management to Percocet instead of morphine, change the esmolol drip to p.o., continue the amiodarone, wean to extubate, hemodialysis today, continue antibiotics, and to discontinue the chest tubes, and to transfer to the floor. Renal came by to see the patient on as well. The patient was seen at hemodialysis. The patient underwent dialysis for four hours. The patient was found to be acidotic, predominantly metabolic acidosis with no respiratory compensation. They recommended to check the lactate level, check the calcium and potassium, and to increase Epogen to 8000 units. On postoperative day two, the patient was on nitroglycerin at 0.6, a sliding-scale, Lopressor, Epogen, morphine, calcium, and Percocet. The patient was afebrile, in sinus rhythm at 94, blood pressure 140/53, satting at 97% on 4 liters nasal cannula. Potassium of 3, blood glucose ranging between 65 and 150. On physical examination, the patient was wake and alert and oriented times three. Heart had a regular rate and rhythm. Lungs had decreased breath sounds on the left side. The sternum was stable and dry. Abdomen was benign. Extremities were warm and edematous. The plan was to transfer the patient to the floor, follow the potassium, discontinue the Foley, ambulate, and to check a chest x-ray. Renal also came by to see the patient on postoperative day two, which was . Their recommendation was to limit p.o. and intravenous 1 liter to 1.5 liters a day. Check potassium and resume potassium binders when starting p.o. diet, and the plan was to undergo hemodialysis on . Cardiology also came by to see the patient on . They recommended a chest x-ray because of the bronchial breathing over the left lung field. No other recommendations. On postoperative day three, the patient under hemodialysis, was afebrile, in sinus rhythm at 93, blood pressure 114/68, satting at 95% on 4 liters. On physical examination, the patient was in no apparent distress. Had decreased breath sounds. Heart had normal S1 and S2. Dressings were clean, dry and intact. The sternum was stable. Abdomen was nontender, nondistended, and soft. Extremities revealed left lower extremity incision was clean, dry and intact. The plan was to continue Percocet, increase the Lopressor, discontinue the wires, hemodialysis. The patient did undergo hemodialysis for 3.5 hours, 1500 units of heparin were administered during dialysis. On postoperative day four, the patient remained afebrile, in sinus rhythm at 77, blood pressure 120/70, satting at 96% on 2 liters, fingersticks ranging between 87 and 125. On physical examination, the patient was in no apparent distress. Lungs had decreased breath sounds, left greater than right, at the bases. Heart was normal S1 and S2. Chest revealed the sternum was stable, clean, dry and intact. The abdomen was nondistended, nontender, and soft. Extremities revealed left lower extremity was clean, dry and intact. The right lower extremity was with edema. The patient was stable. The plan was to continue current medications, discontinue the wires and chest tube, continue physical therapy, resume calcium carbonate and Nephrocaps, and possible hemodialysis planned for . Cardiology also came by and saw the patient on postoperative day four, which was . Recommendations were to continue aspirin and Lopressor and to add an ACE inhibitor if okay with Renal for mortality benefit for diabetics with coronary artery disease. On postoperative day five, the patient underwent hemodialysis for four hours. Renal came by to check the patient during hemodialysis, at which time the patient was stable with shortness of breath or chest pain. | The left ventricular inflow pattern suggests delayedrelaxation.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitaton.PULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appearstructurally normal with physiologic pulmonic regurgitation.PERICARDIUM: There is no pericardial effusion.Conclusions:1. Regional left ventricular wall motion isnormal.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal.AORTA: The aortic root is normal in diameter.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Normal sinus rhythm, rate 93Consider Anteroseptal infarct, oldDiffuse Nonspecific ST-T abnormalitiesSince last ECG, no significant changeABNORMAL ECG PATIENT/TEST INFORMATION:Indication: Left ventricular function.Hyportension.Height: (in) 68Weight (lb): 130BSA (m2): 1.70 m2BP (mm Hg): 83/56Status: InpatientDate/Time: at 09:33Test: TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is normal in size.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.LEFT VENTRICLE: There is moderate symmetric left ventricular hypertrophy. There is moderate symmetric left ventricular hypertrophy. Discoid atelectasis/scarring is seen in the right middle and right lower lobes, not significantly changed from prior exam. Mild (1+) mitral regurgitation isseen. IMPRESSION: Right middle and lower lobe atelectasis, without pneumonic consolidation. Sinus tachycardia, rate 101Consider Anteroseptal infarct, oldDiffuse Nonspecific ST-T abnormalitiesSince last ECG, no significant changeABNORMAL ECG Normal sinus rhythm, rate 95Diffuse Nonspecific T wave abnormalitiesSince last ECG, no significant changeABNORMAL ECG Mild (1+) mitralregurgitation is seen. There is moderatethickening of the mitral valve chordae. Normal sinus rhythm, rate 82Low voltage throughoutConsider Anteroseptal infarct, oldDiffuse Nonspecific T wave abnormalitiesSince last ECG, no significant changeABNORMAL ECG Regional left ventricular wall motion is normal.2. Normal sinus rhythm, rate 87Low voltage throughoutConsider Anteroseptal infarct, oldDiffuse Nonspecific T wave abnormalitiesSince last ECG, no significant changeABNORMAL ECG The leftventricular cavity size is normal. Theleft ventricular cavity size is normal. Heart size and mediastinal and hilar contours are normal. Overall left ventricular systolicfunction is normal (LVEF>55%). Since the previoustracing of sinus tachycardia and further ST-T wave changes are present.TRACING #1 Overall left ventricular systolic functionis normal (LVEF>55%). The left ventricular inflow pattern suggests delayed relaxation. Slight compression of the lower thoracic vertebral body is again noted. Since the previous tracing of right-sided chestleads are submitted - no ST segment elevation is evident.TRACING #2 Sinus tachycardia, rate 114Abnormal R wave progression (?ASMI or lead location)Diffuse ST-T abnormalities- Consider IschemiaSince last ECG, ST-T abnormalities more markedABNORMAL ECG Sinus tachycardia. Sinus tachycardia. Consider prior anteroseptal myocardial infarction - clinicalcorrelation is suggested. Anterolateral ST-T wave abnormalities - considerischemia and/or possible left ventricular hypertrophy. The mitral valve leaflets are mildly thickened. Pulmonary vasculature is unremarkable. There are no areas of pneumonic consolidation or pleural effusions. There ismoderate thickening of the mitral valve chordae. Comparison to exam from . | 10 | [
{
"category": "Echo",
"chartdate": "2140-05-20 00:00:00.000",
"description": "Report",
"row_id": 63283,
"text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHyportension.\nHeight: (in) 68\nWeight (lb): 130\nBSA (m2): 1.70 m2\nBP (mm Hg): 83/56\nStatus: Inpatient\nDate/Time: at 09:33\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: There is moderate symmetric left ventricular hypertrophy. The\nleft ventricular cavity size is normal. Overall left ventricular systolic\nfunction is normal (LVEF>55%). Regional left ventricular wall motion is\nnormal.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate thickening of the mitral valve chordae. Mild (1+) mitral\nregurgitation is seen. The left ventricular inflow pattern suggests delayed\nrelaxation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitaton.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\n1. There is moderate symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis normal (LVEF>55%). Regional left ventricular wall motion is normal.\n2. The mitral valve leaflets are mildly thickened. There is moderate\nthickening of the mitral valve chordae. Mild (1+) mitral regurgitation is\nseen. The left ventricular inflow pattern suggests delayed relaxation.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-24 00:00:00.000",
"description": "Report",
"row_id": 126238,
"text": "Normal sinus rhythm, rate 95\nDiffuse Nonspecific T wave abnormalities\nSince last ECG, no significant change\nABNORMAL ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-25 00:00:00.000",
"description": "Report",
"row_id": 126239,
"text": "Normal sinus rhythm, rate 82\nLow voltage throughout\nConsider Anteroseptal infarct, old\nDiffuse Nonspecific T wave abnormalities\nSince last ECG, no significant change\nABNORMAL ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-26 00:00:00.000",
"description": "Report",
"row_id": 126240,
"text": "Normal sinus rhythm, rate 87\nLow voltage throughout\nConsider Anteroseptal infarct, old\nDiffuse Nonspecific T wave abnormalities\nSince last ECG, no significant change\nABNORMAL ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-22 00:00:00.000",
"description": "Report",
"row_id": 126241,
"text": "Normal sinus rhythm, rate 93\nConsider Anteroseptal infarct, old\nDiffuse Nonspecific ST-T abnormalities\nSince last ECG, no significant change\nABNORMAL ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-23 00:00:00.000",
"description": "Report",
"row_id": 126242,
"text": "Sinus tachycardia, rate 101\nConsider Anteroseptal infarct, old\nDiffuse Nonspecific ST-T abnormalities\nSince last ECG, no significant change\nABNORMAL ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-20 00:00:00.000",
"description": "Report",
"row_id": 126243,
"text": "Sinus tachycardia, rate 114\nAbnormal R wave progression (?ASMI or lead location)\nDiffuse ST-T abnormalities- Consider Ischemia\nSince last ECG, ST-T abnormalities more marked\nABNORMAL ECG\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Report",
"row_id": 126244,
"text": "Sinus tachycardia. Since the previous tracing of right-sided chest\nleads are submitted - no ST segment elevation is evident.\nTRACING #2\n\n\n"
},
{
"category": "ECG",
"chartdate": "2140-05-19 00:00:00.000",
"description": "Report",
"row_id": 126245,
"text": "Sinus tachycardia. Consider prior anteroseptal myocardial infarction - clinical\ncorrelation is suggested. Anterolateral ST-T wave abnormalities - consider\nischemia and/or possible left ventricular hypertrophy. Since the previous\ntracing of sinus tachycardia and further ST-T wave changes are present.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2140-05-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 739111,
"text": " 1:35 PM\n CHEST (PA & LAT) Clip # \n Reason: LOW BP/ WEAKNESS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 36 year old woman with low bp\n REASON FOR THIS EXAMINATION:\n ?pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n FRONTAL & LATERAL CHEST:\n\n HISTORY: 36 y/o woman with hypotension, ?pneumonia.\n\n Comparison to exam from .\n\n Heart size and mediastinal and hilar contours are normal. Pulmonary\n vasculature is unremarkable. Discoid atelectasis/scarring is seen in the right\n middle and right lower lobes, not significantly changed from prior exam. There\n are no areas of pneumonic consolidation or pleural effusions. Slight\n compression of the lower thoracic vertebral body is again noted.\n\n IMPRESSION: Right middle and lower lobe atelectasis, without pneumonic\n consolidation.\n\n"
}
] |
48,426 | 108,236 | Upon arrival to the floor, goals of care were discussed with the family. They explained that they did not want to have the patient intubated, and preffered to avoid any invasive procedures including a central line. The understood that this would limit out ability to offer optimal care. When discussed with the patient, he requested to have BIPAP mask removed, expressing full understanding that this would hasten his death. The patient and the family agreed to pursue comfort measures directed care. He was given small doses of IV morphine to treat air hunger, and passed comfortably, with his family at his side, within 50 minutes upon arrival to the unit. | Multi-level thoracic spine degenerative changes are again noted. The aorta is calcified. The underlying rhythm appears to beatrial fibrillation. The left-sided pacer is unchanged with leads terminating in expected location of the right atrium and right ventricle in the setting of cardiomegaly. Max out neo peripherally Pt was alert and want the mask off. Max out neo peripherally Pt was alert and want the mask off. CHEST, PORTABLE FRONTAL VIEW: There is extensive consolidation of the left mid-to-lower lung and increased consolidation of the right lower lung in comparison to , concerning for infection. COMPARISON: Chest radiograph . IMPRESSION: Bilateral airspace consolidation concerning for pneumonia. Evaluate for pneumonia. The cardiac silhouette remains enlarged. MD informed about his condition and pt does not want aggressive treatment but want to be comfortable. MD informed about his condition and pt does not want aggressive treatment but want to be comfortable. There are small bilateral effusions. Small bilateral effusions. Clinician: Nurse YO male admitted from ED @ 0105 w/ non invasive mask ventillation sating 83 to 85% on Fio2 100%. Clinician: Nurse YO male admitted from ED @ 0105 w/ non invasive mask ventillation sating 83 to 85% on Fio2 100%. Ventricular paced rhythm with capture. Compared to the previous tracing of no diagnosticinterim change. Received morphine totall of 4mg to make him comfortable he had ice cream to eat and became asystole @ 0155 family was @ the bedside w/ him. Received morphine totall of 4mg to make him comfortable he had ice cream to eat and became asystole @ 0155 family was @ the bedside w/ him. 10:43 PM CHEST (PORTABLE AP) Clip # Reason: r/o pna MEDICAL CONDITION: year old man with acute dyspnea REASON FOR THIS EXAMINATION: r/o pna FINAL REPORT HISTORY: -year-old male with acute dyspnea. As per pt request BIPAP removed and refused for NRB too. | 4 | [
{
"category": "General",
"chartdate": "2108-01-28 00:00:00.000",
"description": "ICU Event Note",
"row_id": 617096,
"text": "Clinician: Nurse\n YO male admitted from ED @ 0105 w/ non invasive mask ventillation\n sating 83 to 85% on Fio2 100%. Max out neo peripherally Pt was alert\n and want the mask off. As per pt request BIPAP removed and refused for\n NRB too. MD informed about his condition and pt does not want\n aggressive treatment but want to be comfortable. Received morphine\n totall of 4mg to make him comfortable he had ice cream to eat and\n became asystole @ 0155 family was @ the bedside w/ him.\n"
},
{
"category": "General",
"chartdate": "2108-01-28 00:00:00.000",
"description": "ICU Event Note",
"row_id": 617097,
"text": "Clinician: Nurse\n YO male admitted from ED @ 0105 w/ non invasive mask ventillation\n sating 83 to 85% on Fio2 100%. Max out neo peripherally Pt was alert\n and want the mask off. As per pt request BIPAP removed and refused for\n NRB too. MD informed about his condition and pt does not want\n aggressive treatment but want to be comfortable. Received morphine\n totall of 4mg to make him comfortable he had ice cream to eat and\n became asystole @ 0155 family was @ the bedside w/ him.\n"
},
{
"category": "ECG",
"chartdate": "2108-01-27 00:00:00.000",
"description": "Report",
"row_id": 231409,
"text": "Ventricular paced rhythm with capture. The underlying rhythm appears to be\natrial fibrillation. Compared to the previous tracing of no diagnostic\ninterim change.\n\n"
},
{
"category": "Radiology",
"chartdate": "2108-01-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1117759,
"text": " 10:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old man with acute dyspnea\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old male with acute dyspnea. Evaluate for pneumonia.\n\n COMPARISON: Chest radiograph .\n\n CHEST, PORTABLE FRONTAL VIEW: There is extensive consolidation of the left\n mid-to-lower lung and increased consolidation of the right lower lung in\n comparison to , concerning for infection. There are small\n bilateral effusions. The cardiac silhouette remains enlarged. The aorta is\n calcified. The left-sided pacer is unchanged with leads terminating in\n expected location of the right atrium and right ventricle in the setting of\n cardiomegaly. Multi-level thoracic spine degenerative changes are again\n noted.\n\n IMPRESSION: Bilateral airspace consolidation concerning for pneumonia. Small\n bilateral effusions.\n\n"
}
] |
18,237 | 109,560 | # Pancytopenia: On admission the patient was found to be pancytopenic - Hct 14.5, WBC 2.9, ptl 89. The initial differential included idiopathic, medication-induced aplastic anemia (nifedipine, NSAIDs), viral-induced aplastic anemia (HIV, parvo B19), myelodysplastic syndrome (?lymphoma or other malignancy), TTP (without fever, acute renal dysfunction, with mental status changes, anemia, and thromboctopenia)or DIC with elevated INR. There was evidence of hemolysis with LDH in range and hapto <20, D-dimer 2600. The patient received 3 units PRBC in the ED and was transfered to the MICU for further monitorin of his hypotension. He was given an additional 2 Units of PRBC in the MICU. His Hct rose appropriately to PRBC, being 30.3 after a total of 5 Units given. The peripheral smear was most notable for polychromatophilia and anisocytosis. The obtained additional labs revealed a Vit B12 deficiency (75), Folate normal (6.2), elevated Iron (233) and Ferritin (624) and low TiBC (186). Parameters indicating Hemolysis were low: Hapto(<20), elevated tBili (2.6) and dBili 0.7. The Retic Count of 0.9 showed impaired production in the BM. Given that the pt was Vit B12 deficient and that is presentation could be well explained a possible BM biopsy was postponed. He was started on Cyanocobalamin 1000mcg sc/im daily and Folate 5mg iv daily. The LDH increase persisted initially, and then started to steadily go down, same with tBili. Since his Retic Count did not respond as expected to Vit B12 supplementation (being 0.4 on ) a bone marrow biopsy was obtained (on ) to r/o an additional hemolytic disorder, such as AML, aplastic anemia. The BM biopsy confirmed the diagnosis of Vit B12 deficiency as the underlying disorder and showed no signs of leukemia. The pt was kept inpatient over the weekend because his thrombocytes continously dropped (32 on ) despite the initiated Vit B12 therapy; however, his platelets gradually increased and he was discharged to rehab with all counts trending upwards. . # Hypotension On admission the pt presented with BP of 86/48. He reported light-headnesses and dizziness but denied syncopal episodes, falls, CP or SOB. His physical exam did not reveal signs of HF, such as increased JVD, hepatojugular reflux, ascites or peripheral edema. His hypotension was to dehydration and his BP was successfully elevated by volume resuscitation (3l of IVF and 5 Units of PRBC) and d/c of home BP-meds. He was transfered to the MICU for overnight supervision. His SBPs have remained stable over the rest of his hospital stay (SBP 110-130) and he was put back on Lisinopril 10mg po daily. Before discharge patient's blood pressure improved and he was restarted on atenolol 25 with SBP 100-110 range. . # Lethargy, confusion Pt presented with 5 days h/o worsening confusion, possible baseline dementia, to the ED. He has a PMH for stroke in , with no residual deficits per wife. In the ED a CT of the head was obtained to r/o possible stroke as cause for MS changes. It showed subacute/chronic infarcy in right occipital lobe. Neuro evaluated the patient in the ED and felt that this was most likely consistent with chronic infarct. Pt had waxing and episodes of confusion (disoriented to date, location and context; agitation) when still on the MICU and after he was transfered to the floor. Since the CT had been negative for acute bleeding, the changes in his MS to his hypotension on presentation as well as to the Vit B12 deficiency. A EEG was performed, following neuro recs, which showed widespread encephalopathy. Since the pt MS improved over the course of his hospital stay, and considering the facts presented above, Neuro did not think that a MRI of his head was indicated for further work-up. Patient is likely to have baseline dementia (atrophy seen on initial CT) and (resolving) neurologic manifestation from Vit B12 deficiency. . # EKG changes The EKG drawn in the ED showed the following abnormalities: RBBB, ST-depressions and TWI in V1-V6, which were thought to be a result of demand ischemia. His CK was 43 and his Troponin 0.02. There was only little suspicion for ACS as the etiology for his hypotension, since the pt had no complaints of shortness of breath/chest pain or radiating pain. EKG and Troponin were monitored closely over the following days and resolved after the pt was normotensive and had received PRBC. A repeat EKG on showed RBBB, no remaining ST-depressions or TWI. His Troponin on was 0.04. He was started on Lipitor 10mg daily. Given the pt PMH and his strong FH for CAD, he should receive outpatient work-up of underlying CAD. . # Chronic renal insufficiency Creatinine presented with Creatinine of 1.7 on admission, which was his baseline Crea according to old recs. The chronic renal insufficiency might be due to diabetic nephropathy. However, since the creatinine steadily improved over the course of the hospital stay, being 1.1 on , a prerenal component (secondary to dehydration) was thought to play a key role. . # Pt has a h/o DM, which he is seen for by his PCP at the . On admission he was on oral hypoglycemics, metformin and glyburide, but was changed to a ISS (Humalog). Patient was subsequently restarted on his oral hypoglycemic before discharge with suplemental sliding scale. | Sinus rhythmRight bundle branch blockLeft atrial abnormalityAnterolateral ST-T wave abnormalities -may be in part primary and arenonspecific - clinical correlation is suggestedSince previous tracing of same date, no significant change Sinus rhythmRight bundle branch blockLeft atrial abnormalityAnterolateral ST-T wave abnormalities - may be in part primary and arenonspecific - clinical correlation is suggestedSince previous tracing of , ST-T wave abnormalities decreased Sinus rhythm with occasional atrial ectopy. Sinus rhythm with occasional atrial ectopy. HEAD CT IN ED SHOWED NON-ACUTE INFARCT TO RT OCCIPITAL LOBE. Left atrial abnormality. ASA ON HOLD FOR NOW.RESP) LS WITH SCATT RHONCHI THROUGHOUT WITH OCC EXP WHEEZES THIS AM. Otherwise, no significant diagnostic change.TRACING #1 1.5-cm hypodense area in the right occipital lobe, which may represent subacute-to-chronic infarction. WHEEZES GONE AFTER LASIX GIVEN. There is continued mild tortuosity of the thoracic aorta with calcification. PT HAS BEEN ORIENTED X2 AND HAS SHORT TERM MEMORY LOSS. PT HAS NOW BEEN DX'D WITH B 12 DEFICENCY. DIET ADVANCED TO REG/DIABETIC DIET AND TOL WELL BY PT. 1.5 cm hyppodense area in the right occipital lobe, which may represent subacute/chronic infarction. REASON FOR THIS EXAMINATION: Eval for ICH or mass No contraindications for IV contrast WET READ: MNIa MON 11:47 PM No bleed. Sinus rhythmRight bundle branch blockLeft atrial abnormalityDiffuse ST-T wave abnormalities -are in part primary and suggest ischemia -clinical correlation is suggestedNo previous tracing available for comparison NEURO C/S DONE.CV) VSS AND WNL'S. Compared to the previous tracing of atrial ectopyis new. PT HAS = PUPILS, BUT RT PUPIL REACTS SL SLUGGISH COMPARE TO LT, MD AWARE. Note is made of 1.5-cm hypodense lesion in the medial portion of right occipital lobe, which may represent subacute-to- chronic infarction. Compared to the previous tracingof no significant diagnostic change.TRACING #2 hemolysis and ? TECHNIQUE: Non-contrast head CT. No comparison. There is mild congestive heart failure with cardiomegaly and small bilateral pleural effusion associated with bibasilar patchy atelectasis. IF PT NEEDS F/U CT SCAN. PT MIGHT NEED A 1:1 SITTER ONCE TRANSFRED. CHEST AP PORTABLE: The heart size is probably top normal. IMPRESSION: Mild congestive heart failure with cardiomegaly and small bilateral pleural effusion. SBP 117-130'S AND HR 70-80'S. Note added at attending review: There also appears to be some evidence of chronic infarction in the postero-medial right temporal lobe. FINDINGS: The evaluation is somewhat limited due to motion artifact. CM IN NSR WITHOUT ANY ECTOPY. Bilateral ventricles are somewhat prominent with brain atrophy. VIT K THIS AM GIVEN INR OF 1.7 . Somewhat limited study due to motion artifact. Heart size top normal. NO N/V/D AT THIS TIME. The pulmonary vasculature is unremarkable. IMPRESSION: Apparent mediastinal widening and prominent aortic contours may be due to AP technique. IVF @ KVO. No acute intracranial hemorrhage. PT HAS = STRENGHT TO ALL EXT'S. IMPRESSION: 1. Clinical correlation is advised. Clinical correlation is recommended. Clinical correlation is recommended. RR 30-40'S BUT IN NO RESP DISTRESS. COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared with the previous study of yesterday. NO EDEMA NOTED. The lungs are grossly clear without focal consolidation, pleural effusion or pneumothorax. The osseous and soft tissue structures are unremarkable. HO TO ASSESS. Rightbundle-branch block. Brain atrophy. The information was communicated with the referring physician, . 9:30 AM CHEST (PORTABLE AP) Clip # Reason: evidence of pulm edema Admitting Diagnosis: HYPOTENSION MEDICAL CONDITION: 71 year old man with ? PT ALSO HAD NON-PROD COUGH THIS AM, BUT NOT AFTER LASIX THIS PM. If there is concern for aortic pathology, chest CT could be performed. PT DENIES ANY CP OR ANY OTHER CARDIAC SYMPTOMS. Pulmonary vascular congestion has progressed but there is no pulmonary edema. If there is a high concern for acute infarct, MRI will be helpful. ABD DIST/SOFT AND NON-TENDER TO TOUCH. COMPARISON: No prior study available. REASON FOR THIS EXAMINATION: evidence of pulm edema FINAL REPORT AP CHEST, 9:41 A.M., HISTORY: Hemolysis, question lymphoma. ORAL DIABETIC MED'S HELD FOR NOW HIS RENAL STATUS (ELEVATED CREATINE).GU) FOLEY CATHETER D/C'D THIS PM AT 15:00 AND HAS THEN VOIDED TWICE VIA URINAL IN GOOD AMOUNTS.PAIN) PT DENIES ANY DISCOMFORT.SKIN) SKIN INTACT WITH OLD SCARS TO BIL LOWER LEGS.SOC) PT IS MARRIED WITH 7 CHILDREN. No pleural effusion. There is apparent mediastinal widening and prominence of the aortic contours which may be due to the AP technique. FINAL REPORT INDICATION: 71-year-old male with fatigue, lethargy, and hypertension. The lungs are clear otherwise. lymphoma (by labs) s/p several units of blood products and IVF after hypotension. 11:17 PM CT HEAD W/O CONTRAST Clip # Reason: Eval for ICH or mass MEDICAL CONDITION: 71 year old man with fatigue, lethargy, and hypotension. (NEURO) PT HAS BEEN CALM AND COOPERATIVE MOST OF THE DAY, BUT IS STARTING TO BECOME AGITATED AT 17:30. Severe degenerative changes of the spine. 7 AM TO 7 PM:PT HAD AN UNEVENTFUL DAY. IMPRESSION: AP chest compared to at 10:04 p.m. O2SAT 93 ON RA THIS AM AND UP TO 96-98% ON 2 LITER. | 10 | [
