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19,278 | 159,960 | Patient was admitted to the neurosurgery service and underwent an emergent R craniotomy with drainage of his subdural hemorrhage. Postoperatively he was transferred to the intensive care unit extubated and stable. He was maintained on dilantin for seizure prophylaxis, his blood pressure was controlled and he was monitored with close neuro checks. He was also maintained on prn ativan for prevention of alcohol withdrawal considering patient's significant drinking history. A postoperative CT scan demonstrated postoperative changes and an improvement in his subdural. He remained stable, his diet was advanced and he was awake and appropriate. He was found to have a simple urinary tract infection and was treated with ciprofloxacin. He was evaluated by both occupational and physical therapy and cleared for home. He was discharged to home on POD2 in good condition and will follow up in Dr. clinic for wound in approximately 10 days. | There remains some low attenuation right subdural fluid. There remains subfalcine herniation. nsr w/ rare pac noted.resp: lungs clear. subtherapeutic dilantin level this am. The leftward shift of the septum pellucidum, measured at the same location, has decreased from 1.3 cm to 0.8 cm. Superficial to that, underlying and extending inferior to the craniotomy, there is a blood air level in what appears to be the epidural space. Visualized portions of the mastoid air cells and right maxillary sinus are unremarkable. dim rt base. There is much less mass effect following subdural hematoma evacuation. u op qs though c/o foley discomfort.pain: mso4 2mg iv prn for h/a w/ effect. ciwa scale as noted, prn ativan w/ effect thus far.assess: stable day, off neuro intact. TECHNIQUE: Non-contrast head CT. ativan w/ effect.plan: bp < 140, hob flat. neuro checks,clears liquids. hob flat. abd softly distended. prn iv hydralazine and po bid lopressor to maintain sbp< 140 efffect. There is compression of the right lateral ventricle. Just inferior and anterior at that level, there was 1.7 cm leftward shift of the septum pellucidum at the level of the frontal horns, now reduced to 8 mm. diet advance to clears but only taking some h20 at present. ct head repeated.cv: refer to flowsheet for vs. nipride wean to off. 100mg tid began. Overall, there is much less mass effect. IMPRESSION: 1. bsp, no BM, glucose w/ SS coverage. IMPRESSION: Large right subdural hematoma with iso and hyperdense components producing focal effacement and mass effect with subfalcine herniation. The subdural collection seen previously is much smaller and lower in attenuation. There is significant mass effect and effacement of adjacent sulci with 13 mm leftward shift of normally midline structures. sats 99-100%.gi/gu: uop qs. Neuro-pt impulsive, attemting to get OOB, confused at times, reoients to place and time, immediately forgetful and restless, CIWA scale and ativan for agitation, PERL, MAEW, sitter at bedside to maintain safetydilantin TIDCV-Lopressor , VSS MP SB, CSM WNLResp-100% Fio2 per Dr. , Sao2 RA 98, and 100% with O2 on, LS coarse upper lobes, congested cough, encourage IS pt unable to participate due to agitationGI-clear liqueds, +BSGU-foley to cd urine output adequatePlan-sitter for safety, CIWA scale, monitor neuro exam, attempt to remain flat in bed, clear liqs Advance as tolerates, SBP <140 The ambient cisterns are symmetric. FINDINGS: Since the study of the preceding day, the patient has undergone a right frontal/parietal craniotomy. Basal cisterns not effaced. rt eye more swollen this afternoon. The basal cistern is not effaced. o2 100% ofm for neuro reasons. Pt to SICU-R sided SDH, one week history of ataxia, states he may have hit his head on the "bulk head", c/o of H/A and took asa, to OSH where CT showed right subdural hematoma was then transfered to , PMH HTN, NIDDM, hypercholesteromia, drinks per dayOn arrival to SICU: pt 3, MAEW R and