{
"category": "Nursing/other",
"chartdate": "2106-05-18 00:00:00.000",
"description": "Report",
"row_id": 1502236,
"text": "7 AM TO 7 PM:\n\nPT HAD AN UNEVENTFUL DAY. PT HAS NOW BEEN DX'D WITH B 12 DEFICENCY. (B12 WAS 75 THIS AM, NORMAL RANGE 240-900).\n\n(NEURO) PT HAS BEEN CALM AND COOPERATIVE MOST OF THE DAY, BUT IS STARTING TO BECOME AGITATED AT 17:30. HO TO ASSESS. PT HAS BEEN ORIENTED X2 AND HAS SHORT TERM MEMORY LOSS. PT HAS = PUPILS, BUT RT PUPIL REACTS SL SLUGGISH COMPARE TO LT, MD AWARE. PT HAS = STRENGHT TO ALL EXT'S. HEAD CT IN ED SHOWED NON-ACUTE INFARCT TO RT OCCIPITAL LOBE. ? IF PT NEEDS F/U CT SCAN. NEURO C/S DONE.\n\nCV) VSS AND WNL'S. SBP 117-130'S AND HR 70-80'S. CM IN NSR WITHOUT ANY ECTOPY. PT DENIES ANY CP OR ANY OTHER CARDIAC SYMPTOMS. NO EDEMA NOTED. VIT K THIS AM GIVEN INR OF 1.7 . ASA ON HOLD FOR NOW.\n\nRESP) LS WITH SCATT RHONCHI THROUGHOUT WITH OCC EXP WHEEZES THIS AM. WHEEZES GONE AFTER LASIX GIVEN. (LASIX 20 MG X2). RR 30-40'S BUT IN NO RESP DISTRESS. O2SAT 93 ON RA THIS AM AND UP TO 96-98% ON 2 LITER. PT ALSO HAD NON-PROD COUGH THIS AM, BUT NOT AFTER LASIX THIS PM. CXR DONE THIS AM.\n\nGI) BS+ TO ALL QUAD'S. ABD DIST/SOFT AND NON-TENDER TO TOUCH. NO N/V/D AT THIS TIME. IVF @ KVO. DIET ADVANCED TO REG/DIABETIC DIET AND TOL WELL BY PT. PT HAS A GOOD APPETITE.\n\nENDO) PT'S FSBS AT 17:00 WAS 147 AND WAS GIVEN 3 UNITS. ORAL DIABETIC MED'S HELD FOR NOW HIS RENAL STATUS (ELEVATED CREATINE).\n\nGU) FOLEY CATHETER D/C'D THIS PM AT 15:00 AND HAS THEN VOIDED TWICE VIA URINAL IN GOOD AMOUNTS.\n\nPAIN) PT DENIES ANY DISCOMFORT.\n\nSKIN) SKIN INTACT WITH OLD SCARS TO BIL LOWER LEGS.\n\nSOC) PT IS MARRIED WITH 7 CHILDREN. PT LIVES WITH WIFE AND ONE SON. WIFE HAS BEEN UPDATED OF PT'S STATUS AND ABOUT TRANSFER TO FLOOR BY MD.\n\nPLAN) TO BE TRANSFERED TO CC7 FOR FURTHER TREATMENT. PT MIGHT NEED A 1:1 SITTER ONCE TRANSFRED.\n"
},
{
"category": "ECG",
"chartdate": "2106-05-20 00:00:00.000",
"description": "Report",
"row_id": 178784,
"text": "Sinus rhythm with occasional atrial ectopy. Compared to the previous tracing\nof no significant diagnostic change.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2106-05-19 00:00:00.000",
"description": "Report",
"row_id": 178785,
"text": "Sinus rhythm with occasional atrial ectopy. Left atrial abnormality. Right\nbundle-branch block. Compared to the previous tracing of atrial ectopy\nis new. Otherwise, no significant diagnostic change.\nTRACING #1\n\n"
},
{
"category": "ECG",
"chartdate": "2106-05-18 00:00:00.000",
"description": "Report",
"row_id": 178786,
"text": "Sinus rhythm\nRight bundle branch block\nLeft atrial abnormality\nAnterolateral ST-T wave abnormalities -may be in part primary and are\nnonspecific - clinical correlation is suggested\nSince previous tracing of same date, no significant change\n\n"
},
{
"category": "ECG",
"chartdate": "2106-05-18 00:00:00.000",
"description": "Report",
"row_id": 178787,
"text": "Sinus rhythm\nRight bundle branch block\nLeft atrial abnormality\nAnterolateral ST-T wave abnormalities - may be in part primary and are\nnonspecific - clinical correlation is suggested\nSince previous tracing of , ST-T wave abnormalities decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2106-05-17 00:00:00.000",
"description": "Report",
"row_id": 178788,
"text": "Sinus rhythm\nRight bundle branch block\nLeft atrial abnormality\nDiffuse ST-T wave abnormalities -are in part primary and suggest ischemia -\nclinical correlation is suggested\nNo previous tracing available for comparison\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-05-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 913042,
"text": " 11:17 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for ICH or mass\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with fatigue, lethargy, and hypotension.\n REASON FOR THIS EXAMINATION:\n Eval for ICH or mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MNIa MON 11:47 PM\n No bleed. 1.5 cm hyppodense area in the right occipital lobe, which may\n represent subacute/chronic infarction. Clinical correlation is recommended. If\n there is a high concern for acute infarct, MRI will be helpful.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 71-year-old male with fatigue, lethargy, and hypertension.\n\n TECHNIQUE: Non-contrast head CT.\n\n No comparison.\n\n FINDINGS: The evaluation is somewhat limited due to motion artifact. No\n evidence of intracranial hemorrhage. Bilateral ventricles are somewhat\n prominent with brain atrophy. Note is made of 1.5-cm hypodense lesion in the\n medial portion of right occipital lobe, which may represent subacute-to-\n chronic infarction. The osseous and soft tissue structures are unremarkable.\n\n IMPRESSION:\n\n 1. No acute intracranial hemorrhage. Somewhat limited study due to motion\n artifact. Brain atrophy.\n\n 2. 1.5-cm hypodense area in the right occipital lobe, which may represent\n subacute-to-chronic infarction. Clinical correlation is recommended. MRI\n will be helpful for further evaluation.\n\n The information was communicated with the referring physician, . , by\n telephone at the time of interpretation.\n\n Note added at attending review: There also appears to be some evidence of\n chronic infarction in the postero-medial right temporal lobe.\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-05-18 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 913085,
"text": " 9:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evidence of pulm edema\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with ? hemolysis and ? lymphoma (by labs) s/p several units of\n blood products and IVF after hypotension.\n\n REASON FOR THIS EXAMINATION:\n evidence of pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:41 A.M., \n\n HISTORY: Hemolysis, question lymphoma.\n\n IMPRESSION: AP chest compared to at 10:04 p.m.\n\n Pulmonary vascular congestion has progressed but there is no pulmonary edema.\n Heart size top normal. No pleural effusion.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-05-17 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 913035,
"text": " 9:45 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with hypotension\n REASON FOR THIS EXAMINATION:\n eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n 71-year-old male with hypotension.\n\n COMPARISON: No prior study available.\n\n CHEST AP PORTABLE: The heart size is probably top normal. There is apparent\n mediastinal widening and prominence of the aortic contours which may be due to\n the AP technique. The lungs are grossly clear without focal consolidation,\n pleural effusion or pneumothorax. The pulmonary vasculature is unremarkable.\n Severe degenerative changes of the spine.\n\n IMPRESSION: Apparent mediastinal widening and prominent aortic contours may\n be due to AP technique. No prior study available for comparison. Clinical\n correlation is advised. If there is concern for aortic pathology, chest CT\n could be performed.\n\n This was discussed with Dr. at 10:30 p.m. on .\n\n\n\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2106-05-19 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 913241,
"text": " 10:56 AM\n CHEST (PA & LAT) Clip # \n Reason: evaluate for CHF, wide mediastinum\n Admitting Diagnosis: HYPOTENSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 71 year old man with DM and B12 deficiency, with previous CXR showing wide\n mediastinum\n REASON FOR THIS EXAMINATION:\n evaluate for CHF, wide mediastinum\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS\n\n INDICATION: 71-year-old man with diabetes mellitus and B12 deficiency.\n\n COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared\n with the previous study of yesterday.\n\n There is mild congestive heart failure with cardiomegaly and small bilateral\n pleural effusion associated with bibasilar patchy atelectasis. The lungs are\n clear otherwise. There is continued mild tortuosity of the thoracic aorta\n with calcification.\n\n IMPRESSION: Mild congestive heart failure with cardiomegaly and small\n bilateral pleural effusion.\n\n\n"
}
] |
61,673 | 180,117 | 81F with UC, HTN, CAD presenting with hypotension and abdominal pain/diarrhea/pancolitis, consistent with sepsis from abdominal source. See below for discussion of each issue. 1. Hypotension: was related to sepsis. Improved with fluid boluses initially. She was started on broad spectrum abx for presumed intraabdominal sepsis. She then changed her code status to CMO and refused antibiotics for about 12 hours. The next day, she changed her mind and antibiotics were restarted, but she still did not want any aggressive or invasive care. A CT was planned to evaluate her abdomen, but refused by the patient. After about 36 hours since restarting her antibiotics, she again developed hypotension. After talking with the family, pressors were not started and she expired. . 2. Abdominal pain/Pancolitis: Pt with pancolitis on CT scan and malnutrition, failure to thrive. Surgery was consulted and she was not a candidate. GI was consulted and they recommended decreasing her steroids. She remained on steroids until she became CMO. . 3. AF: Not anticoagulated. Was on amio drip initially but pressures did not tolerate. She was switched to PRN metoprolol boluses. . 4. Wheezing/resp distress: Likely related to volume challenge since was not wheezing prior to fluid boluses and has know low EF. Was on supplemental O2 and had no futher shortness of breath. . 5. Goals of care: she was initially DNR/DNI and then refused aggressive and interventional measures. Her sepsis eventually led to shock and she passed away very comfortably with a few doses of morphine for her abdominal pain. | There is a paucity of gas in the ascending, descending colon and rectum. IMPRESSION: Abnormal appearance to midabdominal loops with relatively a featureless appearance. There is a left-sided PICC line with tip close to midline, not yet crossing to the superior vena cava. T waveinversions in leads V1-V2 of unclear significance. Generalized low QRS voltages. The aorta is mildly calcified. There are bilateral lower lobe infiltrates, left greater than right and a small left effusion. IMPRESSION: Worsening CHF. Consider presence ofpericardial effusion, hypothyroidism, large body habitus or diffusecardiomyopathy. There are few scattered air-fluid levels on the decubitus film. Given history of pancolitis this could represent the abnormal appearing transverse colon. The heart is upper limits normal in size. Sinus rhythm. Baseline artifact. FINDINGS: Supine portable and lateral decubitus films show a few gas-filled loops of relatively a featureless bowel in the mid abdomen measuring up to 5.1 cm. Compared to the study from earlier the same day, there is no significant interval change. No previous tracing available for comparison. FINDINGS: There are no old films available for comparison. REASON FOR THIS EXAMINATION: eval NGT placement FINAL REPORT CHEST ON HISTORY: Ulcerative colitis flare. There is no pneumothorax. An underlying infectious infiltrate cannot be excluded. No evidence of obstruction. HISTORY: Central line. REFERENCE EXAMINATION: at 3:30. REFERENCE EXAM: at 06:30. FINDINGS: Compared to the prior study, there has been some increase in the vascular plethora with ill-defined vasculature and bilateral effusions are slightly larger. 3:23 AM PORTABLE ABDOMEN Clip # Reason: please eval for free air, acute process Admitting Diagnosis: GASTROENTERITIS MEDICAL CONDITION: 81 year old woman with pancolitis, hypotension, sepsis REASON FOR THIS EXAMINATION: please eval for free air, acute process FINAL REPORT ABDOMEN FILMS ON HISTORY: Pancolitis, hypotension. 3:22 AM CHEST (PORTABLE AP) Clip # Reason: please eval placement Admitting Diagnosis: GASTROENTERITIS MEDICAL CONDITION: 81 year old woman with midline REASON FOR THIS EXAMINATION: please eval placement FINAL REPORT CHEST ON . 6:19 AM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # Reason: please eval for acute process Admitting Diagnosis: GASTROENTERITIS MEDICAL CONDITION: 81 year old woman with resp distress REASON FOR THIS EXAMINATION: please eval for acute process FINAL REPORT CHEST HISTORY: Respiratory distress. | 5 | [
{
"category": "Radiology",
"chartdate": "2156-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1176642,
"text": " 6:19 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval for acute process\n Admitting Diagnosis: GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with resp distress\n REASON FOR THIS EXAMINATION:\n please eval for acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Respiratory distress.\n\n REFERENCE EXAMINATION: at 3:30.\n\n FINDINGS: Compared to the prior study, there has been some increase in the\n vascular plethora with ill-defined vasculature and bilateral effusions are\n slightly larger.\n\n IMPRESSION: Worsening CHF. An underlying infectious infiltrate cannot be\n excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1176700,
"text": " 2:54 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval NGT placement\n Admitting Diagnosis: GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with UC here with UC flare and sepsis.\n REASON FOR THIS EXAMINATION:\n eval NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON \n\n HISTORY: Ulcerative colitis flare.\n\n REFERENCE EXAM: at 06:30.\n\n Compared to the study from earlier the same day, there is no significant\n interval change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-01 00:00:00.000",
"description": "PORTABLE ABDOMEN",
"row_id": 1176634,
"text": " 3:23 AM\n PORTABLE ABDOMEN Clip # \n Reason: please eval for free air, acute process\n Admitting Diagnosis: GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with pancolitis, hypotension, sepsis\n REASON FOR THIS EXAMINATION:\n please eval for free air, acute process\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN FILMS ON \n\n HISTORY: Pancolitis, hypotension.\n\n FINDINGS: Supine portable and lateral decubitus films show a few gas-filled\n loops of relatively a featureless bowel in the mid abdomen measuring up to 5.1\n cm. Given history of pancolitis this could represent the abnormal appearing\n transverse colon. There is a paucity of gas in the ascending, descending\n colon and rectum. There are few scattered air-fluid levels on the decubitus\n film.\n\n IMPRESSION: Abnormal appearance to midabdominal loops with relatively a\n featureless appearance. No evidence of obstruction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2156-02-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1176626,
"text": " 3:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval placement\n Admitting Diagnosis: GASTROENTERITIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 81 year old woman with midline\n REASON FOR THIS EXAMINATION:\n please eval placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST ON .\n\n HISTORY: Central line.\n\n FINDINGS: There are no old films available for comparison. The heart is\n upper limits normal in size. The aorta is mildly calcified. There are\n bilateral lower lobe infiltrates, left greater than right and a small left\n effusion. There is a left-sided PICC line with tip close to midline, not yet\n crossing to the superior vena cava. There is no pneumothorax.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2156-02-01 00:00:00.000",
"description": "Report",
"row_id": 165775,
"text": "Baseline artifact. Sinus rhythm. Generalized low QRS voltages. T wave\ninversions in leads V1-V2 of unclear significance. Consider presence of\npericardial effusion, hypothyroidism, large body habitus or diffuse\ncardiomyopathy. No previous tracing available for comparison.\n\n"
}
] |
56,996 | 114,004 | 67 yom with history of a.fib, on pradaxa, now presenting with worsening BRBPR and hematuria . # GI Bleed: Patient was monitored in the MICU overnight for GIB given pradaxa use. He remained normotensive throughout his MICU stay without drop in Hct. He was evaluated by GI who felt no urgent colonoscopy was needed, and symptoms were likely secondary hemorrhoidal and exacerbated by anticoagulation. He was transferred to the medical floor where he remained stable o/n. After discussion with Dr. the patient's out- patient cardiologist, given the fact that he has been in sinus for the better part of a year and has not flipped into AFIB he was d/c'd on full dose ASA with GI f/u scheduled. . # UTI: Patient was started on ciprofloxacin for UTI as evidenced by UA and dysuria. He was subsequently switched to cefpodoxime given concern for prolonged QTc in combination with amiodarone. Micro showed a sensitive E. Coli. . # Afib: Patient remained in sinus rhythm. Anticoagulation was initially held, then switched to ASA as above. | The visualized heart and pericardium are unremarkable. The seminal vesicles are unremarkable. retroperitoneal bleed FINAL REPORT (Cont) IMPRESSION: 1. The stomach, small bowel, colon, and rectum are unremarkable. Mild retrocardiac atelectasis. The ureters are unremarkable. The examination of the intra-abdominal organs is limited due to noncontrast technique. These may represent cysts, however, cannot be fully characterized on noncontrast CT scan. Hypodense lesions in each kidney likely represent cysts, however, not fully characterized on nonenhanced CT scan. Bilateral hypodense round lesions in kidneys, likely cysts but cannot fully characterize on non-contrast scan. There are moderate degenerative changes of lower thoracic and lumbar spine, most prominent at L3 through S1 with joint space narrowing and anterior and posterior osteophytes. The intra-abdominal vasculature is unremarkable; however, evaluation is limited due to lack of IV contrast. No retroperitoneal bleed. Given this limitation, the liver, pancreas, spleen and adrenal glands are unremarkable. Normal hilar and mediastinal contours. TECHNIQUE: MDCT images were obtained through the abdomen and pelvis without administration of contrast. No pleural effusions. FINDINGS: As compared to the previous radiograph, the signs indicative of volume overload have decreased but are still clearly present. The bladder wall is thickened and indistinct with some surrounding fat stranding indicating probable cystitis. Compared to prior, there is new central pulmonary vascular engorgement with mild cephalization of the pulmonary vasculature. IMPRESSION: Findings suggestive of mild pulmonary vascular congestion without frank pulmonary edema. There is no retroperitoneal hematoma. Sinus rhythm. There is no free fluid. retroperitoneal bleed CONTRAINDICATIONS for IV CONTRAST: WET READ: PRib WED 2:46 PM Bladder has thick walls with surrounding stranding, likely cystitis. No fractures or suspicious lytic or sclerotic lesions are identified. Thickened bladder wall with surrounding stranding potentially secondary to cystitis and correlation with UA suggested. COMPARISON: None available. There are no hernias identified. Enlarged prostate. Enlarged prostate. retroperitoneal bleed MEDICAL CONDITION: History: 67M with BRB PR, mild diffuse mild low left side pain, new renal failure REASON FOR THIS EXAMINATION: ? The appendix is not visualized; however, there is no evidence of appendicitis. There is a 4-cm round hypodense lesion in the superior pole of the right kidney. Cardiomediastinal silhouette is stable, as are the osseous and soft tissue structures. Coronal and sagittal reformations were performed. There is a 1.5-cm round hypodense lesion in the interpolar region of the left kidney. There is no confluent consolidation or effusion. There is no free air. Q-T interval prolongation. Clinical correlation is suggested. (Over) 1:37 PM CT ABD & PELVIS W/O CONTRAST Clip # Reason: ? 1:37 PM CT ABD & PELVIS W/O CONTRAST Clip # Reason: ? The prostate is enlarged. FINDINGS: The lung bases are clear. FINDINGS: Frontal and lateral views of the chest are compared to previous exam from . 4. COMPARISON: . 3. 2. Compared to the previous tracingof the T wave amplitude has increased while the QTc interval isprolonged. If desired US could help characterize. 11:19 AM CHEST (PA & LAT) Clip # Reason: pls eval ro infectious process MEDICAL CONDITION: History: 67M with hypotension REASON FOR THIS EXAMINATION: pls eval ro infectious process FINAL REPORT CHEST, TWO VIEWS: HISTORY: 67-year-old male with hypotension, rule out infectious process. 7:52 AM CHEST (PORTABLE AP) Clip # Reason: eval for vol overload Admitting Diagnosis: ACUTE RENAL FAILURE MEDICAL CONDITION: 67 year old man with concern for volume overload clinically REASON FOR THIS EXAMINATION: eval for vol overload FINAL REPORT CHEST RADIOGRAPH INDICATION: Volume overload, evaluation. | 4 | [
{
"category": "Radiology",
"chartdate": "2114-02-28 00:00:00.000",
"description": "CT ABD & PELVIS W/O CONTRAST",
"row_id": 1234640,