L side full stregth, denies H/A, PERLLA, smile/tongue midline, denies h/a, denies dizzynessCV-VSS MP SB, CSM WNL HS S1 S2 RRRResp-LS clear A/P Sao2 97 RAGI-NPO, abs round soft distended +BSGU-voidsSkin-intactPlan-pt to OR for Burr holes Deep to the craniotomy, there is epidural high attenuation material, likely hemorrhage, with a large amount of extradural air and an air-fluid level. sicu updates/p subdural burr hole evacuationneuro: pt sleepier this afternoon, though cont to arouse easily. loaded w/ total of 750mg po dilantin in 2 doses. A large ovoid soft tissue density in the left maxillary sinus may reflect large mucus retention cyst. Neurosurgical consult needed! FINDINGS: There is a large right subdural hematoma measuring 3 cm with iso and hyperdense components producing focal effacement and mass effect with right to left shift of the septum pellucidum approximately 13 mm. FINAL REPORT INDICATION: 82-year-old male with known subdural. 3:53 PM CT HEAD W/O CONTRAST Clip # Reason: please reacess; thanks MEDICAL CONDITION: 62 year old man with known subdural REASON FOR THIS EXAMINATION: please reacess; thanks No contraindications for IV contrast WET READ: BTCa SAT 4:58 PM Large right subdural hematoma measuring up to 2.9 cm across with areas of low and high density consitent with acute on chronic bleed. 3. oriented x3, approp in conversation.perl. TECHNIQUE: Contiguous scans were obtained from the skull base to the vertex. 2. Postop: Arrived from OR extubated restless, attempting to sit up in Bed, reoriented, MAEW, s/p burr hole evacuation of subdural hematoma, intraop bradycardia responsive to levophed, levophed off on arrival to SICU MP SR 63, VSS, PRN nipride to maintain SBP <140, pt to remain flat in bed per Dr. , pt started to CIWA scale and PRN ativan due to ETOH historyPlan-CIWA scale, neuro cks, SBP<,140 11:41 AM CT HEAD W/O CONTRAST Clip # Reason: please check post op Admitting Diagnosis: SUBDURAL HEMATOMA MEDICAL CONDITION: 62 year old man with s/p crani w/ evacuation SDH REASON FOR THIS EXAMINATION: please check post op No contraindications for IV contrast FINAL REPORT CT OF THE HEAD CLINICAL HISTORY: Evacuation of subdural hematoma. | 6 | [
{
"category": "Nursing/other",
"chartdate": "2170-06-17 00:00:00.000",
"description": "Report",
"row_id": 1516710,
"text": "Pt to SICU-R sided SDH, one week history of ataxia, states he may have hit his head on the \"bulk head\", c/o of H/A and took asa, to OSH where CT showed right subdural hematoma was then transfered to , PMH HTN, NIDDM, hypercholesteromia, drinks per day\n\nOn arrival to SICU: pt 3, MAEW R and L side full stregth, denies H/A, PERLLA, smile/tongue midline, denies h/a, denies dizzyness\nCV-VSS MP SB, CSM WNL HS S1 S2 RRR\nResp-LS clear A/P Sao2 97 RA\nGI-NPO, abs round soft distended +BS\nGU-voids\nSkin-intact\n\nPlan-pt to OR for Burr holes\n"
},
{
"category": "Nursing/other",
"chartdate": "2170-06-17 00:00:00.000",
"description": "Report",
"row_id": 1516711,
"text": "Postop: Arrived from OR extubated restless, attempting to sit up in Bed, reoriented, MAEW, s/p burr hole evacuation of subdural hematoma, intraop bradycardia responsive to levophed, levophed off on arrival to SICU MP SR 63, VSS, PRN nipride to maintain SBP <140, pt to remain flat in bed per Dr. , pt started to CIWA scale and PRN ativan due to ETOH history\n\nPlan-CIWA scale, neuro cks, SBP<,140\n"
},
{
"category": "Nursing/other",
"chartdate": "2170-06-17 00:00:00.000",
"description": "Report",
"row_id": 1516712,