"text": " 1:37 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? retroperitoneal bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 67M with BRB PR, mild diffuse mild low left side pain, new renal\n failure\n REASON FOR THIS EXAMINATION:\n ? retroperitoneal bleed\n CONTRAINDICATIONS for IV CONTRAST:\n\n ______________________________________________________________________________\n WET READ: PRib WED 2:46 PM\n Bladder has thick walls with surrounding stranding, likely cystitis. No\n retroperitoneal bleed. Bilateral hypodense round lesions in kidneys, likely\n cysts but cannot fully characterize on non-contrast scan. Enlarged prostate.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 67-year-old male with bright red blood per rectum and left side\n pain and renal failure, question retroperitoneal bleed.\n\n TECHNIQUE: MDCT images were obtained through the abdomen and pelvis without\n administration of contrast. Coronal and sagittal reformations were performed.\n\n COMPARISON: None available.\n\n FINDINGS: The lung bases are clear. The visualized heart and pericardium are\n unremarkable.\n\n The examination of the intra-abdominal organs is limited due to noncontrast\n technique. Given this limitation, the liver, pancreas, spleen and adrenal\n glands are unremarkable. There is a 1.5-cm round hypodense lesion in the\n interpolar region of the left kidney. There is a 4-cm round hypodense lesion\n in the superior pole of the right kidney. These may represent cysts, however,\n cannot be fully characterized on noncontrast CT scan. The ureters are\n unremarkable. The bladder wall is thickened and indistinct with some\n surrounding fat stranding indicating probable cystitis. The prostate is\n enlarged. The seminal vesicles are unremarkable.\n\n\n The stomach, small bowel, colon, and rectum are unremarkable. The appendix is\n not visualized; however, there is no evidence of appendicitis. There is no\n free fluid. There is no free air. The intra-abdominal vasculature is\n unremarkable; however, evaluation is limited due to lack of IV contrast.\n There are no hernias identified.\n\n There are moderate degenerative changes of lower thoracic and lumbar spine,\n most prominent at L3 through S1 with joint space narrowing and anterior and\n posterior osteophytes. No fractures or suspicious lytic or sclerotic lesions\n are identified.\n\n (Over)\n\n 1:37 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: ? retroperitoneal bleed\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n IMPRESSION:\n 1. Thickened bladder wall with surrounding stranding potentially secondary to\n cystitis and correlation with UA suggested.\n\n 2. There is no retroperitoneal hematoma.\n\n 3. Hypodense lesions in each kidney likely represent cysts, however, not\n fully characterized on nonenhanced CT scan. If desired US could help\n characterize.\n\n 4. Enlarged prostate.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-02-28 00:00:00.000",
"description": "CHEST (PA & LAT)",
"row_id": 1234623,
"text": " 11:19 AM\n CHEST (PA & LAT) Clip # \n Reason: pls eval ro infectious process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 67M with hypotension\n REASON FOR THIS EXAMINATION:\n pls eval ro infectious process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS: \n\n HISTORY: 67-year-old male with hypotension, rule out infectious process.\n\n FINDINGS: Frontal and lateral views of the chest are compared to previous\n exam from . Compared to prior, there is new central pulmonary\n vascular engorgement with mild cephalization of the pulmonary vasculature.\n There is no confluent consolidation or effusion. Cardiomediastinal silhouette\n is stable, as are the osseous and soft tissue structures.\n\n IMPRESSION: Findings suggestive of mild pulmonary vascular congestion without\n frank pulmonary edema.\n\n"
},
{
"category": "Radiology",
"chartdate": "2114-03-01 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 1234745,
"text": " 7:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for vol overload\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with concern for volume overload clinically\n REASON FOR THIS EXAMINATION:\n eval for vol overload\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Volume overload, evaluation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the signs indicative of\n volume overload have decreased but are still clearly present. No pleural\n effusions. Mild retrocardiac atelectasis. Normal hilar and mediastinal\n contours.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2114-02-28 00:00:00.000",
"description": "Report",
"row_id": 112555,
"text": "Sinus rhythm. Q-T interval prolongation. Compared to the previous tracing\nof the T wave amplitude has increased while the QTc interval is\nprolonged. Clinical correlation is suggested.\n\n"
}
] |
18,556 | 117,069 | The patient was admitted to the Medical service for radiologic catheterization. This revealed a 70 to 80% distal left main with normal ejection fraction lesion. He was evaluated for a bypass graft. On , the patient underwent coronary artery bypass graft times two with left internal mammary artery to left anterior descending and saphenous vein graft to OM. He tolerated the procedure well and was transferred to the CSRU in intubated condition. He was extubated on postoperative day one. It was noted on postoperative day two that his creatinine had risen to 2.2 from a baseline of 1.6. Renal consultation was obtained, and the impression was a prerenal mild acute renal failure. He was started on a Dopamine infusion. On postoperative day three, he developed atrial fibrillation. He was started on Amiodarone. His creatinine continued to rise over the next day. On postoperative day four, his creatinine started trending down again. He continued to be in atrial fibrillation at this time. He was started on Heparin infusion for the atrial fibrillation. He was transferred to the floor on postoperative day five. At this point, he had converted back into normal sinus rhythm. His Heparin infusion was continued for some time. It was then discontinued. His pacing wires were discontinued on postoperative day six. He was ready for discharge on postoperative day seven in stable condition. He will be discharged home. | IMPRESSION: S/P CABG surgery noted. AWARE, EKG DONE AND PT. ID: Tmax 98.6, wbc 11.6, 1 more dose of vanco. Renal: BUN/Cr 29/2.2 (20/1.9). Given 2gm Ca gluconate for Ca 1.11. Extub held until rounds this AM. Heme: Hct 27.4, cts dcd. + BS THRU-OUT, CONT. ABG: 7.34 43 63. GOING INTO CONTROLLED RATE OF AFIB, HR 60-90'S, DR. s/p cabgs: "I'm feeling better"o: continues in af ventricular response 70-110's. SX FOR SCANT CLEAR SECRETIONS, BS CLEAR THRU OOUT, DIM IN BASES SLIGHTLY. NEW L PERIPH IV PLACED. U/O ALSO FALLING, TREATED WITH ADDITIONAL 1L NS WITH MINIMAL EFFECT. continues to diurese. AP BEDSIDE SUPINE CHEST: Recent CABG with sternal wire sutures and skin staples. IMPRESSION: Atelectatic and pleural changes left base. Tip of right IJ line is poorly visualized in mid SVC. ASSESSMENT:NEURO: A&OX3, MAE TO COMMANDS, C/O STERNAL DISCOMFORT MEDICATED WITH 2 PERCOCETS WITH GOOD EFFECT. BS CONT. HAS KNOWN RENAL STENOSIS AND BASELINE SYS B/P ~160'S. SYS B/P CONT. Pt alert and appropriate however ABGs borderline. SYS B/P CURRENTLY AT 150'S. Hypoxemic. S/P recent CABG surgery again noted. L RAD ALINE AND R IJ MULTILUMEN LINE INTACT.RESP: BS INITIALLY VERY COARSE IN BASES, AFTER RECEIVING PERCOCETS ABLE COUGH AND RAISE TAN SECREATIONS, O2 REMAINS ON AT 4L NP WITH SAT'S ~95%. Renal status worse.P: Cont to monitor closely. Sharp lateral right CP angle. Wt unchanged from (9>preop). TOLERATING REG DIET IN SM. ABG REMAINS UNCHAGED FROM PREVIOUS.GI/GU: HOURLY URINES >50CC OF CLEAR YELLOW WHILE ON DOPA GTT, REPEAT CRE LEVEL CONT. SYS B/P >145, N B/P CORRELATING. u/o 70-100cc/hr overnight. Comparison study dated . sbp 120's-140's. CV: BP up to 190/50, rx with SNP .4 to keep BP 150/40. PACER REMAINS ATTACHED BUT OFF.RESP: BS CONT. The left internal carotid is occluded. percocet 2 tabs x1 for incisional discomfort with good effect. Resp Care Note:Pt cont intub on mech vent as per Carevue. CURRENTLY REMAINS IN AFIB, PACER OFF D/T COMPETETING. CONDITION.PLAN: CONT. BY NOON SYS B/P >200, DOPAMINE OFF X1/HR AND PT. oob x 1. INITIALLY SYS B/P 120-140'S RANGE ON 3MCG/KG/MIN OF DOPAMINE. FOR CONSISTENT HR IN THE 50'S AND HYPOTENSION, GOOD CAPTURE WITH A WIRES, NEO GTT NEEDING TO BE TITRATED UPTO 2MCG/KG/MIN TO MAINTAIN SYS ~150'S. Nsg progress noteBP 140-170/ Hr 88-106 Afib. SHIFT UPDATE.PT. SHIFT UPDATE.PT. TO KEEP SYS >150'S WITH NEO GTT, MONITOR U/O CLOSELY. A right central venous line is in place with its tip at the junction of the superior vena cava and the right atrium. There is evidence of fairly marked cardiac enlargement, mainly left ventricular. The peak systolic velocities on the right common, internal and external carotid arteries are approximately 110, 134 and over 300 cm/second respectively. TO BE VERY LABILE BETWEEN 170-220, GIVEN ADDITIONAL 10MG IVP HYDRALAZINE, 2 PERCOCETS & DOPAMINE GTT DECREASED TO 1.5MCG/KG/MIN AT 1330PM. U/O APPROX 25-30CC/HR, PT WT UP 8.7KGGI: PT WIT POOR APPETITE- REQUESTING H20- WELL, ABD SODT, NON TENDER, BOWEL SOUNDS HYPOACTIVE.SKIN: SMALL REDDENNED AREA AT TOP OF PT STATED THAT IT WAS NOT NEW- THIS A "REGULAR" FOR HIM NO OTHER SKIN BREAK DOWN NOTED. Symmetric left ventricularhypertrophy with preserved systolic function and mild resting mid-cavitarygradient. PT APPEARS VERY COMF DESPITE ABG. RESP: PT SOMEWHAT ACIDOTIC ALL NOC 7.32 (AS LOW AS 7.29); WITH O2 73-75. incisions c+d. MOD CT DRG AT TIMES. GU: U/O MARGINAL ALL NOC. ?pericardial effusionHeight: (in) 71Weight (lb): 205BSA (m2): 2.13 m2BP (mm Hg): 202/55Status: InpatientDate/Time: at 13:34Test: Portable TTE(Complete)Doppler: Complete pulse and color flowContrast: NoneTechnical Quality: SuboptimalINTERPRETATION:Findings:LEFT ATRIUM: The left atrium is moderately dilated.RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.LEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy withnormal cavity size and systolic function (LVEF>55%). A mid-cavitary gradientis identified.RIGHT VENTRICLE: Right ventricular chamber size and free wall motion arenormal. GI: OGT-LCWS. LAB: ION CA RX'D. There is a small pericardial effusion. s/p cabgs: moaning-"I moan alot"o: cardiac: afib without vea, ventricular response 111-57,np aware and ? PER DR. . THUS EXTUB. PT UPDATE PT IS S/P CABG X2. hct 32. mag,k and calcium nl. CV: AF 50-110 (on dopa) on po amio load. + bowel sounds. There is paradoxic septal motion consistent with prior cardiacsurgery.AORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Retrocardiac density is unchanged. 1 episode of dry heaves none further. Therhythm appears to be atrial fibrillation.Conclusions:The left atrium is moderately dilated. Consider prior inferior myocardial infarction. UO 2-45/hr. pp palp. on zantac. A mild (peak 20mmHg) mid-cavitary resting gradient is identified.Right ventricular cavity size and systolic function are normal. CVP UP TO 12NOTE PT U/O IN OR 180CC ONLY WITH 2.3L OF CRYSTALOID GIVEN, POST OP HCT IN OR 24- IN 23--DR. No aorticregurgitation is seen.MITRAL VALVE: The mitral valve leaflets are mildly thickened. Finally settled and comfortable @ 2200 p pm care.CV-SBP 170-200 req Hydralazine 10 mg ivp x3 1300-1600. Nsg progress noteBP 150-170/ HR 90-108 afib. The right lateral costophrenic angle is excluded from the film. Multiple change of position w/ slight improvement. Dopa at 3. The aorticvalve leaflets (3) are mildly thickened but not stenotic. ID: Tmax 98.7, wbc 18 (11.6). BUN/Cr cont to rise 43/2.5 (38/2.3). PT. CVP 13-18. There is mild thickening of the mitral valvechordae. sbp 120's to 190 transiently decreases to 140's when @ rest. WANTS TO EXTUB. WANTS TUBE OUT; HAS REMAINED VERY CALM ALL NOC; DESPITE BEING INTUB. is q 2 hours with good effect.bs with expiratory wheeze bibasilar. WANTS TUBE OUT. AT ONE POINT SATS DOWN TO 92-93. Lung sounds decreased at bases L>R. ?attempt diuresis with rising BUN/Cr. There is no significant mitral stenosis.TRICUSPID VALVE: The tricuspid valve appears structurally normal with trivialtricuspid regurgitation. Heme: Blood as above, hct this am between units of blood=26.9. Neo 1-2.5 mcg to keep SBP>150. ALL DSG D&I. NEURO: PT IS CALM. Pt denies pain. DR. Atrial fibrillation with a controlled ventricular response. HELD OFF. Intraventricularconduction defect. 2UPC given, no lasix. Refused Percocet overnigth. cont on Dopamine at 3mcg/kg/min with u/o 80-90cc/hr. Thereare no echocardiographic signs of tamponade.IMPRESSION: Small circumferential pericardial effusion without evidence ofhemodynamic compromise. | 21 | [
{
"category": "Radiology",
"chartdate": "2111-06-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 760135,
"text": " 10:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p cabg with low p02\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with severe peripheral vascular disease with 80% left main\n disease to go to CABG\n REASON FOR THIS EXAMINATION:\n s/p cabg with low p02\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 61 year old man with severe peripheral vascular disease and coronary\n artery disease status post CABG with low oxygen sats.\n\n Portable AP upright chest at 10:40 PM: Comparison is made to prior\n study on at 8:43 PM. The patient is now post op. He is intubated. The\n tip of the ET tube is seen at the level of the medial ends of the clavicles.\n An NG tube is in place, the tip of which is not clearly seen but is below the\n level of the hemidiaphragms. A right central venous line is in place with its\n tip at the junction of the superior vena cava and the right atrium. Sternotomy\n wires, mediastinal tubes and left chest tube as well as an aortic balloon pump\n are in place. There are increased density of the left base most likely\n representing post op changes. No evidence of failure.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-06-12 00:00:00.000",
"description": "CAROTID SERIES COMPLETE",
"row_id": 760082,
"text": " 11:44 PM\n CAROTID SERIES COMPLETE Clip # \n Reason: Asses degree of stenosis on both carotids\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with CAD pre op for CABG\n REASON FOR THIS EXAMINATION:\n Asses degree of stenosis on both carotids\n ______________________________________________________________________________\n WET READ: JMBu SAT 12:06 AM\n Left ICA- 100 % (total occlusion)\n Right ICA- 1 - 39% (mild stenosis)\n Antegrade vertebral flow\n WET READ VERSION #1 JMBu FRI 11:56 PM\n Left ICA- 100 % (total occlusion)\n Right ICA- 40 - 59% (moderate stenosis)\n Antegrade vertebral flow\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Assess degree of stenosis in both carotids prior to CABG.\n\n FINDINGS: Pulsed Doppler and color flow studies were performed to evaluate\n the carotid vasculature bilaterally. The peak systolic velocities on the\n right common, internal and external carotid arteries are approximately 110,\n 134 and over 300 cm/second respectively. The left internal carotid is\n occluded. Flow velocities in the left common and external carotid arteries\n are approximately 68 and over 300 cm/second respectively. Antegrade flow is\n noted in both vertebral arteries.\n\n IMPRESSION: Total occlusion of left internal carotid artery. Mild degree of\n stenosis in the right internal carotid artery of less than 40%. Antegrade\n flow in both vertebral arteries.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-06-15 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 760225,
"text": " 6:52 PM\n CHEST (PORTABLE AP) Clip # \n Reason: INCREASED O2 REQUIREMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old male s/p CAB w/ hypoxia\n REASON FOR THIS EXAMINATION:\n INCREASED O2 REQUIREMENT\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: A single AP upright image is provided.\n\n Comparison study dated .\n\n There is evidence of fairly marked cardiac enlargement, mainly left\n ventricular. S/P recent CABG surgery again noted. The pulmonary vessels show\n no upper zone redistribution and do not indicate cardiac failure at this time.\n Patchy bibasilar atelectasis is noted, most marked in the left lower zone. No\n significant pleural effusions are identified.\n\n Compared with the previous examination the bibasilar atelectases appear\n slightly more extensive. No other significant change is seen.\n\n IMPRESSION: S/P CABG surgery noted. No evidence of cardiac failure.\n Bibasilar patchy atelectasis, particularly on the left side.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-06-16 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 760251,
"text": " 8:42 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old male s/p CAB w/ hypoxia\n REASON FOR THIS EXAMINATION:\n r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post CABG. Hypoxemic.\n\n AP BEDSIDE SUPINE CHEST: Recent CABG with sternal wire sutures and skin\n staples. There is atelectasis in the left lower lobe with associated pleural\n changes but I doubt the presence of consolidation. Right lung clear. Slight\n prominence of the mediastinum and cardiac silhouette are difficult to assess\n in this recumbent exam. No vascular congestion. Tip of right IJ line is\n poorly visualized in mid SVC. Sharp lateral right CP angle. Little change\n from exam one day previous.\n\n IMPRESSION: Atelectatic and pleural changes left base. No CHF, pneumonia or\n short interval change.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-14 00:00:00.000",
"description": "Report",
"row_id": 1506252,
"text": "Resp Care Note:\n\nPt cont intub on mech vent as per Carevue. Lung sounds coarse suct mod th yellow sput. Pt alert and appropriate however ABGs borderline. Extub held until rounds this AM. Plan to extub when ready.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-14 00:00:00.000",
"description": "Report",
"row_id": 1506253,
"text": "RESP WEAN\nD: PT ON CPAP WITH 5 IPS, 5 PEEP, WELL, PT APPEARS CALM COMFORTABLE, TV >500CC, ABG INTIALLY ACIDOTIC BUT IMPROVED. SX FOR SCANT CLEAR SECRETIONS, BS CLEAR THRU OOUT, DIM IN BASES SLIGHTLY. PT AWAKE, ABLE TO LIFT HEAD OFF BED, FOLLOWS COMMANDS\nA: PT \nR: PLACED ON 40% OPEN FM THEN TOO 4L PT ABG AFTER 1HR (PT WITH LARGE SMOKING HX- QUIT 18MON AGO)\nD: PT PERFORMING ONLY ABLE TO GET METER UP TO 700CC- PT MED FOR PAIN WITH PERCOCET- STATED HE WAS NOT IN PAIN. PTCOUGHING AND EVENTUALLY RAISIED THICJ TAN SECRETIONS IN MOD AMT- NO FURTHER SPUTUM PRODUCTION NOTED.\nA: ABG SENT THIS EVE-\nR: PO2 DOWN, PRIOR TO RETURN OF ABG RESULTS, PT SAT NOTED TO BE DOWN TO 91\nA: CPT DONE, DONE PT COUGHING BUT UNABLE TO RAISE SECRETION SAT REMAIN 90-91- INC NP TO 5L THEN TO 6L.\nR: SAT UP TO 93%\nD: UPON LISTENING TO PT NOTED TO HAVE CRACKLES THRU OUT-\nLASIC GIVEN 2 HOURS EARLIER WITH MIN RESPONSE. AT PT CONT ON NEO TO OBTAIN A SBP >150/--FELT DUE TO RENAL INSUFF AND PROLONGED H/O HYPERTENSION, PT KIDNEYS PROBABLY USE TO HIGHER PRESSURES- THUS INC BP RESULT IN INC U/O.\nR: U/O UP TO APPROX 20CC/HR\nQUESTIONED IF MD WOULD CONSIDER DOPAMINE RENAL- FOR INC RENAL PERFUSION, RATHER THAN NEO WITH ITS\"SQUUZING\" EFFECTS. PT HR 67-69 SR NO ECTOPY, CVP 10, BP 165/46 OFF NEO AT PRESENT.\nPLAN: MONITOR RESP.URINE STATUS CLOSELY.\n\nADDEM: PT MED WITH PERCOCET FOR INC PAIN, DOES NOT LIKE THE EFFECTS OF PERCOCET-- :DROWSY\" BUT AWARE HE NEED TO BE ABLE TO TAKE A DEEP BREATH.\n\nNEURO: WNL\nCARDIAC: HR 60'S SP, SBP 160/50 OFF NEO AT PRESENT.\nRESP : AS NOTED ABOVE\nGU: CREAT 1.9 TODAY, 2 DOSES LASIX 40MG GIVEN WITH MIN EFFECT. U/O APPROX 25-30CC/HR, PT WT UP 8.7KG\nGI: PT WIT POOR APPETITE- REQUESTING H20- WELL, ABD SODT, NON TENDER, BOWEL SOUNDS HYPOACTIVE.\nSKIN: SMALL REDDENNED AREA AT TOP OF PT STATED THAT IT WAS NOT NEW- THIS A \"REGULAR\" FOR HIM NO OTHER SKIN BREAK DOWN NOTED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-15 00:00:00.000",
"description": "Report",
"row_id": 1506254,
"text": " Progress Note\nS/O: Neuro: Comf with 2 percocet, slept in long naps.\n CV: BP up to 190/50, rx with SNP .4 to keep BP 150/40.\n Resp: 5L NP with RR 20s, strong prod cough. ABG: 7.34 43 63.\n Renal: BUN/Cr 29/2.2 (20/1.9). UO 25-60/hr. Wt unchanged from (9>preop).\n Heme: Hct 27.4, cts dcd.\n ID: Tmax 98.6, wbc 11.6, 1 more dose of vanco.\n GI: taking pos, on zantac.\n Endo: 4U IV insulin glu 161-135.\n Skin: Intact.\n Rehab: Moving well in bed.\nA: Small dose on SNP controls hypertension. Renal status worse.\nP: Cont to monitor closely. Advance activity as \n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-15 00:00:00.000",
"description": "Report",
"row_id": 1506255,
"text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: A&OX3, MAE TO COMMANDS, OOB TO CHAIR WITH ASSIST X1, VERY STEADY ON FEET. C/O STERNAL DISCOMFORT MEDICATED WITH 2 PERCOCETS WITH EXCELLENT RELIEF.\nCARDIAC: INITIALLY HR >90 WITH SYS B/P >150 VIA L RAD ALINE ON .4MCG/KG/MIN, TREATED WITH 12.5MG PO LOPRESSOR, HR FALLING TO 50'S AND SYS B/P DOWN TO 100, REQUIRING NEO GTT TO MAINTAIN SYS >150 FOR RENAL AND CEREBRAL PERFUSION. AS DAY PROGRESSING NEEDING PT. FOR CONSISTENT HR IN THE 50'S AND HYPOTENSION, GOOD CAPTURE WITH A WIRES, NEO GTT NEEDING TO BE TITRATED UPTO 2MCG/KG/MIN TO MAINTAIN SYS ~150'S. U/O ALSO FALLING, TREATED WITH ADDITIONAL 1L NS WITH MINIMAL EFFECT. ~1200PM PT. GOING INTO CONTROLLED RATE OF AFIB, HR 60-90'S, DR. AWARE, EKG DONE AND PT. STARTED ON AMIODARONE 400MG PO TID, NO IV BOLUS GIVEN. PT. CURRENTLY REMAINS IN AFIB, PACER OFF D/T COMPETETING. SYS B/P >145, N B/P CORRELATING. L RAD ALINE AND R IJ MULTILUMEN LINE INTACT.\nRESP: BS INITIALLY VERY COARSE IN BASES, AFTER RECEIVING PERCOCETS ABLE COUGH AND RAISE TAN SECREATIONS, O2 REMAINS ON AT 4L NP WITH SAT'S ~95%. POOR , DOES BETTER WITH COUGHING AND DEEP BREATHING.\nGI/GU: WITH HYPOTENSION U/O DROPPING TO <10CC FOR 3/HR'S, SLOWING MAKEING 25CC/HR WITH SYS B/P AROUND 150'S. PT. HAS KNOWN RENAL STENOSIS AND BASELINE SYS B/P ~160'S. + BS THRU-OUT, CONT. TO TREAT BS WITH S.S. INSULIN. TOLERATING REG DIET IN SM. AMT'S.\nSOCIAL: WIFE AND CHILDREN INTO VISIT, UPDATES GIVEN REGARDING PT. CONDITION.\nPLAN: CONT. TO KEEP SYS >150'S WITH NEO GTT, MONITOR U/O CLOSELY. TREAT ELECTROLYTES AS NEEDED. MONITOR NEURO STATUS.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-16 00:00:00.000",
"description": "Report",
"row_id": 1506258,
"text": "s/p cabg\ns: \"I'm feeling better\"\no: continues in af ventricular response 70-110's. no vea. sbp 120's-140's. continues to diurese. pulm toilet. oob x 1. 100ml liquid brown stool. open face tent @ 50 % 4lnp with o2 sats > 96%. percocet 2 tabs x1 for incisional discomfort with good effect. lopressor held np .\na: continues to diurese,loose brown stool.\np: monitor comfort, hr and rythym, sbp, i+O goal to keep i=o,labs, pulm toilet, as per orders.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-17 00:00:00.000",
"description": "Report",
"row_id": 1506259,
"text": " Nsg progress note\nBP 140-170/ Hr 88-106 Afib. Given 2gm Ca gluconate for Ca 1.11. Renal function improving with creat down to 1.6 today. u/o 70-100cc/hr overnight. Cont on renal range Dopamine.\nO2 sats 97-100%. Face tent d/c'd and pt kept on 4L nc with sats unchanged. Initial ABG with PO2 58 this morning (?O2 off just prior to ABG drawn) Repeat ABG 7.41/37/69. Pt coughing and deep breathing - cough productive for thick yellow secretions.\nPt given Percocet x2 overnight with good effect. Pt sleeping through most of night.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-17 00:00:00.000",
"description": "Report",
"row_id": 1506260,
"text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: A&OX3, MAE TO COMMANDS, C/O STERNAL DISCOMFORT MEDICATED WITH 2 PERCOCETS WITH GOOD EFFECT. OOB TO CHAIR X4/HR'S, AMBULATING IN HALLWAY WITH PT AND NSG, VERY STEADY ON FEET. PT. C/O FEELING \"VERY TIRED\" & \"LETHARGIC\".\nCARDIAC: REMAINS IN A-FIB THIS AM, HR 90-105. INITIALLY SYS B/P 120-140'S RANGE ON 3MCG/KG/MIN OF DOPAMINE. BY NOON SYS B/P >200, DOPAMINE OFF X1/HR AND PT. GIVEN 40MG IVP LASIX & 10MG IVP HYDRALAZINE. SYS B/P CONT. TO BE VERY LABILE BETWEEN 170-220, GIVEN ADDITIONAL 10MG IVP HYDRALAZINE, 2 PERCOCETS & DOPAMINE GTT DECREASED TO 1.5MCG/KG/MIN AT 1330PM. SYS B/P CURRENTLY AT 150'S. L RAD ALINE INTACT. NEW L PERIPH IV PLACED. PACER REMAINS ATTACHED BUT OFF.\nRESP: BS CONT. TO BE VERY DIMINISHED IN BILT. BASES. STRONG PRODUCTIVE COUGH. O2 REMAINS AT 5L NP WITH SAT'S >97%. ABG REMAINS UNCHAGED FROM PREVIOUS.\nGI/GU: HOURLY URINES >50CC OF CLEAR YELLOW WHILE ON DOPA GTT, REPEAT CRE LEVEL CONT. TO HOLD AT 1.5. + BS THRU-OUT, SEVERAL BOUTS OF LOOSE LIQUID STOOL, APPEPITITE REMAINS POOR, NEEDS LOTS OF ENCOURAGEMENT FOR EATING. BS CONT. TO BE TREATED WITH S.S. INSULIN.\nSOCIAL: BROTHER AND INTO VISIT, UPDATE GIVEN. CONT. TO MONITOR B/P CLOSELY AND TREAT IF SYS SUSTAINED OVER 180 WITH HYDRALAZINE, GOAL OF SYS B/P 140-180'S (NEEDED FOR RENAL STENOSIS AND PREVIOUS CVA).\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-17 00:00:00.000",
"description": "Report",
"row_id": 1506261,
"text": " Nursing Progress Note 3p-11p\n Neuro- A&O x3, , , ambulatory, OOB to chair/commode w/ minimal assist.Slightly restless/anxious, unable to get comfortable for most of evening after getting back to bed @ 1800. Multiple change of position w/ slight improvement. Finally settled and comfortable @ 2200 p pm care.\nCV-SBP 170-200 req Hydralazine 10 mg ivp x3 1300-1600. Lopressor ^ 25mg , 1st dose @1700 w/ good response of SBP 140-160, HR 80's afib.\nRenal- u/o 'd to 5cc/hr x2hr 1900- on Dopa @1.5 mcg/kg/min. MD aware @ ; ^ Dopa to 3mcg/kg/min w/ good response of 50-60cc/hr -2230.\nSocial- Visiting w/ wife and daughter today. Pt and family informed of present status and progress. Informed of probable transfer to floort .\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-13 00:00:00.000",
"description": "Report",
"row_id": 1506250,
"text": "update\nPT S/P CABG X 2- LIMA-LAD, SVG TO OM.\nD: PT TO ON PROPOFOL- ON AND OFF NTG DEPENDING ON SBP-\nNEURO: ONCE , PT FOLLOWING COMMANDS, MAE TO COMMAND, NODDING APPROP.-\nPLAN: ONCE AWAKE, WEAN TO EXTUBATE AS TOL.\n\nRESP: PT SMOKING HX SIGNIFICANT, QUIT 18MON AGO.- INITIAL ABG GOOD WEANED TO 50% THEN AFTER WATCHING SAT >99% WEANED TO FIO2 40%, BS INTIALLY COARSE BUT CLEARED WITH SX.\nPLAN: AS NOTED ABOVE, WEAN TO EXTUBATE--BE AWARE--SMOKING HX.\n\nCARDIAC: SR 70'S SR, A WIRES ONLY, MA 11 TO CAPTURE. NO ECTOPY NOTED.\n\nGI: NPO, OGT REPLACED- NOT IN PLACE UPON ADM TO - DRAINING CL SECRETIONS- CARAFATE GIVEN, ABD SOFT, ABSENT BOWEL SOUNDS\n\nGU: U/O APPROX 30CC/HR, CVP INITALLY 6, PT GIVEN REMAINING 50CC LR FROM OR THEN GIVEN ADDITIONAL LR 1000CC OVER NEXT HOUR. CVP UP TO 12\nNOTE PT U/O IN OR 180CC ONLY WITH 2.3L OF CRYSTALOID GIVEN, POST OP HCT IN OR 24- IN 23--DR. AWARE, AS IS DR .\n\nPLAN: WEAN TO EXTUBATE, MONIOTOR FLUID STATUS, FOLLOW FAST TRACK PROTOCOL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-14 00:00:00.000",
"description": "Report",
"row_id": 1506251,
"text": "PT UPDATE\n PT IS S/P CABG X2.\n\n NEURO: PT IS CALM. PROP OFF LAST EVE. PT DOZES WHEN LEFT ALONE; BUT AWAKENS AS SOON AS HE IS SPOKEN TO OR CARE DONE. VERY APPROPRIATE AND SEEMS TO UNDERSTAND ALL THAT IS SAID. FOLLOWS ALL COMMANDS. HAS REMAINED CALM THROUGHOUT NOC; DESPITE REMAINING INTUB. WANTS TUBE OUT.\n\n RESP: PT SOMEWHAT ACIDOTIC ALL NOC 7.32 (AS LOW AS 7.29); WITH O2 73-75. THUS EXTUB. HELD OFF. AT ONE POINT SATS DOWN TO 92-93. NOW BAKC UP TO 95. PT HAS REMAINED ON CPAP ALL NIGHT-APPEARS VERY COMF-PEEP UP TO 7.5. BUT GOOD TV AND RR MID 20'S. PT APPEARS VERY COMF DESPITE ABG. CXR DONE LAST NIGHT-O.K. PER DR. . AWAITING AM ROUNDS TO SEE IF PT CAN BE EXTUB.\n\n CARDIAC: HR 70'S ALL NIGHT. NO ECTOPY. PACER HAS REMAINED OFF. INITIALLY PT ON NTG; OFF LAST NIGHT, AS DR. THOUGHT HIGHER BP WOULD HELP U/O. CVP 13-16. PT HAS RECEIVED 2 PC. DOES NOT APPEAR TO BE DRY. PT ON NO GTTS ALL NIGHT.\n\n GU: U/O MARGINAL ALL NOC. MOST OF THE TIME 30/HR. DR. AWARE. U/O DID SEEM TO PICK UP AFTER RECEIVING PC AND WITH HIGHER BP.\n\n GI: OGT-LCWS.\n\n LAB: ION CA RX'D. DID NOT NEED K REPLACMEENT. HCT 24-RX WITH 2 PC. UP TO 28. BS 170-200- SS INSULIN COVERAGE.\n\n OTHER: PT SHAKES HIS HEAD HE HAS NO PAIN. HAS APPEARED TO GET REST DURING NIGHT. WANTS TUBE OUT; HAS REMAINED VERY CALM ALL NOC; DESPITE BEING INTUB. ALL DSG D&I. MOD CT DRG AT TIMES. WILL AWAIT AM ROUNDS TO SEE IF DR. WANTS TO EXTUB. PT. OTHERWISE VERY STABLE NIGHT.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-16 00:00:00.000",
"description": "Report",
"row_id": 1506256,
"text": " Progress Note\nS/O: Neuro: Comf with percocet q 4-6 hrs. Slept well.\n CV: AF 50-110 (on dopa) on po amio load. Neo 1-2.5 mcg to keep SBP>150. Dopa at 3. CVP 13-18.\n Resp: RR 14-18, strong cough. Exp wheezes clear with cough/albuterol inhaler. Now on 70% face mask and 6lnp with sao2 96%. Last abg on 40% face mask and 6lnp: 7.27 45 68.\n Renal: Wt up 4.5 kg (12>preop). UO 2-45/hr. BUN/Cr cont to rise 43/2.5 (38/2.3). K 4.8. 2UPC given, no lasix.\n Heme: Blood as above, hct this am between units of blood=26.9.\n ID: Tmax 98.7, wbc 18 (11.6).\n GI: taking pos. on zantac.\n Endo: No insulin required.\n Skin: Intact.\nA: Worsening renal failure causing met acidosis and marginal oxygenation (also hx smoking).\nP: Cont to monitor closely. ?attempt diuresis with rising BUN/Cr.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-16 00:00:00.000",
"description": "Report",
"row_id": 1506257,
"text": "s/p cabg\ns: moaning-\"I moan alot\"\no: cardiac: afib without vea, ventricular response 111-57,np aware and ? next dose of po lopressor and amiodarone to discuss on rounds. sbp 120's to 190 transiently decreases to 140's when @ rest. incisions c+d. pp palp. temp 97.8-96.5 pt denies being cold. hct 32. mag,k and calcium nl. rij dlc dc'd and tip sent for culture.\n resp: presently on 50 % open face mask and 4 l np with o2 sats >97%. rr 13-20. c+r green thick sputum sent for c+s. is q 2 hours with good effect.bs with expiratory wheeze bibasilar.\n neuro: sleepy easily arousable, oriented x 3, mae, following commands, pleasant, perl.\n gi: refusing solids requesting fluids , pt reminded of fluid restriction. + bowel sounds. 1 episode of dry heaves none further.\n gu: marginal uo, recieved 40 mg ivp lasix with good diuresis >120 ml/hr. 12 noon k 4.7\n endo: glucose 146 has not recieved any sliding scale insulin this shift.\n id: wbc 18,blood cultures via aline and rij sent, rij tip sent for c+s. sputum sent for c+s, urine also sent fo c+s.\n pain: recieved 1 percocet @ 1230 , pt got oob with assist of 2 tolerated well, 1345 requested another percocet which he recieved with better relief of inciisional discomfort.\n skin: buttock crease very red and tender, area cleansed .\na: beginning to diurese, ventricular response decreasing,cultured, c+r thick green sputum,\np: monitor comfort, hr and np to reevalute lopressor and amiodarone, sbp, pp, incisions, resp status-pulm toilet, neuro status, i+o-uo dopa continues @ 3 mcq, labs, as per orders.\n"
},
{
"category": "Nursing/other",
"chartdate": "2111-06-18 00:00:00.000",
"description": "Report",
"row_id": 1506262,
"text": " Nsg progress note\nBP 150-170/ HR 90-108 afib. K+ 3.8 this morning, KCl given. cont on Dopamine at 3mcg/kg/min with u/o 80-90cc/hr. Pt denies pain. Refused Percocet overnigth. Lung sounds decreased at bases L>R. Pt coughting and deep breathing. O2 sats 96-99% on 2L NC.\n"
},
{
"category": "Echo",
"chartdate": "2111-06-17 00:00:00.000",
"description": "Report",
"row_id": 71519,
"text": "PATIENT/TEST INFORMATION:\nIndication: H/O cardiac surgery with recent CABG. ?pericardial effusion\nHeight: (in) 71\nWeight (lb): 205\nBSA (m2): 2.13 m2\nBP (mm Hg): 202/55\nStatus: Inpatient\nDate/Time: at 13:34\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is moderately dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and systolic function (LVEF>55%). A mid-cavitary gradient\nis identified.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal. There is paradoxic septal motion consistent with prior cardiac\nsurgery.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. A mitral valve\nannuloplasty ring is present. There is mild thickening of the mitral valve\nchordae. There is no significant mitral stenosis.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. The pulmonary artery systolic pressure could not be\ndetermined.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. The\nrhythm appears to be atrial fibrillation.\n\nConclusions:\nThe left atrium is moderately dilated. There is mild symmetric left\nventricular hypertrophy with normal cavity size and systolic function\n(LVEF>55%). A mild (peak 20mmHg) mid-cavitary resting gradient is identified.\nRight ventricular cavity size and systolic function are normal. The aortic\nvalve leaflets (3) are mildly thickened but not stenotic. No aortic\nregurgitation is seen. The mitral valve leaflets are mildly thickened. A\nmitral valve annuloplasty ring is present. The pulmonary artery systolic\npressure could not be determined. There is a small pericardial effusion. There\nare no echocardiographic signs of tamponade.\n\nIMPRESSION: Small circumferential pericardial effusion without evidence of\nhemodynamic compromise. Aortic sclerosis. Symmetric left ventricular\nhypertrophy with preserved systolic function and mild resting mid-cavitary\ngradient.\n\n\n"
},
{
"category": "ECG",
"chartdate": "2111-06-15 00:00:00.000",
"description": "Report",
"row_id": 175965,
"text": "Atrial fibrillation with a controlled ventricular response. Intraventricular\nconduction defect. Consider prior inferior myocardial infarction. T wave\ninversions in leads I, aVL and V4-V6 may be due to underlying atrial\nfibrillation or myocardial ischemic process. No previous tracing available for\ncomparison. Clinical correlation is suggested.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-06-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 760078,
"text": " 8:46 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pre-op\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with severe peripheral vascular disease with 80% left main\n disease to go to CABG\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative evaluation for coronary artery bypass.\n\n PORTABLE CHEST: An upright view obtained at 8:43 P.M. shows a normal heart\n size. There is no pulmonary vasculature congestion. The lungs are clear, and\n there is no pleural effusion. The right lateral costophrenic angle is\n excluded from the film. The skeletal structures are unremarkable.\n\n There are no prior studies available for comparison.\n\n IMPRESSION: No CHF or pneumonia.\n\n"
},
{
"category": "Radiology",
"chartdate": "2111-06-14 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 760188,
"text": " 9:22 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p chest tube removal\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with severe peripheral vascular disease with 80% left main\n disease to go to CABG\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 61 y/o man with severe peripheral vascular disease, S/P chest\n tube removal.\n\n AP UPRIGHT PORTABLE CHEST AT 9:40 P.M.: Since prior study on , the\n left chest tube has been removed. No evidence of pneumothorax. Retrocardiac\n density is unchanged. Patchy opacity at the right base may represent\n atelectasis or infiltrate.\n\n"
}
] |
22,085 | 182,828 | Admitted on pre-operatively, taken to OR on day of admission. Underwent CABG X 5 (please see operative report for details of surgical procedure) Required phenylephrine & vasopressin post-op for hypotension. These were weaned off by POD # 2, and he was transferred from the ICU in stable condition. His epicardial wires were removed on POD # 4. He has progressed with physical therapy, and has remained hemodynamically stable, and is ready for discharge home on . | Cont on neo & vasopressin gtts. labile BP in csru.neuro: now off propofol. bld tinge ogt dng. titrate neo. Pt on vasopressin and neo gtts. good min volume.gi/gu: lg amt uop. csru adm/updates/p cabg x5. ROS:Neuro: A+O x's 3. C&DB. Now weaning down neo. reversals given.cv: refer to flowsheet for vs. BP labile. PERRLA. PERRLA. EXTREMITIES W/D; AFEBRILE. Chest tubes as noted above.GI: Abd soft w/hypo BS. Current ABG: 7.37/42/298/25. Once tolerating neo off attempt to wean vasopressin gtt. perl. Resp CarePt from OR intubated s/p CABG. CVP 8-15. a-line dampened, removed NP .Resp: NC 4L. Sternal, mediastinal, and left leg drsgs CDI. tol wean fio2 to .4. presently on cpap + ips. booklet given.assess: labile bp post-op cabg x 5.plan: wean to extubation. Generalized edema.Resp: O2 NP, sats 95% or >. on off neo/ntg though mostly neosynephrine dependent. BUN 13, CREATININE 0.8. ABD SOFT, NT, ND. Monitor, tx, support, and comfort. Steady gait.CV: NSR-ST 90-105. Nursing 7a-3pNeuro: A&Ox3. hct upon arrival to csru 31.resp: lungs clear. MAE x's 4. Pulm toilet. Mobilize, OOB. insulin gtt per protocol. HCT STABLE=28.RESP: LS CLR, BASES DIM; O2SATS 92-95% ON 3L NC, RESP RATE 20S-30S; GOOD COUGH, BUT PT NEEDS ENCOURAGEMENT; USES I.S. BP marginally low even w/titrating neo ^. Several fluid bolus given w/minimal effect on BP. CVP 11->20 F/U bs cont >200. 3 units PRBCs ordered. 3 units PRBCs ordered. IM TORADOL GIVEN FOR INCISIONAL PAIN W/GOOD EFFECT; +PERRL.CV: ST LOW 100s INITIALLY TO SR 90S; PACER OFF, A-WIRES DO NOT S/C APPROPRIATELY, V-WIRES S/C APPROP-SEE CAREVUE FOR THRESHOLDS; K REPLETED; BP STABLE 90S-120S, PALPABLE PERIPHERAL PULSES. Lytes repleated. No impaired skin.Gi: Tol reg diet. MAE. Plan is to continue weaning to extubate. Mostly for line management. Lungs cta, dim in bases.Endo: Blood sugars increased. MSO4 IV and PO dilaudid for pain mngt w/good effect.CV: RSR/ST w/o ectopy. Afternoon bs >200, tx per CSRU riss protocol. abd soft. NA 143. RR: 22-30 HR:103 Sa02 96%. Tol thin liquids. Sats >93%. NP aware. Initially asked that meds be crushed. o2 sats 97-100%. No resp distress noted, = rise and fall of chest. Pulmonary toileting. Increase diet & act as tol. OOB to chair w/2 assist. Suctioned prior to extubation for scant white sectretions.Plan: Monitor respiratory status. Insulin gtt started.Skin: See carevue for incisions. nods to questions asked. k+ repleted.social: wife in and updated. Addendum: Nursing Progress Note:Assumed care at 1600. Lungs clear. +BS, NO BM. However swallowing meds whole fine in afternoon.Gu: Min-adequate HUO.Pain: PO dilaudid w/good effect.Social: Family into visit, updated by RN.Plan: Wean neo to off as tol to keep map >60. HUO CLR YELLOW, DIURESED UP TO 450cc/HR. Uses IS weakly to 500 w/encouragement. Current vent settings are: SIMV 600 X 12 60% 5/5. nsr to st. A & V wires present and functioning. cvp mid teens after 3L crystalloid. NO C/O NAUSEA. Weaning neo to keep map >60, unable to wean off. Has 2 mediastinal and 1 pleural chest tubes Y connected together and to 20 cm sx draing sang fluid. Noaortic regurgitation is seen. Mild (1+) MR.TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets withphysiologic PR.PERICARDIUM: No pericardial effusion.GENERAL COMMENTS: A TEE was performed in the location listed above. The ascending, transverse and descending thoracic aorta arenormal in diameter and free of atherosclerotic plaque. IMPRESSION: Stable postoperative chest. No AR.MITRAL VALVE: Mildly thickened mitral valve leaflets. Atelectasis and pleural effusion at the left base are unchanged. No ASD by 2D or colorDoppler.LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function(LVEF>55%).RIGHT VENTRICLE: Normal RV chamber size and free wall motion.AORTA: Normal ascending, transverse and descending thoracic aorta with noatherosclerotic plaque.AORTIC VALVE: Mildly thickened aortic valve leaflets (3). There is no pericardial effusion.POST-BypASS:preserved biventricular systolic function. Three right-sided chest tubes and a right IJ central venous catheter are unchanged in position. Small left apical pneumothorax. No spontaneous echo contrast or thrombus in theLA/LAA or the RA/RAA.RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Rule out pneumothorax. PATIENT/TEST INFORMATION:Indication: Coronary artery disease.Weight (lb): 180BP (mm Hg): 120/70HR (bpm): 72Status: InpatientDate/Time: at 14:38Test: TEE (Complete)Doppler: Full Doppler and color DopplerContrast: NoneTechnical Quality: AdequateINTERPRETATION:Findings:LEFT ATRIUM: Normal LA size. Wean neo as BP tolerates. Right jugular CV line is in right atrium, unchanged since prior films. There is normal postoperative widening of the mediastinum. Patient reports hx of low lung capacity.GI: Abd soft w/active bs. The mitral valve leaflets are mildly thickened.Mild (1+) mitral regurgitation is seen. There is a small left apical pneumothorax. Postoperative appearance of the mediastinum is stable. Has two mediastinal and one pleural chest tube Y connected together draining serosang fluid and connected to 20 cm sx.Resp: Lungs clear and diminished in bases. There are low lung volumes, with retrocardiac atelectasis. IMPRESSION: Right jugular CV line in right atrium. PERRLA.CV: ST/RSR w/o ectopy. The remainder of the chest radiograph is stable. Compared to theprevious tracing of no significant diagnostic change. Left leg drsg and /steri strips, ACE wrap reapplied. Fluid bolus also given for hypotension and Low HUO w/minimal effect. The aortic valveleaflets (3) are mildly thickened but aortic stenosis is not present. Peripheral pulses palpable w/ease. Two mediastinal drains and a left-sided chest tube is present. A right IJ central venous catheter has been placed with tip in the expected location of the atrial caval junction. Portable AP chest radiograph compared to . Non-specific inferolateral ST-T wave changes. Heart size and mediastinal width are unchanged when compared with a prior film of the same date. Right ventricular chamber size and free wallmotion are normal. Sternal and mediastinal drsg . Three left-sided chest tubes are present. Neuro: A+O x's 3. Status post-CABG. There are low lung volumes with no evidence of consolidation. Has RIJ cath w/distal port transduced for CVP = 10 to 16/18 after fluid bolus. Sinus rhythm. FINDINGS: Compared to prior radiograph obtained on , patient is status post CABG procedure with a median sternotomy. | 22 | [
{
"category": "Nursing/other",
"chartdate": "2118-01-13 00:00:00.000",
"description": "Report",
"row_id": 1552025,
"text": "Endo: Insulin gtt resumed d/t rapidly rising FSGsLabs: K, Ca+, and Mag all repleted this AM\n\nHeme: Hct 21.6 after recheck from 21.4, down from yesterday's of 31. 3 units PRBCs ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-13 00:00:00.000",
"description": "Report",
"row_id": 1552026,
"text": "NEURO: Alert, awake, oriented x3, transfer from bed to chair and vice versa with 2 person assist, incisional pain treated with recurring Toradol IM with good effect, Pt states pain free.\n\nRESP: Wean O2 to 2L via NC, Sats in 97%, lung sounds clear at apicals/dim at bases, Pt able to cough/deep breath and uses IS, also states that \"his lungs are not that good\" resp in 30s and reg/unlabored\n\nCV: NSR with HRs in 80-90s, keep MAP >60, wean off Vasopressin, given 3 units of PRBCs for a Hct of 21, post-transfusion Hct was 29, with improved BP and O2 Sats, pacer is off (tested As and not sensing/capturing appropiately, did not test Vs), pedal pulses palpable\n\nGI/GU: Pt on diet with good appetite, Pt tolerates PO meds, has large, formed stool today; Foley draining yellow-amber/clear urine, urine outputs slowly diminished to 20-30cc/hr but responds well to recurring Lasix\n\nENDO: Started on daily Glyburide and Lantus 20units today with SSRI\n\nSOCIAL: Wife and children visited throughout the afternoon.\n\nPLAN: Continue to monitor resp, hemodynamics, urine output, LABS, deline trauma line and start PIV, increase activity as tolerated, ? transfer to floor tomorrow\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-14 00:00:00.000",
"description": "Report",
"row_id": 1552027,
"text": "NEURO: PT IS A&OX3-APPROPRIATE; SLEPT ON/OFF OVERNIGHT; MAES EQUALLY TO COMMAND-NO DEFICITS, THOUGH RELUCTANT TO MOVE. IM TORADOL GIVEN FOR INCISIONAL PAIN W/GOOD EFFECT; +PERRL.\n\nCV: ST LOW 100s INITIALLY TO SR 90S; PACER OFF, A-WIRES DO NOT S/C APPROPRIATELY, V-WIRES S/C APPROP-SEE CAREVUE FOR THRESHOLDS; K REPLETED; BP STABLE 90S-120S, PALPABLE PERIPHERAL PULSES. EXTREMITIES W/D; AFEBRILE. HCT STABLE=28.\n\nRESP: LS CLR, BASES DIM; O2SATS 92-95% ON 3L NC, RESP RATE 20S-30S; GOOD COUGH, BUT PT NEEDS ENCOURAGEMENT; USES I.S. UP TO 750.\n\nGI/GU/ENDO: PT SAYS TOLERATED SM AMTS OF FOOD PREVIOUS SHIFT, H20 W/PO MEDS TOL OVERNIGHT. NO C/O NAUSEA. +BS, NO BM. ABD SOFT, NT, ND. HUO CLR YELLOW, DIURESED UP TO 450cc/HR. BUN 13, CREATININE 0.8. NA 143. BS MONITORED PER CSRU SS, REQUIRED RSSI COVERAGE X1 THIS SHIFT, PT STARTED ON GLYBURIDE & GLARGINE PREVIOUS SHIFT.\n\nSOCIAL: NO PHONE CALLS FROM FAMILY THIS SHIFT.\n\nPLAN: CONTINUE MONITORING CARDIORESP STATUS; MONITOR LABS, PULM TOILET, INCREASE ACTIVITY & PO INTAKE AS TOLERATED; TRANSFER TO 2.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-12 00:00:00.000",
"description": "Report",
"row_id": 1552019,
"text": "Nursing 7a-3p\nNeuro: A&Ox3. PERRLA. MAE. OOB to chair w/2 assist. Mostly for line management. Steady gait.\nCV: NSR-ST 90-105. No ectopy. Lytes repleated. Cont on neo & vasopressin gtts. Weaning neo to keep map >60, unable to wean off. NP aware. CVP 8-15. a-line dampened, removed NP .\nResp: NC 4L. Sats >93%. Uses IS weakly to 500 w/encouragement. C&DB. No sputum. Lungs cta, dim in bases.\nEndo: Blood sugars increased. Afternoon bs >200, tx per CSRU riss protocol. F/U bs cont >200. Insulin gtt started.\nSkin: See carevue for incisions. No impaired skin.\nGi: Tol reg diet. Eating sm amts. Tol thin liquids. Initially asked that meds be crushed. However swallowing meds whole fine in afternoon.\nGu: Min-adequate HUO.\nPain: PO dilaudid w/good effect.\nSocial: Family into visit, updated by RN.\nPlan: Wean neo to off as tol to keep map >60. Once tolerating neo off attempt to wean vasopressin gtt. Monitor blood sugars, wean insulin. Pulm toilet. Increase diet & act as tol.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-12 00:00:00.000",
"description": "Report",
"row_id": 1552020,
"text": "Addendum: Nursing Progress Note:\nAssumed care at 1600. Pt on vasopressin and neo gtts. Insulin gtt restarted for glucose >250.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-13 00:00:00.000",
"description": "Report",
"row_id": 1552021,
"text": "Endo: Insulin gtt resumed d/t rapidly rising FSGsLabs: K, Ca+, and Mag all repleted this AM\n\nHeme: Hct 21.6 after recheck from 21.4, down from yesterday's of 31. 3 units PRBCs ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-11 00:00:00.000",
"description": "Report",
"row_id": 1552013,
"text": "Resp Care\nPt from OR intubated s/p CABG. Current vent settings are: SIMV 600 X 12 60% 5/5. Current ABG: 7.37/42/298/25. Plan is to continue weaning to extubate. No other changes noted.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-11 00:00:00.000",
"description": "Report",
"row_id": 1552014,
"text": "csru adm/update\ns/p cabg x5. labile BP in csru.\n\nneuro: now off propofol. alert and following commands. mae in bed. nods to questions asked. perl. reversals given.\n\ncv: refer to flowsheet for vs. BP labile. on off neo/ntg though mostly neosynephrine dependent. nsr to st. A & V wires present and functioning. cvp mid teens after 3L crystalloid. hct upon arrival to csru 31.\n\nresp: lungs clear. o2 sats 97-100%. tol wean fio2 to .4. presently on cpap + ips. good min volume.\n\ngi/gu: lg amt uop. abd soft. bld tinge ogt dng. insulin gtt per protocol. k+ repleted.\n\nsocial: wife in and updated. booklet given.\n\nassess: labile bp post-op cabg x 5.\n\nplan: wean to extubation. monitor bp,labs, cvp closely. titrate neo.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-11 00:00:00.000",
"description": "Report",
"row_id": 1552015,
"text": "Respiratory care:\nPatient extubated to a 4 l NC without incident. Voice strong. RR: 22-30 HR:103 Sa02 96%. Suctioned prior to extubation for scant white sectretions.\nPlan: Monitor respiratory status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-12 00:00:00.000",
"description": "Report",
"row_id": 1552016,
"text": "CVP 11->20\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-12 00:00:00.000",