"text": "sicu update\ns/p subdural burr hole evacuation\n\nneuro: pt sleepier this afternoon, though cont to arouse easily. oriented x3, approp in conversation.perl. strong equal strength of all extrems. rt eye more swollen this afternoon. subtherapeutic dilantin level this am. loaded w/ total of 750mg po dilantin in 2 doses. 100mg tid began. hob flat. ct head repeated.\n\ncv: refer to flowsheet for vs. nipride wean to off. prn iv hydralazine and po bid lopressor to maintain sbp< 140 efffect. nsr w/ rare pac noted.\n\nresp: lungs clear. dim rt base. o2 100% ofm for neuro reasons. sats 99-100%.\n\ngi/gu: uop qs. diet advance to clears but only taking some h20 at present. abd softly distended. bsp, no BM, glucose w/ SS coverage. u op qs though c/o foley discomfort.\n\npain: mso4 2mg iv prn for h/a w/ effect. ciwa scale as noted, prn ativan w/ effect thus far.\n\nassess: stable day, off neuro intact. ativan w/ effect.\n\nplan: bp < 140, hob flat. neuro checks,clears liquids.\n\n"
},
{
"category": "Nursing/other",
"chartdate": "2170-06-18 00:00:00.000",
"description": "Report",
"row_id": 1516713,
"text": "Neuro-pt impulsive, attemting to get OOB, confused at times, reoients to place and time, immediately forgetful and restless, CIWA scale and ativan for agitation, PERL, MAEW, sitter at bedside to maintain safety\ndilantin TID\nCV-Lopressor , VSS MP SB, CSM WNL\nResp-100% Fio2 per Dr. , Sao2 RA 98, and 100% with O2 on, LS coarse upper lobes, congested cough, encourage IS pt unable to participate due to agitation\nGI-clear liqueds, +BS\nGU-foley to cd urine output adequate\n\nPlan-sitter for safety, CIWA scale, monitor neuro exam, attempt to remain flat in bed, clear liqs Advance as tolerates, SBP <140\n"
},
{
"category": "Radiology",
"chartdate": "2170-06-16 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 916342,
"text": " 3:53 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please reacess; thanks \n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with known subdural\n REASON FOR THIS EXAMINATION:\n please reacess; thanks \n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: BTCa SAT 4:58 PM\n Large right subdural hematoma measuring up to 2.9 cm across with areas of low\n and high density consitent with acute on chronic bleed. There is significant\n mass effect and effacement of adjacent sulci with 13 mm leftward shift of\n normally midline structures. Basal cisterns not effaced. Neurosurgical\n consult needed!\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old male with known subdural.\n\n COMPARISONS: No prior studies are available at this institution for\n comparison.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is a large right subdural hematoma measuring 3 cm with iso\n and hyperdense components producing focal effacement and mass effect with\n right to left shift of the septum pellucidum approximately 13 mm. There is\n compression of the right lateral ventricle. The basal cistern is not effaced.\n No major vascular territorial infarct is identified. Visualized portions of\n the mastoid air cells and right maxillary sinus are unremarkable. A large\n ovoid soft tissue density in the left maxillary sinus may reflect large mucus\n retention cyst. No fractures are identified.\n\n IMPRESSION: Large right subdural hematoma with iso and hyperdense components\n producing focal effacement and mass effect with subfalcine herniation.\n\n The above relayed to the ED dashboard at 4:50 p.m. and flagged for urgent\n attention.\n\n"
},
{
"category": "Radiology",
"chartdate": "2170-06-17 00:00:00.000",
"description": "CT HEAD W/O CONTRAST",
"row_id": 916409,
"text": " 11:41 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please check post op\n Admitting Diagnosis: SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old man with s/p crani w/ evacuation SDH\n REASON FOR THIS EXAMINATION:\n please check post op\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD\n\n CLINICAL HISTORY: Evacuation of subdural hematoma.\n\n TECHNIQUE: Contiguous scans were obtained from the skull base to the vertex.\n\n FINDINGS:\n\n Since the study of the preceding day, the patient has undergone a right\n frontal/parietal craniotomy. Deep to the craniotomy, there is epidural high\n attenuation material, likely hemorrhage, with a large amount of extradural air\n and an air-fluid level. The subdural collection seen previously is much\n smaller and lower in attenuation. Overall, there is much less mass effect.