"description": "Report",
"row_id": 1552017,
"text": "ROS:\n\nNeuro: A+O x's 3. MAE x's 4. PERRLA. MSO4 IV and PO dilaudid for pain mngt w/good effect.\n\nCV: RSR/ST w/o ectopy. BP marginally low even w/titrating neo ^. Several fluid bolus given w/minimal effect on BP. Vasopresson 2.4 units hr initiated and albumin 5% given w/good effects on BP. Now weaning down neo. Sternal, mediastinal, and left leg drsgs CDI. Has 2 mediastinal and 1 pleural chest tubes Y connected together and to 20 cm sx draing sang fluid. Has 2 A and 2 V epicardial pacing wires, sense and capt not checked d/t ^ HR. Generalized edema.\n\nResp: O2 NP, sats 95% or >. Lungs clear. No resp distress noted, = rise and fall of chest. Chest tubes as noted above.\n\nGI: Abd soft w/hypo BS. Taking sips of clear liquids. No c/o N/V. H2 blocker to start this Am for GI prophylaxis.\n\nGU: foley patent draining clear yellow urine in QS.\n\nEndo: Insulin gtt converted to SQ RSSI\n\nLabs: Stable and WNL\n\nsocial: No contact from family or friends this 8 hr shift.\n\nPlan: Wean neo as BP allows. Pulmonary toileting. Mobilize, OOB. Monitor, tx, support, and comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-12 00:00:00.000",
"description": "Report",
"row_id": 1552018,
"text": "CVP 11->20\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-13 00:00:00.000",
"description": "Report",
"row_id": 1552022,
"text": "Neuro: A+O x's 3. MAE x's 4 ='ly. Pain mngt w/IM ketorolac w/good effect. PERRLA.\n\nCV: ST/RSR w/o ectopy. On vasopresson 2.4 units/hr and neo which has been titrated to maintain MAP > 60. Fluid bolus also given for hypotension and Low HUO w/minimal effect. Peripheral pulses palpable w/ease. Has RIJ cath w/distal port transduced for CVP = 10 to 16/18 after fluid bolus. Sternal and mediastinal drsg . Left leg drsg and /steri strips, ACE wrap reapplied. Has 2 A and 2 V epicardial pacing wires, A wires do not sense but do capture. V wires sense and capture. Has two mediastinal and one pleural chest tube Y connected together draining serosang fluid and connected to 20 cm sx.\n\nResp: Lungs clear and diminished in bases. O2 4L NP. Sats 92-95%. Does fair w/deep breathing and poor w/IS and coughing. Patient reports hx of low lung capacity.\n\nGI: Abd soft w/active bs. Taking po's w/o complaints of N/V. H2 blocker for GI prophylaxis.\n\nGU: Foley patent draining dark yellow -> amber cloudy w/sediment in marginal amt even after fluid bolus. UA obtained.\n\nEndo: Insulin gtt off. SQ RSSI for glucose control\n\nLabs: Pending at time of this note.\n\nSocial: Wife phoned at HS for update.\n\nPlan: Mobilize, OOB to chair. Pulmonary toileting. Wean neo as BP tolerates. Ketorolac IM for pain mngt ATC. Resmume home po antihyperglycemics??? Monitor, tx, support, and comfort.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-13 00:00:00.000",
"description": "Report",
"row_id": 1552023,
"text": "Endo: Insulin gtt resumed d/t rapidly rising FSGsLabs: K, Ca+, and Mag all repleted this AM\n\nHeme: Hct 21.6 after recheck from 21.4, down from yesterday's of 31. 3 units PRBCs ordered.\n"
},
{
"category": "Nursing/other",
"chartdate": "2118-01-13 00:00:00.000",
"description": "Report",
"row_id": 1552024,
"text": "Endo: Insulin gtt resumed d/t rapidly rising FSGsLabs: K, Ca+, and Mag all repleted this AM\n\nHeme: Hct 21.6 after recheck from 21.4, down from yesterday's of 31. 3 units PRBCs ordered.\n"
},
{
"category": "Echo",
"chartdate": "2118-01-11 00:00:00.000",
"description": "Report",
"row_id": 82426,
"text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nWeight (lb): 180\nBP (mm Hg): 120/70\nHR (bpm): 72\nStatus: Inpatient\nDate/Time: at 14:38\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 or thrombus in the\nLA/LAA or the RA/RAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending, transverse and descending thoracic aorta with no\natherosclerotic plaque.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nPRE-BYPASS:\nThe left atrium is normal in size. No spontaneous echo contrast or thrombus is\nseen in the body of the left atrium/left atrial appendage or the body of the\nright atrium/right atrial appendage. No atrial septal defect is seen by 2D or\ncolor Doppler. Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Right ventricular chamber size and free wall\nmotion are normal. The ascending, transverse and descending thoracic aorta are\nnormal in diameter and free of atherosclerotic plaque. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. There is no pericardial effusion.\nPOST-BypASS:\npreserved biventricular systolic function. Overall LVEF 55%.\nMild MR>\nAortic contour is preserved.\nTrace TR\n\n\n"
},
{
"category": "ECG",
"chartdate": "2118-01-11 00:00:00.000",
"description": "Report",
"row_id": 208537,
"text": "Sinus rhythm. Non-specific inferolateral ST-T wave changes. Compared to the\nprevious tracing of no significant diagnostic change.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-01-11 00:00:00.000",
"description": "CHEST PORT. LINE PLACEMENT",
"row_id": 939696,
"text": " 5:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: postop film\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p cabg\n REASON FOR THIS EXAMINATION:\n postop film\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 60-year-old male status post CABG. Postoperative film.\n\n COMPARISON: .\n\n TECHNIQUE: Portable chest radiograph.\n\n FINDINGS: Compared to prior radiograph obtained on , patient\n is status post CABG procedure with a median sternotomy. ET tube is seen\n terminating approximately 3.8 cm above the carina. A right IJ central venous\n catheter has been placed with tip in the expected location of the atrial caval\n junction. Tip of the NG tube is in the expected region of the fundus of the\n stomach. Two mediastinal drains and a left-sided chest tube is present. No\n pneumothorax is apparent. There are low lung volumes, with retrocardiac\n atelectasis. No pleural effusions is seen. There is normal postoperative\n widening of the mediastinum.\n\n IMPRESSION: Stable postoperative chest.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-01-12 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 939741,
"text": " 3:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p CABG w/hypotension-r/o PTX\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p cabg\n\n REASON FOR THIS EXAMINATION:\n s/p CABG w/hypotension-r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient after CABG.\n\n Portable AP chest radiograph compared to .\n\n No obvious change. No evidence of pneumothorax is present. No\n consolidations, pulmonary edema, or pneumomediastinum is demonstrated.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-01-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 939991,
"text": " 2:42 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess effusion/infiltrates/chf\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p cabg hct drop\n\n REASON FOR THIS EXAMINATION:\n assess effusion/infiltrates/chf\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of CABG and hematocrit drop.\n\n Status post-CABG. Right jugular CV line is in right atrium, unchanged since\n prior films. Three left-sided chest tubes are present. There is a small left\n apical pneumothorax. Heart size and mediastinal width are unchanged when\n compared with a prior film of the same date. There is atelectasis at the left\n lung base.\n\n IMPRESSION: Right jugular CV line in right atrium. Small left apical\n pneumothorax.\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-01-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 939881,
"text": " 7:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for effusions/infiltrates\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p cabg\n\n REASON FOR THIS EXAMINATION:\n assess for effusions/infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old post CABG.\n\n Portable semi-upright frontal radiograph compared to and 13, .\n\n The lung volumes are reduced. Atelectasis and pleural effusion at the left\n base are unchanged. Pulmonary vascularity is normal. Three right-sided chest\n tubes and a right IJ central venous catheter are unchanged in position.\n Postoperative appearance of the mediastinum is stable.\n\n IMPRESSION: No change compared to one day earlier.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2118-01-13 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 940014,
"text": " 5:05 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: r/o ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man s/p cabg and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man status post CABG and CT removal. Rule out\n pneumothorax.\n\n COMPARISON: Two hours prior.\n\n There has been removal of three left-sided chest tubes. There is no evidence\n of pneumothorax. There are low lung volumes with no evidence of\n consolidation. The remainder of the chest radiograph is stable.\n\n IMPRESSION:\n\n No evidence of pneumothorax.\n\n"
}
] |
7,784 | 118,746 | Impression: 70 yo f w/ h/o ESLD and grade I varices who p/w weakness, LE edema, and anemia. . 1) anemia- felt likely slow GIB given guiac + stool. Egd showed gastritis and grade I varices, and GI consult felt this was the explanation for the patient's hct drop. H. pylori negative. The patient was transfused 2U PRBC, and her hct remained stable throughout her hospital course. She should have a f/u EGD which is already scheduled with Dr. in . She was also started on iron supplementation and protonix. . 2) thrombocytopenia- likely liver dz +/- splenomegaly. Seemed unlikely to be related to med effect and there was no evidence of ongoing infection. Also could be related to acute etoh effect (particularly given elevated AST). Very low suspicion for diffuse marrow process or malignancy. Platelets remained stable and were actually trending up during this hospital course. . 3) ischemia - mild troponin and ecg changes c/w low grade ischemia. No evidence of ACS. Ecg changes resolved w/ support of her hct. . 4) copd- no pfts on record but exam on HD3 and 4 c/w flair and patient has significant smoking history. started on nebs and completed a 5d course of steroids. On transfer to the floor, the patient had clear lungs and did not require O2, nebs or endorse SOB. Discharged patient on combivent inhaler. . 5) esld- initially held lasix/aldactone while in house and this was then resumed. She was also given lactulose for hepatic encephalopathy which was d/c'd when her mental status cleared. She was started back on lasix/aldactone at home dose on but became hypernatremic so subsequently held again. We restarted these medications on discharge and patient should have her electrolytes rechecked within the next week at rehab. She was also started on thiamine and folate. . 6) encephalopathy- likely esld and etoh w/d. Head ct performed given that pt had recent fall and it was negative for ICH. She was treated w/ 3d iv thiamine for possible Wernicke's. Mental status changes resolved w/ aggressive lactulose and clearing of benzodiazepenes. We stopped lactulose when patient's mental status cleared and her NH4 was normal. On discharge, she was at her mental status baseline. . 7) etoh w/d with DTs- req'd extremely large doses of ativan (chosen over valium due to impaired liver fxn), on HD 2 the patient req'd 60 mg ativan througout the day. Titrated off over the subsequent 6 days. On transfer to floor on , patient has not req'd any ativan and was in the clear in terms of ETOH withdrawl. Patient is to be discharged to rehab center. We had a family meeting and discussed all the issues and patient wants treatment for alcoholism and will be discharged to Rehab. . 8) ppx- maintained on pneumoboots given thrombocytopenia initially, then sub q heparin. ppi | K repleated in AM w/ 60mEq, INR 1.6.Resp: remains on 4L NC, rr 19-28, o2sat 92-98, LS coarse upper diminished lower. NS IV bolus or additional x1 IV lasix for decreased UO.ID: Temp 97.0-98.4, WBC 17 (up from 9, md's aware). MICU 7 RN Note 0700-1900Events: Hypernatremia Free H20 bolus, Speech eval, ^PTT, CIWA monitoring.Neuro: Awake lethargic, voice slurred with noted improved level of orientation. recieved lactalose encephalopathyCV: HR 78-90 NSR no ectopy, BP 112-140/40-60. Lactulose continues.GU: Foley to gravity with marginal output, HO aware - no intervention at this time.Endo: No RISSSkin: Stage I pressure area on coccyx/buttocks. Na 153 Free H20 repeat Na trending down.Heme: Hct 31.8 trending down from previous days, Ptt 90 INR 1.7 Heparin SQ d/cResp: RR 22-26 Reg O2 3L/Min NC Sats 95-97% Lungs clear Dim @ bases.ID: low grade temp 100, WBC 10.9, Abx Flagyl/vancoGI/liver: Ads soft distended + BS +stool Mushroom cath in place. Respiratory Care: Pt seen for albuterol and atrovent nebs today. Patient on albuterolQ6 PRN,Atrovent Q6.last Rx done @ 18 0clock.Hard to understand patient,BS diminished without wheezes.Being treated prophylactically for SOB. Hemodynamically stable.Resp: Remains on 3L NC, RR 15-30, O2sat 89-100, LS coarse upper and crackles lower. npn micu 7 westallergies: SulfaFull CodeNeuro: pt is minimally arousable, opens eyes to speech, pupils 3mm brisk, speech is garbled and slurred, pt. CIWA scale 5-10 recieved Ativan 1mg x3 and Haldol 1mg x2. tp has stroung/productive cough, but swallow back.cv: HR 90-116, NSR/ST, no ectopy. CLAMPED WITH BILIOUS DRNG, HEME-. CXR DONE THIS MORNING.GI/GU: ABD SOFT WITH +BS. LACTULOSE AS ORDERED, HELD AM DOSE AS SHE WAS STOOLING.CARDIAC: HR 88-105 SR/ST WITH RARE PVC'S. Wean O2 to maintain sats>95%.Cv: 1 left peripheral/right single lumen PICC placed today in IR, LE edema present, UE bruising/ edematous, HR 90-100 NS-ST, no ectopy, pulses palpable in all four extremeties. PICC with KVO IVF.Resp: Switched to 3LNC, maintains SPO2 high 90's. PT WITH LOW GRADE TEMP OF 99.6 PO. LS coarse to clear with occas ins wheezing. INR 1.7, PTT and PT slightly elevated as well, Hep dose changed to and DIC labs sent, but mostly likely caused by impaired liver function.Resp: started shift on 4L NC, mouth has been very dry and sat's were lower, changed to cool neb @ 40% for moisture and increased o2, tolerating well. Treating w/ standing dose ativan 1mg Q4H and Haldol 0.5-1mg PRN (low dose for liver issues MD). PLEASE SEE CAREVIEW FOR CIWA SCALE.CV: PT IN NSR WHEN ASLEEP BUT WHEN AWAKE HR UP TO THE 120'S. 1900-0700 rn notes micuneuro: in the beggining shift pt very lethargic, minimal withdraw to sternal rub, minimal attempt to open eyes and move in the bed, MD aware, dose of Ativam held, stopped Ativan 1mg q4hr, change Halodol PRN 0.5mg q4hr. RECEIVING LACTULOSE FOR ESLD.CARDIAC: HR 78-91 SR WITH NO ECTOPY. MD AWARE AND DECREASED ATIVAN TO 3MG Q2HRS. d/c'd rectal . Right pleural effusion is incompletely assessed. Single-lumen PICC to R brachial is patent and WNL. Since the previous tracing of minimal slowing ofthe heart rate is seen. ON LEVOFLOX.SKIN: W/D/I. FINDINGS: There is a new small left pleural effusion. COMPARISON: Radiograph dated . A right pleural effusion is incompletely evaluated on this study. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided PICC line placement via the right brachial vein with the tip positioned in SVC. LYTES PER CAREVUE. now w/ new hypoxemia and coarse breath sounds REASON FOR THIS EXAMINATION: eval for pulm edema or pna FINAL REPORT CHEST, SINGLE VIEW, ON HISTORY: New hypoxemia and coarse breath sounds. Since the previous tracing of the heart rate isfaster. Afebrile.GI: Pt. More centrally, there is considerable peribronchial opacification in a region that previously showed abnormality. now w/ new oxygen requirement. MICU NPN 7P-7ANEURO: INITIALLY PATIENT DIFFICULT TO AROUSE. MEDS CHANGED TO IV/SC AS ALLOWED.ID: TMAX 99.4 WITH WBC 11.2. oriented to person, place, and time but when left alone has d/c'd rectal , NGT, and takes off 02. There continues to be mild cardiomegaly. IMPRESSION: Mild penetration which cleared during the swallow. Most likely, this findings are due to CHF. CONTINUE TO TREAT DT'S. As demonstrated on , there is reversal of flow in the main, right, and left portal veins as well as superior mesenteric vein. now w/ PNA and O2 requirement REASON FOR THIS EXAMINATION: eval for improvement FINAL REPORT INDICATION: Pneumonia and decreased oxygen requirement. Normal flow and appropriate waveforms are demonstrated in the main, left, and right hepatic arteries. now w/ PNA and O2 requirement REASON FOR THIS EXAMINATION: interval change FINAL REPORT CHEST RADIOGRAPH. OCCASIONAL CONGESTED NONPRODUCTIVE COUGH.GI/GU: ABD SOFT WITH +BS. HCT @ 24.9, GIVEN 1UPRBC'S WITH AM HCT 32.3. Able to take lactulose po. WHEN CALM LS CLEAR WITH DIMINISHED LEFT BASE. Lungs are clear, bases are diminished at times. Nursing Progress Note:Pt. Nursing Progress Note:Pt. 9:32 AM LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # DUPLEX DOPP ABD/PEL Reason: assess ascites, mark for tap, ? Sinus rhythm, rate 98. IMPRESSION: AP chest compared to and : Heart size is top normal. BP 98-150/45-80. Significant interval improvement of the multifocal pneumonia. can have thickened liquids until further eval of swallow is performed (pt. | 32 | [
{
"category": "Nursing/other",
"chartdate": "2127-08-25 00:00:00.000",
"description": "Report",
"row_id": 1366523,
"text": "npn micu 7 west\nallergies: Sulfa\nFull Code\n\nNeuro: pt is minimally arousable, opens eyes to speech, pupils 3mm brisk, speech is garbled and slurred, pt. lethargic and sleeping most of day, ativan 4mg q 2hrs for DTs.\n\nResp: 3L NC, LS clear, CXR + pNA/r pleural effusion for which she is receiving abx flagyl and ceftriaxone, O2 sats>95%. Wean O2 to maintain sats>95%.\n\nCv: 1 left peripheral/right single lumen PICC placed today in IR, LE edema present, UE bruising/ edematous, HR 90-100 NS-ST, no ectopy, pulses palpable in all four extremeties. IV fluid D5W @ 30cc/hr. Of note: past ECHO normal.\n\ngu\r: foley output >30cc/hr, standing Lasix 40mg IV and Spirolactone PO for end stage liver failure.\n\ngi: Please start TF after midnight via NG, NG patent & clamped, 50 cc residual yellow bile, BS present, last BM (black stool), abd neg for ascites, Lactulose given for encephalopathy. Endoscopy on showed grade 1+2 varices/gastritis, NG lavage negative.\n\nid: T=96.8, WBC 9.3, urine sent, Flagl/Cef for pNA, PO prednisone for possible COPD\n\nsocial: daughter visited today, she was very helpful and supportive of her mother\n\nplan: Start TF, advance as tolerated\n Cont Ativan 4mg IV for DT\n Monitor mental status\n Cont Lactulose\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-26 00:00:00.000",
"description": "Report",
"row_id": 1366524,
"text": "MICU NPN 7P-7A\nNEURO: INITIALLY SEDATED AND DIFFICULT TO AROUSE. DID OPEN EYES TO VOICE BUT ONLY MAKING SOUNDS. MD AWARE AND DECREASED ATIVAN TO 3MG Q2HRS. A BIT MORE RESTLESS AS NIGHT WORE ON TRYING TO PICK SELF UP. THIS MORNING MORE AWAKE WITH EYES OPEN. STATED NAME AND WAS ABLE TO SAY THAT SHE WAS IN A HOSPITAL. FOLLOWED SIMPLE COMMANDS. MOVING ALL EXTREMITIES. RESTRAINED FOR SAFETY. LACTULOSE AS ORDERED, HELD AM DOSE AS SHE WAS STOOLING.\n\nCARDIAC: HR 88-105 SR/ST WITH RARE PVC'S. BP 105-128/49-66. HCT STABLE @32.6. PPP.\n\nRESP: ON 3L N/C WITH RR 15-24 AND SATS 95-100%. LS COARSE WITH DIMINISHED BASES, BUT THIS MORNING WITH A FEW FINE CRACKLES BIBASILAR. FREQUENT CONGESTED PRODUCTIVE COUGH BUT SWALLOWING. CXR FROM SHOWED MULTIFOCAL PNA BUT NO EFFUSIONS. NO SIGNS OD SOB, NEBS AND STEROIDS AS ORDERED.\n\nGI/GU: ABD SOFT WITH +BS. MED LOOSE BLACK TO BROWN STOOL X2. NGT IN PLACE AND PATENT. MARGINAL UOP 15-30CC/HR, 250CC FLUID BOLUS WITH SLIGHT INREASE IN OUTPUT. AMBER AND CLEAR.\n\nFEN: D5W D/C'D. FEEDS STARTED, GOAL 40CC/HR, MODERATE RESIDUALS. LYTES PER CAREVUE. RECEIVED 60MEQ KCL LAST NOC FOR K+ 3.4, NOW 4.1.\n\nID: TMAX 98.4 WITH JUMP IN WBC FROM 9.3 TO 17. CONTINUES ON FLAGYL AND CEFTRIAXONE FOR PNA COVERAGE. NGTD ON CX'S.\n\nSKIN: W/D/I, SEVERAL ECCHYMOTIC AREAS ON ARMS.\n\nACCESS: PIV X1, RIGHT BRACHIAL PICC.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY. CONTINUE TO TITRAE DOWN DOSAGE OF ATIVAN TO BETTER ASSESS MS. FEEDS AS TOLERATED.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-26 00:00:00.000",
"description": "Report",
"row_id": 1366525,
"text": "Nursing Progress Note 0700-1900\n*Full Code\n\n*Access: 2 PIV's (R and L)\n\n*Allergies: Sulfa\n\nNeuro: Pt agitated at times, trying to lift self in bed, putting legs over railings, pulling at restraints. Treating w/ standing dose ativan 1mg Q4H and Haldol 0.5-1mg PRN (low dose for liver issues MD). not be enough for her as behavior continues, however VS remain stable at this time. Follows commands infrequently, insensible words, unable to assess orientation, PERRL 3mm/, (moving in bed).\n\nCardiac: NSR/ST w/o ectopy, HR 93-108, SBP 124-140, Hct stable @ 32.6. Hemodynamically stable.\n\nResp: Remains on 3L NC, RR 15-30, O2sat 89-100, LS coarse upper and crackles lower. CXR shows slightly worsened bilateral infiltrates slightly worse on right than left. Lasix changed from IV to PO QD to remove fluid and help increase Urine output as well. Also ? aspiration aspect to this picture (not new, but prior to hospitalization).\n\nGI/GU: TF @ 30cc increased after residual 10cc, was 110 this AM so did not advance TF til this afternoon (goal 40cc/hr, advance if tolerating). +BS, med stool brown, loose this AM, cont lactulose for goal 3 stools per day. Urine out foley yellow/amber and clear, 40-1100cc/hr w/ higher doses following 20mg IV Lasix, no PO. ? NS IV bolus or additional x1 IV lasix for decreased UO.\n\nID: Temp 97.0-98.4, WBC 17 (up from 9, md's aware). Cont flagyl and ceftriaxone. IV sites wnl.\n\nPsychosocial: Husband visited today, updated on POC and current condition by MD's. Daughter visited later and also updated on POC and condition and ICU environment. Sister also called and told by unit coordinator it would be best to contact her husband or daughter for updates.\n\nDispo: cont to monitor mental status, treat agitation w/ ativan and haldol, cont to monitor resp status, cont med regimen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-27 00:00:00.000",
"description": "Report",
"row_id": 1366526,
"text": "1900-0700 rn notes micu\n\nneuro: in the beggining shift pt very lethargic, minimal withdraw to sternal rub, minimal attempt to open eyes and move in the bed, MD aware, dose of Ativam held, stopped Ativan 1mg q4hr, change Halodol PRN 0.5mg q4hr. overnight became more responsive, opens eyes half way, trying to lift self in the bed, moving all extremeties in the bed, but does not follow commands, incomp sounds, unable to assess orientation.\n\nresp: receievd on NC 3L, pt deast to 90-91%,O2 up to 4L, given nebs for wheezing. LS coarse to clear with occas ins wheezing. tp has stroung/productive cough, but swallow back.\n\ncv: HR 90-116, NSR/ST, no ectopy. SBP 113-135/60-70's. HCT 33.9\n\ngi/gu: foley in place, pr received fluid bolus NS 250ccx2 for u/o 2-17cc/hr with good response. ABD soft/dist, BS +. cont , pt start passing liquid brown stool, mushroom cath placed. cont TF at goal 40cc/hr residual 10-40cc.\n\nid: tmax 99.8 rectal, cont ABX.\n\nsocial: full code, no conatct from family.\n\nplan: cont monitoring neuro/mental status\n repleted lytes as needed.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-24 00:00:00.000",
"description": "Report",
"row_id": 1366520,
"text": "Respiratory Care: Pt seen for albuterol and atrovent nebs today. Pt's breath sounds coarse/wheezes, diminished aeration. Suctioned x 1 by Rt for moderate thick white secretions, pt tolerated well. will continue to monitor.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-24 00:00:00.000",
"description": "Report",
"row_id": 1366521,