\n The leftward shift of the septum pellucidum, measured at the same location,\n has decreased from 1.3 cm to 0.8 cm. Just inferior and anterior at that\n level, there was 1.7 cm leftward shift of the septum pellucidum at the level\n of the frontal horns, now reduced to 8 mm. There remains subfalcine\n herniation. The ambient cisterns are symmetric.\n\n IMPRESSION:\n 1. There is much less mass effect following subdural hematoma evacuation.\n 2. There remains some low attenuation right subdural fluid.\n 3. Superficial to that, underlying and extending inferior to the craniotomy,\n there is a blood air level in what appears to be the epidural space.\n\n\n"
}
] |
82,177 | 176,262 | 38 y/o female with history of autoimmune diseases (Crohn's vasculitis, psoriasis) with autoimmune hemolytic anemia following fever. . 1. Autoimmune Hemolytic Anemia: Etiology includes acquired post infectious autoimmune process, reactive autoimmune process after tappering steroids. Presented febrile. WBC was elevated in the setting of hemolysis and elevated bone marow turnover. Fevers could have been due to vasculitis, infection (unclear source). She received 6 units of PRBC's. She was treated initially with IV solumedrol, to which she had some psychosis. She was later changed to Prednisone 80 mg PO QD. Her hemolysis labs slowly improved. Her HCT was stable in the mid 20's. She was treated with B12 and folate. Hematology will follow her as an outpatient. Would recommend watching for fevers once off steroids. . 2. Non Gap Metabolic Acidosis: Likely lactic acidosis from cell lysis, as LDH was elevated. She was treated with IV fluids- Lactated Ringers. . 3. Elevated Blood Sugars: Likely due to steroids. She was covered with insulin based on a sliding scale. . 4. Vasculitis: Much improved per patient with prednisone. Unclear . Diagnosed and followed at B&W Hospital. . 5. Crohn's: Stable. . 6. Psoriasis: Stable. . FULL CODE | Sinus arrhythmiaSince previous tracing of , the heart rate has decreased | 2 | [
{
"category": "ECG",
"chartdate": "2151-03-22 00:00:00.000",
"description": "Report",
"row_id": 268032,
"text": "Sinus arrhythmia\nSince previous tracing of , the heart rate has decreased\n\n"
},
{
"category": "ECG",
"chartdate": "2151-03-21 00:00:00.000",
"description": "Report",
"row_id": 268033,
"text": "Sinus tachycardia\nShort PR interval\nClinical correlation is suggested\n\n"
}
] |
22,500 | 127,625 | The patient was admitted to the Trauma Team for observation. Secondary to patient's age and multiple rib fractures with associated morbidity, the Anesthesia Department was consulted to perform epidural anesthesia on the patient to aid in the aggressive pulmonary toilet. The patient declined this. The patient was treated with morphine until the morning. Secondary to patient's persistent flank and back pain, the Department of Orthopedics was consulted, L1-L2 transverse processes fractures with stable injuries that required symptomatic treatment and recommended patient being fitted with thoracolumbar corset for comfort. The patient also received CT imaging of the cervical spine. Findings were notable for multiple areas of anterolisthesis of a mild degree at C3-C4, C4-C5, and C6-C7, C7-T1. No fractures were identified. Spinous process of C3 was displaced slightly forward. DENS intact. Lateral masses of C1 were well lined on C2 without any soft tissue swelling. The patient also received Flex X plain radiograph and plain film trauma series of the cervical spine, which were negative. The patient continued to improve during the remainder of the hospital stay under good pain management with morphine and dilaudid. The patient worked with PT and continued to make an improvement. Now, the patient is stable with improved pain control. The patient will be discharged to rehabilitation to progress with independence in mobility. The patient should followup with the Trauma Clinic in