"text": "Micu nursing note \n\nNeuro, pt very restless at 7 am hr 115 ST, pt all over bed, had removed both Iv's\nhands remains in soft restraints, on ciwa scale recieveing ativan q2 hr throught the day, pt had # 22 placed in L hand, pt given iv ativan q1 hr for the first 3hrs, also at the time pt wheezy, with crackles in bases and tacky. pt given resp tx and 20 lasix Iv, pt had good response of 800 plus over 2 hrs, and sounds much better this afternoon\nresp o2^ 4L with sob, and throught day have been able to drop o2 back to 3l sats 100%, previously to getting lasix sats 90-93%, lungs now deminished in bases but no crackles, pt also suctioned for lg amount of secreation nasal/orally x2 now pt much clearer. chest xray also thanken this am with ^ sob, showed some failer ? pneumonia,pt also febrile at that time to 101, pt started back on cefriaxone, and flagly\ncv Pt had a short peried of dropping bp in high 80's sbp after lasix, not treated at that time and bp returned to now BP 90-104/50-60\nGi pt still npo, but ngt dropped in order to give oral meds, pt asperates hem pos, pt also having smearing of stool which is also heme pos,\n pt has foley passing clear yellow urine, started on lasix and sparolactone today.\nId tmax 101.0 this am started anitbiotics, cultures pending\nheme 32.7\nskin intact\nsocial husband in this afternoon\nIV pt has # 22 in hand will consult iv therapy for ? picc placement.\nA/P Continue with ativan as ordered, pul toilet suction prn, follow up on cultures\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-25 00:00:00.000",
"description": "Report",
"row_id": 1366522,
"text": "MICU NPN 7P-7A\nNEURO: RESTLESS AT BEGINNING OF SHIFT BUT SETTLED DOWN. PERIODS OF RESTLESSNESS AND SLIGHT AGITATION THROUGHOUT THE SHIFT. CONTINUES ON ATIVAN 5MG Q2HRS WITH EFFECT. INITIALLY AROUSABLE TO STIMULI (MOUTHCARE, SXTING), WAS RAISING EYEBROWS BUT NOT OPENING EYES AND MAKING A FEW INCOMPREHENSIBLE SOUNDS. NOT FOLL0WING COMMANDS BUT CONTINUED TO MOVE ALL EXTREMITIES. TOWARDS THE AM WAKING UP A LITTLE, OPENING EYES AND INCONSISTENTLY FOLLOWING COMMANDS. ABLE TO STATE NAME BUT NOT BALE TO ANSWER ORIENTATION QUESTIONS. REMAINS RESTRAINED FOR SAFETY. RECEIVING LACTULOSE FOR ESLD.\n\nCARDIAC: HR 78-91 SR WITH NO ECTOPY. BP 98-157/41-62. HCT STABLE @32.6. UNABLE TO TEST STOOL FOR HEME, THOUGH IT WAS BLACK. PPP.\n\nRESP: RECEIVED ON 3L N/C AND INITIALLY WITH RESTLESSNESS SPONTANEOUSLY DESATTED TO 88%. INCREASED TO 5L AND AS PATIENT SETTLED DOWN HER SATS RETURNED TO UPPER 90'S. RR 14-34 WITH SATS 88-100%. LS WITH EXP WHEEZES TO CLEAR WITH A FEW FINE CRACKLES IN RIGHT BASE. NOTED RIGHT PLEURAL EFFUSION ON U/S. NEBS AND STEROIDS AS ORDERED. OCCASIONAL CONGESTED NONPRODUCTIVE COUGH. CXR DONE THIS MORNING.\n\nGI/GU: ABD SOFT WITH +BS. SMEARS OF BLACK LOOSE STOOL. NGT IN PLACE AND PATENT. CLAMPED WITH BILIOUS DRNG, HEME-. UOP 30-110CC/HR AMBER AND CLEAR.\n\nFEN: D5W @30CC/HR. NO EDEMA. -1.1L LOS. ON LASIX AND SPIRONOLACTONE. LYTES PER CAREVUE. NPO FOR NOW.\n\nID: TMAX 96.8 WITH WBC 9.3. ON FLAGYL AND CEFTRIAXONE FOR EMPIRIC ASPIRATION PNA COVERAGE. NGTD ON CX'S.\n\nSKIN: W/D/I.\n\nACCESS: PIV X1.\n\nSOCIAL/DISPO: FULL CODE. PLAN TO GO TO IR TODAY FOR PICC PLACEMENT. CONTINUE ATIVAN AS NEEDED FOR DT'S.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-27 00:00:00.000",
"description": "Report",
"row_id": 1366527,
"text": "Nursing Progress Note 0700-1900\n*Full Code\n\n*Access: 2 PIV's R and L arms\n\n*Allergies: Sulfa\n\nNeuro: remains difficult to orient, garbled speech, able to say year is but difficult to understand, reorient frequently. Moving around in bed, MAE, PERRL 3mm/, says \"no\" when asked if uncomfortable. No haldol or ativan given this shift. Slowly more , MD's feel she is not clearing lg doses of ativan that were given in previous days for withdrawl d/t decreased liver function.\n\nCardiac: NSR w/o ectopy, HR 100-111, SBP 112-153. Hct stable @ 33.9. K repleated in AM w/ 60mEq, INR 1.6.\n\nResp: remains on 4L NC, rr 19-28, o2sat 92-98, LS coarse upper diminished lower. Cough occassionally, appears to be productive and swallows. CXR today slightly improved but still abnormal compared to yesterday MD's.\n\nGI/GU: TF (promote w/fiber)@ goal 55cc/hr, stop for residual >100. +BS, brown liquid stool out mushroom cath. Urine out foley 20-690cc/hr w/ larger amts following PO lasix 20mg, now DC'd. PRN bolus for decreased U/O. FS 109.\n\nID: Temp 97.7-98.3, WBC 12.0. ?aspiration as source of PNA. Cont ceftriaxone, flagyl. IV sites wnl.\n\nPsychosocial: Daughter called this AM updated on status and , husband visited also updated.\n\nDispo: Cont to monitor mental status, cont lactulose, cont to hold sedatives if VS stable, monitor I&O request bolus for decreased U/O, cont med regimen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-27 00:00:00.000",
"description": "Report",
"row_id": 1366528,
"text": "Patient on albuterolQ6 PRN,Atrovent Q6.last Rx done @ 18 0clock.Hard to understand patient,BS diminished without wheezes.Being treated prophylactically for SOB.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-28 00:00:00.000",
"description": "Report",
"row_id": 1366529,
"text": "micu npn 1900-0700\nPlease see carevue flowsheet for all objective data\n\nPatient continues to be agitated and restless through the night. bilateral soft wrist restraints present, also this am, hand mitts added after pt self d/c'd her mushroom catheter x2. opens eyes, shaky and agitated for the most part. Occ follows commands, does not participate in talking or answering questions unless she is angry and yelling. received 2 doses of ativan 2mg w/o much effect. HR has been 1teens-120this am. bp 1teens-140's sys. Pt did not receive ativan during the day yesterday. Pt remains on 4l nasal cannula, sats 92-97%. l/s diminished/coarse. She has lots of dry oral secretions requiring frequent mouth care.\n feeds remain at goal, toelrating well. held overnight as pt put out >500cc last evening. uop remains marginal but adequate, no bolus' given overnight.\npt's daughter calling for update at beginning of shift.\n\nPlan to cont to follow mental status, keep pt safe. asses for s+s of bleeding, follow temp curve/wbc, fluid status. Ativan prn for s+s of withdrawal.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-28 00:00:00.000",
"description": "Report",
"row_id": 1366530,
"text": "Resp Care\n\nPt followed by respiratory for bronchodilator tx Q6. Currently wearing 40% cool aerosol with spo2 in the mid to upper 90s. BS essentially clear with no changes noted post treatment therapy. Pt needs some encouragement keeping mask on at times. Alb/atro given x2 via aerosol mask. Will cont to follow as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-28 00:00:00.000",
"description": "Report",
"row_id": 1366531,
"text": "Nursing Progress Note 0700-1900\n*Full Code\n\n*Access: R PICC, L PIV\n\n*Allergies: Sulfa\n\nNeuro: agitated this AM, HR 140's, SBP 150's, hanging over bedside, was given 4 mg Ativan in previous shift w/ poor effect, this nurse gave 1mg haldol w/ good effect, Pt stable most of the day but difficult to arouse at times; may want to try 0.5mg if additional sedation is required. At this time, still moving around in the bed, asking to go outside, wants to get out of bed, wants a plum, want milk, and at this point still not oriented. No complaints or signs of pain, PERRL 3mm / . MD's feel she may still be having some withdrawl symptoms even though she is 7 days in hospital.\n\nCardiac: NSR/ST w/o ectopy, HR 92-125, SBP 108-155. Hct stable @ 36.3, no s/s of bleeding. INR 1.7, PTT and PT slightly elevated as well, Hep dose changed to and DIC labs sent, but mostly likely caused by impaired liver function.\n\nResp: started shift on 4L NC, mouth has been very dry and sat's were lower, changed to cool neb @ 40% for moisture and increased o2, tolerating well. O2sat 90-98%, rr 15-22, LS clear upper and coarse lower, no cxr today though yesterdays showed some improvement but still abnormal (PNA).\n\nGI/GU: TF @ goal 55cc/hr w/ residual 30cc, stop TF if >100. FWB 250cc thru NGT Q6H for Na 148 this AM. +BS, stool through mushroom cath brown/liquid, 250cc then bag emptied, cont lactulose TID. Urine out foley amber/clear 20-40cc/hr, 500cc NS bolus x2 this shift to try and increase UO, no significant change in output.\n\nID: Temp 97.4Ax - 98.6oral, WBC 13.2. Ceftriaxone to be dc'd tomorrow which will be 7th day. Continue flagyl.\n\nPsychosocial: Husband() and Daughter (), both called this AM and updated on condition and . PCP also visited this afternoon, visits everyday he said.\n\nDispo: cont to monitor mental status (attempt lesser doses of haldol such as 0.5mg if necessary), monitor UO, cont lactulose and awaiting DIC labs, cont med regimen.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-29 00:00:00.000",
"description": "Report",
"row_id": 1366532,
"text": "MICU Nursing 19-07\nNeuro: Gradually more awake through course of night. A&Ox3 at latest, however not appropriately interactive and does not answer many questions correctly beyond basic orientation exam. Frequently calling out, yelling, etc. Gave 0.5mg haldol IM once with no effect.\n\nPain: Denies, and appears comfortable. Screams out with any movement in bed.\n\nCV: Sinus rhythm rate 91-112 BP 118-140/46-69 Palpable pulses in all extremities. HR elevated when more alert. P-boots on, sc heparin. PICC with KVO IVF.\n\nResp: Switched to 3LNC, maintains SPO2 high 90's. Desat's to low 90's on room air. Nebs q6 as ordered. Lungs are clear, diminished bibasilar with upper airway congestion. Swallows sputum.\n\nGI: Abdomen soft, non-tender. TF at goal, minimal residuals. Flushed as ordered. Mushroom cath with lg amounts of brown liquid stool. Lactulose continues.\n\nGU: Foley to gravity with marginal output, HO aware - no intervention at this time.\n\nEndo: No RISS\n\nSkin: Stage I pressure area on coccyx/buttocks. Turned and positioned frequently, barrier cream applied liberally.\n\nID: Tmax 99.9, on antibiotics, known improving PNA.\n\nSocial: Husband called, updated on pt's condition and nursing overnight.\n\nPlan:\nMaintain safety\nPain management\nMinimize sedatives\nFrequent reorientation\nAggressive bowel regimen with lactulose\nNotify team of acute changes\n transfer to floor if mental status continues to improve\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-29 00:00:00.000",
"description": "Report",
"row_id": 1366533,
"text": "MICU 7 RN Note 0700-1900\n\nEvents: Hypernatremia Free H20 bolus, Speech eval, ^PTT, CIWA monitoring.\n\nNeuro: Awake lethargic, voice slurred with noted improved level of orientation. wax and wanes. Pupils/cataract 3mm equal react , tracks surroundings, MAE random and to command equal strength, intermitent tremors of UE. CIWA scale 5-10 recieved Ativan 1mg x3 and Haldol 1mg x2. periods of restlessness/calm agitation requesting somthing to drink. moves about in the bed. no c/o pain. recieved lactalose encephalopathy\n\nCV: HR 78-90 NSR no ectopy, BP 112-140/40-60. Maps>60. Peripheral pulses 3+DP/DT neg peripheral edema. IV access R brachial PICC IV d5W 100cc/hr. K+4.0, mag 2.2. Na 153 Free H20 repeat Na trending down.\nHeme: Hct 31.8 trending down from previous days, Ptt 90 INR 1.7 Heparin SQ d/c\n\nResp: RR 22-26 Reg O2 3L/Min NC Sats 95-97% Lungs clear Dim @ bases.\n\nID: low grade temp 100, WBC 10.9, Abx Flagyl/vanco\n\nGI/liver: Ads soft distended + BS +stool Mushroom cath in place. recieved Lactalose Liq brown trace + stool. NGT R nares TF promte with fiber 55cc/hr @ goal. Speech eval failed Pt remains NPO\n\nGU: foley u/o 20-50cc/h icteric urine.\n\nDerm : skin impaired Dry Coccyx red skin irritaion from stool emollient cream appleid.\n\nSocial: Full code status, Family visited, updated on plan of care.\n\nPlan: called out to floor\n Monitor for dT's CIWA scale med Ativan/Haldol\n To start diuretic \n cont Free H20 Hypernatremia.\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-23 00:00:00.000",
"description": "Report",
"row_id": 1366517,
"text": "NURSING PROGRESS NOTE:\nTHIS IS A 70 YR OLD FEMALE WHO CAME IN THROUGH THE ED WITH C/O PAIN IN HER LOWER EXTREMETIES. AFTER DRAWING HER BLOODS THEY FOUND THAT HER HCT WAS ONLY 14 AND HER K+ WAS 2.6. PT WAS TREATED IN THE ED WITH 2UNITS OF PACKED RBC'S, POTASSIUM SUPPL, AND PROTONIX. PT THEN BROUGHT TO MICU FOR FURTHER TREATMENT AND FIND SOURCE OF HER BLEED.\n\nNEURO: ON ARRIVAL TO THE UNIT PT SEEMED TO BE ORIENTED X 3 BUT AS THE NIGHT WORE ON PT BECAME INCREASINGLY MORE CONFUSED AND AGITATED. PT VERY RESTLESS IN THE BED AND PICKING AT EVERYTHING. PT GOT OOB AND PULLING EVERYTHING OFF. PT ALSO HAS TREMORS AMD HER EXTREMETIES ARE VERY RIGID. PT STATES THAT THE LAST TIME SHE HAD A DRINK WAS OVER LABOR DAY WEEKEND. PT HAS BEEN STARTED ON THE CIWA SCALE AND HAS RECEIVED ATIVAN PO/IV AND ONE DOSE OF VALIUM BEFORE IT WAS D/C'D. PLEASE SEE CAREVIEW FOR CIWA SCALE.\n\nCV: PT IN NSR WHEN ASLEEP BUT WHEN AWAKE HR UP TO THE 120'S. PT HAS RECEIVED ONE UNIT OF PACKED CELLS WHILE IN THE MICU FOR A HCT OF 16. PT HAS RECEIVED A DOSE OF LACTULOSE WHICH HAS NOT IMROVED HER ENCEPHALOPATHY. PT TO CT SCAN OF HER HEAD FOR POSSIBLE HEAD BLEED BECAUSE OF HER NEURO SYMPTOMS AND HER SLURRED SPEECH. PT WITH LOW GRADE TEMP OF 99.6 PO. BOTH LOWER EXTREMTIES ARE REDDENED/SWOLLEN AND VERY TENDER. PT STARTED ON CEFAZOLIN FOR CELLULITIS.\n\nGI: PT WITH POSSIBLE SLOW GI BLEED. PT HAS HAD ONE STOOL AFTER RECEIVING LACTULOSE. STOOL LOOSE/BROWN AND GUIAIC POS. ABD SOFT WITH POS BOWEL SOUNDS. ORAL CAVITY WITH VERY FOUL ODOR. DENTURES REMOVED AND UPPER GUMS VERY SORE LOOKING WITH HER OWN TEETH GROUND DOWN TO THE NUB. GUMS BLEEDING WITH MOUTH CARE. DENTURES TAKEN OUT TO BE CLEANED AND TO OBSERVE MOUTH.\n\nGU: PT HAD RECEIVED A DOSE OF LASIX IN THE ED AND HAS BEEN PUTTING OUT LRG AMT'S OF CLEAR YELLOW URINE.\n\nACCESS: PT WITH TWO PERIPH IV'S BUT HAS LOST THE ONE IN HER LEFT AC.\n\nSKIN: PT'S LOWER EXTREMETIES VERY RED AND SORE, LOOKS LIKE CELLUTLITS.\nPT HAS A LRG HEMATOMA ON RIGHT UPPER BACK. PT DOES NOT KNOW HOW SHE GOT IT..\n\nSOCIAL: PT LIVES WITH SPOUSE AND HAS A DAUGHTER. DAUGHTER CALLED LAST EVENING FOR AN UPDATE. PT IS A FULL CODE.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-23 00:00:00.000",
"description": "Report",
"row_id": 1366518,
"text": "MIcu Nursing note \n\nNeuro pt very restless, orient to person only, pt in soft restraints for saftey reasons, cwai 35, and ativan ^ pt recieved 4 mg iv ativan q1 hr for the first 3 hrs before she was calm, pt was tacky and hypertensive when I arrived at 7 am, now has not received ativan since 2 pm and cwai is now 10\n\nCv Pt hemodynamically stable pulses palp bilaterally, both shins still slightly reddened and firm, pt now sr hr 80-90\n\nResp pt remains on 2L n/c sats 98&% when on ra sats drop tp 90%, pt ^ 4L while having endo this am but has be able to be placed back to 2L n/c, lung clear.\n\nGi pt npo, had endo this am, no beleeding, pt has grade I varices in esph, sever gastritic, gastic varicies and a polyp pt does c/o RUG tenderness, no stool, and bowel sound x4\n\ngu pt passing yellow unine but u/o low house staff aware and after blood if u/o doesn't ^ the will consider ^ ivf\nat present ivf at kvo\n\nId pt tmax 100.3 ax pt was cultured x2 blood and urine , pt started on levoflox this afternoon, tylenol given x2 pr\n\nsocial spoke with husband and daughter which were updates about pt's condition, husband notified that I removed pt's jewlery and credit cards and money sent to be locked up.\n\nheme, hct this afternoon down to 19.9 form 24.5 pt transfused with 1unit prbc's, so of bleeding.\n\nA/P repeat cht this evening, follow cwai scale and prn ativan for dt's per scale, follow up with house staff reguarding ^ ivf because of npo status.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-24 00:00:00.000",
"description": "Report",
"row_id": 1366519,
"text": "MICU NPN 7P-7A\nNEURO: INITIALLY PATIENT DIFFICULT TO AROUSE. NAME CALLED REPEATEDLY BEFORE SHE STARTED TO OPEN EYES. PATIENT UNABLE TO ANSWER QUESTIONS AND MAKING INCOMPREHENSIBLE SOUNDS. LOCALIZING PAIN. LATER WAKING UP BUT FALLING BACK TO SLEEP AFTER SHE WAS AROUSED. WAS ATTEMPTING TO ANSWER QUESTIONS BUT APPEARS SHE BE ONLY ORIENTED TO SELF. CIWA 4 @, 7 @2200. DIFFICULT TO ASSESS CIWA AS SHE WAS UNABLE TO ANSWER ?'S. ~12AM MORE AGITATED, PULLING @SHEETS/GOWN. ATTEMPTING TO SIT UP. CIWA AS SHE WAS C/O MILD HEADACHE. FOLLOWING COMMANDS INCONSISTENTLY. GIVEN 4MG ATIVAN IV WITH MOD EFFECT. AS NIGHT HAS GONE ON PATIENT BECOMING MORE AND MORE AGITATED, CIWA 9-11HAS RECEIVED A TOTAL OF 26MG (4-6MG Q1-2HRS) OF ATIVAN IV SINCE MIDNOC WITH EFFECT NOT LASTING MORE THAN 45MIN. RESTRAINED FOR SAFETY OF LINES, RISK FOR FALLING OUT OF BED.\n\nCARDIAC: HR 76-120 SR/ST WITH NO ECTOPY. BP 98-150/45-80. HCT @ 24.9, GIVEN 1UPRBC'S WITH AM HCT 32.3. PLTS 96. NO SIGNS OF BLEEDING. PPP.\n\nRESP: ON 2L N/C WITH RR 19-40 AND SATS 89-100%. WHEN AGITATED DROPPING SATS AND AUDIBLY WHEEZY. WHEN CALM LS CLEAR WITH DIMINISHED LEFT BASE. OCCASIONAL CONGESTED NONPRODUCTIVE COUGH.\n\nGI/GU: ABD SOFT WITH +BS. SMALL SMEARS OF STOOL, APPEAR BLACK. UOP 25-45CC/HR AMBER AND CLEAR.\n\nFEN: RECEIVING MVI, FOLATE, THIAMINE VIA 500CC D5W. LYTES PER CAREVUE. NOT SAFE AT THIS TIME TO ATTEMPT ANYTHING PO AND WITH GRADE ESOPHAGEAL VARICIES A NGT IS RISKY. MEDS CHANGED TO IV/SC AS ALLOWED.\n\nID: TMAX 99.4 WITH WBC 11.2. ON LEVOFLOX.\n\nSKIN: W/D/I. HEMATOMA TO RIGHT UPPER BACK.\n\nACCESS: PIV X1.\n\nSOCIAL/DISPO: FULL CODE. SON FROM CALLED FOR UPDATE. CONTINUE TO TREAT DT'S.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-30 00:00:00.000",
"description": "Report",
"row_id": 1366534,
"text": "Nursing Progress Note:\n\nPt. is called out but still waiting for bed.\n\nNeuro: Pt. remains confused, at times knows where she is but at others thought she was at home. She was not agitated during the night, slept fairly well, and was not given any Ativan or Haldol.She did appear to be trying to get out of bed a couple times but was easily reoriented.\n\nCV: HR 70s-90s NST with no ectopy, NBP 110s-130s/40s-60s. Single-lumen PICC to R brachial is patent and WNL. IV fluids d/c'd and running at KVO now.\n\nResp: Lung sounds are clear to all lobes with diminished bases. RR teens, 02 sats high 90s except when on room air when it drops to low 90s. No wheezes or crackles noted. Neb txs could probably be changed to PRN as pt. has no hx of use prior to admission.\n\nGI: feeds at goal of 55cc/hour, BSX4, liquid, brown stool via mushroom catheter. MN dose of Lactulose held due to copious liquid stool.\n\nGU: UO is marginal (between 20-30cc/hour). Team is aware and will order bolus if UO drops to <20cc/hour.\n\nSkin: Pt. has a rash which appears to be fungal to perineal area and labia. Anti-fungal ointment applied.\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-30 00:00:00.000",
"description": "Report",
"row_id": 1366535,
"text": "NPN 7a-7p\nNeuro: Pt. oriented to person, place, and time but when left alone has d/c'd rectal , NGT, and takes off 02. Got out of chair and tried to ambulate in room, unsteady gait. Taking lactulose po.\n\nResp: 02 sat 95-96% on room air. Bibasilar crackles. Mild cough with minimal sputum.\n\nCV: HR 80's NSR no ectopy. BP 110-120/60's. Has PIC line which was KVO but stopped KVO so there would be less for her to pull at.\n\nID: Completed course of IV antibiotics for presumed aspiration PNA. Afebrile.\n\nGI: Pt. d/c'd rectal . Small amounts of stool since then-liquid. Able to take lactulose po. Has her dentures in.\n\nGU: Foley intact-urine output approx 20-30cc/hr.\n\nSkin: Rash over perineal area. Nystatin applied.\n\nSocial: Husband in to visit most of the day.\n\nplan:\n-transfer to floor when sitter available.\n-monitor pt. when eating\n-? repeat formal swallowing study\n"
},
{
"category": "Nursing/other",
"chartdate": "2127-08-31 00:00:00.000",
"description": "Report",
"row_id": 1366536,
"text": "Nursing Progress Note:\n\nPt. is called out to floor and has a bed but was not transferred due to needing a sitter (this may change as pt's mental status is improving).\n\nNeuro: Pt. has been alert, oriented, pleasant, and cooperative. She was appropriate and slept well for most of the night. She was found standing by the bed once but was easily reoriented and told to use call light rather than getting out of bed herself. She appeared to understand and there were no further incidents.\n\nCV: HR 70s-90s, NBP 100s-120s/40s-50s. Pt. has single-lumen PICC which is patent and draws well. Area around PICC is ecchymotic.\n\nResp: RR teens, 02 sats in 90s on room air. Lungs are clear, bases are diminished at times. No wheezes or cough, Neb txs held.\n\nGI: BSX4, pt. can have thickened liquids until further eval of swallow is performed (pt. did poorly yesterday). Pt. seems to be fine with thickened liquids, no coughing noted. Pt. initially stooling somewhat formed stool but this changed to thin enough so that mushroom catheter reinserted. Stool is now liquid brown. Lactulose given at MN, held at 0600.\n\nGU: UO remained marginal until 20mg PO Lasix q day ordered and given. UO after thsi increased to 60cc/hour for several hours.\n\nSkin: Rash to perineal area and labia, Aloe Vesta antifungal applied. Scattered ecchymotic areas on extreamities and blood blister to L FA.\n\nSocial: Pt. spoke to family on phone today.\n"
},
{
"category": "ECG",
"chartdate": "2127-08-25 00:00:00.000",
"description": "Report",
"row_id": 144073,
"text": "Sinus rhythm\nProlonged Q-Tc interval - clinical correlation is suggested\nSince previous tracing of , Q-Tc interval appears longer\n\n"
},
{
"category": "ECG",
"chartdate": "2127-08-23 00:00:00.000",
"description": "Report",
"row_id": 144074,
"text": "Sinus rhythm, rate 89. Since the previous tracing of minimal slowing of\nthe heart rate is seen. No other changes are noted.\nTRACING #2\n\n"
},
{
"category": "ECG",
"chartdate": "2127-08-22 00:00:00.000",
"description": "Report",
"row_id": 144075,
"text": "Sinus rhythm, rate 98. Since the previous tracing of the heart rate is\nfaster. Increased ST-T wave abnormalities are seen particularly over the\nlateral precordium.\nTRACING #1\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-08-25 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927381,
"text": " 4:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for improvement\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ETOH cirrhosis here w GIB. now w/ PNA and O2\n requirement\n REASON FOR THIS EXAMINATION:\n eval for improvement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia and decreased oxygen requirement. Eval for\n improvement.\n\n Comparison is made to .\n\n PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: There has been interval placement\n of an NG tube with the tip projecting over the body of the stomach. The side\n hole is located above the gastroesophageal junction. Patchy opacities are\n again seen predominantly in the right upper lobe, but also in the right middle\n and lower lobes and left lower lobe. The right upper lobe opacity is slightly\n improved in the interval. Also, the left lower lobe opacity is less\n prominent. No pleural effusions are seen. No new consolidations are seen.\n\n IMPRESSION:\n 1. Multifocal pneumonia with interval improvement in the right upper lobe\n opacity and left lower lobe opacity.\n 2. Placement of NG tube with the tip in gastric fundus, side hole above GE\n junction. Advancement of approximately 10 cm is recommended.\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-08-27 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927697,
"text": " 9:59 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ETOH cirrhosis here w GIB. now w/ PNA and O2\n requirement\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH.\n\n INDICATION: 70-year-old woman with cirrhosis and shortness of breath.\n\n COMPARISON: Radiograph dated .\n\n FINDINGS: When compared to the prior study, there has been significant\n interval improvement of the multifocal pneumonia. Interval placement of a\n right PICC line with its tip projecting over the SVC near the atrial junction.\n There is no evidence of pneumothorax or pneumoperitoneum. NG tube appears\n stable.\n\n IMPRESSION:\n\n 1. Significant interval improvement of the multifocal pneumonia.\n\n 2. Interval placement of a right PICC line with its tip projecting over the\n SVC, near the atrial junction.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-08-23 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 927209,