two weeks' time. | NEEDS ENCOURAGEMENT FOR FLD INTAKE.GU: VOIDING CLEAR YELLOW ON BEDPAN QS.ID: AFEBRILEA/ HD STABLE. GIVEN FENT 50MCG X2 AND VIOXX WITH EFFECT. )Renal- adequate u/o per foley..clear/yellowResp- 4L nc with rr mid teens to 21 in nonlabored breathing pattern breath sounds are clear with diminished coarse sounds at LLL. afebrile.bp 120-130's when asleep 100 to 120. hr 50's 60's nsr no ectopy. USING IS TO 1200CC WITH EASE.GI: ABD SOFT WITH +BS. Nursing Progress Notes/o- pt systolic pressure down to 100/20, hr in the 50's sinus no ectopi noted. Hr 50-60's Sb w/o ectopy magnesium repleted serial enzymes ongoing(negative so far. PT SUSTAINED LT RIB FX'S AND L1-2 TRANSVERSE PROCESS FXS.PMH: CAD, PVD, CEREBELLAR CVA, HTN, ULCERATIVE COLITIS, MI ', S/P RIH REPAIR, ^CHOLALLERGIES: SULFA, PCN, AND ASA.MEDS: ZESTRIL, PLAVIX, NORVASC, SPIRONOLACTONE, DETROL, PRILOSEC, QUININE, COLACE.N: A/OX3 PLEASANT AND COOP. UNSTEADY GAIT--ASSIST X2.CV: NSR 60-70 NO ECTOPY. T/Sicu Nsg Progress Note0700>>190015:40Events- transfused with PC's 1u for drifting hct(33>>27) and below baseline bp: bp ranging 90-110/ with recommended range of 140-160 per Dr /Aoresty. sats >96 on nasal prongs. routine diuretic and anti-HTN meds on hold today d/t bpNeuro- A&O x3...no issuesPain- c/o left chest pain(at site of injury..lower rib cage) at pre medication and post medication with 12.5mg ivp fentanyl q3/hr. pt u/o 30-40cc clear yellow urinegi- pt taking po fluid, c/o dry mouth, sipping H2O whenever awake.resp- pt Sats down to 90-92, while asleep, nasal canula at 2l increaed to 4l, pt mouth breathing at times, pt rr 16-24, coughs and deep breaths well, with weak cough.Used IS when awake. CXR today reported as no change from -weak NPID- afebrile, wbc wnlHeme- 1 u PRBC'sGI- regular diet with lactose restrictions..well tolerated soft abd; hypoactive bowel sounds...no stoolskin- left lower falnk ecchymosis warm pale skin compression boots in use.Activity- mobilize once hemodynamics are stable son/daughter visiting the day.assess- yo woman s/p fall with left sided rib fx ICU for management of resp status and pain issues. pt moving all extremes prrposefully and to command.Pt wears a soft collar, c/o of increased neck pain.Pt easily aroused when sleepinggu- pt had not voided over last 8h, pt had foley cath inserted #16, u/o 175cc. decreased breath sounds in the bases.skin- intact. reap rate teens low 20's. pt repositioned for comfort.Only c/o of pain with movement. pt given 500cc bolus of NS without effect, pt cont to receive volume, and systolic pressure dropped to 85/20, total of 3 liters NS given overnight, hr remains in a sinus bradycardia,pt hct down to 27. no transfusion at this time. Sinus bradycardiaRight bundle branch blockLateral ST-T changes are nonspecific may be due to myocardial ischemia -clinical correlation is suggestedSince previous tracing, : lateral T wave changes present Cont with C&DB, and use of IS. SBP 110'S-20'S. lytes WNL. Qd vioxx given at 1500.CVS- bp 110-133/40-50 with blood infusing. C/O ONLY MINIMAL PAIN AND MEDICATED WITH EFFECT. PT IS A Y/O FEMALE ADM TODAY AFTER FALL AT HOME IN BR. (BASELINE PER PT.) ivf at kvo. uo initally good dwindled to 20ccs per hr from 3 to 6 then down to 11 ccs at 7am. RESP STABLEP/ TRANSFER TO FLR IF REMAINS STABLE pt alert and oriented X3. potential for resp depression/ resp distress d/t narcotic/injuries.plan- per care plan/ sicu/trauma trauma teams WARM PALP PP.R: LUNGS CLEAR WITH SCATTERED FINE CRACKLES AT BASES. pt alert and coop oriented times three. STRONG PROD COUGH WHEN SPLINTING ABDOMEN. medicated times three with 12.5 of fentanyl for rib pain. good appetite for dinner taking flds but none over night as pt slept well.a stable with low utine out putp start her aldactone this am and watch her urine output. O2 VIA NC 2L. TOL HOUSE DIET. using is. Pt may need swan to determine volume status, with her cardiac history,will discuss transfusion on rounds. son left at 8pm and her daughter is driving to from PA.A/P - pt has had large volume requirement and drop in hct with min u/o. Cont to monitor and support. getting up to 900ccs. ecchymotic L sidePain pt has not received any pain med and she has slept most noc. pt is hard of hearing. | 5 | [
{
"category": "Nursing/other",
"chartdate": "2200-11-14 00:00:00.000",
"description": "Report",
"row_id": 1556642,
"text": "PT IS A Y/O FEMALE ADM TODAY AFTER FALL AT HOME IN BR. PT SUSTAINED LT RIB FX'S AND L1-2 TRANSVERSE PROCESS FXS.\nPMH: CAD, PVD, CEREBELLAR CVA, HTN, ULCERATIVE COLITIS, MI ', S/P RIH REPAIR, ^CHOL\nALLERGIES: SULFA, PCN, AND ASA.\nMEDS: ZESTRIL, PLAVIX, NORVASC, SPIRONOLACTONE, DETROL, PRILOSEC, QUININE, COLACE.\n\nN: A/OX3 PLEASANT AND COOP. GIVEN FENT 50MCG X2 AND VIOXX WITH EFFECT. C/O ONLY MINIMAL PAIN AND MEDICATED WITH EFFECT. UNSTEADY GAIT--ASSIST X2.\nCV: NSR 60-70 NO ECTOPY. SBP 110'S-20'S. WARM PALP PP.\nR: LUNGS CLEAR WITH SCATTERED FINE CRACKLES AT BASES. (BASELINE PER PT.) O2 VIA NC 2L. STRONG PROD COUGH WHEN SPLINTING ABDOMEN. USING IS TO 1200CC WITH EASE.\nGI: ABD SOFT WITH +BS. TOL HOUSE DIET. NEEDS ENCOURAGEMENT FOR FLD INTAKE.\nGU: VOIDING CLEAR YELLOW ON BEDPAN QS.\nID: AFEBRILE\nA/ HD STABLE. RESP STABLE\nP/ TRANSFER TO FLR IF REMAINS STABLE\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-11-16 00:00:00.000",
"description": "Report",
"row_id": 1556645,
"text": "pt alert and coop oriented times three. sats >96 on nasal prongs. reap rate teens low 20's. crackles in bases. using is. getting up to 900ccs. afebrile.\nbp 120-130's when asleep 100 to 120. hr 50's 60's nsr no ectopy. uo initally good dwindled to 20ccs per hr from 3 to 6 then down to 11 ccs at 7am. ivf at kvo. medicated times three with 12.5 of fentanyl for rib pain. good appetite for dinner taking flds but none over night as pt slept well.\na stable with low utine out put\np start her aldactone this am and watch her urine output.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-11-15 00:00:00.000",
"description": "Report",
"row_id": 1556643,
"text": "Nursing Progress Note\ns/o- pt systolic pressure down to 100/20, hr in the 50's sinus no ectopi noted. pt given 500cc bolus of NS without effect, pt cont to receive volume, and systolic pressure dropped to 85/20, total of 3 liters NS given overnight, hr remains in a sinus bradycardia,pt hct down to 27. no transfusion at this time. lytes WNL.\n pt alert and oriented X3. pt is hard of hearing. pt moving all extremes prrposefully and to command.Pt wears a soft collar, c/o of increased neck pain.Pt easily aroused when sleeping\ngu- pt had not voided over last 8h, pt had foley cath inserted #16, u/o 175cc. pt u/o 30-40cc clear yellow urine\ngi- pt taking po fluid, c/o dry mouth, sipping H2O whenever awake.\nresp- pt Sats down to 90-92, while asleep, nasal canula at 2l increaed to 4l, pt mouth breathing at times, pt rr 16-24, coughs and deep breaths well, with weak cough.Used IS when awake. decreased breath sounds in the bases.\nskin- intact. ecchymotic L side\nPain pt has not received any pain med and she has slept most noc. pt repositioned for comfort.Only c/o of pain with movement.\n son left at 8pm and her daughter is driving to from PA.\nA/P - pt has had large volume requirement and drop in hct with min u/o. Pt may need swan to determine volume status, with her cardiac history,will discuss transfusion on rounds. Cont with C&DB, and use of IS. Cont to monitor and support.\n"
},
{
"category": "Nursing/other",
"chartdate": "2200-11-15 00:00:00.000",
"description": "Report",
"row_id": 1556644,