"text": " 3:17 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o intracranial hemorrhage\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ESLD, encephalopathic\n REASON FOR THIS EXAMINATION:\n r/o intracranial hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage liver disease with encephalopathy. Evaluate for\n intracranial hemorrhage.\n\n There are no prior studies for comparison.\n\n NON-CONTRAST HEAD CT SCAN: There is no evidence of acute intracranial\n hemorrhage or shift of the normally midline structures. The ventricles and\n cisterns are normal. There is hypodensity of the cerebral periventricular\n white matter, particularly in the left frontal region, consistent with chronic\n microvascular ischemia. There is also hypodensity of the left subinsular\n white matter consistent with the same process. The visualized paranasal\n sinuses and mastoid air cells are clear. The osseous and soft tissue\n structures are unremarkable.\n\n IMPRESSION: No evidence of acute intracranial hemorrhage. Chronic\n microvascular ischemic changes.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-08-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927140,
"text": " 2:00 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CHF?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ETOH cirrhosis\n REASON FOR THIS EXAMINATION:\n CHF?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:10 P.M., \n\n HISTORY: Alcoholics cirrhosis. Shortness of breath.\n\n IMPRESSION: AP chest compared to and :\n\n Heart size is top normal. Pulmonary vasculature is engorged and there is mild\n interstitial edema at the base of the right lung laterally. More centrally,\n there is considerable peribronchial opacification in a region that previously\n showed abnormality. This may therefore represent deposition of edema in the\n region of previous lung injury, but we could also be seeing right lower lobe\n pneumonia with secondary cardiac decompensation. There is no appreciable\n pleural effusion.\n\n Dr. was paged to discuss these findings, at the time of dictation.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-08-23 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927239,
"text": " 10:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for effusion/pna\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ETOH cirrhosis here w GIB. now w/ new oxygen\n requirement.\n REASON FOR THIS EXAMINATION:\n eval for effusion/pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: New oxygen requirement, question effusion pneumonia.\n\n REFERENCE EXAM: .\n\n FINDINGS: There is a new small left pleural effusion. There continues to be\n mild cardiomegaly. There continues to be hazy pulmonary vasculature and\n increased interstitial edema most marked on the right. There is also an area\n of focal consolidation in the retrocardiac region. Most likely, this findings\n are due to CHF. An underlying infectious infiltrate cannot be excluded.\n\n IMPRESSION: Likely increased CHF.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-08-25 00:00:00.000",
"description": "PICC W/O PORT",
"row_id": 927391,
"text": " 7:19 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: please place PICC\n Admitting Diagnosis: SEVER ANEMIA\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ESLD here w/ GIB. now c/b EtOH withdrawal\n REASON FOR THIS EXAMINATION:\n please place PICC\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: 70-year-old woman with end-stage liver disease, needs long-term\n IV access.\n\n RADIOLOGISTS: Dr. , and Dr. . Dr. , staff radiologist,\n was present for the entire procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia the right brachial\n vein was localized with ultrasound and punctured under direct ultrasound\n guidance using a micropuncture set. Ultrasound images were obtained before\n and immediately after obtaining intravenous access. A micropuncture sheath\n was then placed over the wire. A single-lumen PICC line was then advanced\n through the sheath over the wire and its tip positioned in SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by chest x-ray\n in one view. Guidewire and the peel-away sheath were then removed. The\n catheter was secured to the skin.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided PICC line\n placement via the right brachial vein with the tip positioned in SVC. Total\n length of the catheter is 34 cm. The catheter is ready for use.\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-08-24 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 927318,
"text": " 8:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pulm edema or pna\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ETOH cirrhosis here w GIB. now w/ new hypoxemia and\n coarse breath sounds\n REASON FOR THIS EXAMINATION:\n eval for pulm edema or pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW, ON \n\n HISTORY: New hypoxemia and coarse breath sounds.\n\n FINDINGS: There is a new right upper lobe infiltrate and patchy areas of\n increased opacity in the right lower lobe and left lower lobe as well. Heart\n is moderately enlarged.\n\n IMPRESSION: Probable multifocal pneumonia. CHF with an atypical presentation\n cannot be totally excluded.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-08-24 00:00:00.000",
"description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)",
"row_id": 927325,
"text": " 9:32 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); -59 DISTINCT PROCEDURAL SERVICEClip # \n DUPLEX DOPP ABD/PEL\n Reason: assess ascites, mark for tap, ? liver changes\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with alcoholic ascites, now with fever, tender abdomen\n REASON FOR THIS EXAMINATION:\n assess ascites, mark for tap, ? liver changes\n ______________________________________________________________________________\n FINAL REPORT\n 70-year-old female with alcoholic cirrhosis, now with fever and tender\n abdomen.\n\n COMPARISON: .\n\n FINDINGS: Again demonstrated is the shrunken nodular appearance of the liver\n consistent with cirrhosis. No focal hepatic lesion is identified. There is\n no intra- or extra-hepatic biliary ductal dilatation. The common duct\n measures normal caliber of 4 mm. No ascites is identified. The gallbladder\n is unremarkable without stones, wall thickening, or pericholecystic fluid. A\n right pleural effusion is incompletely evaluated on this study.\n\n As demonstrated on , Doppler evaluation of the liver again\n shows reversal of flow (hepatofugal) of the main, right and left portal veins\n as well as superior mesenteric vein. The splenic vein demonstrates normal\n directionality of flow. The main, left, and right hepatic veins are patent\n with appropriate color flow and waveform. Normal flow and appropriate\n waveforms are demonstrated in the main, left, and right hepatic arteries. The\n IVC is patent.\n\n IMPRESSION:\n 1. Cirrhotic liver, without focal hepatic lesion identified.\n 2. No ascites.\n 3. As demonstrated on , there is reversal of flow in the\n main, right, and left portal veins as well as superior mesenteric vein. The\n hepatic veins and arteries demonstrate appropriate directionality of flow and\n waveform.\n 4. Right pleural effusion is incompletely assessed.\n\n"
},
{
"category": "Radiology",
"chartdate": "2127-09-01 00:00:00.000",
"description": "VIDEO OROPHARYNGEAL SWALLOW",
"row_id": 928307,
"text": " 2:13 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: eval for aspirations with thin liquids\n Admitting Diagnosis: SEVER ANEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with ESLD etoh abuse\n REASON FOR THIS EXAMINATION:\n eval for aspirations with thin liquids\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old female with end-stage liver disease, evaluate for\n aspiration.\n\n OROPHARYNGEAL VIDEO FLUOROSCOPIC SWALLOWING EVALUATION: An oropharyngeal\n swallowing video fluoroscopy study was performed today in collaboration with\n speech pathology. Barium of varying consistencies as well as solids coated\n with barium and a barium pill were administered. There was moderate\n impairment in bolus formation with no premature spillover seen. There was\n mild penetration with no aspiration.\n\n IMPRESSION: Mild penetration which cleared during the swallow.\n\n Please see the speech pathology note under CareWeb for further details.\n\n"
}
] |
22,933 | 127,043 | remaines intubated and vented, weaned to PSV tol ok at this time. OXYGENATING WELL & FI02 WEANED DOWN, SEE FLOWSHEET FOR ABG. care note - Pt. INTUBATED AND ON ASSIST CONTROL, BREATHING OVER SET RESP RATE MINIMALLY. Visualized paranasal sinuses are normally aerated. Again demonstrated in the right hepatic lobe is a TIPS stent catheter, which appears unchanged in position. Pt tolerating well. IMPRESSION: Endotracheal only 1 cm above the carina, and angled towards the right mainstem bronchus. AM LABS PENDING.GI: ABDOMEN SOFT. NGT TO LCWS, SCANT BILIOUS OUTPUT. COMPARISON: Head CTA from . LS clear bilat. LCTAB. Nasogastric tube is in place. GI: Abd soft, pos bs. K+ repleted in am, PM lytes pnd. TECHNIQUE: Non-contrast head CT. ABDOMEN SOFTLY DISTENDED. There is fecalization of the small bowel consistent with resolving obstruction. FLEXI-SEAL CURRENTLY IN PLACE. Endotracheal tube is in place, positioned approximately 1 cm above the carina, and angled towards the right main stem bronchus. REASON FOR THIS EXAMINATION: NOTE: TO BE PERFORMED WITH DOPPLER! Fecalization of the small bowel consistent with slowly resolving small bowel obstruction. Resp. IMPRESSION: Patent TIPS stent with flow velocities within similar range to recent evaluations. FINDINGS: Portable supine chest radiograph is reviewed. Sinus rhythm. Nsg.progress notes:See flow sheet for specific:Neuro: Alert and oriented x3,pleasant and co op with care,c/o head achae,oxicodone prn started with good effect,MAE.CV: NSR,HR in 70-80,no ectopy noted,SBP 110-130,IVF KVO denies CP or discomfort.40mmol kcl replaced this am,pending evening labs.Resp: Remains on RA with O 2sat 99-100%,LS clear.GI:Abd soft,+ BS,liq stool to FIB,flexiseal removed as not draining to the bag,on lactulose q4h.regular diet started and tolerated.GU: Foely cath patent with yellow clear urine adq amt.Endo: Bld sug wnl.Act: Turning alone in bed,skin intact,except redness around rectum from frequent stooling.Social: Husband called x2,updated with him,MICU team also talked to him.Plan: cont monitoring,neuro checks,transfer to floor when bed available. Please assess tube placement. NGT clamped. ASSITING IN CARE, COOPERATIVE. FINDINGS: This was a limited Doppler evaluation of the TIPS stent. Uneventful shift.Tolerating advanced diet. CV: Remains NSR, no ectopy noted. Patient intubated. NURSING PROGRESS NOTEPLEASE SEE CAREVUE FOR DETAILSRESP: EXTUBATED WELL W/NO EVENTS, DR AT BS. Suctioned prn for small amounts of thick brow sputum. NON DISTENDED. Overall, these are in similar range to the prior studies of and . IMPRESSION: 1. Pt denies SOB. Diffuse non-specific ST-T wave changes. NSR HR 90S. IVF kvo, revieved 1.5L NS as ordered. PEERLA. COMPARISON: . SICU NPNS-"I feel much better, thank you. Flexiseal remains intact, draining lg aounts of golden loose stool secondary to frequent lactulose. Again seen is a vascular coil in the region of the right MCA bifurcation aneurysm (there is no evidence of craniotomy), and surrounding encephalomalacia and ex vacuo dilatation of the frontal of the right lateral ventricle, unchanged from prior exam. CALL MICU HO W/ANY CHANGES. IMPRESSION: Endotracheal tube is 6.4 cm from carinal angle. The ventricles and basal cisterns are otherwise normal and unchanged since prior exam. Scout image demonstrates TIPS stent and cholecystectomy clips within the right upper quadrant. The nasogastric tube remains in a satisfactory position. DENIES PAIN. HEART RATE 90'S NORMAL SINUS. Flow velocities within the TIPS stent in the proximal, mid, and distal portions are 127, 173, and 175 cm/sec respectively. PRODUCTIVE COUGH FOR THIN WHITE SECRETIONS.NEURO: A&OX3. BLOOD GLUCOSE WITHIN NORMAL RANGE. NPO.GU: FOLEY PATENT, >30CC CYU HOURLY.SKIN: INTACT, NO BREAKDOWN NOTED. "SEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.O-VSS. Resp Care: Pt recieved on mechanical ventilation. SAT'S 100%. SBP 115-140. REASON FOR THIS EXAMINATION: Evaluate placement of ETT, OGT. Tube withdrawal of approximately 2 to 3 cm is recommended for appropriate positioning. MAINTAIN SKIN INTEGRITY. 11:00 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # Reason: Evaluate placement of ETT, OGT. LUNG SOUNDS CLEARED, SUCTIONED ONCE FOR THICK BROWN/YELLOW SPUTUM. TRANSFER TO FLOOR. Evaluate portal flow, TIPS flow. FOLLOWING COMMANDS. SBP 120-140. Streak artifact from the aneurysm clips does slightly limit evaluation of the right infratemporal region. Recommend withdrawing tube at least 2-3 cm. MONITOR OUTPUT. AWAITING AM LAB RESULTS & REPEAT AMMONIA LEVEL. MAE. 10:54 PM DUPLEX DOP ABD/PEL LIMITED Clip # Reason: NOTE: TO BE PERFORMED WITH DOPPLER! Resp: pt placed on CPAP, PEEP 5, PS 10, FiO2 40%, following O2 sats per MICU, pt without aline. GIVEN LACTULOSE PR AND PNGT FOR ELEVATED AMMONIA LEVEL IN ED. LOW GRADE FEVER. Condition UpdateAssessment:Please see carevue for details Neuro: Pt encephalopathic, lactulose cont Q4hrs with much noted improvement in neuro exam over the course of the day. SBP RANGING 100-130'S. Compared to theprevious tracing of there is no significant diagnostic change. FINAL REPORT CLINICAL HISTORY: Cirrhosis, encephalopathy. Denies CP. Color Doppler evaluation shows wall-to-wall color Doppler signal within the TIPS stent. NO FAMILY CONTACT OVERNIGHT.PLAN: CONTINUE WITH LACTULOSE, TITRATE TO BOWEL MOVEMENTS. ? SLIGHTLY RED ON COCCYX.POC: MONITOR RESP, NEURO. NO ECTOPY. No edema noted. 2. MICU TEAM ATTEMPTED TO PLACE ARTERIAL LINE, UNABLE. CVP ~ 10. There is appropriate hepatopetal blood flow in the main portal vein. IMPRESSION: No acute intracranial process. FINDINGS: There is no intracranial hemorrhage. PATIENT RARELY OPENING EYES WITH REPOSITIONING & STIMULI. FLEXISEAL REMAINS INTACT W/LG AMOUNTS LIQUID GOLDEN BROWN, CONT W/FAIR AMOUNT OF DRAINAGE AROUND FLEXISEAL AS WELL. CURRENTLY ON 40% FIO2 COOL NEB FACE MASK. Heart and mediastinal contours are unremarkable. COMPARISON: Duplex Doppler ultrasound evaluation of the liver and TIPS on and . NURSING NOTEASSESSMENT: PATIENT ARRIVED FROM APPROX 10 PM, UNRESPONSIVE & MINIMALLY WITHDRAWING TO PAIN (PATIENT CURRENTLY DOES NOT WITHDRAW ANY EXTREMITIES). | 13 | [
{
"category": "Radiology",
"chartdate": "2110-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 994959,
"text": " 3:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess tube placement pt in \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with delta MS \n REASON FOR THIS EXAMINATION:\n assess tube placement pt in \n ______________________________________________________________________________\n WET READ: DSsd SAT 4:07 PM\n ETT at or near origin of right mainstem bronchus. Recommend withdrawing tube\n at least 2-3 cm.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old female with altered mental status, now . Please\n assess tube placement.\n\n COMPARISON: .\n\n FINDINGS: Portable supine chest radiograph is reviewed. Endotracheal tube is\n in place, positioned approximately 1 cm above the carina, and angled towards\n the right main stem bronchus. Enteric feeding tube extends below the diaphragm\n and into the stomach. Heart and mediastinal contours are unremarkable. The\n lungs are clear and well expanded. There is no pleural effusion or\n pneumothorax.\n\n IMPRESSION: Endotracheal only 1 cm above the carina, and angled towards the\n right mainstem bronchus. Tube withdrawal of approximately 2 to 3 cm is\n recommended for appropriate positioning.\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-02-22 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 994960,
"text": " 3:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with hepatic sarcoid w/ cirrhosis who p/w MS changes,\n responsive only to pain.\n REASON FOR THIS EXAMINATION:\n Eval for ICH\n CONTRAINDICATIONS for IV CONTRAST:\n RF\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old female with hepatic sarcoid and cirrhosis, presenting\n with mental status changes, and responsive only to pain.\n\n COMPARISON: Head CTA from .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage. There is no mass, mass\n effect, or evidence of acute vascular territorial infarction. Again seen is\n a vascular coil in the region of the right MCA bifurcation aneurysm (there is\n no evidence of craniotomy), and surrounding encephalomalacia and ex vacuo\n dilatation of the frontal of the right lateral ventricle, unchanged from\n prior exam. The ventricles and basal cisterns are otherwise normal and\n unchanged since prior exam. Streak artifact from the aneurysm clips does\n slightly limit evaluation of the right infratemporal region.\n\n There is no fracture. Visualized paranasal sinuses are normally aerated.\n Nasogastric tube is in place.\n\n IMPRESSION: No acute intracranial process. No change from study.\n\n\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-02-24 00:00:00.000",
"description": "Report",
"row_id": 1562265,
"text": "Nsg.progress notes:\nSee flow sheet for specific:\n\nNeuro: Alert and oriented x3,pleasant and co op with care,c/o head achae,oxicodone prn started with good effect,MAE.\n\nCV: NSR,HR in 70-80,no ectopy noted,SBP 110-130,IVF KVO denies CP or discomfort.40mmol kcl replaced this am,pending evening labs.\n\nResp: Remains on RA with O 2sat 99-100%,LS clear.\n\nGI:Abd soft,+ BS,liq stool to FIB,flexiseal removed as not draining to the bag,on lactulose q4h.regular diet started and tolerated.\n\nGU: Foely cath patent with yellow clear urine adq amt.\n\nEndo: Bld sug wnl.\n\nAct: Turning alone in bed,skin intact,except redness around rectum from frequent stooling.\n\nSocial: Husband called x2,updated with him,MICU team also talked to him.\n\nPlan: cont monitoring,neuro checks,transfer to floor when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-02-25 00:00:00.000",
"description": "Report",
"row_id": 1562266,
"text": "SICU NPN\nS-\"I feel much better, thank you.\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN FLOWSHEET.\n\nO-VSS. Uneventful shift.Tolerating advanced diet. Sleeping most of night. Awaiting floor bed.\n\nA/P:\nTransfer to floor when bed available.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-02-23 00:00:00.000",
"description": "Report",
"row_id": 1562260,
"text": "NURSING NOTE\nASSESSMENT:\n PATIENT ARRIVED FROM APPROX 10 PM, UNRESPONSIVE & MINIMALLY WITHDRAWING TO PAIN (PATIENT CURRENTLY DOES NOT WITHDRAW ANY EXTREMITIES). PATIENT RARELY OPENING EYES WITH REPOSITIONING & STIMULI.\n INTUBATED AND ON ASSIST CONTROL, BREATHING OVER SET RESP RATE MINIMALLY. OXYGENATING WELL & FI02 WEANED DOWN, SEE FLOWSHEET FOR ABG. MICU TEAM ATTEMPTED TO PLACE ARTERIAL LINE, UNABLE. LUNG SOUNDS CLEARED, SUCTIONED ONCE FOR THICK BROWN/YELLOW SPUTUM.\n HEART RATE 90'S NORMAL SINUS. SBP RANGING 100-130'S. LOW GRADE FEVER. PATIENT MAKING 30-50 CC URINE HOURLY, IV FLUIDS STARTED. CVP ~ 10.\n ABDOMEN SOFTLY DISTENDED. GIVEN LACTULOSE PR AND PNGT FOR ELEVATED AMMONIA LEVEL IN ED. FLEXI-SEAL CURRENTLY IN PLACE. BLOOD GLUCOSE WITHIN NORMAL RANGE.\n NO FAMILY CONTACT OVERNIGHT.\nPLAN:\n CONTINUE WITH LACTULOSE, TITRATE TO BOWEL MOVEMENTS. WILL NEED SOCIAL WORK CONSULT. AWAITING AM LAB RESULTS & REPEAT AMMONIA LEVEL.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-02-23 00:00:00.000",
"description": "Report",
"row_id": 1562261,
"text": "Resp. care note - Pt. remaines intubated and vented, weaned to PSV tol ok at this time.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-02-23 00:00:00.000",
"description": "Report",
"row_id": 1562262,
"text": "Condition Update\nAssessment:\nPlease see carevue for details\n\n Neuro: Pt encephalopathic, lactulose cont Q4hrs with much noted improvement in neuro exam over the course of the day. Pt now open eys to voice, tracking, nods appropriately to questions, MAE, follows all commands, assists with turning and repositioning.\n\n Resp: pt placed on CPAP, PEEP 5, PS 10, FiO2 40%, following O2 sats per MICU, pt without aline. O2 sat 96-99%. Pt denies SOB. LS clear bilat. Suctioned prn for small amounts of thick brow sputum.\n\n CV: Remains NSR, no ectopy noted. SBP 120-140. No edema noted. Denies CP. IVF kvo, revieved 1.5L NS as ordered. K+ repleted in am, PM lytes pnd.\n\n GI: Abd soft, pos bs. NGT clamped. Flexiseal remains intact, draining lg aounts of golden loose stool secondary to frequent lactulose.\n\n GU: Adequate amounts of clear yellow urine via foley cath.\n\nPlan: Continue with lactulose, monitor labs, monitor hemodynamics, monitor neuro exam, wean vent as tol, pulm toileting, provide pt and family with emotional support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-02-24 00:00:00.000",
"description": "Report",
"row_id": 1562263,
"text": "NURSING PROGRESS NOTE\n\nPLEASE SEE CAREVUE FOR DETAILS\n\nRESP: EXTUBATED WELL W/NO EVENTS, DR AT BS. CURRENTLY ON 40% FIO2 COOL NEB FACE MASK. SAT'S 100%. LCTAB. PRODUCTIVE COUGH FOR THIN WHITE SECRETIONS.\n\nNEURO: A&OX3. MAE. FOLLOWING COMMANDS. ASSITING IN CARE, COOPERATIVE. PEERLA. DENIES PAIN. CONT RECEIVING LACTULOSE EVERY 4 HOURS W/MUCH EFFECT.\n\nCV: AFEBRILE. NSR HR 90S. NO ECTOPY. SBP 115-140. AM LABS PENDING.\n\nGI: ABDOMEN SOFT. NON DISTENDED. FLEXISEAL REMAINS INTACT W/LG AMOUNTS LIQUID GOLDEN BROWN, CONT W/FAIR AMOUNT OF DRAINAGE AROUND FLEXISEAL AS WELL. NGT TO LCWS, SCANT BILIOUS OUTPUT. NPO.\n\nGU: FOLEY PATENT, >30CC CYU HOURLY.\n\nSKIN: INTACT, NO BREAKDOWN NOTED. SLIGHTLY RED ON COCCYX.\n\nPOC: MONITOR RESP, NEURO. MONITOR OUTPUT. MAINTAIN SKIN INTEGRITY. ? TRANSFER TO FLOOR. CALL MICU HO W/ANY CHANGES.\n"
},
{
"category": "Nursing/other",
"chartdate": "2110-02-24 00:00:00.000",
"description": "Report",
"row_id": 1562264,
"text": "Resp Care: Pt recieved on mechanical ventilation. Pt extubated to 40% cool aerosol. Pt tolerating well.\n"
},
{
"category": "Radiology",
"chartdate": "2110-02-22 00:00:00.000",
"description": "DUPLEX DOP ABD/PEL LIMITED",
"row_id": 994999,
"text": " 10:54 PM\n DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: NOTE: TO BE PERFORMED WITH DOPPLER! Evaluate portal flow,\n Admitting Diagnosis: DELTA MS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with hepatic sarcoid, cirrhosis, varices, s/p TIPs,\n idiopathic cardiomyopathy p/w altered mental status now for airway\n protection.\n REASON FOR THIS EXAMINATION:\n NOTE: TO BE PERFORMED WITH DOPPLER! Evaluate portal flow, TIPS flow.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 54-year-old female with history of hepatic sarcoidosis, cirrhosis,\n varices and TIPS placement, now with change in mental status and concern for\n TIPS occlusion or stenosis.\n\n COMPARISON: Duplex Doppler ultrasound evaluation of the liver and TIPS on\n and .\n\n FINDINGS: This was a limited Doppler evaluation of the TIPS stent. Again\n demonstrated in the right hepatic lobe is a TIPS stent catheter, which appears\n unchanged in position. Color Doppler evaluation shows wall-to-wall color\n Doppler signal within the TIPS stent. Flow velocities within the TIPS stent\n in the proximal, mid, and distal portions are 127, 173, and 175 cm/sec\n respectively. Overall, these are in similar range to the prior studies of\n and . There is appropriate hepatopetal blood flow in the\n main portal vein. As before, no definite flow is identified within the left\n portal vein.\n\n IMPRESSION: Patent TIPS stent with flow velocities within similar range to\n recent evaluations.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-02-22 00:00:00.000",
"description": "CHEST (PORTABLE AP)",
"row_id": 995000,