"text": "T/Sicu Nsg Progress Note\n0700>>1900\n\n15:40\nEvents- transfused with PC's 1u for drifting hct(33>>27) and below baseline bp: bp ranging 90-110/ with recommended range of 140-160 per Dr /Aoresty.\n routine diuretic and anti-HTN meds on hold today d/t bp\n\nNeuro- A&O x3...no issues\nPain- c/o left chest pain(at site of injury..lower rib cage) at pre medication and post medication with 12.5mg ivp fentanyl q3/hr. Qd vioxx given at 1500.\n\nCVS- bp 110-133/40-50 with blood infusing. Hr 50-60's Sb w/o ectopy\n magnesium repleted\n serial enzymes ongoing(negative so far.)\n\nRenal- adequate u/o per foley..clear/yellow\n\nResp- 4L nc with rr mid teens to 21 in nonlabored breathing pattern\n breath sounds are clear with diminished coarse sounds at LLL.\n CXR today reported as no change from \n -weak NP\nID- afebrile, wbc wnl\n\nHeme- 1 u PRBC's\n\nGI- regular diet with lactose restrictions..well tolerated\n soft abd; hypoactive bowel sounds...no stool\n\nskin- left lower falnk ecchymosis\n warm pale skin\n compression boots in use.\n\nActivity- mobilize once hemodynamics are stable\n\n son/daughter visiting the day.\n\nassess- yo woman s/p fall with left sided rib fx\n ICU for management of resp status and pain issues.\n potential for resp depression/ resp distress d/t narcotic/injuries.\n\nplan- per care plan/ sicu/trauma trauma teams\n\n"
},
{
"category": "ECG",
"chartdate": "2200-11-15 00:00:00.000",
"description": "Report",
"row_id": 274785,
"text": "Sinus bradycardia\nRight bundle branch block\nLateral ST-T changes are nonspecific may be due to myocardial ischemia -\nclinical correlation is suggested\nSince previous tracing, : lateral T wave changes present\n\n"
}
] |
66,532 | 127,137 | "62 yo F PMH of afib, TIA, memory loss s/p hypoglycemic coma, chronic low back pain, anemia, GERD, a(...TRUNCATED) | "Q2-3 hrs;no desating,gets resp distress that easily clears with suction ,cxr more pul edema pi(...TRUNCATED) | 180 | [{"category":"Nursing","chartdate":"2103-03-04 00:00:00.000","description":"Nursing Progress Note","(...TRUNCATED) |
95,143 | 127,296 | "The patient developed a moderate to large circumferential pericardial effusion, for which he underw(...TRUNCATED) | "Thereis brief right atrial diastolic invagination.IMPRESSIOn: Moderate to large pericardial effusio(...TRUNCATED) | 11 | [{"category":"Radiology","chartdate":"2156-06-15 00:00:00.000","description":"CT ABDOMEN W/O CONTRAS(...TRUNCATED) |
86,645 | 143,608 | "56 year old male with a past medical history of cerebral atriaovenous malformation (AVM) staus post(...TRUNCATED) | "Extensive vasogenic edema involving right hemisphere is unchanged since prior with extensive mass e(...TRUNCATED) | 4 | [{"category":"Radiology","chartdate":"2165-07-14 00:00:00.000","description":"CT ABD & PELVIS WITH C(...TRUNCATED) |
26,523 | 138,682 | "(By issue) 1. Right lower extremity cellulitis and ulcerations - The patient was admitted to the (...TRUNCATED) | "HO aware.RESP: B/L BS diminished. BS hypoactive. Tol clears.Endo: BS 177, 193. BLE edema. Mg+ 1.7, (...TRUNCATED) | 9 | [{"category":"Radiology","chartdate":"2190-03-12 00:00:00.000","description":"CATH INFUSN,PER/CENT/M(...TRUNCATED) |
5,495 | 142,471 | "78 y/o M with PMHx of CAD s/p CABG & MI, Metastatic Carcinoid and chronic abd/back pain who present(...TRUNCATED) | "On , UE showed RIJ occlusive thrombus, left subclavian nonocclusive thrombus, and left basilic ve(...TRUNCATED) | 120 | [{"category":"Physician ","chartdate":"2145-03-04 00:00:00.000","description":"Attending Note","row_(...TRUNCATED) |
4,113 | 138,805 | "Patient is a 45 y/o female with CAD s/p CABG, diastolic HF and kidney transplant presenting from OS(...TRUNCATED) | "CARDIAC CATH: 1. CARDIAC CATH: 1. To IR, R brachial single lumen PICC placed. FS at 22:00- 32 s(...TRUNCATED) | 50 | [{"category":"Echo","chartdate":"2148-09-25 00:00:00.000","description":"Report","row_id":63629,"tex(...TRUNCATED) |
69,472 | 189,088 | "This 57-year-old patient with recent syncopal attacks was investigated and was found to have a crit(...TRUNCATED) | "Mild (1+) aorticregurgitation is seen. Normal ascending aortadiameter. A right-sided PICC line is a(...TRUNCATED) | 13 | [{"category":"Radiology","chartdate":"2144-02-07 00:00:00.000","description":"CHEST (PORTABLE AP)","(...TRUNCATED) |
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