"text": " 11:00 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Evaluate placement of ETT, OGT.\n Admitting Diagnosis: DELTA MS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with cirrhosis, hepatic encephalopathy, intubated for airway\n protection.\n REASON FOR THIS EXAMINATION:\n Evaluate placement of ETT, OGT.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Cirrhosis, encephalopathy. Patient intubated.\n\n CHEST:\n\n The endotracheal tube lies 6.4 cm from the carinal angle and has been\n withdrawn since the prior chest x-ray of seven hours earlier. The nasogastric\n tube remains in a satisfactory position. The lung fields are clear.\n\n IMPRESSION: Endotracheal tube is 6.4 cm from carinal angle.\n\n\n"
},
{
"category": "Radiology",
"chartdate": "2110-02-26 00:00:00.000",
"description": "SMALL BOWEL ONLY (BARIUM)",
"row_id": 995398,
"text": " 9:14 AM\n SMALL BOWEL ONLY (BARIUM) Clip # \n Reason: small bowel with follow-through\n Admitting Diagnosis: DELTA MS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old woman with hepatic sarcoid\n REASON FOR THIS EXAMINATION:\n small bowel with follow-through\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: 54-year-old female with hepatic sarcoid.\n\n SMALL BOWEL FOLLOW-THROUGH: Contrast passes freely through the small bowel\n entering the colon within 50 minutes. There is fecalization of the small\n bowel consistent with resolving obstruction. Note is made of thickening of\n jejunal and ileal folds which is likely related to resolving obstruction and\n chronic liver disease. Scout image demonstrates TIPS stent and\n cholecystectomy clips within the right upper quadrant.\n\n IMPRESSION:\n 1. No evidence of mechanical obstruction. Fecalization of the small bowel\n consistent with slowly resolving small bowel obstruction.\n\n 2. Small bowel fold thickening likely related to resolving obstruction and\n chronic liver disease.\n\n"
},
{
"category": "ECG",
"chartdate": "2110-02-22 00:00:00.000",
"description": "Report",
"row_id": 148378,
"text": "Sinus rhythm. Diffuse non-specific ST-T wave changes. Compared to the\nprevious tracing of there is no significant diagnostic change.\n\n"
}
] |
|
24,149 | 132,161 | Patient was admitted to the preoperative holding area on . He underwent an open abdominal aortic repair with a tube graft. He tolerated the procedure well. Was transferred to the SICU intubated in stable condition. Postoperatively, the patient was monitored by the anesthesia acute pain service secondary to his epidural. Patient was also evaluated by the electrophysiology service to check pacer. The pacer mode was set at a DDD at 60- 120. It was sensing and pacing AV. The P-R interval was adjusted to allow for sinus rhythm instead of V-pacing. Postoperative day 1 overnight events, the patient had 3 episodes of hypotension requiring 4 units of FFP, 4 units of pack red blood cells, and 5 liters of lactated Ringer. The epidural was held secondary to the hypotension. Postoperative hematocrit was 31.1 with a white count of 18.3, platelets 54 K. BUN 23, creatinine 1.0. Postoperative day 2, the epidural was instituted with morphine sulfate as analgesic . A HIT panel was sent secondary to persistent low platelet count, and he continued with aggressive fluid boluses. His troponin was 0.11. His pulse exam remained unchanged. He remained on ventilator support. Postoperative day 4, the patient was extubated. His Swan catheter was replaced with a triple lumen. His Lopressor was increased for rate control. His white count which peaked at 21.5 showed a decreasing count of 16.4, hematocrit remains stable at 30.7. BUN and creatinine were stable at 32 and 0.9. Patient was neurologically intact and oriented x3. He continued to remain NPO. Patient did have bowel sounds, but had not passed flatus. Patient's intrathecal catheter was discontinued. His HIT panel was negative. His platelet count continued to show improvement. Patient was transferred to the VICU for continued monitoring and care. On postoperative day 5, patient had bowel sounds, but no flatus. His diet was advanced. NG tube was removed. He was evaluated by physical therapy who felt that he would benefit from rehab when medically stable for discharge. The patient continued to progress. Postoperative day 7, the Foley was removed. The patient failed to void. A Foley was replaced. An informal consult with urology service determined that the patient should maintain the catheter until he is transferred to rehab, and then they can begin a q.6h. intermittent straight catheterization. Patient then should follow up with the urology clinic and call for an appointment. Patient's remaining hospital course was unremarkable. Patient continued to do well. He was transferred to rehab on in stable condition, tolerating POs. | focus: Dondition Update.please see flowsheet for specific values.Neuro: Pt lightly sedated on Propofol. Plan to extubate pt today.GI: Very faint bowel sounds noted. BS slightly course with minimal secretions noted. Received fluid boluses for low u/o yesterday. ABD soft and distended + hypo BS. cause epidural d/c'd and BP stable since. Follow up abg 7.40/33/100/22. Pt with cool/cyanotic extremities. ABGs acceptable. Incision with small amt old serosanguinous drainage at midpoint of incision. BS are clear, but diminished in the bases bilaterally. BP stable via Arterial line. Resp CarePt had CPAP/PSV trial on %. SICU team aware.Heme: Platelet low. Lung sounds clear, diminished at bases. Lungs Clear to diminished at the bases w/ faint crackle in L base. PT tolerating SBT well.Plan: continue with SBT and possible extubation. Plan is to rest overnite Pt placed back on IMV. Wean on CPAP as tolerated, will placed back on SMIV if needed. SICU NN: See carevue for specifics. 2U FFP given for INR 1.7. pt did desat to 91-93 while on SBT despite adequate ABG.GI/GU: Currently NPO. Resp CarePt admitted to SICU this AM s/p AAA repair. Cleaned with sterile H20 and sxd oral cavity. Respiratory Care NotePt received on PSV as noted. Foley intact and patent. Suctioning small amts of sputum and bs are generally clear with scatter rhonchi. Follows commands, MAE left side stronger than right.CV: afebrile, HR 60-100's SR/ Paced. Remains intubated on full support with increasing fio2 and peep requirement t/o course of the shift. Blood pressure well controlled this am. skin pink, warm, and dry.Plan: Keep CVP 10-14--give fluid as needed when drops or u/o less that 20 cc hr. CVP=. Cont wean vent. IMPRESSION: Lines and tubes in satisfactory position. BP very labile at start of shift. abd inc intact with noted shadow staining.Soc: Supportive family. BP wnl. extubation this am "B" Nsg Progress Note:CVS: T=98.8-99.7, HR=66-90 NSR with some episodes of paced beats. Heart size and mediastinal contours are unchanged. Cont to monitor lytes and replete as needed. HIT sent.skin: No breakdown is noted. VR PVC noted. RESP CARE: pt remains intubated/on vent on PS 5/5/.50. Plan is for extubation 02 sat current 96-97 on .70% Fi02. RSBI-62. Abdomen with staples, clean, dry and intact. Baseline artifactAtrial sensed ventricular paced rhythmSince previous tracing of , atrial sensing SBP by Aline=90-153. Pt placed on SBT - tolerated well with good follow up ABG's. Afebrile. CI=2.3-2.75. Plan is to extubate in the am. creat=0.8-0.9.Neuro: Pt nods appropriately,follows commands,moves all extremities. NPNN: PAtient is awake and alert, following commands moves all extremeties weakly.nodding appropriately.CV: Patient low grade temp all day, hemodynamically stable pulses unchanged. Swann not wedged this shift, pressures adequate. Pt has positive cuff leak. Pt placed on CPAP this afternoon, and appears to be tolerating well. Feet cool,pale but capillary refill adequate. PT rechecked this am with SBT which pt did tolerate initially but did begin to drop sats. Pulses unchanged. with marginal oxygenation. Will cont to monitor oxygenation per ABG and titrate fio2 accordingly. Sinus rhythmProbable left atrial abnormalityIntraventricular conduction delay - may be atypical right bundle branch blockConsider inferoposterolateral myocardial infarct, age indeterminateLeft ventricular hypertrophyDiffuse ST-T wave abnormalities - Cannot exclude in part ischemiaClinical correlation is suggestedSince previous tracing of , paced rhythm now absent RESP CARE: pt rested overnight on SIMV SEE CAREVUE. Lopressor restarted, however, pressure rising now that patient is weaning on CPAP. PP no dopplerable can doppler PT. Pt with low grade temp T-max 38.4 tylenol with effect current temp 37.6. RSBI-63. Pt requiring mult fluid bolus for hypotension and currently for inadequate u/o. with systolic around 140/. Patient follows commands. HCT stable.Resp: patient remains on PSV 50% 5 5 with adeqaute oxygenation occasionally tachypnic when in pain.GI: Very faint bowel sounds no BM or flatus this shift.GU: patient given lasix this am with adequate urine output.Skin: intact. Lungs dim bilat. Will continue to monitor as indicated. change swan to TLCL. Increase urine output to normal range. A pacemaking device overlying the right chest is in unchanged position with stable appearance of electrodes. continue to monitor lytes and replete as needed 8pm troponin=0.11, EKG done, no changes noted. Pt has permanent DDD pacer, rate set at 60. BS- diminished at bases. SBPby cuff=95-140. Thank you Thank you Thank you Patient nods head and mouths words around et tube. Nursing Progress NotePlease see carvue for specifics:Neuro: Lightly sedated on prop and fent for pain. CO 3.7-5.4 with SVR 700's-1200's. ICU team and primary team aware.Resp: Current on SIMV 600X14 with Fi02 70%. Placed on .50 at 0500 with acceptable ABGS. Strong cough noted. No plans to extubate at this point, still receiving fluid for low urines, will check gas on cpap .CV: Pt in NSR with occassional paced beats (pacer set for demand of 60) regular. Pt extubated to cool aerosol w/o incident. 19/07 PT ALERT RELAXED TALKATIVE OCC SHORT PERIODS OF COFUSION EASILY RE DIRECTED SLEEPS LONG PERIODS IN GOOD SPIRITS RESP PLACED ON 6 L NP TOL WELL SAT 97 TO 100 PRODUCTIVE COUGH HEART S1S2 NSR WITH OCC PACED 100 PERSENT CAPTURED POOR PULSES NOTED PLEASE SEE CAREVIEW FOR DETAILS ABD FIRM HYPOACTIVE B/S NPO MAINTAINED WOUND HEALING PLAN PROGRESSIVE AMBULATION ROM P/T FAMILY SUPPORT Patient denies pain. Patient is alert, received morphine intrathecally (administered by anesthesia resident) and appears comfortable. Pt received lasix today and had good return. Abdomen soft. Pt not wedged d/t coags. Will check with Dr. re: more specific parameters and perhaps adding another antihypertensive . Bilateral PT pulses present with doppler, Left DP present with doppler, unable to locate rt DP. Dressing clean and dry. No redness noted.GU: U/O=23-37cc/h amber clear urine. Going by cvp for fluid management, goal to keep cvp 10-14, urines will drop when cvp around 10.GI: No bowel sounds, abd is soft and nontender. | 20 | [
{
"category": "Nursing/other",
"chartdate": "2176-11-26 00:00:00.000",
"description": "Report",
"row_id": 1577100,
"text": "Resp Care\n\nPt admitted to SICU this AM s/p AAA repair. Remains intubated on full support with increasing fio2 and peep requirement t/o course of the shift. BS slightly course with minimal secretions noted. Will cont to monitor oxygenation per ABG and titrate fio2 accordingly.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-26 00:00:00.000",
"description": "Report",
"row_id": 1577101,
"text": "NPN Admitt NOOTE\nPatient is an 85 year old male who was admitted direct fromthe OR S/P AAA. Patient originally stable however patient became increasingly more hypotensive-- HCT dropping oxygenation MD's at bedside. Patient received large amounts of fluid and blood products. Patients daughter in law called early in shift and was updated. Please see care view for all other information. Thank you\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-27 00:00:00.000",
"description": "Report",
"row_id": 1577102,
"text": "Respiratory Care\nPt changed to SIMV 12 PEEP/PS +5/+5 Vt 600 and O2 has been weaned throughout the night.RSBI done this AM and pt placed on SBT. BLBS coarse @ times, sx small to moderate amt thick white secretions.ABGs looked throughout the night. PT tolerating SBT well.\n\nPlan: continue with SBT and possible extubation.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-27 00:00:00.000",
"description": "Report",
"row_id": 1577103,
"text": "Respiratory Care\nSBT canceled due to rise in HR >20% above baseline.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-30 00:00:00.000",
"description": "Report",
"row_id": 1577115,
"text": " 19/07\n PT ALERT RELAXED TALKATIVE OCC SHORT PERIODS OF COFUSION EASILY RE DIRECTED SLEEPS LONG PERIODS IN GOOD SPIRITS\n RESP PLACED ON 6 L NP TOL WELL SAT 97 TO 100 PRODUCTIVE COUGH\n HEART S1S2 NSR WITH OCC PACED 100 PERSENT CAPTURED POOR PULSES NOTED PLEASE SEE CAREVIEW FOR DETAILS\n ABD FIRM HYPOACTIVE B/S NPO MAINTAINED WOUND HEALING\n PLAN PROGRESSIVE AMBULATION ROM P/T FAMILY SUPPORT\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-30 00:00:00.000",
"description": "Report",
"row_id": 1577116,
"text": "SICU nursing progress note\nPlease refer to flowsheet for specific info. and to the nursing transfer note.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-28 00:00:00.000",
"description": "Report",
"row_id": 1577108,
"text": "RESP CARE: pt rested overnight on SIMV SEE CAREVUE. Placed on .50 at 0500 with acceptable ABGS. RSBI-62. Lungs dim bilat. Sxd thick yellow sputum. ? extubation this am\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-28 00:00:00.000",
"description": "Report",
"row_id": 1577109,
"text": "RESPIRATORY CARE:\nPt remains on PSV 5 peep 5 50% with SPO2 99%. Pt received lasix today and had good return. BS- diminished at bases. Plan is to extubate in the am. Will continue to monitor as indicated.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-28 00:00:00.000",
"description": "Report",
"row_id": 1577110,
"text": "NPN\nN: PAtient is awake and alert, following commands moves all extremeties weakly.nodding appropriately.\nCV: Patient low grade temp all day, hemodynamically stable pulses unchanged. HCT stable.\nResp: patient remains on PSV 50% 5 5 with adeqaute oxygenation occasionally tachypnic when in pain.\nGI: Very faint bowel sounds no BM or flatus this shift.\nGU: patient given lasix this am with adequate urine output.\nSkin: intact. Please see flowsheets for all other information. Thank you\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-29 00:00:00.000",
"description": "Report",
"row_id": 1577111,
"text": "SICU NN: See carevue for specifics. Patient is alert, received morphine intrathecally (administered by anesthesia resident) and appears comfortable. Patient denies pain. Patient moves all extremities, right arm weaker than left. Patient nods head and mouths words around et tube. Patient follows commands. ET to vent no issues, o2 sat 94-97% however po2 >100 by abg. Secretions tan and very thick. RSR on cardiac monitor with occasional paced beats. BP wnl. RIJ with cco swan maintained as per policy, no issues. Afebrile. NPO. No bm. Foley intact and patent. Skin intact. Abdomen with staples, clean, dry and intact. No drainage from incision. Patient resting comfortably. Spoke with daughter in law on phone.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-29 00:00:00.000",
"description": "Report",
"row_id": 1577112,
"text": "RESP CARE: pt remains intubated/on vent on PS 5/5/.50. Rested a short time overnight on SIMV to prepare for extubation. Lungs coarse. Sxd for thick tan sputum. Foul smelling odor from oropharynx. Cleaned with sterile H20 and sxd oral cavity. ABGs acceptable. Strong cough noted. RSBI-63. Plan is for extubation\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-29 00:00:00.000",
"description": "Report",
"row_id": 1577113,
"text": "Respiratory Care Note\nPt received on PSV as noted. FiO2 weaned to 40%. BS are clear, but diminished in the bases bilaterally. Pt placed on SBT - tolerated well with good follow up ABG's. Pt has positive cuff leak. Pt has a strong cough. Pt extubated to cool aerosol w/o incident.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-29 00:00:00.000",
"description": "Report",
"row_id": 1577114,
"text": "NPN\nN: Patient awake and alert, only oriented to self, not time or place. Follows commands, MAE left side stronger than right.\n\nCV: afebrile, HR 60-100's SR/ Paced. BP stable via Arterial line. Pulses unchanged. Patient with blueness at capillary bed-- Dr aware. PA catheter changed to TLC.\n\nResp: Patient extubated to shovel mask- currently at 70%. with marginal oxygenation. Patient given Chest PT three times since extubation. Using insentive spirometer when instructed.\n\nGI: abdomen NTND with no bowel sounds no bowel movements.\n\nGU: foley patent voiding adeqaute amounts of urine. Patient diuresing from two doses of lasix. Please see flowsheets for all other information. Thank you\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-27 00:00:00.000",
"description": "Report",
"row_id": 1577104,
"text": "Nursing Progress Note\nPlease see carvue for specifics:\nNeuro: Lightly sedated on prop and fent for pain. Arousable to voice. Pt does follow commands and nods appropriately. Pupils and brisk.\nCV: Pt with large crit drop to 19 on days received 2units of PRBCs over noc which stablized crit. 2U FFP given for INR 1.7. Pt with low grade temp T-max 38.4 tylenol with effect current temp 37.6. BP very labile at start of shift. Pt with episodes of severe hypotension which required levo and fluid. PT also would have episodes of rebound HTN which required some nipride and ^^prop and fent. ? cause epidural d/c'd and BP stable since. SBP 100-120's HR-NSR will AV pace at 60. Pacer interrogated last noc by cardioloy (see cards note for changes). PAD's 15-20. CO 3.7-5.4 with SVR 700's-1200's. Pt not wedged d/t coags. Pt requiring mult fluid bolus for hypotension and currently for inadequate u/o. Pt receive 3L on LR in addition to products. Current wt ^^ 7kgs. Pt with cool/cyanotic extremities. PP no dopplerable can doppler PT. ICU team and primary team aware.\nResp: Current on SIMV 600X14 with Fi02 70%. Pt attemted to wean to cpap early in shift did not tolerated. PT rechecked this am with SBT which pt did tolerate initially but did begin to drop sats. Pt placed back on IMV. Lungs Clear to diminished at the bases w/ faint crackle in L base. 02 sat current 96-97 on .70% Fi02. pt did desat to 91-93 while on SBT despite adequate ABG.\nGI/GU: Currently NPO. NO NGT/OGT in place. ABD soft and distended + hypo BS. Foley patent drng amber colored urine.\nEndo: RISS\nInteg: No drains. abd inc intact with noted shadow staining.\nSoc: Supportive family. Dtr in law is RN in a hospital.\nPlan: Cont with current plan of care. ? change swan to TLCL. Cont wean vent. Cont to monitor lytes and replete as needed.\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-27 00:00:00.000",
"description": "Report",
"row_id": 1577105,
"text": "focus: Dondition Update.\nplease see flowsheet for specific values.\n\nNeuro: Pt lightly sedated on Propofol. He opens his eyes spontaneously, and follows commands consistently. He is receiving Fentanyl for pain, with boluses given for breakthrough pn when turning. Pain service in this am, eipdural cath idenfitied as being intrathecal by dr. and team, no pain med to be give via cath at this time, will assess pain management with ICU team later this p.m.\n\nResp: Lungs clear in the upper lobes, and crackles heard in the bases. Pt on AC this a.m. with Fi02 at 70%, weaned to 50% with sats at 100%. Pt placed on CPAP this afternoon, and appears to be tolerating well. No plans to extubate at this point, still receiving fluid for low urines, will check gas on cpap .\n\nCV: Pt in NSR with occassional paced beats (pacer set for demand of 60) regular. Blood pressure well controlled this am. with systolic around 140/. Lopressor restarted, however, pressure rising now that patient is weaning on CPAP. Will check with Dr. re: more specific parameters and perhaps adding another antihypertensive . Poor pulses in LE's, can hear post tib with the doppler, pedal pulses difficult to hear. Pt has permanent DDD pacer, rate set at 60. Swann not wedged this shift, pressures adequate. Going by cvp for fluid management, goal to keep cvp 10-14, urines will drop when cvp around 10.\n\nGI: No bowel sounds, abd is soft and nontender. Dressing clean and dry. No NGT at this time, will check with team re: placement becasue platlets remain low.\n\nGU: Urine output low, have been giving fluid boluses with little effect. SICU team aware.\n\n\nHeme: Platelet low. HIT sent.\n\nskin: No breakdown is noted. skin pink, warm, and dry.\n\nPlan: Keep CVP 10-14--give fluid as needed when drops or u/o less that 20 cc hr.\n Increase urine output to normal range.\n Wean on CPAP as tolerated, will placed back on SMIV if needed.\n continue to monitor lytes and replete as needed\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-27 00:00:00.000",
"description": "Report",
"row_id": 1577106,
"text": "Resp Care\n\nPt had CPAP/PSV trial on %. MV in the 10L range with rr in the mid 20's. Follow up abg 7.40/33/100/22. Suctioning small amts of sputum and bs are generally clear with scatter rhonchi. Plan is to rest overnite\n"
},
{
"category": "Nursing/other",
"chartdate": "2176-11-28 00:00:00.000",
"description": "Report",
"row_id": 1577107,
"text": " \"B\" Nsg Progress Note:\n\nCVS: T=98.8-99.7, HR=66-90 NSR with some episodes of paced beats. VR PVC noted. SBPby cuff=95-140. SBP by Aline=90-153. PAD= most of night but up to 16 at 5am. CVP=. CI=2.3-2.75. IV Fentanyl drip at 25mcg. IV Propofol drip at 5-15mcg. IV LR at 125cc/h. Bilateral PT pulses present with doppler, Left DP present with doppler, unable to locate rt DP. Feet cool,pale but capillary refill adequate. 8pm troponin=0.11, EKG done, no changes noted. Repeat troponin done at 3am.\n\nResp: Rested on IMV overnight. 5am placed on CPAP+PSV 5/5, FIO2 50%. Sats=97-100%. Lung sounds clear, diminished at bases. Plan to extubate pt today.\n\nGI: Very faint bowel sounds noted. Abdomen soft. Incision with small amt old serosanguinous drainage at midpoint of incision. No redness noted.\n\nGU: U/O=23-37cc/h amber clear urine. Received fluid boluses for low u/o yesterday. creat=0.8-0.9.\n\nNeuro: Pt nods appropriately,follows commands,moves all extremities. Pupils=+.\n\nSkin: Edema noted, no open areas, face red.\n\nPain: No c/o pain.\n\nSocial: Family visited this eve and will be back today.\n\nPlan: Extubate today.\n"
},
{
"category": "ECG",
"chartdate": "2176-11-27 00:00:00.000",
"description": "Report",
"row_id": 177345,
"text": "Sinus rhythm\nProbable left atrial abnormality\nIntraventricular conduction delay - may be atypical right bundle branch block\nConsider inferoposterolateral myocardial infarct, age indeterminate\nLeft ventricular hypertrophy\nDiffuse ST-T wave abnormalities - Cannot exclude in part ischemia\nClinical correlation is suggested\nSince previous tracing of , paced rhythm now absent\n\n"
},
{
"category": "ECG",
"chartdate": "2176-11-26 00:00:00.000",
"description": "Report",
"row_id": 177346,
"text": "Baseline artifact\nAtrial sensed ventricular paced rhythm\nSince previous tracing of , atrial sensing\n\n"
},
{
"category": "Radiology",
"chartdate": "2176-11-26 00:00:00.000",
"description": "BY DIFFERENT PHYSICIAN",
"row_id": 893018,
"text": " 4:40 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for PTX, effusion\n Admitting Diagnosis: ABDOMINAL AORTIC ANEURYSM/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 85 year old man with CAD s/p AAA repair w/desats and hypotension\n\n REASON FOR THIS EXAMINATION:\n eval for PTX, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Coronary artery disease, AAA repair, hypoxia, and hypotension.\n\n FINDINGS: Comparison made with radiograph from earlier the same day.\n\n An endotracheal tube ends below the thoracic inlet, approximately 5 cm from\n the carina. A right IJ Swan-Ganz catheter ends in the proximal right\n pulmonary artery. A pacemaking device overlying the right chest is in\n unchanged position with stable appearance of electrodes. Heart size and\n mediastinal contours are unchanged. No pulmonary parenchymal consolidation,\n failure, effusion, or pneumothorax is seen.\n\n IMPRESSION: Lines and tubes in satisfactory position. No evidence of\n pneumothorax or effusion.\n\n\n"
}
] |